Keynote Speaker Abstracts
The Mental Health of Junior Doctors
S Harvey
Black Dog Institute, University of New South Wales, Sydney, Australia
While being a doctor is often described as one of the most rewarding professions, it is also known to be one of the most stressful and demanding occupations that, at times, can have a negative impact on a doctor’s own mental health and well-being. There is increasing evidence that doctors may have elevated rates of common mental health disorders compared to the general population and have a greater risk of suicide compared to most other professional groups. This increased rate of mental health problems is particularly prominent among junior doctors. There are a range of workplace factors that are likely to play a role in explaining the elevated rates of mental disorder and suicidality among doctors, including a high workload, long and irregular working hours, competitiveness of training programmes, pressure of patient and service demands, the consequences of any errors, poor work–life balance and the risk of moral injury. In recent years, the international medical community has made numerous calls for action, demanding a greater focus on doctor mental health within training programmes, workplaces and the health service more broadly. Psychiatrists must be at the forefront of these efforts.
This presentation will describe results from a recent national survey of junior doctors examining both the rates of mental health problems and the role of workplace factors in explaining any increased risk in this group. The lessons from other high-risk industries, such as first responders, and the results of recent meta-analyses will then be used to explore how health services and medical colleges can facilitate interventions to improve the mental health of junior doctors. The early results from a number of ongoing intervention studies focused on Australian junior doctors will be used to inform this discussion.
Dreamers of the Day: Interrogating Changing Patterns of Mental Disorders in Remote Indigenous Australia
EM Hunter
The Cairns Institute, James Cook University, Cairns, Australia
Background: Over the last half-century, Indigenous Australia has been transformed by political and social forces that have been accompanied by changing patterns of mental disorders.
Objectives: This presentation will reprise research findings from two areas of remote Indigenous Australia to explore how social change is mediated to influence population-level mental health.
Methods: Two sets of research findings are presented, relating to suicide in the Kimberley and psychosis in Far North Queensland.
Findings: Although the increases in rates of suicide and psychosis across these two settings are not synchronous, there are commonalities that suggest the importance of neurodevelopmental adversity.
Conclusions: While the excess vulnerability of Indigenous Australians to adverse mental health outcomes is widespread, it is changing with time and is unevenly distributed. Population-level interventions must be informed by recognition of the underlying historical and contextual factors, and appreciation of the limitations of health sector solutions.
Can We Prevent and Treat Depression Using Diet?
FN Jacka
1,2,3,4,5
1Director, Food & Mood Centre, IMPACT SRC, Deakin University, Geelong, Australia
2Department of Psychiatry, The University of Melbourne, Melbourne, Australia
3Centre for Adolescent Health, Murdoch Children’s Research Institute, Melbourne, Australia
4Black Dog Institute, Sydney, NSW, Australia
5International Society for Nutritional Psychiatry Research
With depressive disorders the leading source of global disability, the development of new prevention and treatment strategies is critical. The 20th century has seen major shifts in dietary intakes, with a profound increase in the consumption of sugars, snack foods, take-away foods and high-energy foods. At the same time, the consumption of nutrient-dense foods, such as vegetables, fish, wholegrains, nuts and seeds, legumes and fruits, is diminishing. As a result, unhealthy diet is now the leading cause of early death in middle- and high-income countries and is number two globally. Critically, there is now an overwhelming body of evidence to tell us that unhealthy diet, in addition to increasing the risk for chronic physical disease, is also a key risk factor for psychiatric illnesses, including depression, anxiety and dementia.
Professor Jacka has pioneered and led the development of a large and robust body of evidence regarding the influence of diet on depression and anxiety and is recognized as a research leader in this new field. In this presentation, she will provide an up-to-date overview of the evidence regarding the impact of diet on mental and brain health across age groups, countries and cultures. She will then discuss the rapidly developing evidence pointing to diet as a critically important and modifiable risk factor in parents prior to conception and in pregnant mothers and their children. She will then focus on the new evidence for the microbiome–gut–brain axis in mood and behaviour. Finally, she will discuss new evidence for diet as a clinical strategy for improving mental and brain health and discuss the research activities being undertaken at the Food & Mood Centre.
Professor Felice Jacka is internationally recognized as a leader in the rapidly developing field of research focused on Nutritional Psychiatry and is the Director of Deakin University’s Food & Mood Centre and the President of the International Society for Nutritional Psychiatry Research (ISNPR).
The Evolution of Cognitive Processing Therapy for Post-Traumatic Stress Disorder
PA Resick
Duke University Medical Center, Durham, NC, USA
This talk will describe how cognitive processing therapy (CPT) for post-traumatic stress disorder (PTSD) was developed in the late 1980s, knowing what we knew then about PTSD. Rather than a purely exposure-based therapy, I focused on teaching patients to change their harmful beliefs about themselves and others regarding the causes and consequences of the traumatic events that lead to negative emotions and PTSD symptoms. The goal was not only to treat the PTSD and depressive symptoms but also to teach patients to think in a new, more balanced and fact-based manner through questions and a progressive series of worksheets that would lead them to becoming their own therapists and to approach future negative life events with a healthier approach. CPT was first developed as a 12-session group treatment and then implemented as an individual treatment with female victims of interpersonal violence. The CPT protocol will be described and subsequent changes will be explained. With successful research on the outcomes of CPT, the therapy was applied to veterans and active military members and a range of traumatic events, and with various co-morbid disorders. CPT has now been implemented in a number of countries and has been studied with 23 published controlled clinical trials and many effectiveness studies with community populations. The changes in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, based on mounting knowledge about the importance of cognitions and emotions, will be described. Improvements in the CPT protocol over time based on research findings, including variable-length CPT, will be discussed and options for implementation will be described. Dissemination efforts will be described. Research on treatment outcome of CPT with different populations will be briefly reviewed and current research and future directions will be described.
Insight or Intrusion? Correlating Routinely Collected Data with Health Risks
M Taylor
Melbourne Law School, University of Melbourne, Melbourne, Australia
Increasingly predispositions and susceptibilities to health conditions might be identified through using data originally collected for other purposes (e.g. via social media, smart speakers, Internet searches, or corporate email). The future is one of pattern matching to yield deeper insight into connections between health risks and other biographical, social and environmental data.
When can companies use data to identify behaviour associated with poor health, including poor mental health? What can they do with that data and under what conditions can they share it? What would good data governance look like and what would be the role and responsibility of health-care professionals to support it?
The legal frameworks of privacy and data protection are considered in both the United Kingdom and Australia to address questions of legal possibility regarding secondary health analysis of routinely collected data. A theoretical conception of the public interest, rooted in the idea of public reason, provides a critical edge to analysis of existing regulatory requirements and professional guidance and grounds an image of good governance.
Law currently leans too heavily on outdated concepts of ‘ask or anonymize’ and an individualistic conception of privacy. Avoidance of a dystopian future depends on reimagining governance tools and protecting reasonable expectations regarding reuse and disclosure of data. Coordinated cross-disciplinary effort is needed to ensure that data are used under conditions that individuals expect, find acceptable and that respect expressed preferences.
Advances in Genetics and Pharmacogenetics in Psychiatry: towards Precision Medicine
N Wray
Institute for Molecular Genetics and Queensland Brain Institute, The University of Queensland, Brisbane, Australia
Technological advances of the last decade have provided overwhelming evidence that the genetic contributions to common psychiatric disorders have polygenic genetic architectures with thousands of DNA variants implicated in the risk of each disorder. At an individual level, this means that each of us harbour risk loci and that each affected person likely carries both a higher burden and a unique portfolio of risk alleles. In addition, genome-wide genetic data have demonstrated important genetic sharing (pleiotropy) between the psychiatric disorders, providing aetiological clues that were often previously undetectable from standard epidemiology. The observed polygenic and pleiotropic architectures are consistent with the difficulties associated with diagnostic classifications based on clinical phenotypes superimposed onto this genetic spectrum of disorders. Much research is now focused on understanding the functional roles of newly identified associated DNA variants, with the long-term goals of new treatments or prevention strategies.
Treatments or interventions tailored to individuals in the so-called precision medicine are viewed as the future of clinical practice. A key question is how will we stratify patients for these personalized approaches. I will discuss the possible utility of genetic risk prediction in population prevention, at clinical presentation and in personalizing treatment options (i.e. pharmacogenetics). These predictive tools are likely to become a useful part of the clinical toolbox, but it is important that the expectations of what genetic and genomic technologies can deliver are realistic and not overstated.
RANZCP Award Winner ABSTRACTS
Mark Sheldon Prize
From Custody to Community: The Indigenous Mental Health Intervention Programme
E Heffernan1,2,3, P Dale3, Y Muller3, F Davidson1,2,3, M Steele1,2, E Waterson1,3
1Queensland Centre for Mental Health Research, Brisbane, Australia
2The University of Queensland, Brisbane, Australia
3Forensic Mental Health Services, Metro North Health and Hospital Services, Brisbane, Australia
Background: Aboriginal and Torres Strait Islander people have the highest rate of incarceration of any population in the world and are 13 times more likely to be imprisoned than non-Indigenous Australians. Poor social and emotional well-being (SEWB) and mental illness are endemic among this group. Despite this, there are very few programmes developed with and for Indigenous Australians to address mental health problems in custody and in transition to the community.
Objectives: This session aims to describe the findings of culturally informed research and demonstrate how this translated into meaningful outcomes for Indigenous people in custody through the development of the Indigenous Mental Health Intervention Program (IMHIP).
Methods: This presentation will overview the findings from two Queensland surveys of the mental health of incarcerated Indigenous Australians and provide a description and evaluation of the IMHIP model of service. Reflections on the process from research to translation that facilitated the successful development and implementation of IMHIP will also be presented.
Findings: The prevalence of mental disorder, psychological distress, trauma experiences and suicidal thoughts and attempts is extremely high among incarcerated Indigenous Australians. These findings, while adverse, have led to meaningful changes through the development of a highly successful Indigenous-led model of mental health and SEWB care.
Conclusions: Opportunities exist to significantly improve outcomes for Aboriginal and Torres Strait Islander people in contact with the criminal justice system through culturally informed models of care.
Margaret Tobin Oration – Ex Veritate Salus: Building Well-Being through Understanding – For Us All
E Moore
Office for Mental Health and Wellbeing, ACT Government, Canberra, Australia
There is a renewed impetus through government, professional and advocacy bodies and individuals to review and implement different frameworks for promoting well-being.
Psychiatrists, through their role as medical leaders, have a unique position to influence culture in mental health service settings and foster collaboration with local networks. However, the mental health service setting needs to be seen in the broader context of the community, and we need to advocate for mental health and well-being in all settings. Kindness is a much underrated value that can sustain and develop service systems, support people in their workplace and enrich local communities.
‘Investing to Save’, the report commissioned by Mental Health Australia in 2018, reinforces the need to look beyond the mental health service sector to the interrelated determinants of mental health and mental disorder and how we can alter these (Mental Health Australia, 2018). Understanding the lens through which others see is an important step to influence. The recently announced Productivity Commission Inquiry into Mental Health offers even more impetus to use the evidence already available to drive change (Australian Government Productivity Commission, 2019).
In this oration I want to explore the evidence in sociology, the built environment and the arts, and give a brief overview of systems thinking so that we, as psychiatrists, feel able to contribute to, and indeed drive, the agenda for well-being – for our patients and their families, for our communities and for us all.
References
Mental Health Australia (2018) Investing to Save – KPMG and Mental Health Australia report – May 2018. Available at https://mhaustralia.org/report/clone-investing-save-kpmg-and-mental-health-australia-report-may-2018.
Australian Government Productivity Commission (2019) Mental health. Available at: https://www.pc.gov.au/inquiries/current/mental-health#issues.
Senior Research Award: Improving the Mental Health and Well-Being of People with Intellectual Disability
JN Trollor
School of Psychiatry, UNSW Sydney, Sydney, Australia
Background: People with intellectual disability (ID) experience a high burden of mental and physical ill health and multiple barriers to access to health services.
Objectives: This session will highlight the mental health gap experienced by people with intellectual disability, outline contextual and contributing factors and critique the progress in improving this situation.
Methods: Diverse research is described from which details have emerged about the specific mental health gaps for people with ID and their determinants and solutions.
Findings: Australian and international research have revealed major health inequalities, problems with health services access, limited professional capacity and training, poor quality mental health care and lack of inclusion of the needs of people with ID in health policy
Conclusions: Recent research has clarified the extent and impact of the mental health disadvantages for people with ID. Key next steps have been identified that require interagency and whole-of-government action. The Royal Australian and New Zealand College of Psychiatrists has a key leadership role in addressing the mental health inequalities for this group.
Invited Speaker Abstracts
Innovation and Translation in Smoking Cessation Care for People with Mental Illness and Substance Use Disorders
B Bonevski
Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia
Background: Tobacco smoking is the largest contributor to the poor physical health of people with mental ill health (MI) and those with substance use (SU), which the first National Mental Health Report Card in 2012 accurately described as a ‘national disgrace’. People living with MI and people with SU typically die 10–20 years earlier than the general population, largely due to smoking-related diseases. They are twice as likely to have cancer, five times as likely to have cardiovascular disease and six times as likely to have asthma as people with no mental health condition. The massive contribution of smoking to their disease burden reflects a complex combination of clinical, behavioural and psychosocial factors that make smoking cessation particularly challenging.
Smokers with MI and SU are as motivated to quit smoking but receive less encouragement to quit from health professionals and are less likely to succeed when they try. Evidence-based smoking cessation interventions are underutilized by smokers with MI and SU, and there are remarkably few programmes that specifically cater for people with MI and SU. There is an urgent need to develop research-informed and highly accessible, appropriately tailored cessation services for smokers with MI and SU.
Objectives: This presentation will provide a research update on the latest developments in smoking cessation treatments for people with MI and SU and their use in practice.
Voices, Visions and Cultural Diversity: Some Reflections from a Māori Healing and Psychiatry Partnership
W NiaNia1, A Bush2
1Te Kuwatawata, Gisborne, New Zealand
2Te Whare Marie, Wellington, New Zealand
Background: Experiences such as hearing voices and seeing visions are often viewed in psychiatric practice as psychotic until proven otherwise. However, indigenous peoples often have their own explanations.
Objectives: This presentation will outline the socio-historical context to this Māori healing and psychiatry partnership and describe some Māori accounts of such experiences. It will illustrate differing Māori healing and psychiatry perspectives on the nature of these experiences with accounts from young people about their voices, visions and other perceptual experiences and the impact on them of a combined Māori healing and psychiatry approach to their mental health care.
Conclusions: Collaboration between Indigenous healers and psychiatrists can offer indigenous young people and their families more appropriate psychiatric assessment and treatment when cultural or spiritual experiences are suspected.
Sexual Sadism – The Role of Psychiatry in Understanding, Assessing and Treating Those Who Are Sexually Aroused By Hurting Others
R Darjee
1,2
1Victorian Institute of Forensic Mental Health (Forensicare), Melbourne, Australia
2Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Australia
Background: Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) and International Classification of Diseases, eleventh revision (ICD-11) include ‘sexual sadism disorder’ and ‘coercive sexual sadism disorder’, respectively, as paraphilic disorders, the essence of which is sexual arousal through inflicting psychological or physical pain on others, which is damaging to self or others.
Objectives: This session will give an overview of recent advances in the understanding of the nature, aetiology, assessment, treatment and management of sexual sadism, particularly as it relates to serious sexual violence.
Methods: Following a historical overview, I will outline recent research and developments in clinical practice and give recommendations regarding the role of psychiatrists in identifying, assessing and treating sexual sadism.
Findings: Sexual sadism has been recognized since the 19th century but is best viewed as the extreme end of a continuum of coercive and aggressive sexual behaviour. Consenting borderline personality disorder and sexual masochism is not a clinical issue or concern: sexual sadism leading to sexual assault, rape or murder is. Identification and assessment is improved by using crime scene behavioural rating scales; sexual sadism has important implications in risk assessment; anti-libidinal medication has an important role in treatment.
Conclusions: Psychiatry has an important role, alongside other disciplines and agencies, in the management of offenders with sexual sadism. Anti-libidinal medication has a key role in the treatment of most cases.
The Neurobiology of Attachment (Why Is Love So Dangerous?)
LF Koopowitz
1,2
1The University of Adelaide, Adelaide, Australia
2South Australian Brain Injury Rehabilitation Services, Adelaide, Australia
The most intimate relationship we will ever have will be with the person whose uterus provided the milieu for our gestation. As soon as we are separated from that uterus, our developing brain may be able to monitor our survival needs but is totally reliant on our caregivers for our actual survival. Caregiver unavailability (which may be experienced as abandonment) is thus a potential death sentence. Even the most wanted baby will have to experience times of caregiver unavailability. Does the intimacy of our most intense post-pubertal loving relationships confuse our already potentiated neural networks? Could this uncover our already primed fear of abandonment? What are the implications for both the lover and the loved?
Different Functional Neurological Disorders – Are They the Same Disease?
A Lehn
1,2
1Mater Centre for Neurosciences, Brisbane, Australia
2Princess Alexandra Hospital, Brisbane, Australia
Background: Patients who present with physical symptoms for which no disease pathology can be found are common in medical practice. In neurology outpatient clinics, patients with functional neurological disorders (FNDs) are the second most common reason for referral after headaches. Common presentations of FNDs include dissociative attacks (causing periods of altered or loss of consciousness and/or abnormal movements resembling epileptic seizures), functional movement disorders such as functional tremor as well as sensory disturbances.
It is unclear whether the various functional symptoms patients present with are due to separate disorders or whether they are different presentations of the same underlying processes.
Methods: After discussing the common clinical features of FNDs this talk discusses underlying processes, similarities and differentiating factors.
Findings: FNDs are a fascinating area of clinical work and research. Regarding underlying (psycho)pathology, there are more similarities than differences between functional symptoms.
Conclusions: Although there are some differences between underlying factors, a significant overlap is seen on cross-sectional studies. However, we still need to learn more about the natural history of functional symptoms through prospective studies.
Mental Health Development in the Asia-Pacific: Current Trends and Future Directions
C Ng
1,2
1The University of Melbourne, Melbourne, Australia
2The Melbourne Clinic, Melbourne, Australia
Across the Asia-Pacific, which is characterized by rapid economic and technological development, less than half of those affected by mental illness receive any treatment. A recent Asia-Pacific Mental Health Integration study, which measures performance relative to integration, examined the extent to which community-based treatment and integration support are provided for people with mental illness. Within the region, mental illness causes a significant health and socio-economic burden, which on average accounts for more than 20% of total years lived with a disability (LYDs). Consequently, the Asia-Pacific Economic Cooperation (APEC), a multilateral forum representing 21 member economies that comprise about 2.8 billion people and half of world trade, has agreed to address mental health issues and promote investment for action. The APEC Digital Hub for Mental Health (Digital Hub) is the coordinating centre for the APEC Roadmap to Promote Mental Wellness in a Healthy Asia Pacific (2014–2020). Implementation of the Digital Hub will heighten exchange and dissemination of best practices and innovations in mental health partnerships and provides an opportunity to enhance government and public recognition on the importance of strengthened investment in mental health to support economic growth. Overcoming the regional gap to deliver community care requires strong mental health policy implementation, consistent efforts and sustainable integration of all sectors to meet the diverse needs of people living with mental illness.
References
Ng CH (2018) Mental health and integration in Asia-Pacific. British Journal of Psychiatry International 15(4): 76–79.
Ng CH, Goodenow M, Greenshaw A, et al. (2017) APEC digital hub for mental health. The Lancet Psychiatry 4(3): PE3–E4. DOI: 10.1016/S2215-0366(17)30034-2.
Death, Voluntary Assisted Dying and the Psychiatrist: A Hypothetical
C Peisah1,2, C Ryan2, AD Macleod3
1The University of New South Wales, Sydney, Australia
2The University of Sydney, Sydney, Australia
3The University of Canterbury, Canterbury, New Zealand
Psychiatrists have unique clinical roles in the area of death and dying. This is all the more so in the light of the Victorian Voluntary Assisted Dying Act 2017 due for commencement in 2019, and active bills and parliamentary inquiries in New Zealand, Australian Capital Territory and Western Australia. In this hypothetical we will use a range of case scenarios to highlight key ethical and clinical issues around death and dying, and particularly voluntary assisted dying. We will explore some of the myths around dying held by the medical profession and the community alike, the importance of understanding and respecting will and preferences, the assessment of capacity, screening for undue influence and voluntary assisted dying in the context of neurodegenerative disorders and mental illness.
Autoimmune Diseases Presenting as Complex Mood Disorders
E Scott1,2, FM Leweke2,3, C Jones4, R Dale2,5, D Brown6, S Blum7, J Scott8, A Harris6, S Cripps2, IB Hickie2
1University of Notre Dame, Sydney, Australia
2The University of Sydney, Brain and Mind Centre, Sydney, Australia
3Central Institute of Mental Health, Heidelberg University, Medical Faculty Mannheim, Mannheim, Germany
4University of Melbourne, Melbourne, Australia
5Kids Neuroscience Centre, Children’s Hospital at Westmead, Sydney, Australia
6The University of Sydney, Westmead Institute for Medical Research, Sydney, Australia
7Princess Alexandra Hospital, Brisbane, Australia
8The University of Queensland, Brisbane, Australia
Background: Autoimmune-associated encephalitis has increasingly been identified among young people with atypical neuropsychiatric syndromes. These syndromes can present with psychotic features, cognitive impairment, major mood disturbance and seizures or abnormal movements.
Objectives: We aim to improve screening of patients, and the functional outcomes in patients presenting with autoimmune-associated subacute atypical neuropsychiatric syndromes, and to gain a deeper understanding of the relationships between immune activation and atypical variants of major mood disorders.
Methods: Recently, international criteria have been established for the clinical diagnosis of autoimmune encephalitis. We have used this template to develop analogous clinical criteria for possible and probable clinical cases of autoimmune-associated major mood disorders. We aim to early initiate relevant immune therapies for autoimmune-associated major mood or psychotic disorders, by establishing an adjunctive, sequential and personalized immune therapy. Relevant assessment and intervention protocols will be developed through a collaborative process with patients, family members and carers.
Findings: Currently, there is an absence of clear guidelines for the management of these patients resulting in a delayed treatment and compromised clinical outcomes. Further, one challenge in developing treatment recommendations has been the very low prevalence of this disorder. Thus, a comprehensive assessment, a consideration of new therapeutic approaches and an incorporation of new perspectives on secondary prevention of adverse outcomes is needed.
Conclusions: The establishment of a standardized diagnostic protocol for autoimmune encephalitis will allow for efficient use of health resources and ensure patients with autoimmune-mediated psychiatric symptoms are detected early to prevent delays in diagnosis and treatment.
Free Will versus Psychiatry
S Stankevicius
1.2.3
1Section of History, Philosophy and Ethics of Psychiatry, Royal Australian and New Zealand College of Psychiatrists, Australia
2Toowong Private Hospital, Brisbane, Australia
3University of Queensland, Brisbane, Australia
Background: Folk notions of ‘free will’ depend on our viewing one another as autonomous persons, capable of taking more than one possible course of action under a given set of circumstances. Debate surrounding free will typically hinges on two points of contention: whether our common ideas of free will are correct and whether the idea of free will has any practical significance, regardless of its existence.
Objectives: This talk aims to dispel myths surrounding the idea of free will. Furthermore, it intends to show that by acknowledging these myths we will move towards an improved psychiatric specialty and society.
Methods: Philosophical and scientific matters related to free will are explored and discussed in a simple and accessible manner. These issues and their implications are examined specifically in relation to psychiatry.
Findings: Free will is an illusion. This is of profound importance, as our failure to connect with this fact contributes to the stigma of mental health patients, is responsible for the shame that mental health patients feel about themselves and negatively affects how psychiatrists view mental illness.
Conclusions: By acknowledging that free will is an illusion, we realize there are reasons for how people think and act, whether or not we can identify those reasons. This can be truly transformative – not only for psychiatry but for every single one of us.
Trauma, Dissociation and Personality Disorder
J Stevenson
1,2
1HammondCare, Greenwich, Australia
2The University of Sydney, Sydney, Australia
Background: We are becoming increasingly aware that childhood abuse in families, institutions, schools, sporting clubs and dancing schools is rampant and the sequelae are lifelong and pervasive, causing damage to the personality resulting in mental symptoms, post-traumatic stress disorder (PTSD), dissociative experiences, mood disorder, anxiety, stress, interpersonal problems and occupational instability.
Objectives: This session will examine the prevalence of trauma, dissociation and personality pathology in 240 psychiatric inpatients, aged from 18 to 100 years, admitted primarily for the treatment of Axis I disorders; the outcome in terms of symptoms, function, well-being, coping strategies, mental and physical morbidity, social supports and readmission rates are assessed.
Methods: Axis I diagnosis was made on admission; Axis II diagnosis was made on discharge. A range of measures were administered on admission, discharge, and 6-month follow-up, comparing those patients with personality pathology with those without.
Findings: Personality disorder and histories of trauma are common in our inpatient population across all Axis I diagnoses. Moreover, trauma affects symptom severity, function, coping strategies, well-being, overall outcome and readmission. Personality pathology is correlated with all forms of childhood abuse, physical, emotional and sexual as well as emotional and physical neglect.
Conclusions: Personality pathology and trauma need to be explored in all patients and taken into account in management.
Pre-Congress Workshop Abstracts
Attachment-Informed Psychotherapy with Disturbed Adolescents
J Haliburn
1,2,3
1Private Practice, Drummoyne, Australia
2Division of Psychological Medicine, University of Sydney, Australia
3Complex Trauma Unit, Westmead Hospital, Australia
Background: Considerable attention is paid to infant–caregiver attachment status, but as the child grows older, that problematic behaviour or dysregulated mood could result from problematic attachment, is farthest from the child psychiatrist’s mind, particularly when diagnosis and pharmacotherapy are prioritized. That is not to say that pharmacotherapy has no place. Efforts must be made to re-establish relational continuity for the child who is experiencing discontinuities in thinking, feeling and behaving. Attachment can be a source of trauma, which is not to say that the parent is bad in all instances. Attachment difficulties affect resilience, increase vulnerability to further traumatization (complex trauma) and increase the number of adverse childhood experiences (ACES).
When adolescents present with unremitting, inexplicable, non-responsive symptoms they are often diagnosed as psychotic, with major depression, or anxiety, with no reference to trauma and relational problems.
Objectives: This session will show assessment of the parent(s)–adolescent relationships are as important as other aspects of assessment and psychotherapy, and with an attachment focus are shown to bring about change.
Methods: Discussion of attachment, types of attachment, neurobiology of attachment and trauma, assessment of an adolescent’s presentation and state of mind with respect to attachment and a phase approach to psychotherapy.
Findings: Improvement in symptoms, particularly dissociation, occurs.
Conclusions: Traumatic attachment accompanied by effects of later trauma present complex psychopathology in adolescence, including dissociation, depression, disturbed behaviour, anxiety and quasi-psychotic symptoms. Psychotherapy, in addition to pharmacotherapy in some instances, potentially improves symptoms and helps re-establish the adolescent’s continuity of experience and relatedness with others and the world.
References
Bretherton I (1992) The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology 28: 759–775.
Gomez-Perales N (2015) Attachment-Focused Trauma Treatment for Children and Adolescents: Phase Oriented Strategies for Addressing Complex Trauma Disorders. New York, USA/London, UK: Routledge.
Haliburn JM (2013) Traumatic attachment as adaptation: the biopsychosocial impact. In: Van Leeuwen T, Brouwer M (eds) Psychology of Trauma. New York, USA: Nova Science Publishers, pp. 1–35.
Metzler M, Merrick M, Klevens J, et al. (2017) Adverse childhood experiences and life opportunities: shifting the narrative. Child and Youth Services Review 72: 141–149.
Stevenson J, Haliburn J and Halovic S (2016) Trauma, personality disorders and chronic depression: the role of the conversational model in the psychoanalytic psychotherapy of treatment resistant depression. Psychoanalytic Psychology 30(1): 23–41.
Being a Volunteer in Global Mental Health: The UK, Australian and New Zealand Experience
S Thomson1, P Robertson2, A Bush3, N Kowalenko4, B Hoadley5, GL Tuitama6, M Allen7, A Paul8
1Royal College of Psychiatrists, London, UK
2University of Melbourne, Melbourne, Australia
3Health Pasifika Mental Health Service, Capital Coast District Health Board, Porirua, New Zealand
4University of Sydney, Sydney, Australia
5Northern Sydney Local Health District and South Eastern Sydney Local Health District, Sydney, Australia
6Head of Department, Ministry of Health, Samoa
7Fiji National University, Suva, Fiji
8Monash Health, Melbourne, Australia
Background: The Royal College of Psychiatrists UK has been active in global mental health and supports a volunteer programme within their college, linking members and international mental health services and practitioners. They have often been using The World Health Organization (WHO) mhGAP (2019) as an evidence-based manual for training practitioners in the assessment and management of common mental, neurological and substance use disorders. The WHO mhGAP is now used worldwide by psychiatrists to train clinicians in various settings, mainly low and middle-income countries (LMICs). The Royal College of Psychiatrists UK has a successful volunteer scheme of international training with the mhGAP manual.
As part of the growing interest in international work, the Faculty of Child and Adolescent Psychiatry (FCAP) has actively sought to engage in forming partnerships in global Child and Adolescent Mental Health (CAMH) predominantly in the Asia–Pacific region. Since 2012 the FCAP has actively supported CAMH in the Asia–Pacific region resulting in a series of projects in Vanuatu, Fiji, Hong Kong, Papua New Guinea and Sri Lanka.
Objectives:
To engage the interest of college members in international work and partnerships in training at senior and primary care levels and to improve their skills and confidence to do this.
To introduce the issues around successful volunteering.
To update college members about current engagement and volunteer work in the Asia–Pacific region by members and invite discussion.
To introduce WHO mhGAP and explore its potential role in developing collaborative relationships between countries such as United Kingdom, Australia and New Zealand and LMICs. Its value will be elucidated through interactive teaching methods using mhGAP components. A more detailed exploration will be undertaken of some of the mhGAP modules including depression and child and adolescent modules.
Finally, senior mental health leaders from Pacific nations will join the group and bring their experience of mhGAP implementation within their countries. This will allow some broader interactive discussion and engagement.
Methods: Descriptive and interactive discussion and teaching methods.
Findings: Partnerships and engagement between Australian and New Zealand child and adolescent psychiatrist with regional partners in mental health are now occurring. Alongside the experience of the Royal College of Psychiatrists UK in global mental health, the required skills and competencies of psychiatrists undertaking international work is better able to be mapped. Evidence from studies in the United Kingdom suggest that this work brings considerable personal and professional benefits to both the psychiatrists and their trainees and practitioners in LMICs.
Conclusions: Current global mental health projects in the Asia–Pacific region and elsewhere have developed ways to improve skills and confidence in the required knowledge and competencies for psychiatrists undertaking international work. The WHO mhGAP offers an acceptable and evidence-based training package.
Reference
World Health Organization (2019) WHO Mental Health Gap Action Programme (mhGAP). Available at: http://www.who.int/mental_health/mhgap/en/.
My CPD: Achieving Your Mandatory Continuing Professional Development
W de Beer1,2, R Harvey2, E Moore2, L Salmon2,3, R Dotson2, M Patton2, B Lloyd2, J Topp2, G Young2, N Jeyasingam2, MO’Connor2, K Baheti2, S Sinha2
1Waikato District Health Board, Hamilton, New Zealand
2Committee for Continuing Professional Development, RANZCP
Background: From January 2017 completion of the Continuing Professional Development (CPD) programme has become mandatory for members of the Royal Australian and New Zealand College of Psychiatrists. The programme has been changed to include elements such as practice development, quality improvement and review that are expected to be required for any future recertification or revalidation regulations that may be introduced. In addition, the online CPD system My CPD was launched in April 2017.
Objectives: This session will increase members’ understanding of how adults learn in the workplace, the CPD programme and the use of the online My CPD system. A particular focus is to explain the audit process and how to achieve a paperless and compliant audit and to explain the requirements of Section Three – Practice Improvement.
Methods: A combination of didactic presentations, hands-on use of the My CPD online system and question and answer, will be used.
Working Dialogically With Networks of Young People Experiencing Psychosis
C Thorpe, R Barbara-May
Alfred Health, Melbourne, Australia
Background: The headspace Youth Early Psychosis Program (hYEPP) in Melbourne has been implementing an Open Dialogue approach to care and treatment of young people and their families. Open Dialogue offers exciting possibilities for improving the way services manage and treat mental illness, while incorporating mandated policy requirements for a shift to person-centred and needs-adapted care.
Objectives: This workshop will provide participants with an introductory insight into the theoretical underpinnings of the Open Dialogue approach. It will include hands-on activities to enable participants to gain a greater appreciation of the practical elements of dialogical practice.
Methods: This workshop will include both experiential and theoretical elements to enable participants to understand the elements of dialogical practice.
Findings: Dialogical approaches are a respectful means to create a person-centred, family-orientated, collaborative and needs-adapted approach to service delivery. We consider the practical processes of organizational change required as well as considering the experiences of young people, families, clinicians and management in service delivery change to implement dialogical approaches.
Conclusions: Shifting a clinical youth mental health service towards a dialogical approach to treatment requires a significant shift in staff understanding as well as practice. This workshop will enable participants to appreciate the practical implications for shifting towards dialogical practice as well as the theoretical underpinnings and the practical skills required to enable the approach to be successfully delivered.
Leadership under Duress: Developing a Culture of Learning and Improvement for Better Patient Care
N Gibson1, J Crawshaw2
1Office of the Chief Psychiatrist, Perth, Australia
2Ministry of Health, Wellington, New Zealand
Background: Leadership in mental health often feels like it’s about ‘keeping the wolf from the door’ – high patient numbers, limited resources and minimal leadership support. While regulation and assurance processes are ever-present, there is good evidence that a culture of learning and quality improvement within services is strongly linked to better patient outcomes. How do busy clinical leaders work with their staff to build a sustainable quality culture?
Objectives: This session aims to identify the components of value of a learning culture and quality improvement to team function and patient outcomes, assist understanding of current evidence and strategies around embedding a quality improvement culture and then applying the theory to a real-life clinical service setting.
Methods: This session will review current best practice in embedding a learning and quality culture. This will be augmented with audience participation in a practical hypothetical scenario.
In the Shadow of Osheroff: Patient’s Right to Effective Treatment in Trauma-Informed Care
G Halasz
Monash University, Melbourne, Australia
Background: The case of Osheroff v. Chestnut Lodge generated much controversy in legal, ethical, psychiatric and lay circles (Klerman, 1990). In the aftermath, intense debates proposed the ‘right of the patient to effective treatment’. I suggested that children have a right to ‘empathic listening’ (Halasz, 1996), a position enshrined by Bloch and Green (2006) who argued for a new ethical framework for psychiatry as ‘a willingness to empathize with the feelings of the anguished parties and the effort to imagine what each of them is experiencing, part of the virtuous process of contributing to a climate of trust’ (p. 11).
Objectives: This session aims to introduce the clinical ‘nuts and bolts’, principles, of treatment-informed care (TIC) in the doctor–patient transference relationship in traumatic situations, beyond empathy, where the doctor is cast into four possible roles: victim, perpetrator, witness or rescuer.
Methods: After nearly 30 years, the Shadow of Osheroff case demands we revisit the construct of ‘vicarious trauma’ (Klerman, 1990) to deliver ‘effective treatment’ in today’s TIC culture.
Findings: I conclude the doctor’s responsibility – and unavoidable conflict of duality – includes serving the interest of both the patient’s needs alongside the doctor‘s self-care.
Conclusions: This need to revisit and to revise the doctor–patient dynamics in TIC arises as a natural consequence of our deeper understanding of the bidirectional nature of ‘relational trauma’. Doctors who neglect or fail to adopt new ‘self-care’ attitudes risk increasing iatrogenic pathologising of our patients.
References
Bloch S and Green SA (2006) An ethical framework for psychiatry. British Journal of Psychiatry 188: 7–12.
Halasz G (1996) The rights of the child in psychotherapy. American Journal of Psychotherapy 50(3): 285–297.
Klerman GL (1990) The psychiatric patient’s right to effective treatment: implications of Osheroff v. Chestnut Lodge. American Journal of Psychiatry 147(4): 409–418.
Approaching the Ranzcp Psychotherapy Written Case Assessment
A Pethebridge
Case History Subcommittee, Committee for Examinations, RANZCP
Background: The Psychotherapy Written Case (PWC) provides the opportunity for the trainee to develop their ability to communicate their assessment, formulation and management of a person with psychiatric problems in written professional English and to provide trainees with an opportunity to demonstrate their capacity to reflect on their clinical involvement with a patient, the contribution of supervision and on their role as part of the broader mental health system.
Objectives: This workshop is designed to assist candidates to understand the nature and standard of the PWC assessment.
Methods: The workshop will include presentations by members of the Committee for Examinations regarding the common challenges faced by candidates and to promote the development of strategies for successfully passing this assessment. In this workshop attendees will be introduced to:
Background to PWC learning objectives
The PWC marking pro forma
Examiners’ commonly identified pitfalls with the PWC
Tips for trainees submitting a PWC
Tips for passing the PWC.
Substantial Comparability Assessor Accreditation/Reaccreditation Workshop
L Rose, D Fenn
Substantial Comparability Assessment Review Panel, Royal Australian and New Zealand College of Psychiatry
Background: Specialist International Medical Graduates (SIMGs) who are assessed by the Royal Australian and New Zealand College of Psychiatry (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 full-day workshop is designed for:
Fellows who have been approved to become Substantial Comparability assessors and require the appropriate accreditation
Existing Substantial Comparability assessors who wish to refresh their skills to maintain their accreditation.
The workshop involves pre-reading and self-calibration using provided resources.
Objectives: This session will assist those aiming 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.
Clinical Supervision Workshop for RANZCP Trainees
P Bailey
Psychotherapy and Counselling Federation of Australia, Australia
Australian Clinical Supervision Association, Australia
New Zealand Association of Psychotherapists, New Zealand
Background: Training and working within mental health can be hazardous to one’s welfare. In this workshop, facilitated by psychotherapist Paul Bailey, we will reflect upon the impact of processes such as vicarious trauma and burnout and the role clinical supervision plays in this context. This workshop is designed for Royal Australian and New Zealand College of Psychiatrist trainees and will focus on what it is to be a supervisee within a clinical supervision setting.
Paul Bailey qualified as a psychotherapist at the Minster Centre, London, in 1982. Paul has worked alongside Robin Shohet and Peter Hawkins, authors of the classic text Supervision in the Helping Professions. Paul has vast experience in this field, including the development and facilitation of clinical supervision training workshops for Queensland Health for more than 5 years.
Objectives: This workshop will allow participants to engage actively in the process of group clinical supervision in a safe, respectful and confidential space. Participants will learn more about the core skills and common processes of clinical supervision. This will include identifying how we each deal with our own vicarious trauma activation and/or propensity for burnout.
Methods: Small group workshop for trainees on clinical supervision.
Conclusions: Clinical supervision is a fundamental component of psychiatric training. When done well, clinical supervision offers an important opportunity to explore issues relevant to our welfare as doctors. Understanding and developing skills as a supervisee is an important step in being able to participate in a meaningful way with this process that is core to our helping profession.
Suicidal Behaviour and Crisis Management for Borderline Personality Disorder
S Rao
1,2
1Spectrum, Personality Disorder Service for Victoria, Melbourne, Australia
2Monash University, Melbourne, Australia
Background: Borderline personality disorder (BPD) is a serious and complex mental illness that affects at least 1% of the population. BPD is common in psychiatry practice, with 20% prevalence in inpatient settings and 10% in community clinics.
Unfortunately 10% of patients with BPD suicide and 85% self-injure. Chronic suicidal ideation, repeated suicidal gestures, threats and attempts are characteristic of BPD. About 70% of BPD patients will attempt suicide at least once in their life time. About 85–90% of patients with BPD make suicidal threats or gestures. These behaviours create significant anxiety in treating clinicians.
This half-day workshop will provide an overview of several key concepts related to suicidal and non-suicidal self-harm behaviours in BPD and discuss crisis management strategies for clinicians.
Objectives: This workshop aims to discuss suicidality and crisis management of BPD using the National Health and Medical Research Council (NHMRC) Clinical Practice Guideline for the Management of Borderline Personality Disorder (2012) and the clinical wisdom developed at Spectrum, Centre of Clinical Excellence for BPD, Victoria, in the last two decades.
The workshop aims to discuss the suicidal and non-suicidal self-harm behaviours and crisis management strategies for BPD.
Methods: The workshop will discuss:
Assessment of management of crisis in BPD with real-life case examples.
Factors that are specific to suicide and self-harm behaviours in BPD.
Crisis management in the context of emergency departments and psychiatric inpatient facilities.
Conclusions: The workshop hopes to improve the understanding competence of clinicians in evaluation and clinical management of suicidal behaviours and emotional crisis in BPD.
Psychiatry Update – Child and Adolescent Psychopharmacology: New Treatments, New Diagnoses
M Turner
University of Adelaide, Adelaide, Australia
Background: As child psychiatry moves ahead with the times, a better and clearer understanding of pharmacology help us make better clinical decisions. This workshop looks at the recent and available evidence to help make decisions around pharmacological treatment of children and adolescents and how to make the decisions around medication prescribing and monitoring.
Objectives: This workshop will cover:
Selective serotonin reuptake inhibitor (SSRI) and selective norepinephrine reuptake inhibitor (SNRI) medication.
Antipsychotics in children.
Mood stabilizers in children and their use.
Sleep and management of sleep with medication.
Autism spectrum disorder and challenging behaviour management – what helps and what doesn’t.
Obsessive–compulsive disorder and Tourette’s disorder: use of antipsychotics and SSRIs.
New findings around psychogenomics and working with children and adolescents with translocation and duplication genetic syndromes.
First Do No Harm: To Yourself (And Others)
C Barnes1,2,3, J Orman1
1Black Dog Institute, Sydney, Australia
2University of New South Wales, Sydney, Australia
3Royal North Shore Hospital, NSLHD, Sydney, Australia
Background: In 2013, Beyond Blue published the results of its National Mental Health Survey of Doctors and Medical Students (Beyond Blue, 2013). They found that the level of very high psychological distress was significantly greater in doctors in comparison to the general population and other professionals (3.4% vs. 2.6% vs. 0.7%). The results were deeply concerning but unfortunately not that surprising to those who have direct contact supervising junior doctors in their various specialties. This has led to several specialist colleges, including the Royal Australian and New Zealand College of Psychiatrists (RANZCP), to start to prioritize the mental health and well-being of its members and affiliates. In November 2017, NSW Health published a junior medical officer (JMO) well-being and support plan that seeks to implement 10 practical initiatives over the next 12 months, which will hopefully make seeking help and support easier for JMOs which, in turn, will hopefully filter to more senior staff who are also at risk. There is now research that has identified workplace interventions that can promote mental health and well-being, and how this can be implemented in a healthcare setting with its specific challenges needs to be considered (Petrie et al., 2018).
Objectives:
To increase awareness of challenges to mental health and well-being faced by psychiatrists and other medical professionals throughout their career pathways and the areas where support can be accessed.
To increase understanding of aspects of work and a workplace that can be promoted to increase well-being at work and reduce risk of development of mental health issues and those aspects of work that present a psychological risk factor.
To increase understanding of personal stress signals and develop a self-care plan and to increase skills around addressing mental health concerns about others in the workplace, especially trainees and colleagues.
Methods: As well as didactic information sharing, the workshop will be designed to encourage small group discussion around the topics outlined and aims to make the attendee familiar with a variety of tools and resources available online and through smart-phone technology.
Conclusions: The RANZCP represents doctors who specialize in the diagnosis and treatment of mental illness. As psychiatrists and psychiatric trainees, the CanMEDs model defines and assists us to understand our various roles and what is expected of us in the various places we work. This workshop is aimed to increase awareness and skills in another area which is promoting mental health, our own, and how to support others around us especially our trainees. It will aim to give insights into the research evidence that now exists around creating mentally heathy workplaces and how we might promote these practices as supervisors and into own workplaces, whatever they may be.
References
Beyond Blue (October 2013). National Mental Health Survey of Doctors and Medical Students. Available at: https://www.beyondblue.org.au/docs/default-source/research-project-files/bl1132-report—nmhdmss-full-report_web.
Petrie K, Joyce S, Tan L, et al. (2018) A framework to create more mentally healthy workplaces: a viewpoint. Australian and New Zealand Journal of Psychiatry 52(1): 15–23. DOI: 10.1177/0004867417726174.
Approaching the RANZCP Scholarly Project Assessment
J Ferguson
Scholarly Project Subcommittee, Committee for Examinations, RANZCP
Objectives: This workshop is designed to assist candidates to understand the nature and standard of the Scholarly Project submission and assessment.
Methods: The workshop will include presentations by members of the Committee for Examinations regarding 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; and
tips for passing the Scholarly Project.
Welcome to the Twitterverse
B Veness
Alfred Health, Melbourne, Australia
Background: This year marks the 10th anniversary of the Royal Australian and New Zealand College of Psychiatrists joining Twitter (@RANZCP). Twitter Inc. reports an average of 335 million monthly active users worldwide as of July 2018. For the same month in Australia, there were approximately 4.7 million monthly active Twitter users – equating to almost one in five Australians. In June 2013, the noun and verb ‘tweet’ (in the social media sense of the word) was officially included in the Oxford English Dictionary. As in previous years, the 2019 RANZCP Congress in Cairns will have a conference hashtag and delegates will be encouraged to tweet about what they see, hear and learn. This interactive workshop is an opportunity for delegates to learn about and discuss social media’s role in psychiatry and to finally join the Twitterverse themselves.
Objectives:
Appreciate the key risks and benefits of doctors engaging in social media.
Learn how to set up a Twitter account and use all its key features, particularly hashtags in the context of medical conferences such as Congress.
Develop an understanding of the Medical Board of Australia’s social media policy and the Australian Medical Association’s ‘Social Media and the Medical Profession’ guide.
Conclusions: Twitter offers psychiatrists new opportunities to learn, share information with colleagues, educate patients, enhance professional networks and have fun. It also comes with risks, and thus, it is important to know how to use the platform to both get the most out of it and prevent inadvertent harm.
References
Simpson J (2013) A Heads Up for the June 2013 OED Release [webpage], June 6. Available at: https://public.oed.com/blog/june-2013-update-a-heads-up-for-the-june-2013-oed-release/ (accessed 21 August 2018).
Twitter Inc. (2018) Q2 2018 Letter to Shareholders, July 27. Available at: https://investor.twitterinc.com/static-files/610f4a82-5b52-4ed9-841c-beecbfa36186 (accessed 21 August 2018).
Vivid Social – Social Media Agency (2018) Social Media Statistics Australia – July 2018 [webpage], August 1. Available at: https://www.socialmedianews.com.au/social-media-statistics-australia-july-2018/ (accessed 21 August 2018).
Clinical Update Abstracts
Clinical Update: Recent Advances in Attention-Deficit Hyperactivity Disorder
D Coghill1, C Middeldorp2,3
1University of Melbourne, Melbourne, Australia
2University of Queensland, Brisbane, Australia
3Child and Youth Mental Health Service, Children’s Health Queensland Hospital and Health Service, Australia
Background: Attention-deficit hyperactivity disorder (ADHD) is a common and complex neurodevelopmental disorder that affects about 5% of children and 2.5% of adults and is associated with a wide range of negative impacts. In Australia, ADHD has traditionally been treated by paediatricians; however, it is increasingly seen within psychiatric settings, and we need to ensure that our training keeps us well prepared.
Objectives: This session aims to present an update on recent advances in our understanding of ADHD and the evidence-based approaches to assessment and treatment across the lifespan.
Findings: Recent studies have started to throw light onto the complex causal pathways to ADHD. We are starting to identify specific genetic markers (G) and risk factors and the importance of environmental factors (E) and G × E interactions are becoming clearer. Imaging and cognitive studies are increasingly demonstrating biological heterogeneity. While complicating our understanding of ADHD on one level, it also presents possible approaches to personalizing treatments. The recommendations of evidence-based ADHD guidelines are increasingly convergent regarding medication treatments for ADHD; however, questions remain about long-term effectiveness and safety and the efficacy of non-pharmacological approaches. It may be more helpful to think about what these approaches can add to medication treatments. ADHD has a significant impact on families and the parents of those with ADHD often require support. We will discuss each of these issues commenting on new evidence, clinical decision-making and translation into practice.
Conclusions: ADHD is easy to treat but hard to treat well: this clinical update will provide options for optimizing outcomes.
Occupational Psychiatry: What is the Role of Work in the Aetiology of Common Mental Disorder?
S Harvey
Black Dog Institute, University of New South Wales, Sydney, Australia
Mental ill health is now the leading cause of long-term sickness absence and work incapacity in Australia and most other developed countries. Allegations of work or work practices causing mental illness are a common cause of civil legal disputes. However, in spite of this, there is relatively little consensus about which work factors are true risk factors for mental ill health and what, if anything, employers can do to protect the mental health of their staff. This presentation will provide a summary of what is known about workplace risk factors for mental ill health and, drawing on a number of recently published systematic reviews and randomized controlled trials, will describe an evidence-based framework for what employers can reasonably be expected to be doing to provide a mentally healthy workplace. The second part of the presentation will focus on a number of common points of contention in civil cases involving the workplace with a discussion about what the research evidence can tell us about these contentious issues.
Partnering With Police to Improve Outcomes in Mental Health Crisis Situations
E Heffernan1,2,3, C Meurk1,2,3, E Waterson1,3, M Steele1,2
1Queensland Centre for Mental Health Research, Brisbane, Australia
2The University of Queensland, Brisbane, Australia
3Forensic Mental Health Services, Metro North Health and Hospital Services, Brisbane, Australia
Background: Police are frequently the first to respond to an individual experiencing a mental health crisis. These situations often present a significant challenge for both parties. Access to mental health expertise in real time could help improve outcomes. Despite the frequency and significance of these situations, there is limited evidence to guide timely and effective collaborative police–mental health responses.
Objectives: This session aims to describe how mental health and police can collaborate to improve outcomes for people suffering a mental health crisis and outline evidence to inform the further development of such collaborations.
Methods: Unique models for police–mental health responses to emergency calls, and police negotiator events will be outlined. In addition, the findings arising from the Partners in Prevention study – a large data linkage study of demand, characteristics and outcomes, and an investigation of knowledge, skills, attitudes and confidence of police in these situations – will be presented.
Findings: Data on mental health and suicide-related crises in Queensland over the 3-year period, 2014–2017, will be presented. The role that police–mental health collaborations have played in responding to these events, and police views about their ability to respond effectively to mental health and suicide crisis situations, will be discussed.
Conclusions: Mental health crises involving police are extremely common. The experiences of delivering services and developing the evidence base have highlighted unique opportunities for future innovations to improve outcomes for individuals, families and services.
Clinical Update on Neuroimaging in Neuropsychiatry: Interactive Cases, Images and Discussion
JCL Looi
1,2,3
1Academic Unit of Psychiatry and Addiction Medicine, Canberra Hospital, Canberra, Australia
2ANU Medical School and Canberra Health Services, Canberra, Australia
3Neuropsychiatry Unit, Royal Melbourne Hospital and Department of Psychiatry, University of Melbourne, Melbourne, Australia
Background: Skilful use of neuroimaging is essential for diagnosis and management of psychiatric conditions.
Objectives and methods: This interactive clinical session will involve discussion of neuropsychiatric neuroimaging case-based series of interest to general psychiatrists, delivered through the Radiopaedia Web-based platform. The cases and images will be projected live on-screen in the session and discussed with the participants, facilitated and guided by the presenter.
Conclusion: Participants will gain improved skills in ordering, interpreting and integrating neuroimaging in clinical psychiatric practice, especially in relation to diagnosis and management.
Clinical Update in Neuropsychiatry: Five Things Which Have Surprised Me Recently
D Velakoulis
1,2
1Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Australia
2Melbourne Neuropsychiatry Centre, University of Melbourne, and Melbourne Health, Melbourne, Australia
Background: Neuropsychiatry is a broad clinical discipline that draws from psychiatry, neurology, medicine and investigational fields of medicine. Given the breadth of the clinical conditions, I am constantly coming across new developments or research findings that range from ‘that’s interesting’ through to ‘I didn’t expect that!’.
Objectives and methods: This presentation aims to share this new knowledge with psychiatry colleagues and identify the relevance to clinical practice across all of psychiatry.
Conclusions: I will aim to inform psychiatry colleagues of my ‘favourite’ new developments in neuropsychiatry and how these developments relate to our clinical work.
Combined Symposium Abstracts
Collaborative Care Model for Psychiatric Disorders among Older Adults Seen in Primary Care
P Dham1, N Kates2, K Saperson2, T Rajji3,4, C McAiney2,5, L Lourenco3, N Malik3, F Parascandalo2
1Gold Coast University Hospital, Gold Coast, Australia
2McMaster University, Hamilton, Canada
3Centre for Addiction and Mental Health, Toronto, Canada
4University of Toronto, Toronto, Canada
5University of Waterloo, Waterloo, Canada
Background: Given the increasing older adult population in the community, there is a need for effective models of care for psychiatric disorders in the primary care setting.
Objectives:
Understand the need for collaborative care models in psychiatry and existing gaps in implementation and research.
Discuss the implementation and evaluation of a collaborative model of care for depression, anxiety and mild cognitive impairment (MCI) in primary care settings in Canada.
Discuss the role of psychiatrists in the process of implementation and support of this model in primary care.
Methods: The symposium includes three presentations on the theme of collaborative care. We present the increasing need for such models, existing evidence and gaps in implementation and research. This is followed by a presentation of design, implementation and evaluation of a collaborative care model for depression, anxiety and MCI among older adults in a primary care setting. In this we discuss the baseline data and preliminary results. We end by a discussion on the role of psychiatrists in delivery of such a model and its impact on resource utilization.
Findings: There is evidence for collaborative care models in depression. However, multiple conditions, especially MCI, have not been addressed. Also, translation of findings from large-scale randomized controlled trials to implementation in the community has shown less consistent results. Our proposed model has been implemented in a variety of primary care settings in Ontario, Canada, which has helped to evaluate the differences based on practice location and type. It has been feasible to implement the model and has shown benefit especially in terms of access to specialist psychiatrist input and support.
Conclusions: It is feasible to implement the model in a variety of primary care settings with an efficient use of psychiatrist resource. However, there are differences in the mode of implementation based on the setting.
Presenter 1
Collaborative Care Models for Delivery of Mental Health Care in Primary Care Settings
N Kates
McMaster University, Hamilton, Canada
Background: With an increasing population of older adults in the community, the burden of mental health problems is also on the rise. Most common psychiatric conditions are depression, anxiety and cognitive impairment, and these are often complicated by co-morbid medical illnesses and psychosocial stressors. In this scenario, it becomes important for specialist psychiatric services to work in collaboration with primary care services, where these problems often present, to deliver the most effective form of care.
Objectives:
Describe the burden of mental health in primary care with a focus on the geriatric population.
Outline the existing evidence for the effectiveness of collaborative care models.
Discuss the gaps and future directions in research and implementation.
Methods, findings and conclusions: Large randomized controlled trials of collaborative care models have shown evidence of their benefits in terms of improved clinical outcomes and cost savings. However, implementation of the model outside of research settings has been a challenge with less consistent results. We identify the core components of a model for integrating mental health services within primary care and the keys to its success. These include multidisciplinary approach, structured means of communication among various stakeholders, use of treatment algorithms or integrated care pathways and regular monitoring and feedback.
Presenter 2
Collaborative Care Initiative for Mental Health Risk Factors in Dementia: Depression, Anxiety and Mild Cognitive Impairment
P Dham
Gold Coast University Hospital, Gold Coast, Australia
Background: Provision of mental health in collaboration with primary care is an important strategy that can help with early detection and improved care in older adults.
Objectives:
Describe the collaborative care model in primary care setting for diagnosis and treatment of depression, anxiety and mild cognitive impairment (MCI) in older adults
Understand the process of implementation and barriers to integration
Describe the impact of the model on diagnosis, initiation of treatment and outcomes.
Methods: Working with five primary care practices in two cities in southern Ontario, Canada, patients with MCI, depression and anxiety were identified. Case and comparison groups were identified based on their year of birth. They were screened for anxiety, depression, and MCI. If they reached a threshold level of symptom burden, cases were enrolled into the integrated care pathway (ICP arm) and the comparison group received treatment as usual (TAU).
The ICP offered evidence-informed treatment for the management of these syndromes in a routine, algorithmic fashion. All enrolled patients were provided with general interventions that addressed lifestyle and medical factors and linked to brief psychotherapy as needed. Based on symptom severity, evidence-based pharmacotherapy was offered using a standardized titration schedule. Collaboration was built into the ICP using electronic medical records and specialist psychiatrist input. The participants had repeat assessments every 6 months for up to 24 months.
Focus groups with the clinics and minutes from meetings regarding the ICP were documented to examine the process of implementation, adaptations needed, and to identify barriers or facilitators to implementation.
Findings and Conclusions: The results of study will focus on the baseline characteristics of enrolled participants and preliminary analysis. We will also discuss the process of implementation and barriers encountered. This is further discussed in the context of available evidence on collaborative care.
Presenter 3
Role of a Psychiatrist in Delivery of a Collaborative Care Model for Psychiatric Disorders in Primary Care
K Saperson
McMaster University, Hamilton, Canada
Background: In primary care settings, given the co-morbid medical issues, delivery of psychiatric care for older adults can be complicated, and access to psychiatric consultation is frequently identified as a problem by primary care physicians, along with challenges in communication and ongoing support.
Objectives:
Describe the role of a psychiatrist in the delivery of a collaborative care model for psychiatric disorders in a primary care setting
Compare the role of a psychiatrist in delivery of collaborative care model and other models of care for psychiatric disorders in a primary care setting.
Methods, Findings and Conclusion: This presentation describes how a psychiatrist has been integrated into five family practices in Southern Ontario, Canada, to assist with the management of seniors’ mental health issues. We discuss the role of a psychiatrist in delivering a collaborative care model in primary care and their different activities, including direct care, indirect care, monitoring populations, education, system navigation and telephone back-up in-between visits, and how they work with/fit into the primary care team. We also discuss how a psychiatrist can help in the efficient use of specialist psychiatry resources and support primary care services in the most difficult task of managing older adults with psychiatric illnesses.
Management of Behaviours of Concern in a Public Hospital Setting
I Rauchberger1, F Whitecross1, E Symons1, B Hobbs1, C Breadon1,2
1Alfred Health, Melbourne, Australia
2Monash University, Melbourne, Australia
Background: Behaviours of concern (BOC) have come into more focus in public hospitals in recent years with an increased focus on violence and aggression. The experience of occupational violence can cause significant physical and psychological harm to staff, and impact patient care. Patients observing or being a victim of aggressive or violent behaviour can be traumatized, potentially worsening distress. Beyond aggression, other BOC occur and place the patient and others at risk of harm.
Objectives: This session will identify BOC that are prevalent in a public hospital setting and review some novel interventions that have been adopted to address BOC.
Methods: Review of BOC across three settings of patient care, in particular the Emergency Department (ED), the Acute Psychiatric Ward and the Surgical Wards of a Tertiary Hospital. We review the effectiveness of a BOC call-out process in the ED, Psy–BOC calls in the psychiatric ward setting and a De-escalation intervention Early Response Team (DiVERT) call in the surgical wards.
Findings: There are significant levels of BOC across each setting of this public hospital. The use of a standardized team approach in the ED, including the use of BOC assessment rooms, has led to improved patient care, reduction in use of security staff and increase in staff confidence in managing BOC. Psy-BOC calls have led to a significant reduction in restrictive interventions, aggression, absconding, sexual vulnerability and self-harm on the acute psychiatric unit. The DiVERT call-out has resulted in earlier therapeutic interventions and a reduction in Code Grey incidents in surgical wards.
Conclusions: BOC are prevalent in a general hospital setting. Taking a systematic approach to the management of BOC leads to reductions in BOC and improved outcomes.
Presenter 1
Understanding Behaviours of Concern (BOC) and Improving the Management of BOC on the Acute Psychiatric Unit
I Rauchberger, F Whitecross
Alfred Health, Melbourne, Australia
Background: Recognising and responding to physical health deterioration in the form of ‘MET’ calls to prevent Code Blue calls has been widely validated. By contrast, there is often no systematic process to escalate deteriorating behaviours of concern (BOC) in the acute psychiatric setting.
Objectives: This session aims to help understand BOC in an acute psychiatric inpatient unit and to evaluate whether a Psychiatric BOC team can reduce BOC.
Methods: Review of all BOC that have been documented in RISKMAN in an acute psychiatric unit over a 12-month period. Develop a systematic response to BOC by the establishment of a multidisciplinary team that responds to a Psychiatric BOC call (Psy-BOC) to offer early support and intervention to patients presenting with BOC.
Findings: The most frequent BOC over a 12-month period included verbal and physical aggression, absconding, self-harm and sexual harm. Implementation of Psy-BOC demonstrated a significant reduction in aggression, absconding, self-harm, sexual harm and restrictive interventions. There was also a reduction in aggressive incidents towards staff.
Conclusions: BOC are common on the acute psychiatric ward. The implementation of a systematic approach to escalate and respond to BOC leads to significant reduction in BOC and restrictive interventions.
Presenter 2
Improving the Response to People Presenting to the Emergency Department with Behaviours of Concern
E Symons, B Hobbs
Alfred Health, Melbourne, Australia
Background: This hospital’s Emergency and Trauma Centre (ED) has seen increasing numbers of people presenting with acute behaviours of concern (BOC). Staff are expected to expertly manage a range of BOC in ED, in particular patients who are aggressive or suicidal, often in the setting of alcohol and/or methamphetamine intoxication. A standardized process to responding to BOC was developed in the ED with the aim of minimising risk to patients, staff and visitors, and to ensure that the best possible clinical care is provided.
Objectives: This session aims to conduct a comparative review of security data recording all BOC presentations over a 3-month period in 2017 and in 2018.
Methods: Data recorded by the security service in the hospital was obtained for the 3-month period in question, and data were correlated with hospital clinical data to determine patient wait times, patient disposition and specialist service referrals.
Findings:
The study found:
a 12% increase in patients presenting to ED with mental health (MH) and/or alcohol and other drugs (AOD) problems.
an increase in total numbers of patients accessing specialist MH and AOD assessment and intervention.
a decrease of 20% in the time MH and AOD patients spent in ED
National Emergency Access Target improved from 58% to 72% for MH and AOD patients
reduction in patients who do not wait
reduced hours of security standby.
Conclusions: Adopting a collaborative and standardized early response to patients presenting to ED with BOC results in safer, more efficient and more effective outcomes.
Presenter 3
Trialling a Novel Approach to Early Intervention (Divert Response) For People with Behaviours of Concern in Two Surgical Wards of a Tertiary Hospital
C Breadon1,2, B Hobbs1
1Alfred Health, Melbourne, Australia
2Monash University, Melbourne, Australia
Background: In line with this hospital’s long-term plan to promote a healthy, respectful and safe workplace, a project team developed a new model of early response to patients at risk of behaviours of concern (BOC). Adopted from the MET and Psy-BOC models, the De-escalation intervention Early Response Team (DiVERT) response was implemented in August 2018 on two surgical wards.
Objectives: This session discusses the piloting and evaluation of the DiVERT call-out process on two surgical wards at the Alfred Hospital.
Methods: Audit of Riskman, Code Grey and recorded security data to compare incidents on surgical wards pre-implementation and post-implementation of DiVERT.
Findings: Preliminary data so far suggest that a clinically led team aimed at early recognition and intervention in BOC reduces incidents of harm to self or others, absconding and code greys.
Conclusions: Early identification of patients at risk of BOC and the implementation of a multidisciplinary team-based intervention improves safety of staff and quality of treatment for patients on surgical wards.
‘Not All Bedtime Stories Have a Happy Ending’: Clinical Update on Binge Eating Disorder
S Touyz1, W Ward2, P Hay3
1University of Sydney, Sydney, Australia
2University of Queensland, Brisbane, Australia
3University of Western Sydney, Sydney, Australia
Background: In 2013 binge eating disorder (BED) reached full diagnostic status in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Since then, there has been major research into the epidemiology, burden and treatment of BED.
Objectives: This symposium brings together leading researchers into BED and new and recent data addressing major questions. How common is BED worldwide? Does BED merit its status as a mental health disorder? What is its distribution and burden across the lifespan? How does it present? How is it treated?
Conclusions: At the end of this presentation, the audience will be able to recognize how the occurrence of this disorder may impact on the individual’s life and its consequences on public health, how it presents and is assessed and treated.
Presenter 1
Binge Eating Disorder Epidemiology and Burden
P Hay, M Bagaric, B Ghabrial, J Conti
Translational Health Research Institute, Western Sydney University
Background: Although binge eating disorder (BED) is considered the most common eating disorder accompanied by substantial distress, impairment, and co-morbidity; relatively few studies have assessed its prevalence and correlates in the general population. The vast majority of data come from the USA and there is an important need for more information about BED estimates from different world regions.
Objectives: The objective of this presentation is to review the current knowledge about BED prevalence and correlates worldwide.
Methods: We report new data from a 2017 Australian population-based state-wide survey on prevalence, burden, cost and health utilisation.
Findings: Of note, the lifetime prevalence of BED was 2.6%, which is higher than reported in previous studies and an age cohort effect was found that suggested the prevalence is plateauing. Further, there was a wide treatment gap with very low treatment-seeking from a mental health specialist for people BED. Data on personal and societal costs of BED will be presented.
Conclusions: BED is common and, despite a notable health burden, the treatment gap is wide.
Resenter 2
Binge Eating Disorder: Assessment and Diagnosis
W Ward
University of Queensland, Brisbane, Australia
Background: This presentation will cover the new Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria and how to differentiate binge eating disorder (BED) from other eating disorders and common co-morbidities. Assessment and assessment tools will be delineated. Participants will gain a clear understanding of assessment and diagnosis of people with BED.
Presenter 3
Update on Psychological Treatments for Binge Eating Disorder
S Touyz
University of Sydney, Sydney, Australia
Background: There is significant evidence supporting the efficacy of psychological therapy for binge eating disorder (BED), with randomized controlled trials utilising specific therapies, particularly cognitive behaviour therapy (CBT) and CBT-Enhanced. In addition, CBT has been translated into guided and pure self-help forms. The management of people with high body mass index (BMI) and BED will also be discussed. Participants will gain a clear understanding of the role of psychological therapy for the treatment of BED.
Military and Veterans’ Mental Health: Australian Research in Military and Veterans’ Mental Health
M Van Hooff1, E Lawrence-Wood1, T Bayliss2, M Hopwood3,4
1Centre for Traumatic Stress Studies, University of Adelaide, Adelaide, Australia
2Australian Institute of Health and Welfare, Canberra, Australia
3Phoenix Australia, Melbourne, Australia
4Department of Psychiatry, University of Melbourne, Australia
Background: There is increasing concern about the prevalence of mental disorders and the incidence of suicide in serving and ex-serving Australian Defence Force (ADF) personnel.
Objectives and Methods: This session presents findings of reports from: the Transition and Wellbeing Research Programme (TWRP); the Australian Institute of Health and Welfare Incidence of Suicide among Serving and Ex-serving Australian Defence Force Personnel: Detailed Analysis 2001–2015 (2017); and the National Suicide Monitoring of Serving and Ex-Serving Australian Defence Force Personnel: 2018 Update (2018). Also, some of the work of the Centenary of Anzac Centre will be presented.
Findings:
Results from the TWRP Mental Health Prevalence Report show ADF members transitioning from full-time military service represent a group at particular risk for mental disorder.
The TWRP Pathways to Care Report found that the majority of those with mental health concerns had engaged in care for these concerns, despite high rates of endorsement of stigma-related beliefs.
The National Suicide Monitoring of Serving and Ex-Serving Australian Defence Force Personnel: 2018 Update found that after adjusting for age, the suicide rate for ex-serving men was 18% higher (statistically significant) than the rate for all Australian men.
The Centenary of Anzac Centre Practitioner Support Service (PSS) will be described and observations from the early phases of their Rapid Exposure Supporting Trauma Recovery (RESTORE) trial will be discussed.
Conclusions:
The Mental Health Prevalence Report concluded that personnel transitioning out of the ADF would benefit from proactive strategies that aim to lessen the burden of mental illness and assist the transition process.
The Pathways to Care Report found it was important to address the issue of concern about the career implications of seeking care, requiring a policy focus on improving rehabilitation and occupational retention after care has been delivered.
Data in the Incidence of Suicide study may help to inform policy and to develop interventions to reduce suicide rates among serving and ex-serving ADF personnel.
The Centenary of Anzac Centre is working to ensure better treatments and improved lives for Australia’s veterans and their families through the PSS and innovative research such as the RESTORE Trial.
Presenter 1
Mental Health and Well-Being Transition Study: Mental Health Prevalence Study
M Hooff1, E Lawrence-Wood1, S Hodson2, N Sadler3, H Benassi4, C Hansen1, B Grace1, J Avery1, A Searle1, M Iannos1, M Abraham1, J Baur1, A McFarlane1
1Centre for Traumatic Stress Studies, University of Adelaide, Adelaide, Australia
2Veterans and Veterans Families Counselling Service, Australia
3Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
4Joint Health Command, Department of Defence, Australia
Background: Approximately 5000 serving men and women transition out of the regular Australian Defence Force (ADF) each year, either discharging completely or transferring into the Active or Inactive Reserves. This represents a significant number of personnel in the critical, early stages of adjusting to civilian life and reintegrating into their community.
Objectives: This session aims to determine the prevalence of mental disorders among ADF members who have transitioned from Regular ADF service between 2010 and 2014, and to examine self-reported mental health status of Transitioned ADF and the 2015 Regular ADF.
Methods: A robust two-phase design, including a self-report survey, a gold-standard structured diagnostic interview for assessing International Statistical Classification of Diseases and Related Health Problems, tenth edition (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM–IV) mental disorder, and a two-stage statistical weighting methodology to correct for differential non-response were used.
Findings: An estimated 46% of Transitioned ADF members met 12-month diagnostic criteria for either an affective (23.1%), anxiety (37%) or alcohol disorder (12.9%). Post-traumatic stress disorder was the most common 12-month disorder type in recently Transitioned ADF members (17.7%) with the spectrum of mental disorders reported being broader than anticipated. When compared to a contemporaneous sample of Regular serving ADF members, the Transitioned ADF had significantly greater levels of psychological distress, depression, anxiety, anger, suicidality and alcohol use.
Conclusions: The high prevalence and varied range of disorder identified among those who transition warrants attention. The findings highlight the importance of taking a longitudinal perspective of the mental health of those who serve in the Australian military. This includes consideration of ADF service along a continuum that includes the entire spectrum of career and transition.
Presenter 2
Mental Health and Well-Being Transition Study: Pathways to Care
E Lawrence-Wood1, D Forbes2, M Van Hooff1, N Sadler2, S Hodson3, H Benassi4, C Hansen1, J Avery1, T Varker2, M O’Donnell2, A Phelps2, J Frederickson2, M Sharp2, A Searle1, A McFarlane1
1Centre for Traumatic Stress Studies, University of Adelaide, Adelaide, Australia
2Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
3Veterans and Veterans Families Counselling Service, Australia
4Joint Health Command, Department of Defence, Australia
Background: This report provides an overview of the self-reported pathways to care in transitioned and currently serving Australian Defence Force (ADF) members to determine if appropriate mental health care is being received.
Objectives: This session aims to assess pathways to care for Transitioned ADF and the 2015 Regular ADF, including those with a diagnosed mental disorder.
Methods: This report examined: care seeking, the time it takes to decide to seek care, the types of problems driving decisions to seek care, the types of professionals consulted and the types of treatments received in the Transitioned ADF and the 2015 Regular ADF. It also described the common attitudes and beliefs that exist in the military in relation to mental health and help-seeking.
Findings: Results showed that the majority of the Transitioned ADF and 2015 Regular ADF with a mental health concern sought help within the first 12 months, with a considerable number doing so within 3 months. However, while the rates of initial engagement and uptake of services are reasonably high, due to an accumulation of factors that occur at each phase of the help-seeking process, the findings suggest an under-engagement with evidence-based treatment for those with a current disorder.
Conclusions: There is a need for integration and coordination of services including development of outreach capabilities. The findings also highlight the importance of continuing to build knowledge of military culture and key clinical presentations among community providers providing care, in addition to bolstering the skills and effectiveness of treatment for those with disorder.
Presenter 3
Incidence of Suicide among Serving and Ex-Serving Australian Defence Force Personnel 2001–2016
T Bayliss, B Davis, M Ellis, M Gourley, N Grange, M Petrie, A Powierski, A Reynolds, D Whitelaw
Australian Institute of Health and Welfare, Canberra, Australia
Background: The study is the first to take a population-based approach to the analysis of suicide in Australian Defence Force (ADF) personnel.
Objectives: This session aims to: quantify the incidence of suicide among serving and ex-serving ADF personnel with at least one day of service from 2001; to identify factors that may be associated with suicide; and to establish measures for longitudinal population suicide monitoring.
Methods: A population-based study design with linked administrative data from the Department of Defence and mortality data from the Australian Institute of Health and Welfare were used to identify suicides in ADF personnel. Standardized mortality ratios and crude rates were used to estimate suicide risk in the study populations and changes in risk over time. Logistical regression was used to model service-related suicide risk factors for ex-serving personnel.
Findings:
In 2001–2016, there were 373 suicides in ADF personnel.
In 2002–2016, ex-serving men had a suicide rate 18% higher than Australian men; serving men had a rate 51% lower than Australian men and reserve men 47% lower. These differences were statistically significant.
Ex-serving men younger than 30 years were at particular risk of suicide.
Discharge in ranks other than commissioned officer and involuntary discharge for a medical reason were both associated with increased suicide risk in ex-serving personnel, after controlling for all other factors.
Conclusions: Suicide risk in serving and ex-serving ADF personnel varied from the Australian population with some variation by service characteristics in ex-serving personnel. Annual updates will continue to be released to inform policy development and evaluation.
Presenter 4
Practitioner Support Service: Working With Veterans with Mental Health Problems
M Hopwood
Phoenix Australia and Department of Psychiatry, University of Melbourne, Melbourne, Australia
Background: The Centenary of Anzac Centre is a Phoenix Australia initiative funded by the Department of Veterans’ Affairs (DVA) that aims to ensure better treatments and improved lives for Australia’s veterans and their families. It comprises both a Treatment Research Centre (TRC) and a Practitioner Support Service (PSS).
Objectives: This session aims to describe the work of the PSS and the Rapid Exposure Supporting Trauma Recovery (RESTORE) trial conducted by the TRC.
Methods: The PSS is a free, national service, providing expert multidisciplinary guidance and support to health practitioners, support organizations and others working with Australian veterans with mental health problems with the aim to enhance the quality and effectiveness of clinical care being delivered. RESTORE is a clinical treatment trial being conducted through Phoenix Australia in collaboration with DVA and the Australian Defence Force (ADF). It is a two-arm, multisite, non-inferiority, randomized controlled trial comparing the effectiveness and tolerability of prolonged exposure therapy (PE) for post-traumatic stress disorder delivered via an intensive two-week protocol versus a standard ten-week PE protocol.
Findings and Conclusions: The trial methodology will be outlined and observations from the early phases of the trial discussed.
Joint RANZCP/JSPN Symposium: ‘Innovations in Psychiatric Continuing Professional Development’
K Jenkins1, Regional guests2
1The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
2Japanese Society of Psychiatry and Neurology, Tokyo, Japan
Background: Continuing professional development (CPD) is essential in medical practice. In psychiatry, as in other medical specialties, a key focus of CPD is quality improvement. CPD programs help ensure that psychiatrists not only maintain their knowledge and skills, but also review and develop their own professional practice.
This joint symposium between the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Japanese Society of Psychiatry and Neurology (JSPN) will outline and showcase innovations that both organizations have made to their CPD programs.
These improvements in CPD include the establishment of peer review groups, a focus on workplace learning, and promotion of reflective learning activities.
Representatives from the RANZCP and the JSPN will give presentations about CPD in their respective jurisdictions. This will be followed by roundtable discussions to identify opportunities for collaboration.
Kua Tae Te Wa – The Time is Right
M Milne, P Tangitu, TP Winiata, R Tapsell, W Blissett, M Baker
Te Kaunihera, The Royal Australian and New Zealand College of Psychiatrists, New Zealand
Background: There has been much research and discussion around Indigenous mental health and addiction in New Zealand in the past two decades. Māori continue to ask to be part of the solution to contribute to ensuring psychiatry and mental health and addiction services are delivered in a way that would produce positive outcomes for Māori.
An eclectic super-group of Māori Health Leaders, with passion and experience in the mental health and addiction sector, are thrilled to present some of the most insightful conversations from an Indigenous perspective to the Congress 2019.
We are Indigenous thinkers and leaders, and members of Te Kaunihera (Royal Australian and New Zealand College of Psychiatrists, RANZCP) (past and present) with experience of working in Māori and non-Māori contexts. It is our belief that now is the time for change – a change that is needed for the indigenous peoples of New Zealand.
Objectives: The objective of this symposium is to raise ‘this is a time for change’ – a change from the monocultural and single-lens perspective to mental health and addiction care and service delivery. A change to one of Māori leadership; Māori infrastructure; total inclusion of Māori; of cultural competency; of cultural knowledge; cultural strategies and solutions as valid evidence-based methods for wellness recovery. A variety of perspectives will include the following.
Stories about transformative changes among health workforces’ receipt of training, workshops and wananga that have focused on building leadership rooted in a responsibility to Māori communities.
An overview of the Government Mental Health and Addiction Inquiry and the various Treaty of Waitangi Health claims that are underway and what this will mean for psychiatry in New Zealand.
Case examples of what’s possible when innovation is led by Māori.
Deliberate, provocative conversations about the relationship with the impacts of increasing substance use and the increased diagnoses of schizophrenia among Māori and are we ready for it?
Sharing some of the emerging Te Kaunihera (RANZCP) aspirations and plan.
A Māori-centred grounded theory called Seeking Solutions to Being Restricted will provide insights to the Māori experience and recommendations to mental health professionals.
Presenter 1
Sharing Moments from Transformative Journeys
M Milne
Te Kaunihera, The Royal Australian and New Zealand College of Psychiatrists, New Zealand
Background: Some of Moe’s experience has comprised of providing various trainings, workshops, and wananga; all of which focus on building leadership rooted in a responsibility to Māori communities and utilising strategies to improve Māori well-being. Over time my approach has been inclusive to non-Indigenous leaders who are often key people working at the frontline of health services.
Objectives: In an Indigenous story-telling style, Moe will her share insights of what it has taken to build a culturally efficient workforce in the mental health sector, and what shifts have occurred as a result at individual and systemic levels.
Methods: A narrative methodology employed in this presentation is informed by Indigenous experience in health, mental health and education sectors.
Findings: Moe has a belief that it is essential for health professionals to have the capacity and capability to be better informed by Māori knowledge and culturally based learning methodologies, thus informing good practice. Yet, it is often the self-transformation of health professionals that then appreciate the power and privilege structures of colonialism, institutional racism and systems. All aspects are foundational for meaningful, healing, and long-lasting solutions to be implemented with Māori.
Conclusions: As Indigenous peoples strive to build healing solutions and practices, there is a need to create a foundation among all health professionals to build the type of leadership in all health workforces to be rooted in responsibility to Māori.
Presenter 2
Forward Thinking
P Tangitu
Te Kaunihera, The Royal Australian and New Zealand College of Psychiatrists, New Zealand
Background: The health of Māori should be the responsibility of all in New Zealand; the health system needs to take responsibility for ensuring the needs of Māori are met, given the current climate, the completion of the Government’s Mental Health and Addiction Inquiry and the number of Treaty Waitangi Health Claims. There is opportunity to focus on the systems responsibility, and the responsibility of psychiatry as leaders in the health system.
Objectives: The objective is to provide an overview of both the Inquiry and various Treaty of Waitangi Health claims that are underway and what this will mean for psychiatry in New Zealand.
Methods: The Government’s Mental Health and Addiction Inquiry was underway in New Zealand from October through to December 2018. During this time the Waitangi Tribunal heard claims concerning grievances relating to health services and outcomes of national significance. There were 205 claims that participated and there is no cut-off date for the filing of claims. The Tribunal will hear claimants who clearly specific eligible health-related grievances against the Crown in their statements of claim and notify their intention. Stage one (with hearings running from October to December 2018 and closing is likely in March 2019) will inquire into aspects of primary care. Stage two will cover three priority areas encompassing mental health (including suicide and self-harm), Māori with disabilities, and issues of alcohol, tobacco and substance abuse. Phyllis will provide a summary of the key issues that claimants have raised and consider the summary of what services can do to acknowledge the issues and develop solutions. Further, the Mental Health Inquiry in New Zealand report was published in November 2018. Phyllis will provide a high-level summary and how the health sector could implement the findings and recommendations of the Inquiry.
Conclusions: The inquiry and various Tribunal claims will contribute to a significant era of development in health in New Zealand. The recommendations from these will form the basis of what could transform the system.
Presenter 3
Innovation by Māori Design
T Winiata
Te Kaunihera, The Royal Australian and New Zealand College of Psychiatrists, New Zealand
Background: Indigenous health practice, systems and solutions in New Zealand often require infrastructure and investment approaches that disrupt the western philosophies of how care should be provided to them, in addition to the paternalistic funding arrangements.
Drawing on the experiences from Kaupapa Māori health services and models of practice, Te Puea will provide case examples of what is possible when innovation is led by Māori. These examples of practice will demonstrate tino rangatiratanga (self-determination) with the power of whanau (families and extended networks) when able to take the lead, in addition to what is possible when collaborative partnerships are formed across service providers to communities.
Objectives: Te Puea will share and provoke the conversation about the evidence that matters about the promising practices and health outcomes in communities in New Zealand, even in some of the most challenging circumstances, where we see the most significant changes, as whanau have the ability to aspire and meet their full potential.
Methods: This oral presentation is informed by practice-led case examples and models of care that are by Māori for Māori. Consent to present from whanau (families) is granted.
Conclusions: When Māori are well supported, they will identify their aspirations and be able to build their capacity to achieve their goals.
Presenter 4
Is It Such a Great Leap?
R Tapsell
Te Kaunihera, The Royal Australian and New Zealand College of Psychiatrists, New Zealand
Background: It is estimated that substance misuse and other addictions are experienced by more than one-quarter of Māori in their lifetime. Substance misuse disorders commonly coexist with other mental health problems and co addictions are also common.
As an indigenous psychiatrist working in the heart of Waikato, a region with a growing Māori population, Rees’s observations are of increasing numbers of Māori with experience of drug use and schizophrenia.
Objectives: Rees will lead the conversation by asking: Do we really understand the relationship between the impacts of increasing substance use and the increased diagnoses of schizophrenia among Māori? And are we ready for it?
Methods: This presentation is informed by qualitative and quantitative methods and informed by clinical evidence in a Māori community.
Conclusion: Outcome will provide for critical discussion about what is needed to prepare for the increasing numbers of Māori with schizophrenia.
Presenter 5
Workforce
W Blissett
Te Kaunihera, The Royal Australian and New Zealand College of Psychiatrists, New Zealand
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has committed to a focus on Māori Psychiatry, and there has also been considerable work across the college to increase the participation of indigenous health. Te Kaunihera (RANZCP) has worked consistently to enhance the Māori voice, and we ask, ‘Is there an opportunity to accelerate our workforce approach with an equity lens’?
Objectives: This session is informed by the experiences from Te Kaunihera (RANZCP), which will identify some of the gains, yet the various challenges to break the glass ceiling on what is needed to strengthen and increase the critical mass of the Indigenous psychiatric workforce.
Methods: Qualitative.
Conclusions: Wayne will share emerging Te Kaunihera (RANZCP) aspirations and plans. Wayne will also share thoughts about what will be needed for a new generation of psychiatrists, mental health and addiction workforces for the future of New Zealand’s mental health services.
Presenter 6
Do We Really Understand the Problems Māori Experience?
M Baker
Te Kaunihera, The Royal Australian and New Zealand College of Psychiatrists, New Zealand
Background: We know Māori experience the most disproportionate rates of mental health and addiction-related harm in New Zealand. Do we as practitioners really know or understand what Māori view as their main problems or how they are solving them?
Objectives: The objective of this presentation is to share succinct insights from a doctorate study that was completed with Māori with experience of mental illness and mental health services. An outcome of the study is a Māori-centred grounded theory called Seeking Solutions to Being Restricted and provides insights to the Māori experience.
Methods: Qualitative and Māori centred.
Findings: A Māori-centred grounded theory called Seeking Solutions to Being Restricted will provide insights to the Māori experience and recommendations to mental health professionals.
An Introduction to Eating Disorders for the Non-Specialist Psychiatrist
V Singh1, F Salter1, L Miller2,3, A Fursland3, L Chadwick1
1Hollywood Clinic, Perth, Australia
2Sir Charles Gairdner Hospital, Perth, Australia
3WA Eating Disorders Outreach Consultation Service, Perth, Australia
Background: Eating disorders are severe mental illnesses with serious co-occurring medical conditions and risk of mortality from malnutrition, purging and/or suicide. They affect approximately up to 15% of the population, but often go undiagnosed, as most presentations to psychiatry are for other psychiatric disorders.
Increasingly eating disorders are understood as neurobiological disorders. Emerging evidence suggests early intervention, including assertive nutritional rehabilitation and structured psychological support with a multidisciplinary plan for relapse prevention, can significantly improve prognosis.
Severe malnutrition and ‘starvation syndrome’ can be experienced in people at any weight, resulting in physical and cognitive effects including poor insight regarding nutritional and medical risk.
Objectives: This symposium aims to improve the understanding the potential challenges and an overview of evidence-based treatment for eating disorders,. It will provide an opportuntity for psychatrists to become familiar with recent advances in treatment approaches.
Methods: Relevant literature and case examples will be presented to illustrate best practice care for people with eating disorders. A multidisciplinary group will offer insights into current treatment approaches.
Findings: Eating disorders treatment is rapidly evolving, and ongong research and clinical practice provide us with greater undertanding of appropriate care. Since many patients seen by psychiatrists will have an (undiagnosed) eating disorder, it is incumbent on all psychiatrists to develop a greater understanding about appropriate care for these patients.
Conclusions: Psychiatrists are encouraged to improve their knowledge of eating disorders and to follow evidence-based practice for this population.
Presenter 1
Risk Assessment, Neurobiology and Decision-Making in Eating Disorders – What the Generalist Psychiatrist Needs to Know
L Miller
1,2
1Sir Charles Gairdner Hospital, Perth, Australia
2WA Eating Disorders Outreach Consultation Service, Perth, Australia
Background: Increasingly eating disorders are understood as neurobiological disorders, which sit at the interface of physical and mental health care. Severe malnutrition and ‘starvation syndrome’ can result in changes in the brain, which profoundly impair insight and decision-making. Emerging research suggests brain atrophy drives the preoccupations and disordered cognitions of the eating disorder.
Thus, early intervention, including assertive nutritional rehabilitation, is critical for improving prognosis.
Objectives: The aim of this presentation is to offer an overview of the neurobiological changes in the brain that accompany an eating disorder and how these impact on emotion regulation, impulse control and interactions with health services. Participants will be introduced to guidelines for safe risk assessment in the patient with an eating disorder and for initiating and optimizing nutrition safely in the medical or mental health non-specialist inpatient setting.
Methods: Drawing upon changes in the care of people with eating disorders in a large tertiary hospital led by the liaison psychiatry service before and after the introduction of the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of eating disorders, and the subsequent roll out of this model State-wide.
Conclusions: Psychiatrists can draw upon their existing skills of providing team leadership, psychoeducation and scaffolding of impaired decision-making to support people with eating disorders from the point of initial presentation, with the aim of optimising opportunities for early intervention and long-term prognosis for patients and their families.
Presenter 2
Food is Medicine: The Evidence for Re-Feeding
F Salter
Hollywood Private Hospital, Perth, Australia
Background: The functional effects of starvation in anorexia nervosa (AN) include impairment of cognitive function, concentration, information processing, memory, spatial processing and central coherence – all of which render psychological and medical treatments ineffective. Re-feeding with the associated weight restoration is therefore the first step to recovery. Recent guidelines have been developed to safely guide practitioners managing the re-feeding process.
Objectives: This update aims to improve the psychiatrist’s understanding of the re-feeding process in AN; the importance of re-feeding, management of re-feeding in different settings, re-feeding in practice and the importance of the multidisciplinary team.
Methods: Recently published national and state guidelines as well as relevant literature and case studies will be presented to assist practitioners to identify appropriate treatment settings and identify goals for weight restoration. Research supporting the use of re-feeding protocols to safely support faster rates of weight restoration, resulting in shorter hospital stays while avoiding Re-feeding Syndrome, will be discussed.
Findings: The evidence base for safe and effective re-feeding to a normal body weight in AN is growing, although it continues to require further research to improve and refine.
Conclusions: Psychiatrists are encouraged to improve their knowledge of the role of nutrition rehabilitation in AN, to follow evidence-based practice and to collaborate with colleagues, both eating disorder specialists within their own discipline as well as other members of the multidisciplinary team, to improve access and quality of care to patients with AN.
Presenter 3
Optimising Treatment Delivery and Reducing Length of Stay in an Adult In-Patient Unit
V Singh, F Salter, F Cartwright
Hollywood Clinic, Perth, Australia
Background: Overall the prevalence of eating disorders is increasing. Worldwide, the number of patients with eating disorders needing admission is doubling. Conservative treatment approaches and long lengths of stay have both direct and indirect costs for patients, hinder access to the service for potential patients and reduce service cost effectiveness.
Objectives: The Hollywood Clinic is a private 10-bed adult eating disorder inpatient service in WA. Over the past 4 years our focus has been on optimizing treatment delivery and reducing length of stay. The aim of this presentation will be to outline the indications for hospital admission in patients with eating disorders and to outline interventions to optimise treatment outcomes in an inpatient setting
Methods: A brief review of the guidelines for inpatient management will be presented, as well as interventions used to optimise outcomes at The Hollywood Clinic.
Findings: Average length of stay has progressively reduced from 52 days in 2013 to 24 days in 2017. Concomitantly there has been a significant increase in the average rate of weight restoration.
Conclusion: These results suggest that it is possible to lower the length of stay for inpatients with eating disorders while still optimising outcomes.
Presenter 4
Best Practice Outpatient Treatment for Eating Disorders
A Fursland
WA Eating Disorders Outreach Consultation Service, Perth, Australia
Background: Eating disorders are mental illnesses. Anorexia nervosa, the most serious eating disorder, has the lowest recovery rates and the highest mortality, partly because of the medical complications that commonly occur, and the overwhelming fear of eating and regaining weight. This distress associated with treatment often results in the individual avoiding treatment and can lead to suicide. While most patients with an eating disorder can be treated on an outpatient basis, some will need admission (often to a medical ward). Evidence-based treatments for eating disorders are still emerging.
Objectives: The aim of this presentation is to offer an overview of best practice outpatient treatment for people with eating disorders. Treatment of the most common eating disorder diagnoses will be discussed (anorexia nervosa, bulimia nervosa and binge eating disorder) as well as a new diagnosis, avoidant/restrictive food intake disorder, and atypical presentations (e.g. purging disorder, and atypical anorexia nervosa).
Methods: Outcomes research will be summarized, screening of eating disorders will be discussed, and a brief description of the leading psychological treatments will be given.
Findings: Recovery rates for eating disorders are disappointingly low, but long-term outcomes show that many patients will recover. Early intervention increases the likelihood of a full recovery from an eating disorder.
Conclusions: Psychiatrists play an important role in early identification of an eating disorder and in managing co-occurring psychiatric illnesses in people with eating disorders.
Presenter 5
An Overview of Binge Eating Disorder
L Chadwick
Hollywood Clinic, Perth, Australia
Background: Binge eating disorder (BED) has been moved from the obscurity of an appendix in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) to being designated in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) as a fully fledged diagnosis that parallels the other main eating disorders of anorexia nervosa (AN) and bulimia nervosa (BN). BED is the most prevalent of all eating disorders affecting approximately 6% of the population, yet is still not well recognized or understood in psychiatric practice. Distinct from other eating disorder subtypes, the male to female ratio is closer to 1:1, and BED often presents with mood symptoms or overweight/obesity. BED is commonly co-morbid with other psychiatric disorders and is linked to significant psychiatric and medical risk, yet the diagnosis is often missed.
Objectives: To improve the recognition and treatment of BED among psychiatrists in Australia.
Methods: The history of BED emerging as a recognized separate disorder will be reviewed, the symptom complex will be outlined, and screening methods and treatment options will be detailed.
Conclusions: BED is under-recognized, under-treated, and associated with significant psychiatric and medical co-morbidity. Improved screening, targeted diagnosis, and appropriate treatment should be the province of all psychiatrists.
Welcome to the Breakfast Club: Fostering Culture, Diversity and Mutual Learning Among Registrars and Early Career Psychiatrists Through Research
S Suetani1,2, S Parker1,2, J Frater1,2, F Ng3, K Moss2,4, E Mahendran1, B Eyre5, D Lu1, F Dark1,2, J Scott2,6
1Metro South Addiction and Mental Health Services, Brisbane, Australia
2University of Queensland, Brisbane, Australia
3Child Health Queensland, Brisbane, Australia
4West Moreton Hospital and Health Service, Brisbane, Australia
5Griffith University, Brisbane, Australia
6Royal Brisbane and Women’s Hospital, Brisbane, Australia
Background: The Breakfast Club is a peer review group consisting of registrars and early career psychiatrists with interest in academic psychiatry in Brisbane, Queensland. The Club meets every 2 months for breakfast. At each meeting, we invite a Pancake Prince or Princess – an established academic psychiatrist – as a guest of honour to share his or her wisdom and foster inter-generational transmission of the research culture.
Objectives: This session aims to showcase the diverse research that are being conducted by members of the Breakfast Club.
Methods: Six members of the Breakfast Club will present their research. The symposium will be chaired by a Pancake Prince (James Scott) and a Pancake Princess (Frances Dark). There will be an interactive discussion with the audience about how research can be incorporated into clinical practice/training throughout the symposium.
Findings: Members of the Breakfast Club are involved in a wide range of research using many different research methods. Some topics are training related (e.g. scholarly project, supervision) while others are clinically orientated (e.g. physical activity), or public health orientated (e.g. lithium in drinking water). Some studies use traditional research methodologies such as systematic review and qualitative analysis while others explore novel methods such as Mendelian randomization.
Conclusions: The Breakfast Club has been successful in fostering research culture and mutual learning among registrars, early career psychiatrists and established academic psychiatrists in Brisbane, Queensland. We believe that a similar approach can be successful in many other areas of Australasia.
Presenter 1
Lithium in the Drinking Water: A Systematic Review
E Mahendran1, B Eyre2, S Suetani1,3, J Firth4, S Kisely1,3, D Siskind1,3
1Metro South Addiction and Mental Health Services, Brisbane, Australia
2Griffith University, Brisbane, Australia
3University of Queensland, Brisbane, Australia
4University of Western Sydney, Sydney, Australia
Background: Long since Australia’s revolutionary work with lithium and bipolar disorder, its remarkable neuroprotective effects and wide-reaching scope has been postulated. Lithium occurs naturally within drinking water, with a large variation in concentration geographically. Given the worldwide prevalence of neuropsychiatric disorders, the potential benefits of this naturally occurring mineral is one of substantial public health interest.
Objectives: We aimed to investigate the rates of neuropsychiatric conditions among people exposed to higher levels of lithium in drinking water compared to those exposed to lower levels.
Methods: A systematic search of PubMed, Embase, Web of Science, PsycINFO and CINAHL was conducted using MeSH terms and text words of lithium-related terms and neuropsychiatric outcomes.
Findings: There were 1203 published articles relating lithium with neuropsychiatric outcomes, of which 23 met the inclusion criteria. Ten out of 13 epidemiological studies found an association between higher lithium levels and reduced suicide rates. Three studies using a cross-sectional survey or patient interview demonstrated an inverse correlation between lithium levels and depressive symptoms, while one study showed decreased anxiety symptoms. Two out of four studies showed lower mental health hospital admissions. One study out of three showed a significant association between increased lithium levels in drinking water and reduced dementia or bipolar disorder rates.
Conclusions: Our findings suggests higher lithium levels in drinking water is associated with a lower incidence of suicidality, depression, anxiety, mental health hospital admissions and dementia.
Presenter 2
Supervision Contracts in Psychiatry: A Systematic Review and Proposal for Future Exploration
D Lu1, S Suetani1,2, S Parker1,2
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2University of Queensland, Brisbane, Australia
Background: The use of formal supervision contracts is an emerging practice across non-medical mental health professions. However, use of such contracts is not a requirement of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Competency-Based Fellowship Programme (CBFP). Given their widespread uptake and advocacy, it is logical that these should be considered for incorporation within the CBFP. In considering their relevance, an appropriate first step is determining what empirical evidence exists that supports their use.
Objectives: This session critically examines the evidence to support the use of formal supervision contracts, and presents a template for a supervision contract to guide practice and future research.
Methods: A systematic review of empirical studies relating to the outcomes of supervision contracts was completed. Included records were subject to quality appraisal. Additionally, a supervision contract template was generated through author consensus.
Findings: Two studies met the inclusion criteria; both were assessed to be of low quality. One study found improved supervision effectiveness associated with the use of supervision contracts, the other found no significant differences associated with formal contracting.
Conclusions: Despite strong advocacy, limited empirical evidence supported the value of formal supervision contracts across mental health professions. The proposed template provides a starting point for RANZCP supervisors and trainees to consider the relevance of these contracts for their own work and to guide future research.
Presenter 3
Stepping Forward: Challenges and Pathways to Building a Vibrant Research Culture through the Scholarly Project
F Ng1, A Ayres1, S Suetani2,3, S Parker2,3
1Child Health Queensland, Brisbane, Australia
2Metro South Addiction and Mental Health Service, Brisbane, Australia
3The University of Queensland, Brisbane, Australia
Background: The Scholarly Project (SP) is an important step in the training of the future generation of psychiatrists to create, synthesize and critically appraise evidence to improve service provision and patient outcomes. However, there are several impediments to trainees’ confident completion of this project.
Objectives: This session aims to highlight, synthesize and propose strategies and practical solutions to assisting trainees and supervisors to support completion of the SP.
Methods: The authors reviewed recent literature on the challenges voiced by trainees, as well as solutions posed by clinician–researchers and medical educators.
Findings: Without an infrastructure to support research skills development, trainees in the Competency-Based Fellowship Programme face a challenging tension between service provision and research skills development.
Conclusions: There are several pathways available to alleviate barriers to trainees’ timely commencement and completion of the SP, including enhancing research capacity within services, familiarity with the requirements, and increasing access to supervisors and additional supports for trainees.
Presenter 4
Mendelian Randomization in Psychiatry: A Guide for Clinicians in Understanding the Latest in Epidemiological Genetic Research
J Frater1,2, J McGrath1,3
1University of Queensland, Brisbane, Australia
2Metro South Addictions and Mental Health Service, Brisbane, Australia
3National Centre for Register-based Research, Aarhus University, Denmark
Background: Mendelian randomization (MR) refers to a process of using genetic information as a ‘natural’ experiment to provide evidence between causal relations, risk factors and outcomes in observational data. In short, genetic proxies for the exposure of interest are determined, making them potentially easier and quicker to do than traditional observational studies. MR studies have been reported to be as good as randomized controlled trials (RCTs) in being able to exclude confounders from assessment of causality. The popularity of MR as a technique to understand causal relations in psychiatry is increasing, with a large number MR studies in psychiatric research being published over recent years. However, as with all epidemiological and population-based methods, certain assumptions may impact on results, and the immediate clinical relevance of results may be limited.
Objectives: This session aims to describe the core concepts and assumptions in MR studies, with a focus on how to read and interpret MR papers within the context of psychiatric research.
Methods: This presentation will cover key concepts and limitations of MR, using examples from recent psychiatric literature.
Findings and Conclusions: MR is a valid and useful epidemiological tool for understanding causal relationships from observational population data and has relevance to current psychiatric research. Many psychiatrists and trainees may be familiar with RCTs; however, due to the recent development of MR and the use of genetic variants as proxies, many may not have familiarity with this new research methodology.
Presenter 5
The Physical Health, Activity and Activation Measures of Patients with Severe Mental Illness Residing in a Secure Facility
K Moss1,2, E Heffernan2.3, C Meurk2.3, M Steele2,3
1West Moreton Hospital and Health Service, Brisbane, Australia
2University of Queensland, Brisbane, Australia
3Queensland Centre of Mental Health Research, Brisbane, Australia
Background: Addressing the physical health needs of forensic patients in high-security settings is complex. The physical health of patients is often compromised by the requirement of long-term inpatient stays, limited access to physical activity and a high prevalence of psychotic illness and antipsychotic treatment. It is important to consider diverse treatments, learn from previous research and address whether specific treatments will fit within the culture of an organization.
Objectives: This presentation will explore: (i) current physical health status and health risk factors; (ii) current physical activity; and (iii) patient activation measures of patients at the High Secure Unit of The Park, Centre for Mental Health.
Methods: This study is a descriptive study using a mixed-methods approach. Both quantitative and qualitative date will be reported on.
Findings: The following data will be reported on: (i) metabolic factors (height, weight, waist circumference, blood pressure, fasting glucose, triglycerides/cholesterol, HDL/LDL), weight change since admission, rates of metabolic syndrome/type 2 diabetes; (ii) medical history, family history of cardiovascular risk factors Patient Activation Measure (PAM); and (iii) International Physical Activity Questionnaires Short Form (IPAQ–SF).
Conclusions: It is anticipated that this study will demonstrate the ongoing poor physical health status of long-stay psychiatric patients. By considering diverse treatments and taking into consideration the culture of an organization, it is anticipated that improved treatment options can be devised.
Presenter 6
Qualitative Methods in Mental Health Research: Understanding Its Value and How to Do It Well
S Parker
1,2
1Metro South Addiction and Mental Health Services, Brisbane, Australia
2University of Queensland, Brisbane, Australia
Background: Qualitative research methodologies play an essential role in mental health research. At times qualitative research methods are undervalued or actively de-valued by researchers who focus predominantly on quantitative methods. These behaviours may arise from limitations in the understanding of the relevance of qualitative research, and of standards of quality in qualitative research.
Objectives: This presentation will explore: (i) the role of qualitative research in the field of mental health; (ii) how quality in qualitative research is understood; and (iii) provision of practical guidance to novice researchers interested in commencing a qualitative research project.
Methods: A narrative synthesis of the literature.
Findings: Qualitative research plays an essential role in the field of mental health, including enabling and augmentative quantitative approaches. Doing qualitative research well requires planning and preparation.
Conclusions: Qualitative research is necessary and important. Further efforts to bridge the divide between quantitative and qualitative approaches should be encouraged.
Chromosomes, Country, Catatonia and Contrasts: Intellectual Disability and Autism in Queensland
C Franklin1,2, J Galstuch-Leon3, A Shek2, M White2,4, A White3, A Webster3, C McLorinan5
1Mater Research Institute-University of Queensland, The University of Queensland, Brisbane, Australia
2Mater Intellectual Disability and Autism Service, Mater Misericordiae Limited, Brisbane, Australia
3Specialist Disability Services Assessment and Outreach Team, Department of Communities, Disability Services and Seniors, Queensland Government, Brisbane, Australia
4Faculty of Medicine, The University of Queensland, Brisbane, Australia
5Gold Coast University Hospital, Gold Coast, Australia
Background: The psychiatry of intellectual and developmental disability (IDD) is a subspecialty that has established a presence in Queensland particularly over the last 10 years, with a growth in numbers of psychiatrists interested and involved. There is a great need for increased service capacity for this group, which necessitates innovation in service delivery as well as continued education and support for those interested in IDD.
Objectives: This symposium aims to highlight interesting areas from the current practice of IDD psychiatry in Queensland: the relevance of genetics and behavioural phenotypes to psychiatry; the psychiatry of intellectual disability (ID) and autism in rural and remote Queensland; a review of the literature with clinical insights into the presentation of catatonia in ID and autism and finally a review of the mental health needs of children and adolescents with IDD.
Methods: We will use a wide approach, ranging from clinically based discussions, clinical service review and systematic review of the current literature relevant to the psychiatry of IDD to explore areas of relevance to psychiatrists.
Findings: The psychiatry of IDD is evolving rapidly, aided by advances in genetic technologies; however, clinical understanding of behaviour and mental illness in this group would benefit from greater research to better define behavioural phenotypes. There are challenges in delivering specialized IDD psychiatric services to rural and remote areas, but a consultation–liaison (CL) model may be efficacious in overcoming some of these barriers. Catatonia has a long history but is still poorly understood and researched, especially in the area of IDD. Children and adolescents with IDD have significant mental health needs and there is a major lack of service capacity for this group in Queensland.
Conclusions: The psychiatry of ID and autism is a rich and complex area that has seen significant developments in the last 10 years, across clinical practice, research and service delivery. There remains much scope, particularly for improved services for this population in Queensland, and indeed Australia.
Presenter 1
The Relevance of Genetics and Behavioural Phenotypes to Psychiatry
C Franklin
1,2
1Mater Research Institute-University of Queensland, The University of Queensland, Brisbane, Australia
2Mater Intellectual Disability and Autism Service, Mater Misericordiae Limited, Brisbane, Australia
Background: The concept of the behavioural phenotype was developed to describe the typical patterns of behaviours associated with a specific chromosomal or genetic abnormality (O’Brien, 2006). Advances in genetic technologies have enabled identification of many more genetic abnormalities but our understanding of the associated behavioural phenotypes is lagging behind.
Objectives: This presentation aims to provoke thought and greater understanding of the potential value to the psychiatrist in understanding the relationship between behavioural phenotypes and the presentation of mental illness in a variety of genetic conditions. These concepts will also be considered with respect to autism and its association with mental illness.
Methods: The presentation will begin with an overview of the current literature in relation to the behavioural phenotypes of common genetic syndromes, focusing on syndromes of particular relevance to psychiatrists. It will examine the concept of the behavioural phenotype, its relationship to genetic changes and the frame it provides to inform psychiatric assessment.
Findings: Current knowledge of behavioural phenotypes can inform and assist with psychiatric diagnosis in common genetic syndromes and autism. Further research is needed to increase the depth and specificity of understanding of behavioural phenotypes of common disorders and this could be extended as a potentially useful frame for understanding mental illness in autism spectrum disorders.
Conclusions: The concept of behavioural phenotypes is useful in detecting and diagnosing mental illness in a number of syndromes, and will be aided by ongoing refining of the literature. The diagnosis of mental illness in autism could benefit from the use of the concept of behavioural phenotype associated with autism.
Reference
O’Brien G (2006) Behavioural phenotypes: Causes and clinical implications. Advances in Psychiatric Treatment 12: 338–348.
Presenter 2
Intellectual Disability and Autism in Rural and Remote Queensland
J Galstuch-Leon1, A Shek2, A White1, A Webster1
1Specialist Disability Services Assessment and Outreach Team, Department of Communities, Disability Services and Seniors, Queensland Government, Brisbane, Australia
2 Mater Intellectual Disability and Autism Service, Mater Misericordiae Limited, Brisbane, Australia
Background: It is well established that people with developmental disability experience higher rates of mental illness and medical co-morbidities than the general population. There are also higher levels of stigma, community exclusion and carer burden. Collaboration between health services; non-government organizations; education, housing and employment sectors; and Disability Services are vital for optimal outcomes. Specialized medical and allied health practitioners and support services are limited in rural and remote Queensland.
Objectives: This session aims to explore: (i) the prevalence and types of dual diagnosis presentations seen in rural and remote Queensland; and (ii) the barriers and limitations to accessing health and support services in remote localities.
Methods: Qualitative investigation of clinical experience from a metropolitan-based consultation–liaison (CL) outreach service will be used to explore the prevalence of mental illness in people with developmental disability and systematic barriers that prevent access to care.
Findings: There is a high prevalence of mental illness presentations in people with intellectual disability living in rural and remote areas. Barriers to timely diagnosis and treatment are multifactorial and systematic, encompassing issues such as shortages in workforce and resources, cultural differences, and stigma. A CL community outreach model may assist in overcoming some of these barriers.
Conclusions: Rural and remote areas of Queensland encompass vast geographical distances and mental health services are limited, resulting in poor access to mental health services. This situation is even more pronounced in intellectual disability mental health where patients have highly complex needs. A CL model of care may be helpful in addressing workforce and resource shortages in regional areas.
Presenter 3
Catatonia in Intellectual Disability and Autism
M White
1,2
1Faculty of Medicine, The University of Queensland, Brisbane, Australia
2Mater Intellectual Disability and Autism Service, Mater Misericordiae Limited, Brisbane
Background: While there is a growing body of literature on the higher prevalence of catatonia in patients with intellectual and developmental disability, its association with a broad variety of underlying conditions with little in common argues against a single common cause for catatonia. It is still unclear whether catatonia is a general neuropsychiatric clinical phenotype with different underlying neuronal mechanisms or whether catatonia has a common phenotype and pathology.
Objectives: This session aims to present the results of a scoping systematic review looking at the field of studies in intellectual and developmental disability and catatonia. In addition, a clinical case study of a young man with autism and catatonia will be presented with digital recordings demonstrating his catatonic features.
Methods: The terms ‘intellectual disability’ OR ‘intellectual impairment’ OR ‘developmental disability’ AND ‘catatonia’ were searched in the databases PubMed, Embase, Scopus, Web of Science, Psycinfo and Cochrane. A total of 187 abstracts were returned; 59 duplicates were excluded. The remaining articles were reviewed to identify cognate themes in this field.
Findings: There were no controlled trials. The majority of articles returned were case studies. There were prospective and cohort studies with varied findings. There is a paucity of basic science in this area.
Conclusions: Comments will be made by the speaker upon the findings of the scoping review regarding the range of clinical presentations of catatonia, the presence of identified risk factors and successful treatment strategies.
Presenter 4
Mental Health Needs and Services for Children and Adolescents with Intellectual Disabilities
C P McLorinan
Gold Coast University Hospital, Gold Coast, Australia
Background: Children and young people with intellectual disability (ID) have higher rates of mental disorder than their peers who do not have ID. Intellectual Disability Child and Youth Mental Health Services (ID CYMHS) have developed significantly over the past 10 years in Northern Ireland. However, there are very limited services in Queensland mental health services for this population.
Objectives: This presentation will provide information on the ID CYMHS population in Northern Ireland, including updates on definitions and the evidence base in relation to the mental health needs of children and adolescents with ID.
Methods: Research including randomized controlled trials/systematic review, national guidelines and unpublished small-scale outcome data related to a specific service will be presented, in addition to practice-based evidence.
A specialist ID CYMHS inpatient service model in Northern Ireland will be described, with reference to a qualitative study project (2008), institutional resettlement and outcomes (2010), evolution of the service model between 2010 and 2017, outcome measurement and associated challenges (2017). The evidence from both the literature and clinical practice relating to psychiatric assessment, intervention and prescribing in children and young people with ID and co-morbid mental health needs will be presented.
Findings: Children and adolescents with ID are a population with significant mental health issues. There is an ongoing need for better understanding of interventions that can effect change and effective service models to improve outcomes for this vulnerable population.
Conclusions: Significant challenges remain, including provision of adequate funding, development of a skilled workforce, development of a consistent model and the challenge of demonstrating effectiveness of interventions in a population with underlying significant impairments.
Mental Health Service Provision in Australian Immigration Detention Settings
J Holdaway, J Spencer, D Lienert, C Li
International Health and Medical Services, Sydney Australia
Background: International Health and Medical Services (IHMS) provides primary and mental health care to people in immigration detention facilities and Regional Processing Countries, on behalf of the Australian Department of Home Affairs.
Objectives: This symposium aims to provide the audience with information about the provision of health services to the Australian immigration detention population and to people living offshore in a Regional Processing Country. This symposium provides an opportunity to consider the unique aspects of mental health delivery in this setting with mental health staff who have direct experience of working within the immigration detention system.
Methods: IHMS presents five sessions highlighting different issues arising within the context of health service provision in immigration detention settings.
Findings: Providing mental health services in immigration detention settings has many parallels to health service provision elsewhere, with added complexities relating to the practice setting and client population.
Presenter 1
Mental Health Service Provision in Australian Immigration Detention Settings
J Holdaway, C Li
International Health and Medical Services, Sydney, Australia
Background: In the last 5 years, the Australian onshore immigration detention network has undergone changes as a result of the reduction in people arriving by boat and, in 2015, changes in the Australian Migration Act 1958. This has resulted in changes in the patient population within onshore immigration detention, and in mental health service needs.
Objectives: This session aims to provide an overview of mental health services provided in onshore immigration detention, and changes that have occurred in the onshore immigration detention network population over the last 4 years.
Methods: Collated data on health service consultations and prescriptions within the onshore detention setting are used to illustrate changes in the detention cohort and associated health needs over the last 4 years.
Findings: Changes in the population entering immigration detention since 2015 have resulted in the emergence of parallels to mental health issues found more often in the corrections population.
Conclusions: Mental health service provision within onshore immigration detention is adapting to changes in the immigration population, in line with changes in population and operational demands. Health services in this setting require significant flexibility to adapt to the changing population, geography and legislation, while continuing to provide quality clinical care.
Presenter 2
Food and/or Fluid Refusal in Immigration Detention: Roles for Mental Health Services
J Holdaway, D Lienert
International Health and Medical Services, Sydney Australia
Background: Food and/or fluid refusal (FFR) is encountered by clinicians across a number of settings, including immigration detention. People refusing food and/or fluid in immigration detention may be doing so in the context of medical of psychiatric illness, as a communicative behaviour deriving from a sense of hopelessness, or as part of a protest in relation to their circumstances.
Objectives: This session will discuss the presentation and phenomenon of FFR in the onshore immigration detention setting, with a particular focus on the role of the psychiatrist in collaborative assessment, formulation and management of this issue.
Methods: The procedure for management of FFR in onshore Immigration detention is described, including the role of health services in early intervention, assessment and management. Opportunities and challenges around the assessment of mental capacity and the use of advanced directives in the detention setting are discussed. The limits of care within the detention centre and liaison with local hospital services are also discussed and illustrated through case vignettes.
Findings: There are complex clinical, legal, ethical and liaison issues to consider in managing FFR, both within immigration detention and tertiary care settings.
Conclusions: FFR occurring in immigration detention settings involves roles specific to mental health services, including the psychiatrist.
Presenter 3
Management of Complex Mental Health Presentations in Australian Onshore Immigration Detention
J Spencer
International Health and Medical Services, Sydney, Australia
Background: When working within onshore immigration detention, psychiatrists face the task of providing safe and effective mental health care to clients from diverse backgrounds with a broad range of mental health problems, as well as clients manifesting distress or protest behaviours related to their immigration situation.
Objectives: To raise awareness among psychiatrists of the issues in managing these complex cases as many such cases require input from nearby hospital and community mental health services.
Methods: This session will use case vignettes to discuss the complexity of managing risk, promoting recovery, and interfacing with public mental health services when working with clients in immigration detention.
Findings: The immigration detention setting in Australia poses unique complexities for clinicians providing mental health care, including issues arising in the interface between private and public mental health services external to the detention setting.
Presenter 4
Mental Health Services for Refugees and Asylum Seekers in Nauru
J Holdaway
International Health and Medical Services, Sydney, Australia
Background: International Health and Medical Services has provided primary and mental health services for refugees and asylum seekers in Nauru for more than 5 years, with significant evolution of services over this time. This presentation will focus upon the child, adolescent and adult mental health services provided in this context, with a particular focus on the last 2 years.
Objectives: This session aims to provide information to allow the audience to gain further understanding of the mental health services provided to refugees and asylum seekers in Nauru, and the challenges and opportunities of working in this environment.
Methods: An overview of mental health service provision over the last 2 years in Nauru is provided. This includes information on services and facilities available, the community environment for refugees, and an overview of challenges in providing mental health care in this setting.
Findings: Mental health services in Nauru for refugees and asylum seekers face unique contextual challenges.
Conclusions: Managing the mental health needs of refugee and asylum seekers in Nauru remains an ongoing priority.
Presenter 5
Caring For the Carers
D Lienert
International Health and Medical Services, Sydney Australia
Background: Health service staff in immigration detention operate in a complex and often emotionally charged practice environment. In addition, some detainees have experienced torture or trauma in their countries of origin, which may result in exposure of staff to the vicarious effects of this trauma. The unique intrapersonal and interpersonal dynamics of the setting, the few practitioners in the field who have experiential understanding of the environment, the relative secrecy of the environment and strong views expressed by others external to the setting all provide potential stressors for staff providing health services to this population.
Objectives: This session aims to discuss both the positive and negative aspects of working in this unique setting.
Methods: A literature review on this topic is presented along with results from a survey of International Health and Medical Services staff exploring this issue in the Australian context. Efforts to support staff working within Villawood Immigration Detention Centre (VIDC) are described.
Findings: Most staff describe their experience of working within a detention setting in positive terms but there are important factors that need to be considered in supporting staff.
Conclusions: Regular supervision, training and support for staff working in immigration detention settings is important to maintain quality and compassionate care and to ensure staff are adequately cared for.
Royal Australian and New Zealand College of Psychiatrists: Alcohol Harm and Mental Health Advocacy Campaign
Alcohol Harm and Mental Health Working Group, Royal Australian and New Zealand College of Psychiatrists
Background: Following on from the Royal Australian and New Zealand College of Psychiatrists’ (RANZCP’s) successful advocacy campaign on physical health for patients with mental illness, the College’s next advocacy campaign will focus on the impact of alcohol use on mental health. Presenters will speak to the campaign and the effect of alcohol use on different life stages and population groups.
Objectives: The campaign aims to reduce the mental health harms associated with alcohol use across Australia and New Zealand, helping people to better understand the links between mental health and substance use, and the role that psychiatrists play in people’s treatment and recovery.
The campaign gives a voice to the stories of people, families and whānau affected by alcohol-related harm, and will seek to explore:
the range of mental health harms associated with alcohol use, particularly psycho-social functioning, neurocognitive development, societal impact and public health implications
bidirectional links between mental health and alcohol use
early warning signs that alcohol use is contributing to adverse mental health outcomes
help-seeking behaviours and service access pathways
the range of evidence-based or evidence-supported practices
barriers to successful treatment outcomes and potential solutions.
Methods:
Phase 1: Establishment of a Working Group and development of the campaign project proposal
Phase 2: Scoping and commissioning of a preliminary environmental scan and development of a report providing the evidential foundation for the campaign
Phase 3: Design and implementation of the advocacy campaign and the communications action plan
Phase 4: Evaluation and impact reporting.
Findings: An outline of the campaign’s report on alcohol harm and mental health, inlcuding the problem definition, evidence base and key underlying themes will be presented along with a summary of the campaign components proposed for implementation.
Conclusions: Alcohol is associated with a range of mental illnesses and excessive consumption can lead to brain function impairment and injury. The RANZCP advocacy campaign will help to reduce alcohol-related harm by improving awareness among clinicians, key decision-makers, and the broader community, about evidence-based programs and treatments, and the important role of psychiatrists in assessment and treatment.
Hypothetical on Leadership and Management in Psychiatry
R Parker
Top End Mental Health Services, Darwin, Australia
Background: Psychiatrists in clinical leadership positions often face challenges from a range of competing priorities. They often have to address a number of knowledge paradigms to address clinical, organizational and political issues impacting on a particular situation.
Objectives: The hypothetical will involve senior and junior psychiatrists in clinical leadership positions responding to a complex scenario that has impact for a service client and their family along with service and political implications.
Methods: The hypothetical will involve a facilitator leading the panel of psychiatrists to involve a lively discussion and debate about the complex evolving scenario.
Findings: Psychiatrists in leadership and management have to rely on a range of knowledge and strategies that may change as situations evolve.
Conclusion: Leadership and management in psychiatry relies on both learned knowledge from psychiatry, along with adaptive knowledge of the organizational and political environment affecting psychiatric practice, to function effectively.
Cultural Intelligence throughout a Lifetime
S Balaratnasingam, V Dann, E McEntyre, J Egan, M Haar, D Hellsten, D Jans, M Ketchell, J Lee, L Matthews, K Mulholland, A Rosen, S Schuh, W Taft, D Tran, M Watson
Royal Australia and New Zealand College of Psychiatry Aboriginal and Torres Strait Islander Mental Health Committee, Melbourne, Australia
Background: A key priority of the Royal Australia and New Zealand College of Psychiatrists’ (RANZCP’s) Strategic Plan for 2018–2020 is to continue to ‘advocate for improved health outcomes and access to mental health services for Māori, Aboriginal and Torres Strait Islander peoples. An essential component to making progress on this priority is to ensure that all psychiatrists and trainees are supported to work with each other and with the peoples they care for in culturally sensitive and intelligent ways and in culturally safe environments.
The RANZCP’s Aboriginal and Torres Strait Islander Mental Health Committee, comprising clinicians and community members, will present this interactive symposium for psychiatrists, supervisors, trainees, junior doctors and medical students.
Objectives:
This session aims to:
discuss the meaning, importance and value of being culturally aware, competent and safe
provide practical examples of best-practice in working with Aboriginal and Torres Strait Islander peoples across the lifespan and in different mental health care settings (e.g. health services, custodial settings, aged care)
share how psychiatrists and trainees can help to improve culturally safe learning and work environments for Indigenous doctors, trainees and students
provide participants with an understanding of actions they can undertake to gain/strengthen their knowledge and skills in cultural safety
provide discussion of the practical steps they can take to improve cultural safety with colleagues, patients, and in health services and other settings.
Methods: Members of the Aboriginal and Torres Strait Islander Mental Health Committee will take participants on a journey through the lifespan, providing narratives of culturally safe mental health care, from childhood to aged care. The symposium will provide an opportunity to share experiences, ask questions and join in discussion.
Conclusions: Participants will gain knowledge about the meaning and importance of cultural safety as well as practical steps that can be taken to improve culturally sensitive mental health care as well as safe learning environments and work settings.
Competition & Complementarity: Managing Multiple Roles in Psychiatry
K Baheti1,2, I Lim1,3, S Mathews1,4, T Muller1,5
1Trainee Representative Committee, The Royal Australian and New Zealand College of Psychiatrists
2Western Sydney Local Health District, Sydney, Australia
3Austin Health, Melbourne, Australia
4Rockingham General Hospital, Western Australia, Australia
5Waikato District Health Board, Waikato, New Zealand
Background: Psychiatrists often wear several hats, but managing multiple concurrent roles is not always easy. When there is conflict or competition between the responsibilities associated with different roles, ethical and interpersonal challenges can arise. Lack of role clarity, role boundaries and role declaration pose particular threats to effective and ethical practice. Conversely, knowledge and skills cultivated in one role may complement or enrich the performance of another role. There is much to be learned from the experience of managing multiple roles.
Objectives: In this symposium, three Trainee Representative Committee members will explore different manifestations of complexity associated with performing multiple roles.
Methods: Dr Baheti will consider the relationship between training requirements and service provision. Dr Mathews will then consider the intersection of supervision, assessment and management roles. Finally, Dr Muller will consider the interplay between our professional and personal selves.
Findings & Conclusions: Multiple role performance is an inevitability for psychiatrists. Effectively managing role conflict and utilizing role complementarity is a valuable skill in our work. Some reflection on how different roles relate to each other can help psychiatrists recognize the opportunities and pitfalls that exist, and make considered choices about how to navigate these.
Presenter 1
Conflict between Service and Training Needs
K Baheti
1,2
1Trainee Representative Committee, The Royal Australian and New Zealand College of Psychiatrists
2Western Sydney Local Health District, Sydney, Australia
Background: Medicine has been based on a model where the focus is to train doctors to deal with individuals and not organizations. Doctors have been trained to do their best for each patient rather than make trade-offs in a resource-constrained setting. Little training is given to prepare doctors for this and as a result they face substantial difficulties, which leads to stress and frustration (Nigel et al., 2002).
It is challenging for a trainee to navigate the expectations of their employers and their training college. There is a dissonance between what trainees might have expected their training to be and how it is in practice.
Objectives: This session aims to explore how service requirements could be different to training requirements.
Methods: To discuss various examples highlighting conflicts between service and training requirements.
Findings & Conclusions: There will always be a gap between a trainee’s expectations and organizational needs and we should try to bridge this gap to ensure better care for patients.
Reference
Nigel E, Mary JK, Jack S (2002) Unhappy doctors: What are the causes and what can be done? British Medical Journal 324: 835–838.
Presenter 2
Supervisor Roles
S Mathews
1,2
1Trainee Representative Committee, The Royal Australian and New Zealand College of Psychiatrists
2Rockingham General Hospital, Western Australia, Australia
Background: Supervision is a critical component of psychiatric training. The Royal Australian and New Zealand College of Psychiatrists’ Competency Based Fellowship Programme (CBFP) changed the nature of supervision. The focus on workplace-based assessments brought structure at the expense of flexibility and reflective space. The supervisor role transformed to one of assessor, possibly adding complexity and conflict, particularly when the supervisor is also the line manager. Opportunities for growth and development arise from conflict and complexity, with potential for modelling and skill development to assist trainees in managing multiple roles as they progress through training.
Objectives: This session aims to explore the intersecting roles of supervisor, assessor and manager, and their impact on training.
Methods: Discussion of the multiple supervisor roles, the shift to supervisor as assessor with the CBFP, and the influence of a supervisor’s ability to manage these intersecting roles on the trainee.
Findings and Conclusions: Quality supervision supports personal and professional development, assists trainees in navigating the service-training interface, models ethical and reflective practice, and fosters skills in managing multiple roles. Substandard supervision may adversely impact training and welfare. Improving supervision by identifying and addressing supervisor struggles with boundaries and managing multiple intersecting roles will enhance training and ultimately produce better future supervisors and psychiatrists.
Presenter 3
The Personal and Professional Selves
T Muller
Trainee Representative Committee, The Royal Australian and New Zealand College of Psychiatrists
Waikato District Health Board, Waikato, New Zealand
Background: Through both training to become a psychiatrist and working as one, one forms a professional identity. This identity is shaped partly by the expectations of the College, via examinations and training requirements, as well as through the values of the College set out in codes of ethics and position statements. The College’s contemporary mould of a psychiatrist includes a variety of roles as defined by the CANMEDS framework, including that of scholar, communicator and advocate in addition to the traditional role of medical expert.
The formation of professional identity may also be influenced by local and organizational culture, and examples set by mentors.
However, prior to the development of the professional self exists the personal self, or what Winnicott (1965) referred to as the ‘true self’. This self consists of one’s values, beliefs and ways of being and relating. This self is forged in infancy by forces that act across the lifespan.
Ideally, the personal and professional selves coexist in harmony; however, the potential for conflict is ever present. Additionally, the balance of the needs of personal and professional life affects this harmony.
Objectives: This session aims to explore the separation and integration of the personal and professional selves.
Methods: Discussion of the two different selves, their commonalities, the boundaries between the identities, and appropriately managing the coexisting selves.
Findings & Conclusions: Awareness of the two selves and their appropriate balance and integration should be aimed for.
Reference
Winnicott DW (1965) Ego distortion in terms of true and false self. In: The Maturational Process and the Facilitating Environment: Studies in the Theory of Emotional Development. London: Karnac Books, pp. 140–157.
Autism Spectrum Disorder Over the Life Course: From Diagnosis to Management
V Eapen1, S Arnold 1,2, D Harley3, J Trollor1
1UNSW Sydney, Sydney, Australia
2Cooperative Research Centre for Living with Autism (Autism CRC), Brisbane, Queensland, Australia
3University of Queensland and Mater Hospitals, Brisbane, Australia
Background: Autism spectrum disorder (ASD) is a heterogeneous condition with varying aetiology and clinical presentations. The prevalence estimates range from 1 in 160 (World Health Organization 2017) to 1 in 58 (Centers for Disease Control and Prevention 2018) with an estimated annual cost of $9.7 billion to the Australian economy (Synergies Economic Consulting 2011).
Objectives: The variability in ASD signs and/or symptoms, along with the considerable overlap with other developmental and psychiatric conditions, poses a unique challenge in both diagnosis and management. This symposium will use a life course approach to cover early identification in the preschool years to diagnostic challenges during adulthood.
Methods: Review of literature and a critique of Australia’s first national guideline for the assessment of ASD concerns, which outlines processes for both diagnostic decision-making and the comprehensive assessment of individual support needs.
Findings: While diagnostic manuals such as the Diagnostic and Statistical Manual for Mental Disorders (DSM) and the International Classification of Diseases (ICD) provide clear behavioural criteria for diagnoses, the appraisal of co-morbid conditions such as anxiety, depression, attention-deficit hyperactivity disorder, obsessive–compulsive disorder and challenging behaviours relies significantly on clinician experience and skill sets. Symposium presenters will discuss issues around accurate identification and comprehensive assessment as well as the general principles of pharmacological management of such co-morbidities. Psychosocial and quality of life issues will also be addressed.
Conclusions: Early and accurate diagnosis alongside comprehensive assessment and management of co-morbidities can significantly improve the overall outcomes for individuals with ASD.
References
Centers for Disease Control and Prevention 2018 Prevalence of Autism Spectrum Disorder among Children Aged 8 years – Autism and Developmental Disabilities Monitoring Network, 11 sites, United States 2014. In Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. 2018, US Department of Health and Human Services.
Synergies Economic Consulting (2011) Economic Costs of Autism Spectrum Disorder in Australia, April 2011, pp. 1–144.
World Health Organization (2019). Autism spectrum disorders – key facts, 4 April 2017. Available at https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders.
Presenter 1
Journey is the Destination: Assessing ASD and Co-Morbid Conditions
V Eapen
Academic Unit of Child Psychiatry Southwest Sydney (AUCS), UNSW Sydney, Sydney, Australia
Background: The variability in the signs and symptoms of autism spectrum disorder (ASD), along with the considerable behavioural overlap with other neurodevelopmental conditions often leads to significant diagnostic challenges.
Objectives: This presentation will cover the overlap in clinical symptoms and the unique differentiations between ASD and the common co-morbidities such as attention-deficit hyperactivity disorder, obsessive–compulsive disorder (OCD) and Tourette syndrome.
Methods: Genetic, neuroimaging and clinical phenomenological studies will be examined to provide a framework for understanding the converging and yet distinct neuropathological processes involved in the pathogenesis of these conditions.
Findings: Neuroanatomical substrates involved in translating genetic vulnerability to varying clinical phenotypes mediated by disruption in neuronal development and circuitry formation will be discussed.
Conclusions: Understanding the convergence and divergence in the genesis of different clinical symptom constellations and clinical conditions has implications for the assessment and management of ASD and associated co-morbidities.
Presenter 2
Use of Psychotropic Medications in Adults with Autism?
D Harley
1,2,3
1Queensland Centre for Intellectual and Developmental Disability, South Brisbane, Australia
2Mater Research Institute – UQ, The University of Queensland, South Brisbane, Australia
3Mater Hospitals, Brisbane, Australia
Background: Autism spectrum disorder (ASD) is fairly common with prevalence estimated between 1 in 160 and 1 in 58. The cost to the Australian health system is high. Psychiatric illness, intellectual disability and challenging behaviour are frequent associations. Psychotropic drugs are often used. These sometimes improve patient’s lives, but evidence of effectiveness is not strong, and response is powerfully influenced by the social environment. Management decisions must be tempered by consideration of polypharmacy and co-morbidities. The latter include conditions associated with ASD (epilepsy particularly) and with high population prevalence (e.g. diabetes).
Objectives: To review the evidence for effectiveness and harm. Drug classes are antipsychotic and antidepressant medications. Use in challenging behaviour, psychosis, depression and anxiety will be discussed.
Methods: Evidence from observational and interventional epidemiological studies involving autistic participants will be examined. Where no evidence is available evidence will be obtained from studies of other patient groups.
Findings: Findings will be presented on the effectiveness and harms of psychotropic medications in adults with autism.
Conclusions: Adults with ASD present particular challenges in psychotropic prescribing. Greater evidence regarding efficacy and harm is needed.
Presenter 3
‘The Single Most Important Thing That Has Happened To Me in My Life’: The Impact of Receiving an Autism Diagnosis in Adulthood
S Arnold
1,2
1Department of Developmental Disability Neuropsychiatry, UNSW Sydney, Sydney, Australia
2Cooperative Research Centre for Living with Autism (Autism CRC), Brisbane, QLD, Australia
Background: Often with a history of misdiagnosis, a lost generation exists where autism diagnosis is only being realized in adulthood. Increased public and clinician awareness of autism, as well as changing diagnostic guidelines and understanding of the autism spectrum, is leading to this cohort of adults realizing their life experiences are best explained through the lens of autism. Few, primarily qualitative studies, have considered the self-reported impact of receiving an autism diagnosis in adulthood.
Objectives: With a focus on the ongoing development of the Impact of Diagnosis Scale – Revised (IODS-R), this presentation will cover the psychological impact for adults receiving autism diagnosis, linking to considerations for diagnosing clinicians.
Methods: The IODS (Courtney and Makinen, 2016) was initially developed with a focus on borderline personality disorder. A revised version is being developed in conjunction with a group of autistic advisors, with data gathered from the Cooperative Research Centre for Living with Autism’s Australian Longitudinal Study of Adults with Autism.
Findings: Preliminary analysis of IODS-R data suggests improved psychological well-being and greatly improved self-understanding across participants (n = 76), although there were neutral responses with regard to service accessibility following diagnosis. In synchrony with interview studies, several participants reported ‘relief’ at receiving an autism diagnosis, with past diagnostic overshadowing.
Conclusions: Autism is not a childhood-only condition. Many adults experience relief and improved self-understanding when correct diagnosis of autism is finally achieved. Screening tools are available and new diagnostic guidelines released. Clinicians need to understand the autism spectrum beyond stereotypes portrayed in the media.
Reference
Courtney DB and Makinen J (2016) Impact of diagnosis disclosure on adolescents with borderline personality disorder. Journal of the Canadian Academy of Child and Adolescent Psychiatry 25(3): 177–184.
Presenter 4
Old Dog, New Tricks: An Adult Psychiatrist’s View on Using the New Guideline for the Assessment and Diagnosis of Autism Spectrum Disorder in Clinical Practice
J Trollor
Department of Developmental Disability Neuropsychiatry, UNSW Sydney, Sydney, Australia
Background: Although autism is a lifelong condition, the current clinical focus within our profession is on children and younger people. About 1% of adults have an autism spectrum disorder, but many of these adults have not received a formal diagnosis. Reasons for this include barriers to assessment and limited availability of diagnostic assessments for those in older cohorts.
Objectives: This presentation will describe the implications of the new Guideline for the Assessment and Diagnosis of Autism Spectrum Disorder (the Guideline) released by the Cooperative Research Centre for Living with Autism (Autism CRC), for the assessment and diagnosis of autism in adults.
Methods: The role and responsibilities of the psychiatrist in the approach to adults presenting for diagnostic assessment of possible autism spectrum disorders will be examined with reference to the Guideline. The implications for the adult psychiatrist, including further need for training and clinical skills development, will be explored.
Findings: A comprehensive approach to the assessment of individuals presenting for diagnostic assessment of possible autism spectrum disorder has been outlined in the Guideline. The merits of such a rigorous approach will be discussed.
Conclusions: Adult psychiatrists have a key role in the diagnosis and management of adults with autism spectrum conditions. Knowledge and skills in this area will ensure people on the spectrum are supported to maintain optimum mental health.
Can the Arts Promote Workplace Culture Change – A Look at the Verbatim Theatre Play ‘grace Under Pressure’
L Nash1,2, KM Scott3, C Hooker4, K Ivory5, P Dwyer6, P Macneill4, J River7, J Dalton6, D Williams6
1Brain and Mind Centre, University of Sydney, Sydney, Australia
2Sydney Local Health District, Sydney, Australia
3Discipline of Child and Adolescent Health, University of Sydney, Westmead, Australia
4Sydney Health Ethics, University of Sydney, Sydney, Australia
5Sydney Public Health, University of Sydney, Sydney, Australia
6Performance Studies, University of Sydney, Sydney, Australia
7Faculty of Nursing, University of Sydney, Sydney, Australia
Background: Workplace mistreatment, burnout and suicide among front-line healthcare staff, particularly junior staff, remain significant issues in Australian healthcare. A multipronged approach including culture change is required.
Objectives and methods:
Report background research conducted by members of the Sydney Arts and Health Collective, highlighting the extent of medical students’ and junior clinicians’ experiences of bullying and harassment.
Describe the theoretical underpinning and methodology of applied theatre in addressing difficult social issues. As an example, we discuss the verbatim theatre play Grace under Pressure (script by David Williams and Paul Dwyer in collaboration with the Sydney Arts and Health Collective), which explores healthcare professionals’ experiences at work.
Explore the interrelationship between social and stage drama (Turner and Schechner) through an analysis of focus groups convened with audience members after Grace under Pressure.
Show filmed excerpts from Grace under Pressure that enable discussion of workplace difficulties, such as verbal mistreatment, burnout and suicidality, and safety with regard to shift work and fatigue.
Findings: Medical student and Junior Medical Officer surveys show mistreatment rates are high and often have poor outcomes if reported.
Verbatim theatre is a powerful means of making these issues topics of thoughtful discussion among healthcare staff. The play has promoted conversations about changing culture and the filmed excerpts can promote focused discussions in workshops.
Conclusions: The audience is invited to offer their responses to excerpts of the play. We encourage creative responses that facilitate positive change and discussion of barriers to change and suggestions for overcoming them.
Presenter 1
Mistreatment of Medical Students and Junior Doctors
K Scott1, L Nash2,3, K Ivory4
1Discipline of Child and Adolescent Health, University of Sydney, Westmead, Australia
2Brain and Mind Centre, University of Sydney, Sydney, Australia
3Sydney Local Health District, Sydney, Australia
4Sydney Public Health, University of Sydney, Sydney, Australia
Background: The mistreatment of student and junior health professionals has been highlighted in recent research publications and media reports in Australia and internationally.
Objectives: We report on research into medical students’ and junior doctors’ experiences of mistreatment in NSW and Victoria.
Methods: A 2014 survey about the experience of ‘teaching by humiliation’ was conducted at two Australian medical schools. Quantitative data were analysed using descriptive statistics, with thematic analysis of qualitative data. The Junior Medical Officer (JMO) survey was designed by junior doctors and delivered by snowballing to doctors in their first and second postgraduate year in 2015 and 2016 in NSW. Mixed methods were used to examine frequency and reporting outcomes of bullying and harassment.
Findings: In the research with 146/151 medical students (relative risk (RR) = 97%), 74.0% reported experiencing ‘teaching by humiliation’ and 83.1% had witnessed it. Students reported a range of responses to mistreatment, from disgust and regret about becoming a doctor, to approval of teachers publicly highlighting students’ poor knowledge. The results of the JMO survey with responses from 374 junior doctors in 2015 and 440 in 2016 (estimated RR = 17–20%) found that 54–58% had been bullied and 16–19% sexually harassed. Reasons for not taking action include workplace normalization of the behaviour, fear of reprisal and lack of confidence in the reporting process. Most respondents who took action reported ineffective or personally harmful outcomes.
Conclusions: Rather than focusing on improving students’ and junior doctors’ resilience, systemic changes are needed to target the normalization and consequences of mistreatment and increased training of front-line staff responsible for dealing with complaints.
Presentation 2
Art, Health and Social Change: The Impact of Verbatim Theatre on Health Professionals
L Nash1,2, KM Scott3, C Hooker4, K Ivory5, P Dwyer6, P Macneill4, J River7, J Dalton6, D Williams6
1Brain and Mind Centre, University of Sydney, Sydney, Australia
2Sydney Local Health District, Sydney, Australia
3Discipline of Child and Adolescent Health, University of Sydney, Westmead, Australia
4Sydney Health Ethics, University of Sydney, Sydney, Australia
5Sydney Public Health, University of Sydney, Sydney, Australia
6Performance Studies, University of Sydney, Sydney, Australia
7Faculty of Nursing, University of Sydney, Sydney, Australia
Background: The verbatim theatre play Grace under Pressure premiered at the 2017 Big Anxiety Festival in Sydney. The play examined workplace and training cultures that impact on young health professionals. The script was crafted solely from spoken words of 27 nurses and doctors at different career stages. Following Turner and Schechner’s theory about verbatim theatre’s interrelationship between social and stage drama, we wanted to stimulate debate about healthcare culture and how it might be improved. Our follow-up research, presented here, explores audience members’ response to Grace under Pressure.
Objectives: This session aims to describe the reasons for and the making of Grace under Pressure, and to present our follow-up research, exploring audience responses to Grace under Pressure.
Methods: Three focus groups of 84–126 min each were held with audience members from medical and nursing backgrounds 1 to 2 weeks after the play. Audio recordings were transcribed. Data were analysed through theoretical thematic analysis, following Turner and Schechner’s theory, using line-by-line coding and the constant comparison process.
Findings: Three main themes emerged. Participants reported that through watching Grace under Pressure, they: (i) recognized personal experiences, training experiences, the health system and how health professionals treat each other and their patients as an aspect of professionalism; (ii) obtained new insights into their personal situation as a health professional, the health system and broader society; (iii) identified the importance of addressing the problems faced by health professionals in the workplace.
Conclusions: Verbatim theatre proved to be a creative means to stimulate health professionals to reflect on and discuss healthcare workplace structures and culture. The results of this project also indicate there is momentum to challenge mistreatment in health professional education and healthcare settings.
Presentation 3
Excerpts From Grace Under Pressure: An Education Resource
L Nash1,2, KM Scott3, C Hooker4, K Ivory5, P Dwyer6, P Macneill4, J River7, J Dalton6, D Williams6
1Brain and Mind Centre, University of Sydney, Sydney, Australia
2Sydney Local Health District, Sydney, Australia
3Discipline of Child and Adolescent Health, University of Sydney, Westmead, Australia
4Sydney Health Ethics, University of Sydney, Sydney, Australia
5Sydney Public Health, University of Sydney, Sydney, Australia
6Performance Studies, University of Sydney, Sydney, Australia
7Faculty of Nursing, University of Sydney, Sydney, Australia
Background: Verbatim theatre is created from the words of the subjects of the play. Grace under Pressure was written by playwrights Paul Dwyer and David Williams in collaboration with the Sydney Arts and Health Collective, from interviews with doctors and nurses. The play premiered in October 2017 in Sydney with great success and continues to have rerun requests.
In addition to the play, video excerpts were filmed 1 week after the play and are used as a teaching resource. They vary in length from around 1 to 3 min.
Objectives and methods: This session aims to show several of the 12 teaching videos and to showcase teaching points from these videos and invite audience discussion.
Findings: In previous workshops/symposia, the filmed scenarios have promoted discussion and debate on the need and how to change the workplace culture.
Conclusions: Grace under Pressure opens a space for conversation about workplace issues in a compelling, confronting and hopeful work of theatre. The use of the arts for reflection on the workplace culture opens a space for conversations that can lead us towards culture change.
Telling Our Stories
N Beamish1, S Mackersey2, I Lim3, T Rhode4
1Chair of Membership Welfare Sub-Committee, Royal Australian and New Zealand College of Psychiatrists
2Chair of Membership Engagement Committee and Current Board Member, Royal Australian and New Zealand College of Psychiatrists
3Trainee Representative on the Membership Welfare Committee, Royal Australian and New Zealand College of Psychiatrists
4Cairns and Hinterland Mental Health and ATODS Service
Background: Storytelling has long been a part of human nature. To tell or to hear a story has the ability to bring to life the challenges we face, tune our moral compass, connect us to others or realize a truth. The Royal Australian and New Zealand College of Psychiatrists Membership Engagement Committee’s primary focus is on member welfare. We believe that storytelling has a role to play in collectively considering and exploring welfare matters in the College by allowing a reflective creative space for presenters and the audience to consider together member welfare.
Objectives: This symposium has the objective of bringing together a diverse group of psychiatrists to tell a story of their choice. The focus of the symposium will be to bring to light matters that affect member welfare.
Methods: Four to six storytellers will have 10 min each to tell their story. Stories may include music, art or multimedia productions. The Chair will contribute to the session by weaving their own and other stories together. Storytellers are anticipated to have some time to talk among themselves about the stories presented. The format of the symposium will not include question time.
Findings: It is anticipated that the creative flow and personal nature of the stories in the symposium will allow attendees a reflective space to consider the often complex matter of member welfare.
Conclusions: Diversity in the College membership brings a richness to our professions. By providing a forum for members to tell their stories, this symposium hopes to bring creativity, truth and light to the difficult matter of how we manage our occupations and lives via the stories we all carry within us.
Novel Perspectives on Obsessive–compulsive and Related Disorders
V Brakoulias1,2, D Castle2, L Fontenelle3,4,5,6, I Perkes2,7, V Eapen7, P Bosanac8,9
1Blacktown Hospital, Sydney, Australia
2The University of Sydney, Sydney, Australia
3Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
4D’Or Institute for Research and Education, Rio de Janeiro, Brazil
5Monash University, Melbourne, Australia
6The Brazilian Consortium on Obsessive–Compulsive Spectrum Disorders, Brazil
7University of New South Wales, Sydney, Australia
8St Vincent’s Hospital, Melbourne, Australia
9University of Melbourne, Melbourne, Australia
Background: Obsessive–compulsive disorder (OCD) is one of our most disabling medical disorders. It is associated with either a relapsing–remitting or chronic course and it is regarded as challenging to treat.
Objectives: This symposium aims to present some novel perspectives on the conceptualization and treatment of OCD.
Methods: Local and international experts will present recent findings from the cutting edge of OCD research.
Findings: Research indicates that OCD often develops early in life and that subthreshold symptoms may be present many years before the onset of the disorder. Longer delays in treating OCD are associated with more severe and disabling OCD symptoms. There is merit in establishing prevention and early intervention programmes for OCD. There are also several novel biological therapies, such as deep brain stimulation, that are being tested on patients with OCD and that are providing hope for chronically affected and treatment-resistant patients.
Conclusions: Novel perspectives on the conceptualization of OCD and innovative treatments and prevention programmes are being researched. It is likely that treatment outcomes for patients with OCD are going to improve in the coming decade.
Presenter 1
Early Intervention and Prevention For Obsessive–compulsive Disorder
V Brakoulias
1,2
1Blacktown Hospital, Sydney, Australia
2The University of Sydney, Sydney, Australia
Background: Obsessive–compulsive disorder (OCD) can strike early in life and lead to significant disability. With patients reporting subclinical symptoms prior to the development of their disorder, together with positive family histories, clinicians are taking note of emerging research indicating that early treatment is associated with improved outcomes and are calling for early intervention programmes for OCD.
Objectives: This session aims to review the evidence for early intervention and prevention for OCD.
Methods: Recent literature and potential approaches to early intervention will be discussed.
Findings: Primary prevention strategies for OCD are limited by our current limited understanding of the factors associated with the development of OCD. Psychoeducation and the reduction of family accommodation (i.e. the act of parents, siblings or partners accommodating to an affected individual’s requests to comply with their compulsions) are promising areas for secondary prevention and early intervention in high-risk groups. Tertiary prevention strategies also have significant potential when considering that patients experience delays in receiving evidence-based therapies (e.g. exposure and response prevention, and harmful complications such as renal impairment, skin conditions and contractures).
Conclusions: There is merit in considering early intervention and prevention for OCD. Although more research is needed in relation to the prevention of OCD, there is potential for strategies addressing environmental factors (e.g. family factors), providing psychoeducation for parents with OCD themselves, and tertiary prevention strategies for reducing the impact of OCD when it has developed. Practical strategies to improve access to appropriately trained and experienced therapists may produce significant benefits for patients with OCD.
Presenter 2
The Speed of Progression Towards Obsessive–compulsive Disorder: Heading From Compulsivity to Diagnosis
LF Fontenelle1,2,3,4, YA Ferrão4, AR Torres4, MC Rosário4, RG Shavitt4, M Yücel4, EC Miguel4, The Brazilian Consortium on Obsessive–Compulsive Spectrum Disorders
1Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
2D’Or Institute for Research and Education, Rio de Janeiro, Brazil
3Monash University, Melbourne, Australia
4The Brazilian Consortium on Obsessive–Compulsive Spectrum Disorders, Brazil
Background: There is current interest in the elaboration of early intervention programmes in obsessive–compulsive disorder (OCD). To this end, it is important to investigate how fast is the progression from subthreshold symptoms towards clinically diagnosable OCD.
Objectives: In this study, we have retrospectively investigated the speed of progression towards full-blown OCD and the correlates of acuteness in a large sample of Brazilian OCD patients.
Methods: A total of 961 patients enrolled in the Brazilian Consortium on Obsessive–Compulsive Spectrum Disorders were interviewed with a comprehensive assessment battery that included the interval (in years) between the onset of subthreshold symptoms and the distress resulting from OCD symptoms. A linear regression was performed to investigate predictors of faster onset.
Findings: It took a mean of 9.6 years (standard deviation = 11.5 years) for subthreshold symptoms to convert to diagnosable OCD. A faster onset of full-blown symptoms was associated with younger age, increased suicidality, more severe sex/religious symptoms, less severe hoarding and greater family history of alcohol abuse.
Conclusions: There is a specific phenotype within the OCD population that is more likely to escalate suddenly to clinical levels. This phenomenon, akin to the so-called ‘telescoping effect’ seen in alcohol and behavioral addictions, may indicate the existence of a vulnerable population that is more likely to benefit from early intervention initiatives.
Presenter 3
The Features and Treatment of Obsessive–compulsive Disorder in Children and Adolescents
IE Perkes
1,2
1University of New South Wales, Sydney, Australia
2University of Sydney, Sydney, Australia
Background: Understanding obsessive–compulsive disorder (OCD) and its treatment in children and adolescents is critical for psychiatrists to improve early intervention.
Objectives: Identify relevant features and treatment of OCD in children and adolescents.
Methods: An Internet-based literature search and review.
Findings: Early childhood ritualistic behaviour may predict OCD; however, evidence does not support treatment at this stage. Prepubertal OCD is associated with a greater genetic contribution and male preponderance. OCD has a bimodal (11 and 18 years of age) onset. Many children with OCD do not report obsessions, even with long-term follow-up. These factors impact on treatment selection.
OCD, attention-deficit hyperactivity disorder and tic disorders are genetically linked and commonly co-morbid. Sequelant depression and anxiety may trigger presentation. These co-morbidities should be routinely screened for and treated if present.
Behavioural ‘accommodation’ of compulsions by family members predicts poorer outcomes and family-based interventions can reduce accommodation and improve outcomes. First line treatments (selective serotonin reuptake inhibitors (SSRIs) and exposure and response prevention) are similar to adults except that exposure and response prevention needs to be tailored to include families. However, there is minimal evidence supporting second-generation antipsychotic augmentation in this cohort.
Conclusions: OCD normally has its onset during childhood or adolescence. Exposure and response prevention and SSRIs are treatment mainstays. Accommodation should be screened for and managed by including families in assessment and therapy. Evidence does not support second-generation antipsychotic augmentation.
Presenter 4
Understanding the Relationship Between Tic Disorder and Obsessive–compulsive Disorder
V Eapen
University of New South Wales, Sydney, Australia
Background: Gilles de la Tourette syndrome (GTS) and related neurodevelopmental disorders such as obsessive–compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD) may share overlapping and yet distinct genetic underpinnings, neuropathological processes as well as neurochemical and circuitry involvement. For example, those with only striatal circuitry involvement may present with ‘pure’ GTS characterized by predominantly tic symptoms, while those with more extensive involvement of the frontocortical networks may be associated with ADHD and impulse dyscontrol behaviours, while basal ganglia limbic circuitry involvement may present as co-morbid obsessive compulsive symptoms, resulting in what is described as GTS ‘plus’.
Objectives: This presentation will cover the overlap in clinical symptoms and the unique differentiations between GTS and the common co-morbidities such as obsessive–compulsive behaviours and OCD.
Methods: Genetic, neuroimaging and clinical phenomenological studies will be examined.
Findings: Available evidence suggests that the co-morbidities and severity of involvement may be a function of the site and extent of involvement of the cortico-striato-pallido-thalamo-cortical circuitry as impacted by the penetrance, as well as the gender-dependent, differences in the expression of the putative gene(s) in addition to other modulating factors including epigenetic, perinatal and postnatal biological, immunological and environmental factors.
Conclusions: Recent advances in genetic technology coupled with the availability of statistical programmes that allow cross-disorder transdiagnostic analysis of risk, further facilitated by neuroimaging studies and animal models, is expected to advance the field and help elucidate the genetic as well as clinical phenotypic link between GTS and OCD.
Presenter 5
New Treatments in Obsessive–compulsive Disorder
P Bosanac
1,2
1St Vincent’s Hospital, Melbourne, Australia
2University of Melbourne, Melbourne, Australia
Background: Obsessive–compulsive disorder (OCD) affects around 2% of the general population. Even when evidence-based treatments are utilized, approximately 30–40% of consumers do not respond adequately and 10% remain severely afflicted. Hence, there is a substantial need for novel and effective treatments for severe and treatment-refractory OCD.
Objectives: This session aims present the clinical and qualitative outcome of six participants who have had deep brain stimulation (DBS) bilaterally to the nucleus accumbens, between 2014 and 2018 at St Vincent’s Hospital, Melbourne.
Methods: Quantitative psychopathology and qualitative data will be presented.
Findings: The outcomes have been encouraging, although variable: one participant had a dramatic, almost total resolution of OCD symptoms with the ‘burden of normality’, while four others have had a slower improvement trajectory, and another has had minimal response. Clinical heterogeneity, psychiatric co-morbidity and the absence of treatment-response predictors impact on evaluation and prognostication.
Conclusions: While DBS in OCD can have significant and beneficent quantitative and qualitative outcomes, clinical staging for treatment-refractoriness, prognosis and response, and more personalized DBS treatment algorithms and psychological approaches are required.
The Guddi Partners Project
P White1, C Townsend2,3,4, J Cullen1,4, A Lakhani3, A White1, M McIntyre2,3, C Wright2,3
1Specialist Disability Services Assessment and Outreach Team, Department of Communities, Disability Services, and Seniors, Brisbane, Australia
2Synapse Australia, Brisbane, Australia
3The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
4James Cook University, Townsville, Australia
Background: The Guddi Partners Project is a collaboration between Synapse; Specialist Disability Services Assessment and Outreach Team, Department of Communities, Disability Services, and Seniors; Griffith University; and Indigenous communities. We form partnerships with communities and organizations to develop culturally safe ways of understanding complex disablement including mental health disorders and neurocognitive disability. We advocate for policy and service development and reform built on this knowledge.
Objectives:
This session aims to:
establish the extent and nature of complex disablement among marginalized Aboriginal and Torres Strait Islander peoples;
enhance service capacity to understand and respond effectively to this cohort using culturally safe processes;
promote intersectoral collaboration and influence policy.
Methods: Multiple projects focused on the needs of Indigenous people with complex disabilities, underpinned by community partnerships and rigorous mixed-method data analysis. Central to the project is the Guddi Protocol, a culturally safe assessment tool, and ‘Proper Way’ methodologies. Each piece of work stands alone but is linked to the others by framework, structure, values and methodologies.
Findings: A total of 250 Guddi assessments undertaken across Australia revealed high levels of complex disability and high service uptake of the Guddi Protocol. The evidence base established has informed policy and service development by focusing on the needs of First Peoples who experience complex disability.
Conclusions: Research within The Guddi Project can inform effective, culturally safe evidence-based policy reform. Better understandings of complex disability across sectors including mental health and disability; homelessness; criminal justice; and youth justice are needed to inform policy and practice.
Presenter 1
Development of the Guddi Protocol
P White1, C Townsend2,3,4, J Cullen1,4, A Lakhani3, A White1, C Wright2,3, M McIntyre2,3
1Specialist Disability Services Assessment and Outreach Team, Department of Communities, Disability Services, and Seniors, Brisbane, Australia
2Synapse Australia, Brisbane, Australia
3The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
4James Cook University, Townsville, Australia
Background: The extent, experience and assistance needs of Indigenous peoples with complex disability including mental health disorders and neurocognitive disability (NCD) is unknown. NCD relates to any disorder of the brain affecting cognitive, physical, emotional and/or behavioural functioning. Services report lack of knowledge or tools to understand and support people with complex disability. Many remain disengaged from research and mainstream services due to a lack of culturally safe practices.
Objectives: This session aims to:
develop a culturally safe and culturally informed assessment tool and engagement methodology to support services and communities to identify and respond effectively to First Australians experiencing complex disablement and
add to the evidence base to better address policy and service responses to this cohort.
Methods: The Guddi Protocol is a culturally safe assessment process including questions relating to thinking skills, psychosocial functioning, depression, psychosis, post-traumatic stress disorder and alcohol and drug use.
Findings: Services report that training in The Guddi Protocol has increased workforce and organizational capacity. The establishment of a data repository provides evidence to influence policy.
Conclusions: Community partnerships and culturally safe methodologies facilitate service user engagement in research and contribute to an accurate evidence base to inform the development of policy and services that more effectively meet the needs of Aboriginal and Torres Strait Islander people affected by complex disability.
Presenter 2
Understanding Complex Disablement Among Marginalized Indigenous Australians: Insights from the Quigley Street Night Shelter Project
P White1, C Townsend2,3,4, J Cullen2,4, A Lakhani3, A White1, M McIntyre2,3, C Wright2,3
1Specialist Disability Services Assessment and Outreach Team, Department of Communities, Disability Services, and Seniors, Brisbane, Australia
2Synapse Australia, Brisbane, Australia
3The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
4James Cook University, Townsville, Australia
Background: In Australia, Indigenous peoples experience higher rates of complex disability including poor mental health and neurocognitive disability (NCD) (Baldry et al., 2012). Indigenous Australians with complex disability are particularly at risk of homelessness. The level and nature of complex disability among homeless Indigenous Australians is poorly understood, and their needs have been minimally serviced. Lack of knowledge and culturally safe assessments contribute to challenges for service providers.
Objectives: The study sought to:
establish and describe the extent and nature of complex disability in a cohort of (primarily) Indigenous people experiencing homelessness in Cairns, North Queensland;
increase service capacity to identify and respond to complex disability through training; and
contribute to a data repository.
Methods: A point prevalence study was undertaken. People using the Anglicare Quigley Street Night Shelter Cairns undertook a clinical assessment, including the Guddi assessment protocol (n = 60). Stakeholder interviews were also undertaken.
Findings: High prevalence of complex disability including: acute psychosis (n = 7); post-traumatic stress disorder; depression; NCD (n = 37), chronic illness, psychosocial issues, and functional impairment. Training in The Guddi Protocol increased workforce and organizational capacity.
Conclusions: Better understandings of complex disability in this cohort needed to inform policy and practice. Culturally safe and appropriate assessment processes and enhanced service capacity are vital to better outcomes for this underserved cohort.
Presenter 3
Exploring the Experiences and Needs of Homeless Aboriginal and Torres Strait Islander Peoples with Neurocognitive and Complex Disability
C Townsend1,2,3, M McIntyre1,2, C Wright1,2, A Lakhani2, P White4, J Cullen1,3
1Synapse Australia, Brisbane, Australia
2The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
3James Cook University, Townsville, Australia
4Specialist Disability Services Assessment and Outreach Team, Department of Communities, Disability Services, and Seniors, Brisbane, Australia
Background: Aboriginal and Torres Strait Islander peoples are significantly over-represented in homeless, mental illness and disability populations. Understandings about the lived experiences of this cohort are poor and are needed to guide policy and practice.
Objectives: The study sought to understand the experiences of homeless Indigenous people with complex disability residing in Far North Queensland.
Methods: The study design utilized culturally safe and respectful methods, informed by the principles of participatory action research, which seeks to promote social justice, transformation and collaboration (Reason, 1994). A culturally safe and acceptable structure of ‘past, present and future’ was applied to open-ended questions. Thematic analysis (Braun & Clarke, 2006) was used to code and analyse data.
Findings: Thematic analysis identified four major themes: (i) normalization of illness and disability; (ii) trauma and loss; (iii) socioeconomic disadvantage; and (iii) disempowerment.
Conclusions: While causal links between life experience, mental illness, disability and disablement are not always clear, our findings suggest that attempts to address homelessness must engage with this complexity. The application of holistic, intersectoral supports that understand the impact of individual and intergenerational trauma and encompass culturally informed, community-driven approaches to safe and effective service provision must be adopted.
Presenter 4
Identifying Complex Disability in Murri Court Participants
M McIntyre1,2, P White3, C Townsend1,2,4, A White4, J Cullen1,4
1Synapse Australia, Brisbane, Australia
2The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
3Specialist Disability Services Assessment and Outreach Team, Department of Communities, Disability Services, and Seniors, Brisbane, Australia
4James Cook University, Townsville, Australia
Background: The need for improved assessment and management processes to identify complex disability including mental health disorders, alcohol and drug misuse and neurocognitive disability (NCD) in the Criminal Justice System (CJS) and reduce Indigenous incarceration and reoffending is well recognized (COAG, 2016; Sofronoff, 2016). There is an absence of culturally safe assessments to inform the court as to the presence and nature of complex disability and its impact on offending behaviour and adherence to bail conditions and court orders. This impacts on the court’s ability to determine appropriate sentencing, diversionary programmes and post-release support.
Objectives: To improve information provided to Brisbane Murri Court regarding complex disability including mental health disorders, alcohol and drug misuse, and NCD through application of a culturally safe assessment tool (The Guddi Protocol).
Methods: Routine Guddi assessments were undertaken for people pleading guilty in the Murri Court at pre-sentencing, and reports made available to the Court to inform sentencing and post-release decisions. The interview questionnaire explored the utility and acceptability of the tool in this setting.
Findings: Results included high levels of complex disability and functional impairment; improved assessment of Murri Court participants; enhanced quality of information provided to the Murri Court; enhanced Court knowledge about impacts of complex disability; and a high level of acceptance of the Guddi Protocol by stakeholders.
Conclusions: The Guddi Protocol shows promise as a culturally safe and appropriate method to identify complex disability in Murri Court participants; the Protocol contributes to more effective sentencing responses, which could ultimately reduce recidivism and prison overcrowding.
References
Baldry E, Dowse L and Clarence M (2012) People with intellectual and other cognitive disability in the criminal justice system. Sydney: University of New South Wales.
Braun V and Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101.
COAG (Council of Australian Governments) (2016) Prison to work report.
Reason P (1994) Three approaches to participative inquiry. In: Denzin NK and Lincoln YS (eds), Handbook of qualitative research, 1st ed. Thousand Oaks, CA: Sage, pp. 324–339.
Sofronoff W (2016) Queensland Parole System Review. Final Report November 2016. Queensland Corrective Services: Brisbane
Pacific Mental Health Forum
K Jenkins, Invited guests
The Royal Australian and New Zealand College of Psychiatrists
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has held Asia–Pacific Mental Health Forums since 2013 and continues to prioritize cementing the RANZCP as a leading collaborator in mental healthcare throughout Asia and the Pacific.
In 2018, the RANZCP held its first Pacific Mental Health Forum, and more than 30 regional mental health leaders were invited to discuss a range of issues pertinent to their respective countries, including mental health service delivery, workforce and training.
Conclusion: The 2019 Pacific Mental Health Forum will expand on these discussions to develop strategies to better support mental health practice in the Pacific region, with a particular focus on education and training. The Pacific mental health leaders will share how mental healthcare and training can best be tailored for the needs of local populations, which will be followed by a roundtable discussion to identify opportunities for collaboration.
Factors Influencing the Course of Mental Disorders in Childhood and Beyond
CM Middeldorp1,2,3, JG Scott4,5,6, M Tunbridge7, S Stathis7, AJ Guastella8, D Coghill9
1Child Health Research Centre, University of Queensland, South Brisbane, Australia
2Child and Youth Mental Health Service, Children’s Health Queensland Hospital and Health Service, South Brisbane, Australia
3Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
4Faculty of Medicine, The University of Queensland, Herston, Australia
5Queensland Centre for Mental Health Research, Wacol, Australia
6Metro North Mental Health, Royal Brisbane and Women’s Hospital, Herston, Australia
7Child and Youth Mental Health Service, Children’s Hospital and Health Service District, South Brisbane, Australia
8Brain and Mind Centre, University of Sydney, Sydney, Australia
9Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
Background: Epidemiological studies have shown that about 50% of the children with mental disorders still fulfil the criteria for a mental disorder in adulthood.
Objectives: The symposium discusses factors influencing course of childhood psychopathology and possible interventions to prevent poor outcome.
Methods: The symposium will start off with a presentation about the role of genetic and other familial factors influencing childhood psychopathology, including anxiety, depression, attention-deficit hyperactivity disorder (ADHD) and behavioural problems. The other presentations will focus on specific disorders or symptoms (i.e. aggression, social problems and ADHD).
Findings: All mental problems in childhood show some continuity into adulthood, but there is also variation in course.
Conclusions: Interventions should particularly focus on improving long-term outcomes for childhood psychopathology.
Presenter 1
The Course of Childhood Psychopathology: The Role of Genetic Factors and the Association with Parental Symptoms
CM Middeldorp
1,2,3
1Child Health Research Centre, University of Queensland, South Brisbane, Australia
2Child and Youth Mental Health Service, Children’s Health Queensland Hospital and Health Service, South Brisbane, Australia
3Biological Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
Background: It is well established that psychopathology runs in the family, mostly due to heritable factors, but in childhood also due to common environmental factors. These genetic and familial factors may also influence the course.
Objectives: This presentation will focus on (i) how genetic factors influence stability and (ii) how the course of childhood psychopathology is associated with childhood mental health.
Methods: The role of genetic factors in stability has been investigated by analyses of twin data. Further, polygenic risk score analyses have been performed to show whether genetic factors play a role in the transition of childhood symptoms into severe adult mental illness such as schizophrenia.
Finally, data collected in families evaluated at child and adolescent psychiatric outpatient clinics in the Netherlands were analyzed to estimate the association in the course of parental and offspring psychopathology
Findings: The twin and polygenic risk score analyses revealed that genetic factors explain most of the persistence of symptoms from childhood to adulthood and also the development into severe mental illnesses. The clinical data showed that children with parents with mental health issues still have higher symptom scores at the end of treatment, which is mainly explained by their higher symptom scores at the start and by ongoing associations with parental symptoms.
Conclusions: Genetic factors play a role in the course of psychiatric symptoms from childhood onwards. Families with both child and parent(s) suffering from psychopathology are a vulnerable group as they are at risk for poor outcomes.
Presenter 2
An Overview of Aggression in Children and Adolescence
JG Scott1,2,3, M Tunbridge4, S Stathis4
1Faculty of Medicine, The University of Queensland, Herston, Australia
2Queensland Centre for Mental Health Research, Wacol, Australia
3Metro North Mental Health, Royal Brisbane and Women’s Hospital, Herston, Australia
4Child and Youth Mental Health Service, Children’s Hospital and Health Service District, South Brisbane, Australia
Background: Aggression is a common transdiagnostic clinical problem seen in children and adolescents presenting to health services. Understanding the risk factors and trajectory of aggression in children can inform preventative and intervention strategies.
Objectives: This presentation provides an overview of the individual and environmental factors that lead to persistence of aggression from early childhood to adolescence. It examines the outcomes of children with aggression and considers opportunities for prevention and intervention.
Methods: The presentation reviews the literature on the trajectory of aggression in children. It reviews the preventative strategies and interventions available to manage aggression in children.
Findings: Aggressive children are more likely to experience physical and mental illness, unemployment, poverty and forensic problems as adults. Strategies to prevent aggression must address risk factors: low maternal education, adolescent pregnancy, in utero exposure to tobacco and alcohol, poverty, coercive parenting, childhood maltreatment and bullying victimization.
Conclusions: The aggressive child requires a comprehensive assessment to identify and manage underlying or co-morbid problems, to understand the reasons for aggressive behaviour and to detect modifiable factors which exacerbate or perpetuate the aggression. Psychosocial interventions include parenting skills training and child-directed cognitive behavioural therapy while pharmacotherapy may be used to treat underlying developmental or mental health problems or to manage the aggression.
Presenter 3
A Unified Approach for Targeting Circuits to Improve Social Development Outcomes
AJ Guastella
Brain and Mind Centre, University of Sydney, Sydney, Australia
Background: Social impairments are a core feature of developmental disorders such as autism spectrum disorder (ASD). Targeting social development in early life improves outcomes. There has been little research, however, integrating behavioural and neurobiological approaches to identify common mechanisms and circuits to optimize intervention.
Objectives: This presentation provides a brief review of social cognitive development across the lifespan in ASD and proposes a unified treatment model focusing on targeting specific circuits to improve social development in children. The model is then used to explore how treatment might be more precisely delivered to improve intervention outcomes.
Methods: The presentation reviews literature leading to conceptual development of a circuit-specific model of social learning. The notion of critical periods for learning are reviewed. Examples of relevant circuit and developmentally specific interventions are also reviewed.
Findings: Social impairments are a common and lifelong feature of disorders like ASD. Neurobiological targets to enhance outcomes are presented. Future intervention is likely to involve synergistic and developmentally specific approaches to medical and behavioural therapies to optimize social development.
Conclusions: Developmental disorders are complex and heterogenous disorders that are associated with multiple aetiologies and contributing factors. By providing a unified framework that focuses on treatment targets, there is greater potential to accelerate intervention efforts to improve outcomes for children with social difficulty.
Presenter 4
Plotting the Course of Attention-deficit Hyperactivity Disorder: Understanding the Developmental Trajectories Across the Lifespan
D Coghill
Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
Background: Attention-deficit hyperactivity disorder (ADHD) was for many years considered a disorder of childhood. It has now become clear that, while ADHD does sometimes remit early in life, many of those with ADHD continue to have impairing symptoms as adults.
Objectives: This presentation will describe the developmental trajectories for ADHD and investigate mediators and moderators of persistence and remission.
Methods: The presentation is based on a review of recently reported findings in the international literature.
Findings: There is a consensus that many of those with ADHD as a child continue to suffer from ADHD-related impairments as adults and that a proportion of those with childhood ADHD will continue to meet full diagnostic criteria. While the initial data from the United States suggested rates of persistence around 20% more recent data from Europe puts the figures much higher (even as high as 90%). There are both continuities and discontinuities at the clinical level across development. Several theories have been proposed to explain these differences. More recently, it has been proposed that ADHD can arise de novo in adults. This claim has been extremely controversial and is still being hotly debated. The mediators and moderators of persistence and remission have been difficult to identify; however, several candidates have been identified.
Conclusions: ADHD is a complex neurodevelopmental disorder that usually starts in childhood but often continues into adulthood. The trajectories of ADHD are varied but there are clear patterns. The clinical skills required to assess and manage ADHD are common to other aspects of our clinical work.
Zero Suicide in Mental Healthcare: The Gold Coast Experience
K Turner1, R Krishnaiah1, J Sveticic1, C Stapelberg1,2
1Gold Coast Health, Gold Coast, Australia
2Faculty of Health Science and Medicine, Bond University, Gold Coast, Australia
Background: In 2016, the Gold Coast Mental Health and Specialist Services (GCMHSS) initiated a Suicide Prevention Strategy (SPS) based on the Zero Suicide Framework. The strategy incorporates a systems approach to suicide prevention, with an aspiration of zero suicides, workplace culture change and process as well as outcomes evaluation.
Objectives: We present the broad range of outputs and outcomes that have been achieved across the life of the SPS, including implementation milestones, evaluation challenges and achievements and cultural change.
Methods: We present the SPS implementation in line with systems approaches, simultaneous implementation of strategies, as well as quantitative approaches to evaluation of the SPS
Findings: Progress of SPS implementation is described, along with organizational cultural change, and embedding of Restorative Just Culture Principles. Significant changes in clinician behaviour are demonstrated. Challenges in the identification and coding of suicide attempts and self-harm, and quantitative results of preliminary outcomes evaluation, are presented.
Conclusions: GCMHSS has achieved most of the key actions planned within the SPS, despite significant challenges and competing demands within the service, with changes to workplace culture evident and preliminary evidence of lower rates of suicide attempt representations for those engaged in the SPS. Learnings from the evaluation of this strategy have informed planning for the next phase of implementation.
Presenter 1
A Suicide Prevention Strategy Based on the Zero Suicide Framework: Progress and Achievements
K Turner
Gold Coast Health, Gold Coast, Australia
Background: In 2016, the Gold Coast Mental Health and Specialist Services (GCMHSS) initiated a Suicide Prevention Strategy based on the Zero Suicide Framework: The Suicide Prevention Strategy 2016–2018: Journey to Zero Through Leadership, Support and Continuous Improvement.
Objectives: The Zero Suicide Framework outlines a systems approach to suicide prevention within a health service that includes a strong focus on workplace culture change and stated ambitions of targeting zero which support this culture change. Also central is the provision of suicide specific, evidence-based practices, adherent to a continuous quality improvement approach. GCMHSS emphasized a Restorative Just Culture framework within this strategy.
Methods: GCMHSS Suicide Prevention Strategy engaged staff at all levels of the service, in partnership with consumers and carers and key external stakeholders, such as Patient Safety, Emergency Department Physicians, Primary Health Network and Community Members. In line with systems approaches, simultaneous implementation of strategies to address all of the seven key elements (Leadership, Training, Identify/Engage/Treat, Transition and Improve) was undertaken.
Findings: This presentation will outline the broad range of outputs and outcomes that have been achieved across the life of this Strategy, involving all weven essential elements of the framework.
Conclusions: By late 2018, GCMHSS had achieved most of the key actions planned within the Strategy, despite significant challenges and competing demands within the service. Broader organizational achievements have gained momentum due to the overall Strategy implementation process. Learnings from the evaluation of this strategy have informed planning for the next phase of implementation.
Presenter 2
Implementing a Suicide Prevention Pathway Within the Gold Coast Mental Health Service
R Krishnaiah
Gold Coast Health, Gold Coast, Australia
Background: In 2016, the Gold Coast Mental Health and Specialist Services (GCMHSS) implemented a Suicide Prevention Strategy based on the Zero Suicide Framework. Central to this framework is a Pathway of Care that meets the needs of each consumer, and includes collaborative safety planning, counselling on access to lethal means, evidence-based treatments that directly target suicidality, and ensuring continuous contact and support.
Objectives: GCMHSS engaged with staff, reviewed literature, engaged with leaders in suicide prevention efforts and collaborated with trainers to develop a Pathway of Care and associated supportive training. A change management and continuous quality improvement approach was undertaken to embed the Suicide Prevention Pathway into practice.
Methods: Critical elements of the pathway included adding Chronological Assessment of Suicide Events (Shawn Shea), a Prevention Oriented Risk Formulation (Pisani et al.), a Safety Planning Intervention including Counseling on Access to Lethal Means (based on Stanley and Brown) and rapid follow-up in the community. Training for all clinical staff supported the implementation.
Findings: Significant changes in clinician behaviour were demonstrated, with a shift from categorical risk prediction to formulation, and embedding brief interventions for suicidality within a busy emergency department setting. Good fidelity to the pathway is being demonstrated.
Conclusions: Results in the first 18 months of the implementation of the Suicide Prevention Pathway look promising, with a shift in workplace culture accompanying implementation of the Zero Suicide Framework, and improved outcomes for consumers who present with suicidal behaviour.
Presenter 3
How Can We Effectively Prevent Suicides in Healthcare If We Cannot Accurately Enumerate Them? Analysis of ICD-10 Codes Assigned to Self-harm Presentations in Emergency Departments
J Sveticic
Gold Coast Health, Gold Coast, Australia
Background: Accurate recording of suicidality in patients presenting to emergency departments (EDs) has been recognized as a particularly challenging element of suicide prevention and one that can have far-reaching implications on the provision of care, policy development and allocation of funding.
Objectives: Most hospital-based administrative data sets allocate each ED presentation relevant codes based on the International Statistical Classification of Diseases and Related Problems (ICD-10). We sought to determine which ICD-10 codes are being assigned to self-harm presentations, including suicide attempts and non-suicidal self-injury (NSSI), at Gold Coast Health and Specialist Services (GCHSS).
Methods: All self-harm presentations that occurred between July and December 2017 on the Gold Coast were identified through the application of a software tool Suicide Presentation Identification Tool for Emergency Department Information System (EDIS) Data. ICD-10 codes assigned to these cases were also extracted from EDIS. Clinical notes were examined for each presentation to confirm if the presentation was due to a suicide attempt or NSSI.
Findings: While a range of ICD-10 codes pertain to presentations due to intentional self-harm, only X84 (intentional self-harm by unspecified means) was utilized at GCHSS. Of 716 suicide attempts and 166 NSSI cases recorded in the 6-month period, 15.2% and 36.1%, respectively, had X84 recorded as the primary diagnosis. The most frequently assigned codes in suicide attempts were poisoning-related (ICD codes T38–T58).
Conclusions: An integrated and systemic approach is required to improve recording of suicide attempts in hospital settings through the development of more specific coding guidelines and training of ED staff.
Presenter 4
Suicide Prevention Strategy Outcomes Evaluation for 6-month 2017 Data – Information Gained and Next Steps
C Stapelberg
1,2
1Gold Coast Health, Gold Coast, Australia
2Bond University Faculty of Health Science and Medicine, Gold Coast, Australia
Background: In 2016, the Gold Coast Mental Health and Specialist Services (GCMHSS) implemented a Suicide Prevention Strategy, a key component of which was a clinical Suicide Prevention Pathway (SPP).
Objectives: An outcomes evaluation was undertaken with the objective of assessing whether repeated presentations to the emergency department (ED) after a suicide attempt were reduced for those on the SPP.
Methods: Suicidal presentations to GCMHSS EDs were assessed using World Health Organization (WHO) criteria, and the Consumer Integrated Mental Health Application (CIMHA) database to characterize type of self-harm and the number of re-presentations to ED. This outcome measure was compared between consumers who went on the SPP against those who did not, for the months of June–December 2017.
Findings: The percentage of index suicide attempt presentations to ED, followed by further suicide attempts, was lower for those who went on the SPP compared those consumers who did not, 7, 14, 30 and 90 days after index presentation.
Conclusions: Preliminary data suggest a reduction in subsequent ED representations for those consumers engaging in the SPP. Implications and limitations of the data are discussed and the next steps in outcomes evaluation are presented.
Presenter 5
Responding to Critical Incidents Including Suicides Using a Restorative Just Culture Framework
K Turner
Gold Coast Health, Gold Coast, Australia
Background: Aspirational goals such as targeting zero are believed to assist culture shifts and healthcare practice innovation and subsequent improvements in outcomes such as suicides. However, bold goals may lead to a blame culture or sense of failure and guilt among survivors, carers and clinicians. A Restorative Just Culture can mitigate against those risks.
Objectives: The Gold Coast Mental Health and Specialist Services (GCMHSS) recognized the need to embed a Just Culture alongside the implementation of the Zero Suicide Framework.
Methods: A review of concepts of Just Culture was undertaken by the service. Feedback from staff regarding their experiences following the loss of a consumer to suicide was obtained.
Findings: Restorative Just Culture moves away from retributive, backward-looking justice to a forward-looking model that asks the questions: who is hurt; what do they need; and whose obligation it is to meet that need, which facilitates healing, learning and improving. Engaging with all parties (the consumer, their families, clinicians and the organization) and addressing their needs is essential.
Conclusions: Moving beyond a theoretical framework, Restorative Just Culture Principles have been explicitly embedded into the process of responding to and learning from critical incidents such as suicides including the enhancement of clinician disclosure and postvention support of families; a programme to support clinicians following adverse events; a move away from a root cause analysis process to a central role for both the family and clinicians in the review process; and improvements in learning and sharing of learnings within the system and with family.
Neurosurgery for Psychiatric Disorders: An Update
P Mosley1,2,3, P Silburn2,3, T Coyne3,4, R Marsh2,5
1Systems Neuroscience Group, QIMR Berghofer Medical Research Institute, Herston, Australia
2Neurosciences Queensland, St Andrew’s War Memorial Hospital, Spring Hill, Australia
3Queensland Brain Institute, University of Queensland, St Lucia, Australia
4Brizbrain and Spine, the Wesley Hospital, Auchenflower, Australia
5Department of Psychiatry, Royal Brisbane and Women’s Hospital, Herston, Australia
Background: The overall goal of this symposium is to provide an overview of the use of neurosurgery to treat severe and treatment-resistant psychiatric disorders. It includes a review of the evidence for lesional and deep brain stimulation (DBS) therapies, as well as an overview of how DBS can be applied to mental disorders defined as disorders of neural network functioning. Preliminary results are presented from a current Australian trial of DBS for obsessive–compulsive disorder that incorporates novel electrophysiological and neuroanatomical data. The patient journey in a randomized, double-blind, sham-controlled DBS trial is described, in addition to qualitative reflections from patients and clinicians. This symposium includes contributions from a neurologist and neurosurgeon, both of whom are world experts in the practice of DBS and who contribute to the international science of this discipline.
Presenter 1
A Review of Neurosurgery for Psychiatric Disorders
T Coyne
1,2
1Queensland Brain Institute, University of Queensland, St Lucia, Australia
2Brizbrain and Spine, The Wesley Hospital, Auchenflower, Australia
Background: Neurosurgery for movement disorders such as Parkinson’s disease has a long and successful history, comprising stereotactic lesional surgery and (more recently) deep brain stimulation (DBS). Both surgical procedures are in widespread use in neurological conditions with demonstrated efficacy and safety. Neurosurgery for severe and treatment-resistant psychiatric disorders is an emerging treatment modality.
Objectives: This session aims to review the evidence, clinical and ethical considerations of neurosurgery for psychiatric disorders.
Methods: Data pertaining to lesional and DBS therapies for depression, obsessive–compulsive disorder (OCD), anorexia nervosa and addiction are presented.
Findings: Lesional therapy and DBS show considerable promise as therapies for intractable psychiatric conditions. Both treatment modalities have advantages and disadvantages. The response to neurosurgery appears to be slow and peak treatment effects are generally seen after 1 year or longer. Data are particularly strong for OCD and some bodies advocate for this to be an ‘accepted’ therapy. Randomized, double-blind, sham-controlled trials of DBS for depression were disappointing but the reasons for this can be partly explicated and novel data generate new optimism.
Conclusions: Neurosurgery for psychiatric disorders has a growing evidence. Collaboration between psychiatrists, neurologists and neurosurgeons is essential to ensure the optimization and effective delivery of this therapy.
Presenter 2
Deep Brain Simulation to Modulate Brain Networks in Psychiatric Disorders
P Silburn
1,2
1Neurosciences Queensland, St Andrew’s War Memorial Hospital, Spring Hill, Australia
2Queensland Brain Institute, University of Queensland, St Lucia, Australia
Background: Deep brain stimulation (DBS) is a minimally invasive surgical therapy that allows targeted modulation of brain networks implicated in psychiatric disease.
Objectives: This session aims to describe the practice and mechanism of DBS and its application to circuit models of psychiatric disease.
Methods: The application of DBS to specific psychiatric and neurological disorders is outlined.
Findings: DBS involves collaboration between a large group of scientists and clinicians. Using novel investigative techniques, neural activity underlying specific symptoms can be directly examined.
Conclusions: Some psychiatric disorders can be conceptualized as neural network disorders. DBS offers the opportunity to treat severe and intractable disease while contributing to knowledge about disorders of brain function and advancing neuroscience.
Presenter 3
Deep Brain Simulation of the Nucleus Accumbens For Severe, Treatment-resistant Obsessive–compulsive Disorder
P Mosley
1,2,3
1Systems Neuroscience Group, QIMR Berghofer Medical Research Institute, Herston, Australia
2Neurosciences Queensland, St Andrew’s War Memorial Hospital, Spring Hill, Australia
3Queensland Brain Institute, University of Queensland, St Lucia, Australia
Background: Some persons with obsessive–compulsive disorder (OCD) have treatment-refractory symptoms despite best-available pharmacological and psychological therapy. Emerging data suggest that deep brain stimulation (DBS) may be an effective treatment for such individuals.
Objectives: This session aims to describe the initial psychiatric and scientific outcomes from a clinical trial of DBS of the nucleus accumbens (NAcc) conducted at St Andrew’s War Memorial Hospital, Brisbane.
Methods: Eight individuals with treatment-refractory OCD received DBS of the NAcc in a randomized, double-blind, sham-controlled investigation incorporating longitudinal postoperative electrophysiological recordings from the NAcc using novel ‘sense and stimulate’ electrodes.
Findings: DBS of the NAcc was a safe and well-tolerated therapy and the majority of participants responded to treatment. Response to stimulation could be correlated with electrophysiological, functional imaging and anatomical data.
Conclusions: DBS of the NAcc for treatment-resistant OCD is a promising therapy for refractory symptoms. We contribute further data to global evidence supporting the use of this treatment modality to relieve suffering and improve quality of life.
Presenter 4
Deep Brain Stimulation in Psychiatry: The Patient’s Journey, Clinical Dilemmas and Ethical Issues
R Marsh
1,2
1Neurosciences Queensland, St Andrew’s War Memorial Hospital, Spring Hill, Australia
2Department of Psychiatry, Royal Brisbane & Women’s Hospital, Herston, Australia
Background: Deep brain stimulation (DBS) is an emerging therapy for treatment-resistant psychiatric disorders but many clinicians will have little practical experience of DBS, including how to refer suitable candidates and evaluate issues that might arise after a patient has received DBS.
Objectives: The aim of this session is to describe the journey of a patient through the DBS assessment and treatment pathway.
Methods: The qualitative experience of participants in a clinical trial of DBS for obsessive–compulsive disorder (OCD) is described, accompanied by the reflections of treating clinicians in the DBS team.
Findings: DBS for OCD had remarkable, life-changing benefits for some participants. Most individuals found that DBS reduced the salience of obsessive thoughts, allowing them to engage in exposure therapy for the first time. Cessation of stimulation was associated with a rebound of symptoms, necessitating close monitoring to prevent battery depletion. Existing challenges related to the healthcare system in Australia means that it is difficult for patients to receive ongoing therapy with DBS after completion of the clinical trial, a significant practical and ethical dilemma.
Conclusions: Internationally, DBS is increasingly becoming recognized as a beneficial treatment for previously treatment-resistant patients with psychiatric disorders. As a novel therapy, there are unique considerations that apply to this group and at present the treatment is restricted to clinical trials in specialized centres. However, as evidence accrues for the efficacy of DBS for OCD in particular, the use of DBS outside of a clinical trial could be justified.
Leadership and Management Debate: Clinical Governance is a Waste of Effort and Resources
N O’Connor1, Brett Emerson2,3, Ruth Vine4,5, Scott Clark6,7, Rees Tapsell8,9
1Northern Sydney Local Health District, Sydney, Australia
2Metro North Mental Health, Brisbane, Australia
3University of Queensland, Brisbane, Australia
4Northwestern Mental Health, Melbourne, Australia
5University of Melbourne, Melbourne, Australia
6Western NSW Local Health District, Orange, Australia
7University of Newcastle, Newcastle, Australia
8Waikato District Health Board, Waikato, New Zealand
9Auckland University, Auckland, New Zealand
Background: Rates of harm to patients in our hospitals and mental health services are significant and have not reduced substantially despite 20 years of investment. Clinical governance efforts have been focused on reducing medical errors, policy and procedures and compliance. There are many examples of accreditation and regulatory processes failing to prevent poor and unsafe practice and culture.
There are also examples of high-performance health organizations and a new generation of clinical governance approaches including resilient healthcare approaches and application of safety engineering from aviation and other high-performance industries.
Objectives: The debate aims to explore and elaborate on the problems, strengths, challenges, opportunities and new technologies of clinical governance.
Methods: Debate format:
Debate Moderator introduces the topic and speakers;
Moderator elicits an audience show of hands for and against the motion;
Two speakers for and two speakers against the motion;
Each speaker will speak for 10 min with PowerPoint slides if desired;
Each speaker will reply for 2 min (no PowerPoint slides);
Audience questions and discussion facilitated by the Moderator; and
Moderator revisits an audience show of hands for and against the motion.
Conclusions: Much can be learned from a systematic examination of the evidence in relation to the history, practice and outcomes of different approaches to clinical governance.
Indigenous Healing and Psychiatry: Partnerships and Capacity Building in Western Australia, Northern Queensland and Aotearoa New Zealand
H Milroy1, M Mitchell2, M Wenitong3, W NiaNia4, A Bush5
1School of Psychiatry, University of Western Australia, Perth, Australia
2Specialist Aboriginal Mental Health Service, Perth, Australia
3Apunipima Cape York Health Council, Cairns, Australia
4Te Kuwatawata, Tairawhiti District Health Board, Gisborne, New Zealand
5Te Whare Marie, Maori Mental Health Service, Capital Coast District Health Board, Porirua, New Zealand
Background: Indigenous healing practices for Aboriginal and Torres Strait Islander peoples in Australia, and Māori in Aotearoa, New Zealand, were the ‘mainstream’ for many generations prior to the systematic colonial suppression of Indigenous languages and healing practices following the arrival of European settlers. These practices commonly addressed spiritual healing and incorporated holistic values and Indigenous elders and health leaders have continued to insist that these aspects are necessary to address health problems for their communities. This symposium will describe partnerships between Aboriginal, Torres Strait Islander and Māori healers, and western medicine and psychiatry in a diverse range of contexts and locations from Western Australia, northern Queensland and New Zealand and focus on the processes involved in developing such services, outcomes and implications for Indigenous service provision in other contexts.
Burning Out, Burning in and Burning Around: Let’s Talk About Our Own Welfare in Psychiatry
M Forbes1, L Lampe2,3, D Nguyen4,5, K Jenkins3, S Suetani6
1Melbourne Medical School, University of Melbourne, Parkville, Australia
2School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
3Committee for Examinations, Royal Australian and New Zealand College of Psychiatrists
4Toowong Specialist Clinic, Toowong, Australia
5School of Medicine, The University of Queensland, St Lucia, Australia
6Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia
Background: Psychiatrists and psychiatry registrars are vulnerable to experiencing burnout due to factors such as patient violence, suicide, limited resources, high work demand, responsibility without authority, conflict between responsibility towards employers versus towards the patient and isolation. Doctor burnout is associated with negative effects on patient care and professionalism and can present a threat to the viability of the healthcare systems.
Objectives: This session aims to present some empirical information and personal views about the welfare of psychiatrists and trainees with the aim of increasing awareness of the topic and promoting active consideration of personal and systemic actions that can be taken to improve the welfare of psychiatrists and trainees.
Methods: A trainee psychiatrist, an early career psychiatrist, the Chair of the Committee for Examinations and the President of the College will integrate evidence from the literature with their own perspectives on welfare-related issues in psychiatry. The audience will be invited to participate in a 30-min panel discussion with the presenters after the individual presentations.
Findings: Welfare issues are common in all stages and areas of psychiatry and may be present with varying levels of severity and impact. There are significant personal, professional and community consequences when these issues are neglected. There are many potential solutions to increase well-being and overcome or reduce the burden of welfare-related distress.
Conclusions: Promoting the welfare of psychiatry registrars and psychiatrists is of upmost importance at a personal, College and systemic level.
Presenter 1
M Forbes
Melbourne Medical School, University of Melbourne, Parkville, Australia
Background: System-level failures (understaffing, adverse working environments, lack of support) can lead to individual burnout. While there have been efforts to enhance the resilience of doctors in Australia, resilience strategies alone will not be effective. They must be combined with system-level improvements.
Objectives: This session aims to provide practical examples of system barriers to trainee welfare and local and national strategies seeking to overcome these barriers.
Methods: Integration of findings from research literature and personal experience from my work on College Committees including the Trainee Representative Committee.
Findings: I will highlight a local example of a de-identified hospital with unsafe work hours for registrars and how the College and hospital network intervened to protect trainee welfare. I will also discuss broader strategies including the system-based approach to doctors’ health taken by the Australian Government in May 2016 with the introduction of a network of nationally consistent doctors’ health services (Drs4Drs.com.au).
Conclusions: The College, the Australian Medical Association and the Australian Government are all taking concerted action to reduce the risk of burnout in Australian doctors.
Presenter 2
L Lampe
1,2
1School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
2Committee for Examinations, Royal Australian and New Zealand College of Psychiatrists
Background: Becoming a psychiatrist requires successful navigation of a decade or more of assessment hurdles as medical students and psychiatry trainees. This calls for considerable fortitude. It is also an opportunity to develop the habits and resilience that can stand a psychiatrist in good stead for future ‘assessment’ hurdles such as postgraduate and continuing professional education, timely report writing and more stressful events such as critical events and inquiries.
Objectives: This session aims to:
demonstrate elements of continuity between assessment demands in medical school and psychiatry training and later professional practice and
highlight the importance of a longitudinal view and commitment to developing lifelong strategies for managing stress and promoting well-being.
Methods: Integration of findings from the research literature with personal observation and experience.
Findings: Assessments and their consequences present somewhat differently at different stages of a medical career; however, factors have been identified that are likely to increase coping and resilience. A long-term perspective, active identification of personally relevant strategies and positive practice are recommended for early adoption and continuing use.
Conclusions: Assessment-related stress can impact welfare but is not limited to the learner stages of a psychiatric career. Individuals are encouraged to develop their own repertoire of strategies to protect and nurture personal welfare.
Presenter 3
D Nguyen
1,2
1Toowong Specialist Clinic, Toowong, Australia
2School of Medicine, The University of Queensland, St Lucia, Australia
Background: Career transitions have been known to impact doctors, particularly with the steep learning curves that may not be apparent to them. Psychiatry is not immune to this. While the Royal Australian and New Zealand College of Psychiatrists examinations and Competency-Based Fellowship Programme aims to reduce this anxiety, the transition from registrar to Junior Consultant still creates angst among trainees and can lead to difficulties.
Objectives: This session aims provide a first-hand experience of the challenges of transitioning from a registrar to Junior Consultant, including welfare concerns, patient perceptions, managing difficult situations/scenarios, life–work balance and continued training (including continuing professional development (CPD)) from the lens of an Early Career Private Psychiatrist.
Methods: Discussion of challenges and possible strategies to help with managing the transition and early career. Challenges involve the case-mix, treating fellow doctors/psychiatrists and practitioners, self-care, supports, navigating CPD, the mindset of the ‘imposter’, perceptions of the public of your expertise and aspects of building your practice.
Findings: While the transition may provide anxiety, there are strategies and supports provided that may assist in this. More work needs to be done to help junior consultants be more at ease with their role and facilitate and encourage a long and enjoyable career in psychiatry.
Conclusions: Facilitating discussion regarding this is an important part of supporting future psychiatrists.
Presenter 4
M Forbes1, L Lampe2,3, D Nguyen4,5, K Jenkins3, S Suetani6
1Melbourne Medical School, University of Melbourne, Parkville, Australia
2School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
3Committee for Examinations, Royal Australian and New Zealand College of Psychiatrists
4Toowong Specialist Clinic, Toowong, Australia
5School of Medicine, The University of Queensland, St Lucia, Australia
6Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia
Background: Our own welfare is very important. There are many factors that impact our welfare at different levels.
Objectives: To facilitate a lively discussion among the audience and the panel/presenters.
Methods: Panel discussion.
Findings: To be discussed.
Conclusions: To be concluded.
First Responders’ Mental Health
K Jenkins, Invited Guests
The Royal Australian and New Zealand College of Psychiatrists
Background: In the past year, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) has turned its attention to the unique occupational risks associated with first responder and emergency service worker roles, and the mental health issues faced by some Australian first responders and emergency service workers. The RANZCP advocates for greater access to high-quality mental healthcare for this population.
This special presidential symposium, hosted by Dr Kym Jenkins, President, RANZCP, will consist of a panel of experts who work in first responder mental health and the heads of first responder organizations.
Methods: Panel members will describe the issues they see as crucial for improving first responder mental health.
Conclusions: Representatives from first responder organizations will outline the initiatives that their respective organizations have developed and established, and the psychiatrists who work in this field will showcase the opportunities for improving understanding, knowledge and best-practice mental healthcare for first responders.
Re-building Capacity in the Psychiatry of Intellectual and Developmental Disability: An Australian Jurisdictional Perspective
D O’Connor1, C Bennett2, C Franklin3, A Livingstone4, J Trollor5
1Department of Health and Human Services, Melbourne, Australia
2Victorian Dual Disability Service, St Vincent’s Hospital, Melbourne, Australia
3Queensland Centre for Intellectual and Developmental Disability, University of Queensland, Brisbane, Australia
4Psychiatry of Intellectual Disabilities, Child and Youth Mental Health Service, Townsville, Australia
5Department of Developmental Disability Neuropsychiatry, University of New South Wales, Sydney, Australia
Background: Mental health services throughout Australia have largely withdrawn from the field of intellectual and developmental disability. There are small publicly funded specialist services in some capital cities providing limited primary and secondary assessment and care, and a few private specialists with an interest in this area. In the United Kingdom, by contrast, intellectual disability psychiatry is a substantial field of endeavour.
While disability services provide excellent supports, they struggle to care for some individuals with very severe behavioural, psychological and behavioural symptoms. This results in some maladaptive ‘buck passing’ between service sectors. In extreme cases, people with disabilities are marooned in inappropriate mental health and even custodial settings for lengthy periods of time.
Conclusion: This symposium will describe the state of disability psychiatry in parts of Victoria, New South Wales and Queensland and explore reasons for this parlous state of affairs. Speakers will outline initiatives to re-build training and service capacity in a desperately under-resourced field.
A New College Faculty: The Faculty of Adult Psychiatry – How We Developed A Faculty and What the Adult Faculty Can Bring to Fellows
A Agnew1, M Atchison2, G Weir3
1Faculty of Adult Psychiatry, Royal Australian and New Zealand College of Psychiatrists
2Subcommittee for Advanced Training Adult Psychiatry, Royal Australian and New Zealand College of Psychiatrists
3Advanced Trainee Adult Psychiatry, Royal Australian and New Zealand College of Psychiatrists
Background: In 2017, a committee was formed to address the lack of a Faculty for what is arguably the largest group of specialists within the Royal Australian and New Zealand College of Psychiatrists (RANZCP). This is a description of the process of forming the Faculty and will discuss the purpose, aims and activities of the new Faculty into the future.
Objectives: The aim of the symposium is to articulate the aims and activities of the new Faculty and to encourage discussion and seek other ideas for ways in which the Faculty can further the cause of Adult Psychiatry for the benefit of people with mental illness and their carers and families.
Methods: The presenters will discuss the way in which the Faculty was set up, the organizational requirements for the Faculty and how these were met. The trainee representative will discuss how this has impacted on interest in Adult Psychiatry as a specialty training option and the Chair Subcommittee for Advanced Training Adult Psychiatry RANZCP will discuss the impacts of having an Adult Faculty on advanced training in Adult Psychiatry. There will be an opportunity for discussion and feedback from audience participants.
Presenter 1
The Development of an Adult Faculty: Growth and Birth of an Idea
A Agnew
Faculty of Adult Psychiatry, Royal Australian and New Zealand College of Psychiatrists
Background: In 2017, a committee was formed to address the lack of a Faculty for what is arguably the largest group of specialists within the College of Psychiatrists. This session will describe the process of forming a new Faculty and will articulate the aims and objectives of the Faculty.
Presenter 2
The Adult Faculty and Training in Adult Psychiatry
M Atchison
Subcommittee for Advanced Training Adult Psychiatry RANZCP
Background: This presentation will describe the activities of the Faculty over the next 2 years and will detail how the new Faculty will benefit training and promote a high standard of clinical practice, training and research pertaining to the practice of psychiatry with adults.
Presenter 3
An Adult Faculty: The Perspective of an Advanced Trainee in Adult Psychiatry
G Weir
Advanced Trainee Adult Psychiatry, Royal Australian and New Zealand College of Psychiatrists
Background: This presentation will discuss the benefits of having a Faculty from the perspective of an Advanced Trainee in Adult Psychiatry.
Borderline Personality Disorder: Diagnostic Complexity, Acute Service Utilization and Coronial Involvement – an Urgent Need for Training and Effective Intervention
S Rao, JH Broadbear, L Cheney, J Beatson
Spectrum, Personality Disorder Service for Victoria, Richmond, Australia
Background: Borderline personality disorder (BPD) is a chronic, relapsing disorder associated with severe psychological distress, social dysfunction, long-term disability and chronic suicidality. The critical shortage of BPD-appropriate psychotherapy contributes to a reluctance to diagnose, a high incidence of polypharmacy, frequent hospitalization, emergency department (ED) re-attendance and coronial involvement.
Objectives: The four presentations aim to highlight important BPD-related issues:
challenges in diagnosing depression when it co-occurs with BPD;
addressing the lack of age-appropriate screening tools for detecting BPD in the elderly;
presentation and experience of people with BPD who present to emergency departments; and
representation of BPD in death by suicide in Victoria.
Methods:
Depression severity was assessed in patients with BPD using a range of clinician and self-report instruments.
A retrospective case identification was conducted using the Victorian Suicide Registry.
A retrospective electronic audit of ED presentations was conducted in outer eastern Melbourne.
Registration details and participant feedback reported for six national webinars.
Findings:
Self-reported depression severity exceeded clinician-scored severity.
The incorporation of symptoms that reflect changes in BPD expression over the lifespan improves screening for BPD.
People with BPD are likely to re-attend the ED, wait longer to see a doctor and be admitted to Inpatient Psychiatric Unit (IPU).
On average there is one BPD-related suicide in Victoria every week; most had contact with health services proximal to suicide.
Conclusions: The importance of upskilling mental health services to provide evidence-based care is vital for arresting this vicious and self-perpetuating cycle.
Presenter 1
BPD and Depression
L Cheney, S Rao, JH Broadbear
Spectrum, Personality Disorder Service for Victoria, Richmond, Australia
Background: Research findings and clinical experience suggest that people with borderline personality disorder (BPD) are more likely to report greater severity of depressive symptoms than is objectively measured by their clinician. Previous work assessing differences in clinician and self-rated depressive symptom severity in patients with a sole diagnosis of major depressive disorder has shown that disparities may predict response to treatment; patients who had greater self-rated severity had a significantly lower rate of remission.
Objectives: This session aims to assess the outcomes using a range of depression rating scales, including ‘gold standards’ (the Hamilton Depression Rating Scale and Beck Depression Inventory) in people with BPD.
Methods: We administered commonly used rating scales to identify rates of depression among clients with BPD presenting to a specialist, personality disorder service. Data were collected using various clinician and client-rated scales at the time of initial assessment for BPD.
Findings: There were discrepancies between clinician and client ratings of depression. Clients were likely to self-report higher depression severity scores compared with clinician-rated scales, particularly on the K10 rating scale commonly used in general practice settings.
Conclusions: These results help to explain why people diagnosed with BPD do not respond to the standard treatments for depression. The findings also suggest the need for a new clinical approach to assessing depression in BPD, such as adopting a scale that incorporates personality features into depression rating scales to improve clinical practice.
Presenter 2
Pilot Study Evaluating a Brief Screening Tool for Borderline Personality Disorder in the Aged
J Beatson1, F Moss2, K Rodrigo2, H Jayaram3, A Planinic3, JH Broadbear1, Kuruvilla George3, S Rao1
1Spectrum, Personality Disorder Service for Victoria, Richmond, Australia
2St George’s Health Service, Aged Care, Kew, Australia
3Peter James Centre, Eastern Health, East Burwood, Australia
Background: There are no validated screening tools for the detection of borderline personality disorder (BPD) in elderly patients (60 years or older). This has led to failures in diagnosis and appropriate management. We developed a screening tool that reflects the changing symptomology of BPD during the ageing process.
Objectives: This session aims to examine the sensitivity of our Brief Screening Tool for BPD in Old Age (BPDOA) in (i) BPD confirmed and (ii) BPD negative individuals referred to aged psychiatry services.
Methods: Participants were drawn from two aged psychiatry services in Melbourne (Peter James Centre and St George‘s Hospital). We compared our BPDOA screening tool with the Diagnostic Interview for Borderlines–Revised (DIB–R) and the McLean BPD screening tool designed to detect BPD in adults aged 18–60 years.
Findings: The three instruments were completed in 20 patients previously diagnosed with BPD and 20 matched controls. The BPDOA screening tool was the most reliable indicator of clinically assessed BPD; the DIB–R (a gold-standard diagnostic instrument) had very low sensitivity, likely due to the restrictive ‘prior 2 years’ to which items referred. The McLean screening tool accurately screened fewer than half of the participants with BPD.
Conclusions: Changes in BPD symptom expression over the lifespan render determining the diagnosis more difficult in elderly patients. Our BPDOA incorporates what is known about BPD symptom expression in the elderly. This pilot study suggests that the BPDOA may be useful for flagging possible BPD in elderly people, paving the way to fuller evaluation and appropriate management and treatment interventions.
Presenter 3
Emergency Department Utilization by Patients with a Diagnosis of Borderline Personality Disorder: What Can We Learn?
JH Broadbear1, JA Rotella2, S Rao1
1Spectrum, Personality Disorder Service for Victoria, Richmond, Australia
2Austin Hospital, Heidelberg, Australia
Background: Patients with borderline personality disorder (BPD) often present to the emergency department (ED) experiencing emotional crises and associated suicidality. The ED is an important first point of contact; difficulties in caring for patients with BPD in the ED setting can result in iatrogenic harm and may exacerbate destructive behaviours.
Objectives: This session aims to describe our study of the prevalence and nature of ED presentations by patients with BPD in Outer Eastern Melbourne.
Methods: A retrospective electronic audit identified 1123 BPD-related ED presentations between May 2015 and April 2016; 583 were unique presentations. These were matched with ‘depression-only’ cases based on age, sex and presentation.
Findings: Patients with a diagnosis of BPD are more likely to be female (81%); re-attend ED on multiple occasions; arrive by ambulance; have co-morbid substance abuse, psychotic or bipolar disorder; have an ‘aggression alert’ file note; have an existing treatment plan; be under the care of a psychiatrist; be case-managed; and be admitted to an inpatient ward. Only 38% of BPD and depression patients were seen by the doctor within the recommended time. Despite their greater severity and complexity, the ED experience of patients with BPD was indistinguishable from patients with a depression diagnosis with respect to triage category, waiting time to see a doctor and referral to mental health triage. A possible moderator is the greater frequency with which patients with BPD re-attend the ED.
Conclusions: Developing effective ED referral pathways will address a chronic and persistent need for BPD-appropriate treatment and reduce the reliance on hospital EDs for acute episodic care.
Presenter 4
Identification of Opportunities for Intervention Prior to Death By Suicide in People With Borderline Personality Disorder
S Rao1, L Bugeja2, J Dwyer3, JH Broadbear1
1Spectrum, Statewide Service for Personality Disorder, Richmond, Australia
2School of Nursing and Midwifery, Monash University, Clayton, Australia
3Coroners Court of Victoria, Southbank, Australia
Background: People with borderline personality disorder (BPD) experience intense psychological distress that frequently results in self-destructive behaviours. The chronic suicidality associated with BPD underscores the need for effective psychotherapeutic interventions.
Objectives: This session aims to examine factors associated with death by suicide in people diagnosed with BPD in Victoria.
Methods: A retrospective case identification was conducted using the Victorian Suicide Registry. Information extracted included sociodemographics, physical health, previous contact with mental health services and/or law enforcement, medication, illicit drug use, life-stressors and suicide method.
Findings: Between 2009 and 2013, 193 deaths of Victorians diagnosed with personality disorder were classified as suicide by the Coroner. Men and women were equally represented. Diagnoses included BPD (94%), antisocial (13%) and narcissistic personality disorder (9%), with co-occurring substance abuse disorder (31%; 54% male), schizophrenia (17%; 61% male), mood disorder (73%; 55% female) and anxiety (40%; 54% female). The most common suicide methods were death by hanging (45%; 52% male) and poisoning (31%; 65% female). Nearly all (99%) had contact with mental health services within the 12 months prior to their suicide. Most (88%) had contact with psychiatrists (55%), allied mental health (46%), family doctor (38%) and emergency departments (25%) within 6 weeks of suicide.
Conclusions: These conservative data demonstrate that BPD-related suicide occurs regularly, despite the high frequency and variety of contacts with mental health services. The frequency of co-occurring diagnoses underscores their complex needs. The high likelihood of contact with mental health services proximal to death highlights opportunities for evidence-based interventions aimed at reducing future suicides.
The National Mental Health Service Planning Framework: Model and Application
H Whiteford1,2,3, S Diminic1,2, K Fjeldsoe1
1School of Public Health, The University of Queensland, Brisbane, Australia
2Queensland Centre for Mental Health Research, Brisbane, Australia
3Institute of Health Metrics and Evaluation, University of Washington, Seattle, USA
Background: Historically, there has been no nationally agreed or consistent approach to mental health service planning in Australia.
Objectives: This session aims to describe the National Mental Health Service Planning Framework (NMHSPF), a model designed to establish national targets for the mix and level of mental health services required at a population level.
Methods: The Australian Government Department of Health has contracted a multi-year programme of work to develop and disseminate the NMHSPF. The first version was developed in 2011–2013, led by the NSW Ministry of Health. Since 2016, a team at the University of Queensland has led refinement of the framework and its dissemination to planners in state/territory health departments, local hospital networks and primary health networks.
Findings: To date, 170 service managers and planners, public and private sector clinicians, community sector professionals, consumers, carers, technical experts and academics have contributed to development of the NMHSPF. The model includes a Planning Support Tool and supporting documentation. More than 200 planners nationally have been trained to understand and apply the NMHSPF. This symposium will summarize the model’s development and structure and provide an example of its application to regional planning.
Conclusions: The NMHSPF is a useful tool providing nationally agreed, evidence-based planning benchmarks across the full spectrum of mental health services. Further work is underway to refine its application to special populations and services.
Presenter 1
Development of a National Mental Health Service Planning Framework for Australia
H Whiteford
1,2,3
1School of Public Health, The University of Queensland, Brisbane, Australia
2Queensland Centre for Mental Health Research, Brisbane, Australia
3Institute of Health Metrics and Evaluation, University of Washington, Seattle, USA
Background: Experts have argued for decades that the needs of the whole population with mental illness should be in scope when services are planned. The National Mental Health Service Planning Framework (NMHSPF) is the first national planning model designed to plan from an epidemiological basis for population mental health needs across the spectrum of services.
Objectives: This presentation aims to provide an overview of the policy context that led to the NMHSPF, its historical development, and its current role in regional planning.
Findings: Australia’s first three national mental health plans drove significant investment in the mental health system, but none set national benchmarks for the resourcing and delivery of services. The view that funding for mental health services should be allocated on the basis of population need gradually gained support and was progressed by models such as Tolkien II and the NSW Mental Health Clinical Care and Prevention model. The NMHSPF was developed in 2011–2013 under the Fourth National Mental Health Plan, drawing on MH–CCP and state/territory planning expertise. The NMHSPF has since undergone iterative user testing and further refinement to improve the model and its application to different types of service needs. The Fifth National Mental Health Plan identifies the NMHSPF as a resource to ‘be applied at a regional level to support planning and resource allocation in a nationally consistent manner’ and it has been made available to local hospital networks and primary health networks to support integrated service planning.
Presenter 2
An Overview of the National Mental Health Service Planning Framework Needs-based Planning Model and the Epidemiology
S Diminic
1,2
1School of Public Health, The University of Queensland, Brisbane, Australia
2Queensland Centre for Mental Health Research, Brisbane, Australia
Background: The National Mental Health Service Planning Framework (NMHSPF) is a needs-based planning model that identifies mental health needs in the community at a population level and then defines the services and resources required to meet those needs.
Objectives: This presentation will provide an overview of the NMHSPF model structure and the methods used to develop its estimation of mental health service needs.
Findings: The NMHSPF is built on evidence from published literature, mental health service models, health surveys, administrative data and expert consensus. Epidemiological data are used to quantify the prevalence and distribution of mental health needs in the population by age group. The prevalent population is apportioned based on severity (early intervention, relapse prevention, mild, moderate and severe illness) and each severity group is assigned an expected rate of service demand. These severity levels are then broken down further into 155 need groups based on additional indicators of complexity and specific service needs. For each need group, there is a care profile outlining service requirements, which is combined with service models to determine the workforce requirements and costs to deliver services to the population.
Presenter 3
An Overview of the National Mental Health Service Planning Framework Service Modelling and Resource Estimation
K Fjeldsoe
School of Public Health, The University of Queensland, Brisbane, Australia
Background: The National Mental Health Service Planning Framework (NMHSPF) models the level and mix of mental health services required to deliver evidence-based, appropriate care to the population.
Objectives: This presentation aims to provide an overview of the methods used to develop the NMHSPF service modelling and how these combine to produce resource benchmarks for planning.
Findings: The NMHSPF provides an agreed national taxonomy of mental health services across the spectrum of service delivery, including mental health promotion and prevention, primary and specialized community treatment, bed-based care and psychosocial support services. This provides a common language and clear definitions of core mental health service functions. Staffing profiles describe the mix of staff required for bed-based and team services, and workforce categories and qualifications are identified for all services. Each staff type is associated with a salary and overhead costs, and estimates of required beds and workforce full-time equivalents (FTEs) are modelled at desirable, efficient operational rates. For each need group, a care profile outlines the average types and quantities of services required over a 12-month period to provide adequate mental healthcare. Drawing on the above, the NMHSPF–Planning Support Tool (PST) produces benchmarks for the resources (e.g. beds, FTE staff, dollars) and activity (e.g. service contacts, hours) required to deliver this adequate care to defined populations. The NMHSPF–PST can be customized to address local planning questions. This presentation will discuss application of the NMHSPF–PST to identify the priorities for investment and disinvestment at a regional level.
Mental Health in Aboriginal and Torres Strait Islanders: Clinicians’s Perspectives from the Top End of Australia
R Parker1,2,3, M Das1,2, T Mirza1,4, S Bridges1, T Kingi1, A Arandiga1, R Kini1, G Garg1,2, D Chapman1, R Weerasundera1, A Patton1, U Khalid1
1Top End Mental Health Service, Darwin, Australia
2Flinders University, Darwin, Australia
3James Cook University, Townsville, Australia
4Headspace, Darwin, Australia
Background: The Northern Territory (NT) has the largest proportion of its population (30%) who are of Aboriginal and Torres Strait Islander origin, compared with other states. It is well established that there is a higher prevalence of psychiatric disorders in the Aboriginal and Torres Strait Islander peoples compared to the general Australian population.
Objectives: A significant proportion of clients presenting to mental health services in the NT are of Aboriginal and Torres Strait Islander origin, with mental health clinicians having developed specific skills/expertise in their clinical management. This symposium aims to share first-hand the experience of psychiatrists and aboriginal mental health workers working in the Top End and provide a perspective into the complexities in the management of this group of clients.
Methods: Four specific domains will outline mental health issues and management in Aboriginal and Torres Strait Islander clients: (i) epidemiology – overview of mental health morbidity in the Aboriginal and Torres Strait Islander population; (ii) development of an expert consensus of clinical practice guidelines for prescribing antipsychotics in this population; (iii) relationship between culturally held beliefs and psychopathology; and (iv) expertise and the role of the Aboriginal mental health worker.
Findings: Increased mental and physical health morbidity are determined by a plethora of psychosocial factors and historical determinants. Attitude and compliance to treatment in this population are influenced by complex social, cultural, and biological factors determining antipsychotic prescribing. Understanding of cultural issues determining clinical presentation is key to management. ‘Stories’ are presented by Aboriginal mental health workers of their experiences of managing Aboriginal and Torres Strait Islander clients.
Conclusions: Development of a specific knowledge and skill base is essential for clinicians in the practice of Indigenous mental health.
Presenter 1
Mental Health Issues in Aboriginal and Torres Strait Islanders: An Overview and Understanding of Determining Factors
R Parker
1,2,3
1Top End Mental Health Service, Darwin, Australia
2Flinders University, Darwin, Australia
3James Cook University, Townsville, Australia
Background: The Aboriginal and Torres Strait Islander peoples constitute 3.3% of the Australian population, having been present in the country for more than 50,000 years before the colonization of Australia. Aboriginal culture and society is structured around the community, with strong kinship, belief systems, family ties and networks.
Objectives: This session aims to provide an overview of mental health morbidity and the psychobiosocial factors determining these are presented.
Methods: Epidemiology of mental illness, suicide, substance misuse among other presentations are discussed, based on the current literature.
Findings: The Aboriginal and Torres Strait Islander population faced significant adversities, with loss of their traditional way of life, land and resources; marginalization, poverty, racism and policies such as the ‘Stolen generations’ causing intergenerational trauma. These factors are considered as important for a subsequent increase in mental health and other health issues. Aboriginal and Torres Strait Islander peoples have poorer outcomes compared to other Australians in areas of physical health and life expectancy. They have higher rates of mental illness, suicide, alcohol/substance misuse, incarceration and being subject to violence. There are government policies/initiatives to reduce the disparity, which has been slow to bear results. Clinical presentation/management can be different in this group. There have been innovative strategies to improve mental illness outcomes.
Conclusions: The presentation illustrates the significant mental health issues faced by the Aboriginal and Torres Strait Islander population. Epidemiological research is lacking in this population because of methodological difficulties. There is need for research to understand and address the core issues that drive health inequalities in this group of disadvantaged Australians.
Presenter 2
Antipsychotic Prescribing in Aboriginal and Torres Strait Islander Populations: Formulation of Guidelines for Clinical Practice
M Das1,2, R Kini1, A Arandiga1, G Garg1,2, D Chapman1, R Weerasundera1, A Patton1, U Khalid1, R Parker1,2,3
1Top End Mental Health Service, Darwin, Australia
2Flinders University, Darwin, Australia
3James Cook University, Townsville, Australia
Background: While there is lack of comprehensive data, the incidence of psychosis in Aboriginal and Torres Street Islander peoples is higher than the rest of the Australian population. There are data to suggest higher co-morbidities (cognitive impairment, substance misuse). There is a need for guidelines regarding prescribing of antipsychotic medication in this population.
Objectives: This session aims to present the project’s scope and purpose of developing prescribing guidelines for antipsychotics in the Aboriginal and Torres Strait Islander population.
Methods: These preliminary guidelines have been developed by psychiatrists, nurses, pharmacists and allied professionals from the Top End with significant experience of treating Aboriginal and Torres Strait Islander patients. The Agree II protocol for practice guideline development was followed. This involved defining scope, stakeholder involvement, literature reviews and peer focus groups to refine recommendations and examine applicability. A detailed literature search did not reveal any guidelines for antipsychotic prescribing. Secondary searches were completed covering areas relevant to prescribing (e.g. physical health, co-morbidities and compliance). Focus groups, and expert consensus opinion of clinicians, determined the guidelines.
Findings: There were a number of key findings. Given high prevalence of cardiovascular and metabolic risk in the Aboriginal and Torres Strait Islander population, consideration should be given for detailed initial screening, choice of ‘metabolic sparing’ antipsychotics, caution with doses and polypharmacy, more intensive monitoring for side-effects and physical status, renal impairment and medical co-morbidities. A collaborative approach should be considered in prescribing that incorporate principles of cultural safety and involvement of Aboriginal mental health workers. Prescribing of depot should be considered (due to issues of compliance, remoteness and medication storage). Prescribing clozapine and prescribing in children has unique considerations.
Conclusions: Special considerations for antipsychotic prescribing in Aboriginal and Torres Strait Islander peoples and implications of these guidelines for clinical practice are discussed.
Presenter 3
First Australians Deserve First-class Psychiatric Care: Towards a Better Sociocultural Understanding
T Mirza
1,2
1Top End Mental Health Service, Darwin, Australia
2Headspace, Darwin, Australia
Background: Incidence of disabling psychopathology in Aboriginal and Torres Street Islander peoples is higher compared to other sample groups in Australia. A general lack of understanding of cultural underpinnings of various psychiatric presentations in Aboriginal and Torres Strait Islander peoples is a significant barrier for treatment provision.
Objectives: The case reports in this session aim to highlight the interface between culturally expected beliefs and psychopathology (e.g. psychotic symptoms), and the challenges faced by the clinicians working in rural and remote regions.
Methods: De-identified case reports were compiled in consultation with the clients involved, their families or mob, elders of the community, spiritual healers and Aboriginal mental health workers (AMHW).
Findings: Inherent difficulties of a culturally appropriate assessment process and subsequent management, given the remoteness of the Indigenous communities and cultural beliefs about medical treatment, are highlighted in these case reports. Use of AMHW, interpreters, spiritual healers, involvement of the community elders, a culturally acceptable model of illness and utilization of least restrictive and less coercive measures yielded fruitful results and good outcomes.
Conclusions: Working with Aboriginal and Torres Strait Islander populations can pose its unique challenges but with appropriate training, supervision and cultural knowledge acquisition, population-specific clinical frameworks can be devised and practised and the NT is a goldmine for such training and clinical experience. Collaborative work and partnerships with the local stakeholders is the key to success of operational sides of clinical management in remote areas.
Presenter 4
Stories from the Front Line: The Role of the Aboriginal Mental Health Worker
S Bridges, T Kingi
Top End Mental Health Service, Darwin, Australia
Background: According to the Royal Australian and New Zealand College of Psychiatrists (RANZCP), Aboriginal and Torres Strait Islander mental health workers (AMHWs) refers to Aboriginal and Torres Strait Islander peoples working in roles in both government or community controlled organizations with varied qualifications, skills and criteria. They work in the area of mental health or emotional, social or spiritual well-being, cultural liaison, community engagement or a combination.
Objectives: This session aims to elaborate on the role of the AMHW in clinical practice in the Top End.
Methods: De-identified, real-life clinical vignettes are used to illustrate ‘stories’ of Aboriginal clients’s journeys to recovery through the mental health system.
Findings: The complexity of mental illness issues for Aboriginal and Torres Strait Islander peoples makes understanding of cultural, historical, familial and societal issues an important prerogative. Language, stereotyping, stigma and mental health literacy pose barriers to Aboriginal and Torres Strait Islander clients accessing appropriate and effective care. AMHWs have an important role to play in the negotiation of these barriers.
The role of the AMHWs may extend to outside of the normal clinical experience of the patient–therapist relationship with a role in local community development; and contact outside normal geographical and time parameters, contrary to non-Indigenous practitioners.
The incorporation of traditional healing, ‘story telling’ and culturally adapted management plans such as ‘The Stay Strong Plan’ are important initiatives used by AMHWs in the Top End to assist with a client’s recovery.
Conclusions: The AMHW plays an indispensable role in Indigenous mental health: development of their role should be an area of service development.
Volunteering and Development Work at Home and Abroad: Alternative Career Pathways for Early Career Psychiatrists
C Ng1,2,3, S Thomson4, B Visa5,6, K Sevar7
1Healthscope Chair of Psychiatry, The Melbourne Clinic, Melbourne, Australia
2Department of Psychiatry, Melbourne Medical School, University of Melbourne, Melbourne, Australia
3International Unit, WHO Collaborating Centre in Mental Health, St Vincent‘s Hospital, Melbourne, Australia
4Royal College of Psychiatrists’ Volunteering and International Psychiatrist Special Interest Group (RCPsych, VIPSIG), London, UK
5Royal Women’s Hospital, Melbourne, Australia
6Cabrini Asylum Seeker and Refugee Health Hub, Melbourne, Australia
7Fiona Stanley Hospital, Perth, Australia
Background: Volunteering and health development work are rewarding experiences that many doctors blend into their careers. There are many opportunities for medical students and doctors-in-training to volunteer in Australia and New Zealand and overseas in low resource settings; however, anecdotally, opportunities to participate seem to decrease as the demands of training, and then consultant work, increase. Psychiatrists appear to engage in such work to a limited extent, as compared with other specialties. There is, however, growing interest among early career psychiatrists (ECPs) to be involved in volunteering and mental health development.
Objectives: This session aims to (i) identify a range of opportunities to engage in volunteering and mental health development work overseas and (ii) discuss practical issues facing ECPs wanting to develop careers in such work, or with marginalized groups at home. A range of issues will be discussed that may include availability of postings, preparation, ethical and cultural issues, sustainability and unintended impacts on the host service and community; workplace flexibility; financial opportunity cost; and peer review.
Methods: Presentations from senior psychiatrists with volunteering and international mental health experiences will describe their entry into this career path, barriers, challenges, achievements and rewards, risks, pitfalls and failures. Various models of collaboration will serve as a case study of how psychiatrists can collaborate to create a sustainable and culturally and ethically safe programme for mental health development work.
Findings: There are many psychiatrists from Australia and New Zealand who are volunteering locally or overseas in low resource settings in mental health development.
Conclusions: This Royal Australian and New Zealand College of Psychiatrists’ Symposium is an opportunity for ECPs to hear about alternative career paths, including volunteering in Australia, New Zealand and other countries in low resource settings. ECPs would benefit from the experience and support from senior colleagues, and structured programmes, in pursuing these careers.
Presenter 1
Global Mental Health Development: Opportunities for Clinical, Teaching, Research and Service Engagement
C Ng
1,2,3
1Healthscope Chair of Psychiatry, The Melbourne Clinic, Melbourne, Australia
2Department of Psychiatry, Melbourne Medical School, University of Melbourne, Melbourne, Australia
3International Unit, WHO Collaborating Centre in Mental Health, St Vincent’s Hospital, Melbourne, Australia
Background: Possessing a wide interest in academic and clinical psychiatry, Professor Ng’s expertise covers psychopharmacology, mood and anxiety disorders, transcultural psychiatry and global mental health. Professor Ng has served as an international consultant for the World Health Organization (WHO), the Commonwealth of Nations and the Asia–Pacific Economic Cooperation, and has worked with several health ministries on mental health projects in the region. He is the Director of the Professorial Unit of The Melbourne Clinic, International Unit and WHO Collaborating Centre at St Vincent’s Hospital, Melbourne, and past Secretary General of the Pacific Rim College of Psychiatrists, and the Co-Editor of Asia–Pacific Psychiatry journal.
Objectives: This session aims to describe the breadth and depth of opportunities in global mental health work, based on his past and current engagement with international mental health projects and programmes.
Methods: Through a presentation and a moderated question and answer session, Professor Ng will reflect on his career development in global mental health and provide examples of paths for ECPs to be able to develop an interest in this important field.
Findings: There are many potential paths for a career and developing an expertise in global mental health, including volunteering in clinical, academic and government consultation roles, with projects overseas and collaboration both locally and globally.
Conclusions: An interest in global mental health can be developed among ECPs in Australia and New Zealand, leading to volunteering and work across the Asia–Pacific region, which can lead to a satisfying and productive career, as well as leadership potential in international mental health.
Presenter 2
From Australia, to the UK, to the World: The Royal College of Psychiatrists’ Volunteering and International Psychiatrist Special Interest Group (VIPSIG)
S Thomson
Royal College of Psychiatrists’ Volunteering and International Psychiatrist Special Interest Group (RCPsych, VIPSIG), London, UK
Background: Sophie is an Australian medical graduate who trained as general physician, then completed her psychiatry training in the United Kingdom, working for 20 years as a consultant psychiatrist in the National Health Service. She is currently the Chair of Volunteering and International Psychiatrist Special Interest Group (VIPSIG), which has over 2600 members. VIPSIG attracts registrars and early career psychiatrists, as well as retiring senior psychiatrists. Over the past few years, Sophie has taught the World Health Organization Mental Health Gap Action Programme – a training programme that scales up services for mental, neurological and substance use disorders for low- and middle-income countries (LMIC) (e.g. Sudan, Kashmir, the Solomon Islands) – and has been lead trainer in Myanmar. She trains RCPsych psychiatrists for volunteer work nationally and internationally.
Objectives: RCPsych VIPSIG will serve as a case study of how psychiatrists can collaborate to create a sustainable and culturally and ethically safe programme for development work.
Methods: Sophie will discuss her career trajectory and present a summary of VIPSIG; its history, structure, current members, resources and projects around the world.
Findings: A study of feedback from volunteers showed increased cultural awareness, improved presentation and teaching skills as well as acquiring skills from LMIC colleagues about coping in low-resource settings.
Feedback from recipients of training includes initial results of the formal evaluation of one project in Myanmar, which showed statistically significant improvement in clinical skills and confidence in 392 general practitioners 12 months after training over 4 days by RCPsych volunteers.
Conclusions: Psychiatrists benefit personally and professionally from volunteer work and bring back benefits to their service and future careers.
Presenter 3
Clinician and Non-Clinical Volunteer Work in Australia and Overseas
B Visa
1,2
1Royal Women’s Hospital, Melbourne, Victoria
2Cabrini Asylum Seeker and Refugee Health Hub, Melbourne, Victoria
Background: Bharat is an Australian medical and public health graduate who undertook a volunteer public health internship at the World Health Organization (WHO), Department of Mental Health, in Geneva. Closer to home, Bharat has also volunteered his clinical skills as a consultant psychiatrist at the Cabrini Asylum Seeker and Refugee Health Hub.
Objectives: The WHO public health internship programme is a well-known opportunity for early career psychiatrists (ECPs) to gain experience in developing mental health systems and learning about health politics, primarily related to low and middle income countries (LMIC). Knowledge of global health and political systems is valuable for ECPs to work in the field as clinicians. While in Geneva, Bharat had the opportunity to contribute to the development of the Mental Health Gap Action Programme (Humanitarian version). Volunteering as a consultant psychiatrist working with asylum seekers and refugees in Australia provides clinical and personalized perspectives on cross-cultural psychiatric practice, and issues regarding mental health in countries of origin (most often low resource, LMIC settings) and complex migration experiences.
Methods: Bharat will present and discuss his experiences at the WHO and the Cabrini Asylum Seeker and Refugee Health Hub, to show how they have helped guide his career plans as an ECP.
Findings: A public mental health internship at WHO Geneva is an accessible and valuable opportunity for ECPs to develop an understanding of, and skills in, global health academia and politics. Volunteering in Australia with marginalized groups can be added to an ECPs mainstream career in public psychiatry.
Conclusions: Psychiatrists benefit personally and professionally from volunteer work and bring back benefits to their service and future careers.
Presenter 4
Volunteering With a Non-government Organization in Malawi
K Sevar
Fiona Stanley Hospital, Perth, WA, Australia
Background: Katherine is a UK medical graduate who completed her psychiatry training in Australia, including rotations in remote Aboriginal communities in Queensland, and works in consultation liaison and perinatal psychiatry. She was medical director at the Cabrini Asylum Seeker Health Hub, Melbourne, where she volunteered for 6 years. Katherine has volunteered overseas for two small non-government organizations (NGOs). Katherine delivered mental health workshops in sub-Saharan Africa, on a regular basis, over 3 years through the NGO Specialists Without Borders (SWB). Katherine was a lecturer at the undergraduate psychiatry programme at the University of Malawi through the Scotland–Malawi Mental Health Education Project (SMMHEP), an ongoing project funded by the Scottish Government. Katherine is completing a Masters in Public Health through James Cook University.
Objectives: The SWB and SMMHEP programmes will serve as case studies to illustrate how early career psychiatrists (ECPs) can collaborate with existing sustainable and culturally and ethically safe programmes for development work.
Methods: Katherine will discuss her career trajectory and present a summary of her volunteering experiences, and in the question and answer discussion, expand on her advice for ECPs interested in this area.
Findings: Volunteering in psychiatry is possible at various stages of one’s career and can be a very rewarding experience for ECPs.
Conclusions: Psychiatrists benefit personally and professionally from volunteer work and bring back benefits to their service and future careers.
Military and Veterans’ Mental Health: Managing Military Personnel with Mental Disorders – What Psychiatrists Need to Know
J Lane1,2, D Wallace3,4, Representative5, S Hodson6
1Centre for Traumatic Stress Studies, University of Adelaide, Adelaide, Australia
23rd Health Support Battalion, Australian Army, Hobart, Australia
3Centre for Mental Health, Australian Defence Force, Sydney, Australia
4University of New South Wales, Sydney, Australia
5Australian Defence Force, Canberra, Australia
6Open Arms – Veterans and Families Counselling, Canberra, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has a key role in the mental health of current and ex-serving Australian Defence Force (ADF) members. In recognition, the RANZCP recently established the Military and Veterans’ Mental Health Network (the Network).
Objectives and methods: The objectives of the Network include promoting further education and training of psychiatrists and trainees to provide care to military personnel and veterans. This symposium will provide essential information on: military culture; the ethical and practical requirements of military psychiatric practice; the perspectives of a military unit commander on the management of service personnel with mental disorders; and, finally, what psychiatrists should know about the clinical services provided by the Department of Veterans’ Affairs.
Findings and conclusions:
Military and Veterans have a strong role-based identity which may leave them vulnerable to difficulties during both employment and later transition, especially if medically discharged. They need to be engaged in a different manner to others, with sensitivity to their experiences, expectations and their value system.
Understanding the roles of the ADF, possible ethical dilemmas encountered, the structured assessment of patients, use of clinical practice guidelines for post-traumatic stress disorder and providing prompt reports to referrers with specific advice on fitness for duties will improve your practice as a psychiatrist to serving members and veterans.
Military commanders and treating psychiatrists share common goals in the provision of good mental healthcare to service personnel. Better understanding of the perspectives and constraints of their two different roles is essential for good clinical outcomes.
To provide an individualized, patient-centred approach to the management of veterans, psychiatrists need to know about the range of clinical services provided by the Department of Veterans’ Affairs.
Presenter 1
Task, Mission, Purpose: An Overview of the Military Mentality
J Lane
1,2
1Centre for Traumatic Stress Studies, University of Adelaide, Adelaide, Australia
23rd Health Support Battalion, Australian Army, Hobart, Australia
Background: The military and veteran community is a unique population group by nature of the training, occupation and experiences. There is shared history, language and associations that are often leading to poor mental health outcomes.
Objectives: This session aims to describe the differences between individual (occupational roles) and shared (deployments and other activities); common personal and behavioural traits; value systems; common mental health issues; and suggested techniques for engaging military and veteran personnel.
Methods: Discussion of the above objectives with reference to the recent Transition and Wellbeing Research Report findings.
Findings: There is a distinct lack of information describing the ‘military mentality’ and culture within the Australian context. Military and veterans have a strong role-based identity which leaves them vulnerable to difficulties during both employment and later transition, especially if medically discharged. They need to be engaged in a different manner to others, with sensitivity to their experiences, expectations and their value system.
Conclusions: Military and veteran personnel have a unique culture which is different to that of other people. Clinicians need to be aware of these differences, how to approach the patient population in an appropriate manner, and common pitfalls that can be encountered through the common personal and behavioural traits.
Presenter 2
How to Be a Good Military Psychiatrist
D Wallace
1,2
1Australian Defence Force Centre for Mental Health, Sydney, Australia
2University of New South Wales, Sydney, Australia
Background: There is growing concern about the mental health of military and veterans with recent reports indicating increased prevalence of mental disorders and increased risk of suicide in those who have transitioned from the Australian Defence Force (ADF).
Objectives: This session aims to improve the assessment and treatment of military personnel and veterans by attending psychiatrists.
Methods: Discussion of the importance of understanding the nature of the ADF, its recent deployments and occupational roles of members; the ethics of practicing as a military psychiatrist – dealing with the dilemma of the ‘dual role’; the use of screening tests and diagnostic confirmatory tests to standardize diagnosis; the use of clinical practice guidelines in the treatment of post-traumatic stress disorder; and advice on reporting to referring military doctors.
Findings and conclusions: Psychiatrists are encouraged to overcome anxiety and lack of knowledge about military psychiatry to take up the mental healthcare of those who have volunteered to serve their nation.
Presenter 3
What is the Role of Military Commanders in Managing Personnel With Mental Health Conditions?
Representative
Australian Defence Force
Background: Military commanders are tasked with maintaining the mental health and physical well-being of personnel in their units. However, their involvement is constrained by confidentiality issues, which can produce tensions between commanders and psychiatrists.
Objectives: This session aims to describe how to improve and better coordinate the mental healthcare of serving members of the Australian Defence Force.
Methods: By informing treating psychiatrists of the roles and responsibilities of military commanders in the care of their personnel and advising of their views as to what constitutes good psychiatric management.
Findings and conclusions: Military commanders and treating psychiatrists share common goals in the provision of good mental healthcare to service personnel. Better understanding of the perspectives and constraints of their two different roles is essential for good clinical outcomes.
Presenter 4
Clinical Service Provision by the Department of Veterans’ Affairs: We Do More Than Just Request Reports!
S Hodson
Open Arms–Veterans and Families Counselling, Canberra, Australia
Background: The demographics of Australian military veterans are changing with increasing numbers of younger veterans, including significant numbers of women, while veterans from past conflicts are ageing. Recent reports have shown increased prevalence of mental disorders in those who have recently transitioned out of the military.
Objectives: To inform psychiatrists attending military personnel and veterans of the range of clinical services available to Australian military veterans.
Methods: Mental health programmes tailored for veterans and their families are described.
Findings and conclusions: To provide an individualized, patient-centred approach to the management of veterans, psychiatrists need to know about the range of clinical services provided by the Department of Veterans’ Affairs.
A Presidential Symposium: Valuing the Contributions of Overseas-Trained Psychiatrists
K Jenkins, Invited Guests
The Royal Australian and New Zealand College of Psychiatrists
Background: Overseas-trained psychiatrists (OTPs) make a valuable contribution to mental health services across Australia and New Zealand and form a significant proportion of the Australian and New Zealand workforce.
This special presidential symposium, hosted by Dr Kym Jenkins, President, Royal Australian and New Zealand College of Psychiatrists, will consist of a panel of OTPs who are established and thriving in their careers ‘down under’.
The interviewees will describe their journey through training and practice in their home country and their transition into practice in Australia and New Zealand. The panel will also share some of their own professional and personal experiences and provide career advice for taking up leadership opportunities across academic and clinical settings.
Refining Long-acting Antipsychotic Therapies with New Paradigms
N Tran1,2, D Castle1,2, M Warden1,2, C Mach1, B Morrison1
1St Vincent’s Mental Health – Melbourne, Fitzroy, Australia
2Department of Psychiatry, The University of Melbourne, Parkville, Australia
Background: There is increasing evidence that long-acting antipsychotic injections (LAI) can improve the outcomes in chronic psychotic illnesses. Despite the advent of ‘atypical’ antipsychotic formulations (aripiprazole, paliperidone, risperidone and olanzapine) as well as increasing evidence for efficacy and effectiveness, there remain significant barriers to their use. Furthermore, there are evidences that the mechanism of action and delivery process of LAI may be poorly understood by mental health clinicians.
Objectives: We will present:
findings from a nation-wide audit into the use of LAI in Australia;
results from our service-wide audits in relation to the potential problems in the LAI delivery process; and
recommendations for how to refine reconstitution, administration and documentation of LAI.
Methods:
Analysis of Australian data on a large cohort of people with psychosis with a focus on variation in rates of use and barriers to use.
In-house survey and retrospective file audits to assess variability in the delivery process utilizing ‘Kahoot’ and our uniquely designed audit tools.
Development of a new LAI medication (LAIM) chart as our quality improvement activity.
Findings:
Wide variation in rates of LAI use impact the decision to use or not to use LAI.
Findings from the in-house survey and file audit revealed great variations in reconstitution, administration and documentation of the three new LAI.
Conclusion: Understanding the prescribing patterns and barriers to LAI use will help inform clinical decision-making and empower a shared decision-making regarding LAIs. In addition, elucidation of any variability in the delivery process will enhance therapeutic outcomes.
Presenter 1
Lais in Clinical Practice: Why Such Variation in Use?
D Castle
1,2
1St Vincent‘s Mental Health – Melbourne, Fitzroy, Australia
2Department of Psychiatry, The University of Melbourne, Parkville, Australia
Background: Long-acting injectable (LAI) forms of antipsychotic medications have experienced something of a renaissance in use in many jurisdictions with the advent of ‘atypical‘ antipsychotic formulations (risperidone, paliperidone, aripiprazole and olanzapine) as well as increasing evidence for efficacy and effectiveness. However, significant barriers remain to their use, and there is very wide variation in uptake across countries and between different mental health services in the same country (or indeed, even in the same city).
Objectives: This presentation will address the issue of variation in use of LAIs, both at the international level as well as in the local Australian context.
Methods: The literature pertinent to LAI use will be reviewed, with a focus on variation in rates of use and barriers to use. Australian data on a large cohort of people with psychotic disorders will be analysed with a view to determining the profile of current ‘LAI patients’ in the Australian context.
Findings: There is wide variation in rates of LAI use, and a number of clinician, patients and service factors impact the decision to use – or not use – LAIs.
Conclusions: Understanding patterns of LAI use and barriers to use, as well as the profile of LAI use in Australia, will help inform clinical decision-making and enhance a shared decision-making mindset regarding LAIs.
Presenter 2
Comparing Variability in the Delivery Process of the New Long-acting Antipsychotic Injections in the Acute Inpatient and Community Mental Health Settings
M Warden
1,2
1St Vincent‘s Mental Health – Melbourne, Fitzroy, Australia
2Department of Psychiatry, The University of Melbourne, Parkville, Australia
Background: There is increasing evidence that the use of long-acting injectible (LAI) antipsychotics can improve the outcomes in chronic psychotic illnesses, particularly in terms of reduction of relapse events. It seems increasingly likely that it is the relapse events that are related to a negative prognosis. Despite this the rates of LAI use in Australia remain well less than 20%. There is evidence that they are underused by psychiatrists and their mechanisms of action may be poorly understood.
Objectives: We will present findings from our service-wide audit into the use of LAI antipsychotics, an examination in the potential problems in the administration of these drugs and how to refine the delivery process and an examination of the use, acceptability and outcomes of LAIs on an acute inpatient ward.
Methods: A review of inpatient records to ascertain the rate of LAI antipsychotic use, and outcomes including readmission rates, on an acute inpatient ward.
Findings: Results from in-house surveys and retrospective file audits revealed that shaking, needle gauge and injection sites are routinely not noted by clinicians in either inpatient or outpatient settings, despite the demonstrative evidence showing its profound impact on therapeutic outcomes.
Conclusions: LAIs remain an underused treatment option in schizophrenia and have been shown to improve outcomes. They need to be administered correctly and many treatment failures are associated with incorrect delivery. They need to be considered as a treatment option early in overall illness and in each episode of illness.
Presenter 3
Refining Long-acting Antipsychotic Therapies with New Paradigms
N Tran
1,2
1St Vincent‘s Mental Health – Melbourne, Fitzroy, Australia
2Department of Psychiatry, The University of Melbourne, Parkville, Australia
Background: Long-acting antipsychotic injections (LAI) such as aripiprazole, paliperidone and risperidone are subject to substantial variability in reconstitution, administration and documentation, which can affect pharmacokinetics and hence therapeutic outcomes.
Objectives: This session aims to describe refining of the optimal delivery process of the new LAI antipsychotics by elucidating any variability to ensure consistent clinical practice and therefore therapeutic outcomes.
Methods:
In-house audits from our mental health services by utilizing the “Kahoot” audit tool.
Retrospective file audits of the new LAI aripiprazole, paliperidone and risperidone to assess variability of the delivery process using a uniquely designed audit tool.
Development of a new LAI medication (LAIM) chart to ensure consistent delivery of LAI in all mental health settings.
Findings:
In-house audits revealed great variations in reconstitution, administration and documentation of the three new LAI.
Results of the retrospective file audit of 227 patients indicated the importance of correct shaking and injection sites of the new LAI with respect to efficacy and adverse effects.
Feedback received from the new LAI chart satisfaction surveys showed positive reinforcement of correct reconstitution, administration and documentation of the new LAI.
Conclusion: Delivery of LAI antipsychotics is complex and proper delivery is needed to maintain patient trajectory. The new LAIM chart will ensure that the LAI delivery process is optimized, and consistency in reconstitution, administration, documentation and prescribing will be achieved.
Antipsychotic Use for Schizophrenia in Australia: A Retrospective Longitudinal Analysis
H Hustig1, J Mullan2, M Acar3, P Juneja4, MH Kouhkamari4, S Siva5, N Pai6,7
1Consultant Psychiatrist, Adelaide, Australia
2Centre for Health Research Illawarra Shoalhaven Population (CHRISP), University of Wollongong, Wollongong, Australia
3Real World Evidence, Janssen-Cilag
4Prospection Pty Ltd, Eveleigh, Australia
5Medical and Scientific Affairs, Janssen-Cilag
6Graduate Medicine, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
7Illawara Shoalhaven Local Health District, Wollongong, Australia
Background: Antipsychotics are the primary treatment for the management of schizophrenia; however, in Australia, there is no research that describes the clinical use of antipsychotics for schizophrenia.
Objectives: To describe the use of antipsychotics for the treatment of schizophrenia in Australia using longitudinal Pharmaceutical Benefits Scheme (PBS) claims data.
Methods: A retrospective cohort analysis was conducted using the PBS 10% sample data, including patients who claimed an antipsychotic with a schizophrenia authority code, made between July 2013 and July 2017. Data were analysed by type of antipsychotic (typical, atypical, clozapine), route of administration and patient demographics.
Findings: Atypical antipsychotics by oral administration were prescribed to the most patients (62%). Typical long-acting therapies (LAT) were the second-most prescribed (19%), followed by typical orals (9%), atypical LATs (7%) and clozapine (3%). Older patients tended to be prescribed a higher proportion of typical antipsychotics and younger patients more atypical antipsychotics. Further general findings of the analysis will be discussed as part of the symposium. Prescribing patterns have been relatively consistent over the study period.
Conclusions: The study highlights that the clinical use of antipsychotics in Australia for schizophrenia is not in accordance with the Royal Australian and New Zealand College of Psychiatrists’ evidence-based, best practice guidelines for the treatment of schizophrenia. Along with this key challenge, further questions in relation to antipsychotic use will be discussed. An outline of the specific challenges and a more detailed discussion of the data will be espoused in the subsequent presentations.
Presenter 1
Antipsychotic Use For Schizophrenia in Australia: Duration of Therapy by Antipsychotic and Route of Administration
J Mullan1, H Hustig2,3, M Acar4, P Juneja5, MH Kouhkamari5, S Siva6, N Pai7,8
1Centre for Health Research Illawarra Shoalhaven Population (CHRISP), University of Wollongong, Wollongong, Australia
2Consultant Psychiatrist, Adelaide, Australia
3University of Wollongong, Wollongong, Australia
4Real World Evidence, Janssen-Cilag
5Prospection Pty Ltd, Eveleigh, Australia
6Medical and Scientific Affairs, Janssen-Cilag
7Graduate Medicine, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
8Illawara Shoalhaven Local Health District, Wollongong, Australia
Background: To our knowledge, there is no Australian study describing the clinical use of antipsychotics for schizophrenia – specifically the duration of therapy by antipsychotic (typical, atypical, clozapine) and the recommended route of administration (oral or long acting).
Objectives: This session aims to describe continuous antipsychotic treatment, as well as discontinuation, by antipsychotic type and route of administration.
Methods: A retrospective cohort analysis was conducted using the Pharmaceutical Benefits Scheme 10% sample data, including patients who claimed an antipsychotic with a schizophrenia authority code, made between July 2013 and July 2017. Patients were estimated to have commenced therapy if they had a period of 12 months with no prior antipsychotic dispensed. Data were analysed by type of antipsychotic (typical, atypical, clozapine) and route of administration. Persistence was estimated using Kaplan–Meier methodology from date of the antipsychotic being first dispensed to the last day it was dispensed. A patient was classed as discontinued if they switched therapies or failed to have a therapy dispensed for 6 months.
Findings: Patients taking clozapine are significantly more likely to continue with their treatment compared to patients taking other types of antipsychotics. Patients prescribed atypical long-acting therapies were the second group of patients who were significantly more likely to continue their treatment. Female patients were slightly more likely to continue with treatment than male.
Conclusions: Duration of antipsychotic therapy is significantly affected by the type of antipsychotic and the route of administration.
Presenter 2
Antipsychotic Use For Schizophrenia in Australia: Time to Switching Antipsychotic Groups
N Pai1,2, H Hustig3, J Mullan4, M Acar5, P Juneja6, MH Kouhkamari6, S Siva7
1Graduate Medicine, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
2Illawara Shoalhaven Local Health District, Wollongong, Australia
3Consultant Psychiatrist, Adelaide, Australia
4Centre for Health Research Illawarra Shoalhaven Population (CHRISP), University of Wollongong, Wollongong, Australia
5Real World Evidence, Janssen-Cilag Pty Ltd
6Prospection Pty Ltd, Eveleigh, Australia
7Medical and Scientific Affairs, Janssen-Cilag Pty Ltd
Background: To our knowledge, there is no Australian study describing the clinical use of antipsychotics for schizophrenia. This component of the study examined the time trends associated with switching from one antipsychotic to another antipsychotic.
Objectives: This session aims to describe the time to switch, from one antipsychotic group to another, in the treatment of schizophrenia.
Methods: A retrospective cohort analysis was conducted using the Pharmaceutical Benefits Scheme 10% sample data, including patients who claimed an antipsychotic with a schizophrenia authority code between July 2013 and July 2017. Patients were estimated to have commenced therapy if they had a period of 12 months with no prior antipsychotics. Time to switch and median was estimated using Kaplan–Meier methodology, calculated as the first date antipsychotic was dispensed to the date of switch. A patient was classified as switched if they moved from one antipsychotic group to another.
Findings: Only 5% of patients were switched from an atypical oral to an atypical long-acting therapy (LAT) in the first 12 months of treatment, with a median time to switch of 8 months. Less than half (43.8%) of typical oral patients were switched to a typical LAT in the first 12 months, with a median switch of 1 month. Conversely, patients on typical LATs have a median time to switch of 1 month for orals and 2 months for atypical LATs.
Conclusions: Switching antipsychotics for the treatment of schizophrenia occurs at differing medians, depending on the antipsychotic agent and the route of administration. The implications pertaining to the time to switching of an antipsychotic will be discussed.
Integration of Research Into Psychiatric Practice: A Guide for New Investigators and the Scholarly Project
D Siskind1,2,3, S Lawn1,4, S Kisely1,2, N Warren2,3, B O’Donoghue5,6,7, A Harris8,9,10
1Committee for Research, Royal Australian and New Zealand College of Psychiatrists
2Metro South Addiction and Mental Health Service, Brisbane, Australia,
3University of Queensland School of Medicine, Brisbane, Australia
4Department of Psychiatry, Flinders University, Adelaide, Australia
5Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Australia
6Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
7Orygen Youth Health, Melbourne, Australia
8Discipline of Psychiatry, University of Sydney, Sydney, Australia
9Prevention Early Intervention and Recovery Service (PEIRS), Western Sydney Local Health District, Sydney, Australia
10Clinical Director, Brain Dynamics Centre, The Westmead Institute for Medical Research, Westmead, Australia
Background: There is an increased interest among fellows and trainees in incorporating research into clinical practice. This fits with the paradigm of evidence-based mental healthcare. Acquiring clinical research skills can occur any stage in a career, from trainee to senior Fellow. The integrated clinical psychiatrist-scientist is the aspiration for including research training in the Royal Australian and New Zealand College of Psychiatrists’ Competency-Based Fellowship Programme (CBFP), though the mandatory scholarly project training requirement. A psychiatrist should have well-developed skills for interpreting, explaining and applying research in practice.
This symposium aims to inform novice researchers about the process of research including statistics, rating scales publishing, co-creation with community members and upscaling small projects into larger research projects.
Objectives: This symposium is designed for registrars and fellows who have an interest in better integration of research with their clinical practice. It will particularly assist registrars planning their approach to the Scholarly Project. The symposium will provide information about how to survive in research, including addressing the following questions of how to:
avoid predatory journals;
co-create research with community members;
upscale small research into larger projects;
understand and apply statistical techniques; and
use rating scales.
Methods: A series of individual presentations will be followed by group discussion with the presenting panel.
Findings: This symposium will provide practical approaches to starting out in research for the novice investigator, irrespective of stage of training or Fellowship.
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
Predatory Journals and Dubious Publishers: How to Avoid Being Their Prey
S Kisely
1,2,3
1Committee for Research, Royal Australian and New Zealand College of Psychiatrists
2Metro South Addiction and Mental Health Service, Brisbane, Australia
3University of Queensland, Brisbane, Australia
Background: Open-access publishing has a dark side, the predatory publishers and journals that exist for revenue rather than scholarly activity.
Objectives: This session aims to help researchers identify some of the common characteristics of predatory journals and their publishers.
Findings: Although the number of predatory publishers grew from just 18 in 2011 to 1294 in early 2017, there are several ways to avoid potentially dubious publications. The first is to check whether the journal appears on blacklists that are available on the Internet or if it has some of the following characteristics: (i) publication fees in spite of a lack of peer review or editorial oversight; (ii) unsolicited mass emails inviting submission or to serve on editorial boards; (iii) quick acceptance of low-quality papers; (iv) false information about the publisher’s location; and (v) non-existent, or misrepresented, impact factors. The second is to check if the journal appears on whitelists such as the Directory of Open Access Journals (DOAJ) or if it meets DOAJ seal criteria. A final approach is the use of checklists such as those on the ‘Think. Check. Submit’ website. No strategy is foolproof and the World Association of Medical Editors recommends a combination of all three.
Conclusions: If you have not heard of the journal, check bibliographic databases, tools such as Incites, and websites such as ‘Stop Predatory Journals’ or ‘Beall’s list’. In addition, do not believe the journal’s website – ask colleagues and look at indicators of journal impact. Finally, never respond to unsolicited emails.
Presenter 2
Co-Creating Research with Community Members
S Lawn
1,2
1Committee for Research, Royal Australian and New Zealand College of Psychiatrists
2Department of Psychiatry, Flinders University, Adelaide, Australia
Background: Involving community members, beyond their role as research participants, is now an expectation of most health research conducted in Australia and internationally. Involving the end users of research in its formulation and conduct enhances its quality and appropriateness and improves the translation of research outcomes. Yet this area is rapidly succumbing to the influence of rhetoric in which the true meaning, value and practice of research co-production needs to be understood and demonstrated.
Objectives: The aim of this presentation is to equip emerging mental health researchers with the skills for co-producing research with community members.
Methods: The presentation will describe the differences between co-production and various forms of consultation with community members, and their impacts on the research process and its outcomes. It will describe the processes of co-planning, co-design, co-delivery and co-evaluation that together form co-production of research. It will also articulate strategies to avoid token involvement and discuss practical examples to demonstrate how researchers can enhance community members’ meaningful involvement in research.
Conclusions: In addition to the above, attendees will receive further resources and materials to assist them with co-creating research with community members.
Presenter 3
Going Large: An Early Career Researcher’s Tips for Moving from a Scholarly Project to Ongoing Research
N Warren
1,2
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2University of Queensland School of Medicine, Brisbane, Australia
Background: Research into the causes and treatments of mental health disorders is essential to improving outcomes for consumers. Through increased awareness of, and participation in, research during registrar training, appropriate skills and interests can be developed by the next generation of early career researchers. However, embarking in research outside of the more structured scholarly project presents different challenges.
Objectives: This session aims to review the pitfalls and opportunities involved in early career research and discuss a structured method of developing, supporting and completing research as a senior registrar or new fellow.
Methods: Individual presentation and facilitated group discussion.
Findings: Continuing research commitments beyond the Scholarly Project offers opportunities for deepened understanding of research goals and methods, further development of skills, pursuit of novel insights in areas of clinical interest and potential for clinical and academic career advancement. Developing an achievable research plan often requires support and mentorship from senior colleagues. There are steep learning curves particularly when navigating research funding and governance. Work–life balance and time management become additional challenges when also beginning clinical practice as a consultant. Presentation skills and publication success may be improved with a structured approach. Completing research as a senior registrar or early career psychiatrist may also bring opportunities for gaining leadership and supervision skills.
Conclusions: Pursuing a mix of clinical and academic careers brings additional complexity to the life of an early career consultant. Developing a strong support framework with a motivated supervisor may avoid or minimize many of the pitfalls.
Presenter 4
All That You Ever Wanted to Know About Statistics, But Were Too Afraid to Ask
B O’Donoghue
1,2,3
1Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Australia
2Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia
3Orygen Youth Health, Melbourne, Australia
Background: Trainees are required to complete a Scholarly Project as part of their fellowship training and knowledge of statistics is required for this component of training. The selection of the appropriate statistical test to undertake is based on the research question and the characteristics of the data.
Objectives: The aim of this presentation is to equip trainees with the skills as to how to code data for analysis using Excel or the Statistical Package for the Social Sciences (SPSS) and how to undertake basic statistics to describe data, compare groups and derive statistics such as odds ratios.
Methods: The differences between parametric and non-parametric data will be described and this will lead to how the appropriate statistical test can be selected based on the characteristics of the data and the research question. Descriptive statistics will be explained and demonstrated in SPSS, in addition to the following statistical tests: t-tests, paired t-test, Krustal–Wallis test, Wilcoxon, Chi-squared test and analysis of variance (ANOVA). The basics of binary logistical regression will be discussed and when Poisson regression and Cox regression analysis is indicated.
Conclusions: In addition to the above, trainees will be advised on materials that can assist them with statistical analysis and how they could access more specialist statistical advice if needed.
Presenter 5
How Do You Measure That? Rating Scales for Researchers
A Harris
1,2,3
1Discipline of Psychiatry, University of Sydney, Sydney, Australia
2Prevention Early Intervention and Recovery Service (PEIRS), Western Sydney Local Health District, Sydney, Australia
3Clinical Director, Brain Dynamics Centre, The Westmead Institute for Medical Research, Westmead, Australia
Background: Quantitative research requires measurement, but how do you measure symptoms such as mood, anxiety or thought disorder? Most conditions or symptoms in psychiatry have a plethora of measures that more-or-less adequately allow researchers to measure them. Choosing the best measure requires attention to issues such as the psychometric qualities of the rating scale, training opportunities and inter-rater reliability.
Objectives: The aim of this presentation is to review the issues around the selection and use of rating scales in psychiatric research. It will provide a framework by which trainees and early career researchers can investigate and select the instruments that best suit their research.
Methods: Commonly used rating instruments such as the Positive and Negative Syndrome Scale, the Hamilton Depression Rating Scale and the Social and Occupational Functioning Assessment Scale will be used as exemplars to discuss key aspects, both theoretical and pragmatic, of rating scale selection. Resources for obtaining rating scales and available training will be identified as well as practical means to gain experience in their use. Strengths and weaknesses of commonly used rating scales will be discussed.
Conclusions: The optimal use of measurement in psychiatric research is essential for good quality research. This requires a broad knowledge of available rating scales and access to advice and training about their use.
The Delivery of State-wide Transcultural Mental Health Services and Models of Care
S Burton, D Illeana, E Truong
Queensland Transcultural Mental Health Centre, Brisbane, Australia
Background: The Queensland Transcultural Mental Health Centre (QTMHC) is a state-wide specialist mental health service which aims to facilitate culturally responsive mental healthcare to individuals from culturally and linguistically diverse (CALD) backgrounds across the age range and continuum of care (from population-level to individual-level clinical interventions). Referrals are received from a wide range of service providers in the primary care, non-government organizations and public mental health sectors.
The service model of QTMHC is based on a recognition that to improve the accessibility of mental health services for CALD individuals, the capability of mental health service providers to deliver culturally responsive services must be strengthened. In addition to consultation–liaison services, the QTMHC supports sector development through policy and planning input, research and partnership with academia, cross-sector engagement and collaboration with mental health services across Queensland’s Hospital and Health Services and workforce development.
Objectives: This session aims to present an example of an effective public mental health service model that incorporates culture-based frameworks when working with individuals from a CALD background while also building the skills and capability of other service providers to deliver culturally responsive services. This symposium would be relevant to mental health service providers and policymakers as it provides an example of how a principles-based approach to service delivery can guide how services are delivered to better meet the needs of individuals and their carers or families.
This presentation will include an exploration of the transcultural clinical service models utilized. The strengths and limitations of different models including co-assessment, matching of cultural and linguistically diverse clinicians to individuals and use of interpreters will be discussed. Clinical examples and data demonstrating these models will be presented.
Recovery from Psychosis: Medication and Shared Decision-Making
M Taylor1, B Baune2, T Theodoros3
1University of Queensland, Brisbane, Australia
2University of Melbourne, Melbourne, Australia
3Metro South Health, Brisbane, Australia
Background: Recent evidence suggests earlier use of long-acting injectable (LAI) preparations in schizophrenia can potentially decrease rates of relapse through improved medication adherence and reducing re-hospitalization. This highlights the importance of providing an LAI treatment option to patients and encourages shared decision-making (SDM) between the care provider and their patient. SDM may assist to improve a patient’s functional outcomes, quality of life and treatment satisfaction.
Objectives: This session aims to describe new LAI preparations available on the market, providing both the care provider and patient with options to choose from through SDM. We will cover how SDM can help improve utilization of LAIs to potentially improve treatment outcomes for patients with schizophrenia, their overall functioning and quality of life.
Methods: Meta-analyses were conducted to observe outcomes of oral versus LAI antipsychotics on the functioning of patients with schizophrenia. Structured questionnaires were used to examine SDM.
Findings: The findings are described in each of the abstracts below.
Conclusions: LAI antipsychotics are an important and arguably under-utilized therapeutic option, particularly where medication adherence is a priority, and where an informed patient opts for this formulation. SDM is an important part of improved care and outcomes.
References
Theodoros T, Taylor M, Huang HCH, et al. (2018) Going the distance: reviewing antipsychotic depot or long-acting injectable treatments in Australasia. Australian Psychiatry 26(3): 1–4.
Nott J, McIntosh A, Taube C, et al. (2018) Shared decision-making in psychiatry: a study of patient attitudes. Australian Psychiatry 26(5): 1–4.
Presenter 1
Shared Decision-Making in Mental Health
M Taylor
University of Queensland, Brisbane, Australia
Background: Shared decision-making (SDM) and supported decision-making are increasingly being incorporated into mental healthcare policy. The opinions of healthcare providers on the topic are available, but more evidence on patient perspectives is required.
Objectives: SDM is promoted as beneficial in mental healthcare, despite a dearth of supportive evidence. We aimed to obtain patients’ perspectives on SDM in a ‘real-world’ hospital sample.
Methods: Structured validated questionnaires were used to examine SDM with regard to treatment choices, and whether SDM influences attitudes towards treatment. The Mini-Mental State Examination was used to assess decision-making capacity.
Findings: A total of 109 individuals participated, with 60% reporting experiencing SDM. SDM was positively correlated with positive attitudes to medication. Those detained under the Mental Health Act 2014 had lower levels of SDM.
Conclusions: SDM leads to more positive attitudes towards medication and may improve adherence with treatment. SDM may particularly benefit those subject to involuntary treatment and is not onerous to practice.
Reference
Nott J, McIntosh A, Taube C, et al. (2018) Shared decision-making in psychiatry: a study of patient attitudes. Australian Psychiatry 26(5): 1–4.
Presenter 2
Functional Outcomes of Patients with Schizophrenia
BT Baune
The University of Melbourne, Melbourne, Australia
Background: Impairment in psychosocial function is common in schizophrenia. Long-acting injectable atypical antipsychotics (LAI–A) are thought to enhance psychosocial function by boosting adherence. However, no systematic review has examined the effects of LAI-As on psychosocial (day-to-day and general) function in clinical trials.
Objectives: This session aims to present the findings on the systematic review and meta-analysis of the existing literature on the effects of long-acting injectable (LAI) antipsychotic medication on functional outcomes in schizophrenia.
Methods: We searched major databases including Medline/PubMed, PsychINFO, EMBASE, CINAHL, Scopus, Web of Science, Cochrane Central Register of controlled trials and clinical trial registries for randomized controlled trials that compared LAI–A to placebo, oral antipsychotics or LAI–A for all years until 2018, with no language limits. We performed a systematic review of findings on change in psychosocial function and the predictors in the included reports. Data on change in psychosocial functioning were meta-analysed using the random effects model.
Findings: A total of 25 studies with 11,097 adults and 67.1% males were included. LAI–A was superior to placebo (standardized mean difference [SMD] = 0.39; 95% confidence interval [CI] = 0.32, 0.47; p < 0.001; I2 = 0%) and oral medications (SMD = 0.16; 95% CI = 0.01, 0.31; p = 0.04; I2 = 77%) for improved psychosocial function and the superiority was maintained in short and long trials. Poor psychosocial function was predicted by longer treatment duration, severe symptoms, poor cognition and poor insight. Functioning was assessed by either a single or a combination of a range of measures but not the primary outcome in most studies. Other sources of bias include poor blinding and reporting of randomization.
Conclusions: LAI–As are beneficial to psychosocial function recovery, although the magnitude of superiority over orals was small. Severe psychopathology can help predict those who may benefit from intensive psychosocial therapies. Future ‘true’ effectiveness trials that include psychosocial function as the main outcome a priori are needed to capture the real-world impact of LAI–A and to address methodological biases.
Reference
Tiihonen J, Mittendorfer-Rutz E, Majak M, et al. (2017) Real-world effectiveness of antipsychotic treatments in a nationwide cohort of 29 823 patients with schizophrenia. JAMA Psychiatry 74: 686–693.
Presenter 3
The Use of With Antipsychotic Medications in Schizophrenia in Public Mental Heatlh: Real-World Data, Metabolic Monitoring and Polypharmacy
T Theodoros
Metro South Health, Brisbane, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) released an update of the Clinical Practice Guideline for the Management of Schizophrenia and Related Disorders in 2016. Australia has no national registry monitoring the use of psychotropic medications. Real-world usage of antipsychotic medication, rates of polypharmacy, compliance with national guidelines and appropriate metabolic monitoring with antipsychotic use has not been well explored in Australian populations.
Objectives: This session aims to review the use of antipsychotic medication in an Australian population. This includes exploring the rates of antipsychotic long-acting injectable (LAI) use in a real-world population; defining the rates of antipsychotic polypharmacy; reviewing the rates of appropriate lipid monitoring with antipsychotic use; and exploring compliance with the RANZCP guidelines.
Methods: A large Hospital and Health Service in Australia conducted three clinical audits to review the use of antipsychotic use on discharge from an inpatient mental health unit; to review the rates of lipid monitoring with antipsychotic use (particularly on commencement of therapy); and to compare the rates of LAI versus oral antipsychotic use in a community psychosis team.
Findings: Rates of antipsychotic polypharmacy in a public metropolitan Australian mental health unit were lower than expected and were lower than rates published in international literature. Prescription of antipsychotic medication occurred mostly in accordance with RANZCP Guidelines. LAI antipsychotic medications were well utilized in inpatient and community settings; however, the rates were lower than expected. Lipid monitoring was unfortunately poorly completed and was rarely the fasting reading.
Conclusions: LAI antipsychotics are an important and arguably under-utilized therapeutic option, particularly where medication adherence is a priority, and where an informed patient opts for this formulation. Real-world prescription of antipsychotic medication aligned well with RANZCP Guidelines. Lipid monitoring was poorly completed and made an argument for preferring more metabolically neutral LAIs.
Furthermore, it is recommended that the RANZCP consider a formal position statement regarding antipsychotic polypharmacy.
References
Barnes TR (2011) Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 25: 567–620.
Barnes TRE and Paton C (2011) Antipsychotic polypharmacy in schizophrenia: benefits and risks. CNS Drugs 25: 383–99.
Galletly C, Castle D, Dark F, et al. (2016) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry 50: 410–72.
Lochmann van Bennekom MW, Gijsman HJ and Zitman FG (2013) Antipsychotic polypharmacy in psychotic disorders: a critical review of neurobiology, efficacy, tolerability and cost effectiveness. Journal of Psychopharmacology 27: 327–36.
McMillan SS, Jacobs S, Wilson L, et al. (2017) Antipsychotic prescribing for vulnerable populations: a clinical audit at an acute Australian mental health unit at two-time points. BMC Psychiatry 17(1): 139.
Taylor D, Barnes T, Young A, South London Maudsley NHS Trust (2018) The Maudsley Prescribing Guidelines in Psychiatry, 13th edn. Chichester, West Sussex, Hoboken, NJ: John Wiley & Sons.
Tiihonen J, Mittendorfer-Rutz E, Majak M, et al. (2017) Real-world effectiveness of antipsychotic treatments in a nationwide cohort of 29 823 patients with schizophrenia. JAMA Psychiatry 74: 686–693.
Tiihonen J, Suokas JT, Suvisaari JM, et al. (2012) Polypharmacy with antipsychotics, antidepressants, or benzodiazepines and mortality in schizophrenia. Archives of General Psychiatry 69(5): 476–483.
Waterreus A, Morgan VA, Castle D, et al. (2012) Medication for psychosis – consumption and consequences: the second Australian national survey of psychosis. Australian and New Zealand Journal of Psychiatry 46: 762–73.
The Value of Connectedness: Lived Experiences of Loneliness and Isolation in Our Communities
S Stafrace1,2, D Backman-Hoyle1,3, B Vickers1,4, S Lawn1,5, H McGowan1,6, D Vecchio7, D Ferrie8, S Howe8, S MacLean8, A Darvall8
1Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists
2The Alfred Hospital, Melbourne, Australia
3Inspired Workforce Performers, Peregian Beach, Australia
4Northland DHD, Whangarei, New Zealand
5Flinders University, Adelaide, Australia
6WA Mental Health Network, Department of Health, Shenton Park, Australia
7Armadale Mental Health Service, Melbourne, Australia
8Melbourne Inner South-East Metropolitan Partnership, Victorian Department of Environment, Land, Water and Planning, Melbourne, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists partners with people who have a lived experience of mental illness through our Community Collaboration Committee (CCC). The CCC is made up of six psychiatrists and eight community members from Australia and New Zealand.
Objectives: This session aims to:
share different perspectives regarding the impact of loneliness upon individuals within the community and how this is influenced by context;
share current guidance regarding the issue of loneliness; and
seek audience perspectives.
Methods:
Presentation on the lived experiences and research of CCC members representing binational perspectives.
Presentation on the structure and successes of the Trieste model.
Evaluation of the current suicide prevention framework and impact of loneliness on suicide risk.
Discussion of an individual case study that explores loneliness in the community.
Audience participation.
Findings: Loneliness is increasingly being recognized as an area of significant concern for both consumers and carers in mental healthcare. The stigma surrounding mental health issues can quite often leave those personally impacted through their own or others mental illness with feelings of isolation.
Conclusions: Social connectedness and partnerships within the community are important considerations in improving the experience of those with mental illness, their carers, family and whānau. The CCC invites Congress attendees’ participation in discussing this important issue.
Presenter 1
Loneliness From A Mental Health Lived Experience Perspective: More Than Needing A Social Network
B Vickers1, S Lawn2
1Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists, Northland DHD, Whangarei, New Zealand
2Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists, Flinders University, Adelaide, Australia
Background: Social connection that nurtures a clear sense of meaning and connection with others is a key ingredient of living a contributing life; one where we feel understood by others, able to trust and reach out to others, feeling a sense of being part of a social network, and not feel alone in the world. These are all important to mental health and well-being and to personal and community resilience.
Objectives: This session aims to present how loneliness manifests from a lived experience perspective.
Methods: The presenters will draw on personal experiences of living within their communities in the presence of mental illness, and how this impacts on social connections and relationships. The presentation will include a discussion of the perceptions of those with lived experience (Whaiora) about how social networks can be limited or enhanced.
Findings: The experience of loneliness is an embedded part of the lives of many mental health consumers and carers, as a consequence of how individuals perceive themselves and are perceived by others. Hence, addressing loneliness requires a deeper understanding of how to build and sustain social networks so that further stigma, isolation and community disconnection is not inadvertently created.
Conclusions: By addressing loneliness, recovery and citizenship are strengthened.
Presenter 2
Loneliness Lessons From Trieste: An Insider’s and an Outsider’s View
H McGowan1, D Vecchio2
1Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists, WA Mental Health Network, Department of Health, Shenton Park, Australia
2Armadale Mental Health Service, Armadale, Australia
Background: The Trieste model has long been regarded as successful in creating social support networks and overcoming social isolation, which in turn develops the capacity of carers and consumers to better cope with the challenges of mental ill health. The two presenters have different perspectives of the Trieste model: Dr Vecchio completed her training in psychiatry in the Trieste region and Dr McGowan visited the Trieste service in late 2014 as part of a small group visit led by the WA Minister for Mental Health.
Objectives:
This session aims to (i) present the evidence that reduction of social isolation improves the mental health of consumers and families and (ii) identify the processes and context that have supported the reduction in social isolation.
Methods: Review the evidence for the Trieste model actively supporting the reduction of social isolation and loneliness and the impact this has on mental health outcomes. Consider and review the evidence that the Italian social context actively supports the Trieste model.
Findings: Italian culture tends to be inclusive and tightly knit and expects all to be contributory. This has influenced the development of the Trieste model – such that people with mental illness are less likely to be excluded and lose social networks and also are expected to remain engaged and contributing in some role even if they are early in their mental illness journey and recovery. This means there is considerable support to engage with, education, training, voluntary work and/or employment. This in turn maintains social integration, minimizes loneliness and leads to better mental health outcomes. The mental health services actively promoted the creation of social support networks, which included mutual help groups, social clubs and early and ongoing consumer engagement with therapeutic programmes and training, education and/or the workforce.
Conclusions: There are lessons to be learnt from the Trieste model but will require adaptation for the Australasian social and legislative context.
Presenter 3
Suicide Prevention Framework
D Backman-Hoyle
Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists, Inspired Workforce Performers, Peregian Beach, Australia
Background: Research indicates that loneliness is a significant predictor of suicidal risks but is it simply a case of creating social relationships of meaning to counter the risk?
Is loneliness is a key factor of suicide and suicidal ideation? How is this knowledge being utilized within existing Australian suicide prevention frameworks?
Objectives: In this presentation, we review key research that provides evidence of the risk of loneliness to suicide and suicidal ideation. We will discuss how the topic of loneliness is being considered against high-risk age groups such as youth and the elderly.
We will explore what suicide prevention frameworks integrate these data into service options.
Methods: Presentation and group discussion.
Findings: Understanding the need to consider wider social constructs such as loneliness into the work of suicide prevention.
Conclusions: Loneliness is a real and sometimes painful reality that impacts the quality of life for many: the lack of a meaningful relationship with oneself and wider social dynamics does increase the risks of suicide for our society. Tackling loneliness may have a real impact in reducing the loss of lives to suicide in Australia.
Presenter 4
Tackling Loneliness At A Regional Level: A Public Health Challenge For A Community and the Royal Australian and New Zealand College of Psychiatrists?
S Stafrace1, D Ferrie2, S Howe2, S MacLean2, A Darvall2
1Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists, The Alfred Hospital, Melbourne, Australia
2Melbourne Inner South-East Metropolitan Partnership, Victorian Department of Environment, Land, Water and Planning, Melbourne, Australia
Background: Individuals who lack meaningful social connections are at risk of loneliness, the physical and mental health consequences of which are subject to a growing literature. Loneliness is a concern of people with lived experience of mental illness and is seen as a barrier to a contributing life and a source of personal and social vulnerability. Psychiatrists may have a role to play in addressing problems of loneliness at an individual and community level.
Objectives: This session aims to provide a brief overview of the literature, with a focus on individual and social approaches to the alleviation of loneliness. In addition, it describes the Inner South-East Metropolitan Partnership in Melbourne, how it identified loneliness as a matter of concern to its local community and used its influence to start a conversation with state and local governments.
Methods: Literature review. Reflections on the personal experience of a psychiatrist who was a member of the Inner South-East Metropolitan Partnership.
Findings: There is consistent evidence linking loneliness and social isolation to worse mental health and cardiovascular outcomes for people suffering from mental illness and the general community. Interventions that address social cognition have greater impact than interventions that address social support, social skills and opportunities for social intervention. Existing frameworks and approaches have only engaged with these topics in limited ways and there is also scope for intervention through local government, health services and the voluntary sectors.
Conclusions: Loneliness is a public health and public mental health challenge, which impacts directly upon the mental health and well-being of our communities and of people with a lived experience of mental illness. Should the Royal Australian and New Zealand College of Psychiatrists consider whether to develop a public position recognizing the impact of loneliness and social isolation on people with a mental illness and their families and outlining the role psychiatrists can play? Psychiatrists can have a positive impact on loneliness, through an individual therapeutic approach with patients, by working with other clinicians, peer workers and families, and in community settings that promote social connection.
Presenter 5
Audience Engagement
S Stafrace1, D Backman-Hoyle2, H McGowan3, D Vecchio4, B Vickers5, S Lawn6
1Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists, The Alfred Hospital, Melbourne, Australia
2Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists, Inspired Workforce Performers, Peregian Beach, Australia
3Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists, WA Mental Health Network, Department of Health, Shenton Park, Australia
4Armadale Mental Health Service, Armadale, Australia
5Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists, Northland DHD, Whangarei, New Zealand
6Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists, Flinders University, Adelaide, Australia
Background: Facilitated discussion will be centred around ideas for improving existing and building new partnerships within communities. The audience is invited to reflect on what is working well and the priorities for improvement.
Objectives: This session aims to emphasize that individuals are to drive change and support neighbours, friends and families.
Methods: The section will involve an open discussion/participation with the audience on the topics presented in the symposium. The facilitation will focus on what we as individuals, the health system and governments can do better to address loneliness and how we can improve the delivery of services and partnerships to communities.
Findings: The solutions to loneliness and isolation challenges in the community will not primarily come from top-down interventions about mobilizing the community to be more aware of the issues and to take action.
Conclusions: Loneliness is a deeply complex, multifaceted issue that impacts the quality of life for many within our communities.
Illuminating Light Or Glaring Sun? Insights Into Service Models, Resources and Workforce Development From National Surveys of Consultation–liaison and Old Age Psychiatry Services
J Hopkins1, W Lee2, B Copeland3
1Psychological Medicine Middlemore Hospital, Auckland, New Zealand
2Devon Partnership NHS Trust, Exeter and University of Exeter, Devon, UK
3Mental Health Services for Older People, Tauranga Hospital, Tauranga, New Zealand
Background: National surveys have the potential for identifying the status of psychiatric services, highlighting issues and challenges and tracking changes over time. Drivers for national surveys include government policy, service and workforce considerations and local networking. Psychiatry of Old Age (POA) services in New Zealand has been surveyed three times in the last 20 years; Liaison Psychiatry in England has undergone a series of annual surveys since 2013; and Consultation–Liaison Psychiatry (C–LP) in New Zealand has recently conducted its first national survey.
Objectives: This session aims to contextualize and compare a series of national surveys of POA and C–LP services conducted in New Zealand and England and identify training and workforce challenges in light of these surveys.
Methods: A variety of survey methods were employed. One survey used SurveyMonkey, while the other two series used written questionnaires. Many question areas were common to all three survey series, but each series had unique questions. Two surveys were small (13 and 17 services) whereas one was large (180 services).
Findings: The national surveys of POA and C–LP in New Zealand and Liaison Psychiatry in England have produced useful cross-sectional and longitudinal data on these service sectors. They have identified both common and specific service, training and workforce challenges.
Conclusions: Whether national surveys of POA and C–LP services are an illuminating light or a glaring sun will depend on their drivers, the challenges facing that sector, the engagement with the services surveyed, how frequently they are repeated and whether the issues identified lead to constructive change.
Presenter 1
The State of Play – The First National Survey of Consultation–liaison Psychiatry Services in New Zealand May 2018
J Hopkins
Psychological Medicine Middlemore Hospital, Auckland, New Zealand
Background: Unlike related services in New Zealand (Old Age Psychiatry) and England (Liaison Psychiatry), there has not been a national survey of Consultation–Liaison Psychiatry (C–LP) services in New Zealand.
Objectives: This session aims to describe the conduct a comprehensive survey of C–LP services in New Zealand.
Methods: A survey based on the Multidimensional Matrix for Consult–Liaison Psychiatry was developed using SurveyMonkey and sent to one psychiatrist at each of 12 identified services. Existing data for Middlemore Hospital was added for completion.
Findings: The survey had 12 respondents; a 100% completion rate; and on average took 8 min to complete. The survey confirmed how variable C–LP services are in New Zealand. The greatest variability is in the coverage of the emergency department, young people and older people. Most services are fully funded and managed by mental health, the vast majority operate within office hours, none had a full multidisciplinary team and most hospitals have psychologists and other allied health staff outside and separate to the C–LP service. Liaison with other hospital specialties is generally underdeveloped, but these services are surprisingly active in providing teaching to staff of the general hospital.
Conclusions: The survey has provided a useful snapshot of C–LP services in New Zealand in 2018 and revealed a striking heterogeneity among these services, with no ‘archetypal’ New Zealand service and no single best-practice model. The survey has established a base for further extension by the addition of more quantitative data and a baseline for comparison with future surveys.
Presenter 2
Lessons From A Sequence of Four National Staffing Surveys in England
W Lee
1,2
1University of Exeter, Devon, UK
2Devon Partnership NHS Trust, Exeter, UK
Background: Liaison Psychiatry has been growing inconsistently in the United Kingdom, driven by local interests, enthusiasms and perceived need. In 2013, a confluence of political interest and a favourable evaluation of the economic case for Liaison Psychiatry resulted in a comprehensive survey of Liaison Psychiatry in England. Shortly afterwards, growth in Liaison Psychiatry became a government target. We have since undertaken three further surveys of Liaison Psychiatry in England.
Objectives: To complete annual, high-quality staffing surveys of Liaison Psychiatry services in England and to determine progress towards the government target.
Methods: We identified those acute hospitals in England that have an emergency pepartment. We agreed to an appropriate set of questions and piloted them. We then contacted clinicians in each liaison service. Responders and non-responders were tracked. Services were graded into No Service, Subcore, Core (6 nurses and 2 consultants), Core 24 (15 nurses and 2 consultants) and Enhanced+ (more than Core 24).
Findings: The response rates for all four Liaison Psychiatry Surveys of England (LPSE) were above 90%. Comparing the 2014 and 2015 surveys (LPSE–2 and LPSE–3), No Service dropped from 19 to 9, Subcore and Core categories showed little change (131 to 132 and 16 to 18, respectively), Core 24 increased from 5 to 13 and Enhanced+ was unchanged at 4. Detailed LPSE–4 data will be available at the presentation.
Conclusions: Liaison services in England are growing towards the government target but will need to grow at a faster rate to meet the target by 2021.
Presenter 3
The Third New Zealand Psychiatry of Old Age Services and Workforce Survey
B Copeland
Mental Health Services for Older People, Tauranga Hospital, Tauranga, New Zealand
Background: Psychiatry of Old Age (POA) services in New Zealand has been surveyed twice before, in 1998 and 2003, and a considerable period (14 years) has elapsed since the previous survey.
Objectives: This session aims to conduct a current survey of the POA services and workforce in New Zealand.
Methods: The New Zealand branch of the Faculty of POA contacted the POA lead clinician and/or service manager of the 20 District Health Boards (DHBs) and completed a survey based on variables used in two similar previous national surveys.
Findings: Seventeen services responded. We found acute inpatient beds and clinical staff time are funded differently across DHBs. Although there has been an increase in non-medical clinical staff time in the community teams, most DHBs are not planning to increase their medical staff time in the next 3 years. Specialist services for people with intellectual disabilities and young-onset dementia, and older people with substance use disorder, are generally not provided from within POA services.
Conclusions: A wider POA and non-POA services mapping is required to determine the level of services for clinical populations that have high and complex clinical needs. DHB funders should review the expected population growth in people older than 65 years and consider increasing the funding for these under-served clinical populations.
Presenter 4
Training and Workforce Development to Meet the Needs of Psychiatry of Old Age and Consultation–liaison Psychiatry Services
G Cheung1, J Hopkins2, W Lee3
1University of Auckland, Auckland, New Zealand
2Psychological Medicine Middlemore Hospital, Auckland, New Zealand
3Plymouth University and Devon Partnership NHS Trust, Plymouth, UK
Background: This presentation summarizes the annual numbers of trainees entering and completing training in Psychiatry of Old Age (POA) and consultation–liaison (C–L) psychiatry in Australia and New Zealand. Some of the challenges for, and potential future developments of, POA and C–L training will be discussed, with particular focus on how to meet the evolving workforce needs of POA and C–L services. The authors will also compare and contrast the Royal Australian and New Zealand College of Psychiatrists POA advanced training with the POA training in the United Kingdom.
Conclusion: This presentation finishes with a panel discussion on the issues raised in this symposium.
Inform, Drive, Evaluate: Harnessing Collective Expertise to Improve Health Service Delivery For Suicide Prevention in Queensland
J Reilly, J Martin
Office of the Chief Psychiatrist, Mental Health Alcohol and Other Drugs Branch, Clinical Excellence Queensland, Queensland Health, Brisbane, Australia
The Suicide Prevention in Health Services Initiative (SPIHSI) (249)
Background: Suicide prevention is a shared responsibility requiring a comprehensive whole-of-government approach. Queensland suicide rates are consistently above the national average and the significant increase recorded in 2015 was a catalyst for an innovative state-wide health services approach. An analysis of suicide data revealed that approximately one-quarter of individuals had contact with a Queensland Health service within 7 days of death by suspected suicide. The Suicide Prevention iIn Health Services Initiative (SPiHSI) was established in 2016 to focus on how health services can contribute to reducing suicide in Queensland.
Objectives: The aim of this session is to show how health service reform is driven by addressing systemic issues in health service delivery in the context of suicide risk, partnering with hospital and health services, primary health networks and people with a lived experience.
To improve health service responses to whole-of-population and specific cohorts by collaboratively exploring evidence-based treatment options to inform suicide prevention prioritization and implementation in health services.
Methods: We will describe how priority areas for suicide prevention in health services can be addressed by integrating leadership, clinical expertise, research evidence and lived experience perspectives. Consideration of how to design, implement and evaluate sustainable change within a clinical governance framework will be discussed.
Findings: Symposium presentations will highlight key SPiHSI projects, including overarching governance. To demonstrate progress made in the planning, implementation and evaluation of multiple priority areas and tangible examples of suicide prevention innovation delivered in a phased approach.
Conclusions: The symposium will articulate how systemic health service delivery improvements relevant to suicide prevention can be achieved through coordinated state-wide activity and leadership.
Presenter 1 – Governance of the Suicide Prevention Iin Health Services Initiative (249)
J Reilly, J Martin
Office of the Chief Psychiatrist, Mental Health Alcohol and Other Drugs Branch, Clinical Excellence Queensland, Queensland Health, Brisbane, Australia
Background: Queensland suicide rates continue to be above the national average and health services are approaching this in a number of innovative ways.
Objectives: The aim of this presentation is to consider overarching governance of health service reform in relation to suicide risk management and Queensland’s current approach to improving health service responses within wider community suicide reduction approaches.
Methods: We will describe how priority areas for suicide prevention in health services have been identified and addressed in Queensland by the Suicide Prevention iIn Health Services Initiative (SPiHSI), including consideration of the clinical governance framework within a national context and the requirements for an effective evaluation.
Findings: The governance and evaluation processes adopted will be outlined.
Conclusions: We will identify how Queensland’s current health service delivery improvements relevant to suicide prevention can be achieved and evaluated.
Presenter 2
Improving Health Service System Responses For Individuals At Risk of Suicide Through A Multi-incident Analysis of Suspected Suicides (244)
L Leatherbarrow, K Dingli
Mental Health Alcohol and Other Drugs Branch, Clinical Excellence Division, Queensland Health, Brisbane, Australia
Background: The Multi-Incident Analysis (MIA) was developed in response to Queensland Health data indicating the high proportion of individuals who had recent contact with a health service prior to death by suspected suicide in 2015. Analysis of clinical and coronial information can reveal systemic and modifiable system factors to improve health service responses for people at risk of suicide. The MIA is a clinical review of linked data related to suspected suicide death where individuals had contact with a health service in Queensland 1 month prior to death (2015 and 2016), with a focus on identified priority cohorts (Aboriginal and Torres Strait Islander people, children and young people, older persons and acute mental healthcare).
Objectives:
To identify health service system factors from linked data to improve health service responses to individuals experiencing a suicidal crisis.
To involve clinicians, cohort specialists and people with a lived experience in the analysis and formulation of recommendations for health service reform (systemic and cohort specific).
To build the evidence base that informs the Suicide Prevention in Health Services Initiative (SPiHSI) priority areas and suicide prevention literature.
Methods: We will highlight the analysis process and key findings used to inform recommendations for improving health service system factors. The influence of MIA findings on other areas of the SPiHSI will also be discussed.
Findings: Data inform the systemic and cohort-specific themes underpinning the suicide prevention focused recommendations developed from clinical and lived experience perspectives.
Conclusions: MIA findings and methodology are robust examples of translating research collaboratively into targeted health service reform.
Presenter 2
Collaborative Methodology to Implement Zero Suicide in Healthcare
M Heather
Mental Health Alcohol and Other Drugs Branch, Clinical Excellence Division, Queensland Health, Brisbane, Australia
Background: The Zero Suicide in Healthcare Multi-Site Collaborative (ZSiH–MSC) aims to improve care and outcomes for individuals at risk of suicide in the healthcare system. The Zero Suicide in Healthcare (ZSiH) framework represents a commitment to patient safety and to the safety and support of clinical staff caring for individuals experiencing a suicidal crisis. The ZSiH framework is being implemented across 11 Hospitals and Health Services (HHS) in Queensland’s metropolitan, regional and rural/remote areas using multisite collaborative methodology.
Objectives: This session aims to outline:
essential components of the ZSiH framework;
key elements of collaborative methodology for achieving service-level clinical change;
experience of participating HHSs of collaborative methodology to drive service-level change; and
how participating services adapted and strengthened the clinical care pathway for people experiencing suicidality to match local consumer needs and the service context.
Methods: We will demonstrate how collaborative methodology is being used to inform and sustain service-level leadership, culture, process and clinical practice change to improve care and outcomes for individuals at risk of suicide.
Findings: Highlight the benefits described by the HHSs who participated in the project, detailing the value of a collaborative methodology to introduce sustainable change across complex acute care settings. The collaborative methodology was pivotal to key success factors and enhanced the ability of our participating sites to explore, implement and develop tools and resources collectively.
Conclusions: The symposium will allow us to demonstrate how a collaborative methodology was instrumental in the implementation of clinical pathways for suicide prevention in the acute care setting, which demonstrated the importance of integrating care teams across a variety of HHSs.
Sexual Safety in Residential Mental Health Settings
V Lakra1,2, D Rudolph1, K Jagadheesan1, S Mouat1, J Barrowman1, J Babb3, J Hope4, N Keks5
1North West Area Mental Health Service, Melbourne, Australia
2Office of the Chief Psychiatrist, Melbourne, Australia
3Eastern Health, Central East and Outer East Mental Health Services, Melbourne, Australia
4Delmont Hospital, Melbourne, Australia
5Monash University, Melbourne, Australia
Background: In 2012, 17% of women and 4% of men aged 18 years and older reported sexual assault since their age of 15 years in Australia (Australian Bureau of Statistics, 2012). According to an Australian study, the lifetime prevalence of sexual assault was 56.9% among psychiatric inpatients with women reporting higher rates (McFarlane et al., 2006).
Objectives:
This session aims to (i) discuss the strategies of the Victorian Chief Psychiatrist in improving sexual safety in inpatient settings and to illustrate the experiences of two public and one private mixed-gender psychiatric wards and in improving sexual safety of acutely unwell patients.
Methods: The quality improvement cycle methodology was carried out. The Victorian Chief Psychiatrist project used the mental health services data set of notification of sexual assault incidents. The two mental health services projects used the Riskman data. In addition, Eastern Health analysed the service-specific complaints to the Mental Health Complaints Commissioner. The private hospital study used a 12-month audit data and data from the Private Mental Health Alliance.
Findings: The Chief Psychiatrist of Victoria has implemented a new sexual safety incident reporting tool. Both public mental health services have successfully implemented gender-sensitive practices in acute care settings and found a cultural change in early identification and reporting of sexual safety issues. Although there was no reported incident of sexual assault at the private psychiatric hospital, 2–3% of patients reported feeling unsafe during their admission.
Conclusions: A state-wide sexual safety incident reporting tool facilitates the mental health services to provide a uniform set of information. Service-wide initiatives need to include preventative strategies and early identification and management of sexual safety breaches.
References
Australian Bureau of Statistics (2012) Personal safety survey. In Demographics of those who have experienced sexual assault. Available at: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4906.0Chapter5002012.
McFarlane A, Schrader G, Bookless C, et al. (2006) Prevalence of victimization, posttraumatic stress disorder and violent behaviour in the seriously mentally ill. Australian and New Zealand Journal of Psychiatry 40: 1010–1015.
Presenter 1
State-wide Strategies to Promote Sexual Safety in Mental Health Settings: Victorian Experience
V Lakra, C Salmon
Office of the Chief Psychiatrist, Melbourne, Australia
Background: In Victoria, the Chief Psychiatrist is responsible for promoting continuous improvement in the quality and safety of mental health services. According to the Victorian government Chief Psychiatrist’s Guideline Promoting Sexual Safety, Responding to Sexual Activity, and Managing Allegations of Sexual Assault in Adult Acute Inpatient Units, sexual activity is incompatible with the acute treatment environment and is unacceptable. The Guideline requires reporting sexual safety incidents to the Chief Psychiatrist; however, the threshold for reporting incidents and the content of these reports varies significantly across Victorian services. This results in the Chief Psychiatrist not having a clear understanding of the extent of sexual activity incidents in adult acute inpatient units including the number of allegations of sexual assault in these facilities.
Objectives: This presentation is aimed at sharing the experience of developing and implementing a state-wide reporting tool for sexual safety incidents.
Methods: Based on recent sexual safety incident notifications, The Chief Psychiatrist Office recognized the need for development and implementation of a new reporting process for all sexual safety incidents in adult acute inpatient units. The Chief Psychiatrist Office developed and implemented a new reporting process in 2018, including a clinician checklist giving clear guidance about reporting such incidents.
Findings: The presentation will highlight the findings of an evaluation of a 3-month period of quantitative and qualitative data. It will address the issues in a broad sense including introduction of the new reporting tool and share the findings from the pilot period. It will also address the issues related to data collection, challenges in incident identification and reporting and future considerations for service providers and government to improve sexual safety in mental health services.
Conclusions: A state-wide reporting tool, including a checklist, has been implemented successfully. The data from the pilot period will contribute to revision of the Chief Psychiatrist Guideline.
Presenter 2
Improving Sexual Safety in An Adult Acute Psychiatric Inpatient Unit: A Quality Project At North West Area Mental Health Service
V Lakra1,2, D Rudolph1, K Jagadheesan1, S Mouat1, J Barrowman1
1North West Area Mental Health Service, Melbourne, Australia
2Office of the Chief Psychiatrist, Melbourne, Australia
Background: Mental health services are expected to provide a safe environment for patients in their service. A number of health service standards incorporate safety of patients as an important element for delivery of services. Patients who are admitted to acute inpatient units are more vulnerable and at risk of harm. In Victoria, the Chief Psychiatrist provides clinical leadership by developing guidelines for improvement in the quality and safety of mental health services. The Chief Psychiatrist’s Guideline Promoting Sexual Safety, Responding to Sexual Activity, and Managing Allegations of Sexual Assault in Adult Acute Inpatient Units provides guidance for addressing sexual safety issues in adult acute inpatient units.
Objectives: The aim of this presentation is to share the experiences of the leadership team in implementing strategies to monitor and promote sexual safety in the acute psychiatric ward at North West Area Mental Health Service.
Methods: North West Area Mental Health Service provides mental health services in the north-west region of metropolitan Melbourne. The service embarked on a ‘safety first’ initiative as part of quality improvement initiatives. Improving sexual safety in the adult acute inpatient unit has been part of these safety initiatives.
Findings: The presentation will describe the journey in improving sexual safety in a mixed-gender adult acute inpatient unit addressing a range of issues including, but not limited to, identification and reporting of incidents, revision of policy, data collection and monitoring, staff training and education, supports for patients and families, and relationship with multiple stakeholders.
Conclusions: Promotion of sexual safety in a mixed-gender acute psychiatric setting requires active support from the leadership team and involves a multipronged approach.
Presenter 3
Improving Sexual Safety in An Adult Acute Psychiatric Inpatient Unit: A Service Improved Project At Central East and Outer East Mental Health Services
J Babb
Eastern Health, Central East and Outer East Mental Health Services, Melbourne, Australia
Background: All people receiving inpatient psychiatric care have the right to feel safe. Many mental health consumers have past histories of sexual abuse, neglect or violence. Women consistently report feeling unsafe in mixed-gender units.
Objectives: The aim of this presentation is to share the experiences and strategies associated with promotion of sexual safety in acute psychiatric settings at Eastern Health.
Methods: Eastern Health has three adult inpatient units, each with 25 beds, including a 4–5 bed Intensive Care Area. With males outnumbering females in acute mixed-gender wards, these environments can expose female patients to incidents of sexual, physical or emotional abuse. Eastern Health carried out a project to improve sexual safety for all consumers and to promote the privacy and safety of female patients.
Findings: Culture change has taken time; however, in 2018, the culture in all adult units is now a strong focus on sexual safety and proactive strategies to prevent breaches in safety. There is also a clear rapid senior response when any breach of sexual safety arises. Eastern Health aims to address these issues through the establishment of the Female Only Mental Health Inpatient Unit at Maroondah Hospital, by converting one of the current 25-bed mixed-gender adult inpatient units into a single sex ward.
Conclusions: Promotion of sexual safety in bed-based services is achievable through a set of actionable strategies that improve the culture of the healthcare settings and supports prompt senior response. A long-term sustainable solution is to convert a mixed-gender ward to a single sex ward.
Presenter 4
Tracking and Improving Perceived Sexual Safety in An Adult Acute Psychiatric Private Inpatient Unit: Different Challenges
J Hope1,2, N Keks1,2
1Delmont Hospital, Melbourne, Australia
2Monash University, Melbourne, Australia
Background: Private psychiatric hospitals in Australia treat a predominance of female patients, often with a high proportion of mood, anxiety and personality disorders (Keks et al., 2018). Many inpatients also have a history of sexual abuse, creating vulnerability to a perceived lack of safety in mixed-gender units.
Objectives: We analysed admission audit data in conjunction with perceived experience of care data collected by the Private Mental Health Alliance (Morris-Yates, 2015) to attempt to better understand the experiences of patients admitted to Delmont Private Hospital in Melbourne.
Methods: Data collected over 12 months from an 88 inpatient bed private hospital, including adult general, substance use/addiction and psychogeriatric wards of Delmont Hospital, was analysed for demographic variables and satisfaction with care including sense of privacy and safety.
Findings: Women outnumbered men by a factor of 1.3 in admissions and occupied a greater number of bed days during 2017. There were no incidents of sexual assault recorded. Most respondents felt safe in the hospital environment but 2–3% reported feeling unsafe, although this does not specifically isolate sexual safety. Culture change through low thresholds for reporting sexual violence incidents (e.g. verbal abuse, intimidation and touching) may alter both reporting and institutional response to sexual violence.
Conclusions: Although low rates of sexual violence are reported, satisfaction with care indicates that up to 2–3% of respondents are dissatisfied with their perceived safety. Private hospitals continue to develop strategies to meet the needs for safety for all people admitted to mixed-gender wards.
References
Keks N, Hope J, Pring W, et al.(2018) Characteristics, diagnoses, illness course and risk profiles of inpatients admitted for at least 21 days to an Australian private psychiatric hospital. Australasian Psychiatry (in press).
Morris-Yates A (2015) Development and implementation of the PMHA’s Patient Experiences of Care Survey (PEx) for private hospital-based psychiatric services (with selected statistics for the 2014 calendar year). Australian Medical Association (on behalf of the Private Mental Health Alliance), Canberra.
Continuous Professional Development
W de Beer1,2, R Harvey2,3, E Moore2,4, L Salmon2,5, R Dotson2,6, B Lloyd2,8, J Topp2, G Young2,9,11, M O’Connor2,10, S Sinha2,15, N Jeyasingham2, K Maheti2,7, M Patton2,14, J Pettigrew2,13
1Waikato District Health Board, Hamilton, New Zealand
2Committee for Continuing Professional Development, Royal Australian and New Zealand College of Psychiatrists
3Deakin University, Geelong, Australia
4Consultant Psychiatrist, Perth, Australia
5Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists
6Consultant Psychiatrist, Canberra, Australia
7Trainee Representative Committee, Royal Australian and New Zealand College of Psychiatrists
8Consultant Psychiatrist, Adelaide Australia
9Capital and Coast District Health Board, Napier, New Zealand
10University of Melbourne, Australia
11University of Otago, New Zealand
12Consultant Psychiatrist, New Zealand
13Consultant Psychiatrist, Katherine, Australia
14Northland District Health Board, Whangarei, New Zealand
15Overseas Trained Psychiatrists Committee, Royal Australian and New Zealand College of Psychiatrists
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Continuing Professional Development (CPD) programme provides a pathway for participants to review and further develop professional practice, maintaining knowledge, skills and performance and optimizing provision of adequate and safe medical care. RANZCP Fellows through the Committee for Continuing Professional Development set the identified standards for psychiatrists’ CPD in Australia and New Zealand. The programme is an essential part of the public assurance of the professionalism of Fellows and the quality of the care they provide.
Objectives: This symposium seeks to present various aspects of CPD, including reflective learning, what psychiatrists report as CPD activity and how psychiatrists working less than full time can meet their CPD requirements.
Methods: Presentations are based on a review of the data from the annual audit of records for the 2017 CPD year, literature reviews, and members’ examples. An overview of the changes being introduced by the regulating bodies in Australia and New Zealand is provided to set context.
Findings: The introduction of the online My CPD system has provided access to data on what activities are reported by psychiatrists. Data from the 2017 annual audit will illustrate the variety of CPD activities reported by participants and the extent to which reflection on learning is reported. Practice Improvement activities are a source of concern for participants who appreciate examples and templates.
Conclusions: CPD is an essential component of psychiatry practice. Changes to the RANZCP programme administration are allowing a greater understanding of how psychiatrists undertake their CPD and will enhance the ability of psychiatrists to meet their regulatory requirements.
Presenter 1
Continuing Professional Development and Regulation
W de Beer1,2, R Harvey2,3, E Moore2,4, L Salmon2,5, R Dotson2,6, B Lloyd2,7, J Topp2, G Young2,8,9, M O’Connor2,10, S Sinha2,11, N Jeyasingham2, K Maheti2,12, M Patton2,13, J Pettigrew2,14
1Waikato District Health Board, Hamilton, New Zealand
2Committee for Continuing Professional Development, Royal Australian and New Zealand College of Psychiatrists
3Deakin University, Geelong, Australia
4Consultant Psychiatrist, Perth, Australia
5Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists
6Consultant Psychiatrist, Canberra, Australia
7Consultant Psychiatrist, Adelaide, Australia
8Capital and Coast District Health Board, Napier, New Zealand
9University of Otago, New Zealand
10University of Melbourne, Australia
11Overseas Trained Psychiatrists Committee, Royal Australian and New Zealand College of Psychiatrists
12Trainee Representative Committee, Royal Australian and New Zealand College of Psychiatrists
13Northland District Health Board, Whangarei, New Zealand
14Consultant Psychiatrist, Katherine, Australia
15Consultant Psychiatrist, New Zealand
Background: Recertification or revalidation has been an area of intense focus for the Medical Board of Australia (MBA) and the Medical Council of New Zealand (MCNZ), with both regulators proposing changes to Continuing Professional Development (CPD) programmes for medical practitioners.
Objectives: This presentation will outline the background to the development of the recertification/revalidation programmes in Australia and New Zealand and provide an update on the current status of developments and how they impact on the Royal Australian and New Zealand College of Psychiatrists’ CPD programme.
Methods: Information available in the public domain, along with information provided to the Committee for Continuing Professional Development through discussions and workshops with the regulating bodies will inform the presentation.
Findings: In both Australia and New Zealand, there are changes to CPD requirements being imposed by the regulating bodies as part of the move to recertification/revalidation. These include changes to the allocation of CPD hours to activities, the introduction of mandatory components, the strengthening of practice review activities and an increasing emphasis on reflective learning based in the workplace.
Conclusions: The MBA and the MCNZ have an increasing focus on CPD, including mandatory practice improvement activities and increased reporting requirements. These changes will affect all members of the RANZCP and how they undertake their CPD.
Presenter 2
Reflective Learning
W de Beer1,2, R Harvey2,3, E Moore2,4, L Salmon2,5, R Dotson2,6, B Lloyd2,7, J Topp2, G Young2,8,9, M O’Connor2,10, S Sinha2,11, N Jeyasingham2, K Maheti2,12, M Patton2,13, J Pettigrew2,14
1Waikato District Health Board, Hamilton, New Zealand
2Committee for Continuing Professional Development, Royal Australian and New Zealand College of Psychiatrists
3Deakin University, Geelong, Australia
4Consultant Psychiatrist, Perth, Australia
5Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists
6Consultant Psychiatrist, Canberra, Australia
7Consultant Psychiatrist, Adelaide Australia
8Capital and Coast District Health Board, Napier, New Zealand
9University of Otago, New Zealand
10University of Melbourne, Australia
11Overseas Trained Psychiatrists Committee, Royal Australian and New Zealand College of Psychiatrists
12Trainee Representative Committee, RANZCP
13Northland District Health Board, Whangarei, New Zealand
14Consultant Psychiatrist, Katherine, Australia
15Consultant Psychiatrist, New Zealand
Background: Reflective practice has been defined as ‘the capacity to reflect on action so as to engage in a process of continuous learning’ and is embedded in both the Royal Australian and New Zealand College of Psychiatrists’ (RANZCP’s) training programme and the Continuing Professional Development (CPD) programme.
Objectives: This presentation will outline the principles of reflective learning, its practice and its role in the RANZCP CPD programme.
Methods: The principles of reflective learning will be outlined. The role of reflective learning in the RANZCP programme will be discussed, with particular reference to the Professional Development Plan and with the completion/reporting of CPD activities. Examples will be discussed.
Findings: Reflective learning is embedded in both the RANZCP Fellowship training programme and the CPD programme, but reporting of reflections is variable by participants in the CPD programme.
Conclusions: Reflective learning is an expectation of the RANZCP CPD programme and has an increasing emphasis for psychiatrists.
Presenter 3
What Do Psychiatrists Do for Their CPD?
W de Beer1,2, R Harvey2,3, E Moore2,4, L Salmon2,5, R Dotson2,6, B Lloyd2,7, J Topp2, G Young2,8,9, M O’Connor2,10, S Sinha2,11, N Jeyasingham2, K Maheti2,12, M Patton2,13, J Pettigrew2,14
1Waikato District Health Board, Hamilton, New Zealand
2Committee for Continuing Professional Development, Royal Australian and New Zealand College of Psychiatrists
3Deakin University, Geelong, Australia
4Consultant Psychiatrist, Perth, Australia
5Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists
6Consultant Psychiatrist, Canberra, Australia
7Consultant Psychiatrist, Adelaide, Australia
8Capital and Coast District Health Board, Napier, New Zealand
9University of Otago, New Zealand
10University of Melbourne, Australia
11Overseas Trained Psychiatrists Committee, Royal Australian and New Zealand College of Psychiatrists
12Trainee Representative Committee, Royal Australian and New Zealand College of Psychiatrists
13Northland District Health Board, Whangarei, New Zealand
14Consultant Psychiatrist, Katherine, Australia
15Consultant Psychiatrist, New Zealand
Background: The change to the online My CPD system provides an opportunity for analysis of what activities are undertaken by psychiatrists and how many hours are reported across the Continuing Professional Development (CPD) programme sections.
Objectives: This presentation will review descriptive statistics of the variety and breadth of CPD activities reported by a sample of the Royal Australian and New Zealand College of Psychiatrists’ CPD programme.
Methods: Each year 10% of CPD participants are randomly selected for an audit of their CPD record. In 2017, with the online My CPD system used for the first time, detailed information on the types of activities reported and the hours reported against the different sections can be analysed and reviewed for trends that may influence the development of the CPD programme. A total of 402 CPD records were audited for the 2017 year and analysis of the activities undertaken.
Findings: The results of the analysis of the 2017 CPD audit will be presented including the:
average and range of CPD hours reported overall and by section;
range of conferences and workshops reported;
range of Learnit hours and modules reported; and
types of Section 3 activity reported, with examples provided (with permission of the CPD participant).
Conclusions: The change to online reporting of CPD allows the annual CPD audit to be analysed in greater depth to provide rich information on the CPD practices of participants and to inform the development of the programme.
Presenter 4
How to Meet CPD Requirements When You Don’t Work Full Time
W de Beer1,2, R Harvey2,3, E Moore2,4, L Salmon2,5, R Dotson2,6, B Lloyd2,7, J Topp2, G Young2,8,9, M O’Connor2,10, S Sinha2,11, N Jeyasingham2, K Maheti2,12, M Patton2,13, J Pettigrew2,14
1Waikato District Health Board, Hamilton, New Zealand
2Committee for Continuing Professional Development, Royal Australian and New Zealand College of Psychiatrists
3Deakin University, Geelong, Australia
4Consultant Psychiatrist, Perth, Australia
5Community Collaboration Committee, Royal Australian and New Zealand College of Psychiatrists
6Consultant Psychiatrist, Canberra, Australia
7Consultant Psychiatrist, Adelaide, Australia
8Capital and Coast District Health Board, Napier, New Zealand
9University of Otago, New Zealand
10University of Melbourne, Australia
11Overseas Trained Psychiatrists Committee, Royal Australian and New Zealand College of Psychiatrists
12Trainee Representative Committee, RANZCP
13Northland District Health Board, Whangarei, New Zealand
14Consultant Psychiatrist, Katherine, Australia
15Consultant Psychiatrist, New Zealand
Background: The registration standards in both Australia and New Zealand do not allow for Continuing Professional Development (CPD) hours to be reduced for medical practitioners working less than full time. This presents some challenges to psychiatrists who are working in short-term locum posts, part time for family or health reasons or who are reducing hours as they approach retirement.
Objectives: This presentation will address some of the challenges for practitioners working less than full time and provide examples of how CPD requirements can be met.
Methods: The requirements of the Medical Board of Australia and the Medical Council of New Zealand will be reviewed, including their standards for recency of practice. A review of the options available for each section of the CPD programme will be provided, with examples of activities that can be undertaken.
Findings: The range of options will be presented for practitioners who practice less than full time. These options include:
peer dyads, supervision, second opinions and how to use My CPD to find a PRG to meet Peer review requirements (Section 2);
Learnit modules and literature reviews for Practice Improvement (Section 3); and
examples of workplace-based learning opportunities for Practice Improvement and Self-guided learning (Section 3 and 4).
Conclusions: It is possible for psychiatrists working less than full time to meet their CPD requirements.
Cross-cultural Connections: Overseas-trained Psychiatrists Working in Australia and New Zealand
Overseas Trained Psychiatrists Representative Committee, Royal Australian and New Zealand College of Psychiatrists
Background: Overseas-trained psychiatrists working in Australia and New Zealand often bring in different patterns of thinking, communicating and connecting with both the Royal Australian and New Zealand College of Psychiatrists and their place of work. These differences present a challenge, particularly during the first few months following the move, often resulting in isolation and difficulties building supportive collegial networks, with risks of mental distress and work and professional dissatisfaction. As overseas-trained psychiatrists become more accustomed to the ‘new’ home, the same differences that are initially challenging, transform into rich and effective cross-cultural connections.
This symposium brings together speakers who will bring to life the meaning of cross-cultural connections made by overseas-trained psychiatrists working in Australia and New Zealand.
Objectives: The symposium aims to describe some initiatives undertaken by the Overseas-Trained Psychiatrists Committee, including:
results of a survey addressing the welfare and workplace experiences of overseas-trained psychiatrists;
initiatives aimed at addressing the welfare of overseas-trained psychiatrists working in Australia and New Zealand;
the Hippocratic Oath as related to self-care for doctors; and
effective cross-cultural connections.
Methods:
Phase 1: Development of a survey addressing the welfare and workplace experiences of overseas-trained psychiatrists.
Phase 2: Initiatives to address welfare and to reduce the challenges faced by overseas-trained psychiatrists.
Phase 3: Narrative describing effective cross-cultural connections.
Findings: Survey development and findings and implementation of sustainable initiatives will be described. Narrative describing the journey of overseas-trained psychiatrists.
Conclusions: Challenges faced by overseas-trained psychiatrists transform to effective cross-cultural connections and improved collegial relationships. This symposium outlines the important role played by overseas-trained psychiatrists within the college and within the work place.
Quality and Safe Use of Clozapine: A Practioner’s Guide
B O’Donaghue1,2,3, S Clark4, S Every-Palmer5,6, D Siskind7,8
1Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia
2Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
3Orygen Youth Health, Melbourne, Australia
4Discipline of Psychiatry, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
5University of Otago, Wellington, New Zealand
6Capital and Coast District Health Board, Wellington, New Zealand
7Metro South Addiction and Mental Health Service, Brisbane, Australia
8University of Queensland, School of Medicine, Brisbane, Australia
Background: Clozapine is the most effective medication for treatment-refractory schizophrenia (TRS). However, there is a significant burden of adverse drug reactions, and not all people on clozapine achieve adequate response. Safe and quality prescribing of clozapine requires a fine balance between management of psychotic symptoms and amelioration of the adverse drug reactions our consumers bear.
Objectives:
Understanding of the role of clozapine in early intervention for schizophrenia
Awareness of the impact on clozapine on psychosocial function
Management of constipation, a serious adverse drug reaction associated with clozapine
How to safely augment clozapine when the response is inadequate.
Methods: The presenters will present clinical data and review the current literature on quality and safe use of clozapine. We will focus on timely access to clozapine, its role in psychosocial function, management of constipation and augmentation strategies.
Findings: Clozapine is significantly more effective than other antipsychotics for TRS early in treatment; however, augmentation strategies may be required. Although monitoring focuses on preventing agranulocytosis, a range of other complications are associated with significant co-morbidities including constipation and cardiometabolic illness.
Conclusions: At the end of this symposium, practitioners will be proficient in the quality use of clozapine.
Presenter 1
Clozapine Use Within An Early Intervention For Psychosis Service
B O’Donoghue1,2,3, K Thien1,2, P McGorry1,2
1Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia
2Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
3Orygen Youth Health, Melbourne, Australia
Background: The superior efficacy of clozapine in treatment-resistant schizophrenia (TRS) has been clearly demonstrated, yet there are often delays in the commencement of clozapine. To address these delays and to manage the associated cardiometabolic side-effects, a clozapine service was established with an early intervention (EI) service.
Objectives: This session aims to describe the study progression and outcomes. First, the proportion of young people with a first episode of psychosis eligible for clozapine treatment will be determined and their outcomes described. Second, the cardiometabolic outcomes of those commenced on clozapine with the EI service will be described.
Methods: This study included all young people who were treated at the Early Psychosis Prevention and Intervention Centre clinic between 1 January 2011 and 31 December 2013 and those commenced on clozapine since the inception of the clozapine service on 1 April 2016.
Findings: A total of 544 young people were included and 9.4% (N = 51) were deemed eligible to commence clozapine, of whom 30 were commenced on clozapine. The median delay to the commencement of clozapine was 42 weeks. Some (24.4%) discontinued clozapine and 60.0% of discontinuations were due to cardiac complications and the remainder were due to non-compliance. Since the commencement of the clozapine service, 36 young people have been commenced on clozapine. Over the course of 18 weeks, there was a mean increase in weight of 3.3 kg; however, 55.6% gained weight, while 25.9% lost weight. Changes in the other components of metabolic syndrome will be presented.
Conclusions: These findings suggest that early intervention for psychosis services have a crucial role in ensuring timely initiation of clozapine in individuals with a diagnosis of TRS.
Presenter 2
Is Clozapine Superior For Psychosocial Function in Schizophrenia?
A Olagunju1,2, S Clark1, T Baune1,3
1Discipline of Psychiatry, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
2Department of Psychiatry, University of Lagos, Lagos, Nigeria
3Department of Psychiatry, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
Background: Clozapine has unique efficacy for symptoms in treatment-resistant schizophrenia (TRS); however, symptomatic remission is not necessary nor sufficient for functional improvement.
Objectives: We conducted a systematic review and meta-analysis to compare the effects of clozapine with other antipsychotics on psychosocial function in randomized controlled trials.
Methods: We searched MEDLINE/PubMed, PsychINFO, EMBASE, CINAHL, Scopus, Web of Science, Cochrane Central Register of controlled trials and clinical trial registries till April 2018, with no language limits. We included randomized controlled trials of clozapine versus typical or atypical antipsychotics among adults withTRS. Effect sizes of studies were pooled using generic inverse variance and random-effects models and presented as standard mean differences (SMDs).
Findings: Nine studies with 1279 participants (69.7% male) were included. Clozapine showed beneficial effects on psychosocial function, but both short-term trials [n = 3; comparing 99 people taking clozapine with 97 controls (SMD = 0.04; 95% confidence interval (CI) −0.24, 0.32; p = 0.77; I2 = 0%)] and long-term trials [n = 5; comparing 415 people taking clozapine with 427 controls (SMD = 0.05; 95% CI −0.16, 0.27; p = 0.64; I2 = 50%)] showed no superiority of clozapine to other antipsychotics in this regard.
Conclusions: Clozapine does not appear superior to other antipsychotics for improvement of psychosocial function in clinical trials. Standardization of psychosocial function measurement is needed to improve the quality of evidence. Further exploration of the predictors of good psychosocial outcomes with clozapine treatment may improve personalization of care.
Presenter 3
Clozapine and the Colon: A Clinical Perspective
S Every-Palmer
1,2
1University of Otago, Wellington, New Zealand
2Capital and Coast District Health Board, Wellington, New Zealand
Background: ‘Slow gut’ (gastrointestinal hypomotility) caused by clozapine is a vexed adverse effect spectrum. It is often overlooked, and uncertainty remains about the best management strategies. It is the most common fatal adverse effect among people taking clozapine.
Objectives: The aim of this session is to present a review of current research on clozapine ‘slow gut’ through a clinical lens.
Methods: We present a summary of recent evidence, with particular focus on our Australasian translational research, which has combined modern psychopharmacological and gastroenterological techniques to better understand how clozapine affects the gut, and how this can be mitigated in a clinical setting.
Findings: Colonic motility studies show 80% of clozapine-treated patients have significant ‘slow gut’, with it taking four times longer for contents to pass through the large intestine of someone taking clozapine compared with someone else. A study using ‘smartpills’ to track gut function in clozapine users found delayed gastric emptying – gastroparesis – occurred in almost half of clozapine users, but clinically symptoms were often disregarded or mistaken for oesphageal reflux. Serious or life-threatening complications of slow gut such as bowel obstruction or perforation occur in 0.4% of people on clozapine, often with fatal consequences. However, judicious laxative use and careful monitoring of ‘red flag’ symptoms results in improved colonic function and reduced morbidity and mortality.
Conclusions: Clinicians need to maintain a high level of awareness and assertively manage the clozapine slow-gut spectrum. Key strategies for prevention, identification and management will be presented.
Presenter 4
What to Do When Clozapine Response Is Inadequate? Augmentation Strategies
D Siskind1,2, M Lee2, A Ravindran2, Q Zhang2, E Ma2, B Motamarri1,2, S Kisely1,2
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2University of Queensland School of Medicine, Brisbane, Australia
Background: Clozapine is the most effective medication for treatment-refractory schizophrenia (TRS); however, only 40% of people will meet response criteria.
Objectives: We conducted a systematic review and meta-analysis of the global literature on strategies for clozapine augmentation.
Methods: PubMED, PsycInfo, Embase, Cochrane Database, Chinese Biomedical Literature Service System and China Knowledge Resource Integrated Database were systematically reviewed for randomized control trials of augmentation strategies for people with clozapine-resistant schizophrenia. We undertook pairwise meta-analyses of within-class interventions.
Findings: A total of 46 studies of 25 interventions were included. The most effective augmentation agents for total psychosis symptoms were aripiprazole (standardized mean difference (SMD) −0.48; 95% confidence interval (CI) −0.89 to −0.07); fluoxetine (SMD −0.73; 95% CI −0.97 to −0.50); and sodium valproate (SMD −2.36; 95% CI −3.96 to −0.75). For negative symptoms, memantine may be effective (SMD −0.56; 95% CI −0.93 to −0.20). Many results included poor quality studies. Electroconvulsive therapy was highly promising.
Conclusions: On the basis of the limited available data, aripiprazole, fluoxetine and sodium valproate have the best evidence for use as augmentation agents for total psychosis symptoms. However, these conclusions are tempered by generally short follow-up periods and poor study quality.
Physician Assisted Suicide: Updates on Changes in the Law and the College’s Work
R Harvey, G Young
Committee for Professional Practice, Royal Australian and New Zealand College of Psychiatrists
Background: Voluntary assisted dying has been legalized in Victoria for people who are suffering from an incurable medical condition and who are experiencing intolerable suffering. Other legislative schemes for physician-assisted dying (PAD) are being considered in other jurisdictions from New Zealand to Western Australia. The impending implementation of PAD in Victoria, and the potential for PAD to be legalized in other jurisdictions, presents a range of complex issues for psychiatrists including ethical and practical considerations around participating or conscientiously objecting to the scheme.
Objectives: This symposium aims to present a panel discussion with practical updates on existing legislation, as well as continuing debates, across various jurisdictions in Australia and New Zealand.
Methods: A range of speakers will provide updates on legislative changes and policy discussions regarding PAD across various jurisdictions in Australia and New Zealand. These updates will inform further discussions on the Royal Australian and New Zealand College of Psychiatrists’ role in this space.
Findings: The symposium will present a range of perspectives on PAD to inform development of the Royal Australian and New Zealand College of Psychiatrists’ binational position statement as well as further policy and advocacy work in jurisdictions considering the legalization of PAD.
Conclusions: While PAD continues to be widely debated in Australia and New Zealand, psychiatrists can play a crucial role in informing the debate about PAD by virtue of their expertise in physical and mental illness.
Oral Presentation Abstracts (including Pif Presentation and Rapid Fire Presentations)
Continuity in a World of Change Culture, Diversity and Mutual Learning: Sri Lanka’s Experience in the Area of Mental Health
J Mendis1, Ghadambhanathan2, A Mendis3
1Consumer Action Network Mental Health Lanka, Mulleriyawa, Sri Lanka
2District Teaching Hospital, Batticoloa, Sri Lanka
3Adelaide Medical School, Adelaide, Australia
Background: Sri Lanka has a population of 21 million people; the 2012 census confirmed that 70% of its population were Buddhist, 12.6% were Hindu, 9.7% were Muslim and 7.6% were Christian. Additionally, most Christians are Sinhalese and all most all Hindus are Tamils. Therefore, to function as a broad-based and effective mental health professional in Sri Lanka, it is essential to understand the cultural differences and diversities prevalent among all ethnic groups. For example, Buddhists go to temple, Christians to church, Hindus to Hindu temples and Muslims to the mosque.
All the ethnic groups have their individualized methods and rituals. Communities perform different folks that have some similarities and dissimilarities to the three cultures of the community. Different beliefs and opinions, healing institutions and practices are performing in different cultures.
Most cultures perform various rituals, verbal and non-verbal gestures for therapy and for mental health promotional activities. As a mental health professional who is part of the community, it is essential to understand these ritualistic activities. It is critical to gain this understanding and add it to the biopsychosocial model of management to optimally manage mental health-related disorders in Sri Lanka.
It is necessary to blend the understandings of cultures and their rituals with Western medical models to support both patients and their relatives for the best standard of care. The methods and rituals are discussed in this presentation in detail.
Buddhism’s Relevance to Psychiatry: It’s More Than Mindfulness
T Wettasinghe
Waikato District Health Board, Hamilton, New Zealand
Background: Buddhism has been used as a spiritual and philosophical way of navigating life for over 2500 years. It holds much potential for guiding psychiatric practice in the present day.
Objectives: This talk will highlight some of Buddhism’s central concepts and history in order to outline how they could be useful for the practice of modern psychiatry. This will include the following:
Brief review of Buddhism’s current contribution to psychotherapy, via mindfulness development, especially in the third wave psychotherapies such as dialectical behaviour therapy and mindfulness-based cognitive therapy.
Buddhism’s potential to decrease stigma about mental illness by understanding the universality of suffering (including mental suffering).
Buddhism’s tolerance of other spiritual/philosophical beliefs. This concept could help schools within psychiatry to avoid dogmatism and embrace pluralism.
Seeing Buddhism’s Noble Eightfold Path as a code of ethics that could help to guide the virtuous psychiatrist.
Buddhism’s links with positive psychology and their relevance for promoting recovery in our patients and decreasing burnout within our profession.
Can the Onset of Major Depression Be Predicted Using Physiological Biomarkers? Critical Transitions in the Psycho-Immune-Neuroendocrine Network
N Stapelberg
1,2
1Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
2Gold Coast Hospital and Health Service, Robina, Australia
Background: Using a systems biology framework, the putative biological pathways underpinning major depressive disorder (MDD) can be viewed as belonging to a complex network. The psycho-immune-neuroendocrine (PINE) network is a physiological regulatory network, which comprises central nervous, immune, endocrine and autonomic systems, as well as the gut microbiome.
Objectives: The session aims to present testable hypotheses in relation to a change from health, through a pre-disease state, to a critical transition to MDD, as well as transitions in response to treatment.
Methods: The PINE network model has been constructed from physiological pathways described in the literature and the model, as well as hypotheses related to critical transitions in the PINE network, have been published.
Findings: Several interlaced regulatory negative feedback loops exist within the PINE network that become perturbed by chronic stress, potentially transitioning to positive feedback loops. It is hypothesized that feedback loop transitions can drive a critical transition of the entire PINE network from health into major depression. Putative physiological feedback loops are identified within hypothalamic–pituitary–adrenal and autonomic axes, the kynurenine pathway, gut function and the gut microbiome.
Conclusions: It is hypothesized that biomarkers that measure system instability can predict the critical transition from a pre-disease state to MDD. They may also be used to monitor treatment response in MDD. Examples of biomarkers are provided that may detect early warning signs of impending critical transitions within the PINE network. These markers may detect disease onset and may also provide measures of response to treatment.
Will the Current Standards of Care For Patients Diagnosed With Major Depressive Disorder at the Gold Coast Mental Health and Specialist Service Meet the Standards of Care Suggested By the Royal Australian and New Zealand College of Psychiatrists’ Mood Disorders Clinical Practice Guidelines?
S Hossain1, A Hodal1, L Olsen2, N Jeyarajah2, D Garg1
1Gold Coast Mental Health and Specialist Service, Gold Coast, Australia
2Griffith University, Gold Coast, Australia
Background: Major depressive disorder (MDD) is recognized as one of the most common and debilitating diseases worldwide, corresponding to 5.8% of the total years lost due to disability (YLD) across all diseases (World Health Organization, 2018). The lifetime prevalence of MDD is approximately 17% of the population, which results in tremendous secondary costs to society (Kessler et al., 2005Greenberg et al., 2015; Wang et al., 2003) (ranked third in global burden of disease (Mrazek et al., 2014)). It is important that high standards of care and treatments are followed when treating patients with MDD to achieve best possible outcomes for patients, their families and society. It is envisaged that better standards of care will reduce the financial burden of MDD on society.
Objectives: This session aims to describe the check for compliance with Section two – MDD of Royal Australian and New Zealand College of Psychiatrists’ (RANZCP’s) Clinical Practice Guidelines for Mood Disorder (Mahli et al., 2015) at the Gold Coast Mental Health and Specialist Service (GC MHSS).
Methods: The participants would be selected in a stratified manner from a list of all patients treated at the GC MHSS aged 18 years and older with a diagnosis of MDD during 1 January 2016 to 31 March 2018. The data will be analysed using both quantitative and descriptive methods.
Findings: The initial audit cycle data collection has been completed and it is expected that the data analysis and implementation of the recommendations will be completed prior to RANZCP Congress 2019.
Conclusions: Recommendations for improvement of care will be generated following discussion of findings in various forums. An implementation strategy will be generated of key recommendations and a re-audit will be carried out within a year to measure change in practice. We envisage that this will improve standards of care for patients treated for MDD at the GC MHSS.
References
Greenberg PE, Fournier A, Sisitsky T (2015) The economic burden of adults with major depressive disorder in the United States (2005–2010). Journal of Clinical Psychiatry 76 (2): 155–162.
Kessler RC, Chiu WT, Demler O, et al. (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62(6): 617–627.
Mahli GS, Bassett D, Boyce P, et al. (2015) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian and New Zealand Journal of Psychiatry 49(12): 1–185.
Mrazek DA, Hornberger JC, Altar CA, et al. (2014) A review of the clinical, economic, and societal burden of treatment-resistant depression: 1996–2013. DOI: 10.1176/appi.ps.201300059.
Wang PS, Simon G and Kessler RC (2003) The economic burden of depression and the cost-effectiveness of treatment. International Journal of Methods in Psychiatric Research 12(1): 22–33.
World Health Organization (2018) Global Health Estimates 2016: Disease burden by Cause, Age, Sex, by Country and by Region, 2000–2016. Geneva
Effect of Agomelatine 25–50 mg on Social Functioning Over 6 Months in Adults and Elderly Patients With Major Depressive Disorder
M Hopwood1, F Picarel-Blanchot2, C de Bodinat2
1Department of Psychiatry, University of Melbourne, Melbourne, Australia
2Institut de Recherches Internationales Servier (IRIS), Suresnes Cedex, France
Background: Depression is the leading cause of disability worldwide. By assessing the level of functioning in addition to depressive symptoms, one likely achieves a more complete picture of ‘real-world’ outcomes of depressed patients.
Objectives: This session describes the present work assessing the effect of agomelatine on functioning compared to placebo in adults and elderly patients suffering from major depressive disorder.
Methods: Data from two randomized, parallel, double-blind, placebo-controlled agomelatine studies, one in adults (average age: 44 years) and one in elderly depressed patients (average age: 72 years), evaluated the long-term effect on social functioning are reported. The two studies included 633 patients, 422 on agomelatine and 211 on placebo.
The long-term effect of agomelatine on functioning was assessed using the Sheehan Disability Scale (SDS), to evaluate SDS total and sub-item scores as well as functional response (SDS total score ⩽ 12) and remission (SDS total score ⩽ 6).
The percentages of patients with functional response and/or remission on the last post-baseline value were assessed in each study (post-hoc analysis).
Findings: In each study, depressive symptoms and SDS scores were significantly improved versus placebo. In adults, the percentages of patients achieving functional response and functional remission were 73.5% and 53.1% on agomelatine versus 53.7% and 27.8% on placebo, respectively.
In elderly patients, the percentages of patients achieving functional response and functional remission were 60.5% and 37.4% on agomelatine versus 47.8% and 21.7% on placebo, respectively.
Conclusions: In the long term, agomelatine improves the social functioning of adults and elderly depressed patients.
Physical Activity of People With Mental Disorders Compared to the General Population: A Systematic Review of Longitudinal Cohort Studies
S Suetani1,2,3, B Stubbs4,5, J McGrath1,2,6, J Scott1,7,8
1Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia
2Queensland Brain Institute, The University of Queensland, St Lucia, Australia
3Metro South Addiction and Mental Health Services, Brisbane, Australia
4Department of Health Service and Population Research, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
5Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK
6National Centre for Register-based Research, The Aarhus University, Aarhus C, Denmark
7School of Public Health, The University of Queensland, Herston, Australia
8Metro North Mental Health, Royal Brisbane and Women’s Hospital, Herston, Australia
Background: There has been limited examination of the bidirectional association between physical activity (PA) and mental disorders using longitudinal studies.
Objectives: This session provides acurrent review aimed to investigate if: (i) people with lower PA have an increased risk of subsequent mental disorders (compared to those with higher PA) and (ii) people with mental disorders have reduced subsequent PA (compared to those without mental disorders).
Methods: A systematic review of longitudinal studies examining PA and mental disorders was conducted. Longitudinal studies were population-based. Mental disorders were defined by the International Classification of Diseases or Diagnostic and Statistical Manual of Mental Disorders. The results were described in a narrative summary.
Findings: Eighteen studies were included and all measured self-reported PA. The majority (16) examined mood disorders and PA. Three studies found a reduced risk of subsequent mood disorders in those with increased PA, five reported mixed results and five found no association. One study reported an increased risk of reduced PA in those with prior mood disorders but three other studies examining the relationship found mixed results. Of four studies examining anxiety disorders and PA, one study found that those with prior anxiety disorders had reduced subsequent PA. Among three studies examining the reciprocal relationship, no association was identified between PA and subsequent anxiety disorders. None of the included studies found association between PA and subsequent substance use disorders or psychotic disorders.
Conclusions: There is a lack of consistent evidence linking PA as either a risk factor or a consequence of mental disorders.
Cross-sectional Association and Longitudinal Relationship Between Common Mental Disorders and Physical Activity Status in Young Adults: A 30-Year Birth Cohort Study
S Suetani1,2,3, A Mamun4, G Williams5, J Najman5, J McGrath1,2,6, J Scott1,7,8
1Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia
2Queensland Brain Institute, The University of Queensland, St Lucia, Australia
3Metro South Addiction and Mental Health Services, Brisbane, Australia
4Institute for Social Science Research, The University of Queensland, Indooroopilly, Australia
5School of Population Health, The University of Queensland, Herston, Australia
6National Centre for Register-based Research, The Aarhus University, Aarhus C, Denmark
7School of Public Health, The University of Queensland, Herston, Australia
8Metro North Mental Health, Royal Brisbane and Women’s Hospital, Herston, Australia
Background: Common mental disorders – including affective disorders, anxiety disorders and substance use disorders – are highly prevalent and are associated with substantial burden of disease. In recent years, physical activity (PA) has been gaining attention as a potentially modifiable risk factor for the onset of the illness, as well as a treatment target of symptoms of common mental disorders.
Objectives: This session describes a study aimed to explore the cross-sectional association between diagnoses of common mental disorders and PA status, and the longitudinal course of common mental disorders on PA status.
Methods: Prospective data from the Mater-University of Queensland Study of Pregnancy, consisting of 1611 young adults, were analysed. The course of mental disorder diagnoses between the ages of 21 and 30 years were derived from the Composite International Diagnostic Interview, and PA status at age 30 years was estimated using the International Physical Activity Questionnaire. Cross-sectional associations between common mental disorders and PA at 30 years and association between the longitudinal course of common mental disorders between 21 and 30 years and PA at 30 years were examined using logistic regression.
Findings: After adjusting for confounding factors, there were no cross-sectional or longitudinal associations between common mental disorder diagnoses (affective disorders, anxiety disorders, and substance use disorder, as well as any common mental disorder) and PA status at age 30 years.
Conclusions: The findings of this study suggest that there is no association between common mental disorder diagnoses and PA status in young adults.
Royal Australian and New Zealand College of Psychiatrists’ Clinical Practice Guidelines for the Treatment of Anxiety Disorders
L Lampe1,2 G Andrews1,3, C Bell,1,4, P Boyce1,5, C Gale1,6, O Marwat1,2,7, R Rapee1,8, G Wilkins1
1Clinical Practice Guidelines Team for Panic Disorder, Royal Australian and New Zealand College of Psychiatrists, Social Anxiety Disorder and Generalised Anxiety Disorder, Melbourne, Australia
2Discipline of Psychiatry, School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
3Clinical Research Unit for Anxiety and Depression, University of New South Wales School of Psychiatry, St Vincent’s Hospital, Sydney, Australia
4Department of Psychological Medicine, University of Otago Christchurch, Christchurch, New Zealand
5Discipline of Psychiatry, Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
6Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
7Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia
8School of Medicine, The University of Notre Dame Australia, Sydney, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has recently published new clinical practice guidelines (CPG) for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder.
Objectives: The aim of this session is to provide an overview of the new CPG.
Methods: A systematic review of the literature informed the guidelines. Evidence-based and consensus-based recommendations were formulated by synthesizing the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatments in Australia and New Zealand, potential for fidelity, acceptability to patients, safety and costs. Public consultation and peer review informed the final version.
Findings: Psychoeducation and advice on lifestyle factors is recommended, with initial treatment selected in collaboration with the patient from evidence-based options, accounting for symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smart-phone application), pharmacotherapy (selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers) or the combination of cognitive–behavioural therapy and pharmacotherapy. There was insufficient high-quality evidence to allow specific recommendations for one treatment over another, nor for specific situations, levels of disorder severity or treatment resistance; consensus-based recommendations were made where possible.
Conclusions: These guidelines represent a synthesis of high-quality evidence and expert consensus. More research is needed to allow more specific evidence-based recommendations, especially for complex situations and treatment non-response. The RANZCP is undertaking activities to promote the translation of these guidelines into practice.
The End of the Drought? The First 12 Months of an Australia-wide Telemental Health Service
D Carmody1,2, B Chia1,3
1Call to Mind, Melbourne, Australia
2Eastern Health, Box Hill, Australia
3Hobsons Bay Clinic, South Kingsville, Australia
Background: Recent changes to the funding around telemental health and the spread of faster Internet in rural and remote areas has created an opportunity for the wider use of telehealth to address the disparity in access to psychiatrists and psychologists. In May 2018, a group of psychiatrists and psychologists began offering services to clients in telehealth-eligible areas across Australia.
Objectives: This session aims to detail the process of establishing this service, the demographics of both clients and referrers and the experience of the service from clinician, client and referrer perspectives.
Methods: We describe the structure of a telemental health service, funding sources, the demographics of clients referred and qualitative data derived from anonymous surveys of clinicians and referrers.
Findings: Note these are preliminary findings, as data are still being collected. Early responses indicate there are factors specific to both individual referrers and geographical areas that predict uptake of the service. For example, northern Tasmania and northern NSW have been areas of higher referrals. There are also trends appearing suggesting younger clients are more likely to seek out mental healthcare via video, but that acceptability of the service is high across age groups.
Conclusions: Telemental health is a viable alternative to face-to-face consultations in rural areas, though further research is required to better understand what makes referrers and clients more likely to utilize these services.
Principles of Optimal Mental Healthcare For Adolescents and the Impact of System-wide Barriers
M Platell, K Martin, A Cook
University of Western Australia, Perth, Australia
Background: The early onset of many mental health issues, and the potential for profound and long-lasting effects on an adolescent’s life, indicates that receiving timely intervention from mental health services is crucial. With the high prevalence of mental health issues in Australian adolescents, it is concerning that the utilization of a professional mental health service is low.
Objectives: This session aims to describe the identification of:
adolescent mental health services referral and service delivery processes within Perth, Western Australia;
principles underpinning optimal mental health service provision for adolescents as identified by mental health service professionals; and
facilitators and barriers to providing optimal mental health services to adolescents as perceived by mental health service professionals.
Methods: The methods include semi-structured, face-to-face interviews with 23 purposively recruited government and non-government mental health professionals. The data were thematically analysed.
Findings: The mental health professionals identified three main service feature principles underpinning optimal mental health service provision for adolescents: (i) flexibility, (ii) consistency and (iii) trust. Participants identified practices within mental health services that were facilitators and barriers to these three principles.
Conclusions: The main characteristics that mental health professionals believe are required to provide optimal mental healthcare for adolescents differentially contrast with the reported current service provision process. These results highlight that mental health services for adolescents remain fragmented, with little system-wide planning to streamline processes and, thus, negatively impact adolescent mental healthcare. Ongoing demands of the system have created an environment where constant client turnover and rigidity are a must to cope.
A Review of Best Practice in Mental Health Networks: How Can Networks Optimally Influence Mental Healthcare?
H McGowan1,2, F Ackermann3, G Hill3
1North Metropolitan Health Service, Perth, Australia
2WA Mental Health Network, Perth, Australia
3School of Management, Curtin University, Perth, Australia
Background: Mental health networks (MHN) take a variety of forms but all have the potential to enable service users and clinicians to inform and positively influence reform. MHNs do not manage services or reform but draw on the expertise of providers and experience of service users to inform those responsible for policy, planning and care.
Objectives: This session aims to provide an overview of best practice in MHNs within Australia and other relevant jurisdictions.
Methods: The available academic and professional literature on MHNs was reviewed, concentrating on Australia but also exploring MHNs in the United Kingdom. This review informed the development of semi-structured interviews with 20 individuals involved in the creation, management and oversight of MHNs from Western Australia, Queensland, New South Wales, Victoria, South Australia and Tasmania. Each interview was subsequently transcribed and coded based on a set of emergent and a priori (informed by the literature) codes and subject to qualitative analysis.
Findings: Effective MHNs require high-quality leadership that builds on existing networks, are responsive to local context and governance structures and articulate clear goals. They are independent, inclusive and support a community of practice, which communicates effectively and fosters coherent engagement, collaboration, sharing of best practice and influences policy and decision-making. Central to effective operation is accountability, transparency, focus on improvement of care and monitoring of MHN performance.
Conclusions: MHNs can provide an important contribution to mental health systems committed to continuous improvement, informed by clinical expertise and lived experience.
Psychiatrist Peer Review Groups: A Mixed-Method Evaluation
L Nash1,2, A Karageorge1, S Prager3, J Lancaster3
1Brain and Mind Centre, University of Sydney, Sydney, Australia
2Sydney Local Health District, Sydney, Australia
3Private Psychiatry Practice, Melbourne, Australia
Introduction: Peer review groups (PRGs) are a small group-learning activity pioneered by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Fellows in the 1990s. They are a popular continuing professional development activity and have been adopted by other medical specialties within Australia and beyond. However, since the 1990s little research on their functioning has been undertaken. The limited literature indicates that, as well as updating medical knowledge, the collegiality of PRGs is used to manage the uncertainties of actual practice and to enhance the well-being of the practitioner.
Objectives: This session aims to explore the experience of participants in psychiatry PRGs considering perceived impact on clinical practice and personal and professional well-being, and to consider how PRGs can be improved and utilized in the future.
Methods: A mixed-methods survey and interview questions were designed from the literature and the surveys of the initial PRG research from the 1990s. Demographics, form of groups and function of groups are explored. Towards the end of 2018, the survey was emailed to PRG participants who expressed interest in being contacted at the RANZCP 2018 Congress and those who expressed interest directly to the research team. Survey participants were invited to take part in an interview or focus group early in 2019.
Findings: Quantitative and qualitative results from the survey will be reported at the Conference as will preliminary findings from the interviews and focus groups.
Conclusions: This research will further the evidence on the use of PRGs and will potentially guide the future use of PRGs in psychiatry and other disciplines.
Mental Health in the Workplace: A Report From A Preliminary Survey Done in a Tertiary Hospital of Northern India
R Gupta, DK Nehra
Institute of Mental Health, Rohtak, Haryana, India
Background: The importance of mental health in the workplace is increasingly becoming a matter of concern. It is a great challenge for the employers to keep the workplace stress-free for their employees. Healthcare settings are more demanding with multitudes of stresses. Keeping in view these alarming concerns, there is a need to develop effective strategies for making the work environment conducive and productive.
Objectives: This session aims to describe the prevalence of work stress, depression, anxiety and substance use in the employees working in the hospital setting, University of Health Sciences, Rohtak, Northern India.
Methods: A hospital-based descriptive cross-sectional study was conducted by screening 610 randomly selected employees of the University of Health Sciences, covering all the medical, non-medical and administrative staff. A semi-structured questionnaire was designed to obtain the requisite personal information and to evaluate the work stress and indicate the associated problems (depression, anxiety, stigma and drug abuse). Data analysis was done using the Statistical Package for the Social Sciences (SPSS-17).
Results: There was an alarmingly high level of work stress (49.65%). The results also confirmed a high prevalence of depression (35.33%), anxiety (22.60%) and stigma (51.69%). Besides, approximately 10% of the employees were using alcohol and other substance in some form. Furthermore, there was a high correlation (p < 0.05) among work stress, depression, anxiety, stigma and substance abuse.
Conclusion: We found a high prevalence of work stress, depression and anxiety in our study group. Providing psychological support to this vulnerable population is important to rebuild their coping skills and develop a better work–life balance. Steps to combat this problem are discussed.
Assessment of Anxiety in the Presence of Dementia
GJ Byrne1,2, E Arnold1, NA Pachana1
1University of Queensland, Brisbane, Australia
2Royal Brisbane and Women’s Hospital, Brisbane, Australia
Background: Anxiety symptoms and anxiety disorders occur commonly among older people and often in association with cognitive impairment or dementia. Unlike depression, anxiety is infrequently measured using a valid and reliable instrument and there is uncertainty as to whether self-rated or informant-rated anxiety should be preferred.
Objectives: This session aims to describe the investigation of whether generalized anxiety can be validly assessed in the presence of cognitive impairment or dementia and whether informant ratings of anxiety perform better than self-ratings of anxiety in this context.
Methods: Consecutive memory clinic attendees (N = 199; 45% female) were recruited and for each patient an informant was also recruited. Self-reported anxiety was measured on the Geriatric Anxiety Inventory (GAI) and informant-rated anxiety was measured on the Informant Questionnaire for Anxiety in Dementia (IQAD). The Mini International Neuropsychiatric Interview was used to generate current anxiety diagnoses. Receiver operating characteristic (ROC) analysis was used to compare the sensitivity and specificity of the GAI and IQAD in detecting anxiety disorder.
Findings: The mean age of patients was 77.9 years, 129 (64.8%) had dementia, 33 (17.1%) had a current anxiety disorder and 17 (8.5%) had both. Mean (standard deviation) GAI and IQAD scores were 4.3 (5.2) and 23.9 (6.9), respectively. Area under the ROC curve did not differ significantly between self- and informant-ratings. Anxiety could be validly rated in the presence of dementia of mild to moderate severity.
Conclusions: Anxiety can be validly assessed in the presence of cognitive impairment and mild to moderate dementia. Both informant-ratings and self-ratings of anxiety are valid.
Process of Determining Driving Safety in People With Dementia: A Review of the Literature and Guidelines From Five English-speaking Countries
L Walsh1, E Chacko1,2, G Cheung1,2
1University of Auckland, Auckland, New Zealand
2Auckland District Health Board, Auckland, New Zealand
Background: In Australasia general practitioners (GPs) identify patients who have dementia and are unsafe to drive, often with limited standardized evidence-based guidelines and resources.
GPs can refer to a geriatrician or psychogeriatrician, who are generally better at identifying risky drivers, but they can still be inaccurate (Breen et al., 2007). The occupational therapy (OT) specialist driving assessment is considered internationally to be the ‘gold-standard’ for driving safety; however, it is often not publically funded in Australasia. It has also been proposed that Australasian transport authorities could employ specialist physicians to support GPs in licensing decisions (Registrar of Motor Vehicles, 2016).
Objectives: This session aims to review the literature and guidelines related to the process of determining driving safety in people with dementia.
Methods: Four electronic databases were searched in December 2016–January 2017. We limited our search to literature and guidelines published in the United Kingdom, United States, Canada, New Zealand and Australia.
Findings: General practitioners are primarily responsible for driver licensing; however, they often feel ill-equipped and it can compromise the therapeutic relationship. OT driving assessment is considered as the ‘gold-standard’ but they are costly and often not available (Fisher and Thomson, 2014). Medical advisory boards assist the assessment process by providing independent licensing decisions (Registrar of Motor Vehicles, 2016).
Conclusions: General practitioner training, funding for occupational therapist driving assessment and the establishment of a medical advisory board could be considered to improve the current practice of driving assessment in dementia.
References
Breen DA, Breen DP, Moore JW, et al. (2007) Driving and dementia. British Medical Journal 334: 1365–1369.
Fisher M and Thomson S (2014) Dementia and driving safety: a clinical guideline. Version 3.
Registrar of Motor Vehicles (2016) The Alternative Older Driving Licensing System for Tasmania [Internet]. Tasmanian Transport Agency, 2016. Last retrieved 28 June 2018 from http://www.transport.tas.gov.au/?a=110857.
Impact of Very Old Age Upon Care Needs of Inpatients With Mood Disorders
R McKay
1,2
1Health Education and Training Institute Higher Education, Sydney, Australia
2University of New South Wales, Sydney, Australia
Background: There is very limited information available regarding the care needs that must be addressed to support activities of daily living (ADL) of very old people with mood disorders in inpatient settings. Resource Utilization Groups–ADL subscale (RUG–ADL) data from the Australian National Outcomes and Classification Collection is a source of relevant data publically reported through the web Decision Support Tool (wDST).
Objectives: This session aims to (i) describe and contrast the ADL support needs of people with mood disorders in inpatient mental healthcare in Australia aged 85 years or older with those aged 65–74 years and (ii) discuss the impact of the above ADL support needs upon the provision of inpatient mental healthcare for older people.
Methods: The RUG–ADL data publically available through the wDST were analysed. Reflection upon the potential impact of the differing needs of people were differentiated by age.
Findings: RUG–ADL records were reported for more than 300 admissions of people with mood disorders aged 85 years or older, and over 1900 admissions of people aged 65–74 years. Approximately 44% of people aged 85 and older required assistance with at least one ADL on admission, compared with 13% of people in the younger age group. The degree of difference in care needs varied significantly between support required for bed mobility, toileting, transfers and eating.
Conclusions: Very old age has a significant impact upon the care needs of people with mood disorders admitted for inpatient care. Staff mix, training and models of care must consider these needs.
Physical Illness and Elderly Suicide in Rural China: A Case–Control Psychological Autopsy Study
G Wang1, L Zhou2
1Shenzhen Kangning Hospital, Shenzhen, China
2Guangzhou Huiai Hospital, Guangzhou, China
Background: Physical illness and suicide of rural elderly were the highest among all age groups in China; however, little is known about the relationship between them in this rapidly growing population.
Objectives: This session aims to describe the prevalence of physical illness and its influence among the rural elderly of China and to examine the relationship between physical illness and suicide.
Methods: This matched case–control psychological autopsy study was conducted during June 2014 to September 2015. Consecutive samples of suicides (242) aged 60 years or older were identified in three provinces of China. Living comparisons were 1:1 matched with the suicides in age, gender and living location. Two informants for each subject were interviewed to collect data on demographic characteristics, physical illness and severity index, depressive symptoms, hopelessness, activities of daily living, mental disorder and social support.
Findings: A significant difference was found between suicide cases and living comparisons regarding the prevalence of physical illness (83.5% vs. 66.5%, p < 0.001). Independent risks of suicide included activity of daily living [odds ratio (OR) 1.06, 95% confidence interval (CI) 1.01–1.12], mental disorder (OR 7.96, 95% CI 2.08–30.54), depressive symptoms (OR 1.15, 95% CI 1.05–1.26) and hopelessness (OR 1.47, 95% CI 1.18–1.82). Structural equation model indicated that the relationship between severity index of physical illness and suicide mediated by activities of daily living, depressive symptoms, hopelessness and mental disorders.
Conclusions: Physical illness can elevate the suicide risk through increasing depressive symptoms, hopelessness, mental disorder, and decreasing activity of daily living. Efforts for suicide prevention should be integrated with strategies of physical illness treatment and psychological intervention.
Safety and Use of E-cigarettes As A Harm Minimization Measure – What’s the Evidence?
S Kisely1,2, D Arroyo1, D Siskind1,2
1School of Medicine, The University of Queensland, Brisbane, Australia
2Princess Alexandra Hospital, Brisbane, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists has called for the controlled introduction of e-cigarettes as a harm reduction measure and this approach is similar to policy in Great Britain and Canada. According to Public Health England, e-cigarettes pose only a small fraction of the risk of smoking and encourage smokers to switch completely to vaping, which would produce substantial health benefits. The review, an update of Public Health England’s 2015 review, found no evidence that e-cigarettes were a route into smoking among young people, and that e-cigarettes did not seem to be undermining the United Kingdom’s long-term decline in cigarette smoking among young people. This is in contrast to Australian guidelines that oppose the use of e-cigarettes as a harm-minimization measure. One reason for this range of views is the methodological quality of different guidelines.
Objectives: This session aims to review the quality of current e-cigarette guidelines in English with systematic search of scientific databases, central government health authority websites, medical peak bodies, guideline clearing houses and Google. Two reviewers assessed guideline quality using the Appraisal of Guidelines for REsearch and Evaluation II instrument.
Findings: Guidelines from the United States and the United Kingdom had consistently higher scores than those from Australia. Documents with higher scores favoured the use of e-cigarettes for harm minimization.
Conclusions: Existing Australian policy towards e-cigarettes should be amended. In the first instance, nicotine-containing e-cigarettes should be legalized.
The Influence of Child Maltreatment on Nicotine and Alcohol Use Disorders in Young Adulthood: A Birth Cohort Study
S Kisely1,2, R Mills1, 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
Background: Retrospective studies have shown a high association between child abuse and subsequent tobacco or alcohol use. Prospective studies, particularly addressing outcomes of emotional abuse and neglect, are far rarer.
Objectives: This session aims to describe a study of data linked from a statutory child protection agency of prospectively notified and substantiated child abuse to a birth cohort of participants recruited from the main maternity hospital of the Australian city of Brisbane. This included consideration of physical, sexual and emotional abuse, as well as neglect. The main outcomes were alcohol and tobacco use at 21-year follow-up, as well as persistence of smoking from 14 to 21 years. Twelve-month and lifetime diagnoses of nicotine and alcohol use disorders were available for participants who completed the Composite International Diagnostic Interview-Auto version.
Findings: Of the 3758 young people at the 21-year follow-up, 282 (7.5%) had a history of notified maltreatment by 16 years. Of these, 167 cases were substantiated. On adjusted analyses, participants who had experienced all forms of notified and/or substantiated maltreatment were approximately twice as likely to be smokers at 21 years of age and persistent smokers from 14 years of age. All forms of maltreatment, except sexual abuse, were also associated with an increase in nicotine use disorders. By contrast, only neglect was associated with heavy drinking at 21 years or lifetime alcohol use disorders.
Conclusions: Child maltreatment is associated with both an increased onset and persistence of smoking from adolescence into young adulthood. This may have implications for targeted smoking cessation programmes. Only neglect is associated with problem drinking.
From Passive ‘receivers’ to Active ‘co-creators’: Empowering Staff to Improve the Quality and Safety of Care
G Smith
1,2
1Office of the Chief Psychiatrist, Perth, Australia
2Division of Psychiatry, University of Western Australia, Perth, Australia
Background: The challenges of implementing changes in clinical practice are well documented with a recent observation that the drive for improved quality has ‘frozen in time’. Despite widespread acknowledgement of the importance of engagement of front-line staff in the change process, the prevailing quality improvement strategies have largely been top-down with increasing control and standardization. Dealing with this stagnation has proved remarkably difficult – so we need to tackle it in a new way.
Objectives: This session aims to describe the use of Self-Determination Theory (SDT), a widely researched and empirically validated theory of human need fulfilment and motivation, to provide a clearer understanding of why the implementation of change in clinical settings succeeds or fails.
Methods: Selected examples of implementation studies, derived from a narrative review of the literature, are analysed using the lens of SDT to provide practical guidance on how to promote behavioural change within workplaces/organizations.
Findings: Evidence suggests that the critical determinant in staff buy-in to practice change is not in the nature of the specific interventional tool(s), but in the degree to which the process is experienced by staff as meeting their psychological needs for autonomy, competence and relatedness.
Conclusions: Recognition needs to be given to the critical importance of engagement of front-line staff in the co-creating and shaping of clinical practice change as a means of generating a sense of buy-in and ownership.
Associations Between Stigma, Perceived Aetiology of Mental Illness, Past Experience of Mental Illness and Future Career Choice in a Cohort of Medical Students
S Rotstein1,2,3, A Hudaib1
1Monash Alfred Psychiatry Research Centre, Melbourne, Australia
2Monash University, Melbourne, Australia
3Alfred Health, Melbourne Australia
Background: Recent decades have seen a dramatic increase in public mental health literacy and a greater appreciation of the importance of help-seeking for mental ill health. However, there is evidence to suggest that this increased validation for mental illness has not translated into a decrease in stigma towards individuals with mental illnesses.
Objectives: To measure overall stigma in a group of medical students and to determine factors associated with highly stigmatizing views.
Methods: An online survey was distributed to medical students. The survey utilized the Mental Illness Clinicians’ Attitudes Scale Version 2 (MICA-2), a scale previously developed to measure stigma towards mental illness in medical student cohorts. A series of items assessed the students’ perceived views on the aetiology of mental illness.
Findings: The total MICA-2 score correlated most strongly with a perceived aetiological model of mental illness as occurring due to ‘personal weakness’ and there was a weak negative correlation with a view of mental illness as being a ‘brain disorder’. Unsurprisingly, total MICA-2 scores negatively correlated with likelihood of choosing psychiatry as a future career. Interestingly, students’ own experience with mental illness was not found to be significantly correlated with total MICA-2 scores.
Conclusions: Although there are some statistically significant correlations between MICA-2 total scores and perceived aetiology of mental illness, none of these correlations had a large effect size. Further investigation is needed to determine other factors that are associated with stigmatized views of mental illness.
Diagnosing Autism Spectrum Disorder in Children, Youth and Adolescents in 2019
M Turner
University of Adelaide, Adelaide, Australia
Background: Autism spectrum disorder (ASD) and the definition of what that is, has undergone many changes over the last 10 years. The current diagnostic criteria, assessments used for diagnosis and how to manage some of the more challenging parts of assessment are reviewed.
Objectives: This session aims to review current assessment methods for ASD and to understand their differences and applicability.
Methods: Review of the Autism Diagnostic Observation Schedule, Childhood Autism Rating Scale II, Ritvo assessment (The Ritvo Autism Asperger Diagnostic Scale–Revised (Ritvo et al., 2011)), Autism Diagnostic Interview and the new ‘National Guideline for the Assessment and Diagnosis of Autism Spectrum Disorders in Australia’ (Autism CRC, 2018).
Findings: There are a variety of assessment tools, which can be applicable in different circumstances that should be used to allow an appropriately informed diagnostic process.
References
AutismCRC (2018 National guideline for the assessment and diagnosis of autism spectrum disorder in Australia. Available at: https://www.autismcrc.com.au/knowledge-centre/resource/national-guideline.
Ritvo RA, Ritvo ER, Guthrie D, et al. (2011) The Ritvo Autism Asperger Diagnostic Scale–Revised (RAADS–R): a scale to assist the diagnosis of autism spectrum disorder in adults: an international validation study. Journal of Autism and Developmental Disorders 41(8): 1076–89. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3134766/.
Appreciative Inquiry in Peer Groups
L Ng
The University of Auckland, Auckland, New Zealand
Background: Peer review groups may be of most value when they promote reflection and learning. Appreciative inquiry is a framework that focuses on dialogue to strengthen relationships.
Objectives: This session aims to describe research that has explored the use of appreciative inquiry in peer groups.
Methods: Registrars participated in a peer-coaching exercise using appreciative inquiry over a period of 3 months. They contributed to a focus group. Interviews were thematically analysed.
Findings: Appreciative inquiry facilitated: connectedness, structure for dialogue, space for reflection and generative conversations.
Conclusions: Appreciative inquiry may enable focused and meaningful encounters between peer group members.
Identifying the Welfare Issues and Needs of Psychiatrists and Trainees at a Metropolitan Health Service
C Roberts, J Panther
Gold Coast Mental Health and Specialist Services, Gold Coast, Australia
Background: The unique training and working environments of doctors can have a significant impact on our health and well-being. State-wide and national support services have appeared as a result. At Gold Coast Mental Health and Specialist Services, we have established a Doctors Wellbeing Working Group with the aim of identifying and addressing the specific needs and challenges of our large and varied cohort of psychiatrists and psychiatry trainees.
Objectives: This session aims to (i) identify the current welfare issues affecting psychiatrists and psychiatry trainees working at Gold Coast Mental Health and Specialist Services, with a focus on physical and mental health and well-being, workplace and environmental, and lifestyle factors and (ii) generate solution-focused discussion around addressing modifiable factors impacting on welfare from within the surveyed cohort.
Methods: An anonymous electronic survey of all psychiatrists and psychiatry trainees currently employed with Gold Coast Mental Health and Specialist Services will be conducted. The first part of the survey will identify the specific welfare issues doctors are experiencing and the personal, workplace and other factors contributing to these. The second part of the survey will invite participants to formulate solutions to address modifiable factors impacting on doctors’ welfare.
Findings: Findings will be made available on conclusion of the survey.
Conclusions: Conclusions will be made dependent on findings.
Managing Burnout in Doctors
T Cookson1, B Dowsett2
1Members Welfare Committee, Royal Australian and New Zealand College of Psychiatrists, Australia
2South Eastern Sydney Illawarra Health Service, Sydney, Australia
Background: The impact of ‘burnout’ on doctors, in terms of personal welfare as well as professional performance, has received increasing attention in the literature in recent years. However, evidence for practical strategies to manage burnout that can be utilized by individuals, in supervision, and by organizations, is less clear. Many current resources focus on concepts of self-care and resiliency building as primary interventions for individuals experiencing burnout. It is critical to identify if these resources are effective prior to being adopted as a recommended approach within health organizations.
Objectives: This session aims to identify evidence-based strategies for managing burnout at an individual and organizational level.
Methods: A literature review will identify the current evidence base for management of burnout in doctors. This evidence will be applied to a workplace setting to identify practical steps to manage burnout, including in a supervision setting.
Findings: Burnout in doctors is common, with a significant impact on personal well-being, professional performance and organizational factors such as staff retention. There is growing evidence that organizational-level changes are required to adequately address burnout in medical settings.
Conclusions: Until we understand what is effective in managing burnout, we will be unable to make meaningful change in the domain of doctor welfare. Identifying practical evidence-based interventions that drive better doctor and patient outcomes creates an ethical imperative to ensure that these strategies are acted upon within current health workplaces.
Psychiatric Liaison With Neurology in Functional Neurological Disorders: A Case Series of Psychoeducation, Formulation and Psychotherapy
M Gutkin
1,2,3
1Royal North Shore Hospital, St Leonards, Australia
2University of Melbourne, Melbourne, Australia
3University of Sydney, Sydney, Australia
Background: Functional neurological disorders (FND) are common in neurological patients with high rates of chronicity and disability. FND has been associated with five characteristics: dissociation, panic, maladaptive illness beliefs, abnormal illness behaviour and chronic interpersonal stress. Evidence for treatments is lacking, and acceptance of the diagnosis is often poor.
Objectives: This session aims to determine the benefit of psychoeducation, formulation and psychotherapy in a cohort of patients with FND targeted at the above five characteristics, in terms of acceptance of diagnosis, well-being and function.
Methods: Adults diagnosed with FND by a neurologist were invited to participate. Participants were seen four times by a psychiatrist who provided individualized psychoeducation, formulation and management using psychotherapeutic techniques. Subjective and objective outcome measures were compared before and after. Adult attachment and diagnostic interviews were undertaken at baseline. Interventions were recorded for thematic analysis.
Findings: Seventeen participants were recruited, of whom 15 completed the study. Characteristics, themes and outcomes were summarized and compared. The intervention demonstrated benefit in some measures and supported the association with the above five characteristics.
Conclusions: The intervention is complex and requires further refinement and study but provides weak evidence for the potential benefit of psychiatric liaison with neurology in FND.
Efficacy and Safety of Long-Term Treatment With Lurasidone in Adolescents With Schizophrenia: Results of a 2-Year, Open-Label Extension Study
C Correll1,2, R Goldman3, M Tocco3, A Pikalov3, L Deng3, A Loebel3, D Coghill4
1Department of Psychiatry and Molecular Medicine, Hempstead, USA
2Zucker Hillside Hospital, Recognition and Prevention Program, Glen Oaks, USA
3Sunovion Pharmaceuticals, Fort Lee and Marlborough, USA
4The Royal Children’s Hospital, Victoria, Australia
Background: Limited long-term efficacy and safety treatment data are available in adolescents with schizophrenia.
Objectives: The study aims to describe long-term data obtained on the safety and effectiveness of lurasidone in adolescents with schizophrenia.
Methods: Patients aged 13–17 years with schizophrenia who completed 6 weeks of double-blind (DB) treatment with lurasidone were enrolled in a 2-year, open-label (OL), flexible-dose (20–80 mg/day) extension study. Efficacy measures included the Positive and Negative Syndrome Scale (PANSS) total score.
Findings: In the DB study, mean improvement in PANSS total score at week 6 was significantly greater for lurasidone (37 and 74 mg) versus placebo (−18.6 and −18.3 vs. −10.5; p < 0.001 for both comparisons). A total of 271 patients completed DB treatment and entered the 2-year OL study; 115 (42%) discontinued prematurely. Mean change from DB baseline in PANSS score at weeks 52 (n = 189) and 104 (n = 24) were −32.4 and −34.3, respectively. The most common adverse events were headache (24.0%) 104, and nausea, anxiety, schizophrenia (each 12.5%). Median change in laboratory parameters from DB baseline to weeks 52 and 104, respectively, were total cholesterol, −3.0 and −2.0 mg/dL; triglycerides, +3.0 and +9.0 mg/dL; and haemoglobin A1c, 0.0 and 0.0%; and the mean change from DB baseline in weight at weeks 52 and 104 were 3.3 and 5.0 kg, versus an expected weight gain of 3.4 and 5.7 kg, based on the gender-and-age specific Centers for Disease Control growth chart.
Conclusions: In adolescents with schizophrenia, long-term treatment with lurasidone was associated with continued improvement in symptoms of schizophrenia, with minimal effects on weight, lipids and glycemic indices.
Funded by Sunovion Pharmaceuticals Inc., Sumitomo Dainippon Pharma and Servier Australia
ClinicalTrials.gov identifier: NCT01914393
Two Phase 3, Long-Term Studies of Esketamine Nasal Spray Plus Oral Antidepressant in Patients With Treatment-Resistant Depression: Sustain-1 (Randomized, Withdrawal, Double-Blind, Relapse Prevention Study) and Sustain-2 (Open-Label, Safety and Efficacy Study)
J Singh
Janssen Research and Development, New Jersey, USA
Background: Esketamine nasal spray plus antidepressant treatment has previously demonstrated adequate safety, and robust efficacy, in treatment-resistant depression (TRD).
Objectives: This session aims to evaluate long-term efficacy and safety of esketamine nasal spray plus oral antidepressant in patients with TRD.
Methods:
SUSTAIN-1: After a 16-week induction with esketamine (56 or 84 mg) + antidepressant, patients achieving stable-remission/response were randomized 1:1 to esketamine + same antidepressant or same antidepressant + placebo. Time-to-relapse in stable-remitters (primary endpoint) was assessed.
SUSTAIN-2: Following a 4-week induction, responders entered a 48-week open-label optimization/maintenance phase (28, 56 or 84 mg), then 4-weeks of follow-up. Safety (the primary endpoint) was evaluated.
Findings:
SUSTAIN-1: Twenty-four patients (26.7%) in the esketamine + antidepressant group and 39 patients (45.3%) in the placebo + antidepressant group relapsed (two-sided p = 0.003). Esketamine + antidepressant decreased the risk of relapse by, on average, 51% compared to placebo + antidepressant among stable-remitters: hazard ratio (HR) (95% confidence interval (CI)) 0.49 (0.29; 0.84).
SUSTAIN-2: Overall discontinuation rate due to adverse events (AEs) was 9.5%. The most common treatment emergent adverse events (TEAEs) (⩾10% patients) were dizziness (32.9%), dissociation (27.6%), nausea (25.1%), headache (24.9%), somnolence (16.7%), dysgeusia and hypoaesthesia (11.8% each), vertigo (11.0%), vomiting (10.8%) and viral upper respiratory tract infection (10.2%). Higher cognitive functions remained stable. Patients ⩾65 years of age had slowing reaction time (single domain) beginning week 20 but with high variability. Fifty-five (6.9%) patients experienced serious TEAEs and there were two deaths.
Conclusions: Randomized continuation of esketamine treatment in SUSTAIN was superior to randomized discontinuation of esketamine treatment in delaying relapse in TRD patients and was well tolerated with no new safety concerns.
Family Violence Psychiatry Network: Improving Capacity of Mental Health Services to Respond to Family Violence
M O’Connor1,2, D Neillie3
1Family Violence Psychiatry Network, Royal Australian and New Zealand College of Psychiatrists
2Department of Psychiatry, The University of Melbourne, Melbourne, Australia
3Queensland Health, Brisbane, Australia
Background: The Family Violence Psychiatry Network (FVPN) was established by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Board on 19 November 2017. The objective of the Network is to assist the Board to create awareness among psychiatrists and trainees of the mental health aspects of family violence in Australia and New Zealand. The activities of the Network are led by a committee, established on a binational basis, which formed in September 2018.
The FVPN aims to promote research, education and training and the use of best practice models of care for mental health consumers in the community who are experiencing family violence as well as for those who perpetrate family violence.
Objectives: This session aims to:
outline the background to the development of the FVPN focusing on activities undertaken by the Victorian Branch Family Violence Working Group;
outline the purpose and goals of the FVPN; and
present a summary of key issues in relation to mental health and family violence.
Methods: Presentation of (i) significant activities undertaken through the Victorian Branch Family Violence Working Group; (ii) goals of the FVPN; and (iii) key issues in the approach to assessment and management, including the role of risk assessment.
Findings: The role of the FVPN in supporting the delivery of high-quality models of care and in improving workforce capability will be outlined.
Conclusions: The presentation will demonstrate the need for mental health service engagement in addressing mental health determinants and consequences of family violence and the role of the RANZCP FVPN.
Physical Health and Mental Illness: Can Implementation Science Assist in Addressing the Needs of Forensic Patients in Secure Facilities?
K Moss1,2, E Heffernan2.3, C Meurk2.3, M Steele2,3
1West Moreton Hospital and Health Service, Brisbane, Australia
2Faculty of Medicine, University of Queensland, Brisbane, Australia
3Queensland Centre for Mental Health Research, Brisbane, Australia
Background: Implementation science developed out of the finding that evidence-based practices take, on average, 17 years to be incorporated into routine practice in health. There is now widespread evidence documenting the benefits of physical activity (PA) for patients with severe mental illness. A forensic setting poses unique challenges with regards to implementing PA interventions for patients. Despite this, incorporating PA into treatment programmes for patients who reside in government-run, secure settings can be regarded as an important component of recovery and care.
Objectives: This presentation will report the findings of a questionnaire informed by implementation science (theoretical domains framework) and semi-structured interviews with patients exploring barriers and facilitators to PA for patients with severe mental illness residing in a secure facility.
Methods: This study gathered qualitative data using a questionnaire and semi-structured interviews.
Findings: The following data regarding PA in a high-secure setting will be reported on patient knowledge, environmental context and resources, motivations and goals, beliefs about capabilities, skills, emotions, social influences, beliefs about consequences, action planning, coping planning and goal conflict.
Conclusions: This study highlights the barriers and facilitators to PA as reported and experienced by patients with severe mental illnesses residing in a secure facility. Implementation science can assist in identifying these factors.
The Relationship Between Mental Illness and Offending: A Queensland-Wide Analysis of Linked Health and Criminal Justice Data
S Kisely1,2, A Stewart2, T Allard2
1School of Medicine, The University of Queensland, Brisbane, Australia,
2School of Criminology and Criminal Justice, Griffith University, Brisbane, Australia
Background: Understanding the relationship between mental illness and offending is important to assist the criminal justice and health systems manage and treat mentally ill offenders. However, prospective studies are rare.
Objectives: This session describes a prospective record-linkage analysis of three longitudinal birth cohorts and their subsequent contacts with the criminal justice and mental health system in Queensland.
Methods: This database included 128,803 individuals who were born in 1983, 1984 and 1990. These records were linked to data provided by Department of Communities (child protection, conferencing and juvenile court), Queensland Police Service (police cautioning of juveniles), Department of Justice and Attorney General (adult court appearances), Queensland Corrective Services (community and custodial orders) and Queensland Health (child and youth, prison and adult mental health). We examined the association between psychiatric outpatient and inpatient episodes (including diagnosis) and the number of charges, ever imprisoned and ever supervised (probation, parole or community supervision).
Findings: Of the 128,803 individuals, 12,978 had been psychiatric outpatients and 9530 inpatients; 36,276 had an adult offence. After adjustment for potential confounders, all the criminal justice variables showed a significant association with psychiatric inpatient and outpatient contacts, as well as earlier admission. The same applied to all psychiatric diagnoses including emotional or conduct disorders, as well as adult conditions such as psychosis (odds ratio = 6.75; 95% confidence interval = 5.57–8.15), affective, post-traumatic stress and personality disorders. Eating disorders were the only exception.
Conclusions: These results highlight the importance of early psychiatric intervention for both adults and youth in contact with the criminal justice system.
The Differential Functions of Cognitive Emotion Regulation Strategies in Chinese Adolescents With Different Levels of Anxiety Problems in Hong Kong
DFK Wong, XY Zhuang
Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
Background: It is generally believed that adaptive emotion regulation (ER) strategies would have positive influences and maladaptive ER strategies would have negative influences towards psychopathology across various contexts. However, increasing evidence appears to suggest that while maladaptive ER strategies generally contribute to the development of psychopathology, adaptive ER strategies may not necessarily be related to different forms of psychopathology. Therefore, there is a need to further clarify how specific adaptive and maladaptive ER strategies influence psychopathology in different contexts.
Objectives: This session aims to present a study aimed at examining different effects of adaptive and maladaptive cognitive ER strategies on anxiety symptoms in two groups of Chinese adolescents with clinical and at-risk levels of anxiety in Hong Kong.
Methods: A total of 136 adolescents who met the at-risk level and clinical levels of anxiety according to the Spence Child Anxiety Scale were identified by school social workers. A battery of standardized questionnaires were administered to the participants.
Findings: Regression analyses found only two maladaptive ER strategies, self-blame and rumination, that significantly predicted anxiety among the clinical group, while only adaptive ER strategies, positive refocusing and reappraisal predicted anxieties among the at-risk group. When compared to a Western sample of adolescents with internalizing problems, Chinese adolescents in our sample reported higher levels of self-blame, other blame and catastrophizing.
Conclusions: The findings shed light on how differently maladaptive and adaptive ER strategies function among adolescents with different levels of anxiety. Practical implications for the development of intervention programmes for different levels of adolescent anxiety are discussed.
Psychiatric Disorder and Its Correlates in Indigenous Australian Prisoners: A Systematic Review
S Bridges1, R Kini1, R Parker1,2,3, M Handley1, M Das1,2
1Top End Mental Health Service, Darwin, Australia
2Flinders University, Darwin, Australia
3James Cook University, Townsville, Australia
Background: Extant literature evidences that psychiatric morbidity is higher in the incarcerated compared to the general population. Rates of imprisonment among the Indigenous population is greater than Australia’s general population.
Objectives: The study reviewed existing literature that examined the prevalence of psychiatric disorders and its correlates in prisoners of Aboriginal and Torres Strait Islanders ethnicity.
Methods: A systematic review of the literature examined studies up to the year 2018 using relevant electronic databases including PubMed, Scopus, Web of Science, MEDLINE, PsycINFO, CINAHL, Cochrane library and Google Scholar. Quantitative studies reporting prevalence of mental disorders and psychosocial correlates were examined.
Findings: The review found 13 articles examining mental health in incarcerated Indigenous individuals. Mental disorders prevalence rates for adults in these studies were psychotic disorders (6.6–11%), affective disorders (13.1–43.1%), anxiety disorders (25.2–58.6%), substance use (11.8–93.9%), psychosocial stressors (7.6–78.0%) and suicidal ideation and self-harm (1.4–38.2%).
Indigenous women had higher mental disorder prevalence rates compared to non-Indigenous women. Indigenous men had higher prevalence rates for alcohol and cannabis use. Indigenous youth had higher prevalence rates of attention and behavioural disorders. Suicidal ideation and attempts were higher in Indigenous populations. Most studies did not show an increased prevalence of mental illness in Indigenous men compared to non-Indigenous counterparts.
Conclusions: The review identified a higher prevalence of psychiatric morbidity in Indigenous women but not men. This may be due to the under-reporting of mental health symptoms by Indigenous people and the dearth of validated assessment tools for this population. This makes further methodologically robust research necessary.
Coping with a Patient Suicide: An Exploratory Study with Psychiatry Trainees
J Henry1, M Ramages2, G Cheung3
1Auckland Regional Psychiatric Registrar Training Programme, Royal Australian and New Zealand College of Psychiatrists Fellowship Program
2Mental Health Services for Older People, Waitemata District Health Board, Auckland, New Zealand
3Department of Psychological Medicine, School of Medicine, The University of Auckland, Auckland, New Zealand
Background: Patient suicide is one of the most stressful events for psychiatrists and psychiatry trainees (Gitlin, 2007). However, there is a lack of consistent support offered to clinicians, including post-vention (Dransart et al., 2015; Prabhakar et al., 2013; Prabhakar and Balon et al., 2014; Scocco et al., 2012).
Objectives: This session aims to describe an exploratory study that explored self-rated knowledge and issues related to patient suicide in psychiatry trainees.
Methods: A mixed-method approach was used. All trainees in the Auckland Regional Psychiatry Registrar Training Programme were invited to complete an online survey. The authors then delivered a 1.5-h workshop as part of the Stage 1 formal education course where a Stage 3 trainee reflected on her experience following a patient’s death by suicide. Small group discussion was then facilitated by the authors.
Findings: A total of 40 trainees completed the online survey (63.4% response rate). The survey highlighted gaps in knowledge related to the steps to take next following a patient suicide. Most trainees were unaware of available support systems. Nine Stage 1 trainees attended the workshop. The main themes emerged were distressing emotions and cognitive distortion impacting on work; internal conflict between the trainee needing to attend to their own self-cares versus the trainee wanting to support the rest of the team by being present at work; uncertainties about contacting the family; uncertainties and fear about legal responsibility, serious incident report process and coronial process.
Conclusions: There is an urgent need to develop a guideline/protocol to support psychiatry trainees following a patient suicide. This could improve their training experience and facilitate the development of resilience as they progress through training to become a psychiatrist.
References
Gitlin M (2007) Aftermath of a tragedy: reaction of psychiatrists to patient suicides. Psychiatric Annals 37(10): 684–687.
Prabhakar D, Anzia JM and Balon R (2013) ‘Collateral damages’: preparing residents for coping with patient suicide. Academic Psychiatry 37(6): 429–430.
Prabhakar D, Balon R, et al. (2014) Helping psychiatry residents cope with patient suicide. Academic Psychiatry 38(5): 593–597.
Scocco P, Toffol E, Pilotto E, et al. (2012) Psychiatrists’ emotional reactions to patient suicidal behaviour. Journal of Psychiatric Practice 18(2): 94–108.
Dransart D, Heeb J, Gulfi A, et al (2015) Stress reactions after a patient suicide and their relations to the profile of mental health professionals. BMC Psychaitry 15: 265.
Academic Psychiatry in New Zealand
D Buchanan1, F Sundram2, G Cheung2
1Auckland Regional Psychiatric Registrar Training Programme, Royal Australian and New Zealand College of Psychiatrists Fellowship Program
2Department of Psychological Medicine, School of Medicine, the University of Auckland, Auckland, New Zealand
Background: Academic psychiatry is at risk of extinction in Australasia (Henderson et al., 2015). However, there is a lack of data describing the experiences of academic psychiatrists in New Zealand. Understanding the challenges in academic psychiatry may help counter the slow demise of the field.
Objectives: This session aims to describe a study that explored the characteristics, experiences and motivations of academic psychiatrists in New Zealand. Factors that modulated recruitment and retention were also investigated.
Methods: A qualitative study, using individual in-depth semi-structured interviews, was conducted between 2015 and 2017. All academic psychiatrists from the University of Auckland and the University of Otago were invited to participate. One-on-one audio-recorded interviews were conducted with 11 participants, and recordings were then transcribed verbatim. Thematic analysis was performed by the authors, assisted by the use of Nvivo (Braun and Clarke, 2006).
Findings: Four main themes emerged: (i) factors that influenced entry to academic roles (e.g. academic mentors/role models); (ii) enjoyable factors of being an academic, such as satisfaction from teaching/research; (iii) challenges faced by those working in academia (e.g. financial remuneration, time constraints, pressure to secure research grants and teaching workloads); and (iv) strategies to address concerns related to the future of academic psychiatry.
Conclusions: Although academic psychiatrists enjoy the work they do, academic psychiatry in New Zealand faces many of the same challenges faced internationally. Overall, academic psychiatry remains fragile but there are possible opportunities to strengthen the field and foster the next generation of academic psychiatrists.
References
Braun V and Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101. DOI: 10.1191/1478088706qp063oa.
Henderson S, Porter RJ, Basset D, et al. (2015) Why academic psychiatry is endangered. 49(1): 9–12. DOI: 10.1177/0004867414563453.
Therapeutic Alliance and Psychoeducation for Depression – Testing the Effectiveness of a Brief Intervention Training Programme: A Pilot Study
D Burridge1,2, E Frickey1, G Branjerdporn1, A Almeida-Crasto1, N Gill1,2, D Garg1
1Gold Coast University Hospital, Gold Coast, Australia
2Griffith University, Gold Coast, Australia
Background: Major depressive disorder (MDD) is one of the most prevalent and disabling of all psychiatric disorders. The therapeutic alliance has been identified as a strong predictor of treatment outcomes among sufferers of MDD, including those presenting in crisis. Such crisis presentations represent a window of opportunity to build a therapeutic alliance and provide psychoeducation to enhance treatment adherence and follow-up. Many mental health practitioners (MHPs) lack formal training in ways to facilitate a positive therapeutic alliance and deliver effective psychoeducation.
Objectives: This session aims to describe preliminary evidence obtained of the feasibility and effectiveness of a brief (<4 h) intervention training module for MHPs designed to enhance the therapeutic alliance and delivery of psychoeducation (PE) for patients presenting with MDD to an emergency department or crisis outpatient service.
Methods: A mixed-methods approach integrating thematic analysis of focus group discussions (FGDs) involving MHPs (n = 20) with a quantitative analysis of patient (n = 50) self-reports using a modified version of the Working Alliance Inventory (m–WAI) will be utilized. MHPs will participate in FGDs before and after completing online and face-to-face training. Patients presenting to the acute care setting will complete the m–WAI immediately following assessment with MHPs.
Findings: It is anticipated that a significant increase in patient-reported therapeutic alliance will emerge following MHPs engagement in brief training. FGD analysis will shed light on the barriers and facilitators to establishing an effective alliance and providing PE to MDD sufferers.
Conclusions: Recommendations drawn from the results of the study to inform clinical care and further training and development will be presented.
An Educational Programme to Facilitate Scholarly Project Completion: Reflection and Future Directions
G Cheung, S Cullum, L Ng
Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
Background: The Scholarly Project (SP) is a summative assessment within the 2012 Royal Australian and New Zealand College of Psychiatrists’ (RANZCP’s) Fellowship Programme. It involves a trainee undertaking original research in an area relevant to psychiatry.
Objectives: We developed an education programme to facilitate SP completion. The aims were to deliberately focus attention on formulating a research question, developing research skills to conduct research and planning the stages of a SP over a realistic timeline.
Methods: A spiral curriculum approach was used to develop the programme. This was informed by a New Zealand trainee survey and the authors’ experiences in research supervision.
Findings: Stage 1 trainees learnt how to formulate a researchable question using a team learning exercise based on a clinical case. In the second year, trainees attended a workshop titled ‘transforming a good idea into a tangible SP’. This explored specific area(s) in psychiatry of interest to trainees using reflection on personal values and experiences. In the third year, trainees attended two full-day workshops to work up their research proposal and exchange ideas with workshop facilitators and fellow trainees. Stage 3 trainees reported their research progress to the group, sought feedback, gained practical tips on how to troubleshoot and made decisions to advance their SP to completion.
Conclusions: These teaching encounters provided opportunities for trainees to develop their own research idea and execute their research. They were highly valued by trainees, as reflected in their feedback and evaluation. Future directions could include support for novice SP supervisors and the appointment of a SP coordinator who can further facilitate and monitor trainees’ progress.
Psychiatry and Addiction Career Medical Officers (CMOS) in NSW: Description, Role and Education Needs
L Nash1,2, M Meltzer3,4, A Karageorge1, A Ndaba4, A Singh4
1Brain and Mind Centre, University of Sydney, Sydney, Australia
2Sydney Local Health District, Sydney, Australia
3Ryde Community Mental Health, Ryde, Australia
4Health Education and Training Institute of NSW Health, Sydney, Australia
Background: Career Medical Officers (CMOs) in NSW working in psychiatry or addiction medicine are largely an unknown and undocumented entity. Their training and education needs are therefore also unknown.
Objectives: This session aims to ascertain the number, the place of work, the role and the educational needs of CMOs in NSW public hospital positions and to implement key education supports.
Methods: Phone calls and emails were sent to all psychiatry contacts in NSW through the Health Education and Training Institute (HETI) to ascertain who and where CMOs worked. Finding this information through private hospitals was unsuccessful.
A working party of CMOs and key HETI members developed and delivered a mixed-methods survey to examine the role and education needs of CMOs in NSW.
Findings:
Forty-one CMOs publicly employed in NSW were identified and emailed the survey with 25 respondents (61% response rate). Most (90%) indicated they were satisfied with their role but 13% felt that their role was not valued by other staff.
About 48% had been CMOs for more than 11 years and most described a particular area of expertise such as clozapine, metabolic health or electroconvulsive therapy.
About 80% of CMOscame from a psychiatry trainee background.
All respondents undertook Continuing Medical Education.
The majority (80%) were interested in attending a monthly CMO peer review group and 95% were interested in attending a one-day symposium for CMOs in psychiatry and addiction medicine.
Conclusion: CMOs provide a valuable yet occasionally not valued role. Education support requires targeting areas for which CMOs want expert education. Peer Review Groups and a targeted symposium are two avenues that the working party will implement and report on at the Congress.
Psychotropic Medication Prescribing Patterns in a Child and Youth Mental Health Service in Australia
A Dharni
Central Coast Local Health District, Garden Suburb, NSW, Australia
Background: There has been a rise in the use of psychotropic medication in young people, despite limited risk–benefit profile of psychotropic medication for this population. Given their side effect profile, the use of psychotropic medications should occur with caution.
Objectives: This session aims to describe a study investigating psychotropic prescribing patterns in a public youth community mental health service and gives an estimate of the general level of psychotropic medication use in this setting.
Methods: A retrospective file review was undertaken of young people aged 12–17 years who received care from the service in 2016 (N = 189) for a range of mental health problems, excluding psychosis. Files were reviewed for demographical information (age, gender), diagnosis/presenting issues, prescribed medications, indications of medications and prescriber type (e.g. psychiatrist, general practitioners, paediatrician). The data were analysed descriptively.
Results: More than 60% (60.8%, n = 115) of young people were prescribed psychotropic medications. More than half of the entire sample were taking antidepressants (51.32%, n = 97), nearly one-quarter (n = 46, 24%) on antipsychotics, 6% on attention-deficit hyperactivity disorder medications (6.35%, n = 12) and one-fifth (19.58%, n = 37) on polypharmacy. Antidepressants and antipsychotics were mostly used off-label, prescribed by public psychiatric staff. Quetiapine was the most prescribed antipsychotic predominantly for insomnia. Fluoxetine and fluvoxamine were the most prescribed antidepressants predominantly for anxiety disorders.
Conclusions: A high proportion of young people were prescribed psychotropic medication, including antipsychotic medication, mostly for the treatment of anxiety and depressive disorders. There is little evidence around how psychotropic medication is used in youth mental health settings. This study contributes to this gap.
Violence Risk Assessment and Management Framework – Mental Health Services
J Reilly, D Neillie, C Longhitano
Queensland Health, Brisbane, Australia
Background: The Violence Risk Assessment and Management Framework – Mental Health Services (MHS) (the Framework) arose from Queensland’s Sentinel Events Review into homicides and public MHS, ‘When Mental Health Care Meets Risk’. It provides a structured three-tiered approach for the identification, assessment and management of consumers who pose a risk of violence towards others.
The three tiers are risk screening (Tier 1) and violence risk assessment and management (Tier 2) in general MHS, and specialist assessment and response in forensic MHS (Tier 3). The focus will be on applying the new Violence Risk Assessment and Management (V–RAM) pro forma at Tier 2.
Objectives: This session aims to:
outline the Framework including training, monitoring and review components;
outline the development and application of the V–RAM, informed by structured risk assessment tools in collaboration with forensic experts, as a clinical tool to guide development of a violence risk summary and prevention-oriented management plan; and
present an evaluation of the V–RAM and Framework.
Methods: Application of the V–RAM will be illustrated through a case study, examining implications for clinical practice, service delivery and consumer outcomes with emerging data from services including regional.
Findings: Evaluation will examine referrals; standard of assessment and management; review processes; capability to identify, assess and manage violence risk; impact on violence and aggression; and coordination between general and specialist forensic MHS.
Conclusions: The presentation will demonstrate application of the Framework as a model to improve the capability and capacity of MHS to comprehensively assess and manage violence risk.
Is stori-30 a useful tool to measure recovery at prevention and recovery care (parc) setting?
K Jagadheesan1, K West1, V Lakra1, F Castle2, C Ramsay2
1North West Area Mental Health Service, Melbourne, Australia
2Mind Australia, Melbourne, Australia
Background: Clinical and personal recovery are not necessarily the same. There are a few instruments of psychological recovery but Victorian public mental health services are only expected to administer and report clinical outcome measures (e.g. Health of the Nation Outcome Scales (HoNOS)).
Objectives: The main purpose is to evaluate the usefulness of a 30-item self-administered recovery tool (STORI-30) in relation to clinical outcomes (i.e. admission and discharge in a prevention and recovery care (PARC) setting. The secondary aim is to examine for socioclinical correlates of self-rated recovery as per changes in STORI-30 (improved versus not improved).
Methods: STORI-30 has been routinely used at North-West PARC (NW–PARC) since March 2018. It has five domains reflective of stages of recovery. This study will include all consumers who entered NW–PARC from March to October 2018. Sociodemographic and clinical variables will be collected. Data analysis will be done using the latest version of the Statistical Program for the Social Sciences (SPSS).
Findings: Admission and discharge scores of STORI-30’s five domains will be compared. Based on STORI-30, study participants will be divided into two recovery groups (improved and not improved). These groups will be compared on sociodemographic variables, clinical characteristics and outcome variables (HoNOS scores; those who achieved versus not achieved their recovery goals; and discharge destination (i.e. hospital care versus home)).
Conclusions: This study is expected to provide information around the usefulness of STORI-30 in a residential recovery care facility, PARC.
‘Pathway to Care’ Survey For Adult Attention-Deficit Hyperactivity Disorder in Private Practice: Analysis of Issues and Pitfalls in Service Delivery
S Guha
Marsai Clinic, Belmont Private Hospital, Brisbane, Queensland, Australia
Background and objectives: There are not many publications or research regarding a pathway to care for adult attention-deficit hyperactivity disorder (ADHD) in Australia or other countries. There is a notion that adults with symptoms of ADHD, who have not been formally diagnosed with ADHD as a child, may not be a major ‘target-population’ for most mental health services (MHS). Most such studies in this area are mapping the ‘gaps’ in transitioning between adolescents diagnosed with ADHD to adults.
The progression of ADHD across the lifespan from childhood to adulthood is between 40% and 55%. New incidences of diagnosis of adult ADHD are increasing. This is estimated between 3% and 5%. Unmanaged and undiagnosed ADHD in adults has a significant negative socioeconomic impact on our society. Also, there is a high prevalence for co-morbidities, which further increases the burden of care.
There is a perceived lack of a well-defined ‘pathway to care’ for adults with ADHD in Australia, both in private and public MHS. The present paper aims at providing an overview of the Pathway to Care for adult ADHD in a private psychiatric practice setting in Brisbane.
Methods: A total of 50 randomly selected adult ADHD patients registered with the practice were sent an anonymous electronic survey with 31 questions in 2018.
Results and conclusions: The results of this survey were analysed to provide a unique snapshot of the issues with pathway to care for adults with suspected ADHD. Their experiences and reported issues will be discussed at length in this presentation to assist future service provision decisions across the MHS.
Consumer Perspective on BPD Management: How are the National Health and Medical Research Council Borderline Personality Disorder Guidelines Faring in Practice?
J Proctor, S Lawn
Flinders University, Adelaide, Australia
Background: Many individuals with borderline personality disorder (BPD) experience increased levels of stigma are more likely to be viewed as manipulative and evoke negative responses from clinicians more frequently, compared with individuals with other mental health diagnoses.
Objectives: This session aims to present understandings of the consumer perspective regarding BPD management, and how the National Health and Medical Research Council (NHMRC) BPD guidelines are faring in practice.
Methods: Individuals who identified as having a BPD diagnosis completed a 75-question survey, delivered Australia-wide online via SurveyMonkey, in 2011 (N = 153), and again in 2017 (N = 424). Qualitative and quantitative data provided comparative data sets to evaluate changes over time in the consumer perspective of BPD management.
Findings: Common themes emerged, highlighting the ongoing difficulty many people with BPD experience when seeking help. Delays in receiving a BPD diagnosis, inadequate explanations of BPD, dismissal by clinicians and multiple barriers to accessing appropriate services were some of the themes that persisted from 2011 to 2017. Of note is the shift from consumers primarily seeking support from psychiatrists in 2011 (76.2%, N = 80) to psychologists in 2017 (84.19%, N = 245).
Conclusions: Consumers demonstrated increased health literacy and help seeking in 2017, primarily through online and consumer-led support groups, an understanding of which may provide an opportunity for psychiatrists to build a stronger therapeutic relationship with the person in their care. Limited explanations of BPD at time of diagnosis continued to prove problematic for consumers. Financial and physical barriers to accessing services also persisted. More focus on embedding the NHMRC guidelines into practice is needed.
A Systematic Review of the Effectiveness of Clozapine in the Treatment of Personality Disorder
M Das1, R Kini1, G Garg1,2, M Handley1, R Parker1,2,3
1Top End Mental Health Service, Darwin, Australia
2Flinders University, Darwin, Australia
3James Cook University, Townsville, Australia
Background: While psychological approaches form the mainstay of treatment in personality disorder (PD), increasingly antipsychotics, antidepressants and mood-stabilizers have been evidenced to be useful adjuncts and there is emerging literature on the utility of clozapine.
Objectives: This session aims to report the examined evidence for the effectiveness of clozapine in the treatment of PD focusing on specific symptom domains of PD.
Methods: A systematic review following the Preferred Reporting Items for Systematic reviews and Meta-Analyses model was conducted on databases (PubMed, Scorpus, Web of Science, MEDLINE, PsycINFO, CINAHL, Cochrane library, Google Scholar). Studies were included if clozapine was used to treat PD subjects with no co-morbid schizophrenia spectrum disorder.
Findings: No randomized controlled trial was identified. In total, 17 studies met the eligibility criteria and were reviewed. Of these, 16 studies were case reports/series, open-label design and 1 retrospective mirror image. All but one study were on borderline personality disorder (BPD) and the remaining study was on antisocial personality disorder (APD). We found that across studies, clozapine led to improvement in all symptom domains and proxy markers of improvement (seclusion/restraint, incidents, aggression/violence, self-harm, hospital admissions). Three studies reported clinical improvement in adolescents with BPD.
Conclusions: Treatment with clozapine can have beneficial effects in BPD and there is initial report of effectiveness of clozapine in violence risk reduction in APD. Symptom improvements for both BPD and APD were noted in affective dysregulation, impulsive–behavioural dyscontrol and cognitive-perceptual symptom domains. However, there are significant methodological shortcomings in the evaluated studies, and there is need for case-controlled and randomized controlled trials.
Chronology of an Inquiry
L Ng
The University of Auckland, Auckland, New Zealand
Background: The conduct of inquiries into mental health services after serious incidents is a topic that has rarely been studied. This research examined various stakeholder perspectives of the inquiry process following a homicide committed by a service user.
Objectives: This session aims to describe the identification of optimal conduct of mental health inquiries following a homicide.
Methods: Interpretative phenomenological analysis of individual in-depth interviews with three stakeholder groups: families of victims, professional staff and members of inquiry panels.
Findings: Facets of ‘a good inquiry’ may include clarity of purpose, focus on learning and systemic factors, dissemination of findings, reflection and follow-up of recommendations and optimal care of families and staff in the process.
Conclusions: Inquiries following serious incidents emphasize learning, which may be enhanced by providing opportunities to families and professional staff to reflect on findings. A central repository of findings may serve as a valuable resource for disseminating learning further.
Broken Heart Syndrome (Takotsubo Cardiomyopathy) – What Psychiatrists Need to Know: Case Report and Review
J Johnson1,2, G Byrne1,2
1Royal Brisbane and Women’s Hospital, Brisbane, Australia
2University of Queensland, Brisbane, Australia
Background: Takotsubo cardiomyopathy (TTC), also known as broken heart syndrome, is an acute and reversible cardiac condition with a 30-day mortality rate of about 5%. TTC is usually preceded by a significant stressor such as the loss of a loved one. Recent literature suggests sympathetic hyperactivation as a likely pathological mechanism. This is consistent with findings that chronic anxiety, associated with increased bursts of sympathetic activity due to mental and physical stress, and the predisposing factor of early life trauma, increase the risk of TTC. Thus, psychiatrists may be involved in the care of these patients and should be aware of the risk of TTC following significant stress, anxiety and relapse of psychiatric illness.
Objectives: This session aims to present a case of TTC in the context of major neurocognitive disorder and identify important considerations for psychiatrists.
Methods: Case report and relevant literature review.
Findings: Most cases of TTC are preceded by a significant stressor, thus often involving psychiatric assessment. Chronic anxiety and childhood trauma are risk factors. Patients with neurocognitive impairment are at increased risk of TTC. Common medications used for anxiety and depression, especially those that cause hyponatraemia, may act as a precipitant for TTC.
Conclusions: Dementia can increase the risk of developing TTC following anxiety-inducing life events. Antidepressants and hyponatraemia may play a role in precipitating TTC as well as its recurrence, which psychiatrists need to consider when treating these patients.
The Utility and Effectiveness of Royal Australian and New Zealand College of Psychiatrists Training For Psychiatric Practice in the Maldives
A Mohamed
Indhira Gandhi Memorial Hospital, Malé, Maldives
Background: Originally from the Maldives, I undertook Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) training in New Zealand. I returned to work in the Maldives as the sole local psychiatrist in 2013, after completing the Fellowship in 2011.
Objectives: This session aims to present a reflective account of the strengths and limitations of the RANZCP training in preparing me for psychiatric practice in the Maldives, a low and middle-income country (LMIC) with a different cultural and systemic context.
Methods: This qualitative study uses autoethnography and personal reflection.
Findings: RANZCP training grounded me with a broad knowledge base and a wide range of clinical experiences. Furthermore, the academic environment and regular supervision offered the opportunity to contextualize and individualize my learning. The flexibility and ability to improvise training was particularly helpful. I was able to pursue overseas clinical exposure during Basic Training and completed Generalist Advanced Training part-time with concurrent postgraduate studies in public health to broaden my horizons in population health. In terms of limitations, particular clinical areas (such as neurology) and attention to leadership skills (planning, management and pedagogical practice) would have been beneficial. Despite the anticipation and preparation, lack of support systems as an early career psychiatrist returning to work in an LMIC proved to be a significant ongoing challenge.
Conclusions: While the RANZCP training was robust and effective in terms of clinical practice in the Maldives, my experience identifies niche areas of need for trainees following my journey, including support systems for overseas Fellows.
What Is Clinical Supervision?
Paul Bailey
1,2,3
1Psychotherapy and Counselling Federation of Australia
2Australian Clinical Supervision Association
3New Zealand Association of Psychotherapists
Background: Janine Bernard and Rodney Goodyear (1992) state at the beginning of their classic text: ‘mental health professions are more alike than different in their practise of (clinical) supervision. Regardless of professional discipline, clinical supervision can be described in terms of core skills and common processes’.
In this presentation, Paul Bailey will share with you what these core skills and common processes are, and how clinical supervision, when done well, benefits patients, clinicians, and organizations.
Objectives: This session aims to understand the difference between clinical supervision and professional supervision, the importance of clinical supervision in psychiatric training and practice and its role in members welfare.
Methods: Specialist presentation.
Findings: Professional supervision is what psychiatrists know well: its task is professional gatekeeping. Clinical supervision is, in contrast, about the clinician and the clinician–patient alliance and is always clinician-led. It is based on a respectful and confidential relationship that aims to provide a safe emotional space in which supervisees can discuss their professional work-related concerns. The process aims to empower supervisees through guided reflection that is learner-centred and learner-led. The essence of clinical supervision’s effectiveness relies on clinicians having a choice about who their clinical supervisor is. Clinical supervisors require training and their own supervision to function well within this complex task.
Conclusions: Clinical supervision is a critical component of psychiatric training and practice. When done well, clinical supervision benefits patients, clinicians and organizations.
Reference
Bernard JM and Goodyear RK (1992) Fundamentals of Clinical Supervision.
Resilience in Medicine: Panacea Or Plaster
T Ewais1,2, A Teodorczuk1,3
1Griffith University, Gold Coast, Australia
2Mater Health, Brisbane, Australia
3Prince Charles Hospital, Brisbane, Australia
Background: Resilience has been described as the ability to adapt positively to adversity (Balme et al., 2015). With an increased awareness of the negative impact of burnout on patient and financial outcomes, there is heightened interest at an organizational level to develop resilience in health professionals.
Objectives: This session aims to present an evidence-based overview of resilience. With reference to the literature and findings from a research project, we outline controversies in conceptualization of resilience and evaluate the impact of therapeutic interventions targeting resilience (Joyce et al., 2018).
Methods: Narrative review of the literature on resilience, well-being and burnout in pre- and post-qualification settings. Evaluation of a bottom-up intervention to improve medical student resilience at Griffith University. The ‘student bundle’ intervention was developed following focus groups with staff and students and implemented in October 2018. Measures include resilience levels (CD-10) along with other indices of psychosocial functioning evaluated in a pre-test post-test manner.
Findings: We found caution should be used when utilizing the term ‘resilience’. Resilience can be seen as an oversimplistic panacea to solve all individual, educational and healthcare systems issues. Moreover, an over focus on resilience can potentially be misused as a plaster for covering up system flaws (Balme et al., 2015; Launer, 2015; Teodorczuk et al., 2017; Thistlethwaite, 2018). We will also be presenting preliminary findings from the evaluation of the student bundle.
Conclusions: Resilience is a hot topic and our findings shed light on development of educational well-being approaches aimed at preventing, promoting resilience and managing those with high levels of distress or burnout.
References
Balme E, Gerada C and Page L (2015) Doctors need to be supported, not trained in resilience. British Medical Journal (Online) 351: 1–6.
Joyce S, et al. (2018) Road to resilience: a systematic review and meta-analysis of resilience training programmes and interventions. BMJ Open 8(6): 1–9.
Launer J (2015) Resilience: for and against. Postgraduate Medical Journal 91(1082): 721.
Luthar SS, Cicchetti D and Becker B (2000) The construct of resilience: a critical evaluation and guidelines for future work. Child Development 71(3): 543–562.
Teodorczuk A, et al. (2017) When I say … resilience. Medical Education 51(12): 1206–1208.
Thistlethwaite J (2018) Be positive: resilience is all you need. The Clinical Teacher 215(5): 359–360.
Finding the Right Balance Between Exam Preparation and Professional Development in Psychiatry Formal Education Courses
R McKay1,2, S O’Callaghan1
1Health Education and Training Institute Higher Education, Sydney, Australia
2University of New South Wales, Sydney, Australia
Background: Attending a Formal Education Course (FEC) is a mandatory for participants within Stages 1 and 2 of the Royal Australian and New Zealand College of Psychiatry training programme. Although all follow a standard content curriculum, FECs in different jurisdictions have differing degrees of focus on exam preparation alongside knowledge transfer and professional skill development.
Objectives: This session aims to describe the impact of increasing time allocated to exam preparation and professional transition support within the first year of a FEC.
Methods: To increase focus upon exam preparation and professional transition as a new psychiatry registrar, one hour of each week of Semester One, Year One, was allocated for focus on these issues. To maintain coverage of the mandated curriculum, recorded seminars were provided to supplement face-to-face teaching.
Findings: Trainees reported a high satisfaction with the content of the sessions but found timely watching of the recorded seminars problematic. They requested the new sessions be condensed in duration to allow content in supplementary seminars to be taught within FEC hours. The opportunity for, and perceived expectation by some, trainees to sit exams earlier in training appeared to increase their desire for earlier exam-focused material within FECs.
Conclusions: FECs must continue to adjust their content and delivery to meet evolving trainee needs. The Health Education and Training Institute FEC will be introducing streamlined professional development content and exam workshops within the first year of a FEC in response to trainee feedback. The balance of these activities with curriculum coverage is likely to require ongoing review.
Self-Practice/Self-Reflection: A Flexible Approach to Enhance Psychotherapy Training and Therapist Self-Care
S Waite
The Queen Elizabeth Hospital, Adelaide, Australia
Background: Self-practice/self-reflection (SP/SR) is a self-experiential training strategy in which participants practice cognitive behavioural therapy (CBT) on themselves and then reflect on the implications for their personal and professional lives. The primary aim of SP/SR has been to develop therapist competence; however, there is emerging evidence of a range of beneficial outcomes including improved empathy for patients, as well as improved therapist self-care and confidence. Although SP/SR research has involved participants of varying disciplines and different levels of experience, there has been limited research to date with doctors.
Objectives: The aim of this study was to develop a viable model to integrate SP/SR into a CBT course for doctors. Outcomes were assessed in relation to personal and professional development, negative reactions and barriers to participation.
Methods: Three groups of doctors ranging in experience from Junior Medical Officers to Advanced Psychiatry Trainees completed an evaluation after attending a group CBT training course facilitated by a psychiatrist. The course was delivered in different formats and incorporated the self-practice exercises and structured reflection questions from a CBT SP/SR workbook (Bennett-Levy et al., 2015).
Findings: Results endorsed a wide range of benefits of SP/SR, along with some limitations and suggestions for improvement of the learning experience.
Conclusions: SP/SR may be a useful tool for enhancing CBT knowledge and procedural skills, as well as improving reflective ability, interpersonal skills and therapist self-care. The training approach can be set up flexibly with doctors of varying levels of experience. Further research could be extended to larger numbers of psychiatry registrars and psychiatrists who aspire to enhance their effectiveness as psychotherapists and pay more attention to their well-being.
Reference
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.
Family Presence During Electroconvulsive Therapy
K George, A Elias, A Ang
Eastern Health, Victoria, Australia
Background: The practice and utilization of electroconvulsive therapy (ECT) is often hampered by stigma and ignorance among patients and families. Family presence at ECT has not been systematically studied.
Objectives: This session aims to present the results of systematically studying the impact of family presence during ECT on the attitudes of those attending.
Methods: From January 2017 to May 2018, 69 patients and their family members were approached for family attendance at ECT. The inclusion criteria for entry to the ECT suite were consent from families and patients, age above 18 years. After watching ECT, family members completed a multiple-choice questionnaire about their experience.
Findings: A total of 21 family members watched ECT. A majority viewed the idea of attendance at ECT as reassuring and a few indicated that it was anxiety provoking. Five participants (24%) felt distressed while watching the procedure whereas 16 family members rated their experience as comfortable or rewarding (76%). In terms of the outcome, a clear majority have responded that watching the procedure alleviated their fears of ECT or provided transformative knowledge whereas others felt no change in their attitude towards ECT (71% vs. 29%). Most of the participants recommended watching ECT to other family members whereas a minority was uncertain about their opinion (62% vs. 38%). There were no adverse effects, premature exits from the ECT suite, interferences with the treatment or any litigation.
Conclusions: A clear majority of families viewed their attendance at ECT as a beneficial experience. Family presence during ECT may have the potential to promote its practice by reducing stigma and misconceptions.
Developing A New Threshold Titration Chart For Electroconvulsive Therapy (ECT)
S Gill
1,2,3
1South Australian Psychiatry Branch Training Committee, Adelaide, Australia
2Central Adelaide Local Health Network, Adelaide, Australia
3Ramsay Health Care, Adelaide, Australia
Background: An accurate determination of seizure threshold in electroconvulsive therapy (ECT) allows a stimulus dose to be set relative to that threshold. Titration charts prescribe the doses to be used during a threshold titration and determine what treatment dose is set relative to that threshold. Current charts may overestimate the threshold in some patients and, therefore, lead to an excessive dose. Also, most services use different charts for different types of ECT, which can increase confusion.
Objectives: This session aims to describe the derivation of a single titration chart that can be used for all commonly prescribed placements and pulse width combinations, that strikes a balance between the need to accurately detect the seizure threshold and the need to avoid excessive subconvulsive stimuli when doing so.
Methods: The available literature for stimulus dosing and threshold titration for all placements and pulse widths was reviewed, with a focus on the literature regarding optimum Stimulus Dose Relative to Seizure Threshold (SDRST).
Findings: There is a need for a titration chart that more accurately determines the actual ST and sets doses closer to the optimum SDRST.
Conclusions: A titration chart will be presented that provides more accurate threshold and SDRST determination, as well as placing this on a single A4 page for all common placement and pulse width combinations.
Efficacy of Repetitive Transcranial Magnetic Stimulation in the Treatment of Depression With Co-Morbid Anxiety Disorders
E Clarke1, C Galletly2,3,4, S Gill2, P Clarke2, L Hahn2,3
1The University of Adelaide, Adelaide, Australia
2The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, Adelaide, Australia
3Discipline of Psychiatry, School of Medicine, The University of Adelaide, Adelaide, Australia
4Northern Mental Health, Adelaide Health Service, Adelaide, Australia
Background: Repetitive transcranial magnetic stimulation (rTMS) has been shown to be effective for treatment-resistant depression, but there is little research examining the efficacy of rTMS in patients with depression who have co-morbid anxiety disorders.
Objectives: This session aims to present findings on investigating the efficacy of rTMS in patients with treatment-resistant major depressive disorder (MDD) who have co-morbid anxiety disorders.
Methods: This study included 248 patients with treatment-resistant MDD; 172 of these patients had one or more co-morbid anxiety disorders. Generalized anxiety disorder (GAD) was most common (N = 102), while 32 had obsessive–compulsive disorder (OCD), 26 had post-traumatic stress disorder (PTSD), 41 had panic disorder with agoraphobia, 61 had agoraphobia alone and 58 patients had generalized social phobia. There were no significant differences between patients with and without co-morbid anxiety in terms of age, gender, years since onset of depression, number of antidepressants trialled, and whether ECT had previously been trialled.
Findings: Patients both with and without co-morbid anxiety disorders showed improvement in their depression after rTMS treatment, with no significant difference in remission rates between the groups. In the cohort with co-morbid anxiety disorders, 39.5% met the criteria for a response and a further 23.3% of patients met the criteria for remission. For each anxiety disorder diagnosis (GAD, OCD, PTSD, panic disorder with agoraphobia, agoraphobia, GAD), there was a significant reduction in the Hamilton 21-Item Rating Scale for Depression (HAM-D21), Montgomery–Åsberg Depression Rating Scale and The Zung Self-Rating Depression Scale (ZUNG) scores (p ⩽ 0.001 for all).
Conclusions: Our study indicates that rTMS is an effective treatment for MDD in people with co-morbid anxiety disorders.
Credentialling Requirements For Psychiatric Registrars to Perform Electroconvulsive Therapy Independently
T Mohan
Flinders University, Adelaide, Australia
Background: Electroconvulsive therapy (ECT) is a safe treatment for management of depression and other psychiatric conditions. There is a general expectation that a psychiatrist would be administering ECT to a patient but there could be local resource limitations or remoteness that may lead to psychiatrists-in-training (registrars) to administer ECT. While this practice makes intuitive sense given the relative simplicity of the ECT procedure (in comparison to a minor surgery done by a trainee surgeon) – the stigma and negative publicity surrounding ECT warrants strict quality control measures for registrars to administer ECT.
Objectives: This session aims to propose a standardized credentialing requirement that can be administered with objectivity, before permitting a psychiatric registrar to administer ECT independently.
Methods: A literature review will focus on Australasian and overseas guidelines that specify requirements for credentialing psychiatric trainees to administer ECT. Peer review by the Section of ECT and Neurostimulation would be sought to achieve consensus on minimum credentialing requirements.
Findings: Jurisdictions differ in detail about specific, objectively testable criteria for credentialing registrars to perform ECT. An approval from the Director of the ECT service towards credentialing appears to be a common recommendation.
Conclusions: The proposed credentialing criteria are expected to be objective, locally modifiable and to address safety and quality aspects with respect to a trainee performing ECT.
Assessment of Risk Factors of Violence Among Patients With Psychiatric Disorders in Egypt
A Afify1, A Eltantawy2, K Anwer2, H Sayed2
1General Secretariat of Mental Health and Addiction Treatment, Cairo, Egypt
2Suez Canal University Hospital, Faculty of Medicine, Ismailia, Egypt
Background: Mental illness and violence are seen as linked, deepening the stigma of patients and creating an uncomfortable treatment environment, and carries serious consequences by discrimination and a sense of isolation from society. Thus, violence assessment should become a priority in the practice of civil psychiatry to determine whether violence and mental illness are synonymous, connected or coincidental.
Objectives: This session aims to assess the dynamics of different risk factors of violence within psychiatric patients in comparison to those who are not psychiatric patients.
Methods: Cross-sectional comparative design comprising a sample size of 142 participants, divided into two groups; of 71 psychiatric patients from the outpatient clinics and a ‘comparative group’ of 71 normal participants, from the blood donation section of the Suez Canal University Hospital. The data recorded were patient sociodemographics, semi-structured clinical interview, Positive and Negative Syndrome Scale (PANSS) results, Historical-Clinical-Risk Management-20, Version 3 (HCR20–V3) and final opinions.
Findings: There were highly significant statistical correlations between the extracted judged violent patients (n = 16) and violent normal people (n = 7) regarding the ‘risk of serious physical harm’, and the ‘risk of imminent violence’, and the risk factor ‘problems with personal support’ (p < 0.01), and significant statistical correlations between both subgroups regarding the ‘risk of future violence’ (p < 0.05). There was no statistical significance regarding the risk factors of ‘problems with past violence’, ‘relationships’, ‘employment, ‘coping with stress’, ‘cultural miss-norms’ and ‘substance abuse’ (p < 0.05).
Conclusions: Psychiatric patients mostly commit violence through the dynamic of the combined roles of different risk factors collectively, and mediator variables, which is not primarily based on major mental illness symptoms.
Vulnerabilities of Prisoners With Autistic Traits
J McCarthy1, E Chaplin2, L Underwood1, A Forrester3, R Mills4, D Murphy3
1University of Auckland, Auckland, New Zealand
2London South Bank University, London, England
3King‘s College London, London, England,
4Research Autism, London, England
Background: There is increasing recognition of people with autism spectrum disorders (ASDs) across the criminal justice system. Prevalence studies of prisoners found rates of 1% to 4% for ASD with rates up to 18% in specialist juvenile courts. More recently, there has been an increasing recognition of the vulnerabilities of offenders with ASD including their risk for self-harm behaviour and mental illness.
Methods: A total of 240 male prisoners were recruited in a prison in London and screened for an ASD using the autism-spectrum quotient (AQ-20). The Mini International Neuropsychiatric Interview was used to assess for depression, anxiety, self-harm behaviour and suicide.
Results: A total of 46 male prisoners had significant autistic traits and 12 met the diagnostic threshold for ASD using the Autism Diagnostic Observation Schedule. Those with autistic traits were significantly more likely to have a current episode of depression (30% vs. 6%, p < 0.001) and generalized anxiety disorder (27% vs. 11%, p = 0.019) and 15% injured themselves on purpose in the past month (vs. 1.5%, p < 0.001).
Conclusion: In order to support offenders with ASD at different points of their journey, we need to improve approaches to the identification of such offenders across the criminal justice system, including correction services.
Is involuntary treatment a predictor of higher psychotropic medication use? A clinical audit
C Proffitt1, S McMillan1, T Theodoros2, A Wheeler1
1Griffith University, Brisbane, Australia
2Metro South Addiction and Mental Health Services, Brisbane, Australia
Background: Involuntary treatment has previously been associated with worse clinical outcomes; however, limited literature exists investigating psychotropic polypharmacy and high-dose prescribing in this vulnerable population.
Objectives: This session aims to investigate the relationship between involuntary treatment and rates of psychotropic polypharmacy and/or high-dose prescribing practices in a large metropolitan mental health unit over 4 years.
Methods: A retrospective clinical audit encompassing 800 adults from a metropolitan Queensland inpatient mental health unit was undertaken. Data were collected for 200 patients, discharged on at least one psychotropic agent, at four different time points: cohort 1 (on or before 31 January 2014), cohort 2 (2015), cohort 3 (2016) and cohort 4 (2017). The number of prescribed medicines and total daily dose was reviewed for alignment with current clinical guidelines. Outcomes (psychotropic polypharmacy and high-dose prescribing) were compared by patient voluntary/involuntary status using χ2 and rank-sum tests. Associations between outcomes and covariates were assessed using binomial logistic regression analysis.
Findings: Patients treated involuntarily were 58.5 times more likely to be prescribed antipsychotic polypharmacy (two or more antipsychotics) at discharge than those treated voluntarily. Involuntary treatment was also associated with longer hospital admissions [odds ratio: 1.1; 95% confidence interval (1.043, 1.095); p < 0.001].
Conclusions: Implicit review of justifications for increased medication burden and longer duration of admission in those treated involuntarily is required to ensure that clinical outcomes and overall quality of life are optimized for this vulnerable population. Clearly documented medication histories, reconciliation at discharge and directions for medication management after discharge are necessary to ensure quality use of medicines.
Implementation of ‘Dynamic Appraisal of Situational Aggression’ and Acute Behavioural Disturbance Management Guidelines in a Busy Acute Inpatient Unit
M Anand, A Amini, R Bell, A Jayasinghe, R Malloy
Gold Coast University Hospital, Gold Coast, Australia
Background: The Acute Behavioural Disturbance Management guidelines (ABDM) were developed by Queensland Health to advise management of acutely disturbed consumers in adult inpatient mental health units. It specifies a series of step-wise interventions informed by an evidence-based approach. Similar guidelines have been developed in a variety of healthcare services around the world.
The Dynamic Appraisal of Situational Aggression (DASA) is a violence risk assessment instrument developed to determine the short-term risk of violence among adult inpatient psychiatric consumers. It is scored by nursing staff and has been demonstrated to be effective in predicting short-term risk of violence of consumers in acute inpatient psychiatry units.
Objectives: This session aims to describe the: evaluation of compliance with use of DASA and ABDM in a busy adult inpatient psychiatric unit; and the improvement of compliance with use of DASA and ABDM by educational interventions for nursing and medical staff.
Methods: Retrospective data concerning the demographics, clinical diagnosis, risk assessment, use of DASA and use of sedation were collected and related to consumers admitted between 1 October 2017 and 30 November 2017. A questionnaire pertaining to the use of the DASA and ABDM were administered to nursing/ medical staff.
Following implementation of an educational intervention informed by collected data, the same questionnaire was administered to nursing and medical staff to evaluate success and data collected.
Findings: Improved use of DASA and consistent application of principles of the ABDM in acute adult inpatient psychiatric settings.
Conclusions: Standards of care in acute inpatient settings could be improved using an intervention and measuring improvement within a ‘plan–do–study–act’ framework.
Eliminating Seclusion and Reducing Restraint: Hope on An Acute Adolescent Psychiatric Ward
A Padhi, J Norcott, E Yoo, A Vakili
Redbank House, Westmead Hospital, Sydney, Australia
Background: Recently, the NSW Government made a major commitment to preventing the use of seclusion and restraint in NSW Health acute mental health units (NSW Health, 2012). Redbank House Acute Adolescent Unit held some of the highest rates of seclusion and restraint across all Child and Adolescent Mental Health units in NSW. Consequently, a need for multifaceted change was identified.
Objectives: This session aims to describe the objective of this project of significantly reducing seclusion and restraint through introducing consumer-led, recovery-oriented principles in all aspects of patient care (Huckshorn, 2005).
Methods: Following a multifaceted, consumer-focused, recovery-oriented approach, the acute ward underwent a cultural transformation. Some changes included:
staff training in de-escalation strategies;
removal of restrictive visiting hours;
on-call Executive available to support nursing staff 24/7;
introduction of a community meeting to address ‘Our Mutual Expectations’ and provide an opportunity to voice any concerns; and
ward environment changes.
The rate, duration and frequency of seclusions and restraints on the ward were collected for the 12 months prior to, and the 12 months after, implementing the changes.
Findings: Our data illustrate that in the year prior to implementation (July 2016–June 2017), we had 23 episodes of seclusion and 36 episodes of restraint. In the year since implementation (July 2017–June 2018), this has diminished to 0 episodes of seclusion and 3 episodes of restraint. Statistical Analysis will be presented.
Conclusions: A multifaceted, consumer-focused, recovery-oriented approach may yield significant reductions in the necessity for use of seclusion and restraint in acute mental health settings.
References
Huckshorn KA, CAP I, Director NTAC (2005) Six core strategies to reduce the use of seclusion and restraint planning tool. National Association of State Mental Health Program Directors. Available at: https://www.nasmhpd.org/content/six-core-strategies-reduce-seclusion-and-restraint-use
NSW Health PD2012 035 (2012) Aggression, Seclusion and Restraint in Mental Health Facilities in NSW. Available at: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2012_035.pdf.
A Targeted Approach to Adolescent Self-Harm
S Cabarkapa1, J King2,3
1St Vincent’s Hospital Melbourne, Melbourne, Australia
2The Melbourne Clinic, Melbourne, Australia
3University of Melbourne, Melbourne, Australia
Background: The 2015 Child and Adolescent Mental Health and Wellbeing Study demonstrated that 1 in 10 teenagers reported previous self-harm with twice as many females to males (Lawrence et al., 2015). Self-harm refers to deliberately hurting or injuring oneself without intent to suicide and is often done secretly. There are a range of aetiological theories to explain this phenomenon, and a variety of management approaches exist.
Objectives: This session aims to explore the issue of self-harm in adolescents and a tailored approach to management.
Methods: A brief literature search was completed to identify relevant information pertaining to this topic.
Findings: Self-harm among adolescents is often completed to regulate a distressing psychological experience and is less likely to harbour true suicidal intent. Self-harm behaviours commonly have high repetition rates, which need to be minimized due to adolescents’ poor understanding of the varying degrees of lethality in self-harm behaviours. Psychotropics and other pharmacological interventions are not advised; rather, targeted psychological interventions with multidisciplinary involvement should be prioritized following a thorough assessment of the patient.
Conclusions: Due to the multifactorial nature of self-harm, the impact of risk factors at both individual and population levels need to be considered. Public awareness of depression and self-harm behaviour, especially in vulnerable patients, needs to be enhanced to diminish the stigma that at-risk adolescents face.
Reference
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.
A Curious Case of Gut Post-Traumatic Stress Disorder
T Ewais1,2,3, M Mortimore1,2
1Mater Health, Brisbane, Australia
2University of Queensland, Brisbane, Australia
3Griffith University, Gold Coast, Australia
Background: Visceral gut hypersensitivity refers to increased pain sensitivity in response to gastrointestinal sensory stimulus in patients with organic disease and those without any identifiable structural or biochemical abnormality (Cervero, 2012; Farmer and Aziz, 2014; Mayer and Bushnell, 2009; Sikandar and Dickenson, 2012). Although gastrointestinal visceral pain has been recognized as a major cause of impaired health-related quality of life and burgeoning healthcare costs, the research on the effective treatment pathways is inconclusive (Farmer and Aziz, 2013).
Objectives: This session aims to present an evidence-based overview illustrating the diagnostic and treatment challenges of gastrointestinal visceral hypersensitivity syndrome. We use the findings from a literature review and a complex case discussion to inform future treatment and research directions.
Methods: Narrative review of the literature on gastrointestinal visceral pain syndrome, its relationship with mental health co-morbidities and evidence-based treatments. We present a 27-year-old woman with an 8-year history of severe visceral sensitivity, gut dysmotility, post-traumatic stress disorder and eating disorder following a motor vehicle accident with seat belt injury to the bowels. We employ case-based learning to illustrate treatment opportunities and the role of integrated care.
Findings: We found that, although significant advances have been achieved in understanding of the underlying mechanisms of visceral hypersensitivity, translation into effective treatments and improved health outcomes remain elusive. Moreover, an overemphasis on separating biological from psychosocial causes and treatments can result in fragmentation of care and negative patient outcomes.
Conclusions: Visceral gut hypersensitivity is an important area of unmet need. Our findings outline current understanding of its underlying causes and inform the development of evidence-based treatments and provision of integrated care for this complex condition.
References
Cervero F and Cervero F (2012) Understanding Pain: Exploring the Perception of Pain. ProQuest, editor: Cambridge, Mass.: MIT Press.
Farmer AD and Aziz Q (2013) Gut pain and visceral hypersensitivity. British Journal of Pain 7(1): 39–47.
Farmer AD and Aziz Q (2014) Mechanisms of visceral pain in health and functional gastrointestinal disorders. Scandinavian Journal of Pain 5(2): 51–60.
Mayer EA and Bushnell MC (2009) Functional pain syndromes: presentation and pathophysiology. In: International Association for the Study of Pain, editor: Seattle: IASP Press.
Sikandar HS and Dickenson HA (2012) Visceral pain: the ins and outs, the ups and downs. Current Opinion in Supportive and Palliative Care 6(1): 17–26.
Recognition and Management of Paediatric Delirium in a Children’s Hospital Setting
F Ng
Queensland Children’s Hospital, Brisbane, Australia
Background: Delirium is a severe neuropsychiatric syndrome of rapid onset, precipitated by multiple aetiologies (Jones et al., 1992; Traube et al., 2014). Delirium is associated with significant morbidity with a mortality rate as high as 26% but can be difficult to identify in children (Hatherill, 2010). There is limited literature on the recognition and management of delirium in children. National guidelines have been amended to include hospital-wide management of acute mental state and general wards require clear pathways of identification and management of delirium.
Objectives: This session aims to:
provide an updated review of the available literature on recognition and management of delirium in hospitalized children;
identify screening tools and management pathways used in paediatric hospitals; and
develop guidelines for the assessment and management of delirium in the Queensland Children’s Hospital.
Methods: A narrative review approach is used to examine the literature produced in the last 10 years on recognition of paediatric delirium in hospital settings, the tools used to screen for delirium and management pathways accessed by hospital staff.
Findings:
Outside of the paediatric intensive care unit, the local state-wide Queensland Children’s Hospital did not yet have a hospital-wide protocol for recognizing and managing children with delirium.
There are numerous assessment tools and no local consensus as to which assessment tools should be prioritized in the case of suspected delirium.
Conclusions: An assessment and management pathway is proposed. Increasing the early recognition of delirium and having a clear pathway for managing delirium in a hospital setting will be useful in preventing unnecessary investigations, prolonged patient and staff anxiety, and hospital costs.
References
Hatherill S (2010) Delirium among children and adolescents in an urban sub-Saharan African setting. Journal of Psychosomatic Research 69(2): 187–192.
Jones SM, et al. (1992) Behavioral changes in pediatric intensive care units. The American Journal of Diseases of Children 146(3): 375–379.
Traube C, et al. (2014) Cornell assessment of pediatric delirium: a valid, rapid, observational tool for screening delirium in the PICU. Critical Care Medicine 42(3): 656–663.
A Forgotten Shell Shock Doctor: Aldren Turner
S Macleod
Canterbury District Health Board, Canterbury, New Zealand
Health Sciences Department, The University of Canterbury, Christchurch, New Zealand
Background: In early 1915, William Aldren Turner (1864–1945), neurologist at King’s College Hospital, was posted to France for 3 months to visit base hospitals and the War front and to report on the emerging condition known then by its lay term, ‘shell shock’. His published report delineated cases of exhaustion and those attributable to ‘shock’. These included organically induced transient stupor (concussion) and spinal shock. He also considered the impact of psychological ‘shock’ causing functional states (deaf-mutism) and ‘post-traumatic emotional states’. In a 1918 publication, he conceptualized shell shock as a consequence of an initiating stressor event ‘fixed’ by subsequent psychosocial influence, particularly the soldier’s conflict between fear and duty. He stressed the importance of interference with consciousness as a trigger. This could be organic (commotional), phylogenetic (fear) or psychological (horror). He recognized the fluidity of these symptoms, and the latency to onset.
Objectives: This session aims to present a consideration as to whether post-traumatic stress disorder (PTSD)-like states were recognized in World War I.
Methods: A re-consideration of this medical literature on shell shock was undertaken.
Findings: Turner was unusual among the British doctors for he recognized the limitations of the prevailing dualist viewpoint and attempted to incorporate both organic and psychogenic aetiological influences. His publications described symptoms that today we would consider to be those of classical PTSD.
Conclusions: Contrary to the historical public opinion supportive of the psychogenicity of shell shock, clinicians such as Turner presented biopsychosocial conceptualizations.
‘What We Talk About When We Talk About Anxiety’: Psychiatry, Psychoanalysis, Philosophy and Theology
B Vialle
1,2
1Toowoomba Hospital, Toowoomba, Australia;
2University of Queensland Rural Clinical School, Toowoomba, Australia
Background: Clinical psychiatry largely approaches anxiety with a biomedical and categorical disposition. The emphasis is usually on the neurobiological underpinnings of hyperarousal, applying a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis category and commencing medication or referring elsewhere for cognitive behavioural therapy (CBT). However, other contrasting approaches to the concept of anxiety may also be informative, particularly when existential concerns are prominent.
Objectives: The aim of this presentation is to explore some conceptualizations of anxiety in psychoanalysis, philosophy and theology. It seeks to glean insights for clinical psychiatry from these other disciplines’ formulations of anxiety.
Methods: The presentation will include an examination of conceptualizations of anxiety from three sources: (i) Freud’s psychoanalytic theory; (ii) the existentialist philosophy of Søren Kierkegaard; and (iii) the existentialist theology of Paul Tillich. The presentation will consider how these contrasting conceptualizations may be relevant to psychiatry.
Findings: While psychiatrists are often familiar with Freudian psychoanalytic theory, other compelling conceptualizations of anxiety are also found in existentialist theology and philosophy. They may have value in psychotherapeutic exploration or in examining negative cognitions in CBT. These conceptualizations of anxiety may help illuminate patient experiences of crisis, adjustment disorder, and depression, as well anxiety disorders themselves.
Conclusions: Psychoanalysis, philosophy and theology offer some conceptualizations of anxiety that provide diversity and contrast to that of psychiatry. They may be particularly useful when the existential framework appears more applicable than the biomedical. Above all, their contributions can shed light on the anxieties, stresses and sadnesses of every patient – and indeed every person.
Imagined Ugliness of the Self: A Qualitative Study of Avoidant Personality Disorder
L Lampe1, G Malhi2, F Merritt3
1University of Newcastle, Newcastle, Australia
2University of Sydney, Sydney, Australia
3University of Notre Dame, Sydney, Australia
Background: Avoidant personality sisorder (AVPD) is defined as a fear of rejection in the presence of a longing for social relationships. It is characterized by prominent social anxiety, and the overlap in definition and symptomatology with social anxiety disorder (SAD) has raised questions about whether AVPD is a distinct condition. Relatively little research has focused specifically on AVPD.
Objectives: This presentation presents a study aiming to identify key features of AVPD from the lived experience of individuals with the condition.
Methods: Recruitment occurred from the community and psychiatric clinics. After brief telephone screening, consenting participants completed online questionnaires and attended for a structured diagnostic interview and semi-structured qualitative interview. Thematic analysis of qualitative interview transcripts was conducted using principally an inductive and phenomenological approach.
Findings: A common self-view as being deeply defective was a striking finding, far more severe and encompassing than the Diagnostic and Statistical Manual of Mental Disorders description of a sense of ‘inferiority’. The ‘defective self’ was associated with intense emotional pain as well as being a potent driver of fears of rejection. It seemed completely at odds with the warmth and apparent personal qualities of each participant. A parallel with dysmorphophobia, known commonly as ‘imagined ugliness syndrome’, is suggested.
Conclusions: This novel study adds considerably to the current depth of understanding of AVPD. An awareness of the possible depth and severity of the negative self-concept in AVPD is likely to be particularly valuable when providing psychological therapy to persons with the condition.
Unbreakable Threads: The True Story of an Australian Mother, A Refugee Boy and What Family Really Means
E Adams
Locum Psychiatrist
Background: When Dr Emma Adams witnessed the conditions for asylum seekers in detention in Darwin first-hand, a situation of mothers and children trapped in utter despair, she made up her mind to do something. This is where she meets Abdul, an unaccompanied Hazara boy and she decides to challenge the government and immigration minister by offering to take him and his brother into her family.
Objectives: This session aims to bear witness to and show how recent immigration policies have affected the mental health of asylum seekers and to change the narratives about asylum seekers in our wider community.
Methods: Dr Adams will describe the themes of her memoir, Unbreakable Threads: The true story of an Australian mother, a refugee boy and the real meaning of family, published in August 2018 by Allen and Unwin.
Apart from asylum seeker themes, Dr Adams, from her viewpoint as a psychiatrist and a Wiradjuri woman, describes a much bigger picture regarding issues of national identity, connections to country and a community’s trauma.
Findings: There is more to connect us than we recognize. In these dark days of governmental policies causing ongoing harm, as psychiatrists we can advocate in many ways.
Conclusions: Dr Adam’s story is one of hope, casting a light to the darkness surrounding Australia’s recent treatment and demonization of refugees.
The Clinical Utility of Brain Imaging (Computed Tomography and Magnetic Resonance Imaging) in First Episode Psychosis: A Systematic Review
M Forbes1, D Stefler2, J Trudel3, D Velakoulis1, S Stuckey4, H Eyre5, M Boyd6, S Kisely6
1Department of Psychiatry, University of Melbourne, Melbourne, Australia
2Department of Epidemiology and Public Health, University College London, London, UK
3Department of Psychiatry, University of Sherbrooke, Sherbrooke, Canada
4Department of Imaging, Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
5Texas Medical Centre, Houston, USA
6Department of Psychiatry, University of Queensland, Brisbane, Australia
Background: Australian and USA guidelines recommend routine brain imaging, either computed tomography (CT) or magnetic resonance imaging (MRI), to exclude structural lesions in presentations for first-episode psychosis.
Objectives: This review examines the evidence for the appropriateness and clinical utility of using CT or MRI to exclude structural lesions in presentations of first-episode psychosis.
Methods: A systematic review of studies reporting diagnostic outcomes of screening with CT or MRI in patients with psychosis.
Findings: There were 16 suitable studies published between 1988 and 2017 with the majority examining the outcomes of screening with CT. Most were observational studies with retrospective design. The majority found that while structural abnormalities were a common finding, these findings rarely required clinical intervention and were very rarely the cause of the psychotic symptoms. Only 2 of the 16 studies concluded that brain imaging should be routinely ordered in first-episode psychosis.
Conclusions: There is insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment. National guidelines should reflect evidence-based data.
Hotspots of Complaint Risk Among Mental Health Practitioners: A Retrospective Cohort Study of Complaints About Psychiatrists and Psychologists in Australia
B Veness1, M Bismark2
1Alfred Health, Melbourne, Australia
2Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
Background: Learning from complaints offers a pathway to improved patient care.
Objectives: This session aims to explore complaint risk among Australian mental health practitioners.
Methods: Using national data from Australian health regulators for 2011 to 2016, we compared complaints about mental health practitioners (psychiatrists and psychologists) with complaints about physical health practitioners (physicians, optometrists, physiotherapists, osteopaths and chiropractors). We described the frequency, source and nature of complaints. We calculated incidence rate ratios (IRRs) to identify hotspots of risk. Finally, we used a multivariate regression model to identify predictors of complaints about mental health practitioners.
Findings: Mental health practitioners had a complaint rate that was more than twice that of physical health practitioners. Risk of complaints was especially high in relation to reports (psychiatrists vs. physicians, IRR = 9.0; psychologists vs. other allied health practitioners, IRR = 10.9), records (psychiatrists, IRR = 5.6; psychologists, IRR = 4.7), confidentiality (psychiatrists, IRR = 5.0; psychologists, IRR = 7.9), interpersonal behaviour (psychiatrists, IRR = 3.2; psychologists, IRR = 3.6) and sexual boundary breaches (psychiatrists, IRR = 3.0; psychologists, IRR = 2.6). Among mental health practitioners, males (psychiatrists, IRR = 1.6; psychologists, IRR = 1.9) and older practitioners (65 years and older compared with 36-to-45 years: psychiatrists, IRR = 2.4; psychologists, IRR = 1.8) were at increased risk of complaints.
Conclusions: Our findings suggest a greater emphasis is needed on professional ethics and written communication skills in both practitioner training and ongoing professional development. They also indicate a need to better-support the mental health of mental health practitioners themselves and to ensure the fitness to practise of mental health practitioners as they age.
In the Shadow of Osheroff: Patient’s Right to Effective Treatment in Trauma-Informed Care
G Halasz
Monash University, Melbourne, Australia
Background: The case of Osheroff v. Chestnut Lodge generated much controversy in legal, ethical, psychiatric and lay circles (Klerman, 1990). In the aftermath, intense debates proposed the ‘right of the patient to effective treatment’. I suggested that children have a right to ‘empathic listening’ (Halasz, 1996), a position enshrined by Bloch and Green (2006) who argued for a new ethical framework for psychiatry as ‘a willingness to empathize with the feelings of the anguished parties and the effort to imagine what each of them is experiencing, part of the virtuous process of contributing to a climate of trust’ (p. 11).
Objectives: This session aims to introduce the clinical ‘nuts and bolts’, principles, of treatment-informed care (TIC) in the doctor–patient transference relationship in traumatic situations, beyond empathy, where the doctor is cast into four possible roles: victim, perpetrator, witness or rescuer.
Methods: After nearly 30 years, the Shadow of Osheroff case demands we revisit the construct of ‘vicarious trauma’ (Klerman, 1990) to deliver ‘effective treatment’ in today’s TIC culture.
Findings: I conclude the doctor’s responsibility – and unavoidable conflict of duality – includes serving the interest of both the patient’s needs alongside the doctor’s self-care.
Conclusions: This need to revisit and to revise the doctor–patient dynamics in TIC arises as a natural consequence of our deeper understanding of the bidirectional nature of ‘relational trauma’. Doctors who neglect or fail to adopt new ‘self-care’ attitudes risk increasing iatrogenic pathologizing of our patients.
References
Bloch S and Green SA (2006) An ethical framework for psychiatry. Britain Journal of Psychiatry 188: 7–12 (p. 11).
Halasz G (1996) The rights of the child in psychotherapy. American Journal of Psychotherapy 50(3): 285–297.
Klerman GL (1990) The psychiatric patient’s right to effective treatment: implications of Osheroff v. Chestnut Lodge. American Journal of Psychiatry 147(4): 409–418.
The Inflammasomes Are Linked to Both Depression and Coronary Artery Disease in Vietnam Veterans
W Akosile1,3, J Voisey2,3, B Lawford2, D Colquhoun3, R McD Young1,3, D Mehta1
1School of Psychology and Counselling, Faculty of Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Australia
2School of Biomedical Sciences, Faculty of Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Australia
3Gallipoli Medical Research Institute, Greenslopes Private Hospital, Greenslopes, Australia
Background: Previous research has shown that post-traumatic stress disorder (PTSD) is associated with excess inflammation. Several studies have shown an elevation of both pro- and anti-inflammatory cytokines in PTSD. Studies have also shown that individuals with PTSD are at higher risk of developing coronary artery disease. The role of innate immunity and nuclear factor NF-κB-mediated inflammation in PTSD and its increased association with cardiovascular disease is yet to be fully elucidated. A polymorphism in the Nucleotide-Binding Oligomerization Domain, Leucine Rich Repeat and Pyrin Domain Containing 12 (NLRP12) is associated with PTSD and its co-morbidities.
Objectives: The aim of this session is to present a study to identify the role of the inflammasome NLRP12 in depression and coronary artery disease using genetic data.
Methods: In a cohort of trauma-exposed Vietnam War veterans (n = 299; 159 cases, 140 controls) NLRP12 polymorphisms were associated with depression and coronary calcium scores.
Results: The NLRP12 polymorphism, rs34436714, was associated with a higher Depression and Anxiety Stress Scale (DASS) 21 Score for depression (p = 0.037). NLRP12 polymorphisms rs34971363 (CG) and rs6509825 (CT) (p = 0.022 and p = 0.020) were associated with raised coronary calcium score.
Conclusions: To our knowledge, this is the first time rs34436714 has been investigated in PTSD identifying the AC as a risk genotype for depression in Caucasian cohorts. It is also the first time the rs34971363 (CG) and rs6509825 (CT) genotype have been associated with raised coronary calcium score. Further research is needed to replicate our results in larger, equally well-characterized cohorts.
Reward-Related Attentional Capture Is Associated With Severity of Obsessive–Compulsive Symptoms
L Albertella1, L Fontenelle1, ME Le Pelley2, S Chamberlain1,3, M Yucel1
1Brain and Mental Health Research Hub, Monash University, Australia
2School of Psychology, UNSW, Australia
3Department of Psychiatry, University of Cambridge, UK
Background: Reward-related attentional capture has been linked to compulsive behaviours in addiction. Assuming a transdiagnostic approach to understanding compulsivity, reward-related attentional capture might be sensitive to compulsivity in general, including in obsessive–compulsive disorders (OCDs).
Objectives: This session aims to present a study examining whether reward-related attentional capture (by Pavlovian reward cues) is associated with severity of subclinical obsessive–compulsive symptoms.
Methods: Participants were 177 adults [mean age 35 years (standard deviation = 8.6), 42% female] who completed an online assessment, which included a visual search task to measure reward-related attentional capture and questionnaires to assess compulsive behaviours, impulsivity and psychological distress.
Findings: Reward-related attentional capture was associated with severity of OCD-related compulsive behaviours as well as impulsivity (negative urgency and sensation-seeking). Obsessive–compulsive symptoms were also associated with greater levels of impulsivity and compulsive Internet use.
Conclusions: The current findings have implications for understanding the mechanisms that underlie compulsive behaviours and highlight reward-related attentional capture as a promising cognitive risk marker for compulsivity.
Recovery From Anti-Nmdar Encephalitis: A Qualitative Content Analysis
G McKeon1,2,3, S Parker1,4, J Scott2,3,4
1Metro South Addiction and Mental Health Services, Brisbane, Australia
2The University of Queensland Centre for Clinical Research, Royal Brisbane and Women’s Hospital, Brisbane, Australia
3Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, The Park – Centre for Mental Health, Brisbane, Australia
4School of Public Health, Faculty of Medicine, University of Queensland, Herston, Australia
Background: Limited research has explored patient perceptions of recovery from anti-NMDAR encephalitis. This study sought to identify factors that patients viewed as influencing their recovery from this severe, immune-mediated neurological disorder.
Methods: Seven patients were interviewed about their experience of recovery from anti-NMDAR encephalitis. Measures of psychological distress, vocational activity, community participation and functional impairment were completed. Interviews were transcribed and subjected to qualitative content analysis.
Results: Facilitators of recovery included support system and treatment-related factors. Major barriers related to aspects of hospital-based care includes perceived psychiatric stigma, insufficient illness education and lifestyle disruptions to accommodate for ongoing treatment. Adverse physical, psychological and neurocognitive sequelae of anti-NMDAR encephalitis that impacted upon functioning were described. Methods of coping with these issues were also outlined, with most patients (71–85%) describing strategies to manage neurocognitive deficits, fatigue and anxiety. Approaches to coping included metacognitive strategies, reduced demands, maintaining activity, and emotional regulation techniques.
Conclusions: Anti-NMDAR encephalitis presents a significant burden to patients, their families and health services. Physical, psychological and cognitive changes contribute to long-term disease morbidity. To optimize recovery, further attention must be directed towards illness education, reducing stigma and role disruption. Results highlight parallels between perceptions of recovery from anti-NMDAR encephalitis and other neuropsychiatric disorders. The established recovery principals for mental disorders could inform the development of effective interventions for anti-NMDAR encephalitis.
Psychiatry, Physiology and Mathematical Modelling: Critical Insights That Deserve to Be Incorporated Into Clinical Practice
B St George
Private Practice, Sydney, Australia
The realization that the current classification of psychiatric disorders does not ‘carve nature at the joints’ has led to the search for new ways of understanding the mechanisms of psychiatric disorder. The incorporation of mathematical modelling into research in psychiatric disorders has yielded fresh insights. This presentation looks at some of these insights in addiction, depression and psychosis and their added benefit to further individualize the assessment and management of people suffering these disorders.
Background: The transition from categorical diagnoses to a dimensional approach to symptomatology has led to a greater need to understand the neurobiological correlates of key cognitive mechanisms and how their malfunction results in various disorders. There are now mathematical models along with their physiological substrates that reveal the computational steps that guide learning and decision-making. It is very satisfying for psychiatrists to explain seemingly complex behavioural phenomena in terms of simpler underlying mechanisms that allow individualized management of the patient.
Objectives: This presentation describes how the combination of physiological and mathematical modelling insights increase our understanding of the underlying biological mechanisms of psychiatric disorders. Analysing the nature of the mathematical problem that the brain faces, the algorithms it uses to solve them and how the algorithms are implemented in the biology of the brain will be explored. Psychiatrists can better inform and improve our understanding of the nature and course of these disorders if we embrace the psychiatric, physiological and mathematical aspects concurrently.
Methods: Examples will be given in which physiological and mathematical models are generated that reflect learning and decision-making processes across different categories of illness and thus provide a dimensional approach to assessment and treatment.
Findings: The quality of care provided by clinicians for the person with psychiatric disorders can be improved through a better understanding of the underlying physiology and mathematical modelling, and inform the choice and targets of treatment.
Conclusions: It is hoped that broadening our aetiological view to encompass mathematical modelling encourages psychiatrists to review the ways in which the person with a psychiatric disorder is characterized and invest more in understanding the advances in the mathematical and neurobiological mechanisms and the opportunities to increase the effectiveness of our interventions.
‘Right Now, I’m Not That Desperate’: Young Womens’ Perspectives of Egg Freezing
L Egan1, B Haire2, N Stephenson1
1University of New South Wales, Sydney, Australia
2The Kirby Institute, Sydney, Australia
Background: Following the development of a more effective ‘snap-freezing’ technique, fertility clinics began offering oocyte cryopreservation (OC) to women who want to preserve their fertility for an increasingly diverse range of reasons. The normative use of OC by women undergoing chemotherapy was extended to use in other contexts, giving rise to the dichotomized idea of women who freeze their eggs as either ‘medical’ or ‘social’ freezers. Apple and Facebook’s recent decision to include OC as part of their employee benefits packages heralded a wave of bioethical concerns about whether ‘social freezing’ is empowering for women, or renders them vulnerable to exploitation by corporations.
Objectives: The aim of this presentation is to explore how these young women perceive OC, and how they see themselves using it in the future.
Methods: This is a qualitative study that explored the issue of OC in a population of young, educated women who might be targeted to use it.
Findings: This study found that the women in the study did not use the medical–social binary prevalent in bioethics to define their potential use of OC. Their conjectured use of OC was simply based on whether there was any ‘threat to normative fertility’.
Conclusions: Without the presence of a threat to normative fertility, these women had no desire to use OC – offering an explanation as to why young women at the medically ideal age to freeze their eggs are currently unwilling to do so. Although the women did not hope they would have to freeze their eggs, these women were glad the option was there as a ‘back-up plan’.
Culturally Sensitive Practice in Child and Family Mental Health
S Basu1, M Konidaris2, M Chandradasa3, P Kasiannan2, V Raykar4
1Monash Health, Monash University, Melbourne, Australia
2Monash University, Melbourne, Australia
3Latrobe Regional Hospital, Monash University, Traralgon, Australia
4Goulburn Valley Health Services, Melbourne University, Shepparton, Australia
Background: Children from culturally and linguistically diverse (CALD) backgrounds have a higher probability of mental health difficulties due to complex psychosocial factors (Bhugra, 2004). However, research in this area is sparse (Karnik and Dogra, 2010).
Objectives: This presentation will aim to address the need for considering cultural factors as key points in comprehending the difficulties young persons from CALD backgrounds may present with. It will aim to address clinical and conceptual areas important in developing skills in culturally sensitive practice and dealing with children and families presenting with mental health issues. Issues of migration and mental health of children (Pumariega et al., 2005), biracial identity, bilingualism (Toppelberg and Collins, 2010), mental health of Indigenous children, possibility of overdiagnosis of severe mental illness including autism spectrum disorder and parent–infant mental health in the CALD group will be explored. The challenges of a culturally different clinician will also be discussed.
Methods: Topics such as cultural humility, cultural formulation, language culture and adaptation, cultural challenges to diagnosis and treatment and immigration paradox will be covered in didactic lecture. Case examples will be used to workshop on key issues.
Findings: The role of culture and its impact on the understanding the predicament of the child is often neglected in mental health services (Jellinek et al., 2009). This can lead to diagnostic dilemmas and missed opportunities in understanding the children and their families.
Conclusions: Mental health issues of alienated cultural minorities can have a devastating impact on families and the broader communities and hence there needs to be more robust understanding, training and research towards early identification and interventions for this group (Basu and Issacs, 2018).
References
Basu S and Issacs A (2018) Profile of transcultural patients in a regional Child and Adolescent Mental Health Service in Gippsland, Australia: the need for a multidimensional understanding of the complexities. International Journal of Culture and Psychiatry (in press).
Bhugra D (2004) Migration and mental health. Acta Psychiatrica Scandinavica 109(4): 243–258.
Jellinek MS, Henderson SW, Pumariega AJ, et al. (2009) Cultural competence in child psychiatric practice. Journal of the American Academy of Child and Adolescent Psychiatry 48(4): 362–366.
Karnik NS and Dogra N (2010) The cultural sensibility model: a process-oriented approach for children and adolescents. Child and Adolescent Psychiatric Clinics 19(4): 719–737.
Pumariega AJ, Rothe E and Pumariega JB (2005) Mental health of immigrants and refugees. Community Mental Health Journal 41(5): 581–597.
Toppelberg CO and Collins BA (2010) Language, culture, and adaptation in immigrant children. Child and Adolescent Psychiatric Clinics 19(4): 697–717.
The Importance of Oral Health and How Psychiatrists Can Help
S Kisely1, N Cockburn2, A Pradhan2, M-W Taing3, P Ford2
1School of Medicine, University of Queensland, Brisbane, Australia
2School of Dentistry, University of Queensland, Brisbane, Australia
3School of Pharmacy, University of Queensland, Brisbane, Australia
Background: People with mental illness have increased physical co-morbidity. There are fewer data on dental disease, especially tooth decay, in spite of risk factors in this population, including psychotropic-induced dry mouth (xerostomia). Importantly, poor oral health predisposes to chronic physical diseases, such as myocardial infarction, stroke and diabetes.
Objectives: We highlight the importance of considering oral health in psychiatric management, including the side effects of psychotropics.
Methods: We systematically reviewed the online Monthly Index of Medical Specialties (eMIMs) database for oral side effects of all antidepressant, antipsychotic, anticonvulsant and anxiolytic medications. This was supplemented by a search of Meyler’s Side Effect of Drugs Encyclopaedia.
Results: Fifty-seven drugs were identified: 23 antidepressants, 22 antipsychotics or mood stabilizers and 12 anxiolytics. Of the 28 identified symptoms, xerostomia (88%) was the most common among all medication classes. Other common adverse effects included abnormal taste or dysguesia (57%) for antidepressants and tardive dyskinesia (83%) for antipsychotic medications.
Conclusions: The increased focus on the physical health of psychiatric patients should encompass oral health. Although xerostomia is the most common adverse effect of psychotropic drugs, we identified additional side effects, including dysguesia, from antidepressants and tardive dyskinesia from antipsychotics. Possible interventions include oral health assessment with standard checklists that can be completed by non-dental personnel, help with oral hygiene, management of iatrogenic dry mouth (e.g. artificial saliva) and early dental referral. Clinicians should also consider the oral consequences of psychotropic medication when prescribing. This could mean choosing agomelatine or certain atypical antipsychotics.
When Psyche Meets Thanatos
K Myhill
Southern Adelaide Palliative Service, Adelaide, Australia
Background: The contribution of psychiatrists to the care of the dying has a rich legacy and is characterized by significant contributions to theoretical concepts, research initiatives and clinical practice.
For individuals who are dealing with life-limiting illness and end-of-life issues, many factors may contribute to their overall perception of distress, suffering and quality of life. Hence, there is a need for impeccable assessment to tailor management and offer intervention strategies appropriate to individual needs. Consequently, the psychiatrist – working within the biopsychosociocultural and spiritual framework – has much to consider.
Objectives: This presentation will explore the practical considerations and numerous challenges that often arise when the psychiatrist is confronted by requests for assessment of individuals who are experiencing distress and suffering in association with life-limiting illness and who may express a wish to hasten death or request withdrawal of treatment.
Methods: Through case presentations and supported by literature, the audience will be introduced to concepts and frameworks that underpin palliative care and the interface with psychiatry – both of which will provide a foundation for the exploration of diagnostic dilemmas, management conundrums and ethical challenges that are often encountered in clinical practice.
Conclusions: This presentation will highlight the important role of the psychiatrist in the provision of holistic assessment, comprehensive understanding of the individual and the application of combined management approaches in the provision of quality care at the end of life and compassionate care of the dying.
Conversion Disorder: Dsm-5 and the Challenges For Psychiatrists
S Macleod
Canterbury District Health Board and University of Canterbury, Christchurch, New Zealand
Background: The aetiology, diagnosis and management of Conversion Disorders remain uncertain and speculative.
Objectives: The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria for Conversion Disorders (Functional Neurologic Symptom Disorder) are considered from the psychiatrist’s perspective.
Methods: The DSM-5 criteria are reviewed.
Findings: The DSM-5 confines conversion to pseudoneurological conditions, reintroduces the term ‘functional’, bases the diagnosis on meticulous (but contentious) positive neurological signs and investigations and discounts historical psychogenic influences on aetiology. Dissociative conditions remain a separate diagnosis. Freud has been relegated and Charcot again promoted.
Conclusions: Psychiatry has been excluded from the diagnostic process. Is neurology up to the diagnostic task and possess the crucial (psychological) clinical skills to therapeutically manage acute presentations? Will our only clinical role be in managing chronic cases in conjunction with physiotherapy and occupational therapy?
Reduction in Bed Days Utilized Following Development of Intensive Care Community Teams Following A Standardized Model of Care
A Tait
North Metropolitan Health Service – Adult Mental Health Service, Dalkeith, Australia
Background: The Intensive Clinical Outreach Team (ICOT) consists of four teams covering different catchment areas in Perth Metro (WA) following a standardized Pathway to Care based on the principles of the Assertive Community Team (ACT) model but, with limited staff, falling significantly short of ‘fidelity to the model’.
Methods: Our study documents the clinical impact of the initiation of ICOT teams in the North Metropolitan area of Perth, WA, comparing 2 years of clinical resource utilization before and after ICOT initiation.
Findings: One-hundred ninety individuals were treated in the ICOT cohort with most (81.6%) carrying a diagnosis of schizophrenia, schizotypal and delusional disorders. Inpatient Bed Days use was calculated for the 2 years prior to admission to ICOT and for 2 years after. There was a significant increase in the rate of mental health admissions in the 2 years prior to ICOT initiation (with a more pronounced increase in the 12 months before initiation) with a corresponding reduction after ICOT initiation. For inpatient mental health admissions, rates decreased from 54.1 inpatient days per patient year to 35.2 days per patient year, a reduction of 18.9 days per patient year. Overall, there was no significant reduction in emergency department (ED) presentation rates for the ICOT cohort before and after initiation into the ICOT team. After-admission to the ICOT community increased from 62.9 h before ICOT initiation to 92.7 hours after ICOT initiation.
The cost of care: a $4,483,392 reduction in inpatient cost of care over the course of a single year over the entire ICOT cohort was identified. There was also a small reduction realized on the cost of care for the ED, but as the rate change was not statistically significant, we excluded this from overall calculations. This was partially offset by an increase in annual cost of $892,570 for increased provisioning of ICOT in the community.
Conclusions: Overall, there was a statistically significant and sustained reduction in inpatient admissions after the enrolment into ICOT, confirming findings presented in some non-randomized studies into the effectiveness of ACT-like services but not in randomized controlled trials.
What Have We Learnt From More Than 20 Years of Clinically Operated Community-Based Residential Rehabilitation For Severe Mental Illness in Australia
S Parker1,2, G Hopkins2, D Siskind1,2, M Harris1, G McKeon2, F Dark1,2
1Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia
2Metro South Addiction and Mental Health Services, Brisbane, Australia
Background: Community-based residential rehabilitation services, such as Community Care Units, emerged in the context of de-institutionalization. These services are resource intensive, and there has been considerable expansion in capacity over recent years.
Objectives: This session will describe a systematic review aimed to clarify the types of service models available in Australia, the consumers who access them, and the outcomes achieved.
Methods: The review was completed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Searches were undertaken in academic databases (1995–2018) and grey literature sources. The analytic process generated: (i) a service typology; (ii) synthesis of consumer characteristics; and (iii) a critical narrative review of qualitative and quantitative research.
Findings: Thirty-three records were included in the analysis. Two service types were defined: (i) community-based residential care (C-BRC); and (ii) the more recent (and currently dominant) transitional residential rehabilitation (TRR) approach. Distinguishing features were described using a domain-based typology, comprising staffing focus, built environment, tenure, philosophy and treatment focus. TRR consumers were more likely than C-BRC consumers to be male, referred from the community, and voluntary. Qualitative studies revealed consumers reflected favourably on both service types. Quantitative studies indicated C-BRC services achieved their original aim of supporting people in long-term inpatient care to live in the community. There is an absence of methodologically robust quantitative studies considering consumer outcomes for TRR services.
Conclusions: Although there is qualitative evidence to suggest consumers reflect favourably on these services, there is a limited quantitative evidence base in relation to the currently dominant service type.
What Do Consumers Want From Residential Mental Health Rehabilitation: A Qualitative Analysis
S Parker1,2, F Dark1,2, C Meurk2
1Metro South Addiction and Mental Health Services, Brisbane, Australia
2School of Public Health, Faculty of Medicine, University of Queensland, Herston, Australia
Background: Residential mental health rehabilitation is a high-cost intensive service model that has become increasingly available in Australia over recent years. Most consumers who access these services have a diagnosis of schizophrenia or a related psychotic disorder. One of the known problems with rehabilitation services is the issue of engagement. Listening to what consumers understand and expect of these services may provide a pathway to improving their engagement with relevant rehabilitation support.
Objectives: This session aims to describe a study that explored consumer understanding and expectations on commencement at three Community Care Units (CCUs) – a model of clinically operated community-based residential rehabilitation support available in Queensland, Australia.
Methods: Semi-structured interviews were completed with 24 consumers around the time of their commencement at a CCU. A pragmatic approach to grounded theory guided the analysis. Respondent verification was used to enhance the trustworthiness and relevance of the findings.
Results: Consumer’s understanding of the CCUs generally aligned with the model of service; however, the most frequently reported motivation for engagement related to accommodation needs rather than the availability of rehabilitation support. Consumers consistently expressed the hope that the CCU would offer an improvement on previous experiences of care. The nature of support they hoped to receive aligned with known principles of recovery-oriented mental healthcare.
Conclusions: Consumers have positive expectations of mental health rehabilitation at the time of commencement. However, the availability of rehabilitation support was not the primary driver for engagement. The findings also suggest that mental health services generally continue to struggle to actualize recovery-oriented care.
Effects of High Intensity Interval Training in People With Severe Mental Illness: A Systematic Review of Intervention Studies – Considering Diverse Approaches to Improving Mental and Physical Health Outcomes
N Korman1,2, JJ Chapman1,3, J Firth4, M Armour4, S Suetani1,2, S Rosenbaum5, D Vancampfort6, B Stubbs7, D Siskind1,2
1Addiction and Mental Health Services, Metro South Health Services, Australia
2School of Medicine, University of Queensland, Brisbane, Australia
3Queensland Institute of Medical Research, Brisbane, Australia
4NICM, Western Sydney University, Australia
5School of Psychiatry, University of New South Wales, Australia
6KU Leuven, Department of Rehabilitation Sciences, Belgium
7Kings College London, Department of Psychological Medicine, UK
Background: Incomplete remission rates for traditional pharmacological and psychotherapeutic treatments have led to consideration of diverse strategies to improve health outcomes for people with severe mental illness (SMI). While there is evidence that exercise interventions improve mental and physical health of people with SMI, the optimal type and intensity of exercise interventions is unclear. High-intensity interval training (HIIT) has emerged as a promising intervention in other chronic disease populations. However, impact of this novel intervention on mental and physical health of people with SMI remains uncertain.
Objectives: This session aims to describe the purpose of a study to systematically review the literature regarding the feasibility, and mental and physical health outcomes of HIIT for people with SMI.
Methods: A literature search was conducted to identify journal articles published up to October 2018 that described intervention studies using HIIT to improve mental and/or physical health outcomes in adults (18–65 years) with SMI. Methodological quality was assessed using PEDRO, a quality assessment tool for exercise interventions.
Findings: Five unique articles were identified involving 195 participants. Preliminary findings revealed feasibility and tolerability, with improvements in total symptoms and mood. However, studies were heterogeneous, and quality of studies was poor, limiting conclusions.
Conclusions: Based on a small number of available studies, HIIT appears to be a feasible type of exercise intervention for people with SMI, and few safety concerns. However larger studies comparing HIIT to other types of exercise, designed with more robust methodology and conducted over a longer duration are required to understand the effect of HIIT as a therapy for people with SMI.
Prevalence of Eating Disorders in Migrants to Australia
SL Cheah1, P Hay2, E Jackson2
1University of Newcastle, Newcastle, Australia
2University of Western Sydney, Sydney, Australia
Background: There are limited data on the epidemiology of eating disorders (ED) in migrants. Recent research suggests that migrants are at lower risk of eating disorders (Mustelin et al., 2017); however, to our knowledge there have not been comparable studies exploring eating disorders in Australian migrant populations.
Objectives: This study aims to explore the prevalence of EDs in first-generation migrants to Australia in comparison with the Australian-born population. A secondary aim was to explore ED prevalence across migrants from different regions of origin (Europe, Asia, Americas, Oceania and Africa).
Methods: We conducted and pooled data from sequential cross-sectional population surveys in adults (aged older than 15 years) in 2015 and 2016 (n = 6052). Demographic data were collected and migration status was inferred based on a country of birth outside Australia. Questions asked regarding disordered eating were based on the Eating Disorders Examination.
Findings: The 3-month prevalence of any ED was found to be significantly lower in migrants born outside Australia (4.5%) in comparison to the Australian-born population (6.4%). In particular, migrants born in countries in Asia (4.0%) and Europe (4.5%) had a significantly lower prevalence of EDs.
Conclusions: First-generation immigrants to Australia may be at lower risk of eating disorders, in support of a ‘healthy immigrant effect’. However, further study is required.
Reference
Mustelin L, et al. (2017) Risk of eating disorders in immigrant populations. Acta Psychiatrica Scandinavica 136(2):156–165.
Investigation of Mental Health Literacy in Outpatients With Mental Illness and Their Carers
X Dan1, M Ying2, H Meilian3, X Zhichun4, R Li5, Z Sufen6
1ShenZhen Kangning Hospital, ShenZhen, China
2Zhongshan Third People’s Hospital, Zhongshan, China
3The Third People’s Hospital of North Guangdong, Shaoguan, China
4Jiangmen Third People’s Hospital, Jiangmen, China
5Guangzhou Huiai Hospital, Guangzhou, China
6The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
Background: Good mental health literacy in psychiatric patients and their carers may lead to better outcomes, although there are few investigations in this field conducted in China. There is a great need to conduct comprehensive research in mental health literacy to make interventions to improve health literacy.
Objectives: This session aims to investigate mental health literacy in psychiatric outpatients and their carers in China.
Methods: A cross-sectional survey designed by the authors was conducted in 2016, among 218 patients and 269 carers from the psychiatric outpatient department in six hospitals of Guangdong.
Results: Patients-26-items mental health literacy score was 26 ± 11.1 (0, 1, 2 score), the top 3 weakest skills were ‘access to available social resources’, ‘prevent relapse and detect the signs’ and ‘contact and support with peers’ (40.4%, 34.9%, 33.9%; patients scored none = 0). Carers-15-items mental health literacy score was 13.58 ± 6.42; the top three weakest skills were ‘contact and support with peers’, ‘access to available social resources’, ‘access medication knowledge’ (46.0%, 43.6% 34.3%; patients scored none = 0). About 80.7% of patients and 86.7% of carers showed their expertise consulation needs.
Conclusions: The level of health literacy in patients with mental illness and their carers is low, which indicates a greater demand for mental health literacy from nursing.
Does legislative change affect the use and duration of compulsory treatment orders?
R Vine1,2, H Tibble3, J Pirkis3, F Judd2,4, M Spittal3
1NorthWestern Mental Health, Parkville, Australia
2Department of Psychiatry, The University of Melbourne, Melbourne, Australia
3Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
4Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
Background: Victoria introduced reformed mental health legislation in 2014. The Act was based on a policy platform of recovery-oriented services, supported decision-making and minimization of the use and duration of compulsory orders.
Objectives: This session aims to compare service utilization and legal status after being on a community treatment order (CTO) under the Mental Health Act 1986 (MHA) with that under the Mental Health Act 2014.
Methods: We obtained data sets of persons who had been on a CTO for at least 3 months and their subsequent episodes over 2 years for the periods 2008–2010 (MHA 1986) and 201 –2016 (MHA 2014). The two sets were compared to assess the difference in use, duration and odds of having a further admission over two years.
Findings: Compared with the MHA 1986, under the MHA 2014 index CTO were shorter; there was a reduction in the mean number of CTO in the 2 years following the index discharge; a 51% reduction in days on an order; and a reduction in the number of subsequent orders for those whose order expired or was revoked by the psychiatrist. The number of orders that were varied to an inpatient order by the authorized psychiatrist was notably greater under the MHA 2014.
Conclusion: The reformed MHA has been successful in its intent to reduce the use and duration of compulsory orders. The apparent increase in return to inpatient orders raises questions regarding the intensity and effectiveness of community treatment and context of service delivery.
Are the Disability Costs Associated With Common Mental Health Disorders Sustainable, and What is the Role of Psychiatry?
K Dimarco
1,2
1Insych Consulting, Sydney, Australia
2Level 8 Practice, Sydney, Australia
Background: Mental illness is now the leading cause of work absence and long-term work incapacity in the developed world, most commonly anxiety and depression. In 2013, mental disorders surpassed musculoskeletal problems as the main cause of long-term work incapacity in Australia.
Objectives: This session aims to describe trends and the scope of economic costs of disability due to mental health conditions in Australia. To consider the role of psychiatrists in assessing and managing work absence and incapacity.
Methods: Data from different disability schemes will be examined, including workers’ compensation, disability support pension and life insurance.
The role of psychiatrists will be discussed, including treating psychiatrist work capacity assessments, potential challenges in the treatment frame if there is a disability scheme or other stakeholder involved, and ways to promote occupational recovery.
Findings: Costs of work incapacity due to common mental illness are increasing. Psychiatrists play an important role in assessing and managing work incapacity.
Conclusions: The growing direct and indirect economic costs of common mental health conditions are becoming an expensive scare for society.
Why Do Australians With Severe Mental Illness Die 20 Years Prematurely? Answers From A Retrospective Nation-Wide Cohort Study of Colorectal, Cervical and Prostate Cancer Screening
S Kisely1,2, K Tuesley3, S Jordan3, B Kendall1,2, D Siskind1,2
1School of Medicine, The University of Queensland, Brisbane, Australia
2Princess Alexandra Hospital, Brisbane, Australia
3Queensland Institute of Medical Research, Brisbane, Australia
Background: People with severe mental illness have similar cancer incidence, but higher mortality than the general population. Participation in cancer screening may be a contributing factor but existing studies are conflicting.
Objectives: We used de-identified data from a random 10% sample of people registered for Australia’s universal healthcare system to investigate the frequency of cancer screening (colorectal, prostate and cervical) among people with, and without, severe mental illness. There were three cohorts: those aged 50–69 years (n = 760,058); women aged 18–69 years (n = 918,140); and men aged 50–69 years (n = 380,238). We used Poisson Regression to estimate incidence rate ratios (IRR) and 95% confidence intervals (CIs) for the association between severe mental illness and rates of faecal occult blood testing, pap smears and prostate-specific antigen testing.
Findings: Having severe mental illness was associated with a 17% reduction in rates of pap smears (IRR = 0.83; 95% CI 0.82–0.84) and prostate-specific antigen testing (IRR = 0.83; 95% CI 0.81–0.85), compared to the general population. By contrast, incidence rates of faecal occult blood testing were only lower in people with severe mental illness among the participants who visited their general practitioner less than an average of five times per year (IRR = 0.83; 95% CI 0.73–0.94).
Conclusions: Our results suggest that differences in screening frequency may explain some of the mismatch between cancer incidence and mortality in people with severe mental illness and indicate that action is required to improve preventative screening in this very disadvantaged group.
Coping With Change: A Descriptive Study of Referral, Access and Care Pathways to a Child and Youth Mental Health Service
S Ghosh1,2, V Cullity1, S Rebgetz1, Sue Patterson3,4
1Child and Youth Mental Health Service, Metro North Hospital and Health Service, Brisbane, Australia
2School of Medicine, University of Queensland, Queensland, Australia
3Metro North Hospital and Health Service, Queensland, Australia
4Department of Applied Psychology, Griffith University, Queensland, Australia
Background: Approximately 14% of Australian children and adolescents experience mental health issues. Redcliffe–Caboolture Child and Youth Mental Health Services (RCCYMHS) serve evolving communities with varying socioeconomic characteristics. The projected population growth from 2011 to 2026 is expected to be 55% for Caboolture and 13% for Redcliffe.
This study, part of a quality improvement programme, aims to obtain a detailed contextualized understanding of the needs of this changing community, to ensure appropriate eligibility criteria and subsequent service delivery.
Objectives: This session aims to describe RCCYMHS referrals with reference to: (i) demographic and clinical characteristics including reasons for referral; (ii) pathways to referral; and (iii) responses and outcomes of referrals.
Methods: We conducted a retrospective review of 100 randomly selected referrals received over 2 months, involving collection and analysis of patient demographics, source, reasons and outcome of referrals, with emphasis on understanding the nature of referrals and identifying gaps in care provision.
Findings: The average number of ‘reasons for referral’ is 4 for consumers offered case management versus 2.89 for consumers not accepted for ongoing support. The most common reasons for referral in descending order of frequency are psychosocial issues, followed by suicidal ideation/self-harm, specific mental health issues, trauma, care-related issues, developmental issues, school-related issues and others. The most common referral sources for case-managed consumers were the emergency department, inpatient unit and a parent or guardian. A total of 29/100 initial referrals were re-referred within 12 months.
Conclusions: Consumers referred to RCCYMHS have complex needs and co-morbidities. Consumers presenting with significant risks are generally offered case management. Further review of referrals ‘not accepted’ will identify gaps in service provision to improve access to community care.
Optimizing Psychiatric After-Hours Duty: The Implementation and Impact of a Short Cycle After-Hours Roster
B Johnson1, G Bruxner1, S Patterson2,3
1Redcliffe-Caboolture Mental Health Service, Caboolture, Australia
2Metro North Mental Health, Herston, Australia
3The University of Queensland School of Dentistry, Herston, Australia
Background: Long hours and on-call have long been a part of practising medicine – psychiatry is no exception. While 24-h care is a necessity, increasing acknowledgement of the interlinked risks to doctors’ well-being and patients’ safety associated with fatigue obliges health services to reconsider practices and develop rosters that optimize safety without sacrificing performance.
Objectives: Within an outer-metropolitan mental health service, a new ‘short cycle’ after-hours roster (SCR) has been created in response to an identified need and to bring it in line with national guidelines (AMA, 2016). This session will present the project aims to describe the acceptability and sustainability of the SCR, and the impact upon those involved.
Methods: Evaluation of impact of after-hours rosters before and after implementation of the SCR using questionnaires administered to the affected registrars/Principal House Officers/Senior Medical Officers. Data describing perceived effects upon personal well-being, mood, social activities, education/training, lifestyle and absenteeism are being collected, along with general views about after-hours work.
Findings: Preliminary findings indicate largely negative effects of the current roster across multiple domains, with mixed views regarding specific preferences for number, length and frequency of shifts. Findings following implementation of the incoming roster will be presented at the Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) 2019 Congress.
Conclusions: Conclusions will be presented at the RANZCP 2019 Congress.
Reference
Australian Medical Association (2016) AMA National Code of Practice – Hours of work, shiftwork and rostering for hospital doctors. Available at: https://ama.com.au/system/tdf/documents/FINAL_NCP_%20Hours_of_work_2016.pdf?file=1&type=node&id=37826.
Neuropsychiatry Aspects in Space Travel
O Rodríguez
University of Melbourne, Melbourne, Australia
Background: Human space travel is associated with numerous stressors such as radiation, microgravity, isolation and confinement just to name a few.
Many scholars have published scientific articles describing the human biological, psychological and psychiatric changes associated with space flight. Understanding the neuropsychiatry aspects of human space missions is pivotal and crucial, given the complex interaction between the neuropsychological and psychiatric factors with biological, sociocultural factors in space’s unique and hostile environment can compromise space missions.
Objectives: This session describes a literature review that aims to raise awareness of neuropsychiatry risk in space travel, as well as identifying critical studies and research gaps.
Methods: A thorough literature review of the neuropsychiatry aspects of space travel on humans. The review was based on academic articles published over the last decade that focus on various biological, psychological and social–cultural dimensions of space travel on astronauts. The paper adopts Engel’s biopsychosocial model as the framework when explaining the neuropsychiatry aspects of space flight.
Findings and conclusions: A holistic approach of assessing an astronaut’s mental health is proposed using the biopsychosocial model.
Radiation, microgravity and immunological changes increase the neuropsychiatry risks in deep space exploration. One of the literature gaps identified is the lack of research around problems related to mood and psychotic disorders in deep space exploration. Further research is warranted in different areas to help understand and evaluate the neuroinflammatory responses that occur during a long-term mission and the adjustment reaction in short-term missions. This facilitates the formulation of protocols in addressing psychiatric emergencies in space travel.
Efficacy of Repetitive Transcranial Magnetic Stimulation As An Outpatient Procedure For Major Depressive Disorder: A Description of Clinical Outcomes in a Real-World, Decentralized, Multiclinic Australian Tms Service
T Cassidy1, PB Fitzgerald1,2,3
1TMS Australia, Sydney, Australia
2The Epworth Clinic, Melbourne, Australia
3Monash Alfred Psychiatry Research Centre, Melbourne, Australia
Background: Transcranial magnetic stimulation (TMS) is increasingly used in clinical practice worldwide for the treatment of depression, Unusually, most TMS programmes in Australia operate on an inpatient model due to the lack of an outpatient funding mechanism. However, outpatient TMS is gaining popularity although to our knowledgeno studies have explored naturalistic outcomes of repetitive (rTMS) treatment in Australia.
Objectives: This session aims to explore the real-world outcomes of rTMS treatment in Australia, across a multiple clinic environment where there is a need to maintain consistency of standards of practice.
Methods: Retrospective data were aggregated from patients diagnosed with major depressive disorder (MDD) who received TMS treatment at a TMS Australia clinic. A Clinician-rate Quick Inventory of Depressive Symptomatology (QIDS-C) was administered by TMS-trained psychologists to assess progress. The questionnaire was administered during initial assessment and at discharge.
Findings: The data of 130 patients were analyzed. A total of 118 patients (90.8%) completed 20 or more sessions and 79 patients (60.8%) received a full acute course of 30 sessions. The QIDS-C response rate was 55% (n = 71), and remission was 35% (n = 45). Partial response rate was 19% (n = 25). No statistically significant difference emerged when considering: site of application (left/10 Hz, right/1 Hz), funding source (private patient, veteran affairs or work cover) and clinic attended. Efficacy was positively correlated to the number of sessions attended. No major side effect was reported.
Conclusions: Results are similar to data available in the literature. Outpatient TMS is as effective and safe as inpatient and is a viable treatment option for MDD at a fraction of the cost.
Magnesium in Depression: The Evidence
S Thomas
Latrobe Regional Hospital, Traralgon, Australia
Background: Anecdotally, magnesium is used by many practitioners to aid sleep and in the treatment of mood disorders. Its level in diet is calculated, dietary advice is accordingly given, and often serum, plasma and red blood cell magnesium concentrations are measured. As the Australian Integrative Psychiatry Interest Group seeks to explore promising non-pharmacological therapies, and to better understand pathophysiology and the mechanisms of pharmacological therapies, there is a need for a review of what is known about the link between magnesium and depression.
Objectives: This session aims to categorize and summarize the literature on the relationship of magnesium with depression, to guide clinicians.
Methods: Medline was searched using the term ‘Depression [MeSH Major Topic] magnesium’ on 25 August 2018. The abstracts and papers were examined by the author in enough detail to allow categorization.
Conclusions: A total of 151 papers were returned by this search strategy. Of these, 64 were judged to contain pertinent information. Magnesium levels in serum, plasma or cerebrospinal fluid have no relationship with depressive symptoms. Low dietary magnesium is associated with depression. Five trials and case studies showed that supplemental magnesium assists with depressive symptoms, whereas 2 papers showed that such supplementation had no effect on depressive symptoms.
Transcultural Psychiatry – It’s Everyone’s Business
S Burton
1,2
1Queensland Transcultural Mental Health Centre, Brisbane, Australia
2World Wellness Health and Medical Clinic, Brisbane, Australia
Background: This rapid-fire talk is aimed to highlight to psychiatrists, psychiatric registrars and other clinicians present how the work of transcultural psychiatry is everyone’s business given what we know about culturally and linguistically diverse (CALD) populations and their needs.
Objectives: This session aims to outline the steps steps that clinicians can take in addressing healthcare disparities and optimizing the mental health of CALD clients. The outline will be structured in four parts: (i) he landscape (the cultural and linguistic diversity of Australia); (ii) what we know (mental health/ mental healthcare disparities in CALD populations in Australia); (iii) what we don’t know (difficulties in accurate understanding of needs of CALD population due to data gathering issues); and (iv) what we can do (practical and attitudinal shifts every clinician can make).
Mental Health Needs in a Metropolitan Aboriginal and Torres Strait Islander Health Service
B Clark1,2, N Gill1,2
1Gold Coast Health, Gold Coast, Australia
2School of Medicine, Griffith University, Gold Coast, Australia
Background: Aboriginal and Torres Strait Islanders have significantly higher mental health needs than other Australians; however, they have lower access to mental health services and professionals (Australian Institute of Health and Welfare, 2014). The World Health Organization has emphasized the need for primary care now more than ever and The Fifth National Mental Health and Suicide Prevention Plan has laid out priority areas to ensure a better mental health system for all Australians (Department of Health, Australian Government, 2017). The establishment of a psychiatry service within the local Aboriginal and Torres Strait Islander health service was implemented to support primary care and to allow better access to mental health services.
Objectives: This session aims to (i) describe the social demographics and clinical profile of patients referred to the psychiatry service provided at three Aboriginal and Torres Strait Islander health service metropolitan clinics over an 18-month period of service and (ii) identify the proportion of all registered patients who required any mental health referral over the same 18-month period.
Methods: Review of notes retrospectively to determine age, gender and diagnosis of patients seen and those who did not attend or cancelled. Audit of all mental health referrals generated within the practice software.
Findings: The findings will be presented at the RANZCP 2019 Congress.
Conclusions: Primary care is managing patients with complex mental healthcare needs and benefits from specialist support. The current model servicing these clinics is for one-off review; however, due to significant unmet need, a more intensive service needs to be considered. A high rate of non-attendances is a barrier that needs to be explored further.
References
Australian Institute of Health and Welfare (2014) Aboriginal and Torres Strait Islander Health Organizations, Online Services Report 2012–2013. Canberra: AIHW, Canberra.
Department of Health, Australian Government (2017) Fifth National Mental Health and Suicide Prevention Plan. Canberra.
Marriage As A Nostrum For Women With Schizophrenia: A Close Scrutiny
A Mulmule1, A Bansod2
1Dr Mulmule Hospital, Nanded, India
2Cairns Hospital, Cairns, Australia
Background: Marriage is a commonly prescribed nostrum in Indian culture for varied reasons, including mental illnesses. Schizophrenia, a disease common in the marriageable age group, thus has wide implications for the clients and also the treating teams, when clients enter marriages as a cultural norm.
Objectives: This session aims to (i) compare the marital characteristics and clinical features among married and single women with schizophrenia and (ii) study and compare the relation between illness severity and family functioning and familial interaction among married and single cases of schizophrenia.
Methods: Study site: Mental Health unit of a tertiary care hospital in central India. This analytical cross-sectional study has a patient and a comparison group selected by random sampling methods over 1.5 years (1 Dec 2012 to 31 May 2014), with due ethical approvals. The cases group was comprised of 40 clients who got married after the diagnosis of schizophrenia using the International Classification of Diseases, tenth revision (ICD-10) and fulfilled the inclusion criteria while the comparison group was 40 age matched single schizophrenia clients.
Instruments: Semi-structured pro forma to record demographics, clinical variables; brief psychiatric rating scale (BPRS) for illness severity; family assessment device and family interaction pattern scale to assess family functioning.
Findings: There was an increase in severity of illness after marriage with about 97.5% of women reporting exacerbation of illness and poor medication compliance post marriage. Cases with children had lesser separation rates with better marital adjustment. Familial interaction deteriorated with increasing severity of illness in either group.
Conclusions: Marriage should be a well-informed decision taken after careful consideration of the above factors and should not be prescribed as a nostrum.
Medicinal Cannabis Prescription For Psychiatry
B Jansen
1,2
1Cannabis Doctors Australia, Australia
2Healthy Not High, Australia
Background: Medicinal cannabis is here to stay, and it should be prescribed for a variety of psychiatric conditions, but there is still a misunderstanding of the role of psychiatry in the use of medicinal cannabis.
Objectives: This session aims to provide a tailored presentation on the medicinal cannabis prescription for psychiatry to cover the primary prescription and ways to counter the effects of black-market cannabis. Presentation of relevant psychiatric and neurological journal papers on medicinal cannabis will be included.
Methods: A presentation of >20 min.
Findings: My presentations thus far have been well received, and the overwhelming response is that doctors simply were not aware of the body of evidence available on medicinal cannabis.
Conclusions: I welcome conference attendees to learn what beneficial role medicinal cannabis can have in their clinical practice.
Physically Active One Way Or Another: North Queensland
J Seymour1, G Pratt2, J Petrucci3, L Griffiths4, S Patterson5 and J Chapman1,2
1Queensland Police–Citizens Youth Welfare Association, Cairns, Australia
2QIMR Berghofer Medical Research Institute, Brisbane, Australia
3Neami National, Cairns, Australia
4Mental Health and Alcohol Tobacco and Other Drugs Service, Cairns, Australia
5Metro North Mental Health Service, Brisbane, Australia
Background: Adults with mental illness are at higher risk of developing cardiovascular and metabolic conditions than the general population. Physical activity (PA) can improve physical and mental health of those living with a mental illness, and there is a need to evaluate the impact of community-based PA interventions.
Objectives: This session aims to compare the effectiveness of two interventions to promote adoption of PA in community-dwelling adults with a mental illness.
Methods: This is a naturalistic evaluation of two interventions delivered by Allied Health Professionals (AHPs) to promote PA: (i) weekly motivational discussions and self-monitoring using fitness trackers; and (ii) supervised gym-based exercise and gym membership. The interventions are delivered at Police–Citizens Youth Clubs (PCYC) Queensland in collaboration with non-government, public and Aboriginal and Islander Community Controlled Health Services. Participants are community-dwelling adults aged between 18 and 65 years currently accessing a mental health service. PA adoption was objectively measured using GENEActiv accelerometers at baseline and continuously during the 8-week intervention. Other outcomes include PA motivation assessed using the Behavioural Regulation in Exercise (BREQ-3), stages of change, and Kessler-6 scale of psychological distress. Physical health measures include blood pressure, waist circumference, height and functional capacity measured using the 6-min walk test.
Findings: Recruitment is ongoing. Preliminary results of changes in PA and motivation, and data from qualitative interviews, will be presented.
Conclusions: PA interventions delivered by AHPs in community settings are a desirable medium for engaging people with mental illness. Combining components of exercise supervision and motivational coaching into a single programme may improve adherence and PA adoption.
Are All Mentors Created Equal? A Pilot Project Evaluating the Effectiveness of Matching Psychiatrist Mentors With Royal Australian and New Zealand College of Psychiatrists Trainee Mentees
P Nadeswaran1, C Quinn-Watson2
1Cumberland Hospital, Sydney, Australia
2Lismore Base Hospital, Lismore, Australia
Background: The well-being of specialty trainees is a high-profile issue within medicine and in the Australian media. Mentoring provides medical trainees with an increased sense of professional well-being and work satisfaction. Despite these benefits, accessing a mentor has often been difficult in psychiatry training. Multiple membership groups have requested formal, organized mentoring as a means of supporting the personal and professional development of psychiatry trainees.
Objectives: This session aims to help initiate a formal mentoring programme to match NSW psychiatry trainee mentees with Fellows of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) mentors. Trainees would have the opportunity to experience increased levels of support for career and professional development, work satisfaction and professional well-being. Mentors would be provided with the opportunity to experience increased feelings of competence, clinical confidence and personal satisfaction in helping a junior colleague.
Methods: Surveys of mentees (n = 16) and mentors (n = 16) were conducted at four time-points over a 6-month period. Simple descriptive analysis was undertaken for quantitative data while inductive content analysis was undertaken to describe moments of congruence and divergence in the qualitative data.
Findings: Mentoring was valued by mentees for the non-judgemental space it provided for support of the supervisor–supervisee relationship. The main areas of focus were career development, work–life balance and clinical work. College-mandated assessments were rarely the focus in the partnerships.
Conclusions: Overall satisfaction with a matched mentoring programme between psychiatrists and trainees is high. Based on the finding (after 2 months) that 95% of respondents would recommend future funding for a similar programme, we believe that the RANZCP should consider long-term financial support of a matched mentoring programme for psychiatry trainees.
Psychiatry Trainee’s Experiences Following Patient Suicide Under Their Care
M Ng, S Naveed
Sunshine Coast University Hospital, Queensland, Australia
Background: Nearly 75% of all psychiatry trainees will experience a patient under their care die by suicide. This often has a long-lasting impact on their journey as a psychiatry doctor.
Objectives: To quantify the incidence of patient suicide during psychiatry training within Royal Australian and New Zealand College of Psychiatrists (RANZCP) trainees in Queensland and to assess preparedness for such an event within this cohort.
Methods: An anonymized online survey designed to gather the necessary information to calculate both incidence and impact of patient suicide on a trainee doctor. The survey will then be analyzed using a combination of quantitative and qualitative techniques.
Findings: The survey will be conducted in the next month. Findings will be based on an analysis of collected data.
Conclusions: We hypothesize that about 75% of trainees would experience at least one patient suicide during their training as a psychiatrist and that this is often an upsetting experience. We also speculate that the training to deal with such an event is somewhat lacking within the health system.
Poster Presentation Abstracts
Patient Persistence on Antipsychotic Medications in Australia
N Pai1,2, J Mullan3, M Acar4, P Juneja5, MH Kouhkamari5, S Siva6
1Graduate Medicine, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
2Illawarra Shoalhaven Local Health District, Wollongong, Australia
3Centre for Health Research Illawarra Shoalhaven Population, University of Wollongong, Wollongong, Australia
4Real World Evidence, Janssen-Cilag Pty Ltd, Macquarie Park, Australia
5Prospection, Eveleigh, Australia
6Medical and Scientific Affairs, Janssen-Cilag Pty Ltd, Macquarie Park, Australia
Background: Evidence suggests patient non-adherence to antipsychotic pharmacological therapy when managing schizophrenia results in relapse and rehospitalization (Lambert et al., 2010). Australian real-world persistence to antipsychotic therapy is unknown. However, the Department of Human Services Pharmaceutical Benefits Scheme (PBS) 10% sample data has enabled an investigation into Australian antipsychotic persistence trends.
Objectives: This session aims to describe patient persistence on antipsychotic medication.
Methods: A retrospective cohort analysis was conducted using the PBS 10% sample data, including patients who commenced antipsychotic therapy between July 2013 and September 2017. Antipsychotics were grouped as atypical oral, atypical long-acting therapy (ALAT), typical oral, typical long-acting therapy (TLAT), and clozapine. Patient persistence to antipsychotic therapy was estimated using Kaplan–Meier methodology. A patient was estimated to have discontinued treatment if no antipsychotic therapy was dispensed for 6 months (with 3-month sensitivity), or if they switched antipsychotic groups. Time on therapy was calculated as time from first to last dispensation. Variables available for analysis were gender, state, age and prescriber specialty.
Findings: Patients persisted on ALATs for a median of 13 months. Median persistence for typical orals was 6 months, TLATs was 9 months and atypical orals was 8 months. A clozapine median was not reached. All differences in persistence were statistically significant. Females had higher persistence than males, with medians of 13 and 10 months, respectively.
Conclusions: The sample data suggest that patients treated with clozapine have the highest persistence to treatment as it tends to be reserved for cases of treatment resistance. Patients on ALATs persisted longer on treatment than atypical orals, TLATs and typical orals.
Reference
Lambert M, Conus P, Cotton S, et al. (2010) Prevalence, predictors and consequences of long-term refusal of antipsychotic treatment in first-episode psychosis. Journal of Clinical Psychopharmacology 30(5): 565–72.
Patterns of Antipsychotic Medication Prescribing in Australia
N Pai1,2, J Mullan3, M Acar4, P Juneja5, MH Kouhkamari5, S Siva6
1Graduate Medicine, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
2Illawara Shoalhaven Local Health District, Wollongong, Australia
3Centre for Health Research Illawarra Shoalhaven Population, University of Wollongong, Wollongong, Australia
4Real World Evidence, Janssen-Cilag, Sydney, Australia
5Prospection, Eveleigh, Sydney, Australia
6Medical and Scientific Affairs, Janssen-Cilag, Sydney, Australia
Background: The Australian prevalence rate for schizophrenia is estimated to be 3.1 per 1000 people (Australian Government Department of Health, 2011). In recent years, antipsychotic pharmacological treatment options have increased in Australia, including reimbursed atypical long-acting therapies (ALATs). Availability of the Department of Human Services Pharmaceutical Benefits Scheme (PBS) 10% sample data has enabled an Australia-wide investigation into trends of antipsychotic usage.
Objectives: This session aims to describe antipsychotic prescribing patterns in Australia.
Methods: A retrospective cohort analysis was conducted using the PBS 10% sample data, including patients who commenced on antipsychotic therapy for schizophrenia between July 2013 and September 2017. A descriptive analysis was undertaken to understand rates of antipsychotic use. Antipsychotics were grouped as atypical oral, ALAT, typical oral, typical LAT (TLAT), and clozapine. Variables available for subgroup analysis were state, gender, age and prescriber specialty.
Findings: In total, 6740 unique patients were identified in the sample data. Across all lines of antipsychotic therapy, 62% of patients were dispensed an atypical oral, 19% a TLAT, 9% prescribed typical orals, 7% an ALAT and 3% clozapine. This pattern of use was consistent over the study period. Age-based trends were identified, including: higher use of ALATs in a younger population, and higher use of TLATs in an older population. General practitioners (GPs) tended to prescribe ALATs the least, making up 3% of total prescriptions, compared with 9% psychiatrist prescriptions. There were no significant differences in prescribing patterns by gender or state.
Conclusions: The study findings suggest that prescribing of oral atypicals remains relatively high and that ALAT prescribing remains low, particularly among GPs.
Reference
Australian Government Department of Health (2011) People Living with Psychotic Illness 2010: Report on the Second Australian National Survey.
Patient Support Programme For Long-Acting Treated Patients With Schizophrenia in Australia: Impact on Patients’ Persistence
M Acar1, A Puig1, P Gerungan1, A Stockwell2
1Real World Evidence, Janssen-Cilag, Sydney, Australia
2Innovations and Partnerships, Janssen-Cilag, Sydney, Australia
Background: Non-adherence to antipsychotic treatment in schizophrenia results in a higher risk of relapse (Lambert et al., 2010). Reasons for non-adherence include negative attitude, inadequate discharge planning and poor therapeutic alliance (Lacro et al., 2002). The Atlas Patient Support Program commenced in May 2015 to support adherence to Janssen Long-Acting Therapies (risperidone and paliperidone palmitate) in Australia.
Objectives: This session aims to report Atlas program persistence and appointment attendance rate.
Methods: A retrospective analysis was conducted using routinely collected administrative data reported as at July 2018. Patient persistence on the programme was estimated using Kaplan–Meier methodology, from date of enrolment to withdrawal. Patients still enrolled were censored at the reporting date. Appointment attendance was calculated as the percentage of appointments attended over the appointments scheduled. Appointments whose attendance could not be verified were excluded from analysis.
Findings: A total of 386 patients were enrolled in the Atlas program. At 12 months, 66% of patients remained on the program, with a median duration of 21 months. The appointment attendance rate was 95%.
Conclusions: Long-term persistence data and high appointment attendance rates show that appointment reminders and other Atlas services are helpful in supporting patients with mental health conditions and preventing relapse.
References
Lacro JP, Dunn LB, Dolder CR, et al. (2002) Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. Journal of Clinical Psychiatry 63(10): 892–909.
Lambert M, Conus P, Cotton S, et al. (2010) Prevalence, predictors, and consequences on long-term refusal of antpsychotic treatment in first-episode psychosis. Journal of Clinical Psychopharmacology 30(5): 565–572.
Schizophrenia Patient Persistence to Long-Acting Antipsychotic Therapy in New Zealand
K Berney1, A Grant2, M Acar3, S Shaw4
1New Zealand, Janssen-Cilag, Auckland, New Zealand
2Market Access, Janssen-Cilag, Sydney, Australia
3Real World Evidence, Janssen-Cilag, Sydney NSW, Australia
4Medical and Scientific Affairs, Janssen-Cilag, Sydney, Australia
Background: Patient non-adherence to antipsychotic pharmacological therapy for the treatment of schizophrenia can result in relapse and rehospitalization (Lambert et al., 2010). Long-acting therapies (LAT) were designed to improve adherence to treatment. However, real-world persistence in New Zealand (NZ) is unknown. The NZ Pharmaceutical Management Agency (PHARMAC) data set contains all antipsychotic therapy claims and allows for an investigation into persistence.
Objectives: This session aims to estimate persistence on antipsychotic LATs prescribed in the management of schizophrenia.
Methods: A retrospective cohort analysis was conducted using Special Authority claims data provided by PHARMAC under the Official Information Act (OIA). The database includes schizophrenia and other psychotic disorder claims from January 2009 to October 2017. Kaplan–Meier methodology was used to estimate patient persistence to therapy, stratified by molecule. Molecules included in the analysis were injectable paliperidone palmitate (1-month formulation), risperidone and olanzapine.
Findings: A total of 11,667 cases were identified: 5019 patients were treated with paliperidone; 3735 with risperidone, and 2923 with olanzapine. Median time on treatment was highest for paliperidone palmitate (31.5 months), compared with olanzapine (20.5 months) and risperidone (17.5 months).
Conclusions: Patient persistence to LAT therapy is higher than previously reported estimates of antipsychotic therapy. An understanding of the real-world time on treatment for LATs will aid physicians in their decision-making to optimize management and improve clinical outcomes for patients with schizophrenia.
Reference
Lambert M, Conus P, Cotton S, et al. (2010) Prevalence, predictors and consequences of long-term refusal of antipsychotic treatment in first-episode psychosis. Journal of Clinical Psychopharmacology 30(5): 565–572.
Quality Improvement Intervention in Monitoring Rate of Cardiometabolic Risk Factors in a Community Mental Health Centre
J Basnett1, V Eapen2, M Asghari2
1Liverpool Hospital, Sydney, Australia
2Liverpool Hospital, University of New South Wales, Sydney, Australia
Background: Available evidence suggests that people with severe mental illnesses (SMI) have an increased risk of cardiovascular disease. However, despite the availability of screening clinical guidelines, routine monitoring for cardio-metabolic risk factors (CMRFs) in psychiatry is limited. The rate of successful healthcare innovation implementation is dismal. There is a critical need to close the evidence to practice gap in healthcare (Holt and Mitchell, 2015; Mitchell et al., 2012; McEvoy et al., 2005).
Objectives: This session aims to help close the evidence to practice gap in monitoring CMRFs in a community mental health centre.
Methods:
Phase 1: Pre-implementation. A total of 117 patient files were audited to determine the frequency of monitoring of CMRFs at Time 1 (T1). A staff survey examined local barriers and enablers in monitoring CMRFs.
Phase 2: Implementation. Implementing NSW Clinical pathways (CP) for CMRFs (NSW Health, 2012) through: staff education; environmental factors; appointing a champion and use of reminders.
Phase 3: Post implementation. Re-audit of patients’ files for any change in practice at Time 2 (T2).
Findings:
Phase 1: T1 demonstrated low levels of documentation for CMRFs.
Phase 2: Staff survey (n = 21) revealed time constraints and knowledge gaps.
Phase 3: After implementation, T2 showed significant improvement in screening rates for all CMRFs (e.g. blood pressure measurement improved by 79% (p = 0.0001). About 37.5% of patients met the criteria for metabolic syndrome.
Conclusions: Our findings demonstrate that patients with SMI are not receiving optimum physical health monitoring. Having effective CP implementation strategies tailored to the organization’s needs can improve clinical practice and patient`s outcome and reduce the evidence to practice gap.
References
Holt RI and Mitchell A (2015) Diabetes mellitus and severe mental illness: mechanisms and clinical implications. Nature Reviews Endocrinology 11: 79–89.
McEvoy JP, Meyer JM, Goff DC, et al. (2005) Prevalence of the metabolic syndrome in patients with schizophrenia: baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III. Schizophrenia Research 80(1): 19–32.
Mitchell A, Delaffon V, Vancampfort D, et al. (2012) Guideline concordant monitoring of metabolic risk in people treated with antipsychotic medication: systematic review and meta-analysis of screening practices. Psychological Medicine 42(1): 125–147.
Curtis J, Newall HD, Samaras K (2012) The heart of the matter: cardiometabolic care in youth with psychosis. Early intervention in psychiatry 6(3): 347–353.
Prevalence and Impact of Schizophrenia in the New Zealand Population
S Gibbs1, N Brewer1, A Puig2, J Bell3
1University of Otago, Wellington, New Zealand
2Janssen-Cilag, Macquarie Park, Australia
3Janssen-Cilag, Auckland, New Zealand
Background: Schizophrenia is a distressing and costly disorder; however, little is known about the societal impact in New Zealand.
Objectives: This session presents a study aimed to assess the prevalence and the health, social and productivity impact of schizophrenia (SCZ) versus propensity matched controls in the New Zealand population.
Methods: This was a retrospective analysis of routine New Zealand government-linked data. People with a diagnosis of SCZ through 2008 to 2015 were propensity score matched to controls (controls) on age, sex and ethnicity.
Findings: The 12-month prevalence for 2015 was 567 people per 100,000 population. Prevalence was higher for males, the indigenous Māori population and Pacific Islander groups, and lower for females, Asian and European groups. There was a total of 1100 people with their first SCZ diagnosis in 2015 with a crude incidence rate of 24.2 per 100,000. The crude mortality rate for people with SCZ was significantly higher compared to controls in all age groups. People with SCZ had significantly lower educational attainment, lower employment (22%), earned less income and lived in greater deprivation versus controls. Most people with SCZ (71%) received income from social security benefits. Government costs were significantly higher for the SCZ group than controls. People with SCZ were significantly more likely than PMC to come into contact with the criminal justice system.
Conclusions: SCZ has a very significant social and economic burden that impacts individuals’ future employment and earning ability and incurs a substantial government financial cost.
National Borderline Personality Disorder Training and Professional Development Strategy
S Rao1,2, JH Broadbear1, R Brown1,2
1Spectrum, Personality Disorder Service for Victoria, Richmond, Australia
2Australian BPD Foundation, Bayswater, Australia
Background: The Australian BPD Foundation, Spectrum, and the Mental Health Professionals’ Network (MHPN) were funded by the National Mental Health Commission to deliver clinician training to better support people living with a diagnosis of borderline personality disorder (BPD), their families and carers.
Objectives: This session aims to describe the six professional development webinars; in each, a multidisciplinary panel commented on a case study: (i) What is BPD?; (ii) treatment principles for BPD; (iii) evidence-based treatments and access; (iv) BPD in youth and early intervention; (v) management of self-injury and suicidality; and (vi) management in Mental Health Services, primary, public and private sectors.
Methods: Participants registered online for each webinar and could view it ‘live’ or in their own time.
Findings: There were 4256 to 4994 registrations per webinar. Most learned about the series via MHPN email; others through word of mouth. About 36% to 43% of registrants watched the ‘live’ broadcasts, with thousands of views and downloads subsequently. Registrants included psychologists (37%), counsellors (25%), social workers (15%), mental health nurses (7%), occupational therapists (5%), general practitioners (4%), and psychiatrists (1%). Most resided in the eastern states; 92% in major cities or inner regional areas. In feedback, 96% of viewers believed the webinar would improve their work practice; 98% would attend future webinars.
Conclusions: Specialist training via free webinars was well supported by allied mental health professionals across Australia. The flexibility of access and relevance of clinical, carer and consumer viewpoints was regarded as beneficial for clinicians for their interactions with clients diagnosed with BPD.
Long-Term Functioning Outcomes Are Predicted By Cognitive Symptoms in Working Patients With Major Depressive Disorder: Results From the Atworc Study
P Chokka1, J Bougie2, J Proulx2, A Holmegaard Tvistholm3, A Ettrup3, L Bubb4
1Grey Nuns Community Hospital, Edmonton, Canada
2Lundbeck Canada, Montreal, Canada
3H. Lundbeck, Valby, Denmark
4Lundbeck Australia, Sydney, Australia
Background: AtWoRC (Assessment in Work productivity and the Relationship with Cognitive symptoms in patients with Major Depressive Disorder [MDD] taking vortioxetine; NCT02332954) is an interventional, open-label Canadian study assessing the association between cognitive symptoms and work productivity in gainfully employed patients with MDD treated with vortioxetine for up to 52 weeks.
Objectives: This session aims to present the assessment of time-dependent relationships between changes in cognition and functioning measures in MDD using structural equations modelling (SEM) after long-term treatment with vortioxetine.
Methods: Patients (n = 199) received vortioxetine (10–20 mg/day) and were assessed over a total of 52 weeks at routine care visits that emulated a real-life setting in Canada. The primary analysis was partial correlation between changes in self-reported cognitive symptoms and self-reported work productivity loss. Additional assessments performed over 52 weeks included symptom and disease severity, cognitive performance, and global functioning.
Findings: Patients improved significantly in all mood, cognitive and functioning assessments from baseline to week 12, and this was maintained with further improvements to week 52. The significant correlation between patient-reported cognitive symptom and productivity loss scores at week 12 (n = 154) remained at week 52 (n = 107). Standard error of the mean (SEM) analyses found significant (p < 0.05) predictions by patient-rated cognitive symptoms on later patient-rated functioning outcomes. These significant predictions were independent of improvements in overall depressive symptoms as SEM models adjusted for depression severity. The objective cognitive performance measure did not significantly predict subjective measures of functioning, suggesting that objectively-rated and subjectively-rated measures represent distinct assessments of cognitive function.
Conclusions: In gainfully employed Canadian patients with MDD, significant associations between improvements in cognitive symptoms and workplace productivity were observed after 12 and 52 weeks of treatment with vortioxetine.
Effect of Brexpiprazole on Agitation and Hostility in Patients With Acute Schizophrenia
L Citrome1, J Ouyang2, SR Meehan3, R Baker2, C Weiss2
1New York Medical College, Valhalla, USA
2Otsuka Pharmaceutical Development & Commercialization, Princeton, USA
3H. Lundbeck, Valby, Denmark
Background: Hostile, aggressive and/or agitated behaviors frequently lead to hospitalization of patients with schizophrenia, and represent a significant treatment challenge.
Objectives: This session aims to present an evaluation of the efficacy of brexpiprazole, a serotonin–dopamine activity modulator, in reducing hostility/agitation.
Methods: Data were pooled from two Phase 3, six-week studies of brexpiprazole in hospitalized patients with acute exacerbation of schizophrenia (Vector, NCT01396421; Beacon NCT01393613). Agitation and hostility were assessed by Positive and Negative Syndrome Scale–excited component (PANSS–EC) and PANSS Marder Factor Uncontrolled Hostility/Excitement scores. To confirm a specific effect on hostility, changes from baseline in patients with a PANSS P7-hostility item score ⩾ 2 were analyzed. Treatment group differences (including covariate analyses adjusting for presence of positive symptoms, akathisia, and akathisia/somnolence adverse events [AEs]) used mixed-model-repeated-measures analyses.
Findings: At week 6, brexpiprazole was effective on PANSS–EC (4 mg/day [n = 350]; p = 0.0002; 2 mg/day [n = 359], p = 0.0200), and PANSS Marder Factor Uncontrolled Hostility/Excitement score (4 mg/day, p < 0.0001; 2 mg/day, p = 0.0311) versus placebo (n = 358). Brexpiprazole at 4 mg/day was superior to placebo in reducing PANSS P7-hostility at week 6 (p = 0.0024); brexpiprazole at 2 mg/day showed numerical improvement. Improvements were independent of improvements in positive symptoms. When controlling for presence of akathisia, and akathisia/somnolence AEs, brexpiprazole at 4 mg/day reduced PANSS P7-hostility score at week 6 (p = 0.0034; p = 0.0033 versus placebo, respectively). In patients with greater hostility at baseline (P7 ⩾ 3) brexpiprazole at 4 mg/day was superior to placebo in reducing PANSS P7-hostility at week 6 (p ⩽ 0.01, all three analyses).
Conclusions: Brexpiprazole improved symptoms of agitation and hostility versus placebo. Improvement in hostility was independent of change in other positive symptoms, akathisia, and akathisia/somnolence AEs.
Understanding Participation of Medical Staff in Critical Incident Reporting and Learning From Incidents
V Danivas, G Deva, K Irving, J Dinh, V Lakra
North West Area Mental Health Services, North Western Mental Health, Melbourne, Australia
Background: The need for participation of medical staff in reporting critical incidents and learning from them has been stressed in earlier reports. Multiple studies have suggested that the participation of medical staff in these processes have been less than optimal across health systems in many countries.
Objectives: This session aims to improve the understanding of, orientation to and awareness of critical incident reporting and management processes and participation in real-life settings of junior and senior medical staff at our local area mental health service (MHS). To use the date obtained to increase learning and improvement in the safety culture at our Service.
Methods: An online survey delivering 25 questions addressing orientation processes, level of participation in reporting critical incidents and post hoc feedback to all senior and junior medical staff working at the service. Questions were tailored to the seniority levels of the medical staff.
Results: A total of 25 staff responded to the survey, making it a response rate of about 67.5%. The junior medical staff received better orientation compared to senior medical staff, but only 32% of all medical staff were confident of reporting incidents in Riskman (online critical incident reporting tool). 75% of the medical staff do prompt other members in the team to report critical incidents in Riskman and follow up on the incidents reported. Improving the orientation process, better opportunities in participating in the review process and improved communication between the safety and clinical risk management committee and medical staff are a few of the recommendations that the authors are implementing to improve participation.
Young Adults’ Mental Health Literacy in Relation to Depression and Their Attitudes Towards Complementary Medicine Practices
N Foroughi1, L Douglass2, P Hay1,3, K Yu Zhu1, J MacDonald4, C Smith2
1School of Medicine, Western Sydney University, Sydney, Australia
2NICM Health Research Institute, Western Sydney University, Sydney, Australia
3Translational Health Research Institute, Western Sydney University, Sydney, Australia
4School of Science and Health, Western Sydney University, Sydney, Australia
Background: Depression and mental health-related issues are increasingly prevalent in young adolescents and adults and so is the use of complementary therapies (CTs) to treat depression. Systematic reviews have found that of all CTs, acupuncture, exercise and the herbal remedy St John’s Wort have the greatest amount of evidence for efficacy in treating depression.
Objectives: This session aims to present an assessment of the level of mental health literacy and usage of complementary medicine in young adolescents and adults.
Methods: Electronic and paper-based surveys were distributed to two participant groups: (i) a pre-existing cohort of community women; and (ii) a group of young athletes and university students (n = 156, aged ⩾ 16 years). The surveys aimed to assess the participant’s level of mental health literacy and the use of CTs for their own personal health.
Findings: Mental health literacy regarding the identification of depressive symptoms was low, particularly in males younger than 35 years. About 59% of the participants utilized CTs (most commonly vitamins) 12 months prior to the completion of the survey. On the other hand, evidence-based professional services were considered of greater help than self-help methods in treating depressive symptoms.
Conclusions: The findings of this survey support other research indicating high levels of use of CTs. In addition, while there was a favourable regard for professional services, greater education in regards to the identification of depressive symptoms in young men is needed to improve the mental health literacy in the population.
Delirious mania: a case series and narrative review to illustrate diagnostic difficulties, important differential diagnoses and proposed protocol for investigations and treatment
D Garg, M Anand, Y Hamilton, S Hossain, G Kandath, S Naik, P Doluweera, M Goyal
Gold Coast Hospital and Health Service (GCHHS), Gold Coast, Australia
Background: Delirious mania is an acute and life-threatening clinical condition which can pose serious diagnostic and treatment challenges. The concept of delirious mania has varied over time and overlapped with other clinical psychiatric syndromes (e.g. Bell’s mania, excitatory catatonia, lethal catatonia or malignant catatonia). The available literature suggests that prompt diagnosis and treatment can avert serious and potentially life-threatening complications.
Objectives: This session aims to present a case series (minimum 3 cases) and a narrative review to illustrate diagnostic and treatment complexities in managing patients with delirious mania in psychiatric inpatient units. We also aim to propose investigation and treatment algorithms to assist clinicians in providing prompt and effective management of this condition.
Methods: Informed consent has been obtained from patients using Gold Coast Hospital and Health Service policy. A thorough review of the literature is being carried out using narrative review processes and the search items used are: delirious mania, Bell’s mania, excitatory catatonia, excited catatonia, malignant catatonia and lethal catatonia.
Findings: A preliminary review of the literature and our case series highlights the need for prompt identification of cases with delirious mania by using appropriate assessment and investigations to rule out medical, neurological and substance misuse-related conditions and other overlapping psychiatric conditions.
Conclusions: Delirious mania and other overlapping psychiatric conditions discussed in this article are serious clinical syndromes needing prompt diagnosis and treatment. Our algorithms can assist clinicians in the assessment and management of these life-threatening conditions in a timely manner.
Efficacy of Long-Term Treatment With Lurasidone in Children and Adolescents With Bipolar Depression: Interim Analysis of a 2-Year Open-Label Extension Study
MP DelBello1, R Goldman2, M Tocco2, A Pikalov2, L Deng2, J Cucchiaro2, A Loebel2
1Division of Bipolar Disorders Research, Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, USA
2Sunovion Pharmaceuticals, Fort Lee and Marlborough, USA
Background: Limited long-term efficacy data are available in adolescents with schizophrenia.
Objectives: This session aims to present an evaluation of the long-term effectiveness of lurasidone in children and adolescents with bipolar depression.
Methods: Patients aged 10–17 years with bipolar I depression who completed 6 weeks of double-blind (DB) treatment with lurasidone (20–80 mg/day) were enrolled in a 2-year, open-label (OL), flexible-dose (20–80 mg/day) extension study. The primary efficacy measure was the Children’s Depression Rating Scale, Revised (CDRS-R; responders: ⩾ 50% reduction from DB baseline). Remission criteria required a CDRS-R total score of ⩽ 28, a Young Mania Rating Scale total score of ⩽ 8, and a Clinical Global Impression–Bipolar–Scale (CGI-BP-S) depression score of ⩽ 3. We report data from an interim analysis.
Findings: A total of 347 patients were randomized to lurasidone or placebo. In the DB study, mean week 6 improvement in the CDRS-R score was significantly greater for lurasidone versus placebo (−21.0 versus –15.3; p < 0.0001; effect size, 0.45). In this interim analysis, 305 patients entered the OL study. The mean change from DB baseline in the CDRS-R scores at weeks 28 (n = 232), 52 (n = 199) and 104 (n = 95) were: −29.0, −32.2, and −34.3, respectively. The CDRS-R responder and remission rates, from DB baseline to weeks 28, 52, and 104 were: 77.2%/51.3%, 88.4%/61.3%, and 91.6%/86.3%, respectively. During OL treatment, quality of life (as measured by the Pediatric Quality of Life, Enjoyment and Satisfaction Questionnaire) and functioning (as measured by the Children’s Global Assessment Scale) normalized in most patients.
Conclusions: In children and adolescents with bipolar depression, long-term treatment with lurasidone was associated with continued improvement in depressive symptoms and increased rates of remission.
Funded by Sunovion Pharmaceuticals Inc., Sumitomo Dainippon Pharma and Servier Australia
Clinicaltrials.gov identifier: NCT01914393
Safety of Long-Term Treatment With Lurasidone in Children and Adolescents With Bipolar Depression: Interim Analysis of a 2-Year Open-Label Extension Study
MP DelBello1, R Goldman2, M Tocco2, A Pikalov 2, L Deng2, J Cucchiaro2, A Loebel2, D Coghill3
1Division of Bipolar Disorders Research, Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, USA
2Sunovion Pharmaceuticals, Fort Lee and Marlborough, USA
3The Royal Children’s Hospital, Melbourne, Australia
Background: Limited long-term safety data are available in adolescents with schizophrenia.
Objectives: This session aims to present the evaluation of the long-term safety and tolerability of lurasidone in children and adolescents with bipolar depression.
Methods: Patients aged 10–17 years with bipolar I depression who completed 6 weeks of double-blind (DB) treatment with lurasidone (20–80 mg/day) were enrolled in a 2-year, open-label (OL), flexible-dose (20–80 mg/day) extension study. Safety and tolerability assessments included treatment-emergent adverse events, weight (actual and expected, based on Centers for Disease Control (CDC) reference charts), laboratory tests, and electrocardiographs. We present here safety results of an interim analysis.
Findings: At the time of this interim analysis, 305 patients had entered the OL study, and 30 patients (9.8%) had discontinued due to an adverse event. The most common adverse events during OL treatment were: headache (21.3%), nausea (15.1%), and somnolence (9.5%). Median change in laboratory parameters from DB baseline to OL weeks 52 and 104, respectively, were: total cholesterol, 0.0 and –3.0 mg/dL; triglycerides, +1.0 and +6.0 mg/dL; hemoglobin A1c, 0.0 and 0.0%; and mean change from DB baseline in weight at weeks 52 and 104 were 4.25 and 6.68 kg, versus an expected weight gain of 3.77 and 6.94 kg, based on the gender-and-age specific CDC growth chart. No patients had a QTcF readings >460 msec, or an increase in QTcF ⩾ 60 msec.
Conclusions: In children and adolescents with bipolar depression, long-term treatment with lurasidone was well-tolerated, with headache, nausea and somnolence being the most common adverse events. Minimal effects were observed on weight and metabolic parameters.
Funded by Sunovion Pharmaceuticals Inc., Sumitomo Dainippon Pharma and Servier Australia
Clinicaltrials.gov identifier: NCT01914393
Inflammatory Markers and Cognitive Performance in Patients With Schizophrenia Treated With Lurasidone
BJ Miller1, A Pikalov2, C Siu3, M Tocco2, J Tsai2, PD Harvey4, A Loebel2
1Medical College of Georgia, Augusta University, Augusta, USA
2Sunovion Pharmaceuticals, Marlborough and Fort Lee, USA
3COS and Associates, Central, Hong Kong, China
4University of Miami Miller School of Medicine, Miami, USA
Background: Recent studies have linked inflammation, obesity, and lipid dysregulation with cognitive impairment in schizophrenia.
Objectives: This session aims to present an investigation of the potential influence of inflammation, obesity and lipid metabolism on changes in cognitive performance in patients with schizophrenia treated with lurasidone.
Methods: Patients with an acute exacerbation of schizophrenia were treated with lurasidone (80 or 160 mg/day), placebo, or quetiapine XR (600 mg/day) in a 6-week double-blind study. A wide-range C-reactive protein (wr-CRP) high sensitivity assay was used to assess levels of inflammation at baseline and 6-week study endpoint. CRP was evaluated as a log transformed continuous variable and as a categorical variable divided into low (⩽ 2 mg/L), medium (>2 mg/L and ⩽5 mg/L) and high (>5 mg/L) subgroups. Cognitive function was assessed with the CogState computerized cognitive battery.
Findings: Elevated levels of wr-CRP (log) were associated with significant baseline cognitive impairment, higher Positive and Negative Syndrome Scale (PANSS) symptom severity, higher body mass index, lower levels of high-density lipoprotein (HDL) cholesterol and higher haemoglobin A1c. High wr-CRP levels predicted less endpoint improvement in cognitive function. Significantly greater improvement was observed on lurasidone (versus placebo) in patients with either low wr-CRP and high HDL, or lower levels of both wr-CRP and Homeostatic Model Assessment of Insulin Resistance (HOMA-IR). Lurasidone had no significant endpoint effect on wr-CRP levels; and improvement in schizophrenia was independent of baseline levels of wr-CRP, HDL and HOMA-IR.
Conclusions: Our exploratory findings suggest that the joint effects of low wr-CRP combined with either high HDL or low HOMA-IR can predict cognitive improvement in patients with schizophrenia treated with lurasidone.
Funded by Sunovion Pharmaceuticals Inc., Sumitomo Dainippon Pharma and Servier Australia
Efficacy and Safety Ortolerability of Atypical Antipsychotics in the Treatment of Bipolar Depression: A Systematic Review and Network Meta-Analysis
K Hagi1, T Nosaka1, A Pikalov2, A Loebel2, C Correll3,4,5,6, M Hopwood7
1Medical Affairs, Sumitomo Dainippon PharmaCompany, Tokyo, Japan
2Sunovion Pharmaceuticals, Marlborough and Fort Lee, USA
3The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, USA
4Hofstra Northwell School of Medicine, Hempstead, USA
5The Feinstein Institute for Medical Research, Manhasset, USA
6Charité Universitätsmedizin, Department of Child and Adolescent Psychiatry, Berlin, Germany
7The University of Melbourne, Melbourne, Australia
Background: Few evidence-based reviews are available that assess the comparative efficacy and tolerability of atypical antipsychotics (AAPs) in patients with bipolar depression.
Objectives: This presentation aims to report on a systematic review and network meta-analysis to assess the comparative efficacy and tolerability of atypical AAPs in patients with bipolar depression.
Methods: We conducted a Bayesian-framework, network meta-analysis of randomized controlled trials to compare AAPs and placebo in the acute treatment of bipolar depression. The primary outcomes for efficacy and safety/tolerability were the treatment response rate and discontinuation due to adverse event.
Findings: We identified 22 randomized controlled trials (RCTs) (n = 8823) testing 7 different AAPs versus placebo. Five of these AAPs, namely cariprazine (risk ratio (RR) = 1.41), lurasidone (RR = 1.44), olanzapine (RR = 1.31), olanzapine+fluoxetine (RR = 1.85) and quetiapine (RR = 1.37), demonstrated significantly higher treatment response rates compared with placebo. Conversely, aripiprazole and ziprasidone were not significantly different from placebo in treatment response.
Cariprazine, lurasidone, olanzapine, olanzapine+fluoxetine, and ziprasidone were generally well tolerated, as there was no significant difference between these AAPs and placebo in adverse effect-related discontinuation rates. Aripiprazole (RR = 2.20) and quetiapine (RR = 2.03) had significantly higher discontinuation rates due to adverse effects.
Conclusions: Results from this meta-analysis suggest that there are some significant differences in treatment response and discontinuation due to adverse events among AAPs in the treatment of bipolar depression. Choice of medication needs to be integrated with individual patient characteristics (e.g. clinical urgency and adverse effect sensitivity) to optimize the management of acute bipolar depression.
Funded by Sunovion Pharmaceuticals Inc., Sumitomo Dainippon Pharma and Servier Australia
Lurasidone for the Treatment of Major Depressive Disorder With Mixed Features: Results of a 12-Week Open-Label Extension Study
SM Stahl1, A Pikalov2, M Tocco2, Y Mao2, A Loebel2, M Hopwood3
1Department of Psychiatry, University of California at San Diego, San Diego, USA
2Sunovion Pharmaceuticals, Marlborough and Fort Lee, USA
3The University of Melbourne, Melbourne, Australia
Background: Few data are available on the long-term treatment of major depressive disorder (MDD) with mixed features.
Objectives: This session aims to present the evaluation of the efficacy and tolerability of longer-term treatment with lurasidone in patients with MDD with mixed features.
Methods: Patients with MDD who presented with 2 or 3 manic symptoms and who completed 6 weeks of double-blind, placebo-controlled treatment with lurasidone (20–60 mg/day) were enrolled in a 12-week, open-label (OL) extension study in which patients were continued on lurasidone (Lur–Lur group) or switched from placebo to lurasidone (Pbo–Lur group). The primary efficacy measure was the Montgomery–Åsberg Depression Rating Scale (MADRS).
Findings: A total of 48 patients entered the extension study, with a mean MADRS at OL-baseline: Lur–Lur (N = 29), 15.0; Pbo–Lur (N = 19), 24.1; 9 patients (18.8%) discontinued prematurely. Mean change from OL-baseline to week 12 (OC/Last Observation Carried Forward (LOCF)) in MADRS total scores for the Lur–Lur group was –4.1/–3.3, and for the Pbo–Lur group was –11.2/–9.7. In the OL study, adverse events (⩾ 5%) were akathisia (10.4%), diarrhoea (8.3%), upper respiratory infection (8.3%), and headache, sedation, nausea, and fatigue (6.3% each). For the Lur–Lur and Pbo–Lur groups, respectively, median change in metabolic parameters (DB-baseline to week 12-OC) were: cholesterol (–6.5 and +1.5 mg/dL), triglycerides (–3.5 and +20.0 mg/dL), and glycated haemoglobin (HbA1c) (+0.15% and +0.30%). Treatment-emergent mania or hypomania as an adverse event occurred in 2 patients (4.2%).
Conclusions: Treatment with lurasidone (20–60 mg/day) was generally safe and well tolerated for up to 12 weeks in patients with MDD with mixed features. Continued improvement in depressive symptoms was observed.
Funded by Sunovion Pharmaceuticals Inc., Sumitomo Dainippon Pharma and Servier Australia
Clinical Enhancement Service For People Who Pose Fixated Threats in Victoria: The First 60 Days
A Hui, C Hodge, D Rudolph
Mental Health Forensic Interface Team, North Western Mental Health, Melbourne, Australia
Background: The Mental Health Forensic Interface Team (MH-FIT) was established in August 2018 as a clinical enhancement service to complement the work of the Victorian Fixated Threat Assessment Centre (VFTAC) in assessing and managing the risks to the community posed by individuals who make fixated threats against state ministers or hold a pathological grievance against members or organizations in the community.
Objectives: This session aims to describe the operations of MH-FIT and the profile of patients on the MH-FIT caseload during the first 60 days of operation.
Methods: Sociodemographic, clinical and risk data of patients taken on by MH-FIT within the first 60 days of operation were collected, de-identified, and analysed.
Findings: MH-FIT comprises a multidisciplinary team which, upon receipt of referrals from VFTAC, liaises with relevant local area mental health service and/or private providers to formulate the patient’s clinical presentation and risk profile, which informs the development of a management plan.
MH-FIT enrolled 17 patients, of whom 94% were men, 65% were from a metropolitan area, and the mean age was 36 years. About 35% patients presented with fixated threats and 65% with pathological grievance; 47% had a forensic history and 24% were on a legal order. In terms of co-morbid diagnoses, 53% had a disorder of a psychotic type, 24% mood, 35% addiction, 35% personality and 12% neurocognitive. A total of 47% were discharged with a mean episode of care of 35 days.
Conclusions: MH-FIT is a unique and specific clinical service thattreats patients with a heterogeneous clinical profile.
Medicinal Cannabis Prescription For Psychiatry
B Jansen
1,2
1Cannabis Doctors Australia, Australia
2Healthy Not High, Australia
Background: Medicinal Cannabis is here to stay, and it should be prescribed for a variety of psychiatric conditions, but there is still a misunderstanding of the role of psychiatry in the use of medicinal cannabis.
Objectives: This session aims to provide a tailored presentation on the medicinal cannabis prescription for psychiatry, to cover the primary prescription and ways to counter the effects of black-market cannabis. Presentation of relevant psychiatric and neurological journal papers on medicinal cannabis will be included.
Findings: My presentations thus far have been well received, and the overwhelming response is that doctors simply were not aware of the body of evidence available on medicinal cannabis.
Conclusions: Thank you for your consideration. I am flexible with regard to the content of my presentation, and I welcome the Abstract Review Committee’s input.
Characteristics and Outcomes of Patients With Borderline Personality Disorder Admitted To A Short-Term Residential Service, Prevention and Recovery Care Services
L Sekharan1, K Jagadheesan1, P Das1, V Lakra1, K West1, M Baldwin2
1North West Area Mental Health Service, Melbourne, Australia
2Mind Australia, Melbourne, Australia
Background: Usefulness of residential facilities other than crisis admissions in the management of borderline personality disorder (BPD) is not clearly established. According to the National Health and Medical Research Council (NHMRC) guideline, the benefits of long-term inpatient treatment and specialist residential facilities are not adequately evaluated (NHMRC, 2012). Until now, no study has explored the benefits of a recovery-oriented short-term residential facility, prevention and recovery care services (PARC) in BPD management.
Aims: This session presents the main aims of characterizing socioclinical characteristics of patients diagnosed with BPD who were admitted to PARC and to describe 12-month clinical outcomes after the first PARC admission.
Methods: The study will be conducted at North West Area Mental Health Service, Melbourne. This retrospective descriptive study will be based on the medical records of patients with diagnosis of BPD who had their first admission to PARC between 2011 and 2016. Both medical records and a state-wide Client Management Interface, Victoria, will be reviewed to gather information about 12-month clinical outcomes.
Results and conclusions: Findings will be discussed during the presentation.
Reference
National Health and Medical Research Council (2012) Clinical Practice Guideline for the Management of Borderline Personality Disorder. Melbourne: National Health and Medical Research Council.
The Moderation Effects of Autistic Personality Traits on the Association Between Childhood Trauma and Suicide Attempt in a Non-Clinical Sample
J Liu1, J Gong2, Y He3, J Lu1
1Department of Child Psychiatry of Shenzhen Kangning Hospital, Shenzhen Mental Health Center, Shenzhen Institute of Mental Health, ShenZhen Key Laboratory of Mental Health; Shenzhen, China
2Department of Applied Psychology, Traditional Chinese Medicine University of Hunan, Changsha, China
3Mental Health Institute of The Second Xiangya Hospital and Key Laboratory of Psychiatry and Mental Health of Hunan Province, The Central South University, Changsha, China
Background: Childhood trauma is a known risk factor of a suicide attempt. However, the moderation of this relationship remains unclear.
Methods: A total of 1500 first-year students at the Hunan University of Chinese Medicine participated in this investigation in 2017 and 1345 first-year college students were effectively included in data analysis. Logistical regression was used to test the relationship between autistic personality traits and a suicide attempt. Moderation was tested by the Statistical Package for the Social Ssciences (SPSS) macro PROCESS (Bootstrap method with a bootstrap sample of 1000).
Findings: In single-factor analysis, childhood trauma and any type of childhood trauma significantly predicted a suicide attempt (P < 0.05). After controlling for demographic data including age, gender, family economic conditions, parental marital status, single-child, student health status and place of residence, childhood trauma (odds ratio (OR): 1.063, 95% confidence interval (CI): 1.047–1.080), emotional abuse (OR: 1.283, 95% CI: 1.212–1.359), physical abuse (OR: 1.244, 95% CI: 1.168–1.326), sexual abuse (OR: 1.225, 95% CI: 1.121–1.338), emotional neglect (OR: 1.102, 95% CI: 1.060–1.145) and physical neglect (OR: 1.104, 95% CI: 1.049–1.162) were still independent risk factors for a suicide attempt. In addition, the results of the moderation model show that autistic personality traits moderated the relationship between childhood trauma and a suicide attempt (p < 0.05).
Conclusions: Any type of childhood trauma increased the risk of a suicide attempt. Autistic personality traits moderated the relationship between childhood trauma and a suicide attempt in a non-clinical sample.
Blood-Borne Viruses in Mental Health: Screening and Treatment
K Loke1,2, A Thompson3,4, J Kilicasalan1, L Stothers3,4, Z Jenkins1,2, C Rogers1, M Nolan1, G Bennett3,4, K Myers1, M Gregory1, M Scott1, K Day1,5, D Castle1,2
1St Vincent’s Mental Health, St Vincent’s Hospital, Melbourne, Australia
2Department of Psychiatry, The University of Melbourne, Melbourne, Australia
3Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia
4Department of Medicine, The University of Melbourne, Melbourne, Australia
5Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
Background: People with mental illness are at increased risk of having a blood-borne virus (BBV) infection. Reasons for this include a higher prevalence of substance use disorder, a higher rate of high-risk behaviours (e.g. injecting drug use, unprotected sex), and social factors such as homelessness and migration that may also be associated with mental illness. People with mental illness also often have poorer treatment-seeking behaviours. Effective treatments for these three viruses are available and should be offered to those who are carrying these viruses. In particular, the direct-acting antiviral (DAA) treatments for the Hepatitis C virus (HCV) have a high cure rate and are well tolerated.
Objectives: This session aims to determine: (i) the prevalence of three BBVs (Hepatitis B and C, and the human immunodeficiency virus (HIV)) within the consumer population of St Vincent’s Mental Health; (ii) the acceptability of a programme to screen and treat for these viruses in that population; and (iii) what risk factors contribute to BBV positive status in the consumer population of St Vincent’s Mental Health.
Methods: Screening for BBVs (Hepatitis B and C, and HIV) was offered to all outpatient consumers of St Vincent’s Mental Health. A Hepatology Clinical Nurse Consultant and a Research Assistant assisted clinical staff to provide treatment and other follow-up to consumers who were screened.
Findings: Early results suggest that mental health consumers are willing to receive screening and treatment forBBVs.
Conclusions: Mental health services should implement screening and treatment programmes for BBVs for their consumers.
A Brief Intervention to Improve Rates and Quality of Physical Examinations For Admissions To Acute Adult Psychiatry Units
U Munir
Nepean Hospital, Sydney, Australia
Background: People with serious mental illness live on average 10–36 years less than the general population (Royal Australain and New Zealand College of Psychiatrists, 2016). Most of this excess mortality is attributed to physical illnesses (Lawrence et al., 2013).
Objectives: This session aims to describe a brief intervention. The study aimed to find the proportion of the patients who were physically examined within 24 hours of admission to an acute adult psychiatry unit. We also sought to assess the quality of physical examinations.
Methods: Retrospective review of the electronic medical records.
Findings: The proportion of patients receiving a physical examination increased from 36 (50.7%) in the initial audit to 41 (64.1%) in the re-audit. The mean score improved from 7.5 to 9.3 (out of 15). The rates of documenting abdominal palpation, breath sounds, and cardiac sounds increased from 32 (45.1%), 34 (47%), and 31 (43.6%) in the first round to 36 (56.2%), 41 (64.1%) and 37 (57.8%), respectively. Bowel sounds, gait and abnormal movements were referred to in 10 (14.1%), 8 (11.2%), and 5 (7%) in the first round while in the second round they were commented on in 17 (26.6%), 9 (14.1%) and 4 (6.2%), respectively. Body mass index (BMI) was calculated in 92/135 (68.1%) of patients in the study, of whom 32 (34.8%) were overweight while 33 (35.9%) were obese. Hypertension was present in 47/135 (35%) of the patients.
Conclusions: This audit illustrates that the rates of physical examination and their quality can be improved following only a small intervention. The high rates of obesity and hypertension highlight the importance of physical examination in the patients admitted to an acute psychiatric unit.
References
Lawrence D, Hancock KJ, 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: f2539.
Royal Australian and New Zealand College of Psychiatrists (2016) The economic cost of serious mental illness and comorbidities in Australia and New Zealand [Internet]. Melbourne: RANZCP [cited 2018 Oct 14]. Available at: https://www.ranzcp.org/Files/Publications/RANZCP-Serious-Mental-Illness.aspx.
Efficacy and Safety of Aripiprazole Once-Monthly in Patients With Relatively Rapid and Non-Rapid Cycling Bipolar I Disorder
M Malik1, P Such2, RA Baker1, C Zhao1, J Madera1
1Otsuka Pharmaceutical Development and Commercialization, Princeton, USA
2H. Lundbeck, Valby, Denmark
Objectives: This session aims to present an assessment of the efficacy and safety of Aripiprazole Once-monthly (AOM 400) in preventing recurrence of mood episodes in patients with rapid and non-rapid cycling bipolar I disorder (BP-I). The established role of oral aripiprazole in the treatment of BP-I and the potential for a long-acting injectable formulation to improve adherence and prevent recurrence of mood episodes led to the evaluation of AOM 400 mg in the maintenance treatment of BP-I. The objective of this post-hoc analysis was to assess the efficacy and safety of AOM 400 mg in preventing recurrence of mood episodes in patients with non-rapid cycling and relatively rapid cycling BP-I patients.
Methods: The primary objective of an open-label trial (NCT01710709) was to evaluate the effectiveness of an intramuscular (IM) depot AOM as maintenance treatment in BP-I. Rapid cyclers (⩾9 episodes in the past year) were excluded from the study. For this analysis, relatively rapid cycling was defined as cycling four or more manic, hypomanic, or depressive episodes in the past 12 months.
Results: Overall, both the time to recurrence of any mood episode and the proportion of recurrences was similar during the duration of the study. Recurrence occurred in: 93/385 (24.2%) of non-rapid cyclers and in 21/78 (26.9%) of relatively rapid cyclers.
Conclusions: In this post-hoc analysis, AOM 400 reductions in the time to recurrence and recurrence of mood episodes in both non-rapid and relatively rapid cyclers was similar.
The Augmentation of Clozapine With Fluvoxamine: A Retrospective Study in a Tertiary Mental Health Inpatient Unit
J Paul, S Varghese, T Nguyen, K Stevens, G Shymko
Peel and Rockingham Kwinana Mental Health Service, Perth, Australia
Background: Fluvoxamine inhibits the metabolism of clozapine, resulting in higher blood levels of clozapine as well as increasing the clozapine to norclozapine ratio. The augmentation of clozapine with fluvoxamine has been shown in recent studies to reduce the metabolic effects of clozapine, enhance the therapeutic effect of clozapine and help lower the oral dose of clozapine.
Objectives: This session presents a study that aims to describe the experience of augmenting clozapine with fluvoxamine in a tertiary mental health inpatient unit.
Methods: Our study included 21 adult inpatients on clozapine, which was augmented using fluvoxamine. A retrospective review of the medical files was done. Demographic data, oral dosages and blood levels of clozapine and norclozapine, before and after initiation of clozapine, along with weight and metabolic parameters were collected. Details of any side effects and clinical improvement were also noted.
Findings: The combined use of fluvoxamine and clozapine was tolerated well in most patients. There was a significant reduction in the oral dose of clozapine after fluvoxamine was added in all patients. All patients had a significant increase in the blood level of clozapine after fluvoxamine was added. A few patients had an increase in blood levels of clozapine above the recommended range. There were no serious side effects in any of the patients.
Conclusions: The augmentation of clozapine with fluvoxamine can reduce the dose of clozapine required to treat psychosis and to achieve therapeutic blood levels of clozapine. The combination can be used safely in patients who are not tolerating higher dosages of clozapine.
References
Polcwiartek C and Nielsen J (2016) The clinical potentials of adjunctive fluvoxamine to clozapine treatment: a systematic review. Psychopharmacology (Berl) 233(5): 741–750. DOI: 10.1007/s00213-015-4161-1.
Shymko G, Clark V, Shymko L, et al. (2018). Navigating the co-prescription of clozapine and fluvoxamine. Schizophrenia Research 202: 391–393. DOI: 10.1016/j.schres.2018.05.034.
A Rare Case of Striatal Contractures in Drug-Induced Parkinsonism
C Perera1,2,3, A Bragg4, D Dowdall2, T Hollingsworth2
1Redcliffe–Caboolture Mental Health Service, Caboolture, Australia
2Metro-North Mental Health, Brisbane, Australia
3University of Queensland, Brisbane, Australia
4The Prince Charles Hospital, Chermside, Australia
Background: Striatal deformities were first described by JM Charcot in 1877 as being like rheumatoid arthritis but without the inflammation. These contractures occur specifically in patients with Parkinson’s disease. Since these times there is a clear body of evidence describing this presentation in association with the latter stages of Parkinson’s disease. However, we have been unable to clearly identify a reported case of these contractures in a patient with drug-induced parkinsonism (DIP).
Conclusions: Here we present a patient with high probability of DIP with hand striatal deformity as a sign of DIP. The case is extremely rare and may provide some clues to the overlapping nature and pathogenesis of the condition, particularly given the long-term exposure to early generation dopamine antagonists.
Royal Australian and New Zealand College of Psychiatrists’ Work on Asylum Seeker and Refugee Mental Health
Asylum Seeker and Refugee Mental Health Working Group, Royal Australian and New Zealand College of Psychiatrists
Background: Asylum seekers and refugees are among the most vulnerable and marginalized people in our community, many having experienced torture, trauma and other catastrophic events prior to displacement and flight. These groups have poorer mental health outcomes and poor access to health services compared to the general population.
Objectives: This session aims to illustrate some of the initiatives that the Royal Australian and New Zealand College of Psychiatrists (RANZCP) has undertaken to help improve the mental health and well-being of asylum seekers and refugees in Australia.
Methods: To advocate for improved mental health outcomes for refugees and asylum seekers, the RANZCP established the Asylum Seeker and Refugee Mental Health Working Group and maintains two position statements to reflect its concerns, and to call for policy change to improve mental health outcomes. The RANZCP also maintains a professional practice guideline which provides guidance on key ethical and professional practice issues that psychiatrists may encounter when working in immigration detention centres.
The RANZCP’s recognition of the importance of working with other organizations is reflected in its involvement in the national Migrant and Refugee Women‘s Health Partnership and its joining with the Royal Australasian College of Physicians and the Royal Australian College of General Practitioners to write an open letter to the Australian Government about the health and well-being of the men transferred to immigration detention in Papua New Guinea.
Findings: The RANZCP, through its position statements, practice resources, educational opportunities and collaborations with other bodies, has consistently advocated for improvements in mental health outcomes and service provision for asylum seekers and refugees. This includes the RANZCP promoting these issues through the Australian media and with Australian Federal Ministers.
Conclusions: Much more is needed in Australia to improve mental healthcare access and outcomes for asylum seekers and refugees. Psychiatrists have an important role to play in the clinical care of these populations, as well as in advocating for necessary supports and services.
Supporting Quality Clinical Care
Committee for Evidence-Based Practice, Royal Australian and New Zealand College of Psychiatrists
Background: The Committee for Evidence-Based Practice (CEBP), also known colloquially as the ‘What Works Committee’ is a constituent committee of the Royal Australian and New Zealand College of Psychiatrists’ (RANZCP’s) Practice, Policy and Partnerships Committee (PPPC). The Committee’s role is to support high-quality psychiatric clinical practice with a focus on therapeutic interventions and evidence-based practice.
Objectives: The Committee’s objectives include to:
promote the development and updating of policies, guidance and practical resources
provide oversight of the development and updating of Clinical Practice Guidelines and advise on dissemination and implementation
support clinical practice improvement activities
provide input to consultations and enquires from governments and other external stakeholders
consider relevant issues referred by the Board, the PPPC, and other committees, Faculties and Sections.
Methods: The Committee’s membership comprises Fellows, Community Members (consumers/carers) and trainee representation. The Committee meets face-to-face two times per year, with additional teleconferences and email consultation as needed.
The Committee considers and agrees on priorities for the annual work plan through consultation with other RANZCP Committees, Faculties and Sections.
Findings: This poster presentation will highlight the work of the Committee and showcase the policies, guidance and resources that are available for members to support therapeutic interventions and evidence-based practice.
Conclusions: The Committee welcomes the input of RANZCP members to their work, especially in determining priorities and in developing innovative ways to support improved clinical practice.
Enabling Supported Decision-Making
Enabling Supported Decision-Making Committee, Subcommittee of the Victorian Branch, Royal Australian and New Zealand College of Psychiatrists
Background: The Mental Health Act 2014 (Victoria) introduced a supported decision-making (SDM) model for people living with mental illness and who are subject to compulsory assessment and treatment.
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Enabling Supported Decision-Making Committee, made up of equal numbers of consumers and clinicians, coproduced training and resources to support psychiatrists and trainees to enable SDM in practice, funded by the Victorian Department of Health and Human Services.
Objectives: The Committee aims to:
improve outcomes and experiences of care for consumers, carers and families
enable psychiatrists and trainees to support consumers to have control and choice over decisions relating to their treatment, care and recovery
apply co-production methodology to the project
Methods: This project was delivered using a co-production methodology which mirrors the three guiding principles of co-production (Roper et al., 2018).
Findings: In 2018 The RANZCP Victorian branch co-produced training and resources targeted at psychiatrists and trainees, including the Enabling Supported Decision-Making Position Paper, an interactive training workshop and an online module. All interactive training workshop participants were asked to complete a pre-workshop self-evaluation of their knowledge and skills around SDM, a post-workshop self-evaluation and implementation plan, and a 3-month evaluation of change. This poster will present these findings and recommendations for the future.
Conclusions: The RANZCP’s commitment to this project and adopting SDM underscores a commitment to Australia’s signatory status of the United Nations Convention on the Rights of Persons with Disabilities to promote, protect and ensure the full and equal enjoyment of the human rights of all persons with a disability.
Reference
Roper C, Grey F and Cadogan E (2018) Co-production. Putting principles into practice in mental health contexts. Available at: https://recoverylibrary.unimelb.edu.au/__data/assets/pdf_file/0010/2659969/Coproduction_putting-principles-into-practice.pdf.
Royal Australian and New Zealand College of Psychiatrists: Informing and Influencing Mental Health Policy
Practice, Policy and Partnerships Department, Royal Australian and New Zealand College of Psychiatrists
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) undertakes policy and advocacy work on a wide range of priority topics and issues, under the guidance of the Board, the Practice, Policy and Partnerships Committee, the Office of the President and Chief Executive Officer, and other expert committees and groups. As the peak body representing psychiatrists in Australia and New Zealand, the RANZCP is proactive in developing its own policies (e.g. position statements) as well as aiming to inform and influence mental health policy being developed by governments and other key stakeholders.
Objectives: This session aims to report on the extent and impact of the RANZCP’s policy work for the 2018 year on a range of issues at national and jurisdictional levels, relevant to psychiatric practice, mental healthcare service delivery, education, research and mental health outcomes for the community.
Methods: Strategies and initiatives to develop and influence policy include the development of formal submissions to consultations and inquiries being conducted by governments and others. By the end of 2018 it is anticipated that the College will have made more than 150 submissions to jurisdictional and national governments and organizations. The Practice, Policy and Partnerships Department works closely with College committees and groups to draft the submissions, and in collaboration with other sections of the College including external relations and communications.
In addition to submissions the College maintains and continues to strengthen its own suite of policy documentation, which is increasingly used as a basis for advocacy on priority topics with governments and other key stakeholders.
Findings: This poster will present the findings of an analysis of the extent and impact of the RANZCP’s policy work for 2018. Finding direct causal relationships between policy advocacy and policy change is challenging due to the complexity of the policy-making space, which encompasses shifting policy goals as well as external forces and conditions. To address this, the policy team has developed, and is piloting, a number of proxy indicators to assess impact, such as being referenced in final reports, quoted in media, and invited to appear at public hearings.
Conclusions: The RANZCP’s activity in influencing policy is significant and growing. This work requires investment of resources and committees’ and members’ time and expertise, and therefore warrants monitoring and evaluation. A number of factors have been identified as being potential measures and are being piloted. This work will inform the development of an agreed framework to enable future reporting on the extent, impact and influence of the College’s policy work.
A New Scale to Capture Various Facets of Stigmatizing Attitudes Towards Mental Illness Among Medical Students
S Rotstein1,2,3, A Hudaib1
1Monash Alfred Psychiatry Research Centre, Melbourne, Australia
2Monash University, Melbourne, Australia
3Alfred Health, Melbourne Australia
Background: The concept of ‘stigma against mental illness’ covers a broad range of attitudes and misunderstandings regarding mental health, mental illness, psychiatry and psychiatrists. The Mental Illness Clinicians’ Attitudes Scale Version 2 (MICA-2) has been developed to measure medical students’ stigma; however, it is a single-factor scale and does not allow for detection of various types of stigma.
Objectives: This session aims to describe the development of a new scale that captures the various elements of ‘stigma against mental illness.’
Methods: An online survey was distributed to medical students. The scale consisted of 27 items; the 16 items from the MICA-2 and 11 items created based on the investigators’ review of the literature and experience.
Findings: Initial factor analysis revealed a four-factor structure. The four factors have been titled: Legitimacy of Psychiatry, Blame & Undeserving, Hopeless & Danger and Disclosure. The results of further analysis will be presented at the RANZCP 2019 Congress.
Conclusions: The findings support the validity of this new scale and the view of stigma as being composed of various differing facets.
The Young, the Restless and the Forensic Psychiatrists: Psychiatry in Soap Opera Culture
N Rowe
Northern Adelaide Local Health Network, Adelaide, Australia
Background: Soap operas are addictive vehicles for popular culture. But their portrayal of psychiatry is as yet unresearched.
Objectives: This session aims to examine whether the perception of psychiatry in soap opera culture is generally positive or negative, and to identify specific themes for its presentation.
Methods: Brigham Young University’s SOAP database of 100 million words from 22,000 soap opera transcripts from 2001 to 2012, was searched for ‘psychiatrist’, ‘psychiatrists’, ‘psychiatry’ and ‘psychiatric’. The most frequent nouns and adjectives occurring within 5 words of the key words were extracted and coded by their connotations as positive, neutral or negative.
Findings: Fourteen of the hundred most frequent words in the corpus (help, need, right, want, good, care, hope, better, kind, believe, family, treatment, professional and friend) have positive connotations. However, committed, evaluation, court, facility and Judge are also among the hundred most frequently associated words, with prison, wrong, appointed, crazy and shrink among the 125–150 most common.
Conclusions: The most prominent positive words suggest supportive intervention, good treatment and recovery; they also align with the revised Fellowship Competencies of the Royal Australian and New Zealand College of Psychiatrists. The emphasis on forensic work is at odds with its proportion of overall psychiatric practice. The prominence of forensic psychiatry in soap operas may make viewers less likely to realize that psychiatrists can help them with anxiety or depression, which will make for less dramatic television. Whether this discourages help-seeking behaviour is a fruitful avenue for further research.
Improving Schizophrenia Treatment: Optimizing Clinical Trial Length
A Solar1,2, Gary Hulse1, Kelly Bennett1
1University of Western Australia, Perth, Australia
2Sir Charles Gairdner Hospital, Perth, Australia
Background: Three clinical trials are evaluating three new interventions at a Mental Health Unit (MHU). These interventions aim to enhance engaging people with schizophrenia, by choice, with community: alcohol and drug rehabilitation; therapy for distressing voice hallucinations; and supported employment. Recruitment patterns predicted a 7-year maximum trial length. This length can be shortened by asking the single most important question of each trial’s preliminary data.
Objectives: This session aims to demonstrate how to make the timeline more efficient of a single site, single blind, randomized controlled trial.
Methods: Reflection about the trials’ processes because participant recruitment has been operating for 21 months in the first trial and 15 months in the other two trials.
Findings: (i) Preliminary data analysis of 20 participants in the first trial, and 20 and 18 participants in the other 2 trials, respectively, regarding a single key engagement question with either ‘yes’ or ‘no’, using parametric binary statistical analysis, can decrease the number of participants required to show a statistical difference between treatment groups. (ii) Switching to a randomization list allows an even number in each group at the end point determined by this analysis. (iii) The daily presence of the authors and education and communication at the MHU can improve the likelihood of all patients meeting the inclusion criteria, being invited to contribute to clinical research. This presence also increases patient and staff acceptance of participation in research, hopeful of improving treatment for schizophrenia.
Conclusion: Clinical trials to improve treatment from a MHU can answer one question well in a manageable timeframe.
A Comparison Study of Three Physical Activity Measurement Tools Examining Acceptability in People With Psychotic Disorders
S Suetani1,2,3, J Chapman3, N Korman3, C Chapman3, F Dark3, C Dodd3, S Parker2,3, D Siskind1,3
1Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia
2Queensland Brain Institute, The University of Queensland, St Lucia, Australia
3Metro South Addiction and Mental Health Services, Brisbane, Australia
Background: People with psychotic disorders die more than 16 years younger than the general population, partly due to lack of exercise and sedentary behaviour. There has been limited testing of the acceptability and validity of physical activity (PA) measures among people with psychotic disorders.
Objectives: This session aims to compare the acceptability to patients with psychotic disorders of three distinct PA measurement tools: (i) the self-reported Simple Physical Activity Questionnaire (SIMPAQ); (ii) an objective physical activity measurement tool (GENEactiv wrist-worn accelerometer); and (iii) the 6 Minute Walk Test (6MWT).
Methods: Sixty individuals with primary diagnoses of psychotic disorders were recruited. Each participant was given a GENEactiv wrist-worn accelerometer to wear day and night for the following 7 days. On day 8, another face-to-face assessment was conducted to administer the SIMPAQ and 6MWT. We also asked participants to rate the ease or difficulty of completing these measures using a 7-point Likert scale.
Findings: The GENEactiv was the most acceptable of the measurement tools with 60% of the participants preferring it over the other two tools. The SIMPAQ was the least acceptable tool with 49% of participants rating it the most difficult measure to complete. Acceptability of the 6MWT was 23.5%. Of interest, most (86.7%) participants found it easy to wear GENEactiv for 7 days continuously.
Conclusions: These findings suggest that gold standard assessments such as accelerometry wrist monitors are acceptable to assess PA in people with psychotic disorders.
Metabolic Monitoring in a Community-Based Psychosis-Specific Adult Mental Health Service
J Teo, D Siskind
Metro South Addiction and Mental Health Services, Brisbane, Australia
University of Queensland, Brisbane, Australia
Background: Cardiometabolic complications are a significant problem in the management of schizophrenia spectrum disorders, treated with atypical antipsychotics. Clinical practice guidelines recommend metabolic profiling every 612 months, but adherence to these standards may vary.
Objectives: This session aims to describe the determination of the prevalence of cardiometabolic risk factors in a community-based adult mental health service and ascertain the degree of blood testing uptake.
Methods: We retrospectively audited anthropometric and metabolic parameters of patients who attended the centre between December 2017 and August 2018. These parameters included: age, sex, body mass index (BMI) and triglyceride (TG) levels (as an indicator of dyslipidaemia and developing insulin resistance). Patients received a blood request form on initial visit and were reviewed 8 weeks later.
Findings: Of 198 patients (61% male, median age 42 years), 39.9% were from culturally and linguistically diverse (CALD) or Aboriginal and Torres Strait Islander backgrounds. A total of 178 (89.9%) patients were prescribed atypical antipsychotics. The BMI was calculated for 106 patients (53.5%) (median BMI 30.8, range 17.4–60) with 80.2% of patients in the overweight category or above (BMI > 25). TG levels were only available for 62 (31.3%) patients. Median TG level was 1.4 mmol/L (range 0.5–6.1, normal range < 2.2) with 11 (17.7%) patients with elevated TG levels. Adverse parameters were not enriched in CALD or Aboriginal and Torres Strait Islander patients.
Conclusions: Our results demonstrate a high prevalence of obesity in already high-risk patients taking atypical antipsychotics. TG levels were satisfactory; however, most patients did not complete blood testing. Althougha formalized metabolic monitoring programme would facilitate more comprehensive data collection, patient non-adherence to blood testing may represent an important barrier.
Nitrous Oxide-Associated Psychotic Disorder
J Teo, U Kolur
Metro South Addiction and Mental Health Services, Brisbane, Australia
University of Queensland, Brisbane, Australia
Background: Dinitrogen oxide (nitrous oxide, N2O) abuse is increasingly commonplace; N2O bulbs are legally obtainable and readily available. While transient psychotic states have previously been associated with its use, persistent psychosis is less frequently described.
Objectives: This session describes a case of treatment-refractory psychosis related to N2O.
Methods: Case report documenting the clinical features of a rare presentation of N2O-associated psychotic disorder.
Findings: A 37-year-old male, with no prior psychiatric history, was admitted to an acute psychiatric unit, presenting with florid psychosis involving persecutory and misidentification delusions, thought disorder and grossly disorganized behaviour. A fluctuating course was noted, with episodes of severe distress and disorganization, interspersed with periods of relative lucidity. There was a 6-month history of N2O abuse, reported by the patient to involve approximately 6–12 N2O cream charger bulbs inhaled via whipped cream canister daily.
Organic screening, to a ceiling of Computed tomography (CT) brain imaging, was unremarkable. A urine drug screen was unremarkable, with a positive benzodiazepine result iatrogenic in origin.
The patient was unresponsive to sequential trials of two high-potency atypical antipsychotics. Due to his level of behavioural disorganization and agitation, multiple seclusion episodes were required. He received four sessions of electroconvulsive therapy (ECT), with satisfactory improvement. He was subsequently discharged to the community under an Involuntary Order, on risperidone (4 mg daily).
Conclusions: This case highlights a worrying trend of psychosis precipitated by N2O abuse. While previous literature has highlighted the importance of investigation and management of reversible medical causes, the longer-term sequelae of psychotic illnesses triggered by N2O abuse are deserving of further study.
A Case Report of a Catatonic Sailor and an Overview of the Diagnosis and Management of Catatonia in a Tertiary Psychiatric Hospital in Singapore
P Thiagayson, JK Lee, APL Sim, DK Gupta
East Zone, Institute of Mental Health, Singapore
Background: First described by German psychiatrist Karl Ludwig Kaulbaum in 1874, catatonia is a psychomotor disturbance characterized by motor and behavioural changes.
Objectives: In this poster, we present the case of a sailor who was admitted and treated for catatonia at the Institute of Mental Health (IMH), a tertiary psychiatric hospital in Singapore.
Methods: We describe the patient’s initial symptoms while on board his ship, symptoms on presentation to IMH and symptom evolution while an inpatient. We report our use of the Lorazepam challenge test to confirm our diagnosis of catatonia. We detail our management of the patient using a biopsychosocial approach including organic workup, Lorazepam drug therapy and electroconvulsive therapy. During his stay in the inpatient psychiatric unit, the patient was noted to have episodes of tachycardia. His creatinine kinase level was also elevated. Differentials of malignant catatonia and neuroleptic malignant syndrome were considered but eventually ruled out after careful clinical assessment. This will be further elucidated in our poster.
Findings: The patient responded well to treatment and was discharged back to his homeland three weeks after presentation.
Conclusions: It is important to recognize the signs and symptoms of catatonia so that early, appropriate treatment can be instituted. Even if the underlying psychiatric disorder is unclear initially, treatment for catatonia should be instituted without any delay to prevent complications. When managing a catatonic patient with features of autonomic instability, it is important to consider malignant catatonia and neuroleptic malignant syndrome as differentials.
Audit of Antipsychotic Prescribing in People With Learning Disability
A Wighe1, F Ward2
1The Priory Group, Mildmay Oaks Hospital, Berkshire, UK
2Avon and Wiltshire Partnership Trust, Marlborough, UK
Background: Individuals with learning disability have higher mental health co-morbidities and have an increased risk of side effects from antipsychotic medications.
National guidelines recommend standards for prescribing and monitoring of antipsychotic medications for people with a learning disability.
An initial audit in March 2015 identified areas of improvement: enquiring about side effects and monitoring requirements in clinic letters. Subsequently, changes in psychiatry appointment and clinic letters were recommended and the use of a side-effect checklist.
Objectives: This session aims to describe re-auditing practice in relation to prescribing and monitoring of antipsychotic medication in people with learning disabilities and evaluating the impact of the initial recommendations.
Methods: A sample of 10 outpatients open to the learning disability psychiatry service who were currently prescribed antipsychotic medication were included. The Prescribing Observatory for Mental Health (POHM–UK) data collection tool was completed for each case.
Findings: Co-morbidity with learning disability remained high (95%), reflecting the consistency with good practice recommendations and National Institute for Health and Care Excellence (NICE) guidance. Positive improvements included a clearer indication for the use of an antipsychotic and prescribing for ‘behavioural’ problems was consistent with the last audit. A significant improvement (90% versus 50%) in the recording of side effects and movement disorder (55% versus 15%) was evidenced. Improvements in recording of actual values of metabolic parameters was also observed.
Conclusions: Improvement in practice was evidenced across all parameters. Amendments to appointment letters and recording of monitoring requirements in clinic letters was agreed to be an effective measure. Modifications to clinic letters to include monitoring of weight and blood pressure was agreed. Current practice was agreed as acceptable.
A Link to Keep in Your Radar: Dramatic Onset Behavioural Changes and Ovarian Teratoma in a Patient With Suspected Autoimmune Encephalitis At District General Hospital in Ampara, Sri Lanka
WMH Wijesundara1, WLS Mahapitiya2, DARK Dayaratne1, RM Wijesiriwardane1
1District General Hospital, Ampara, Sri Lanka
2 Neurology, Teaching Hospital, Kandy, Sri Lanka
Background: Autoimmune encephalitis (AE) is a disease involving autoantibodies directed against synaptic and neuronal cell surface antigens. Psychiatric manifestations are a common clinical presentation that often leads to misdiagnoses.
A 15-year-old school girl presented with malaise (6–7 days) and headache (4 days). With an appearance of overtalkativeness and irrelevant speech for one day, she was admitted. On day 10 of her hospital stay, psychiatric illness was suspected (mixed mood symptoms, agitation, intermittent disorientation, echolalia, and suspected visual and auditory hallucinations).
A fever spike of 100.8οF (day 12) tipped the increasing suspicion of a physical cause. With suspicion of cerebral infection, she was administered intravenous antibiotics, antiviral therapy and steroids. Neuroimaging was normal; and her electroencephalogram (EEG) was inconclusive. Neuroleptic Malignant Syndrome was excluded. Ceebrospinal fluid studies concluded partially treated bacterial meningitis.
Intravenous immunoglobulin (IVIg) therapy was initiated with a suspicion of AE. Her condition deteriorated (lowering consciousness level and focal seizures, increasing white blood cell (WBC) count and inflammatory markers, slowing on EEG, and requiring ventilation in the intensive care unit).
Ultrasonic detection of an ovarian mass and a unilateral oophorectomy of a benign teratoma led to significant improvement. She recovered and was discharged on day 51 on monthly IVIg.
During her hospital stay, her manic symptoms and agitation persisted and antipsychotics and mood stabilizers were continued. Since discharge, residual features (mood symptoms and cognitive deficits) improved slowly and psychotropic medications were gradually reduced.
Conclusions: Suspicion of AE in young adults with first psychiatric presentation is important. Thorough assessment is needed to detect clues for causes, including ovarian neoplasms, in females.
Analysis of Epidemiological Trends in Admissions to the District General Hospital, Ampara, Sri Lanka From 2012 to 2017 Due To Poisoning
H Wijesundara1, J Sujeewan2, A Ismail1
1District General Hospital, Ampara, Sri Lanka
2Obstetrics and Gynaecology, Base Hospital, Kilinochchi, Sri Lanka
Background: Poisoning is the commonest method of self-harm in Sri Lanka. Evidence suggests changing epidemiology, including regional differences in the pattern of poisoning in Sri Lanka.
Objectives: This session aims to describe trends in epidemiology of acute poisoning from 2012 to 2017 admitted to the District General Hospital–Ampara (DHG–Ampara).
Methods: Anonymous secondary data of all patients admitted with acute poisoning to DGH-Ampara were obtained from the Indoor Morbidity and Mortality data system (eIMMR) with permission from the hospital administration. The eIMMR classification of poisoning (four substance categories using the International Classification of Diseases, tenth revision (ICD-10) diagnoses: ‘organophosphate and carbamates’, ‘other pesticides’, ‘poisoning by medicinal substances’ and ‘other ‘non-medicinal substances’) was used. The 2012 population census data were used to calculate estimated population and annual incidence rates for 2013–2017.
Findings: Annual admission rate due to poisoning decreased from 297 to 159 per 100,000 from 2012 to 2017. Admissions due to ‘medicinal poisoning’, and ‘other pesticides’ decreased (124 to 62/100,000 and 61 to 18/100,000, respectively), while that of ‘carbamates and organophosphates’ remained relatively stable with mean rate of 37/100,000.
A total of 47 patients died due to poisoning. The highest mortality was in 2012 (12) and lowest in 2016 (4) with a fluctuating pattern over time. Overall, case fatality rate halved from 1.62% to 0.77% (2012–2016) but rose sharply in 2017 (1.92%). Gender and age group-related differences were observed trends.
Conclusions: Contrary to known national trends in the last 20 years, this study shows decreasing trends in overall rate of poisoning due to ‘medicinal substances’ and ‘other pesticides’ in Ampara. Poisoning due to agrochemicals remains a challenge with a high case fatality rate.
Consultation–Liaison Psychiatry Services in Shenzhen China: Trends Over An 8-Year-Period
S Zhang, J Liu, G Xie, Z Huang, W Dai, T Liu
Shenzhen Institute of Mental Health, Shenzhen Kangning Hospital, Shenzhen, China
Background: With the promulgation and unfolding of medical insurance policy and mental health services, consultation–liaison psychiatry services have changed in Shenzhen, China.
Objectives: This session describes a study to investigate the long-term trends of changes in consultation–liaison psychiatry services in Shenzhen over an 8-year-period (2009–2017).
Methods: We checked all the consultation–liaison records to collect the sociodemographic and clinical data in Shenzhen Kangning Hospital (the only psychiatric hospital in Shenzhen). Then, we described and compared the related variables with previous studies.
Findings: A total of 1377 consultation requests were received from 75 institutes. The number of consultations was: 74 (5.38%) in 2009; 87 (6.32%) in 2010; 63 (4.58%) in 2011; 108 (7.84%) in 2012; 166 (12.06%) in 2013; 198 (14.38%) in 2014; 202 (14.67%) in 2015; 250 (18.16%) in 2016; and 229 (16.63%) in 2017. They involved 721 male patients and 657 female patients (52.4% versus 47.6%); mean age was 46.70 ± 19.55 years (n = 1355). Among them, only 2.3% were younger than 18 years and 5.9% were older than 65 years. Approximately 79.3% of individuals were between 18 and 65 years of age. The top three consultation departments were: neurology (14.7%); the emergency department (8.8%); and the orthopaedics department (8.2%). The primary psychiatric diagnoses were: substance-related disorder (25.8%); organic mental disorder (23.3%); and schizophrenia spectrum disorder (17.9%). Compared with a similar survey, the gender and age differences were significant (p = 0.021 and p < 0.001).
Conclusions: Although the results were different to the previous reports, we found that the consultation–liaison psychiatry services made substantial progress in Shenzhen over these years. It suggests that the government and the public paid more attention to mental health.
The 2017-18 RANZCP Membership Engagement Survey Report
S Mackersey
Membership Engagement Committee, Royal Australian and New Zealand College of Psychiatrists
Background: In 2017-18, the Membership Engagement Committee (MEC) and the Board completed a survey to assist in understanding and measuring direct membership engagement.
Objectives: To identify relevant issues affecting and influencing the engagement of College members, and to inform future work of the College including the development of appropriate resources and programs.
Methods: From December 2017–February 2018 all members of the College were invited to complete a survey on a de-identified basis. 1,110 members responded, representing 18.4% of the membership.
Findings: Key findings included:
Respondents were generally satisfied with the College with key issues affecting satisfaction identified.
Respondents were generally satisfied with the College’s current communication with them.
The frequency and form of email and newsletter communications emerged as a theme for the College to examine further as members rated email was their preferred communication channel.
The highest rated member benefits were those linked to education and research. The lowest rated members’ benefits were packaged member benefits, such as the Member Advantage Program.
Conclusions: The MEC’s recommendations, adopted by the Board, are for the College to:
Significantly update the approach to obtaining feedback from members.
Improve the College’s current member communications systems and content strategy.
Further enhance online CPD Program management, as planned for 2019.
Develop new communication and engagement avenues via social media platforms.
Improve the information to members on how their fees are spent.
Continue to focus on what the College is doing well, and build on these strengths.
