MISSED APPOINTMENTS AT AN ABORIGINAL PERINATAL AND INFANT PSYCHIATRY CLINIC
Emma Adams
Winnunga Nimmityjah Aboriginal Health Service, Canberra, Australia
Background: This paper reflects on the clinical issue of missed appointments at a perinatal and infant mental health service in an urban Aboriginal medical centre. Non-attendance is a common but important issue occurring in most clinical settings. Non-attendance impacts on an individual's health and the provision of health services to a community.
Rates of social and emotional wellbeing difficulties are high in Aboriginal and Torres Strait Islander communities, especially with regard to trauma and loss. This suggests a significant risk of perinatal and infant issues for young parents and families. To meet this challenge, Winnunga Nimmityjah Aboriginal Health started a perinatal and infant clinic in Canberra. Engaging and collaborating with the community and adapting to what needs were discovered was thought to be the most culturally sensitive approach to starting this clinic.
Objectives: Learning goals are to identify reasons behind non-attendances in order to remedy them, and in the process to learn how factors such as culture and history can impact on service delivery to young Aboriginal and Torres Strait Islander families.
Findings and Conclusions: The audience is encouraged to look beyond any simplistic explanation of “culture” to explain non-attendance. The three major reasons for non-attendance at this clinic were (1) fear of children being taken away, (2) practicalities and survival and (3) being unaware of perinatal and infant mental health issues. The challenge is to look into how these issues can be addressed.
A NEW WAY FOR SIMGS – THE SUBSTANTIALLY COMPARABLE PATHWAY TO FELLOWSHIP
John Allan
1, Diane Neil2, Lois Lowe3
1
New South Wales Health and University of New South Wales, Sydney, CSIMGE, Chair
2
Private Practice, Melbourne CSIMGE ³Royal Australian and New Zealand College of Psychiatrists, Melbourne
Background: The RANZCP is planning to implement a new Comparability Pathway (Substantial Comparability) for Specialist International Medical Graduates (SIMGs) wishing to practise as specialist psychiatrists within Australia and New Zealand in the second half of 2011. In Phase 1, SIMGs who hold one of a limited group of psychiatric qualifications and meet other criteria including current good standing will be eligible to undertake a supervised work placement of at least 12 months and complete regular workplace-based assessments (WBAs). Satisfactory completion of this pathway will make the SIMG eligible for Fellowship of the College without the requirement of completing written and clinical exams. In Phase II additional qualifications will be assessed for comparability against a predetermined set of criteria to assess the ability of each international system to train, register and monitor practice of each psychiatrist with sufficient confidence in standards and the consistency of the group to allow the qualification to be considered substantially equivalent for practice in Australia and New Zealand. Qualifications where the holders have been well represented in the cohort of SIMGs, seeking Fellowship and from those institutions whose members have historically performed well in RANZCP Examinations will be assessed.
Discussion: The paper will describe the rationale for the pathway and details of the process including standards, the WBAs, and recruitment and training of supervisors and assessors. It will show how standards will be maintained, discuss potential problems arising from the process and consider the role of the competency model in future SIMG assessment.
HOW CLOSE OUR RELATIONS REALLY ARE
Georgiana Antoce
Consultant Psychiatrist, Private Psychiatric Practice Brisbane; Senior Lecturer, University of Queensland
In a world devoid of close relationships, we seek a re-connection through a sense of shared meaning. Yet it mostly happens inside therapeutic encounters or private searches that we open ourselves to true dialogue.
Travelling around the world and moving beyond verbal dialogues highlights the possibility of close connections across cultures, which is at the core of our shared humanity. The author will reflect on therapeutic encounters and personal experience and open a discussion about a possible path to closeness and enlarged empathy through modified clinical dialogues.
A JOURNEY OF COMPOUNDING ADVERSITY – HOW CHILDHOOD TRAUMA CHANGES THE BRAIN
Dr Anja Kriegeskotten, Lorren Arezio
Evolve Therapeutic Services, Brisbane North, Brisbane, Queensland, Australia
Background: The brain is a highly complex organ which develops in response to the stimuli and input it receives. In adults new experiences can alter pre-existing neural organisations. In children new experiences provide the organising template for neural systems, and hence form the framework with which the child interprets the world. The majority of brain functions have their foundational origins within growth and connections that occur in the first four years of life. Input during this period sets a lasting framework for how the emerging child will function, interact, perceive and understand the world as they grow. Research indicates that the brain structure of children exposed to chronic trauma and neglect develops differently than in those children raised in secure, healthy environments.
Methods and Objectives: Drawing from emerging research and clinical experience, this paper will examine how exposure to chronic childhood stress and terror results in a brain ‘hard wired’ toward a persisting state of fear; further, how such repeated activation of the stress response results in a generalised, preferred pattern of responding in this way, even if later presented with otherwise non-threatening stimuli.
Findings and Conclusions: Children who have suffered early trauma, abuse and neglect commonly present with multiple persistent sequelae including poor emotional regulation, increased anxiety, poor problem solving and impaired social relationships at all levels. If left untreated, these symptoms compound to further social and health disadvantage, usually all the way into adulthood. Clinical implications for recovery with this client group will be briefly discussed.
RECOVERY-BASED SERVICE DELIVERY AND EMERGENCY PSYCHIATRY
A/Prof. David Ash
Adelaide Health Service, and University of Adelaide
Recovery-based service delivery has increasingly informed and shaped the service organisation, orientation and culture of mental health services in recent years. “The recovery body of knowledge has not been generated and informed from a professional standpoint”, rather “recovery is rooted in the subjective experience through stories and narratives of those who have lived their struggles and triumphs over mental illness” (Helen Glover 2005). ‘Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness.” (Mark Slade 2009).
Emergency psychiatry has become a prominent sub-specialty of psychiatry over the past twenty years. Psychiatric emergencies often involve behavioural disturbance, threat of behavioural disturbance, physiological disturbance, and high-risk assessment. The inherent tension between the traditional medical model (involving benign paternalism) and the central importance of the experience of the consumer is often evident in the delivery of emergency psychiatric services. While presenting new challenges for clinicians, there is also the exciting possibility of embracing a more cooperative, consumer-centred approach in such situations.
This paper aims to explore the issues that arise in the context of incorporating recovery-based services into psychiatric emergency services, including recent developments and potential future changes to service delivery. It also covers the vexed question of whether it is either desirable or possible to measure the effectiveness or otherwise of recovery-oriented services.
EXCESSIVE COMPUTER GAMES AND INTERNET USE, ADDICTION VS EPIPHENOMENON: A CASE SERIES
Soumya Basu, Julie Stone
Latrobe Regional Hospital, Traralgon, Australia
Background: Internet and computer games have become an ever-increasing part of the day-to-day lives of many adolescents. It has been increasingly recognised that some people develop problem internet and computer game use resulting in various negative psychosocial and physical consequences.
Objectives: A broad-based understanding of this phenomenon, and the diagnostic and therapeutic challenges faced by a regional CAMHS.
Methods: Six patients who presented with school refusal and excessive computer and video game use are discussed in the case series. These individuals received a comprehensive assessment and treatment and more than a year of follow-up from a regional CAMHS. All these patients were boys between 13 and 18 years.
Findings: Along with excessive internet and videogames use all these individuals had other complex developmental, psychiatric and social issues. These included autism spectrum disorder, social phobia, PTSD, developmental trauma, emerging cluster A and cluster C traits, depression and complex developmental histories. A range of treatment options including medications, individual therapy, family therapy and group therapy had been employed with mixed results. Three patients had inpatient admissions. Individuals with a small duration of school refusal and with a supportive family and school had the best outcome.
Conclusion: It is evident from this case series that excessive computer use is a challenge which may result in serious psycho-social disadvantage. A broad-based approach, using early intervention along with a preventative approach is important to address this phenomenon which is bound to be a major challenge in this digital age.
HUMOUR AND THERAPEUTIC ENGAGEMENT ON AN ACUTE PSYCHIATRIC WARD: A RANDOMISED CONTROLLED TRIAL
David Bell
1,2, James Telfer2, Gin Malhi1,2
1
University of Sydney, Sydney, Australia
2
Royal North Shore Hospital, Sydney, Australia
Background: Humour benefits medically ill patients, but there is minimal research on its beneficial effects in those with psychiatric disorders.
Objective: This study aimed to understand the role of humour in therapeutic engagement in an acute psychiatric setting.
Method: Baseline data comprised a range of information from 80 patients on an acute psychiatric ward. This study had active and then passive exposure audio-taped components. In the active exposure arm, patients were blind and randomly assigned to a treatment and control group. The treatment consisted of 15 minutes of a nurse or case worker using themes, with a humorous focus, to encourage the patient to reminisce on their childhood experiences. The control condition was identical but minus a humorous focus. During passive exposure, patients viewed two short humorous film clips.
Findings: Greater improvements in therapeutic engagement were demonstrated with the use of humour for short duration relationships on the ward, compared to the control group. Other findings included the preference of many patients for active humour over passive humour, the minimal risks associated with using humour in an acute psychiatric setting, and mismatches between initial negative or neutral expectations of nursing staff and positive outcomes. As well, listening to a range of recordings of the reminiscing discussions provides a rich experience of patient-staff interaction when there is a focus on humour with patients with acute psychiatric conditions.
Conclusion: A focus on the use of humour by staff on an acute psychiatric ward can improve therapeutic engagement with acutely unwell patients.
WORKFORCE ACTIVITY ANALYSIS – FINDINGS FROM BARCODE SCANNER SYSTEM TRIAL
Ken Fielke, Niranjan Bidargaddi
Country Health South Australia, Adelaide, Australia
Objectives: Clinician compliance with capturing activity data is a challenge. The barcode scanner system (BSS) trial aims to explore how this system can assist clinical staff to record activities in real time, without increasing administrative workload and to ensure service planning and development is evidence based.
Methods: Using small barcode scanners, two community mental health teams have recorded real-time workload and patient outcomes data throughout the day. The scanners are then connected to a PC and the data is uploaded to the main database. This allows for easy recording and quick uploading of clinical activity.
Findings: Preliminary findings from the study indicate that the system assists frontline clinical staff in minimising their data entry workload, while improving the ability to monitor patient journey, outcomes and workload, without compromising their clinical time.
From a clinician perspective, the information captured through this system allowed qualitative understanding of work, providing valuable feedback and reflective practice for clinicians.
At an organisational level, this information has been useful in service redesign and workforce management. The data can also be utilised for cost–benefit analysis and benchmarking between services.
Conclusions: Clinicians have embraced the barcode scanner technology and its benefits in tying together data around the patient journey, key performance indicators and the associated workload to achieve outcomes. We believe that this is the first project of its type in mental health in Australia.
ESTABLISHMENT OF A MENTORING PROGRAM IN LEADERSHIP AND MANAGEMENT FOR PSYCHIATRISTS WORKING IN LEADERSHIP AND MANAGEMENT POSITIONS IN RURAL NSW
A/Prof. Scott Clark
1, Ms Maree Earle2, Ms Michelle Briggs3
1
Greater Western Area Health Service, Orange, Australia
2
The Royal Australian and New Zealand College of Psychiatrists, Sydney, Australia
3
The Royal Australian and New Zealand College of Psychiatrists, Sydney, Australia
Background: A mentoring program in leadership and management has been established to provide mentoring for clinicians in leadership and management positions across rural NSW, specifically Clinical Directors and Managers. It is important to have psychiatrists in these senior positions, and providing training and ongoing support will assist in their retention.
Objectives: The stated objectives of the mentoring program include: support for psychiatrists in rural areas; enhancement of leadership and management skills; and providing a positive impact on psychiatric service delivery, management and sustainability in rural NSW.
Method: The first twelve-month program commenced in September 2010 with an Introduction to Mentoring workshop and involves twenty participants (ten mentors and ten mentees). A second twelve-month program will commence in October 2011 involving a further twenty participants. Communication between mentoring partnerships include fortnightly or monthly contact either via telephone, videoconference, email and, where possible, via face-to-face meetings. Formal evaluation will be undertaken at three, six, and twelve months, in addition to post-program evaluation.
Findings: We will be reporting on the establishment of the program as well as presenting data for the first six months of the program.
Conclusion: Providing training, peer support and networking opportunities for psychiatrists in clinical leadership and management roles in rural and remote areas will increase recruitment and retention rates in these senior positions, and will contribute to the overall sustainability of mental health services in rural NSW.
REPORT FOR THE FIRST YEAR OF THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF PSYCHIATRISTS NSW BRANCH RURAL PSYCHIATRY PROJECT
A/Prof. Scott Clark
1, Ms Maree Earle2, Ms Michelle Briggs3
1
Greater Western Area Health Service, Orange, Australia
2
The Royal Australian and New Zealand College of Psychiatrists, Sydney, Australia
3
The Royal Australian and New Zealand College of Psychiatrists, Sydney, Australia
Background: A partnership between the NSW Department of Health and the NSW branch of The Royal Australian and New Zealand College of Psychiatrists saw the establishment of the NSW Branch Rural Psychiatry Project in 2002. Phase II of the Project began in July 2009 and will conclude in October 2012. Over the past year the Project has implemented a number of key initiatives which support psychiatrists and psychiatry training in rural NSW.
Objectives: To promote the development of a skilled rural mental health workforce and reduce the disparity between the number of metropolitan-based and rural-based psychiatrists in NSW.
Findings: During 2009 and 2010 the Project has made a number of achievements and demonstrated outcomes that contribute to building the capacity of the psychiatry workforce in rural NSW. We will present findings for the first twelve months of the Project under the following four key initiatives:
Peer Support and Continuing Professional Development
Establishment of a Mentoring Program for Clinical Leaders
Maintaining a Rural Psychiatry Recruitment Service
Redevelopment of the NSW Rural Psychiatry Project Website to Better Support the Needs of the Rural Psychiatry Workforce.
Conclusion: The Project has continued to further reduce the disparity in distribution of psychiatrists between metropolitan and rural communities in NSW. By increasing the emphasis on recruitment and retention initiatives, including enhancing and supporting training opportunities in rural NSW and improving access to continuing professional development activities, the Project has continued to better support the development of a skilled rural mental health workforce.
THE EFFECT OF PROPOSED DSM-5 DIAGNOSTIC CRITERIA ON THE PREVALENCE AND SEVERITY OF GENERALISED ANXIETY DISORDER IN OLDER ADULTS
Gerard J Byrne
1,2, Daniela C Goncalves1, Nancy A Pachana3
1
School of Medicine, University of Queensland, Brisbane, Australia
2
Royal Brisbane & Women's Hospital, Brisbane, Australia
3
School of Psychology, University of Queensland, Brisbane, Australia
Generalised Anxiety Disorder (GAD) is highly prevalent among older people and is associated with considerable non-fatal disease burden. Prevalence estimates for GAD are sensitive to diagnostic criteria, particularly hierarchical and duration rules. Proposed changes to the diagnostic criteria for GAD in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) might alter both the relative prevalence and severity of GAD among older people, with unanticipated consequences.
Accordingly, the draft DSM-5 diagnostic criteria for GAD were modelled using confidentialised unit record data from the 2007 Australian National Survey of Mental Health and Wellbeing. Diagnostic data were derived from structured interviews using the Composite International Diagnostic Interview (CIDI v3). There were 8,841 participants, including 1,905 (21.5%) aged 65 years and over. Concurrent validity was estimated through the 10-item Kessler Psychological Distress Scale (K10) and the 12-item World Health Organization Disability Assessment Schedule (WHODAS12).
Relaxation of diagnostic criteria was associated with a substantial increase in GAD prevalence for people aged 16 to 64 years. There was a much smaller increase evident in people aged 65 to 74 years. There was no change in GAD prevalence among people aged 75 years and over. Among older adults the draft DSM-5 changes were associated with reduced mean scores on both the K10 and the WHODAS12, indicating reduced severity. Thus, proposed changes to the diagnostic criteria for DSM-5 Generalised Anxiety Disorder are likely to reduce the relative population prevalence of this condition among older people and reduce its validity.
CANNABIS-INDUCED PSYCHOSIS – A PREVENTABLE AND TREATABLE CONDITION?
Andrew Campbell
NSW Mental Health Review Tribunal, VMO with Greater Western Health Services, NSW
Background: The author, with a clinical practice in Far West NSW, has reviewed Compulsory Treatment Orders in NSW over 12 years and has observed the strong association between cannabis and other drug use during adolescence and subsequent persisting psychotic disorders emerging in early adult life requiring ongoing and often compulsory treatment. However, debate still continues about whether the drugs are aggravating a preexisting susceptibility or are actually causing the disorder. Contemporary notions regarding adolescent neural development and brain plasticity indicate the maturing adolescent brain is susceptible to change from toxic substances.
Objectives: To encourage clinicians to take a systematic approach to identifying causative factors in young people with early psychosis and evaluate effective treatment outcomes.
Methods: Collating an accurate drug exposure history including hydroponic vs “bush” cannabis, ongoing use and dependence and diagnosis along with readmission rates and persisting symptoms of psychosis along with clinical course in over 1000 individual cases. Coexisting use of stimulant and other drugs was noted.
Findings: Between 75 and 80 percent of males had an onset of psychosis within five years of initiating psychosis. A lower percentage of females had a history of drug exposure in adolescence. All were given the clinical diagnosis of schizophrenia and readmissions became very uncommon once cannabis use was ceased, with a small percentage having complete symptom resolution after five years of drug abstinence.
Similar findings were noted in “forensic” cases after the individual had committed a serious offence.
Conclusions: Cannabis-induced psychosis should be recognised as a separate entity with its own optimal treatment regime. Often the main persisting disability is due to over-medication with neuroleptic medications. Clinicians will be invited to share their clinical experiences.
PSYCHIATRIC COMORBIDITY IN ADULTS WITH ASPERGER'S DISORDER
Christopher Canaris
Private Practice, Ashfield, NSW
Background: Asperger's disorder is a pervasive developmental disorder usually first diagnosed in early childhood. Many adults, however, present requesting assessment upon encountering depictions of the disorder in the media. Comorbid psychiatric and neuropsychiatric disorders are overrepresented among patients with Asperger's and other pervasive developmental disorders. Patients presenting with other psychiatric problems may have a concomitant Asperger's diagnosis, complicating the management of their presenting problems and overall psychosocial adjustment. Moreover, the literature suggests a significant overlap between the neurobiology of Asperger's disorder and other common psychiatric and neuropsychiatric disorders.
Objectives: To present an overview of psychiatric and neuropsychiatric comorbidity in Asperger's disorder and examine the impact of comorbid Asperger's disorder in a range of psychiatric and neuropsychiatric presentations including anxiety disorders, ADHD, depression, bipolar disorder, schizophrenia, language disorder, psychosexual disorders and epilepsy.
Methods: A brief literature review of psychiatric comorbidity and the putative neurobiology of Asperger's are followed by brief case presentations of patients seen in a suburban private practice setting, coupled with a discussion of the utility of the diagnosis in patient management.
Findings and Conclusions: The manifest diversity of presentations and comorbidity in Asperger's creates challenges and opportunities for the treating psychiatrist. Some patients embrace the diagnosis, providing a framework for positive therapeutic engagement and improved adjustment to the challenges of daily life. For others, the diagnosis may prove a source of stigma, reinforcing their sense of marginalisation.
CROSS-CULTURAL MENTAL HEALTH IN A RURAL SETTING – REPORT ON THE VTPU-GVAMHS SECONDARY CONSULTATION PILOT PROGRAM
Susan Mcdonough
1, Prem Chopra1, Can Tuncer1, Bev Schumacher2, Ravi Bhat2
1
Victorian Transcultural Psychiatry Unit, Melbourne, Australia
2
Goulburn Valley Area Mental Health Service, Shepparton, Australia
Background: In multicultural societies there is an increasing demand on services to provide recovery-oriented care to people from culturally and linguistically diverse (CALD) backgrounds. The Victorian Transcultural Psychiatry Unit (VTPU) is a statewide service that provides training and service development to enhance the cultural responsiveness of mental health services. Goulburn Valley Area Mental Health Service (GVAMHS) provides specialist mental health care to the Greater Shepparton area of rural Victoria, home to an increasingly diverse community that includes newly arrived refugees and migrants as well as more established ethnic communities. A secondary consultation program was developed in the context of a long-term partnership, alongside other service development initiatives and following cultural competence training.
Objectives: To outline the VTPU-GVAMHS Secondary Consultation Program.
Methods: A series of eight consultations were held in 2010. Fifty-seven participants attended and 40 completed evaluations were received. Participant feedback was analysed and supplemented by reflection of the VTPU facilitators and GVAMHS leadership team.
Findings: Participants included all members of the multidisciplinary teams at GVAMHS. Participants valued discussing cultural formulations and reflecting on aspects of culturally sensitive practice. The sessions provided an opportunity to consider how members of CALD communities experience the service, to identify areas for further service reform, and to identify systemic factors that influence recovery-oriented care in the community.
Conclusions: This program provided a valuable opportunity for clinicians in a rural area to reflect on cross-cultural mental health issues. It is proposed that this model will be expanded by the VTPU to provide a statewide secondary consultation service.
MENTAL HEALTH SERVICES IN THE ANANGU PITJANTJATJARA YANKUNYTJATJARA LANDS OF NORTHERN SOUTH AUSTRALIA
Nigel Cord-Udy
1, Maria Tomasic2, Marcus Tabart3
1
Private Practice, Adelaide, SA
2
Private Practice, Adelaide, SA, President, RANZCP
3
Central Australian Mental Health Service, Alice Springs, NT
Abstract: The Anangu Pitjantjatjara Yankunytjatjara (APY) lands are home to approximately 2500 people from three major tribal Aboriginal groups and are located in the vast north-west corner of South Australia, occupying a land area close to the size of England. The people from this region have witnessed massive changes in their social conditions during the last 70 years, having moved from a traditional indigenous lifestyle to one which is semi-urbanised. These communities have frequently been in the media spotlight for all the wrong reasons during the last 10 to 15 years and have been the subject of coronial inquests, Senate enquiries and the Mullighan Royal Commission on child sexual abuse. These communities epitomise the contemporary struggle of traditional Aboriginal culture as it tries to cope with the accelerating social changes of the last 30 years and the failure of policies and resources to effectively address the social and development needs of the communities caught up in the cultural tectonics of a rapidly changing world.
It is in this context that the authors present a clinical overview of the development of mental health services in the nine remotely located communities of the APY lands, focusing particularly upon the last 10 years. We discuss the clinical and individual challenges encountered in providing effective mental health services in this challenging, complex and often fluid environment. The psychiatry services provided have been based upon an outreach consultation liaison model of service delivery in support of local clinicians including remote area general practitioners, clinic nurses and mental health nurses. We offer suggestions for sustainable service provision and hope for the future of effective chronic psychiatric disease management in these areas while remaining cautious about the long-term implications of the unresolved social determinants of mental ill health.
EAST ARNHEM AND TOP END INDIGENOUS MENTAL HEALTH: CYCLONES, CROCODILES, BLACK MAGIC AND MAINSTREAM SERVICES
Verushka Krigovsky
1, Anne Paton1, Rodney Roulstone2, Joan Djamalaka2, Nigel Cord-Udy3
1
Top End Mental Health Service, NT
2
East Arnhem Mental Health Service, NT
3
Medical Specialist Outreach Assistance Program
Arnhem Land has been home to the Yolgnu people for 40,000 years or more. Here there is still great strength in culture and traditions. It is the site of the world famous Garma festival, the creative centre for the Yothu Yindi band's unique blend of traditional and contemporary music and the striking cross-hatching style of traditional painting. The bark petition from Yirrkala community which hangs in the halls of Parliament House in Canberra heralded the start of the indigenous land rights movement in Australia. With communities stretching from Groote Eylandt in the Gulf of Carpentaria across the Arnhem plateau to Millingimbi Island in the Arafura Sea and west to Kakadu National Park, this is a vast area of Aboriginal owned and controlled land. This is the site of Professor John Cawte's anthropological and psychiatric work during visits between 1970 and 1990.
In this paper the authors explore the unique aspects of providing mental health services in this area, in particular the importance of building close relationships across disciplines and service providers. There is particular reference to the pivotal role of Aboriginal mental health workers and the experiences of an Aboriginal psychiatric nurse.
We also focus on the influence of culture in the presentation and management of mental health clients, and the importance of a culturally sensitive multidisciplinary team approach.
REMOTE AREA INDIGENOUS PSYCHIATRY – REFLECTIONS ON NINE YEARS AS A VISITING PSYCHIATRIST
Nigel Cord-Udy
Private Practice, Adelaide SA, Medical Specialist Outreach Assistance Program
In November 2001 the author joined the federally funded Medical Specialists Outreach Assistance Program and developed a new visiting psychiatry service to the opal mining town of Coober Pedy in the far north of South Australia. From this work he developed a passionate interest in Aboriginal mental health. He provides regular clinic visits to communities in Central Australia and East Arnhem Land.
In this paper the author reflects upon the observations and experiences of his work during the last nine years with particular reference to the following topics:
The challenges of remote area service provision including personal and professional demands and sustainability, the outreach consultation liaison model, and collaboration with remote area staff including GP's, nurses, Aboriginal health workers and psychiatric nurses. The role of technology, the interface with tertiary services in cities and regional centres, the experiences of working for an Aboriginal-controlled health organisation, the role of traditional healers and what has and hasn't worked are also considered in this broad ranging overview.
A specific focus is given to the scourge of petrol sniffing, the introduction of Opal fuel and the legacy of lead as well as the intrusion, normalisation and effects of cannabis abuse, an episode of cluster suicides, the training of psychiatric registrars and medical students through remote area visits and the contrast between different areas reflecting community strength and cultural vibrancy. One aim is to demonstrate the complex but fascinating nature of this particular work.
CAREER ASPIRATIONS AND INTEREST IN PSYCHIATRY OF A GROUP OF FOURTH YEAR MEDICAL STUDENTS
Wayne De Beer
The University of Auckland, Auckland, New Zealand
Background and Objectives: Psychiatry training in New Zealand has often been characterised by recruitment difficulties and over-reliance on recruiting international medical graduates (IMG') to vacant training posts. This study reviewed the career aspirations of cohorts of fourth year medical students at the start of their psychiatry attachments at the Waikato Clinical School, New Zealand, during 2009–10.
Methods: Fifty-eight students completed a semi-structured questionnaire asking for both qualitative and quantitative details about future career aspirations, and those factors that either promoted or deterred them from considering psychiatry for vocational training. A thematic synthesis method was used to analyse recorded qualitative data.
Findings: The four predominant themes offered for psychiatry being an attractive area of medicine in which to specialise were: a scientific interest in the area, patient-centred ideals, desired lifestyle options, and previous personal work in the field. Students were deterred from considering psychiatry as a specialty for training because they were already interested in another area, had a preference for “hands on” activities (i.e. viewed psychiatry as too passive), had concerns about the lack of scientific robustness of psychiatry (i.e. a “grey area” of medicine), were influenced by the negative portrayal by the media of the field, and lastly, had personal encounters with mental health issues or patients with mental illness.
Results: The results of this survey highlight the important areas that psychiatry educators can focus on to improve recruitment into psychiatry vocational training.
ALCOHOL-RELATED DEMENTIA IN PATIENTS ADMITTED TO NSW PUBLIC HOSPITALS
Brian Draper
1,2, Rosemary Karmel3,4, Diane Gibson4, Ann Peut3,4
1
University of New South Wales, Sydney, Australia
2
Prince of Wales Hospital, Sydney, Australia
3
Australian Institute of Health and Welfare, Canberra, Australia
4
University of Canberra, Canberra, Australia
Background: Patients with alcohol-related dementia (ARD) are frequently diagnosed in hospital rather than dementia clinics.
Objectives: To describe the principal reasons for admission, medical comorbidities, interventions and outcomes of patients admitted to a NSW public hospital with ARD.
Methods: The Hospital Dementia Services Project extracted data from the NSW Admitted Patient Care Database for nearly 410,000 multi-day hospital admissions ending between July 2006 and June 2007 for people aged 50 and over. Using ICD10-AM codes, we identified ARD patients, their principal reasons for admission and medical comorbidities, and principal procedures undertaken. Outcomes were length of stay (LOS); mortality; discharge destination; and re-admission.
Findings: There were 234 same-day and 882 multi-day admissions for 300 patients diagnosed with ARD (82% male, mean age 63.9 years). ARD patients were more likely to be males and were younger than other dementia patients. Alcohol-related mental disorder was recorded in 62.5% of ARD admissions (‘harmful use’ (44.4%), intoxication (10.8%) and dependence (9.3%)). Principal reasons for admission for multi-day stays included alcohol-related mental disorder (17.6%), alcoholic liver disease (11.2%) and injuries/poisonings (9.8%). Medical comorbidity was common in the multi-day stays (mean of 4.8 diagnosis chapters). Like other dementia patients, ARD patients had longer LOS (mean of 15 days) than non-dementia patients and more transfers to residential care (6.7%). However, mortality was similar to non-dementia patients (5%). Discharge at own risk was high (3.7%). Around 40% of admissions were followed by a multi-day re-admission within 28 days.
Conclusions: ARD hospitalisations frequently have multiple medical comorbidities with poor outcomes.
MOODITATION – MINDFULNESS OF MOODS
Anthony Durrell
Consultant Psychiatrist
I have coined this term ‘mooditation’ to describe a meditation technique which is oriented towards acquiring a ‘thought-free’ mental state by using Mindfulness strategies which focus on emotional equilibrium exercises.
These mood or emotional equilibrium exercises aim to enhance emotional regulation, affect autonomy and promote insight into the links between thought generation, emotional shifts and meditative states.
Paul MacLean's Triune Brain model will be briefly revisited as it provides a framework for a simple psycho-educative mind model with three fundamental components – thoughts, emotions and consciousness.
The relationship between these three mind variables will be explored by way of analogy to very basic references to circuits, OHM's law and Faraday's pivotal experiments with wires and magnets.
The paper aims to spark some thoughtful reflection and motivate the participants towards further exploration of the mind-brain relationship.
A METHODOLOGY FOR PSYCHIATRIC FORMULATION
Irosh Fernando
Gosford Hospital, North Sydney and Central Coast Area Health Service and Department of Electrical Engineering and Computer Science, University of Newcastle
Background: Psychiatric formulation is often considered a challenging task, particularly for trainees and students in psychiatry. The process of arriving at a good psychiatric formulation involves identifying major issues of the patient and developing an explanatory system, which can be derived using known theoretical models in psychiatry. A good explanatory system should provide a high degree of coherence by linking the most relevant data and supplying a justification for the proposed management plan and its feasibility. Unfortunately, the literature on psychiatric formulation is limited, and while most existing literature describes what the formulation would look like, guidance on how to develop it is lacking.
Objective: The main objective of this research was to develop a methodology for psychiatric formulation.
Method: A methodology was proposed based on a repository of templates derived from major theoretical models in psychiatry using knowledge modeling techniques. Based on one or more theoretical models, these templates provide building blocks for linking the patient's current predicament to historical events and treatment interventions. Some templates link a single psychopathology to a recent precipitating event, early life experience, and a particular therapeutic technique based on a particular therapy model. Developing a formulation involves a process of selecting, prioritising and combining templates according to the set of main issues or psychopathology elicited. The pattern resulting from the combination of different templates provides a degree of uniqueness to the explanatory system.
Conclusion: It is expected that this methodology will help trainees and students to develop a broader understanding and skills in psychiatric formulation.
BEING A GOOD ENOUGH MOTHER WHEN YOU HAVE A SERIOUS MENTAL ILLNESS
Julia Feutrill
St John of God Healthcare, Subiaco, Perth, Western Australia
Background: A large proportion of women with schizophrenia and other serious mental illness (SMI) are having children at rates similar to the nonclinical population. There are 80–100 mothers with SMI having babies every year in WA.
It is well recognised that children with parents with mental illness are at increased risk of psychopathology throughout their lives. Much of this is considered to be related to early disruption to the mother-infant relationship and persists well beyond the symptoms of the mental illness.
Objectives: This paper describes clinical work with mothers with serious mental illness, focusing on the mother-infant relationship and utilising the Circle of Security (COS) model. The Circle of Security is a user-friendly schematic representation of the way in which children need their parents as a secure base and safe haven. The COS graphic and the COS DVD program were used in a group setting with women who had previously been admitted to hospital with a severe postnatal psychiatric illness.
Conclusions: The clinical cases are varied in their presentation and highlight challenges and potential pitfalls. These cases reinforce that working with the mother-infant dyad can be life changing for the mother and the child. We suggest that this is a valuable point of intervention and that adult perinatal mental health services are ideally placed to provide this care. The COS DVD program is a potentially low-cost, time-limited therapy with an increasing evidence base, and proved acceptable to this particularly vulnerable group of women.
EGALITARIANISM: VIRTUE OR MODERN-DAY CURSE?
Andrew Frukacz
Psychiatrist in Private Practice, Bathurst, Australia
Visiting Medical Officer, Greater Western Area Health Service, Orange, Australia
Egalitarianism has for a long time been held up as a virtue. In this perhaps controversial talk I will explore the idea that far from being a virtue, the blind and ideological pursuit of equality is a curse that can impact on the health of both individuals and cultures. Beginning with the famous statement in the Declaration of Independence regarding equality, I examine how such a statement flies in the face of the harsh realities that we as health professionals are all too familiar with.
On an individual level, I explore how our current preoccupation with egalitarianism and its cousin, consumerism, contribute to psychopathology, particularly in conditions such as post-traumatic stress disorder and adjustment disorders. I then investigate the connection between the heightened focus on egalitarianism and consumerism and the personality styles of narcissism and shame proneness which then affect the nature and severity of mental illnesses people suffer.
On a community level, the curse of egalitarianism, by denying the real differences amongst cultures and groups, effectively denies people of the care they need and deserve. This is particularly the case in the divide between city and rural, European and indigenous, and between native-born and migrants.
Ultimately we need to move away from simplistic ideological notions of treating people as equals and move towards treating people equally.
INCLUDING THE VOICE OF CHILDREN AND THEIR CLOSE RELATIONS IN PSYCHIATRY TRAINING
Elizabeth Fudge
1, Debbie Ross2, Nick Kowalenko1,3, Lydia Du Rieu1
1
Australian Infant Child Adolescent and Family Mental Health Association, Adelaide, Australia
2
COPMI (Children Of Parents with a Mental Illness) National Family Forum, Australia
3
Senior Clinical Lecturer, Psychological Medicine, University of Sydney
Background: The RANZCP's Position Statement #56, ‘Children of Parents with a Mental Illness’, notes that if children of parents with a mental illness are to benefit from proposed enhancements to practice relating to services provided to their families, “it is essential that psychiatrists themselves are involved in the development, implementation and review of good practice in this area”. For those involved in the training of psychiatrists, however, this requires a focus that is only beginning to be addressed within the profession. Calls for greater involvement of consumers and carers in the training of mental health professionals can challenge educators.
What we did: Over the last three years, the Children of Parents with a Mental Illness (COPMI) national initiative (with funding from the Department of Health and Ageing) developed, pilot-tested, evaluated and launched an online resource that can be used by sole learners and by workforce educators with small groups. It includes an extensive number of video and audio clips from children, parents, other family members and carers, mental health workers and academics. Training programs for workforce educators wishing to use the resource have also been developed and consumers and carers have participated in the training with a view to them being co-facilitators.
What this means for psychiatry workforce educators: The voice of children of parents with a mental illness and their parents is included in the training of psychiatrists. The presentation will highlight a number of ways in which this can be achieved, and highlights how this can improve routine practice.
CHILDREN ARE CLOSE RELATIONS TOO!
Debbie Ross
1, Elizabeth Fudge2, Nick Kowalenko3, Lydia Du Rieu2
1
COPMI (Children Of Parents with a Mental Illness) National Family Forum, Australia
2
Australian Infant Child Adolescent and Family Mental Health Association, Adelaide, Australia
3
Senior Clinical Lecturer, Psychological Medicine, University of Sydney
Background: Concern for their children's well-being is a powerful motivator for parents with mental illness to seek help, but that motivation can be masked if the parent is fearful that speaking openly about their parenting may result in the child/ren being removed from their care, or if it is likely that the child/ren will experience associated stigma. Psychiatric illness can greatly disrupt family life, but psychiatrists can be pivotal in assisting their patients to regain and maintain their parenting role. This not only has ramifications for the parent-patient and their recovery but also for their child. There is now mounting evidence internationally that when a parent is empowered to find meaning for themselves regarding their mental illness as it relates to their parenting and is, in turn, able to talk with their child and develop a shared meaning, there is greater acceptance of the illness by the child and enhanced resilience.
Aims: To highlight psychiatrists’ role in enhancing recovery for a parent-patient while at the same time promoting the mental health of their offspring and possibly modifying the risk of intergenerational transfer of psychiatric disorders. Participants will be provided with a ‘lived experience’ perspective and information and resources to assist them to undertake this role. New resources currently under development by the Children of Parents with a Mental Illness (COPMI) national initiative for the mental health workforce will also be outlined.
IMPACT EVALUATION OF THE AUCKLAND SPECIALIST ALCOHOL and DRUG OFFENDER PROGRAMME
Susanna Galea
1, Sue Carswell2, Judy Paulin, Hector Kaiwai, Keneti Apa
1
Community Alcohol & Drug Services, Auckland, New Zealand
2
Independent Research & Evaluation, Christchurch, New Zealand (Consultant)
Problematic drug and alcohol use by individuals is often linked with offending behaviour. In New Zealand, seven out of every ten offenders apprehended by the police are estimated to be under the influence of drugs in the period leading up to their arrests, and two in every three prisoners are estimated to have ongoing drug or alcohol problems (Department of Corrections, 2009).7 The Auckland Specialist Alcohol and Drug Offender Programme was developed to provide specialist assessment and treatment for alcohol and drug problems in a population of clients referred from the Northern Region Community Probation Services and in the four Auckland prisons. The programme model is designed with the aim of efficiently engaging large volumes of people in treatment and to provide them with a basic assessment and group treatment intervention as well as an entry point for further treatment if necessary.
An independent evaluation of the CADS Offender Programme was carried out to assess the impact of the programme on access and take-up of AOD treatment by different client groups; outcomes for clients; cost-effectiveness and value for money of the programme; and suitability of the programme for replication at other sites within New Zealand.
Overall, the offender programme was considered to have largely achieved its objectives and improved outcomes in a way that is cost-effective and represents value for money.
This presentation will report on key findings of the two-and-a-half-year pilot phase of the programme.
SOCIAL and CULTURAL CHALLENGES FOR INTERNATIONAL MEDICAL GRADUATES
Dr Manjula O'Connor
Medical Indemnity Protection Society Ltd
Background: Currently in Australia there are almost 28,000 or 40% of doctors who have trained overseas. Migrants may experience psychological, emotional or behavioural difficulties and some may have carry-over issues from historical trauma, requiring psychiatric care. For some it may be related to adaptation to the new environment. For international medical graduates (IMGs), these issues can be more acute as they contend with the pressures of practising in a profession requiring a high level of cultural understanding of their patients, excellent communication skills, as well as the art of navigating the complex health system they find themselves in. Research shows immigration can cause cultural dislocation, mental tension, impaired communication skills and loss of a sense of harmony with one's environment. Data from medical defence organisations, medical boards, various complaint bodies, even Medicare, suggests significant numbers of claims and complaints arise from communication difficulties.
Conclusions: Research is urgently needed into understanding the type of assistance best required for IMGs to successfully transition into the Australian medical workforce. This may include bridging the cultural gap with cultural competency skills, improving communication skills, enhancing connectivity with Australian society, or perhaps mentoring from established colleagues. These are questions that need answers.
PSYCHOTIC SYMPTOMS IN YOUNG ADULTS EXPOSED TO BUSHFIRES DURING CHILDHOOD – A 20 YEAR FOLLOW-UP STUDY
Cherrie Galletly
1,2,3, Miranda Van Hooff4, Alexander McFarlane4
1
Discipline of Psychiatry, University of Adelaide
2
Ramsay Health Care (SA) Mental Health Services
3
Northern Mental Health, Adelaide Health Service
4
The Centre for Military and Veterans’ Health, University of Adelaide
Childhood adversity has been shown to increase the risk of psychotic symptoms in adult life. However, there are no previous studies looking at the association between experiencing a natural disaster, such as bushfires, during childhood and the development of psychotic symptoms in young adulthood.
Eight hundred and six bushfire-exposed children and 725 control children were evaluated following the 1983 South Australian bushfires. Five hundred and twenty nine (65.6%) of the bushfire group and 464 (64%) controls participated in a follow-up study 20 years later. Childhood data on emotional and behavioural disorders and dysfunctional parenting was available. The adult assessment included the Australian National Health and Wellbeing psychosis screen and detailed information about trauma, childhood adversity and alcohol and cannabis abuse.
Of the subjects, 5.6% responded positively to the psychosis screen and 2.6% responded positively to a further probe question. Psychotic symptoms were more common in subjects exposed to a greater number of traumas, and were associated with higher rates of childhood adversity, emotional and behavioural disturbance, dysfunctional parenting, and alcohol and cannabis abuse. Subjects exposed to bushfires as children did not have a greater risk of psychosis. Our results indicate that exposure to multiple traumas, rather than a single major trauma, increases the risk of later psychosis.
EXPERIENCE OF IMPLEMENTING SMOKE-FREE MENTAL HEALTH UNITS WITH FOCUS ON INPATIENT UNITS
Ashu R Gandhi, Jose Segal, Jennifer Majoor, Paul H Katz
Eastern Health Mental Health Program, Victoria, Australia
Background: Not very long ago Victoria implemented the smoke-free policy across hospitals and mental health services. Eastern Health has three inpatient units with a total inpatient capacity of 75 beds. Eastern Health implemented the smoke-free policy across the three units in early 2009. Our experiences in implementing the policy uniformly were varied.
Objectives: The objective of this study was to investigate the challenges to the successful implementation of the policy and the barriers, seen or unseen, which affected the implementation.
Methods: We used a survey focusing primarily on the staff in the mental health inpatient units. Because of the limitations of using a structured questionnaire, we decided to use qualitative interviews. Each interview ranged from 30 to 45 minutes and was conducted by a research assistant. The interview used semi-structured questions focusing on staff experience and perception of smoking prohibition. The interview further tapped into staff members’ experience in patient care, implementation of smoke-free units and their perception of patient hostility/aggression, particularly with focus on patients who smoked. Findings: The results of the survey mostly showed a uniform experience among the nursing staff across the three inpatient units. Most of the staff felt that smoking was a rapport-building tool, and with smoke-free policies there was an increased perception of irritability, hostility and aggression from patients, at times resulting in avoidable incidents. The presentation includes detailed results.
Conclusions: Implementation of smoking bans needs careful consideration along with education and staff support for effective implementation.
DIFFERENT PRESENTATIONS OF BORDERLINE PERSONALITY IN CALD COMMUNITIES: A FACT OR AN ARTEFACT?
Nagesh Pai
1, Vikas Garg2
1
University of Wollongong
2
Mirrabook inpatient unit, Shellharbour Hospital
Background: Psychological and socio cultural influences associated with each ethnicity are likely to result in widely differing symptom structures of psychiatric presentations; hence, using existing classificatory systems can pose limitations on the accurate estimation of prevalence of disorders.
Objectives: A pilot project is taken up to examine the prevalence of borderline disorder patients in CALD communities in a hospital setting in the Illawarra region. The characteristic findings of this population are described.
Conclusion: Because emotional expression may be more tolerated in CALD communities, and the isolating effects that dissociation, feelings of emptiness, and fears of abandonment have on individuals from ethnic groups that place a higher value on group cohesion, this has important implications for applied clinical settings and provides a potential framework for assessing and treating the symptomatology within CALD groups.
IDENTIFYING GAPS IN THE NSW MENTAL HEALTH ACT IN THE LIGHT OF INTERNATIONAL CONVENTIONS
Dr Vikas Garg
Consultant Psychiatrist, South Eastern Sydney and Illawarra Area Health Service; University of Wollongong and Illawarra Health and Medical Research Institute
Background: Mental health legislation is complex and needs to be reviewed in the light of new conventions such as the Conventions on the Rights of Persons with Disabilities. The purpose of reviewing a legislation is to keep it up to date with the changing social, cultural and legal dimensions and keep it up to date with newer understanding of mental illness. The WHO Checklist on Mental Health Legislation is a tool that aids in the complex phenomena.
Objective: To review the NSW Mental Health Act in the light of international conventions and identify gaps.
Results: The WHO checklist was applied to the legislation and it was found that the NSW Mental Health Act was in line with international conventions. However, recommendations are made to improve the legislation as there were some aspects that needed revision.
Conclusion: The NSW Mental Health Act is in line with international conventions on many aspects of the WHO checklist.
DIFFERENT COMPONENTS OF MENTAL HEALTH LEGISLATION
Dr Vikas Garg
Consultant Psychiatrist, South Eastern Sydney and Illawarra Area Health Service; University of Wollongong and Illawarra Health and Medical Research Institute
Background: Mental health legislation is complex. The World Health Organization's Checklist on Mental Health Legislation identifies the elements necessary to meet international standards.
Objective: A review of the WHO Checklist on Mental Health Legislation.
Results: The WHO checklist features 26 items and covers in detail what should be present to make legislation relevant to the changing social and cultural reality.
Conclusion: The WHO checklist is an important tool that clinicians should be aware of and use appropriately to work to improve legislation.
ORGANIC WORK-UP: IS IT WORTH IT?
Dr Vikas Garg
1, Dr Hafeez Ahmad2
1
Consultant Psychiatrist, South Eastern Sydney and Illawarra Area Health Service; University of Wollongong and Illawarra Health and Medical Research Institute
2
Psychiatric Registrar, South Eastern Sydney and Illawarra Area Health Service
Background: Organic work-up is a regular and intricate part of psychiatric assessment and management. “Medical clearance” is a basis for psychiatric admission. Inspite of all these, psychiatric patients undergo organic investigation. The commonest test involves complete blood count, biochemistry, liver functions, renal functions, thyroid, MRI brain scan and/or CT brain scan, and EEG. All patients admitted to Mirrabook undergo a complete medical evaluation. We investigated these outcomes to discover whether they were cost-effective?
Objective/methods: We looked at all the admissions at Mirrabook from January to December 2010 and explored the organic disorder outcomes.
Results: More than 250 admission, or less than 10% of patients, showed organic abnormality. Only three patients had an EEG abnormality; three patients had features of lacunar infarct, cortical atrophy; SPECT or PET was done for one patient; a cerebral perfusion scan was done for one patient.
Conclusion: Though organic investigations are used routinely, their yield is low. Their use validates exclusion criteria. Whether regular use of organic investigation is a form of defensive practice or whether it is an overuse still remains debatable.
REDUCING RESTRAINTS AND SECLUSION IN AN ACUTE AGED PERSONS MENTAL HEALTH UNIT
Kuruvilla George, Hemalatha Sivakumaran, Kenneth Pfukwa
Aged Persons Mental Health, Eastern Health, Victoria
Background: The use of restraints and seclusion in inpatient mental health settings has drawn considerable international and national debate with regard to its legal, ethical and clinical dilemmas. There has been little published about acute aged inpatient units.
Objective: This paper captures changes in practice that have led to a significant reduction in restraint and seclusion rates in an acute aged person' mental health unit.
Method: As a quality activity by a multidisciplinary working party, data was gathered in 2009 from reports prepared for the Chief Psychiatrist's Office in Victoria, as well as from a random documentation audit of patient files and qualitative data gathered from a short nursing staff survey. A retrospective look over the last five years and the factors that have influenced change were also gathered through interviews with management.
Results: Four major factors have been positively identified as making an impact on reducing rates of restraint use and seclusion in South Ward. These include leadership and support from management in nursing practices, increased multidisciplinary team input, renovations to the inpatient setting, and changes in treatment-related factors such as collection of behaviour management history and improving documentation in patient files.
Conclusion: Experiences such as this provide insights and practical strategies that can be applied in other aged inpatient units to reduce or eliminate rates of seclusion and use of restraints.
AN INTENSIVE COMMUNITY TEAM IN AGED PERSONS, MENTAL HEALTH
Kuruvilla George, Shraevani Giri
Peter James Centre, Eastern Health, Victoria
Objective: To describe an Intensive Community Team (ICT) in aged persons' mental health.
Method: The rationale for setting up the team, the principles, service activity and findings from the evaluation of the service are described.
Conclusions: The program was found to provide substantial support and patient benefit. ICT does not replace the need for acute inpatient beds, but it does provide an opportunity for some patients to be managed in their homes who otherwise would have been admitted, and it also has the potential to reduce the length of stay for a number of patients.
COMMUNITY TREATMENT ORDERS FOR INDIVIDUALS WITH A MENTAL ILLNESS IN NEW SOUTH WALES: A DESCRIPTIVE ANALYSIS OF PSYCHOTROPIC DRUG USE
Natasa Gisev
1, J. Simon Bell1,2,3, Timothy F. Chen1
1
Faculty of Pharmacy, The University of Sydney, Sydney, Australia
2
Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
3
Clinical Pharmacology and Geriatric Pharmacotherapy Unit, School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
Background: Community Treatment Orders (CTOs) are legal orders which outline a treatment plan that an individual must accept in the community. It is uncertain whether CTOs result in improved clinical outcomes, social functioning, or reduce inpatient admissions.1 Psychotropic drugs are a significant component of CTOs and long-acting antipsychotic injections (LAIs) are often prescribed to promote adherence.2,3
Objective: To evaluate psychotropic drug utilisation patterns among individuals with mental illness receiving a CTO in New South Wales.
Methods: A retrospective review of case notes and treatment plans of a random sample of individuals, using records held by the Mental Health Review Tribunal of New South Wales. The initial sampling frame included all individuals receiving a CTO in 2009 (n = 2856). After the development and piloting of a standardised proforma, information relating to individuals’ treatment management plans as well as demographic, clinical and psychosocial details were collected.
Findings: A total of 378 cases were reviewed. The mean age was 42.6 (SD 13.3) years and 66.0% (n = 250) were male. Psychotic disorders were the principal diagnosis in 64.0% (n = 242) of individuals. The mean number of psychotropic drugs prescribed was 1.8 (SD 0.9). 56.2% were receiving an oral antipsychotic and 43.1% a LAI. Antipsychotic polypharmacy was evident in 39.6% of individuals, with 16.6% receiving a first-generation LAI antipsychotic and a second-generation oral antipsychotic. Risperidone (51.9%, n = 196) and zuclopenthixol (23.0%, n = 87) were the most common antipsychotics prescribed.
Conclusions: Psychotropic drugs were widely prescribed among individuals receiving a CTO, with an equal distribution of oral and LAI antipsychotic users.
Acknowledgments: The New South Wales Mental Health Review Tribunal.
References
1. Kisely SR, Campbell LA, Preston NJ. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews. 2005;Issue 3: Art. No.: CD004408. DOI: 004410.001002/14651858.CD14004408. pub14651852.
2. Lambert TJ, Singh BS, Patel MX. Community treatment orders and antipsychotic long-acting injections. Br J Psychiatry 2009; 195: S57–S62.
3. Muirhead D, Harvey C, Ingram G. Effectiveness of community treatment orders for treatment of schizophrenia with oral or depot antipsychotic medication: clinical outcomes. Aust N Z J Psychiatry 2008; 42:732–739.
WHY IS PSYCHIATRY SO LOW WHEN THE BRAIN IS SO HIGH?
Mila Goldner-Vukov
1,2, Laurie Jo Moore1
1
Cairns and Hinterlands Mental Health and ATODS Service, Cairns, Australia
2
James Cook University Australia
This presentation discusses some aspects of the history and origins of psychiatry through the myth of Psyche. Psychiatry represents one of the most developed disciplines in medicine that integrates a broad spectrum of neurobiology, psychology, sociology, theology, philosophy, anthropology and political science. It explores the dynamic of why other medical disciplines tend to devalue psychiatry, psychiatric patients and their psychiatric colleagues. Several cases will be presented to illustrate this and Bion's group dynamics will be discussed, as well as other possible aetiological factors. Suggestions will be made about what can be done to correct this misunderstanding and improve the quality of care for psychiatric patients.
THE PRACTICE OF PSYCHIATRY IN A MULTICULTURAL ENVIRONMENT ON BOTH SIDES OF THE CONSULTING DESK
James Greenwood
Associate Professor of Psychiatry, University of New South Wales, Sydney, Australia
Background: The population cultural mix in Australia is changing quickly. Our practice of psychiatry has remained based in the historic Anglo-Saxon culture of Australia's past. In metropolitan areas, services are being provided by doctors from other cultures, and patients seeking service also derive more frequently from other cultures.
Although classification systems such as the DSM IV have tried to remove culture from the definitions of mental illness, the practice of psychiatry requires that a culture-based decision be made for diagnosis. In rural and remote regions of Australia, psychiatric services are being provided by an even greater proportion of practitioners from other cultural backgrounds, and to people whose culture can be entirely alien to them, such as traditional Aboriginal communities where English may not be a language option.
Objectives: This presentation attempts to demonstrate the difficulties that can present to the practice of psychiatry, and uses contemporary examples to illustrate where these difficulties have occurred, with discussion of the significant consequences that could potentially arise.
Conclusion: It is becoming more important to make an adequate cultural assessment that includes both the practitioner and the patient in a psychiatric assessment to take cultural variations into account. The benefits and potential adverse consequences show both cost benefit and outcomes benefit.
BEYONDBLUE DOCTORS’ MENTAL HEALTH PROGRAM
Dr Mukesh C. Haikerwal
beyondblue: the national depression initiative, Australia
Background: Research and media reports have highlighted the consistently high rates of depression, anxiety disorders, suicide, substance use and self-prescribing in the medical profession. To address this pattern of illness beyondblue developed, in consultation with key stakeholders, the beyondblue Doctors’ Mental Health Program (bbDMHP).
Objectives: The key objectives of the bbDMHP are to:
increase awareness of the symptoms of depression and anxiety disorders
identify risk factors for depression and anxiety disorders
reduce barriers to help-seeking
promote existing services and supports.
Methods:
beyondblue established an Advisory Committee to inform the development, implementation and evaluation of the bbDMHP, which is complemented by an Expert Reference Group. The first activity of the bbDMHP was to undertake a systematic literature review (SLR) investigating issues associated with the mental health of medical students and practitioners.
Findings: The SLR found that:
there is limited Australian research examining issues associated with the mental health of medical students and practitioners
in Australia, medical practitioners have a higher suicide rate compared with the general population, with female medical practitioners more than twice as likely to die by suicide as females in the general population
a significant proportion of medical students and practitioners reported that they would not seek help for depression.
Conclusions: There is a need for beyondblue and key partners to invest in Australian research that further investigates depression, anxiety disorders and substance use in the medical profession, and activities that reduce stigma and other barriers to help-seeking.
HOMICIDAL ADOLESCENTS — A LITERATURE AND CLINICAL REVIEW
Scott Harden
Child and Youth Forensic Outreach Service, Child and Youth Mental Health Service, Children's Health Services, Brisbane, Australia
Background: Homicidal ideation or threats to harm other people are not uncommon presentations in adolescent patients involved with mental health or juvenile justice services. The Child and Youth Forensic Outreach Service in Queensland have been involved in the provision of advice regarding the assessment of numerous adolescents presenting with homicidal ideation or threats over some years.
Objective and Methods: Clinical cases were reviewed as part of a routine quality assurance process in order to compare them to the available literature in this area of practice, and to assess service response to such potential threats to others.
Findings: The aetiology of the threats or homicidal ideation seemed to fall into a number of relatively distinct clinical groupings which will be described in the presentation, included individuals with predominantly antisocial behaviour and conduct disorder; young people with psychotic disorders; young people with difficulties arising from family attachment and relationship dynamic issues; and individuals suffering from obsessive-compulsive disorder among others.
Services responded in variable ways to the requirement to urgently assess threats made against others and this will be further discussed.
Conclusions: Adolescents who make threats against others or disclose homicidal ideation require rapid assessment of the level of threat they may pose to others, as well as specific interventions related to the aetiology of the threat or homicidal ideation.
CLOZAPINE RECHALLENGE FOLLOWING MYOCARDITIS: RECENT EVIDENCE AND EMERGING PRACTICES
Islam Hassan
1, Ann Brennan2, Andrew Carroll2,3, Mairead Dolan2,3
1
Austin Hospital, Melbourne, Australia
2
Victorian Institute of Forensic Mental Health, Melbourne, Australia
3
Centre for Forensic Behavioural Science, Monash University, Melbourne, Australia
Background: The exact pathogenesis of clozapine-induced myocarditis (CIM) remains unknown. It is also unclear how, in some of the patients who recover from this potentially fatal condition following the cessation of clozapine, rechallenge with clozapine does not result in recurrence of myocarditis. In keeping with the limited theoretical understanding, there has been very little clinical experience in this area. However, several reports of clozapine rechallenge following myocarditis have recently emerged.
Objectives: Evidence to date and recent experience with cases, including our own, are drawn on to discuss the monitoring investigations for CIM in terms of sensitivity, specificity and utility. The utility of the investigations is also considered collectively as part of a coherent monitoring plan informed by the known natural history of CIM.
Conclusions: Despite the limited knowledge of the mechanisms of CIM, the availability of an appropriate monitoring plan may assist future risk-benefit analyses regarding rechallenge. A monitoring plan that negotiates a balance between prioritising safety and avoiding unwarranted discontinuation of the rechallenge is proposed to incorporate: (1) more frequent testing for proposed markers of early myocarditis; and (2) more frequent use of investigations that allow contextual interpretation of other findings of uncertain significance.
WHAT IS PSYCHOTHERAPY?
Dr Peter Heffernan
Psychiatrist and Psychoanalytic, Psychotherapist in Private Practice on the Mornington Peninsula in Victoria, FRANZCP
Member Victorian Association of Psychoanalytic Psychotherapists
The paper is an exploration of the fundamental question “what is psychotherapy?” from a human ethology perspective.
The basic tenant is that over the past million years the psyche of human beings is ‘of and with the clan’.
The fundamental human psyche is a “clan psyche”. Core human experience is formulated through the prism of ‘us’-‘them’.
Following the destruction and collapse of the ‘clan era’, the so-called ‘modern era’ now presents us with the challenge of generating a capacity to ‘engage and live creatively’ in a world with ‘strangers from other clans’ and to grieve the passing of the clan era.
Psychotherapy is one cultural tradition attempting to meet this challenge.
PERINATAL DEPRESSION AND ANXIETY: SPEAKING UP AND TAKING ACTION ACROSS AUSTRALIA
Dr Nicole Highet, Carol Purtell, Rachel Komen
Beyondblue, Melbourne, Australia
Background: During pregnancy and in the first year after the birth of a baby, known as the perinatal period, women and their partners are at a significantly greater risk of experiencing depression and related disorders. Depression and related disorders affect the wellbeing of the woman, the emotional health of her infant and other children, and impacts on her close relationships.
Objectives: Outcomes from national research prompted the development of the National Perinatal Depression Initiative (NPDI-2008-2013). The NPDI has a major focus on health promotion, early intervention and detection of depression and anxiety during the perinatal period. The NPDI aims to provide better care, support and treatment for expectant/new mothers and their families during the perinatal period. Implementation of the NPDI has practice implications for primary health care and mental health professionals.
Findings: This paper will report on the progress on the NPDI including dissemination and implementation of the beyondblue NHMRC Clinical Practice Guidelines for Depression and Related Disorders in the Perinatal Period. Results of qualitative interviews conducted in 2010 with consumers/carers regarding their experiences of depression and anxiety in the perinatal period and health professionals' knowledge and understanding of perinatal mental health will be presented. This qualitative research informed the development of the beyondblue “Just Speak Up” campaign and outcomes of the campaign will be discussed.
Conclusion: This paper highlights how research led to a national initiative and a change in culture and intervention to provide women and their families care, support and treatment in the perinatal period.
The Psychoanalyst in the mood disorder laboratory: what can we learn, and (what) can we contribute?
Jeremy Holmes
Professor of Psychological Therapies, University of Exeter, Barnstaple, United Kingdom
The purpose of my talk is, from a clinician perspective, to juxtapose classical psychoanalytic thinking on depression, updated from an attachment focus, with recent developments in neuroscience. Freud's five planks of his melancholia theory will be reviewed: loss, self-absorption, identification with the lost object, childhood trauma, and the role of ‘primitive emotions’. I'll pick up on Blatt's distinction between anaclytic and introjective depression and relate it to the attachment categories of hyper- and hypo-activation. Freud's theory applies more closely to introspective than anaclitic depression. Recent advances in epigenetic, biochemical and neuro-imaging studies of depression will then be reviewed. I'll suggest a dynamic model of depression, linking interpersonal and intra-psychic perspectives with neuro-anatomical pathways. The paper ends with practical suggestions about contrasting therapeutic strategies based on different neurological circuits. It suggests that psychoanalysis has a unique contribution to make in the treatment of refractory depression, through its duration of treatment, capacity to rework implicit memories, and focus on transference and counter-transference as a means of evoking them.
MONITORING VULNERABLE CONSUMERS IN EXTREME HEAT
Margaret Honeyman, Tracey Siebert
Office of the Chief Psychiatrist, South Australia Health
Background: Extreme heat conditions during the Australian summer cause a rise in the mortality rate of mental health clients. Heat vulnerability is more likely when there is a diagnosis of mental illness, is exacerbated by the types of medication prescribed for this condition, other risk factors and co-morbidities, and the client's living conditions. The death rate of mental health clients during extreme heat conditions rose over three consecutive years: eight deaths were registered during the January 2009 heat event.
In South Australia, a partnership was formed between health services, the State Emergency Service and the Bureau of Meteorology to undertake a joint project.
Objectives: Mandatory intensive contacts of heat vulnerable mental health clients by mental health staff during extreme heat conditions to reduce the heat-related client mortality rate.
Methods: A policy directive was developed by the Department of Health in partnership with health services staff, consumer and carers involved:
development of a heat vulnerability assessment tool in the individual client's electronic record
5000 clients were assessed at the beginning of the summer season for heat vulnerability
State Emergency Services (SES) together with Bureau of Meteorology (BOM) established the criteria for moderate, high and extreme heat warning
During heat events vulnerable clients were contacted.
Findings: Mortality rate was reduced in November 2009 and January 2010 compared with the event in January 2009.
Conclusions: A policy directive for mental health services produced effective interventions shown to reduce heat-related mortality in vulnerable mental health clients.
COMPARATIVE ANALYSIS OF MENTAL HEALTH POLICY, REFORMS AND SERVICE DELIVERY IN AUSTRALIA AND INDIA
Mohan Isaac
The University of Western Australia, Perth, Australia
Background: While there are several published studies of comparative analysis of issues related to mental health in largely similar settings and countries, for example, countries of the European Union, the OECD countries and developed Commonwealth countries, comparisons of mental health services in developed and developing societies are non-existent.
Objectives: The main objective of the study was to carry out a critical, comparative analysis of mental health policy, reforms and service delivery in India and Australia and to search for commonalities and differences.
Methods: The main methods employed to achieve the objectives were: (1) Non-systematic reviews of empirical studies, theoretical papers, published and unpublished governmental reports and policy documents, various case studies and gray literature; (2) Key informant interviews and semi structured interviews of different stake holders and focus group discussions; and (3) Site visits to different types of service settings and observation.
Findings: While the diversity between India and Australia on so many dimensions were evidently obvious and the socioeconomic, demographic and developmental indicators in the two countries were so vastly different, both countries being vibrant, multi-party democracies with an independent judiciary, free press/media and currently being governed by a coalition of political parties, were eminently suitable for comparative analysis of mental health systems and issues.
Conclusion: In the midst of obvious differences in political history, policy and legislative framework, availability of financial and trained human resources and a variety of other socio-cultural factors between the two countries, the similarities of issues, themes and problems in mental health care delivery were most striking.
The effect of midwife-led counselling on mental health outcomes for women experiencing a traumatic childbirth: A RCT
Debra Creedy
1, Jenny Gamble2, Vivian Jarrett2
1
University of Queensland, Brisbane, Australia
2
Griffith University, Brisbane, Australia
Background: The perinatal period is arguably one of the most important life stages in which the accurate detection and treatment of psychological distress is required. Perinatal depression, anxiety and trauma affect approximately one-third of women in Australia. Our past research has shown that one-third of women experience traumatic events associated with childbearing. Furthermore, few women attend referrals to mental health practitioners.
Objectives: To determine the effect of midwifery-led trauma-focused counselling with postnatal women to prevent and treat emotional distress.
Method: 1038 women were recruited from two locations in Australia, during the last trimester of their pregnancy. Women reporting a distressing birth experience were randomised to receive trauma-focused counselling (intervention) or parenting advice (active control). The intervention group and active control group were contacted by midwives during the first and sixth week postpartum. Midwives received specific training and supervision.
Findings: Women experiencing perinatal distress associated with traumatic birth and receiving trauma counselling by midwives reported improved mental health outcomes.
Conclusions: Perinatal mental health initiatives have focused on the psychosocial assessment of women with limited attention to facilitating access to mental health support. Training midwives with advanced skills in counselling to address perinatal distress holds promise for integrating mental health care into maternity services, thereby providing professional support to treat or prevent distress for the majority of women in need.
PSYCHIATRY AND CINEMA: AN EVOLVING FUSION
Linda Kader
ORYGEN Youth Health, Centre for Youth Mental Health, Parkville, Victoria, Australia
The merge and oft-division of the science of psychiatry and the art of cinema is extremely interesting and relevant. Cinema is influenced by psychiatry in many different contexts. Psychiatric treatments and patients with psychiatric disorders are reflected in cinema since the early 20th century with varying degrees and range of interest. Media has a significant influence on the perception of psychiatry and cinema can be used as an educational tool as well. Psychiatry, on the other hand, has to deal with its portrayal in cinema and also the broad impact in society. This presentation will take a non-cinematic account of the development of mutual interests in these two fields and attempt to offer a newer perspective on current mainstream cinema and its take on psychiatry.
PEER SUPPORT: LESSONS LEARNED SINCE 2006
Vivien Kemp
University of Western Australia, Crawley, Australia
Background: Australia's National Mental Health Policy and the Fourth National Mental Health Plan 2009–2014 specifically include the provision of service delivery by peer support workers (PSWs). It is increasingly likely that mental health service providers will treat clients who have the support of a PSW. Peer support services have grown rapidly since the introduction of the Personal Helpers and Mentors (PHaMs) program, funded by the Australian Government's Department for Families and Community Services, Housing and Indigenous Affairs. Organisations that receive PHaMs funding now employ PSWs across Australia. Since peer support is a relatively new innovation in mental health service delivery understanding the nature, benefits and limitations of peer support is crucial to the successful implementation and wide acceptance of peer support services.
Objectives: Much of what is known about peer support comes from overseas literature and there is a need to build a body of evidence about the Australian experience of peer support. This paper will report on the lessons learned so far.
Methods: A review of published Australian literature as well as reported experiences in Western Australia will be presented.
Findings: Organisational culture, recovery orientation, leadership support, adequate training of PSWs and clear job descriptions were found to be the critical factors that ensured successful peer support services.
Conclusions: It is widely hypothesised that peer support services are effective, due to the mutually shared experience of mental illness, but there needs to be more research to understand which models of peer support are most effective from the supported consumers’ perspective.
THE WARD ROUND – PULLING TOGETHER
Jack Kirszenblat
The Alfred Hospital, Melbourne, Australia
The consultation-liaison ward round is a hallowed hospital tradition. This paper examines the ward round from a number of perspectives including contemporary models of learning based on principles of computational and cognitive science, and Wilfred Bion's theory of groups and group experiences. The aim of the paper is to demonstrate that the ward round is a legitimate object for study. The paper will show that: (a) the ward round can be conceptualised as a model of thinking that has important implications for clinical work; (b) the ward round is a key activity that transforms novice psychiatrist trainees into expert psychiatrists; (c) the ward round is a political arena that encloses professional tensions, power relationships and ideological tensions and their current states of play within an hospital; and (d) the ward round is an indispensable collective activity with roots in evolutionary biology and it is the most important activity conducted by a consultation-liaison service because of its clinical, political and ethical dimensions.
DREAMING AS WORLDVIEW
Anthony Korner
University of Sydney; Sydney West Area Health Service, Sydney Australia
Background: The concept of “worldview” has been relatively neglected in modern psychiatric literature, especially in contributions from the English-speaking world. Yet it clearly has significance for mental wellbeing and, arguably, has some degree of malleability for each individual. Hence it is of interest in psychiatric practice.
Objectives: To consider the role of “worldview” in individual psychology and with particular reference to the Australian indigenous perspective.
Methods: Selected literature is reviewed including the contributions of James, Jaspers, Jung and Meares. The traditional Australian indigenous “worldview”, known in English as “The Dreaming”, is also reviewed as an example of a “non-scientific” worldview that nevertheless has been functional and adaptive for a people over many millennia. The Dreaming is a broad perspective that can be seen as recognising personal and communal subjectivities as well as a living relationship to the environment. The impact of technological change and the emergence of heterogeneous societies are discussed in terms of their implications for individuals struggling to develop a worldview. The possibility of sharing of knowledge drawn from different cultural traditions and from the scientific worldview will be considered as part of a potentially adaptive response to a complex global community. The process of modification of worldview is considered.
Conclusions: Conflicting worldviews can be a source of tension and distress at individual and communal levels. Working towards mutual understanding and respect for worldviews involves entering into appropriate conversations based upon a willingness to consider the need for change as a two-way street.
THAT ANNOYING TIME BETWEEN NAPS – CONSCIOUSNESS, PHILOSOPHY OF MIND AND PSYCHIATRY
Eli Kotler
The Alfred Hospital, Melbourne, Australia
Background: There is perhaps no greater philosophical quandary than the mind-body problem. Traditional views maintain either a monist or dualist stance. Yet science, with its roots in philosophy, has only started to broach this issue. Psychiatry, as the medical specialty that examines psychopathology, is at the clinical end of this endeavour. Consequently, psychiatrists must make practical decisions underpinned by a philosophical stance. Yet the position assumed is often a physicalist, reductionist one without due attention to the inherent philosophical problems.
Objectives:
To succinctly delineate the positions in Philosophy of Mind (PoM) and the major arguments for and against.
To define and explore conscious experience and the recent scientific endeavours to understand the phenomenon.
To relate the philosophical conclusions to current psychiatric theory, practice and broader aspects such as resource allocation.
To challenge the audience to question their own assumptions and approach to psychiatric practice.
Methods: A selective perusal of the relevant literature on PoM, and a systematic literature review on PoM and psychiatry.
Findings: PoM incorporates a range of contemporary views; the traditional monist and dualist, as well as attempts to bridge this gap. Each position has relative strengths and weaknesses, and ramifications for modern psychiatric practice.
Conclusions: All mental health clinicians, in particular psychiatrists, should be well versed in PoM. One's philosophical position has practical ramifications for clinical practice and broader health care issues.
PROMOTING THE WELLBEING OF CLOSE RELATIONS IN FAMILIES AFFECTED BY MENTAL ILLNESS
Nick Kowalenko
1,3, Elizabeth Fudge1, Debbie Ross2, Lydia Du Rieu1
1
Australian Infant Child Adolescent and Family Mental Health Association, Adelaide, Australia
2
COPMI (Children of Parents with a Mental Illness) National Family Forum, Adelaide, Australia
3
Senior Clinical Lecturer, Psychological Medicine, University of Sydney, Sydney, Australia
Background: The RANZCP has recently published the findings of the Planning Early Intervention and Prevention Strategies project. This has prioritised the children of parents with mental illness as a target group for preventive strategies through working with them or their families.
Objectives: This paper will briefly review the evidence base for the above and examine how a national approach to implementation of evidence-based interventions is being undertaken by AICAFMHA in partnership with carers, consumers and the college.
Methods: An abridged review of the relevant evidence, a description of strategies for implementation, the development of relevant resources and their dissemination will be described.
Findings: There is increasing visibility of children of parents with mental illness in routine service delivery, in data collection, in NGOs and in the mental health professions, including psychiatry. With appropriate support, the primary care sector could be more involved in implementing prevention and early intervention approaches for this target group.
Conclusions: Implementing a national public mental health approach to promoting the emotional health and wellbeing of children in families affected by parental mental illness is underway. Psychiatrists have a role in supporting these activities, in the clinical care they provide and in their training and other roles.
USE OF PATIENT ASSESSMENTS OF THEIR OWN PROGRESS AND EXPERIENCE OF ALLIANCE IN AN ACUTE INPATIENT SETTING
Andre Lange, Josephine Stanton
Child and Family Unit, Starship Children's Hospital, Auckland, New Zealand
Background: Alliance is vital in effective psychological and pharmacological treatment. Collaborative recovery-oriented work needs tools for bringing forward the patient's voice. Outcome and Session Rating Scales (ORS & SRS) are simple tools for accessing patients’ views on their own level of wellbeing and perception of the elements of therapeutic alliance. Instruments are validated for children and adolescents but have not been studied in inpatient settings.
Objective: To report on initial implementation of the SRS and ORS, in an acute inpatient unit.
Method: Psychiatrists in a child and adolescent inpatient unit have used the SRS and ORS weekly with patients and their families. Results have been collated and concurrent feedback collected.
Results: The rating scales have usually been well accepted by patients and families. Young people presenting with considerable disorganisation and reality distortion were usually able to rate themselves. Early and significant positive change is often seen. Identifying difficulties in therapeutic alliance have allowed issues to be addressed in a timely manner. The results have served as a vehicle for bringing patients’ perceptions into clinical discussions. Early experience is indicating that these perceptions could be given a greater role in clinical decision-making.
Conclusions: These easy to use tools have a potentially useful role in inpatient work.
INVESTIGATING THE MENTAL HEALTH OF ADULT REFUGEES RECENTLY ARRIVED IN WESTERN AUSTRALIA
Jon Laugharne
1, Aesen Thambiran2, Alyssa Lillee1
1
University of Western Australia
2
Migrant Health Unit, Perth, Australia
Background: Australia takes 13,000 refugees per annum via the Australian Humanitarian Program. Approximately 1200 refugees settle in Western Australia (WA) each year. There is a paucity of mental health data in relation to refugees settling in WA.
Objectives: This study aims to identify the level of psychological distress in adult refugees recently arrived in WA.
Methods: Mental health screening of adult refugees seen for routine general medical evaluation was instigated at the WA migrant health unit over a 14-month period. Assessment was carried out within three months of arrival in most cases. Instruments used were the Kessler10 and the World Health Organization PTSD Screener embedded within a general clinical assessment.
Findings: Three hundred consecutive consenting adult refugees were assessed (146 male, 154 female) of whom 163 were from Asian countries, 75 from Africa and 62 from the Middle East. Results from the Kessler10 indicate that 33 (11%) have probable moderate or severe mental disorder and 36 (12%) have probable mild mental disorder. The PTSD Screener indicates probable PTSD in 56 (19%) of the refugees interviewed. These rates are higher than local population norms and are broadly consistent with findings in the international refugee literature.
Conclusions: The screening program is ongoing and will be used to inform service provision and development for this population within the WA mental health system.
ATTACHMENT TO COUNTRY — CLOSE RELATIONS TO THE NATURAL ENVIRONMENT IN TROPICAL NORTHERN TERRITORY AND THE ROLE OF THE NATURAL ENVIRONMENT IN PSYCHIC LIFE
Charles Le Feuvre
Royal Melbourne Hospital, Melbourne, Australia
The global environmental crisis, in particular climate change, necessitates new ways of thinking. In psychotherapy and psychiatry there needs to be a re-evaluation of the role of the natural environment in psychic life.
This paper will focus particularly on tropical NT where the natural environment with all its beauty and danger is close at hand.
The indigenous relationship with the natural environment will be discussed, in particular the attachment to country, which is of such profound significance.
The Western relationship with the natural environment will be discussed, particularly by reference to the Australian ecofeminist philosopher Val Plumwood, who had a life-changing experience in Kakadu National Park.
It is hoped that these examples will highlight the importance of our relationship to the natural environment. Acceptance of this conclusion has both clinical and broader ethical and political implications.
NEUROLEPTIC-INDUCED CATATONIA: CLINICAL PRESENTATION, TREATMENT RESPONSE, AND RELATIONSHIP TO NEUROLEPTIC MALIGNANT SYNDROME
Joseph Lee1,2
1
Graylands Hospital, Perth, Australia
2
University of Western Australia, Perth, Australia
Objectives: Neuroleptic-induced catatonia (NIC), manifested in an extrapyramidal-catatonic syndrome, has been sporadically reported in literature. This study examined its clinical presentation, treatment responses and relationship to neuroleptic malignant syndrome (NMS).
Methods: (a) Reported cases of NIC and related literature regarding its relationship to NMS were reviewed. (b) Eighteen NIC episodes, out of 127 episodes of acute catatonia prospectively identified, were analysed, noting their clinical presentations, laboratory findings, and responses to treatments. The progression of symptoms in each NIC episode was reviewed. All catatonia episodes received benzodiazepines. The responses to of NIC episodes benzodiazepines were compared to those for catatonia episodes associated with mania and schizophrenia.
Findings: (a) NIC has been associated with dystonia, parkinsonism, and rarely choreoathetotic movements. Case reports described the successful use of anticholinergics, amantadine and benzodiazepines in its treatment. The dystonic and parkinsonian forms of NIC showed different clinical courses and treatment responses. Confusion surrounds the relationship of NIC to NMS. It has been suggested that NIC is a variant of NMS. (b) The NIC episodes presented predominantly in the stuporous form associated with parkinsonism. Delirium, autonomic abnormality and elevated serum creatine phosphokinase were all common. NMS was diagnosed in three episodes (17%). The three catatonia groups did not differ significantly in their responses to benzodiazepines. A spectrum of presentation across episodes was noted; “simple” NIC without delirium, autonomic disturbances or fever at one end, and NMS or “malignant” NIC at the other end. Symptoms in individual episodes showed a similar continuum progression.
Conclusions: Findings of this study support that NIC and NMS are disorders on the same spectrum and NIC be regarded as a variant of NMS.
DISSOCIATIVE CATATONIA: DISSOCIATIVE-CATATONIC REACTIONS, CLINICAL PRESENTATIONS AND RESPONSES TO BENZODIAZEPINES
Joseph Lee1,2
1
Graylands Hospital, Perth, Australia
2
University of Western Australia, Perth, Australia
Objective: Dissociative catatonia – catatonia secondary to a dissociative state – has been sparsely reported in literature. This study of 15 episodes of dissociative catatonia examines its symptomatology, longitudinal course, and response to benzodiazepines.
Methods: Out of 149 episodes of catatonia prospectively identified using research criteria, 15 (seven male, eight female) met modified criteria of the DSM IVTR and ICD-10 for dissociative trance (including those occurring during the course of other disorders) or dissociative stupor (catatonic stupor not taken as an exclusion criterion). All received benzodiazepines. A chart review was conducted noting the psychological precipitants, dissociative and catatonic symptoms, sequence of symptom progression, associated psychiatric diagnoses, and responses to benzodiazepines.
Findings: All 15 episodes were brief in duration (mean = 3 days; 1–9) and of sudden onset associated closely in time with psychological stressors. Dissociative stupor occurred in three, dissociative trance in six, dissociative possession trance in two, and dissociative trance and stupor in four. Three developed during the course of schizophrenia and one of mania. Ten manifested in the retarded form of catatonia, three excited and two mixed. ICD10 and DSM IV TR provided no criteria for the differentiation between catatonic stupor and dissociative stupor. In nine both catatonic and dissociative symptoms developed simultaneously, and in six dissociative symptoms first appeared evolving into a catatonic state. All showed prompt responses to benzodiazepines; both catatonic and dissociative symptoms (including psychotic-like manifestations) fully resolved.
Conclusions: Catatonia may develop secondary to a dissociative state. The dissociative catatonic syndrome, promptly responsive to benzodiazepines, may occur as a primary condition or during the course of other disorders. Current diagnostic systems are inadequate in its diagnosis.
PROCESS AND EVALUATION OF A TRIAL OF BALINT CLINICAL REFLECTION GROUPS FOR THIRD YEAR MEDICAL STUDENTS IN THEIR CLINICAL ROTATION IN PSYCHIATRY
Andrew Leggett1, Stephen Parker2
1
Director of Clincial Training, Medical Education Unit, Princess Alexandra Hospital, Woolloongabba, Australia; Senior Lecturer University of Queensland School of Medicine; Provisional Doctoral Candidate School of Psychology and Counselling, Faculty of Health, Queensland University of Technology
2
Advanced Trainee in Psychiatry, Princess Alexandra Hospital Mental Health Service, Woolloongabba, Australia; Associate Lecturer, University of Queensland School of Medicine
Background: The authors are trialing Balint clinical reflection groups for third-year medical students in psychiatry at the Princess Alexandra Hospital. The trial is a vertical integration initiative within the Princess Alexandra Hospital Balint Professional Development Project, one that aims to promote reflection on the quality of clinical relationships.
Objectives: The objective is to report on the establishment of the group and its processes in the first two clinical rotations of 2011, and to present trends in the student evaluations.
Methods: In six of the eight weeks of the clinical rotation in psychiatry, a group of ten third-year medical students meet, for an hour, in a group led by the authors, to present patients encountered in their clinical work. The leaders facilitate discussion focused on the student-patient relationship. The educational value of each meeting is assessed, using questionnaires with statements rated on a five-point Likert scale. Students also complete similarly constructed end-of-rotation evaluations. The process and evaluation of the first two rotations of 2011 are presented and discussed.
Findings: Vignettes demonstrating aspects of group process are presented in the context of the leaders’ experiential account, together with the initial evaluative data and trends in qualitative feedback from students.
Conclusions: Short-term clinical reflection groups can be effectively implemented for medical students in a hospital environment. These groups have the potential to support students in the process of learning to work in doctor-patient relationships. Further evaluation of the project will occur and should be reported.
SUBSTANCE USE DISORDERS IN THE OCI AND CLINICAL PRACTICE
Kah-Seong Loke
Eastern Dual Diagnosis Service and Nexus Dual Diagnosis Service, Melbourne, Australia
Psychiatry trainees and consultant psychiatrists in Australia and New Zealand often have limited opportunities to develop clinical experience in substance use disorders in the Alcohol and Other Drug service settings. This presentation is to provide trainees with an approach to assessing and managing such disorders in the RANZCP OCI context, as well in their general clinical practice. Important data about substance use that should be gathered during the interview will be listed, alongside explanations about how to make use of this data in the diagnostic and aetiological formulations, and in the action plan.
CONSUMERS AS EXAMINERS IN THE RANZCP CLINICAL EXAMINATION?
Joanna Macdonald
2, Graham W. Mellsop1, Selim El-Badri1, David B. Menkes1
1
Waikato Clinical School, University of Auckland, New Zealand
2
University of Otago Wellington, New Zealand
Background: The RANZCP Observed Clinical Interview (OCI) is a key component in ensuring that graduating Fellows have the skills to function as psychiatrists. The judgements in that examination are currently made entirely by psychiatrists. However, it is increasingly apparent that consumers’ views may differ from those of psychiatrists, in terms of the elements of their care and assessment that they consider important. Although they are frequently involved in teaching, there has been no investigation, to our knowledge, of the involvement of consumers as examiners in postgraduate examinations in psychiatry.
Objectives: The aim of this pilot project was to compare the judgments of consumers and psychiatrists in a “mock” examination and thus examine the face validity of the process.
Methods: Psychiatrist examiners (n = 8) and consumers (n = 30) rated 16 aspects of registrars’ performance during 30 “mock” OCIs conducted in the format of examinations.
Findings: Significant differences were apparent in the judgements of examiners and consumers regarding seven of the 16 rated aspects of trainee performance. These differences were not in domains that might be considered more “technical”, e.g. diagnosis, but in domains in which consumers might be considered to have a more valid judgement e.g. understanding.
Conclusions: These findings raise important questions regarding the face validity of the OCI and challenge assumptions that consumers have no role in examinations. The forthcoming changes to the training and assessment for the RANZCP provide an opportunity for the College to demonstrate its commitment to consumer involvement by involving consumers as equal partners in the examination process.
MENTAL HEALTH AND SERVICE USE IN THE INDIAN COMMUNITY IN AUSTRALIA: AN EPIDEMIOLOGICAL SURVEY
Dr Raj Maheshwari
1, Dr Zachary Steel2
1
Consultant Psychiatrist, SSWAHS and NSW Justice Health, Sydney, Australia
2
Psychiatry Research and Teaching Unit, University of New South Wales, Sydney, Australia
Background: Demographically and culturally, Indian-Australians represent a distinct immigrant group. Yet despite expanding body of research on transcultural mental health in Australia, there is a paucity of studies regarding mental health of Indian-Australians.
Objectives: This paper presents an original research estimating the extent of psychological morbidity and related service use among Indian-Australians.
Methods: A time-by-location survey was conducted in a sample of people of Indian background living in Sydney. Measures to assess current levels of psychological distress, functional disability, service use, attitudes towards seeking professional psychological help, and social capital were administered through self-reported questionnaires.
Findings: The prevalence of self-reported high to very high levels of psychological distress was equivalent to general community estimates. Psychological morbidity was associated with high levels of disability. Functional disability and higher levels of psychological distress were associated with increased likelihood for a GP consultation; however, 91% of people with identifiable mental health needs did not seek any mental health consultation.
Conclusions: Psychological morbidity in the Indian-Australian community is associated with high levels of functional disability, both in days and severity, but only a small proportion seeks mental health help. General population mental health surveys have failed to capture estimates of needs in individual ethnic migrant communities; this study highlights the need to address this gap.
CLOZAPINE UTILISATION IN AUSTRALIA
Geethal Malalagama
1, Tarun Bastiampillai2, Rohan Dhillon3, Peter Avina1
1
University of Adelaide, Adelaide, Australia
2
Flinders Medical Centre, Adelaide, Australia
3
Queen Elizabeth Hospital, Adelaide, Australia
Objectives: Comprehensive analysis of clozapine use in Australia including current rates of utilisation, previous rates of utilisation (over the last 10 years) and any interstate and gender-based variations in prescription.
Methods: Access to patient databases of both drug companies currently supplying the Australian market allowed us to ascertain all the required information regarding patient numbers. This information was then modelled against changes in the Australian population to analyse the various rates of clozapine utilisation in Australia.
Findings: 19% of schizophrenic patients (56% of TRS patients) in Australia are currently on clozapine therapy. There is significant interstate variation, from 60% in NSW and VIC to 28% in NT. Clozapine use in Australia has increased by nearly 80% over the last 10 years from 134 mg per capita to 238 mg per capita. The male to female ratio of patients on clozapine is 2.2:1 (p < 0.001). The average age of patients on clozapine was 43 for female patients and 38.5 for male patients (p < 0.001) with an initiation age of 36.3 for females and 31.7 for males (p < 0.001). The average dose for male patients was 433.6 mg compared to 376.1 mg for female patients (p < 0.001).
Conclusion: Nationally, Australia is utilising clozapine appropriately; there are however, significant interstate variations. Clozapine use has increased significantly over the last 10 years coinciding with the release of NICE and RANZCP guidelines. There are significant gender-based differences in clozapine prescription. Males are twice as likely to be prescribed clozapine, they are also commenced on clozapine therapy earlier and are given a higher average dose than female patients.
ENGAGING ABORIGINAL AND TORRES STRAIT ISLANDER YOUNG PEOPLE IN MENTAL HEALTH AND ATOD SERVICES IN A YOUTH DETENTION CENTRE SETTING
Cara Mccormack, Margaret Egan, Sheena Riordan, David Hartman, Amanda Kruger, Virginia Prior
North Queensland Adolescent Forensic Mental Health Service, Queensland Health, Townsville, Australia
Background: Young offenders have a high prevalence of mental health and substance use issues. There is significant over-representation of Aboriginal and Torres Strait Islander young people detained in youth detention centres, with this group representing between 80–90% of detainees in the Cleveland Youth Detention Centre in Townsville. A number of cultural barriers were identified in early 2009 which were leading to poor utilisation of on site mental health and ATOD services by these young offenders.
Objectives: To address these barriers, a ‘cultural engagement process’ led by indigenous health workers was introduced to the North Queensland Adolescent Forensic Mental Health Service in 2009. This process emphasised the importance of a young person's sense of cultural safety in the assessment and treatment process.
Methods: A retrospective study was carried out, comparing the proportion of indigenous young people being assessed and being engaged in active case management and treatment, before and after the introduction of the cultural engagement process.
Findings: As a result of this new process, there has been a great increase in the number of young people agreeing to see clinical staff for both initial assessment and ongoing case management and treatment.
Conclusion: Clinical processes that pay attention to indigenous clients’ cultural safety can result in significant improvements in service accessibility and utilisation.
TESTOSTERONE AND THE CHALLENGE HYPOTHESIS AS A TEST OF THE BIOCOGNITIVE MODEL OF MIND FOR PSYCHIATRY
N. McLaren
Northern Psychiatric Services, Darwin, NT, Australia
The Biocognitive Model of Mind aims to provide psychiatry with a rational model of mental disorder. The purpose of this paper is to test this model against an independently developed model of behaviour, the Challenge Hypothesis, which relates to testosterone and aggression. This hypothesis relates to the surge of testosterone seen in males of many species after a threat/challenge. For the Biocognitive Model, the essential goal is to outline a formal mechanism by which perceptions of threat can activate neurosecretory functions, i.e. the point of transduction of current sensory input to the mediating somatic factors underlying aggressive behaviour. While testosterone is not the only factor in aggression, it is useful as the exemplar in demonstrating how cognitive perceptions and decisions control behaviour. This paper outlines a conceptual path indicating that a molecular implementation of mind-body interaction is theoretically possible. This has profound implications for the current practice of psychiatry.
AN UPDATE ON THE STRANGE CASE OF THE BIO-PSYCHOSOCIAL MODEL: CORRUPTION IN THE PSYCHIATRIC PUBLISHING INDUSTRY
N. McLaren
Northern Psychiatric Services, Darwin, NT, Australia
The author has previously established that the so-called bio-psychosocial model does not exist. Nonetheless, powerful constituencies at the core of the institution of modern psychiatry continue to pretend that it is a reality. Using examples mainly drawn from the Australian psychiatric publishing industry, the author will show how corrupt practices are biasing the intellectual life of the profession in untenable directions. In the event that this matter becomes more widely known, it will have the most dramatic effect on the prestige of the profession. The author proposes an entirely new model of publishing which removes the biases inherent in the current model, which dates from the 19th century.
DEEP BRAIN STIMULATION FOR OBSESSIVE-COMPULSIVE DISORDER: THE FIRST AUSTRALIAN EXPERIENCE
Ramon Mocellin
1,2, Mark Walterfang1,2, Andrew Evans1,2,3, Richard Bittar4,5, Dennis Velakoulis1,2
1
Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Australia
2
Melbourne Neuropsychiatry Centre, University of Melbourne, Melbourne, Australia
3
Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
4
Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Australia
5
Department of Surgery, University of Melbourne, Melbourne, Australia
Background: Obsessive-compulsive disorder (OCD) is one of the most common anxiety disorders with a worldwide prevalence of between 1–3%. Medical interventions have included uses of serotonin reuptake inhibitors and more recently atypical antipsychotic agents. Despite the availability of these treatments 20–30% of patients with OCD fail to improve with pharmacological and psychological treatments and up to 10% develop a severe intractable form of the illness which is resistant to any of these interventions. This group has ongoing severely impaired social and occupational functioning and significant risk of suicide. Although not frequently measured, the suffering of carers and families of these patients is also considerable.
Surgery for psychiatric disorders has a controversial history which has overshadowed the use of stereotactic ablative treatments in OCD. In the context of more recent positive results from prospective trials of anterior cingulotomy for severe OCD and the efficacy of deep brain stimulation (DBS) in movement disorders such as Parkinson's disease, DBS is the emerging treatment for intractable OCD.
Objectives: We describe the first Australian experience of the implementation of a DBS program for patients with severe intractable OCD. This includes the description of administrative and Mental Health Act processes, and details of the procedure involved, including the neurobiological basis of the treatment and choice of stimulation targets. The selection process, assessment, clinical features and outcomes in the first two patients who have undergone this procedure will be discussed in detail.
MYOD: A CLINICAL SERVICE FOR YOUNG PEOPLE WITH DEMENTIA
Ramon Mocellin
1,2, Mark Walterfang1,2, Wendy Kelso1,2, Dennis Velakoulis1,2
1
Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Australia
2
Melbourne Neuropsychiatry Centre, University of Melbourne, Melbourne, Australia
Background: Dementia is recognised as a major contributor to burden of disability and disease and profoundly affects the quality of life of many Australians. What is often not recognised is that dementia can occur in people under the age of 65, many in their 30s and 40s. It is estimated that younger onset dementia affects approximately 10,000 people in Australia today. Younger people with dementia have a number of special needs which are currently unmet by services based in aged care settings.
The most common forms of Young Onset Dementia (YOD) are Alzheimer's disease (>30%), frontotemporal dementias (FTD) (25–30%), vascular dementia, Parkinson's disease-related dementia and rarer neurodegenerative disorders (i.e. synucleopathies).
Objectives: In this presentation we intend to describe the implementation of a statewide service for younger persons with dementia. This includes the development of better cooperation between the inpatinet and outpatient arms of the service and forging links with important external agencies such as Alzhiemer's Australia. A comprehensive summary of referral sources and numbers, presenting features, neuroimaging and neuropsychological findings and final diagnoses will be presented. Progress of cognitive difficulties over time, in particular those patients with a diagnosis of frontotemporal dementia, will also be presented.
Conclusions: YOD is an emerging issue in health service delivery as it represents an example of a group of disorders that fall between the gaps between aged care, acute health and mental health services. We describe how a multidisciplinary service originating in a neuropsychiatric setting can begin to address the needs of such a group.
THE MANY FACES OF COURAGE – EXPLORATION OF A “HEROIC” JOURNEY OF A MANIC PATIENT
Marta Morawiecka
In private practice
Background: Throughout millenniums, myths have continued to provide a statement of the basic truths to live by. In particular, the myth of a hero captures man's eternal struggle for identity, self-acceptance and mastery.
Objectives: In this context, my aim is to present the facts of a manic patient's history in a way that enables us to see the deeper picture of a hero, facing his monsters of illness, great distress and social harm, whilst in a relationship with his psychiatrist.
Method: The hero, a patient known to the author for 20 years, enters the stage of this presentation in an episode of hypomania triggered by an inheritance of a very large sum of money, requesting his psychiatrist to accept power of attorney and manage his affairs. This moment is used as a prism by which to examine what happens next, linking it to different strands of earlier events, in particular the decisions and choices of both the patient and the psychiatrist.
Conclusions: An extension of the previous management plan, utilising advanced directives, is formulated, followed by a discussion of the possible factors which might have influenced the outcome and their usefulness for other patients and services.
THE FAILURE TO DEFINE: A SYSTEMATIC REVIEW OF THE CONCEPTUALISATION OF TREATMENT RESISTANT DEPRESSION (TRD)
Jenifer Murphy, Gerard Byrne
Academic Discipline of Psychiatry, University of Queensland, Brisbane, Australia
Background: TRD has been acknowledged in medical scientific literature since the 1970s as the non-response to treatments known to be effective for depression. Refractory depression has continued to be a significant clinical problem. The conceptualisation of TRD and how to define it in clinical practice has remained ambiguous and highly subjective.
Objective: To systematically review the randomised controlled trials (RCTs) of treatments administered for TRD to determine how TRD is currently conceptualised in medical scientific literature.
Methods: Potential RCTs were sought in several internet databases. RCTs were retrieved for potential inclusion if they were published within a 15-year period (1995 to June 2010). Six hundred and sixty seven articles were retrieved with only 73 meeting the criteria for inclusion.
Findings: The most commonly used definition was the failure of two or more antidepressants (N = 29; 39.7%). The study design, inclusion/exclusion criteria and cut-off scores for depressive symptomatology varied widely between studies. Participants’ previous treatment history was also inconsistently measured.
Conclusions: There is major heterogeneity in the conceptualisation of TRD with studies differing in terms of their study design, inclusion/exclusion criteria, definitional concepts and recording of previous treatment history. This has led to inconsistent research findings, limited replication of results and minimal findings being translated into clinical practice. Future research needs to take into consideration the major variability in methodologies and work towards a standardised definition and/or model of TRD.
SIMG UPSKILLING PROGRAM 2010: AN OVERVIEW
Diane Neill
1, Helen Slattery2, Dennis Handrinos3, Sharon Holloway4
1
CSIMGE
2
Department of Health, Western Australia
3
University of Melbourne
4RANZCP
Background: The Committee for Specialist International Medical Graduate Education (CSIMGE) obtained Federal Government funding in 2010 to support nationwide regional upskilling projects for specialist IMGs working in Australia, in their pathway to Fellowship and beyond. Supported by a project officer and assistant, CSIMGE identified Fellowship attainment coordinators or similar; invited them to prepare submissions for presentation at a workshop in April 2010 where the proposed projects were assessed by CSIMGE and co-opted panelists; and finalised the proposals and funding on the same day or immediately thereafter. Additionally, dedicated fund packages were assigned to provide unique and specialised support for SIMGs working in rural/remote services.
Objectives: The following processes will be described: establishing and operating this program; the seven projects it supported; and the individual packages for further learning and professional development. Detailed analysis of a number of individual projects in this program will be the subject of other papers at this meeting.
MODELLING THE ECE PREPARATION WORKSHOP
Diane Neill
1,2, Lynnette Rose1,2, Sharon Holloway2
1
CSIMGE
2
RANZCP
Background: The Committee for Specialist International Medical Graduate Education (CSIMGE) in association with the Committee for Examinations in 2007 established a national two-day weekend workshop to support IMGs in their preparation for the Exemptions Candidate Examination (ECE) with information about and exposure to the standard and process, with a particular target of reaching IMGs from rural/remote services.
In 2010, Federal Government funding was obtained by RANZCP to establish an accreditation process (including project officer and assistant) for regional ECE preparation workshops modelled on the key elements of the CSIMGE held workshop.
Objectives: The process will be described for analysing the current workshop; identifying the key components and minimum standards; liaising with parties at a regional level interested in seeking accreditation; developing documentation and an accreditation process; and trialling the process with a regional workshop in October 2010. The relative merits of the national and regional workshops, and a forward plan for the program, will be addressed.
PALIPERIDONE PALMITATE: PLACE IN THERAPY AND PRACTICAL USAGE GUIDELINES FOR A NEW LONG-ACTING INJECTABLE ANTIPSYCHOTIC
Richard Newton
1, Saji Damodaran2, Harry Hustig3, Raju Lakshmana1, Joseph Lee4, Balaji Motamarri5, Peter Norrie6, Robert Parker7
1
University of Melbourne and Austin Health, Victoria
2
University of Monash and Southern Health, Victoria
3
Glenside Hospital, Adelaide, South Australia
4
University of Western Australia
5
University of Adelaide and Modbury Hospital
6
Mental Health Services ACT
7
Northern Territories Clinical School, Flinders University, Northern Territory
Background: Paliperidone palmitate (Sustenna®, Janssen-Cilag) is a long-acting injectable (LAI) antipsychotic that was recently approved for use in Australia.
Objectives: In this presentation a group of Australian experts will review the clinical data and practical aspects of treatment with paliperidone palmitate.
Findings: Reviews have found that around half of patients with schizophrenia are non-adherent with oral antipsychotics. This is important because poor adherence has been associated with a 10-fold increased risk of psychotic relapse in first-episode patients.
LAI therapy is often viewed by prescribers as a last-resort treatment, reserved for intractable patients. However consumer attitudinal surveys show that they frequently prefer LAI to oral therapy. This is despite the fact that depot formulations of typical antipsychotics are associated with tolerability issues such as injection site reactions and extra-pyramidal symptoms.
The availability of paliperidone palmitate presents an opportunity for physicians to consider a change in the culture of use of LAI therapy. A number of clinical trials have been completed, establishing the dosing schedule, efficacy and tolerability of paliperidone palmitate. Injections are given monthly, however the dosing schedule is somewhat flexible in time and in site of injection, as deltoid and gluteal injection sites are interchangeable in maintenance therapy.
Conclusions: The characteristics of paliperidone palmitate make it a suitable option in patients who require rapid resolution of symptoms following first relapse and in those at risk of poor adherence with oral medication, to establish whether a person is non-responsive or simply non-adherent and it could be considered for selected first-episode patients.
CHARACTERISTICS OF PATIENTS FOUND ‘NOT GUILTY’ ON THE GROUNDS OF MENTAL ILLNESS IN NSW FROM 1992 TO 2008
Dr Olav Nielssen, Dr Matthew Large
School of Psychiatry, University of New South Wales
Background: There is emerging evidence of a higher risk of serious violence in first-episode psychosis.
Aims: The aim of this study is to compare the clinical characteristics of those found ‘not guilty’ due to mental illness (NGMI) of violent offenses committed before treatment for psychosis, compared with those committed at any time after initial treatment.
Method: Demographic, clinical and offence data was taken from psychiatric reports and court documents from a consecutive series of people found NGMI of homicide, attempted homicide and assaults causing serious injury in the state of New South Wales (NSW), Australia.
Results: In the 17 years from the beginning of 1992, 272 people were found NGMI after homicides (n = 138) or attempted homicides and assaults resulting in serious injury (n = 134) in NSW. Schizophrenia-related psychosis was the most common diagnosis (n = 234, 86%). An additional diagnosis of substance abuse or dependence was made in 93 (34%) offenders. Of the 272, 124 (46%) were classified as being in their first episode of psychosis, including 72 (52%) of the homicide offenders and 52 (39%) of the non-lethal violent offenders. The first-episode subjects were younger, more likely to be migrants from a non-English-speaking country and were more likely to have used a firearm.
Conclusion: The first episode of psychosis is a period of particular risk for homicide and serious violence. Younger age, language and cultural barriers to care and the greater availability of lethal means appear to contribute to an increased risk of homicide and of other serious violent offences in first-episode psychosis.
HONOS Vs MIR-S-CGI: DATA FROM AN ACUTE RECOVERY UNIT
Nick O'Connor
1, Tim Lambert2, Rachael Mulley3, Bianca Grasso3
1
University of Sydney and Concord Centre for Mental Health, Sydney, Australia
2
University of Sydney, Sydney, Australia
3
Concord Centre for Mental Health, Sydney, Australia
Background: The Kirkbride Acute Recovery Unit at the Concord Centre for Mental Health provides specialist recovery support and interventions for people with treatment-resistant schizophrenia. This paper examines the outcomes for of the 18 months after the unit opened. Patients were rated by the treating team fortnightly on the Health of the Nation (HoNOS) and Multidimensional Incomplete Recovery-Clinical Global Impression scale (severity).
Objectives: The purpose of this study were to determine which patients responded to the treatment and therapeutic environment of the Acute Recovery Unit, and to measure their change on two clinical rating scales.
Methods: The data on 84 patients were analysed. Cohort and individual changes were examined. Changes as measured by the two rating scales were compared.
Findings and Conclusions: Some patients made across-the-board progress, albeit by slow and small increments. Others appeared to improve in some domains but not others; negative symptoms and social behaviour were two areas that frequently lagged when compared with positive symptoms.
The two rating scales have significant overlap but appear to measure different aspects of recovery.
ISBAR? IS GOOD! IMPLEMENTING CLINICAL HANDOVER IN AN AREA MENTAL HEALTH SERVICE
Nick O'Connor
1, Rolf Marsden2, Andrew Ng2, Patrick Parker2, Natalie Vella2
1
University of Sydney and Mental Health Services of Sydney and South West Local Health Networks, Sydney, Australia
2
Mental Health Services of Sydney and South West Local Health Networks, Sydney, Australia
Background: Clinical handover has been identified by WHO, the Australian Commission on Safety and Quality in Health Care, and by our own incident investigations as a priority for reform and redesign in relation to improving continuity of care and patient safety. The Sydney South West Mental Health Service Clinical Handover Project designed and implemented a clinical handover initiative that aimed to change culture and practice amongst mental health clinicians. The Clinical Handover Project addressed four specific settings of handover: shift-to-shift, multidisciplinary morning meeting, transfer of care, and after-hours medical handover.
Objectives: To describe the Sydney South West Clinical Handover Initiative and report on evaluation to date.
Methods: Extensive surveying (n = 380) and structured observations (n = 40) were involved in the diagnostic phase. An agreed mnemonic and data set for clinical handover (ISBAR), team procedures and online and face-to-face training modules were developed. The Clinical Handover Project was implemented across six mental health services in the Sydney South West region. The project executive and steering committees addressed risks and barriers as the project developed.
Findings and Conclusions: The Sydney South West Clinical Handover Initiative provides lessons and tips about key success factors in implementing clinical handover.
EXPOSURE TO TRAUMATIC EVENTS AND THE PROBABILITY OF POST-TRAUMATIC STRESS DISORDER (PTSD) IN THE NEW ZEALAND MENTAL HEALTH SURVEY (NZMHS)
Mark Oakley Browne
Discipline of Psychiatry, School of Medicine, University of Tasmania, Hobart, Australia
Background: Previous mental health surveys within Australasia have provided prevalence estimates for post-traumatic stress disorder (PTSD). However, these surveys do not provide any information about the prevalence of traumatic events and the probability of developing PTSD after exposure to such events. Such information would be useful for planning public health interventions.
Objectives: To estimate the lifetime prevalence of traumatic events and the associated probability of DSM-IV PTSD in the adult population in New Zealand.
Methods: A nationally representative face-to-face survey of persons aged 16 years or older was carried out in 2003–2004. A fully-structured diagnostic interview, the Composite International Interview version 3 (CIDI 3.0), was used. The overall response rate was 73.3%. The PTSD section of the interview was completed by 7312 participants.
Findings and Conclusions: 79.3 (0.8)a% of participants have at some time experienced a traumatic event and the overall lifetime prevalence for PTSD is 6.1 (0.3)%. Events categorised as interpersonal violence comprise 26.8 (0.6)% of all traumatic events and the probability of PTSD among events of this class is 6.4 (1.0)%. However, this class of event is associated with 42.9 (0.9)% of all PTSD cases and this percentage greatly exceeds that for other classes of events, which range between 6.1–21.1%. These data suggest that public health interventions aimed at decreasing the rates of PTSD in the population should focus on strategies which seek to decrease the prevalence of interpersonal violence.
a
The numbers in parentheses are standard errors.
GENDER DYSPHORIA IN ASPERGER'S SYNDROME: A CAUTION
John Parkinson
Objective: The incidence of gender dysphoria in people with Asperger's syndrome is reported as being above the average. This paper explores whether the presentation of a gender issue may in some cases reflect the Asperger patient's liability to obsessive preoccupations-which can prove transient.
Methods: Several cases from the author's clinical practice are reviewed.
Findings: Two young men with childhood histories suggesting Asperger's syndrome presented with strong feelings of gender dysphoria, asking for help to live as women. Hormone treatment was withheld and after several years each came to repudiate his “transgender phase.”
Conclusions: Patients of either sex who ask for gender reassignment should be assessed for any indications of Asperger's syndrome. Irreversible treatments should be avoided until it is clear there is a genuine issue of transsexualism.
THE PREDICTIVE VALUE OF RISK CATEGORISATION IN SCHIZOPHRENIA
Michael Paton
1, Matthew Large2, Christopher Ryan3,4, Swaran Singh5, Olav Nielssen2,3
1
Mental Health Drug and Alcohol Service, Northern Sydney and Central Coast Local Hospital Networks, Sydney, Australia
2
School of Psychiatry, University of New South Wales, Sydney, Australia
3
Discipline of Psychological Medicine, Sydney Medical School, University of Sydney, Sydney, Australia
4
Consultation Liaison Psychiatry, Westmead Hospital, Westmead, Sydney, Australia
5
Health Sciences Research Institute, University of Warwick, Warwick, United Kingdom
Background: Risk assessment is increasingly used to inform decisions regarding the psychiatric treatment of patients with schizophrenia and other serious mental disorders.
Objectives: To examine the theoretical limits of risk assessment and risk categorisation as applied to a range of harms known to be associated with schizophrenia.
Methods: Using rates of suicide, homicide, self-harm and violence in schizophrenia, a hypothetical tool with an unrealistically high level of accuracy was used to calculate the proportion of true and false positive risk categorisations.
Findings: Risk categorisation incorrectly classifies a large proportion of patients as being at high risk of violence towards themselves and others.
Conclusions: Risk assessment and categorisation has severe limitations. A large proportion of patients classified as being at high risk will not, in fact, cause or suffer any harm. Unintended consequences of inaccurate risk categorisation include unwarranted detention, misallocation of scarce health resources and the stigma arising from patients being labelled as dangerous.
CHALLENGING BEHAVIOUR AND DISABILITY – A TARGETED RESPONSE: MENTAL HEALTH AND INTELLECTUAL DISABILITY IN QUEENSLAND THREE YEARS ON
Paul White
1, Gregory O'Brien1, Clare Townsend2
1
Mental Health Outreach and Assessment Team, Disability Services Queensland, Department of Communities, Queensland
2
Director for Systems Research, Centre of Excellence for Behaviour Support, University of Queensland
Background: In 2006, in response to concerns about human rights issues, the Honorable Warren Pitt M.P.-Minister for Communities, Disability Services and Seniors-instigated an enquiry by Justice William Carter. The resultant report was Challenging Behaviour and Disability-A Targeted Response. All of Mr Carter's recommendations were adopted by Queensland Cabinet including the establishment of a psychiatry service within the Department of Communities.
Methods: A file review of all referrals to the service and consultations with relevant stakeholders.
Findings: The process of establishing the service is reviewed including the barriers (ideological, political and professional). A profile of the patients seen is presented (including socio demographics, diagnostics and outcomes). The service only recently achieved full staffing of 3.4 FTE psychiatrists, one registrar and three clinical nurse consultants. A total of 230 patients were seen. The majority had not seen a doctor in the previous month and most had a concomitant serious physical illness. All had a co-morbid mental health issue.
Conclusions: Considerable improvements in the human rights of many of the patients have occurred. There is still much to do.
PSYCHIATRY IN AUSTRALIA'S CLOSEST NEIGHBOUR: A HISTORY OF PSYCHIATRY IN THE DUTCH EAST INDIES
Hans Pols
University of Sydney, Sydney, Australia
Compared with other colonial regimes in Asia, psychiatry received a relatively large share of public health funding in the Dutch East Indies. In 1930, about 9,000 beds were available in four large mental hospitals and about a dozen smaller institutions. In this paper, I will explore the contributions of colonial psychiatry in the Dutch East Indies and discuss the organisation of mental hospital care there.
The main contribution of psychiatry in the Dutch East Indies lies in the research on culture-bound syndromes. In 1904, Emil Kraepelin visited the mental hospital near Buitenzorg (Bogor, established in 1881) to compare the expression of schizophrenia in European, Chinese and indigenous patients. At that time, a number of influential publications on amok, lata, and koro had been published, which found an international readership.
In the Netherlands, psychiatry had developed rapidly after the turn of the 20th century, which gave an impulse to its development in the colonies. I will analyse the attempts to decrease the number of inhabitants of mental asylums by finding other institutional arrangements, such as farming colonies for individuals who could no longer benefit from hospitalisation. These reforms were initiated by W.F. Theunissen, medical superintendent of several large institutions on Java. During the Depression years, he was able to institute occupational therapy on a large scale, which resulted in significant savings. Partly as a consequence of these successes, he became the director of the colonial public health service, where he introduced similar initiatives.
REFUSAL OF TREATMENT: A MEDICO-LEGAL CASE ANALYSIS
Alma Rae
Canterbury District Health Board, Christchurch, New Zealand
This paper dissects a UK court decision in which a 37-year-old woman with borderline personality disorder was denied the right to refuse blood transfusions. She had, over many years, cut herself and bled almost to death; she had repeatedly been persuaded against her wishes to accept transfusions and so she finally arranged an advance directive to prevent this. The hospital applied to the court for a determination as to the directive's validity; it was declared invalid on the grounds of the patient's incompetence, while the court considered that further transfusions when the hospital deemed these necessary would be in her best interest. I take issue with both aspects of this decision in a detailed discussion of relevant legal precedent and applicable ethical principles.
MYTHS EXPOSED: STOPPING SMOKING DOESN'T MAKE YOUR MENTAL ILLNESS WORSE
Tanya Ahmed
1,2, Mark Ragg2,3, Rebecca Gordon2, John Allan4,5
1
Sydney South West Area Health Service, Sydney, Australia
2
RaggAhmed, Sydney, Australia
3
University of Sydney, Sydney, Australia
4
NSW Department of Health, Sydney, Australia
5
University of NSW, Sydney, Australia
Background: Many people with mental illness who smoke want to quit, but are not offered adequate support by health professionals, partly out of a belief that quitting smoking will exacerbate symptoms of mental illness and change medication levels, leading to toxicity or lack of effectiveness.
Objectives: To seek evidence to support this belief.
Methods: We carried out literature reviews concerning three questions: (1) What are the clinical consequences of quitting smoking for people taking clozapine? (2) What are the clinical consequences of quitting smoking for people with schizophrenia? (3) What are the clinical consequences of quitting smoking for people with a history of depression?
Findings: Preliminary findings are that there is little evidence to support the belief that quitting smoking is harmful for people with mental illness.
Conclusions: In light of the significant physical and financial benefits of quitting smoking, psychiatrists should advise all their patients to quit, and provide support to help them do so.
MANAGEMENT OF BORDERLINE PERSONALITY DISORDERS IN PUBLIC MENTAL HEALTH SERVICES – A VICTORIAN EXPERIENCE
Sathya Rao
Clinical Director, Spectrum, the Personality Disorder Service for Victoria, Melbourne, Victoria, Australia
Aims: The aim is to describe the experience of Spectrum in the last 12 years in managing patients with borderline personality disorders within the context of public mental health systems.
Method: This paper will describe the primary and secondary consultation models, residential and community care models for managing patients with borderline personality disorder in the public mental health systems.
Results: In the last decade, the Spectrum program has successfully provided secondary consultations (200 per year), supervision and training to clinicians (about 1000 clinicians per year), individual and group psychotherapeutic treatments (62 per year) and residential care (34 patient separations per year) for patients managed within the 26 health services in Victoria. Spectrum also processes about 600 triage calls annually and offers after-hours telephone support services to about 150 patients per year.
Conclusions: Satisfactory management of patients with borderline personality disorders can be achieved within the context of public mental health systems with the help of a specialist statewide service for personality disorders.
USE OF SENSORIMOTOR PSYCHOTHERAPY WITH PATIENTS WITH DUAL DIAGNOSIS
Neelofar Rehman, Manal Darwish, Patrick Tolan, Susan Cavarra
St John of God Pinelodge Clinic, Dandenong, Victoria, Australia
Sensorimotor psychotherapy (Ogden, Minton, & Pain, 2006) utilises research in the neurobiological underpinning of trauma, and provides a framework to understand various behaviours of patients presenting with substance use and complex PTSD. This bottom-up (utilising the body as way to regulate arousal rather than cognitive processes) treatment approach is a unique way of working with complex presentations. A 10-week psychoeducation group, based on sensorimotor psychotherapy was introduced in the day program of a private psychiatric clinic. This initiative was taken to respond to the growing number of patients in a drug and alcohol unit, who presented with a history of trauma.
Group sessions focused on providing the participants with information regarding the neurobiological research and strategies to help them manage their symptoms.
The strategies included grounding, sensorimotor exercises and breathing. Mindfulness strategies were taught to assist them in developing an observational stance and to guide them in making a decision to utilise strategies. Quantitative measures of depression and anxiety were administered to measure the symptoms of these patients. The results point to the significance of psycho education guided by neurological research in the treatment of dual diagnosis.
RECENT TRENDS IN PSYCHOTHERAPY TRAINING AMONG PSYCHIATRISTS IN VICTORIA
Asiri Rodrigo
1,2, Jennifer Majoor1, Frances Minson3
1
Eastern Health, Melbourne, Australia
2
University of Kelaniya, Ragama, Sri Lanka
3
Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Background: Despite the mounting evidence suggesting the efficacy of psychotherapy in a wide variety of psychiatric disorders and psychotherapy being considered a core competency of psychiatry training, there is a growing body of literature indicating a recent decline in the use of psychotherapy among psychiatrists around the globe.
Objectives: We studied the interest in pursuing advanced training in psychotherapy among Victorian psychiatry trainees and psychiatrists between 2003 and 2009. We also investigated the training outcomes in those who joined the training programs during the same period.
Method: This cross-sectional descriptive study was conducted using recorded data from 2003 to 2009.
Findings: The number of applicants who enrolled in the advanced training in psychotherapy had steadily increased from four in 2003 to 11 in 2009. While there had been eight psychodynamic psychotherapy applicants from 2006 to 2009, those in the CBT stream increased from two to five during the same period. Growing interest in psychotherapy was seen among the registrars. During the period of this study nine doctors (17%) withdrew from the training without completing it.
Conclusion: From the limited data available, no decline in the interest in pursuing advanced training in psychotherapy was noticed among the psychiatry doctors in Victoria, although only small numbers of doctors enroll in training and nearly one in five failed to complete the training during the study period. The authors discuss possible reasons for their findings and the apparent increasing interest in psychotherapy training with reference to the international literature.
THE LIVED EXPERIENCE AND CLINICIANS
Roper Graham
Community Member, RANZCP New Zealand
The presentation explores “the lived experience and clinicians” and it's relevance to consumer participation, collaboration and influence.
Background: The debate as to consumer/service-user involvement in the RANZCP is often about what it should look like, how it should function and how it will provide positive improvements.
The method: The presentation centres on a number of issues including appropriate levels of influence, preventing single-agenda issues creating barriers for resolution, understanding the different levels of influence and so on. This particular debate is missing a component of agreement as to “who determines ‘consumer’?”
Exclusion of clinicians due to discrimination or stigma is merely a convenient distraction that enables single-agenda activists (at either end of the spectrum) to create barriers. Barriers and/or silos of this type produce little in the way of positive debate, let alone a process of change.
Objective: So what does it take to facilitate a change?
Conclusion: Clinicians with lived experience (personal or as family/carer) have a unique perspective that would enable and influence various organisations from a lived experience service-user/family perspective.
BEYOND THE CURRICULUM
Lynette Rose
Flinders Medical Centre, Adelaide Health Service, Adelaide, Australia
Deputy Chair, Specialist International Medical Graduate Education Committee (SIMGE), RANZCP
The Federal Government funded a project to develop a process to accredit external providers of the compulsory pre-exam workshop for International Medical Graduates. I chaired this project, and as part of this looked at the curriculum for International Medical Graduates (IMGs), acknowledging that there is no separate or supplementary curriculum for this group.
Drawing on my experience as an IMG supervisor, former examination committee member and specialist IMG education committee member I sought to identify additional areas of knowledge and experience required for IMG's to practice safe and competent psychiatry within Australia and New Zealand. In addition, specific areas of the curriculum or experience that may not have been covered in depth during primary specialist training in other countries were highlighted. This information was then condensed into fourteen key topics. Input from IMG', other SIMGE committee members and supervisors was sought as part of the process.
The current task is to attach suggested references to these topics and make the information available to IMGs, directors of training (DOT), and supervisors.
The presentation will briefly discuss the process of developing this resource, the topics identified as important, and how the resource might be utilised.
IS PSYCHOPATHOLOGY UNIVERSAL OR LOCAL? IMPLICATIONS FOR PSYCHIATRY
Stephen Rosenman
Visiting Fellow, Centre for Mental Health Research, Australian National University, ACT
Background: The World Health Organisation is conducting an epidemiological survey to “obtain accurate cross-national information about the prevalences and correlates of mental, substance, and behavioural disorders” in 29 countries across the Americas, Europe, Africa, Asia (and New Zealand). The survey is driven and coordinated from the USA and Geneva. It uses the Composite International Diagnostic Instrument (CIDI) to make DSM-IV and ICD-10 diagnoses.
Premise: The survey is based on the assumption that human psychopathology is universal, not local, and can be tapped with the appropriate language translation of interview instruments developed in Western countries.
Argument: This assumption is invalid for reasons that go to the heart of philosophy. The survey method is the benevolently-motivated imposition of alien medical theory and the results will be potentially misleading.
Conclusion: The argument has implications for cross-national psychiatric research and for cross-cultural research within Australia.
THE GENETICS OF AGE-RELATED WHITE MATTER LESIONS
Perminder Sachdev
School of Psychiatry, University of New South Wales, and Neuropsychiatric Institute, The Prince of Wales Hospital, Sydney
White matter lesions (WMLs), commonly seen as hyperintensities on T2-weighted MRI scans of healthy elderly individuals, are considered to be due to small vessel disease in the brain, and are often associated with subtle cognitive and functional impairments. While a number of vascular risk factors for WMLs have been identified, genetic factors are also important. Twin and family studies have reported that WMLs have high heritability. Mutations in several genes have been described for WMLs, such as Fabry disease, CADASIL and homocysteinuria. However, most of the focus has been on single nucleotide polymorphisms (SNPs) as genetic risk markers for WMLs, either directly or through their interactions with other genes or medical risk factors. We have examined a number of candidate genes including those involved in cholesterol regulation and atherosclerosis, hypertension, neuronal repair, homocysteine levels, DNA repair, and oxidative stress pathways. Additionally, two genome-wide association study (GWAS) have been reported, and we have recently completed a GWAS on the Sydney Memory and Ageing Study which included 550 elderly individuals with MRI scans and measures of WMLs. Some interesting findings have emerged from these studies which need independent replication. The identification of individuals genetically at risk of developing white matter lesions will have important implications for understanding their aetiology and developing preventative strategies.
HOW CAN WE PROTECT THE BRAIN FROM AGE-RELATED DECLINE?
Perminder Sachdev
School of Psychiatry, University of New South Wales, and Neuropsychiatric Institute, The Prince of Wales Hospital, Sydney
Old age is associated with decline in cognitive functioning. This decline is a combination of ageing-related decline and the accumulation of multiple pathologies in the brain. The risk factors for some of the pathologies are known and may be partially modifiable. Ageing-related decline is less well-understood and may be related to attenuation of neuroplasticity with age. There is good evidence that neuronal numbers do not decline with age, but there is a reduction in dendritic length, number and efficiency of synapses and neurogenesis. Understanding the processes involved in brain plasticity, such as synaptogenesis, neurogenesis and multicellular adaptation as we age will open up new avenues of intervening to prevent the onset and/or delay the progression of ageing-related decline as well as the development of neurodegenerative disorders such as Alzheimer's and Parkinson's disease. The possibilities include growth factors for synaptogenesis, exploiting endogenous neurogenic factors, the use of embryonic and adult stem cells, attention to modifiable risk factors, and cognitive and physical exercise. This presentation will summarise the current knowledge on how to maintain brain fitness well into old age, and provide a view of likely developments in the future.
PROFILE OF EARLY PSYCHOSIS CASES PRESENTING TO AN ADULT AREA MENTAL HEALTH SERVICE
Ajit Selvendra
1,2, Dominiek Baetens1
1
St Vincent's Hospital, Melbourne, Australia
2
University of Melbourne, Melbourne, Australia
Background: There has been an increased focus on early psychosis and early detection in recent years. The youth early psychosis group has been intensively studied in Australia, but patients presenting above this age have received relatively less attention.
Objectives: To review the characteristics of all patients who present with a first episode of psychosis between the ages of 16 and 65 years to an Adult Area Mental Health Service.
Methods: The Early Psychosis Program at St. Vincent's Hospital Melbourne was developed to treat all patients presenting with early psychosis between the ages of 16 and 65 years. A database was used and this database captured a variety of demographic and diagnostic characteristics of the group.
Results: The results demonstrate many cases of first episode of psychosis presenting over the age of 25 years. There were also a higher number of cases of depression with psychotic features in the over 40 age group, however this latter result does not appear to be statistically significant.
Discussion: Older patients presenting with a first episode of psychosis are relatively less studied but appear to have unique qualities of their own. Understanding the needs of these patients is important in tailoring optimal treatment packages and service responses.
A MINDFULNESS PROGRAM FOR YOUNG FEMALE OFFENDERS IN CUSTODY: QUALITATIVE RESULTS FROM A PILOT INTERVENTION
Katherine Sevar, Robert Adler, Sandy Harrison
Adolescent Forensic Health Service, Royal Children's Hospital, Melbourne, Australia
Background: Young female offenders experience a greater rate of psychiatric disorders than the general population.1 Borderline disorders, with actual or threatened self-harm, are particularly common.2 Co-morbid substance use disorders are common.1 Mindfulness techniques are part of several evidence-based psychotherapies including DBT.3 Mindfulness-based cognitive therapy has high level evidence in recurrent depression.4 Promising research using mindfulness techniques for substance use disorders has been conducted in adult and adolescent populations.5,6 This is the first study to examine a ‘mindfulness’ intervention with young female offenders.
Objectives: To trial a four week mindfulness program, delivered by an external provider, and to examine whether this intervention provided subjective improvement in distress tolerance, emotional awareness and regulation, self-soothing and relaxation.
Findings: Six young women (age 14’20) participated in the program, of whom two attended all sessions. Those who attended every session reported the greatest improvement, reporting an increased ability to recognise and tolerate difficult emotional states and an increased ability to self-soothe and relax by employing mindfulness techniques. They also reported greater interest in self-directed emotional management, leading to a greater sense of hope and empowerment despite being in custody. All of the young women found the program acceptable and all expressed disappointment when it finished and requested its continuation.
Conclusions: This pilot mindfulness program with young female offenders shows promise regarding its acceptability and efficacy in improving emotional recognition and distress tolerance. Further research is warranted given the high rates of psychiatric disorder, deliberate self-harm and suicide in this population.
References
Teplin LA, Abram KM, McClelland GM et al. Comorbid psychiatric disorders in youth in juvenile detention. Arch Gen Psychiatry. 2003 November; 60(11):1097–1108.
Black DW, Gunter T, Allen J et al. Borderline personality disorder in male and female offenders newly committed to prison. Compr Psychiatry. 2007 Sep–Oct;48(5): 400–5. Epub 2007 Jul 5.
Chapman AL. Dialectical behavior therapy: current indications and unique elements. Psychiatry (Edgmont). 2006 Sep;3(9): 62–8.
Chiesa A, Serretti A. Mindfulness-based cognitive therapy for psychiatric disorders: A systematic review and meta-analysis. Psychiatry Res. 2010 Sep 14.
Witkiewitz K, Bowen S. Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. J Consult Clin Psychol. 2010 Jun;78(3): 362–74.
Britton WB, Bootzin RR, Cousins JC et al. The contribution of mindfulness practice to a multicomponent behavioral sleep intervention following substance abuse treatment in adolescents: a treatment-development study. Subst Abuse. 2010 Apr;31(2): 86–97.
RURAL AND REMOTE PSYCHIATRY AND WORKING WITH REMOTE INDIGENOUS COMMUNITIES: A REGISTRAR'S EXPERIENCE
Katherine Sevar
1, Jason Lee2
1
St Vincent's Hospital, Melbourne, Australia
2
Townsville Rural and Remote Mental Health Service, Townsville Hospital, Queensland, Australia
Working in a six-month adult indigenous mental health rotation in Far North Queensland provided an invaluable training experience1. The opportunity to access remote indigenous communities enabled the development of skills around engaging these communities including culturally appropriate communication, negotiation and management options.
RANZCP figures from 2009 showed only 9% of registrars completed a rotation in indigenous mental health2 with the remainder completing an indigenous mental health “experience”. It is unclear whether this was due to a lack of available rotations, lack of interest from trainees or barriers to accessing formal educational opportunities within rural mental health services.
The Australian Institute of Health and Welfare reports the rate of full-time employed psychiatrists per 100,000 population is significantly higher in major cities (22 per 100,000) than in remote and very remote areas (three per 100,000)3 but despite these figures there is current controversy around whether trainees will be required to complete a rural rotation.
Three-quarters of surveyed trainees had a positive view on the rural training experience, regardless of mandatory status.4 If this rotation is not mandated there is likely to be a reduction in the number of trainees who would voluntarily take up rural training opportunities, favouring metropolitan posts instead. Barriers to completing rural rotations, such as family commitments, must be considered and a flexible approach applied. By making rotations in rural mental health more accessible there is an opportunity to attract more psychiatrists to practise in these under-resourced and culturally diverse areas.
References
1. Sevar K. Working with Remote Indigenous Communities in Far North Queensland: An Experiential Narrative. Australasian Psychiatry. Aug 2010, Vol. 18, No. 4: 340–352.
2. Royal Australian and New Zealand College of Psychiatrists (RANZCP), Training and CME department, 2009.
3. The Australian Institute of Health and Welfare http://www.aihw.gov.au/publications/ihw/aatsihpf08r-da/atsihpf08r-c03-09.pdf
4. RANZCP 2010 Discussion paper. Mandatory rural training: an educational imperative?
CHILD ABUSE AND DEPRESSION SEVERITY NOT GENOTYPE PREDICTIVE OF RESPONSE TO ANTIDEPRESSANTS
Ajeet Singh
1,2,3, Chee Ng3,4, Keith Byron6, Michael Berk1,2,3,5, Cameron Osborne1,7, Brian Dean3,5
1
School of Medicine, Deakin University, Geelong, Australia
2
Professorial Unit, The Geelong Clinic, Geelong, Australia
3
Department of Psychiatry, The University of Melbourne, Melbourne, Australia
4
Professorial Unit, The Melbourne Clinic, Melbourne, Australia
5
Mental Health Research Institute, Melbourne, Australia
6
Healthscope Molecular, Melbourne, Australia
7Barwon Health, Geelong, Australia
Background: Prediction of antidepressant response would enable clinicians to sooner match patients to effective tolerable medication.
Objectives: To determine if genetic factors (norepinephrine transporter (NET) and blood brain barrier (BBB) polymorphism) or clinical factors (severity, history of child abuse, suicidality, or psychomotor signs) help predict antidepressant response.
Methods: One hundred and thirteen patients treated for major depression were studied over 16-weeks treatment with venlafaxine or escitalopram. Response and tolerability rates were correlated to baseline genotype and clinical features in a prospective candidate gene association study raters blinded to genotype. HAMD, UKU, CGI, CORE, RFL scales and history of child abuse were assayed at baseline in weeks one, four and eight of treatment with telephone follow-up at week 16. Single nucleotide polymorphisms of the NET gene and the BBB's efflux pump P-glycoprotein (MDR1) gene were assayed. patients received clinical care by their psychiatrist with venlafaxine or escitalopram.
Findings: Response rates for low BBB block versus high BBB block genotype RR = 1.092 (95% CI 0.770′1.549) were not significant. NET polymorphism hypothesised to preferentially give better response to venlafaxine actually yielded better response to escitalopram, with non-significant RR = 0.886 (95% CI 0.564′1.394). RR for high side effects if low vs. high BBB block genotype was not significant at 1.228 (95% CI 0.3624′3.4782). Those with child abuse history RR of responding to antidepressants was significant at 0.1857 (95% CI 0.0522′0.6610). CORE (psychomotor signs) scale high versus low score response was significant with RR = 1.5185 (95% CI 1.2181′1.8930). RFLS (reasons for living) higher versus. lower score to response was significant with RR = 0.6061 (95% CI 0.4236′0.8672).
Conclusions: The gene polymorphisms in this study were not significantly response-predictive, but history of child abuse significantly reduced response odds as did lower severity of depression. More highly powered studies may detect small predictive effects of the studied genes.
NOCTURNAL ENURESIS IN ADULTS TAKING CLOZAPINE, RISPERIDONE, OLANZAPINE AND QUETIAPINE: A COMPARATIVE COHORT STUDY
Mira Harrison-Woolrych, Keren Skegg, Janelle Ashton, Peter Herbison, David Skegg
University of Otago, Dunedin, New Zealand
Background: Nocturnal enuresis has been reported in patients taking clozapine, but the incidence has not been accurately established. The incidence of enuresis in patients taking risperidone, olanzapine or quetiapine is unknown.
Objectives: To compare nocturnal enuresis in patients taking clozapine with that in patients taking risperidone, olanzapine or quetiapine.
Methods: Observational cohort study using Prescription Event Monitoring methods. Patients dispensed with atypical antipsychotic medicines were followed up by questionnaires to doctors who asked patients directly about bedwetting.
Findings: Nocturnal enuresis was reported by 17 of 82 (20.7%) patients taking clozapine, 11 of 115 (9.6%) taking olanzapine, 7 of 105 (6.7%) taking quetiapine and 12 of 195 (6.2%) taking risperidone. Compared with clozapine, the risk of nocturnal enuresis was significantly lower in patients taking olanzapine (or = 0.41, 0.19–0.91), quetiapine (or = 0.28, 0.11–0.72) or risperidone (or = 0.25, 0.12–0.53).
Conclusions: Approximately one in five patients prescribed clozapine experienced bedwetting. This was significantly higher than the rate of nocturnal enuresis in patients taking olanzapine, quetiapine or risperidone.
A POLICEMAN'S LOT IS NOW A HAPPY ONE
Sandra Smith
Private Practice, Gosford, NSW
Background: A 50-year-old, medically retired policeman was injured at work in 1986, sustaining a head injury which left him with PTSD, poor balance and hearing loss (L ear). Subsequent surgery exacerbated these symptoms, and over the next 24 years, his balance became progressively worse, so much so that he required a wheelchair. Despite these difficulties, he retrained, completing a law degree using voice recognition software.
Objectives: To treat poor balance and resolve PTSD symptoms.
Methods: To use a BrainPort (a tactile biofeedback device involving nerve stimulation through the tongue), as outlined by Dr Norman Doidge in âThe Brain That Changes Itselfâ to improve balance and resolve PTSD symptoms.
Findings: After being fitted with the BrainPort at LifeMark Rehabilitation Vancouver, Canada, a dramatic improvement in balance and mental state suddenly occurred after three days. The patient is now able to walk unaided and lead a normal life. Further sessions are planned to use the BrainPort to treat PTSD symptoms, when his balance has been stabilised.
Conclusions: This device worked dramatically in this patient, the third Australian to be fitted with a BrainPort. Hopefully they will become available in Australia as they have many potential uses, including stroke recovery, OCD, multiple sclerosis, Parkinsonâs Disease, as well as balance problems.
A PROTOCOL TO IMPROVE RELATIONS WITH PEOPLE WITH ANOREXIA NERVOSA IN ADULT MENTAL HEALTH UNITS
Ann Solar
Department of psychiatry, Sir Charles Gairdner Hospital, Perth, Australia
University of Western Australia, Perth, Australia
Objective: Occasionally, people with chronic, severe, restricting anorexia nervosa failing outpatient therapy end up in adult public mental health units at risk to themselves. Usually, intense relationship conflicts occur because they are not capable of, not ready for, or are ambivalent about change. Having a basic protocol from the outset of the admission embedded in sound generic principles contributing to mental health can significantly reduce conflict.
Method: Reflection on clinical experience and a PsychINFO literature search was used to devise a protocol.
Results: Because of the significant risk and the need for protection, certain non-negotiable requirements regarding continued weight loss and full weight restoration are explained at the outset. This occurs in parallel with a collaborative person-centred approach working wherever possible with the family to stop maintaining factors. Contemporary psychotherapeutic tools, tailored to individual needs, promote change and develop a sense of self beyond the eating disorder.
Conclusion: An unambiguous approach, explained from the start, to continued weight loss and full weight restoration that removes choice, when the person is incapable of making choice, can unburden patient and family and manages risk. Approached in a collaborative, person-centred, biologically and psychotherapeutically informed way, change is promoted and conflict prevented.
THE EXPERT PATIENT
Mr Anthony Stratford
MIND Australia
Since the late 1980′s, there has been a dramatic shift in the mental health field towards what is commonly known as the recovery process. This process is a holistic one that sees the patient as the decision maker on their journey. Each journey is an individual one where the patient may still be experiencing symptoms of their mental ill-health.
iatry and medication play an important role throughout the journey, however, their now needs to be a shift from professional/patient to a greater emphasis on partnership and collaboration not only with the patient but with many others within and beyond professional boundaries, as called for in December 2010 in the United Kingdom. (Recovery is for All – Hope, Agency and Opportunity in Psychiatry, A Position Statement by Consultant Psychiatrists. South London and Maudsley NHS Trust and South West London and St George's NHS Trust).
THE IMPOSSIBILITY OF THE IDEAL PATIENT: PUBLIC AND PRIVATE CONDITIONERS OF COMMUNICATION IN CLIENT AND PRACTITIONER RELATIONSHIPS
Luke Strongman
Open Polytechnic, Lower Hutt, New Zealand
Background: Most of the population is probably unaware of the range of services that psychiatric practitioners may perform. To the layman, definitions of insanity may remain obscure. Within the mass media, most people's exposure to mental illness will most be likely be conditioned by advertising for the remediation of depression – the most commonly diagnosed psychiatric illness. Even within popular psychology, psychiatry and psychiatrists may remain some of the least exposed practitioners within their professions. Whilst diagnostic literature is based on observation of behaviour, physiological theory and empirical research, the conditioner of any psychiatric conversation is at least to some extent a two- or three-way process involving a conversation between practitioner and client.
Objectives: This paper seeks to examine and discuss a re-imagining of the role of psychiatry in society, which functions not only on the deficit or problem-reduction model of scientific enquiry but also on the positivist model of societal commentary and reward. It is the contention of this paper that psychiatrists also have a role as critics and a conscience of public life.
Methods: From an examination of sociological, para-medical and post-structuralist literature, this paper seeks to examine the relationship between the deficit model of health and the role of psychiatry in promoting societal good. Implicit within this is not only patient health, but also the expectations and standards of medical authorities in which practitioner and client are situated.
Findings: Psychiatric practitioners are performing services for their clients, their organisations (if in public or private practice) and also for wider good of society. Client and practitioner conversations are therefore a node within a network of conversational relations. Whilst the ethics of client confidentiality ensures that these conversations are contained, there is a wider role that psychiatrists may enjoy as practitioners and promoters of public good health.
Conclusions: Most people may only encounter psychiatrists professionally when there is psychological or physiological difficulty but what of positive diagnosis? If sanity is a continuum, might not psychiatrists have a social role in diagnosing sanity if it leads to positive health gains in society?
PSYCHOLOGICAL FIRST AID: PERSEPECTIVES FROM THE BOXING DAY TSUNAMI, SRI LANKA, 2004, AND CYCLONE NARGIS, BURMA, 2008
Raymond Tint Way
1, Aye Aye Bartlett1, Russell D'souza2, Suresh Sundram3 Kannan Subramaniam4
1
Burmese Medical Association Australia, Sydney, Australia
2
University of Melbourne, Melbourne, Australia
3
Mental Health Research Institute of Victoria, Melbourne, Australia
4
Pfizer Australia, Sydney, Australia
Major disasters have a significant impact on the physical, social and psychological wellbeing of survivors. The adverse effects following bereavement, injury, loss of home and livelihood result in myriad states from survivor guilt to post-traumatic stress disorder and violent behaviors. After the immediate needs of physical health, nutrition and shelter are addressed a focus on the psychological trauma of the affected population is paramount. While not all disaster survivors have long-term psychological sequelae, some, if not supported immediately, may develop serious outcomes. However, it is not always possible to isolate this group during the immediate aftermath of a disaster. We describe scenarios where Psychological First Aid was promoted and delivered using a culturally congruent “train the trainer” approach following recent major disasters in South Asia.
After the Boxing Day Tsunami in Sri Lanka in 2004, a group of Australian and New Zealand doctors trained in psychological medicine headed to the most affected parts of the country. Local support groups were mobilised, and volunteer caregivers including teachers, health-workers, police and general practitioners were trained to address psychological trauma.
When Cyclone Nargis struck Burma in May 2008, a group of Burmese doctors in Sydney responded by supporting immediate relief efforts through a group of heath volunteers. A psychosocial project was piloted using the “train the trainer” model. A Burmese version of the Red Cross and Red Crescent Training Manual was developed as the training guide. The pilot delivered Psychological First Aid and capacity building training to local health workers and volunteers.
IT WAS A DREAM, BUT IT WASN'T A DREAM – PORTRAYING PTSD-DS THROUGH ‘MY NEIGHBOUR TOTORO’
Shuichi Suetani
1, Gavin Cape2
1
Modbury Hospital, Adelaide, Australia
2
Univeristy of Otago, Dunedin, New Zealand
Background: Cinema is one of the most useful ways of understanding a culture. Cinema has been used increasingly in medical education, in particular for the field of psychiatry, and its usefulness is being rapidly recognised.
Objectives: The paper aims to demonstrate that cinema can be utilised as a tool for teaching and learning in psychiatry. In the process, it discusses clinical manifestation of post-traumatic stress disorder with secondary psychotic features (PTSD-SP) using as an example the film ‘My Neighbour Totoro’ to support this diagnosis as an independent entity.
Method: The film was studied in depth, considering factors such as urban legend and the cultural symbolisms. One of the characters was then chosen to be analysed using recently proposed criteria for PTSD-SP.
Findings: The authors used the newly proposed criteria to demonstrate the manifestations of PTSD-SP in the character concerned. Clinical insights to cultural variations of grief are also evident in the film.
Conclusion: Cinema is a readily accessible and highly useful vehicle for learning about psychiatry. The popular animation film ‘My Neighbour Totoro’ illustrates the proposed diagnostic criteria for PTSD-SP, which may be of relevance to practicing psychiatrists.
CLOSE ENCOUNTERS OF THE CANINE KIND: THE USE OF DOGS AS ‘CANINE CO-THERAPISTS’ IN PSYCHOTHERAPY
Anne-Marie Swan
Private Psychiatrist, c/- NSW Branch Office, PO Box 280 Rozelle NSW 2039
Background: Dogs have figured as close companions of humans since prehistoric times. They have played an important role in healing since ancient times. There is a time-honoured tradition of dogs as therapeutic companions since the time of Freud.
Objectives: This paper seeks to explore the role of dogs as adjunctive therapists in a psychotherapeutic setting.
Methods: Use will be made of historical and clinical perspectives using current ‘live’ material against an historical background of clinical case vignettes in an attempt to counter (in semi-humorous vein) the stereotype of the ‘Black Dog of Depression’. A number of theoretical models will be considered including analytical, experiential, cognitive/ behavioural and mindfulness-based models of therapy.
Conclusions: It is proposed that dogs have the potential to fulfil a number of useful therapeutic functions in the consulting room as well as beyond it and that there is room for a renewed appraisal of their current stereotype as harbingers of depression.
THIRTY YEARS OF THE RURAL SERVICES TEAM SERVICE TO SOUTHERN QUEENSLAND
Dr Mark Kluver
1, Dr Jeffery Thompson2
1
VMO and former Director, Acute and Community Services, Toowoomba Hospital and2 Director, Extended Inpatient Services, Baillie Henderson Hospital, Toowoomba
Thirty years ago the Baillie Henderson Hospital, Toowoomba started sending staff to undertake clinics in rural towns spread over 500,000 sq km. Under the leadership of Dr Joan Ridley, a formalised Rural Services Team was established to visit various towns in the Darling Downs and South West Queensland. This was transferred to the Toowoomba Hospital and no longer functions as a single team but still provides visiting services to Warwick, Dalby, Stanthorpe, Goondiwindi, Chinchilla, Tara, Roma, St George, Charleville and Cunnamulla. Gatton was also visited and is now served by a separate system.
The Service faced many challenges. These included administrative changes within Queensland Health, financial shortages and the problems associated with travel, including aircraft safety.
In 1990 the service provided emergency services to Charleville after disastrous floods, sending a team out at short notice to initially camp at the airfield with evacuees. Later that year one of the pilots who worked with the service was killed in a crash at the end of the runway while staff awaited takeoff.
This caused increased fears by staff but the service was expanded and air travel increased.
An aircraft crash in 2001 killed three team members and the pilot. This led to a significant issue of morale and discussion of the value of the service.
MENTAL ILLNESS AND TRADITIONAL CHILD REARING PRACTICES OF TORRES STRAIT ISLANDERS (OFTEN REFERRED TO AS ISLAND ADOPTION)
Ivy Trevallion
Child and Youth Mental Health Service, Thursday Island, Australia
This paper will look at mental illness and traditional child rearing practices of traditional child rearing practices often referred to as “Island Adoption”.
Torres Strait Islanders have, since time immemorial, managed people with mental illness within their family/families and their community, ensuring that they are safe at all times. Some of the people who have mental illness were traditionally adopted. “Island Adoption” is an integral part of Torres Strait culture and Torres Strait Islander child rearing practices. “Island Adoption” involves transfer of care of children from one family to another. This transfer occurs at birth. In Torres Strait Islander culture children are considered “gifts” from God and if you are given a child it is your responsibility to ensure that the child is raised in a safe and secure home environment. Even when the child grows into an adult, they are still seen as your responsibility by the family.
DEPRESSIVE SYMPTOMS, PERSONALITY TRAITS AND QUALITY OF LIFE IN PATIENTS WITH SEIZURE DISORDERS
Chris Turnbull
1,2, Dennis Velakoulis1,2, Raju Yerra1, Terry O'brien1,2
1
Royal Melbourne Hospital, Melbourne, Australia
2
University of Melbourne, Melbourne, Australia
Background: Patients with seizure disorders have increased rates of depression and anxiety, which affect their quality of life. This is true of both patients with epileptic seizures and non-epileptic seizures. Personality traits have also been shown to affect quality of life in the epilepsy population. However, the relationship between these factors is complex.
Objectives: We aimed to assess the relationship between personality traits, depressive and anxiety symptoms, quality of life and specific seizure diagnoses in a large sample of patients with seizure disorders.
Methods: We assessed patients admitted to Royal Melbourne Hospital Video EEG Unit, a unit that provides diagnostic and therapy-guiding assessments for patients with refractory seizure disorders or seizure disorders of unclear aetiology, including psychogenic non-epileptic seizures. We assessed personality using the Neuroticism-Extroversion-Openness Five Factor Inventory, quality of life using the Quality of Life in Epilepsy scale, and anxiety and depressive symptoms using the Hospital Anxiety and Depression Scale, SCL90 and NuCOG, as well as demographic and clinical data collection.
Findings: Over 5 years, 375 patients were enrolled in the study. Overall quality of life was predicted by HADS depression score, the personality trait neuroticism and seizure frequency, but not by whether seizures were epileptic or non-epileptic in nature. Depression scores correlated highly with neuroticism not with seizure type or frequency.
Conclusions: Neurotic personality traits and depressive symptoms correlate with poorer quality of life in patients with both epileptic and non-epileptic seizures independently of seizure frequency, but are themselves a correlated.
PLANNED PSYCHIATRIC ADMISSIONS TO REDUCE EMERGENCY PRESENTATIONS: A RETROSPECTIVE COHORT STUDY OF ADOLESCENTS
Mohammed Usman, Tracey Dryden-Mead, Catherine Crouch, Phillip Brock
Women's and Children's Hospital, Adelaide, South Australia, Australia
Background: Deliberate self-harm occurs in up to 20% of Australian adolescents and limited strategies are in place for its management. There is a current trend to utilise regular brief scheduled admissions for adolescents who are frequent self-harmers to minimise ongoing self-harm and presentations to emergency departments.
Aims: To present evidence for planned psychiatric admissions as a therapeutic strategy to reduce presentations of adolescents to the emergency departments with self-harm.
Methods: We conducted a retrospective cohort study of all the patients who were offered planned admissions during a 15-month period. The cohort was followed up from a year prior to the intervention and up to a year post-intervention. The primary outcome measure used was the number of presentations to the emergency department.
Results: A total of 19 patients were included in the study. This represents all the patients who were offered planned admissions. All the patients had reduced presentation to the ED post planned admissions.
Discussions: There is a paucity of literature relating to the evidence base of planned hospitalisations for adolescents with significant self-harming behaviours. This is essentially the first study looking at this topic. Planned admissions have a role in this age group as they increase resilience and provide a supportive, non-punitive environment with clear boundaries with limit settings support systems.
Conflict of Interest: No.
PATIENT RIGHT, MORAL DILEMMA, OR ABUSE? CHARGING INVOLUNTARY PATIENTS
Antonella Ventura
1, Nick O'connor2
1
Justice Health, New South Wales, Australia
2
Sydney Local Health Network, Australia
Background: The psychiatrist could be considered as guardian for patients admitted to psychiatric wards under the status of involuntary patient under the Mental Health Act; as such he/she has a professional duty to protect the patient from potential exploitation. The psychiatrist also has a duty to the population he/she serves; resource allocation and the protection of others from violence are some of these duties.
Objectives: The authors will describe two ethical dilemmas. Firstly the ethical arguments around the decision to charge involuntary patients who hold private health insurance will be explored. These will include issues of competency of an involuntary patient to choose private patient status, autonomy and the right of such patients to be private patients, non maleficence and justice, including distributive justice. Secondly the authors will explore the pros and cons of criminal charges being laid on involuntary psychiatric patients who assault staff or other patients in the course of their admission. The issue of fitness to be charged, risk assessment and management, rights and protection of staff and protection of the patient him/herself will be highlighted.
Methods: The authors will present the opposing for and against arguments and allow for participant discussion.
Conclusions: The psychiatrist has many professional roles which call for balancing a number of, at times, opposing interests. When complex, contested issues arise in clinical settings, psychiatrists should be guided by consideration of patient rights, and ethical principles.
GROUP COGNITIVE BEHAVIOURAL THERAPY FOR CLINICAL PERFECTIONISM: TWO CONTROLLED TRIALS WITHIN AUSTRALIAN COMMUNITY SAMPLES
Sue Waite
1, Anna Steele2, Sarah Egan³
1
Adelaide Health Service, Adelaide, South Australia
2
Adelaide Health Service, Adelaide, South Australia
3
Curtin University, Perth, Western Australia
Background: Although there has been disagreement regarding the nature of the construct of perfectionism, it has consistently been implicated as an important factor with respect to the onset, maintenance and course of many forms of psychopathology. Recent treatment trials in mixed samples have targeted perfectionism with cognitive behavioural therapy (CBT) and shown reductions in perfectionism, depression, anxiety and symptoms of bulimia nervosa. There exists no published data on the treatment of clinical perfectionism in a group format with a clinical population.
Objectives: The present study compared the therapeutic effects of CBT for clinical perfectionism in a group format with a waitlist control condition and an information-only condition.
Method: Participants reporting clinically significant levels of perfectionism were recruited from community samples in Metropolitan South Australia and Western Australia. Measures of perfectionism, self-criticism, depression and anxiety were completed at five time-points – baseline, following a four-week wait list control period, following a four-week information-only condition, following an eight-week CBT group program for clinical perfectionism and at three-month follow-up.
Findings: There was a significant reduction in scores on measures of perfectionism, depression, anxiety, stress and self-criticism over time. Specifically, compared with scores at the first three time points, scores were reduced post–treatment and were maintained at three-month follow-up.
Conclusions: This study provides preliminary evidence that group CBT is effective in reducing clinical perfectionism, and is superior to a wait-list and psycho education condition. It suggests that this form of treatment may be an effective transdiagnostic intervention in routine clinical settings.
PSYCHOLOGICAL STRAIN OF STAFF WORKING IN DUAL DIAGNOSIS (INTELLECTUAL DISABILITY AND MENTAL HEALTH) SERVICES
Bruce Jackson
1, Tom Meehan2, Paul White1
1
Mental Health Outreach and Assessment Team, Disability Services Queensland, Department of Communities, Queensland
2
Service Evaluation and Research Unit, University of Queensland on behalf of Dual Diagnosis Research Cell
Background: The Dual Diagnosis (DD) Service at The Park Centre for Mental Health provides services to adults with a mental disorder who are also intellectually disabled and who exhibit persistent aggressive or violent behaviour. These include consumers with a high need for disability support, clinical treatment to improve skills and community support. It has very high Honos “behaviour” scale scores and high levels of assault on staff.
Methods: This study was a cross-sectional survey of staff. Two recognised measures of psychological wellbeing were used: the Maslach Burnout Inventory and the General Health Questionnaire.
Findings: Seventeen staff completed the survey, giving a response rate of 47.2%. There were 12 staff (70.6%) who had worked longer than eight years in the mental health services. Nine (56%) of the respondents were male and seven (40%) were female. The findings from the survey were compared with the MBI scores for mental health workers in two other Australian studies and one from Scotland. We found a high level of emotional exhaustion compared to the other three studies. All four groups reported average levels of de-personalisation. Staff in DD reported average levels of personal accomplishment unlike the other three studies where the respondents reported high levels of personal accomplishment. A quarter of those who completed the survey were considered “GHQ cases”.
Conclusions: We will discuss protective and preventative factors relating to both staff and patients.
SYDNEY'S FIRST ACADEMIC PSYCHIATRISTS
Richard White
1, 2
1
University of Sydney
2
Royal Prince Alfred Hospital, Sydney, New South Wales
Background: Few in our profession know the names of Sydney's first academic psychiatrists, much less their histories. The impact of these psychiatrists on the standard of medical psychology practised in New South Wales has received little attention.
Objectives: To provide a brief narrative account of the careers and the impact on psychological medicine, of the first lecturer and the first three professors of psychological medicine at the University of Sydney.
Methods: Review of the literature relating to the history of psychiatry in New South Wales, together with material acquired from local archival sources and relevant journals and newspapers.
Findings: Between 1882 and 1975 four British-trained psychiatrists, Dr Frederick Norton Manning, Sir James Macpherson, Professor William Siegfried Dawson and Professor William Henry Trethowan, taught psychological medicine at the University of Sydney. Each made significant contributions to psychiatry in New South Wales.
Conclusions: During their years of tenure, Sydney's first academic psychiatrists had a significant influence on the practice of psychiatry and on the training of undergraduate and graduate physicians in psychological medicine in New South Wales.
PSYCHOSURGERY AT THE ROYAL PRINCE ALFRED HOSPITAL
Richard White, Martin McGee-Collett
University of Sydney, and Royal Prince Alfred Hospital, Sydney, New South Wales
Background: During the 1940s and 1950s psychosurgery was practised throughout the developed world. There have always been opponents of psychosurgery, both within and outside the medical profession. The frequency of these operations declined precipitously in the early 1960s. Subsequently there has been a tendency, in the public imagination, to link the psychosurgical era – particularly its failures – with aberrant and maverick physicians, such as Walter Freeman in the USA or Harry Bailey in Sydney.
Objectives: To provide a sketch of the narrative history of psychosurgery, both internationally and in New South Wales, followed by new data about psychosurgery at the Royal Prince Alfred Hospital (RPAH).
Methods: A brief review of the literature relating to the history of psychosurgery will be followed by an account of psychosurgery practiced at RPAH. The latter account relies heavily on a presentation by Dr Rex Money, a Neurosurgeon, at the seventeenth Annual Reunion of the RPAH Medical Officers Association in September 1951.
Findings: Dr Money described the outcomes of his treatment of 13 cases. The RPAH Department of Neurosurgery's annual reports from 1955 to 1964 show that between two and five psychiatric patients underwent surgery during each year until 1960. Only one further operation was performed between 1961 and 1964.
Conclusions: The pattern of psychosurgical procedures at RPAH closely resembles that reported elsewhere. Psychosurgery was a mainstream treatment at RPAH, as it was throughout the world, during the 1940s, 1950s and very early 1960s.
LABELS USED BY YOUNG PEOPLE TO DESCRIBE MENTAL DISORDERS: THEIR DETERMINANTS AND IMPACT ON STIGMA AND HELP-SEEKING
Annemarie Wright
1, Anthony Jorm1, Andrew Mackinnon1, Nicholas Allen1,2
1
Orygen Youth Health Research Centre, The University of Melbourne, Melbourne, Australia
2
Department of Psychological Sciences, The University of Melbourne, Melbourne, Australia
Background: Mental disorders are common in young people, yet many do not seek help. Recognition and labelling are natural components of the help-seeking process and are targets of community awareness initiatives. However, labels may also elicit stigmatising beliefs and inhibit help-seeking.
Objectives: To examine the labels used by young people to describe mental disorders and the association between label use and help-seeking preferences and label use and stigma.
Method: A survey of 2802 young people aged 12 to 25 years was conducted. Label use, help-seeking preferences, and stigmatising beliefs were assessed in response to vignettes of a young person with a mental disorder using percent frequencies and logistic regression analyses.
Findings: Accurate labelling of the vignette varied for depression (69.1%), psychosis (33.4%) and social phobia (5%), and was associated with increasing age, exposure to campaigns and accuracy of parent label use. Accurate labelling predicted a preference for professionally recommended sources of help with greater consistency than any other labels. Generic lay labels predicted less intention to seek any help. Regarding stigma, most mental health labels were associated with seeing the person as sick rather than weak. However, for the psychosis vignette, mental health labels predicted perceptions of dangerousness and unpredictability.
Conclusions: The use of accurate labels, and an understanding of the terms that young people may use in place of them, are potentially important factors to consider in the design of effective help-seeking messages for community awareness initiatives. Campaigns promoting labelling of psychosis may need to proceed with caution.
