REFLECTIONS ON CHALLENGES IN ESTABLISHING A PSYCHOGERIATRIC UNIT IN ILLAWARRA
Nagesh Pai
1, Abdul Burhan2
1
University of Wollongong
2
SMHOP unit, Wollongong Hospital, Wollongong
Background: In recent years changes in the type and severity of problems precipitating inpatient care have changed, with increasingly frail and medically complex patients becoming today's norm. There are distinct advantages in starting an inpatient psychogeriatric unit in a general hospital, including easier access to a full range of health services in addition to facilitating collaboration with acute geriatric services.
Objectives: To describe the evolution of specialist mental health for the older persons’ inpatient unit in Illawarra and to reflect on the challenges of its establishment.
Findings and Conclusion: Effective psychogeriatric services require an integrated range of hospital and community-based staff and resources which should be utilised in a style acceptable to the user, staff and other professionals. Challenges include a willingness to be resourceful in providing services, and the tenacity to be vociferous advocates for the development of new facilities and staff. It is much more likely that effective integrated psychogeriatric services will become a reality if these challenges are met. By working together as an interdisciplinary team, these challenges can be converted into opportunities that expand our knowledge and steer our therapies towards quality of life for the remaining years of frail elderly patients.
FUNCTIONAL HEALTH LITERACY IN PEOPLE WITH MENTAL ILLNESS
Cassandra Burton
1, Aaron Neaves2, Linley Denson2, Cherrie Galletly1,2,3
1
Ramsay Health Care (SA) Mental Health Services, Adelaide, Australia
2
University of Adelaide, Adelaide, Australia
3
Northern Mental Health, Adelaide, Australia
Background: Good health literacy is essential for successful management of disorders such as schizophrenia and depression, both chronic conditions requiring self-monitoring skills and the management of multiple medications and specialist services. However there has been little research into health literacy in people with mental illness.
Objectives: This exploratory study aimed to investigate and describe the state of health literacy in (1) a sample of people being treated for schizophrenia, recruited from community mental health services and inpatient wards and (2) a sample of private hospital outpatients with a diagnosis of major depressive disorder.
Methods: We evaluated health literacy in 30 people with schizophrenia and 30 people with major depression using the Test of Functional Health Literacy in Adults (TOFHLA).
Findings: Twenty-nine people (97%) in the schizophrenia group and 28 (93%) in the depressed group had adequate health literacy. For the schizophrenia group, there was a significant positive correlation between health literacy and global cognition.
Conclusions: The level of health literacy in our mentally ill sample was comparable with that of the general Australian public, and higher than the rates of health literacy in US studies involving elderly Medicaid recipients and people with physical illnesses. The small sample size and lack of control group limited the strength and generalisability of the study's findings. Further research is needed to evaluate health literacy in people with mental illness in Australia, and well-matched international comparison studies would be useful.
CONSULTATION LIAISON GRADUATE SERVICE – A REPORT
Dr Nisar Contractor
Capital and Coast District Health Board, Wellington, New Zealand
This service was established following a study on ‘graduates’ (people with enduring and/or relapsing psychiatric illnesses who graduated in life to become old) as part of a dissertation for FRANZCP in 2003. This work was extended as a Project for Certificate in Psychiatry of Old Age in RANZCP. Following this, the need for service for ‘graduates’ was acknowledged; work began in 2004 and continues to date, headed by the author. The creation of this service has lead to the prevention of ‘raduates’ falling through the cracks of service descriptions of the adult psychiatry services and old age psychiatry. The aim of this service is to assess graduates, provide treatment reviews, establish social connectedness and improve quality of life. A report has been published to demonstrate the workings of this service for a single individual with satisfying outcomes.
NEUROBIOLOGICAL EFFECTS OF EXERCISE ON STRESS-INDUCED DEPRESSION
Harris Eyre
1, Bernhard T. Baune1,2
1
Psychiatry and Psychiatric Neuroscience Research Group, School of Medicine and Dentistry, James Cook University, Townsville, Australia
2
Department of Psychiatry, School of Medicine, University of Adelaide
Background: Recently, a tentative model of Stress-Induced Depression (STR-I-D) was proposed. The aetiology and development of STR-I-D is suggested to be mediated by four neurobiological mechanisms: monoamine dysfunction, hypothalamo-pituitary-adrenocortical axis dysfunction, neurogenesis dysfunction and neuroinflammation.
While exercise is an effective adjunct or standalone therapy in the treatment and prevention of depressive disorders, its neurobiological basis is poorly understood and warrants further investigation.
Objectives: To review the literature on the neurobiological mechanisms involved in the aetiology and development of STR-I-D and to review the influence of exercise on these neurobiological mechanisms and how it may be useful to prevent or attenuate STR-I-D.
Methods: The author systematically reviewed the scientific literature on the subject over the last 30 years, searching PubMed, OvidSP and ScienceDirect databases. Main search terms included: neurotrophin, neuroinflammation, monoamine, hypothesis, psychological stress, murine, human and translational.
Findings: Chronic psychological stress has a multitude of effects on the central nervous system which are known to contribute to the development of depression. These include a reduction in serotonin levels, hypercortisolaemia, reduced brain-derived neurotrophic factor and elevated proinflammatory cytokines (i.e. tumour necrosis factor alpha and interleukin-6). Findings are consistent across murine-based models and human studies. Preliminary data suggests exercise has beneficial effects on these same neurobiological processes, which take part in the development of depression.
Conclusions: Current literature suggests an association between the four neurobiological mechanisms, STR-I-D and exercise. Further research into these mechanisms is needed to improve diagnostic recognition, predict treatment response and to provide a basis for efficient, individualised therapies.
TRAJECTORY TO FELLOWSHIP UNDER CURRENT TRAINING REGULATIONS
Dr Scott Fletcher
1, Dr Stephen Jurd2, Dr Andrew Gosbell3
1
Research and Evaluation Officer, RANZCP
2
Director of Postgraduate Training in Psychiatry, Northern Sydney Central Coast Network
3
Director, Education, RANZCP
Background: The current RANZCP curriculum and training regulations were implemented in November 2003. This involved a new training structure with basic (years 1–3) and advanced (years 4–5) requirements. All summative assessments occur during basic training and generalist or sub-specialty advanced training streams are available. A number of trainees who commenced the current curriculum are now either close to, or have attained, Fellowship.
Objectives: To examine the pathway and barriers to attaining the FRANZCP under the current RANZCP Fellowship Training Program.
Methods: Data was extracted from the College training database for all trainees commencing training between December 2003 and February 2006. Data on assessments, placements, breaks-in-training, part-time, and other items were evaluated. Time taken to complete mandatory training requirements was the key element analysed.
Findings and Conclusions: For those who attained Fellowship within this cohort, the median training time (less than six years) is consistent with the structure of the five-year training program, however a number of trainees had undertaken periods of part-time training and breaks-in-training, which delayed progression. The summative assessments, cases histories and clinical exam were found to delay progression. The ability for candidates in generalist stream advanced training to complete the clinical examination during their first year of advanced training has assisted with progression but potentially influenced the quality of their advanced training experience and reduced the numbers undertaking sub-specialty training.
METHAMPHETAMINE ADDICTION – THE PRACTICALITIES OF RESEARCHING ‘P’ ADDICTION
Susanna Galea
1, Carina Walters1, Mino Lorusso1, Peta Hardley1, Rob Kydd2, Wayne Miles3
1
Community Alcohol and Drug Services, Auckland, New Zealand,
2
Auckland University, Auckland, New Zealand,
3
Waitemata District Health Board, Auckland, New Zealand
A double-blind randomised controlled trial of methylphenidate versus placebo for the treatment of methamphetamine dependence was carried out. This presentation will report on the practicalities of researching methamphetamine addiction, including issues around recruitment, engagement and monitoring of individuals participating in the trial.
SMOKE-FREE MENTAL HEALTH UNITS: A SURVEY OF MENTAL HEALTH PROFESSIONAL KNOWLEDGE AND ATTITUDES
Ashu R. Gandhi
1, Jennifer Majoor2, Dan Lubman3, Paul H. Katz4, Jose Segal5
Eastern Health Mental Health Program, Victoria, Australia
Turning Point, Alcohol and Drug Program, Victoria, Australia
Background: Not very long ago Victoria implemented a smoke-free policy across hospitals and mental health services. There is a complex association between mental illness, treatment, and smoking.
The successful implementation of smoke-free mental health units depends on several factors apart from policies and protocols.
Objectives: The objective of this study was to investigate the attitude and knowledge of mental health professionals towards smoke-free mental health units, and further trying to correlate this with the success/ barriers to effective implementation of this policy in the Eastern Health Mental Health Program.
Methods: We used a questionnaire survey focusing primarily on the medical staff in the mental health service. The pen and paper questionnaire included questions with yes/no responses as well as Likert scale responses. The content of the questions tapped into areas of attitude towards the smoke-free policy, ease of implementation in ensuring the smoke-free policy, whether that was an area included in the intake interview, diagnosis of nicotine addiction, signs of nicotine withdrawal, the interrelationship between smoking and mental illness, the effect of smoking on psychotropic medications, the perceived impact of the smoke-free policy, awareness of interventions for quitting smoking, NRT, whether they had the time to deal with patients who were smoking and attendance at smoking-related training.
Findings: The results were interesting and correlations were sought between years of experience in training and personal attitudes, and awareness and knowledge.
Conclusions: Improving medical staff knowledge and attitude may have an impact on the implementation of smoke-free mental health units.
SEXUAL TRAUMA PROJECT AT MIRRABOOK
Dr Vikas Garg
1, Ms Rebecca Garvi2
1
South Eastern Illawara Health Service, Univeristy of Wollongong and IHMRI
2
Social Worker, SESIAHS
Background: Mirrabook is an acute inpatient unit based at Shellharbour hospital with a catchment area from Nowra and down south along the coast. In 2010, there were more than 250 admissions to Mirrabook. The commonest denominator was sexual trauma. It was important to address this issue that impacts a range of psychiatric diagnoses, re-admissions, discharges and prognoses. Generally, the issue of sexual trauma is not addressed in an inpatient unit for various reasons. It is referred to a psychologist or a specialist counsellor on an outpatient basis. The timeframe for getting help varies sometimes up to one year. Patients feel uncomfortable discussing this matter at all. We decided to address the issue of sexual trauma as it is often the root cause at Mirrabook.
Objective: This is a descriptive paper to share our experiences when dealing with sexual trauma in an inpatient unit. We aim to answer the following question: Is an inpatient unit suitable for sexual trauma therapy?
Results: We share our experiences, though in their infancy. The results have been positive. The patients felt they were listened to and that their concerns were being addressed for the first time, instead of being referred to another mental health professional. Therapeutic rapport is established quickly. We demonstrate this through a case report.
Conclusion: We believe that inpatient units are suitable for sexual trauma therapy and that it should start there before being referred to another professional.
NEUROPSYCHIATRIC MANIFESTATION OF VELO CARDIO FACIAL SYNDROME – A REVIEW
Dr Vikas Garg
1, Prof. Nagesh Pai2
1
South Eastern Illawara Health Service, Univeristy of Wollongong and IHMRI
2
Univeristy of Wollongong
Background: VCFS is a rare genetic syndrome that has shown a direct linkage with chromosomal abnormality. It is associated with a number of psychiatric and medical syndromes. The psychiatric manifestations are generally treatment refractory.
Objective: This is an educative approach to understand the various neuropsychiatric manifestations of VCFS. It involves a review of literature and ends with a case report.
Results: The commonest neuropsychiatric manifestation is schizophrenia treatment refractory to clozapine.
Conclusion: VCFS provides a window of opportunity to explore the aetiopathogenesis of schizophrenia from an genetic end of gene-environment interaction.
MIRRABOOK EUM MODEL OF CARE
Dr Vikas Garg
South Eastern Illawara Health Service, Univeristy of Wollongong and IHMRI
Background: The standard approach to managing inpatient routines commences from handover, patient review by consultant and registrar, family meeting and discharge towards the later part of the day. This is carried out by a multidisciplinary team (MDT). Each member of the MDT has a certain set of responsibilities. I noted that the standard method of care was ineffective with issues including effective time management and resource management leading to delays in patient care requiring crucial decisions. In light of the many irregularities, I introduced the EUM model of care that stands for evaluation, understanding and management. The benefits have been quite startling.
Objective: To introduce the EUM model and explore its intricacies and potential advantages when compared with the standard model of inpatient care. We share our experiences and the changes noticed after introducing this model of care.
Results: The EUM is a better model of care in comparison with the standard one. All patients are reviewed, discussed and MDT plans are made by the afternoon. More than 90% of the daily workload is completed by the midday leaving more time for psychotherapy, family therapy and other activities. Discharge decisions are made by the team and coordinated by the end of the day. To achieve these outcomes in busy inpatient acute psychiatric units is our achievement.
Conclusion: The EUM model of care is an effective method of care for inpatient units from our experience.
MIRRABOOK VOLUNTARY SYSTEM OF CARE
Dr Vikas Garg
South Eastern Illawara Health Service, Univeristy of Wollongong and IHMRI
Background: It is my experience in Australia working in different inpatient units as a psychiatric registrar that most inpatient psychiatric units generally contain involuntary patients who are discharged into community care once they are settled. The rate of re-admission within 28 days is generally high. In my experience, most patients in private psychiatric units are voluntary. The advantages of voluntary admission are significant. Risk management is a crucial issue that determines a patient's length of stay. To hear that a public mental health unit has mostly voluntary patients is unheard of. Mirrabook is an example where most patients are treated on a voluntary basis with adequate risk management.
Objective: Report on the factors involved in treating patients as voluntary and share the advantages learnt over the last 12 months. This is a review of our experiences over the last 12 months, from Jan to Dec 2010.
Results: We found that therapeutic alliance is the key to treating patients on a voluntary basis. The process involves an honest disclosure of information pertaining to patient care, and acting on those promises. It also involves outlining the key responsibilities of patients and staff. We also believe that involuntary treatment is important but it should be for a brief duration and patient's rights should be handed over to them. This improves recovery.
Conclusion: Treating mental health patients on a voluntary basis is a challenging but rewarding experience.
A NATIONAL SURVEY TO ESTIMATE THE AVERAGE RESOURCE UTILISATION AND COST ASSOCIATED WITH ADMINISTERING RISPERIDONE LONG-ACTING INJECTION IN THE AUSTRALIAN COMMUNITY
Judy Hertel
1, Andrew Dalton2, Tim Lambert3, Rudolf Schrover1,4, Dell Kingsford Smith1
1
Janssen-Cilag Pty Ltd, Sydney, Australia
2
University of Melbourne, Melbourne, Australia
3
Concord Medical School and Brain and Mind Research Institute, Sydney, Australia
4
Decisionanalytics Pty Ltd, Sydney, Australia
Background: Risperidone two-weekly long-acting-injection (LAI) is mostly administered to people with schizophrenia by nurses at community mental health centres (CMHC) or through outreach visits. A new four-weekly long-acting-injectable antipsychotic will reduce resource burden.
Aims: To estimate resource utilisation associated with the administration of risperidone LAI, and potential savings of changing from a two-weekly to a four-weekly long-acting-injectable antipsychotic.
Methods: A national survey of 253 Australian CMHCs was undertaken in November 2009. Respondents were asked questions on injection time (including related tasks) and, for outreach visits, distance and time travelled as well as reduction in visits. Results were stratified by the Australian Standard Geographical Classification (ASGC) region, and resource use was quantified and valued in Australian dollars.
Results: The responses represent 26% of the national average risperidone LAI two-weekly-unit sales. Average injection time/risperidone LAI ranged from 18–29 minutes, with a national average of 20.12 minutes. For outreach visits, average distance travelled/patient ranged from 19.4–55.5 km for One Staff Visits and 15.2–218.1 km for More Than One Staff Visits; and average time travelled ranged from 34.1–54.5 minutes for One Staff Visits and 29.2–136.3 minutes for More Than One Staff visits. If an administration of risperidone LAI had not been required, a 20% reduction in mobile outreach visits would occur.
Conclusions: Switching from two-weekly to four-weekly long-acting-injections saves time, travel and reduces outreach visits, leading to a national average saving of $75.14/injection avoided. This could potentially save ∼$11 million per year if all patients taking two-weekly risperidone LAI were switched to a four-weekly long-acting-injectable antipsychotic.
A SURVEY TO ASSESS PAIN ASSOCIATED WITH ROUTINE ADMINISTRATION OF INTRAMUSCULAR RISPERIDONE LONG-ACTING INJECTION
Jayashri Kulkarni
1, Andrew Dalton2, Paul Katz3, Judy Hertel4
, Rudolf Schrover4,5, Dell Kingsford Smith4
1
Monash Alfred Psychiatry Research Centre (MAP-RC), Melbourne, Australia
2
University of Melbourne, Melbourne, Australia
3
Box Hill Hospital, Melbourne, Australia
4
Janssen-Cilag Pty Ltd, Sydney, Australia
5
Decisionanalytics Pty Ltd, Sydney, Australia
Background: Consumers with schizophrenia treated with risperidone long-acting-injections (LAI) may experience injection pain. The intensity and duration of injection pain after administration of risperidone LAI in the Australian community setting has not been reported.
Aims: To describe the intensity and duration of injection pain associated with routine administration of risperidone LAI.
Methods: Between September and October 2009, following IEC approval, eligible subjects with stable schizophrenia attending two outpatient clinics (Box Hill and The Alfred hospitals in Melbourne) who received two-weekly injections of risperidone LAI were recruited. Subjects were invited to self-complete a survey on the severity and duration of injection pain following risperidone LAI, including an estimate of the time it had taken for the pain to resolve on previous occasions they had received an injection.
Results: Of 70 eligible patients approached, 57 (81.4%) participated. The severity of pain was: VAS (0–100) 39.3 (SD 31.5), median 38.0; Likert Scale (0 [no pain] to 7 [unbearable pain]): mean 25.0 (SD 1.8), median 3.0. The type of pain (more than one response per patient allowed) was stinging (n = 31, 55.3%), throbbing (n = 10, 17.9%), aching (n = 10, 17.9%), burning (n = 7, 12.5%) or other (no pain/very mild pain, n = 8, 14.2%). Quantitative (VAS) and qualitative descriptors were well-correlated.
Conclusion: The pain experienced with an injection of risperidone LAI was described as a moderate stinging pain that lasts about one hour.
CATATONIA IN AUSTRALIA – PRESENTATION AND MANAGEMENT
Sachin Jindal
1, Arun Gupta2, Amit Zutshi3
1
Mid West Area Mental Health Service, NWMH, Melbourne, Australia
2
Flinders Medical Centre, Adelaide, Australia
3
Adelaide Health Services, Adelaide, Australia
Background: Catatonia can present treacherously and can be missed easily. However, once identified, there are effective management strategies. Though uncommon, we still encounter catatonia in Australia.
Objectives: Early symptom recognition may lead to implementation of effective management strategies such as ECT and specific medication improving clinical outcomes in both acute and chronic catatonic patients. We present four such different clinical scenarios.
Methods: A case series of four inpatients with catatonia highlighting clinical management and relevant literature.
Findings: ECT showed dramatic improvement in acutely catatonic patients, at times leading to full remission, however, management of chronic catatonia posed a challenge. Quetiapine with diazepam was useful with chronic catatonia in our experience.
Conclusions: ECT and benzodiazepines still remain the backbone of catatonia treatment. Quetiapine with benzodiazepine also showed potential with chronic patients.
SWITCHING TO DULOXETINE FROM SSRI NON- AND PARTIAL-RESPONDERS: DOES THE TYPE OF SSRI PRIOR TO SWITCH INFLUENCE OUTCOMES?
David G. S. Perahia
1,2, Deborah Quail1, Durisala Desaiah3, Inmaculada Gilaberte4, Peter Haddad5, and Katarina Kelin6
1
Lilly Research Centre, Windlesham, Surrey, UK
2
The Gordon Hospital, London, UK
3
Eli Lilly and Company, Indianapolis, IN, USA
4
Lilly Spain, Madrid, Spain
5
Neuroscience and Psychiatry Unit, University of Manchester, UK
6
Eli Lilly Australia Pty Ltd, West Ryde, NSW, Australia
Objectives: This study examined whether the selective serotonin re-uptake inhibitor (SSRI) taken prior to switch influenced subsequent efficacy and safety when comparing two methods of switching SSRI non- or partial-responders to duloxetine.
Methods: Outpatients ≥18 years of age who met DSM-IV MDD criteria despite taking an SSRI for ≥6 weeks, had a Hamilton Depression Rating Scale (HAMD17) total score ≥15, and a Clinical Global Impression of Severity score ≥3 were randomised to abrupt discontinuation of SSRI and simultaneous initiation of duloxetine (direct switch; DS) or tapered discontinuation of SSRI over two weeks and simultaneous administration of duloxetine (start-taper switch; STS). Efficacy and safety were assessed overall and by SSRI at study entry after 10 weeks of duloxetine treatment.
Findings: 368 SSRI non- or partial-responders were randomised to switch to duloxetine via DS (N = 183) or STS (N = 185). Most patients were receiving paroxetine (n = 100; 27.2%), citalopram (n = 75; 20.4%), fluoxetine (n = 70; 19.0%), sertraline (n = 68; 18.5%) or escitalopram (n = 49; 13.3%). Both switch groups had significant within-group improvement in symptom severity measured by mean change from baseline to endpoint in HAMD17 total score and other measures, but no between-group differences in efficacy were observed. Both switch groups had few discontinuations due to AEs (DS 6.6%, STS 3.8%; p = .248), and AE discontinuation rates were similar regardless of SSRI.
Conclusions: In SSRI non- or partial-responders switched to duloxetine, efficacy and safety outcomes were similar regardless of whether a direct or start-taper switch method was employed, and regardless of SSRI taken prior to switch.
EFFICACY OF DULOXETINE ON FUNCTIONAL IMPAIRMENT IN PATIENTS WITH MAJOR DEPRESSIVE DISORDER
David V. Sheehan
1, Adam L. Meyers2, Jonna Ahl3, Apurva Prakash2, Tina Marie Myers Oakes3, and Katarina Kelin4
1
University of South Florida, College of Medicine, Tampa, FL, USA
2
Eli Lilly and Company, Indianapolis, IN, USA
3
Lilly USA, LLC, Indianapolis, IN, USA
4
Eli Lilly Australia Pty Ltd, West Ryde, NSW, Australia
Background: Patients with major depressive disorder (MDD) often have a reduced ability to function socially, maintain and enjoy relationships and work.
Objectives: This was a pooled analysis of data from two separate 9-month studies conducted under the same protocol in patients with MDD (DSM-IV-TR) to examine the efficacy of duloxetine 60 mg/day (n = 518) vs. placebo (n = 258) on impairment in functioning.
Methods: Data pooling was specified a priori to allow for increased power to detect differences between duloxetine and placebo on secondary and exploratory objectives. Measures included: the Sheehan Disability Scale (SDS); the Social Adaptation Self-evaluation Scale (SASS); Massachusetts General Hospital Cognitive and Physical Functioning Questionnaire (CPFQ); and the Profile of Mood States – brief form (BPOMS) subscales vigor/activity (VA) and fatigue/inertia (FI) used as surrogate measures of function. Mean changes from baseline were analysed using a mixed-effects model repeated measures approach (MMRM). An analysis of covariance (ANCOVA) using a last observation carried forward (LOCF) approach was conducted as a sensitivity analysis.
Findings: At baseline patients had moderately severe levels of SDS global functional impairment scores (18.3 ± 6.9). After eight weeks, there was significant improvement from baseline (MMRM) with duloxetine treatment on the SDS global (p = .002), SASS total (p < .001), and BPOMS VA (p = .012) and FI (p = .006) subscales. Duloxetine-treated versus placebo-treated patients had significantly greater improvement from baseline on the SDS global, SASS total, CPFQ total, and BPOMS subscales VA and FI after eight weeks (LOCF imputation).
Conclusions: These results suggest that treatment with duloxetine may improve functional impairment in patients with MDD.
CORE COMPETENCIES IN CONSULTATION-LIAISON PSYCHIATRY – CLARITY IN THE CHAOS?
Jack Kirszenblat
The Alfred Hospital, Melbourne, Australia
This paper will present a list of core competencies in consultation-liaison psychiatry that the author provides to psychiatry trainees entering their basic rotation in this area. The list provides the trainees with a core group of skills that they are expected to master in their rotation and examples of how to demonstrate that they have learnt those skills. The list is intended to constitute an instrument for learning and training, and a guide to the building of a basic skill base. It is in an attempt to provide clarity in the initial chaos of a consultation-liaison rotation and to provide an alternative to the comprehensive but cumbersome college registrar rotation assessments.
IDENTIFYING KEY COMPETENCIES OF CONSUMER CONSULTANTS EMPLOYED IN VICTORIAN PUBLIC ADULT MENTAL HEALTH SERVICES
Raju Lakshmana
Austin Health, Victoria, Australia
Objective: Consumer consultants in mental health are individuals who have a lived experience of mental illness and are employed to provide consumer perspectives to mental health service planning, delivery and evaluation. The main limitations to effective use of this workforce are lack of clarity about their roles and responsibilities and negative staff attitudes. There are no clearly identified competencies, curricula or training to support their roles. This project is designed to identify key competencies of consumer consultants employed in the Victoria Public AMHS.
Methods: Qualitative research methodology was employed. A job analysis was undertaken to identify key roles and responsibilities, which were then mapped to competencies described in health management literature. This was followed by telephone interviews with consenting consumer consultants and AMHS managers to discuss themes and competencies identified and develop a final set of competencies with their input.
Findings: The key competencies identified were those of a leader, an academic, a manager, an advocate, an innovator, and a professional.
Conclusions: Effective consumer participation in AMHS has significant benefits to themselves, the services and the community. Identification of competencies is an initial step towards development of a curriculum and training to support and enhance the roles of consumer consultants.
A RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY OF DESVENLAFAXINE 10 AND 50 MG/D EFFICACY AND SAFETY IN DEPRESSED OUTPATIENTS
Michael Liebowitz
1, Karen A. Tourian2, Eunhee Hwang2, Linda Mele2, Safir Riddington3
1
Columbia University, New York, New York, USA
2
Pfizer Inc, Collegeville, Pennsylvania, USA
3
Pfizer Australia and New Zealand Inc, Australia
Background: Desvenlafaxine (administered as desvenlafaxine succinate) has demonstrated antidepressant efficacy at 50, 100, 200, and 400 mg/d.
Objective: To compare the antidepressant efficacy and safety of desvenlafaxine 10 and 50 mg/d doses with placebo.
Methods: Adult outpatients with MDD and a HAM D17 total score (TS) ≥20 at screening and baseline, were randomised to placebo or desvenlafaxine (10 or 50 mg/d) after a 6 to 14 d placebo lead-in period in an 8-week, phase three, fixed-dose trial. The primary efficacy endpoint was change from baseline in HAM D17 TS.
Findings: Change in adjusted HAM D17 TS for desvenlafaxine 10 mg/d (−9.28) and 50 mg/d (−8.92) failed to separate from placebo (−8.42) (ITT; n = 226, 224, 223). Treatment-emergent adverse events (AEs) occurred in 66% of placebo-treated patients, and 69% of patients treated with desvenlafaxine 10 or 50 mg/d. A total of 2/226 (0.9%) and 4/224 (1.8%) of patients discontinued desvenlafaxine 10 and 50 mg/d, respectively, due to AEs (placebo, 5/223 [2.2%]).
Conclusions: Although previous studies have confirmed the antidepressant efficacy of desvenlafaxine 50 mg/d, in this study the 50 mg/d dose failed to reach statistical significance. In addition, our finding that the 10 mg/d dose failed to separate from placebo is not surprising, given that doses <50 mg/d have not previously demonstrated efficacy.
Supported by funding from Pfizer Inc.
THE NIMH RESEARCH DOMAIN CRITERIA: BAD SCIENCE WILL BREED BAD PSYCHIATRY
N. McLaren
Northern Psychiatric Services, Darwin, NT, Australia
The National Institute of Mental Health has recently declared a new research program for psychiatry, the Research Domain Criteria (RDoC), as the successor of the long-standing diagnostic program. However, the new program is based on a series of assumptions which, on analysis, lack any formal scientific standing. Essentially, the RDoC program, as presently conceptualised, is no more than ideology masquerading as science, and cannot achieve its stated goals. It is argued that the program will lead psychiatry into intellectually sterile areas because it is in fact the wrong research program for this stage of our knowledge.
THE INABILITY OF DSM-5 TO DISTINGUISH BETWEEN TEMPER TANTRUMS AND MENTAL DISORDER: FAILURE IS INEVITABLE (BUT DON'T SHOOT THE MESSENGER)
N. McLaren
Northern Psychiatric Services, Darwin, NT, Australia
The diagnostic entity Intermittent Explosive Disorder will be examined from several points of view, including epidemiological and logical. The inevitable conclusion is that this is not a coherent entity in its own right but correctly belongs to the category of personality disorder. This raises the question of the nature of the process in modern psychiatry by which personality factors are reclassified as formal mental illnesses. It will be argued that this is because modern psychiatry lacks models of personality and thence of personality disorder, and has never articulated a model of mental disorder itself. The outcome is diagnostic anarchy, in which pressure groups trump science. This will inevitably lead to the failure of DSM-5, as has been widely predicted by eminent critics. This paper establishes epistemological reasons for those predictions, thereby immeasurably strengthening them.
EARLY USE OF CLOZAPINE MAXIMISES FUNCTIONAL RECOVERY IN SCHIZOPHRENIA
Dr Narinder Panesar
1, Dr Iveta Valachova2
1
Consultant Psychiatrist, MHRU Shellharbour Hospital
2
Registrar, Braeside Hospital, SSWAHS
Background: Psychiatric rehabilitation begins during the acute stage of a psychiatric disorder and continues throughout the person's life. Rehabilitation is not a specific technique but a strategy designed to contribute to recovery. The functional and symptomatic recovery from schizophrenia is the result of pharmacological and psychosocial interventions of which clozapine is the mainstay of treatment. Research has shown that early and effective pharmacological intervention of a person with a serious mental illness can prevent long-term disability. Among all antipsychotic medications clozapine is widely used in rehabilitation settings.
Objectives: The aim of this paper is to encourage clinicians to consider early use of clozapine in schizophrenia and related disorders as soon as treatment resistance is established.
Conclusion: Treatment with clozapine should not unnecessarily be delayed if a patient has not responded to adequate trials of other antipsychotic medication. We noted that a number of patients in rehabilitation units who had not achieved functional recovery had not received timely clozapine trials. We propose a model of early intervention with clozapine in rehabilitation psychiatry. One of the biggest problems in managing treatment-resistant schizophrenia is therapeutic nihilism, and this is likely to increase once a trial of clozapine has failed. Clozapine should not be viewed as the last therapeutic option; it is an opportunity to explore future treatments.
YOGA AND MENTAL HEALTH
Dr Narinder Panesar
1, Dr Iveta Valachova2
1
Consultant Psychiatrist, MHRU Shellharbour Hospital
2
Advanced Trainee, Braeside Hospital, SSWAHS
Background: The use of various evidence-based therapeutic interventions in psychiatry is a common practice. However yoga has hardly been considered as a part of treatment. It is not only an exercise for a healthy person but also an alternative therapy for an individual with a mental illness. Yoga is a scientific system of physical and mental practices that originated in India over three thousand years ago with the aim of developing a union between a person's own consciousness and the universal consciousness.
Objectives: Aims of this paper are to make mental health practitioners aware of the therapeutic effects of yoga in mental wellbeing and also encourage them to prescribe yoga as part of an holistic approach to patient management.
Methods: We conducted a comprehensive updated literature review, including all relevant meta-analyses, as well as a number of recent international journals using automated and manual searching methods.
Conclusion: There has been growing evidence of therapeutic benefits of yoga for anxiety, depression, dysthymia, obsessive compulsive disorder, alcohol dependency syndrome and to improve cognitive symptoms of schizophrenia. The yogic practice not only serves as a prevention and cure of mental disorders but also results in mental peace. Like other treatments, yoga also has side effects. Not everyone is fit for yoga; therefore it should be practised under guidance of an experienced yogic instructor.
SCHIZOPHRENIA: DID IT EXIST IN ANCIENT TIMES?
Dhara Perera
1, Mahendra Perera2
1
James Cook University, Townsville, Australia
2
University of Melbourne, Melbourne, Australia
Background: The history of schizophrenia continues to engender debate primarily due to a paucity of accurate historical descriptions.
Objectives: Determine whether the early descriptions of ‘madness’ or ‘insanity’ are similar to the condition we call schizophrenia today.
Methods: A literature search was conducted using PubMed with the phrase history of schizophrenia. Relevant articles in the English language were selected.
Findings: There are differences of opinions amongst the authors as to whether or not schizophenia existed in ancient times. Galen and Hippocrates described features of melancholia and mania with psychotic features. Descriptions of psychosis have been given by other Greek philosophers Aretaeus, Aristotle and Plato. Humoural insanities have been described in the ancient ayurvedic medical tradition. These were attributed to imbalances of humours, as well as due to possession by gods or demons. These descriptions start from centuries before Christ (BC).
The problems associated with linking the ancient descriptions with the current concept of schizophrenia is confounded by the lack of a pathological diagnoses. Furthermore, we are at the mercy of the historian, as well as prevailing socio cultural and religious beliefs. However, some of the descriptions of the ‘insanity’, ‘madness’, and ‘possession’ states could be considered as akin to that of the condition we call schizophrenia today.
Conclusions: It is probable that schizophrenia-like illnesses have been present since ancient times, becoming more evident in recent times. The advent of the industrial and scientific revolutions may have brought schizophrenia into sharper focus from the 19th century onwards.
REVIEW OF ICTAL EEG MEASURES IN ECT PRACTICE
Chris Plakiotis
1, Daniel W. O'Connor
1
School of Psychology and Psychiatry, Monash University, Victoria, Australia
Background: Past discussions regarding seizure adequacy in electroconvulsive therapy (ECT) practice have been dominated by seizure duration. However, inconsistent evidence regarding seizure duration as a seizure adequacy marker has prompted research into the use of electroencephalographic (EEG) indices from ECT treatments themselves to assess seizure adequacy and inform treatment decisions.
Objectives: To examine the literature regarding ictal EEG measures in ECT practice, thereby guiding ECT practitioners in their use and interpretation.
Methods: Review of studies of variables affecting ictal EEG measures and of clinical applications of such measures.
Findings: Ictal EEG measures have been found to vary according to demographic and clinical variables: electrical stimulus parameters; stimulus electrode placement; stimulus dose; treatment number; brain region; and anaesthesia. Ictal EEG measures have successfully been applied to a range of clinical problems in research settings, including prediction of suprathreshold stimulus intensity and seizure threshold changes; prediction of treatment efficacy and treatment-related cognitive effects; guidance of stimulus dosing; and predictive differentiation of diagnostic subgroups in depression. However, the use of complex multivariate algorithms has impeded translation of these findings into everyday practice.
Conclusions: A simple manual rating system may be the most practical way of making ictal EEG measures immediately accessible to ECT practitioners. Research correlating ictal EEG measures to other emerging markers of ECT adequacy may establish a more definitive role for such measures alongside a range of approaches for optimising ECT techniques.
Key words: Algorithm, electroconvulsive therapy, electroencephalograpy, treatment response.
TEN YEARS OF ECT IN VICTORIA: AN OVERVIEW
Chris Plakiotis, Daniel W. O'Connor
School of Psychology and Psychiatry, Monash University, Victoria, Australia
Background: Despite the long history of electroconvulsive therapy (ECT) as a psychiatric treatment modality in Australia, the existing literature regarding ECT utilisation and practices in Australia is limited.
Objectives: To examine the provision of ECT in Victoria to adults aged 25 years and over for the 10-year period from 1998 to 2007, compare our results to previous literature in the field and hypothesise on possible explanations for the findings revealed.
Methods: Analysis of statutory data regarding ECT service provision, collected by the Office of the Chief Psychiatrist of Victoria.
Findings: Our findings indicate a decline in ECT use from the early to the mid-2000s, followed by a small increase in use in 2007. A particularly sharp drop was noted in ECT use from 2004 to 2005, occurring among patients who were more likely to be female, older, diagnosed with depression and treated in the public sector, on a voluntary basis only, with bilateral electrode placement. The rate of ECT utilisation for depression did not differ greatly between public and private sectors, but the number of patients treated for psychosis was markedly higher in the public sector. The majority of patients treated with ECT for depression received their treatment voluntarily, but the converse was true for patients with psychosis. Unilateral electrode placement was most commonly used.
Conclusions: Our findings expand upon earlier research in this field and provide a framework for planning ECT service provision and training mental health workers in this important treatment modality.
Key words: Electroconvulsive therapy, epidemiology, utilisation.
TEN YEARS OF ECT IN VICTORIA: UTILISATION AMONG OLDER ADULTS
Chris Plakiotis, Daniel W. O'Connor
School of Psychology and Psychiatry, Monash University, Victoria, Australia
Background: Existing literature suggests a rise in the application of electroconvulsive therapy (ECT) with increasing age. However, detailed data regarding the use of ECT among older adults in Australia is limited.
Objectives: Examination of ECT provision to adults aged 65 years and over in Victoria during the 10-year period from 1998 to 2007 is the focus of this work. Patterns of ECT administration among this age group are compared with those of younger adults. Differences in ECT administration between adults aged 65–79 years and those aged 80 years and over are also explored.
Methods: Analysis of statutory data regarding ECT service provision, collected by the Office of the Chief Psychiatrist of Victoria.
Findings: ECT in older people was used predominantly for the treatment of depression. Adults aged 65 years and over received ECT at a higher rate than younger adults when treatment data was adjusted for age. There was a greater gap in ECT utilisation among older compared to younger adults between the public (more) versus private (less) healthcare sectors. A greater proportion of older adults received treatment on an involuntary basis only and used bilateral electrode placement only.
Conclusions: Our findings are consistent with earlier research showing an increased rate of ECT utilisation among older compared with younger adults. Our findings emphasise the importance of keeping this age group in mind in designing and delivering ECT services and in undertaking research in this field.
Key words: Electroconvulsive therapy, epidemiology, older adults, utilisation.
SYSTEMATIC REVIEWS TO SUPPORT EVIDENCE-BASED PSYCHIATRY: WHAT ABOUT ECT FOR DEPRESSION?
Vincenzo Prisco
Department of Neuroscience, University Federico II, via Pansini 5; 80131, Naples, Italy
Objective: Assessing whether systematic reviews (SRs) can offer valuable support to evidence-based psychiatry about ECT treatment for depression.
Methods: We used two database services (Ovid, PubMed) to identify SRs related to depression, and we found 1099 reviews; only 424 of these, published by 140 journals, were included in our study. We analysed each review to evaluate the conclusions reached by each study we examined, and subdivided the studies into three different groups:
• Reviews reaching certain conclusions
• Reviews reaching uncertain conclusions
• Reviews reaching null conclusions
Then we made a further distinction within “reviews reaching certain conclusions”, stating which results indicated a certain prevalence of the tested treatment against comparison (“Surely Yes”), with “Surely Not” we indicated cases in which the comparison is better than the experimental treatment, and finally with “Surely Neutral” we indicated the cases in which the two treatments were estimated as having the same effects from the systematic review.
Results: We noted that within the category “reviews reaching certain conclusions” that electrical stimulation was always more effective than the controls, even more than we can say for drug therapy or psychotherapy. In fact, we noted that in the 14 SRs treating with electrical stimulation, ECT is better than either placebo or drug therapy.
Conclusions: Electroconvulsive therapy is an effective therapy in cases of moderate to severe levels of depression where there is no real issue using drug therapy and psychotherapy together.
DO MENTALLY DISORDERED OFFENDERS DISPLAY MORE AGGRESSION DURING AN ACUTE INPATIENT ADMISSION? A CASE-CONTROL STUDY
Megha Mulchandani
1,2, Anoop Sankaranarayanan1,2,3, Terry Lewin2,3
1
Hunter Valley Mental Health Service, Maitland, Australia
2
Hunter New England Mental Health Service, Newcastle, Australia
3
Centre for Brain and Mental Health Research, University of Newcastle, Newcastle, Australia
Background: Between 10–25% of psychiatric inpatients exhibit violent behaviour during inpatient stays; the risk is higher in patients who are younger, have a personality disorder, stay longer and have a previous history of aggression. Although nursing observations indicate that mentally disordered offenders pose a higher risk of aggression, this association has not been systematically studied in the past.
Objectives: This study aimed to identify if mentally disordered offenders (defined as patients who were admitted following an offence) were more likely to display aggression during an acute inpatient admission.
Methods: The Hunter New England Human Research Ethics Committee exempted the need for ethics approval as the study was part of a service evaluation audit. All patients admitted to the inpatient unit between July 2004 and June 2009 was eligible for the study. All patients who were admitted via legal services (with reasonable doubt of mental disorder) following an index offence (n = 83) were included as cases, provided they were aged between 18–64 years. Controls (n = 83) included the next available admission (to the case), provided they were matched for gender and age (within a 10-year range of the case) and were not included as cases. The Clinical Information Department assisted in identifying the cases and controls.
Findings and Conclusions: There were more (>4 times) men than women and the mean age of cases was 33.89 years. The majority of the cases (nearly 79%) were unemployed and nearly two-thirds (65%) of them had some form of psychotic illness. The remainder of the data will be presented.
EFFICACY AND SAFETY OF DESVENLAFAXINE 25 AND 50 MG/D IN A RANDOMISED, PLACEBO-CONTROLLED STUDY OF DEPRESSED OUTPATIENTS
Karen A. Tourian
1, Eunhee Hwang1, Linda Mele1, Tadashi Umeda2, Cecile Vialet3, Safir Riddington4
1
Pfizer Inc, Collegeville, Pennsylvania, USA
2
Pfizer Japan Inc, Japan
3
Pfizer Inc, Paris, France
4
Pfizer Australia and New Zealand Inc, Australia
Background: The short-term efficacy of desvenlafaxine (administered as desvenlafaxine succinate) for treating MDD has been demonstrated, with a recommended therapeutic dose of 50 mg/d.
Objective: To assess the efficacy and safety of desvenlafaxine 25 and 50 mg/d doses vs placebo for treating MDD.
Methods: Depressed adult outpatients in the US and Japan with a HAM D17 total score ≥20 at screening and baseline were randomised to placebo or desvenlafaxine (25 or 50 mg/d) after a 6 to 14 d placebo lead-in period in an 8 week, fixed-dose trial. The primary efficacy variable was change from baseline in HAM D17 total score (TS).
Findings: The reduction in HAM D17 TS was significantly greater for desvenlafaxine 50 mg/d (−10.02; P = 0.016), but not 25 mg/d (−8.98), vs placebo (−8.52) after adjusting for multiplicity (ITT; n = 236, 232, and 231, respectively). A total of 8/236 (3.4%) and 8/232 (3.4%) patients discontinued desvenlafaxine 50 and 25 mg/d, respectively, because of adverse events (AEs; placebo, 6/231 [2.6%]). Safety findings were comparable to those of previous desvenlafaxine trials; however, rates of treatment-emergent AEs were slightly lower.
Conclusions: These results confirm the antidepressant efficacy of desvenlafaxine 50 mg/d and support previous findings by demonstrating 50 mg/d as the lowest effective dose for treating MDD.
Supported by funding from Pfizer Inc.
REDUCING CLOZAPINE DOSES IN STABLE SCHIZOPHRENIC PATIENTS AS A THERAPEUTIC STRATEGY: A SINGLE CASE ANALYSIS
Krishna Vaddadi
1,2, Sami Yamin2
1
Monash University, Melbourne, Australia
2
Middle South Community Care Unit, Melbourne, Australia
Background: Pharmacological intervention using high doses of clozapine is used to achieve better symptom control in people with chronic schizophrenia. These regimes pose health risks and therefore it is important to establish optimal strategies for drug maintenance therapy that reduce the overall cumulative effects of antipsychotic medication.
Objectives: We present a case-study of a 23-year-old patient with a history of chronic schizophrenia to outline the potential functional and health benefits of clozapine maintanance dose reduction.
Methods: The patient had commenced taking clozapine and had subsequently gained a significant amount of weight; her overall health was poor with elevated tryglyceride and alkaline phospate levels. She developed fatty infiltration of the liver and sleep aponea secondary to weight gain. Her Global Assessment of Function score (GAF) was 35 and she required assistance for all aspects of daily living. Gradual dose reduction commenced in October 2006 from an initial 600 mg dose of clozapine and 200 mg of amisulpride.
Findings: Over a 36-month period, clozapine was titrated down to 250 mg. Improvements were documented in her mental state and GAF score with significant increase in her functional independence. Significant weight loss also contributed to overall health gains. She was subsequently discharged to independent living with the support of a community mental health team.
Conclusion: These results highlight the need to shift the focus from merely the management of psychotic symptoms to a more dynamic view that aims to minimise the cumulative effects of antipsychotic medication as well as enhance general well being and psychosocial functioning. Dosage optimisation will be discussed.
ESTABLISHMENT OF A PECC UNIT IN A REGIONAL NSW SETTING: OPPORTUNITIES AND CHALLENGES
Dr Nalin Wijesinghe
1, Prof. Nagesh Pai2
1Wollongong Hospital
2Wollongong University
Background: The psychiatric emergency care unit [P.E.C.U.] at Wollongong Hospital opened as a service development that aims to improve emergency care of psychiatric patients, improve clinical care with direct access to mental health staff, provide early mental health responsibility for patients, and reduce access block.
Objectives: Although the stipulated objectives were to improve the clearance of patients from the accident and emergency department and provide brief admissions up to 48 hours, there was also a role in supervising casualty assessment, working with community mental health teams and finding a niche among other psychiatric wards in the Illawarra area.
Findings and Conclusions: The characteristics of patients admitted to this PECC are discussed. The preliminary findings are encouraging in that agitated patients were less likely to be physically restrained in the PECC and less likely to be treated with medications that have a lower safety margin. Unique challenges in establishing of PECC units in regional settings are also discussed.
