Australasian Psychiatry

Objective: To evaluate ‘in-house’ decisions made in respect of major ethical breaches, whether occurring in psychiatry or within the hierarchy of major churches.

Conclusions: The closer professional bodies, churches and other related organizations that have high expectations of the duty of care of their professional members, get to practising democratic ideals and universal standards of human rights, the more such members become accountable, and the less there are special cases or exceptions to the law.

Objective: To examine trends in the use of oral conventional, depot and atypical antipsychotic medications in Australian States and Territories between 1995 and 2001.

Methods: For each 6 month interval between July 1995 and December 2001, prescription data obtained were converted into a measure of drug utilization expressed as the number of defined daily doses per thousand population per day (DDDs/1000/day). Data concerning the major specialty of the prescriber were available for the period 1996–2000.

Results: In each State and Territory, use of atypical antipsychotic medications increased markedly while use of oral conventional and depot medications declined. Between July 2001 and December 2001, the proportion of total prescriptions for antipsychotic medications accounted for by prescriptions for atypical medications varied from 63.1% in South Australia to 76.1% in the Australian Capital Territory (ACT). Relative use of atypical medications was higher in the ACT than in other regions, while relative use of depot medications was higher in the Northern Territory than in other regions. During the year 2000, the proportion of prescriptions for oral conventional and depot medications written by general practitioners (GPs) exceeded 75% in all regions other than the ACT. Between 1996 and 2000, the proportion of prescriptions for atypical medications written by GPs increased markedly in all regions but remained lower than for oral conventional and depot medications.

Conclusions: Atypical antipsychotic medications have replaced conventional medications as the first-line pharmacological treatment for psychotic disorders in all regions of Australia. Continued expansion of programmes designed to foster collaboration between GPs and mental health services will be essential in achieving optimal prescribing of antipsychotic medications.

Objective: To report initial clinical experience with the injectable long-acting microspheres formulation of the atypical antipsychotic risperidone.

Methods: Case reports.

Results: The seven patients described have had good outcomes to date. A patient who has received the drug for 2 years has improved from a state of severe deterioration to full-time employment and participation in a relationship; he has reported mild erectile difficulties but is keen to continue. In all cases extrapyramidal side-effects have been uncommon and brief; weight gain or other physical adverse events have not been observed.

Conclusion: Initial use of long-acting injectable risperidone suggests that the first ‘atypical depot’ is a welcome therapeutic development likely to provide significant clinical benefits, particularly for patients who have previously had unsatisfactory experiences with conventional antipsychotics.

Objective: To examine the status of psychotherapy in an era when evidence-based medicine (EBM) largely determines what constitutes efficacious treatment, and to suggest how psychotherapy might respond to the expectations of EBM, while preserving its identity and role in psychiatry.

Conclusions: If EBM is espoused dogmatically it is likely that psychotherapy will never meet its requirements. Psychotherapy can survive in the climate of an ever-increasing pressure to demonstrate its usefulness by insisting on its own criteria for doing so. This is legitimate in view of the specific features of psychotherapy, which make the standard EBM procedures for assessing the usefulness of treatment largely inapplicable.

Objective: Although the efficacy of a number of psychotherapeutic interventions has been well established in tightly controlled, randomized trials, there remains a paucity of literature examining the effectiveness of these interventions in community practice settings. In light of this, the Australian Capital Territory Mental Health Services (Canberra, ACT) set out to investigate the effectiveness of an empirically supported psychotherapeutic intervention, interpersonal psychotherapy (IPT). The present study describes a pilot evaluation of the training programme for health professionals and the IPT treatment programme.

Methods: Forty community mental health professionals participated in intensive IPT training. Clinicians who completed a course of supervision were asked to apply the treatment with non-psychotic acutely depressed patients. Measures of patients’ health outcomes were taken before and after treatment using a standardized outcome measure.

Results: A total of 17 out of 21 patients who were selected completed a course of 12–16 weeks of IPT. The majority of the patients had a depression originating in the post-partum period. A comparison of pre- and post-treatment scores of treatment completers revealed a significant decrease in mean depression scores. Clinicians who completed a course of training and supervision found that they were able to confidently apply IPT in a clinical setting.

Conclusions: Although there were a number of barriers and obstacles to the introduction of an evidenced-based treatment, the results are promising and demonstrate that IPT can be readily taught to experienced mental health professionals. Further study is required to determine the feasibility of IPT in other non-academic settings using larger sample sizes and homogenous groups of patients.

Objective: To describe a group programme for the treatment of patients suffering the sequelae of childhood trauma.

Conclusions: The programme evolved in response to treatment problems experienced by mental health professionals working with these patients. Patient and therapist experiences are reported and the program content described.

Objective: To provide background and context for the recent Royal Australian and New Zealand College of Psychiatrists (RANZCP) statement on indigenous mental health workers.

Conclusions: There are a number of difficulties facing indigenous mental health workers in Australia today. The RANZCP statement is one step in a move to increase recognition of these workers. National registration of Aboriginal mental health workers or the formation of a national association may further promote their identity.

Objective: To review the development of a psychiatric documentation suite and associated quality improvement processes, comparing suites historically with changes in service delivery and review.

Conclusions: Changes to service delivery principles and frameworks have influenced trends to more comprehensive and modular documentation forms. Documentation of quality improvement processes will help ensure that psychiatry-specific needs for information are met during the transition to a more integrated health system and associated electronic records.

Objective: To describe the development and implementation of a typed ‘continuous’ clinical summary, with a longitudinal formulation and modular episode-based summaries.

Methods: Outline of rationale for this form of summary and the implementation process.

Results: Despite identified technical and training difficulties, over 3000 clinical assessment summary documents have been created with successful implementation across a mental health service.

Conclusions: A typed continuous summary offers many advantages over a traditional discharge summary and can be implemented in routine clinical practice.

Objective: To explore the level of interest among researchers and clinicians in the content of delusions and hallucinations.

Methods: A survey of 58 mental health practitioners and researchers was conducted. The questionnaire included closed and open-ended questions about participants' views concerning the value of attending to the content of delusions and hallucinations.

Results: Participants identified benefits (e.g. heightened understanding of clients' difficulties, enhanced therapeutic relationship, improved risk assessment) and drawbacks (e.g. waste of time, exacerbation of clients' distress, reinforcement of content, blurred distinction between reality and non-reality) associated with attending to content. Half of the participants suggested that their work would be enhanced, while approximately one-fifth felt that their work would be affected adversely, should they attend to content.

Conclusions: Taken together, the data suggest that there is ambivalence towards the practice of attending to content. Participants identified deterrents to this practice that were not only pragmatic but were also related to the customary way in which delusions and hallucinations are conceptualized in the mental health field.

Objective: To assess former activity levels in chronic fatigue syndrome (CFS) subjects, identify differentiating variables and discuss ethical issues arising.

Method: File review of 91 CFS patients from a private psychiatric practice, presenting multiple case reports, with limited case comparison data.

Results: The CFS subjects appeared formerly more athletically inclined than controls. Other helpful differentiating variables included exercise intolerance, excessive need for sleep, hopefulness and subjective memory problems.

Conclusions: Former exercise and other achievement levels warrant systematic research study and consideration in the assessment of CFS patients. Omissions of consideration of premorbid functioning in medicolegal evaluations raise ethical concerns.

Objective: To examine the hypothesis that chronic fatigue syndrome (CFS) is associated with significant psychological and physical issues that can be improved by a multidisciplinary inpatient rehabilitation programme.

Methods: A battery of psychometric instruments was administered to 39 adolescents with CFS. These instruments were administered prior to a 4 week inpatient admission as well as on discharge. The instruments were also administered to 19 adolescents at 6 month follow up.

Results: The sample included 35 girls and four boys. The Beck Depression Inventory demonstrated high depression scores that improved after the 4 week programme (p < 0.001) and these improvements were maintained after 6 months (p < 0.038). Coopersmith self-esteem scores showed low self-esteem, which improved following the programme (p < 0.001) but there was some fall off at the 6 month follow up. Physical functioning scores improved significantly after the 4 week programme (p < 0.001) and were maintained at 6 months (p < 0.001); clinician ratings of functioning matched patient ratings. On Achenbach profiles the teenagers presented with internalizing problems, which significantly improved following admission (p < 0.001). Parents reported similar findings.

Conclusion: These findings confirm the effectiveness of a multidisciplinary approach to the management of adolescents with CFS with improvements in emotional and physical functioning. Most of the improvements were maintained at 6 months follow up.

Objective: To develop a cognitive screening instrument suitable for a neuropsychiatric inpatient, outpatient and consultation—liaison population.

Methods: A number of cognitive screening instruments used clinically and published in the literature were reviewed. A new tool, the Neuropsychiatry Unit Cognitive Screen (NUCOG), was developed on the basis of this review, and piloted in a diverse population of patients in the unit.

Conclusions: The NUCOG demonstrated a high degree of face validity, correlation with the Mini-Mental State Examination, and significant scoring differences between demented and non-demented patients.

Objective: To describe the development and evaluation of the Consumer Expectations, Perceptions and Satisfaction Scale (CEPAS).

Methods: The content of CEPAS was developed from a focus group of patients and carers. A total of 115 consecutive patients discharged from a community mental health service for older people and their carers was asked to complete a postal survey.

Results: The CEPAS was appropriate for 49% of patients (56/115) and 51% of carers (59/115). The response rates were 69% (39/56) for patients and 76% (45/59) for carers. Overall satisfaction had a significant association with the Client Satisfaction Questionnaire (r = 0.67, p < 0.001) and the Clinical Global Impression Scale (r = 0.29, p < 0.01).

Conclusions: The CEPAS was an adequate measure of patient and carer satisfaction in this setting and for this population. More research is needed to evaluate CEPAS in other settings and with other populations.

Objective: To examine the usefulness of the Strengths and Difficulties Questionnaire (SDQ) as an outcome measure for patients referred to a child and adolescent mental health service (CAMHS).

Methods: This was a prospective study of new CAMHS attendees. Questionnaires were completed by clinicians, parents, teachers and children (if aged 11 years or older) at initial attendance and after approximately 6 months.

Results: At 6-month follow up, positive change was detected on the SDQ. There was a significant reduction in the ‘total difficulties’ score as rated by parents, teachers and children. This positive change corresponded to a significant reduction in the clinician-rated Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) scores. Furthermore, there were lowered levels of perceived difficulties and burden on the SDQ impact supplement, and a decrease in the overall impact score.

Conclusion: The SDQ is a useful outcome measure. The HoNOSCA and SDQ complement each other because they provide measures of change from the clinician, the parent and the child.

Objective: To highlight the need for a continuum of care model for the delivery of psychiatric services in Israel.

Conclusion: Crisis assessment teams working in the community in collaboration with community mental health clinics and inpatient psychiatric units are required. The community clinics should have the capacity for providing assertive outreach including home visits as required. General hospital psychiatric units that are able to treat both voluntary and involuntary patients are also needed. The psychiatric service needs to be responsive to special needs groups with high morbidity such as those persons suffering from first-presentation psychosis and post-partum psychiatric illness. Two case vignettes are discussed that demonstrate the need for a continuum of care model.

Objective: To provide a glimpse of psychiatry's past, which the author obtained during a recent sabbatical in Munich.

Conclusions: An examination of Kraepelin's memoirs, his first address to Munich's Ludwig-Maxmilians University and Alzheimer's notes from publications reveal that the two were dedicated and observant clinicians who contributed to the scientific foundations of modern psychiatry.