Australasian Psychiatry

To describe the process adopted by the Committee for Professional Practice (CPP) of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in devising the 5th edition of its code of ethics and to outline principal changes.

CPP members planned, scrutinised and documented the steps taken in preparing the new edition.

The process, following that used in all previous updates of the code and which had proved effective and productive on each occasion, comprised consultations with RANZCP committees and relevant external stakeholders. Canvasing the views of so many groups was regarded as essential to ensure that multiple perspectives were considered and any bias of the CPP avoided.

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) was examined with two aims: promoting a robust clinician and patient partnership, and acknowledging the psychiatrist’s advocacy role. The psychiatrist’s duty to be alert to colleagues’ wellbeing and to safeguard respectful professional relationships was highlighted.

A comprehensive, rigorous and established review process occurred and was carefully documented resulting in a sound and contemporary revision of the code of ethics. RANZCP members will be duty-bound to adhere to, and apply, the code to optimise their ethical standards.

To reflect on the role of psychiatry in authorising physical treatments for Gender Dysphoria and to examine the quality of evidence for gender-reassignment.

A Medline search was performed with the subject term “transsexualism” or “gender dysphoria” and “outcome” or “follow-up” in the title. Studies published from 2005 onwards reporting psychosocial outcomes were selected for review.

Most available evidence indicating positive outcomes for gender reassignment is of poor quality. The few studies with robust methodology suggest that some patients have poor outcomes and may be at risk of suicide.

The author raises questions about the implications for ethical treatment of transgender individuals.

The assessment and management of a patient who refuses medical treatment requires clinical skill, and consideration of the relevant law and the patient’s decision-making capacity. Psychiatrists are often asked to advise in these situations. We aimed to develop an algorithm describing the relevant legal pathways to assist clinicians, especially psychiatrists, working in New South Wales (NSW), Australia.

We reviewed the academic literature on treatment refusal, relevant legislation, judicial rulings and NSW Health policy directives and guidelines. We consulted with clinicians and representatives of relevant tribunals.

We developed an algorithm for managing patients who refuse medical treatment in NSW. The algorithm emphases the evaluation of decision-making capacity and tracks separate pathways depending upon a person’s status under the Mental Health Act 2007 (NSW).

The algorithm provides a clear decision tree for clinicians responding to a patient refusing medical treatment in NSW.

The study aimed to survey hospital staff knowledge of the application of the Mental Health Act 2007 (NSW) (MHA) and the Guardianship Act 1987 (NSW) (GA) in the care and treatment of older persons in a teaching hospital in Sydney.

Over a two-month period in 2017, a survey questionnaire was distributed to staff involved in older persons’ care across the hospital.

The majority of the hospital staff demonstrated basic theoretical knowledge of both the GA (76%) and of the MHA (84.5%). Fewer (64.5%) appeared to understand the practical application of the MHA in the hypothetical clinical situations. An even lower proportion of staff appeared to understand the application of the GA either to obtain consent for medical treatment or to appoint a guardian through the Guardianship Division of the NSW Civil and Administrative Tribunal (NCAT).

Although clinical staff of the hospital displayed fair knowledge and awareness about the application of the MHA and the GA to inpatient care of older adults, further education is necessary, particularly about the application of the GA. The authors suggest similar findings may occur at other New South Wales hospitals, which may raise concern and need for education.

Our aim was to develop a framework for clinical decision-making that can be used to take into account risk in an era of recovery and rights.

We developed a framework influenced by civil liability law to develop a guide for clinical decision-making which emphasises collaboration, clarification of the available information and communication of decisions as essential components of recovery-oriented risk management.

Shared decision-making (SDM) is promoted as beneficial in mental healthcare, despite a dearth of supportive evidence. We aimed to obtain patients’ perspective on SDM in a ‘real world’ hospital sample.

Structured validated questionnaires were used to examine SDM with regard to treatment choices, and whether SDM influences attitudes towards treatment. The Mini-Mental State Examination was used to assess decision-making capacity.

A total of 109 individuals participated, with 60% reporting experiencing SDM. SDM positively correlated with positive attitudes to medication. Those detained under the Mental Health Act had lower levels of SDM.

SDM leads to more positive attitudes towards medication and may improve adherence with treatment. SDM may particularly benefit those subject to involuntary treatment and is not onerous to practice.

This paper identifies publicly available data about the use of involuntary treatment orders within Australia and considers whether this reporting is sufficient given the gravity of the intervention.

A search of mental health tribunal, health department and justice department annual reports was conducted to determine the use of involuntary treatment orders in Australia.

Reporting of involuntary treatment orders varied significantly across jurisdictions; for example, South Australia reported 11,570 distinct orders made during a 12-month period while the Australian Capital Territory reported 627 for the same period.

The publicly available data for involuntary treatment orders in Australia is inadequate for jurisdictional comparisons. This concern should be addressed to enable transparent public reporting and facilitate benchmarking.

It is increasingly recognised that persons with mental illness experience physical health issues at greater rates than the general population and that there are significant barriers to accessing appropriate treatment. One less obvious barrier to appropriate care may be the law. This review examines the legal regimes within Australia and New Zealand that regulate consent for medical and surgical treatment for persons detained under mental health legislation. The review begins with a brief overview of concepts of consent and capacity then examines the law with regards to consent for non-psychiatric treatment for persons detained in psychiatric facilities. The complexity and cross-jurisdictional consistency is considered and potential future directions and possibilities for reform are discussed.

Examination of the different laws regarding consent for medical or surgical treatment for persons admitted to psychiatric facilities are complex and demonstrate lack of consistency across jurisdictions. Reform in this area might be considered to achieve greater consistency and clarity for both health professionals and consumers.

To investigate the presence of different forms of experiences of discrimination in the medical workplace.

A total of 526 questionnaires were sent out, including a demographic survey form and the Everyday Discrimination Scale.

Experiences of being “treated with less courtesy than other people are” and feeling as “others acted if they’re better than [me]” were reported as having occurred with almost daily frequency by 4.1 % of respondents. Those whose main language was not English and classified as “non-whites” had significantly more experiences (“ever”) of discrimination in the medical workplace. The most commonly reported reasons for discrimination were ancestry (31.3%), “race” (28.1%), and gender (21.1%).

The results of this survey indicate that a proportion of doctors experience discrimination in the workplace in Australia. This phenomenon was more commonly reported by doctors of minority status.

This study describes the impact of Motivational Aftercare Planning (MAP) – an intervention to increase consumer/clinician collaboration on the content of mental health recovery plans. The intervention focussed on enhancing existing discharge processes in psychiatric inpatient wards and supporting nursing staff in using motivational interviewing techniques to facilitate the completion of these plans.

We conducted a qualitative thematic content analysis of the recovery plans completed throughout the study (n = 110). Chi-squared tests were then used to compare the occurrence of themes and content identified in recovery plans pre and post the intervention (n = 55).

The thematic content of the recovery plans shifted in focus following the intervention, with a change from third to first person language. Those completed prior to the intervention generally mentioned: decreasing symptoms of mental illness; acceptance of the illness; achieving clinical stability; risk management and treatment compliance. The recovery plans completed after the intervention focussed on: general wellness; participate in meaningful activities; community life; social roles and connections with others.

This study demonstrated that a simple time-limited, facilitated intervention resulted in a change of thematic content in recovery plans. The use of these plans and its effect on care planning will need further evaluation.

Consultation–liaison psychiatry (CLP) services sit between mental health and the general hospital, and risk being poorly understood by both systems. The aim of this study was to develop an operational manual for a CLP service, which defined functions and governance.

The CLP literature was reviewed with a focus on descriptions of CLP roles, organisational processes, quality measures and service development. The CLP team held service planning meetings and met with members of the mental health and hospital executives. Site visits and collaboration with other CLP services occurred in defining the roles of the CLP service and organisational governance.

A CLP operational document was developed, including a description of the service, its functions, staff roles and governance. Procedural information such as the CLP timetable, referral process, triage and assessment, documentation, activity recording, quality assurance and relevant policies were outlined.

The development of a dedicated operational manual for CLP clarified the roles, functions and governance of CLP within the general hospital and mental health systems. The development process facilitated the engagement of key clinicians and administrators of these systems, the determination of quality improvement targets and greater transparency and accountability.

Fatigue is a common and disabling problem in inflammatory bowel disease. We sought to explore the possible determinants of inflammatory bowel disease-associated fatigue including demographic, psychological and disease variables.

Surveys were distributed to 100 patients undergoing infliximab infusion for inflammatory bowel disease in an infusion lounge, assessing attachment style (Experiences in Close Relationships Revised scale), fatigue (Functional Assessment of Chronic Illness Therapy Fatigue – Fatigue Subscore), and depression and anxiety (Hospital Anxiety and Depression Scale). Disease severity was assessed via file review through an independent gastroenterologist rating (Harvey–Bradshaw Index).

There were 67 responses. Depression, as measured by the Hospital Anxiety and Depression Scale, was found to be highly correlated with fatigue (Functional Assessment of Chronic Illness Therapy Fatigue – Fatigue Subscore). Anxiety, insecure attachment, disease severity and female gender were moderately correlated with fatigue. In a hierarchical regression model, depression and female gender emerged as significant predictors of variance in fatigue scores.

Depression was the strongest predictor of variance in fatigue scores. Gender as a cause of fatigue in inflammatory bowel disease requires further exploration. Attachment style, however, may still help clinicians to conceptualise help-seeking behaviour and clinician-patient relationships in medically unexplained symptoms.

This paper reports a pilot study exploring the benefits of offering sensory modulation within a mental health emergency setting for consumers experiencing distress during a psychiatric presentation.

Seventy-four consumers with a mental health presentation reported on their sensory modulation use experiences during their stay in a South Australian tertiary teaching hospital emergency department. An evaluation form was used to document use of items, self-reported distress pre and post sensory modulation use, and other consumer experiences.

Consumers used between one and six sensory items for a median duration of 45 min. There was a statistically significant reduction (t(73) = 15.83, p < .001) in self-reported distress post sensory modulation use, and consumers also reported that use was helpful, distracting, calming and assisted in managing negative emotions and thoughts.

The results demonstrate the potential value of sensory-based interventions in reducing behavioural and emotional dysregulation in an emergency setting whilst also promoting consumer self-management strategies.

The aims of this study are to describe two patients whose manic symptoms persisted for several months after the cessation of corticosteroids, to review the literature and to suggest treatment.

The presentation of two elderly patients with persistent manic symptoms following cessation of corticosteroids several months previously afforded the author the opportunity to examine them carefully, investigate and treat them.

The patients were investigated to rule out other causes and were treated with sodium valproate and quetiapine (in the second patient). When well, the medications were slowly decreased and stopped. Both patients were well at one-year follow-up.

Manic symptoms may persist for many months after stopping corticosteroids and active treatment is needed to control them.

There are some psychosocial factors that have similar importance to biological factors in the genesis of coronary diseases. However, reasons for high rates of coronary heart disease in individuals with post-traumatic stress disorder (PTSD) are yet to be fully elucidated. Using a meta-analysis, we investigated the longitudinal relationship between PTSD and coronary heart disease (CHD) as an independent factor in the aetiology of CHD.

The databases of Medline, EBSCOhost and Psychoinfo were electronically searched for relevant articles.

The pooled hazard ratio (HR) for the magnitude of the relationship between PTSD and CHD was an HR of 1.61, and p-value of p < 0.0005, 95% confidence interval (CI) [1.46–1.77] before adjustment for depression in nine studies (N = 151,144) that met inclusion criteria. The HR estimates for the seven depression-adjusted estimates was 1.46, and a p-value of p < 0.0005, 95% CI[0.26–1.69].

This study demonstrates an association between CHD and PTSD.

This paper aims to describe current approaches in Victoria to the development of perinatal and infant mental health services in regional areas.

The paper outlines the significance of perinatal mental disorder for maternal wellbeing and impact on infant development, and describes the model of care at the Agnes Unit.

The Agnes Unit has been established as a residential therapeutic unit offering short-term treatment that focusses on promoting parental mental health, parenting sensitivity and the parent-infant relationship.

A coordinated and integrated approach with focus on early intervention is needed to deliver perinatal and infant mental health services. Services need to focus on the infant and parent-infant relationship in addition to parental mental health.

Late life depression (LLD) may have a significant vascular component. While this organic basis remains controversial it would explain the refractory nature of LLD. Moreover, depression is a risk factor for venous thrombus embolism (VTE). This paper aims to describe two elderly patients with LLD who developed and were treated for pulmonary embolism (PE).

Two cases of elderly patients who developed PE while they were undergoing inpatient treatment for depression are presented. This is discussed using the vascular and the cytokine hypotheses of depression as an explanatory framework.

Both patients showed significant clinical improvement in their mental state following therapeutic enoxaparin despite no other changes to their management of depression. This observed benefit of enoxaparin can be explained by the vascular hypothesis of LLD, and possibly the cytokine hypothesis of major depression.

Enoxaparin may be a novel adjunct to the treatment of depression in elderly patients. The possible benefit of enoxaparin would require further study to exclude a coincidence in these clinical cases.

Milnacipran is a serotonin noradrenaline reuptake inhibitor (SNRI) approved for treatment of fibromyalgia in Australia, but is used for depression in Europe and elsewhere. This paper will briefly review milnacipran and its utility in psychiatry for the treatment of depression.

Milnacipran is a dual reuptake inhibitor of noradrenaline and serotonin, with greater effect on noradrenaline than serotonin, in contrast to the related drugs venlafaxine, desvenlafaxine and duloxetine. Rapidly absorbed irrespective of food, milnacipran has a half-life of approximately 8 hours, reaches steady state in 2 days and is excreted renally. Milnacipran helps a minority of patients with fibromyalgia by reducing pain and fatigue. It is also an effective antidepressant with efficacy comparable to venlafaxine and duloxetine, and a side effect profile characteristic of SNRIs. The dose range is 50–200 mg, in divided doses. Milnacipran may be useful for patients with depression and pain, and endogenous depression characterised by anergia, psychomotor retardation and hypersomnia. Caution is necessary in the presence of heart disease, hypertension, renal impairment, epilepsy, glaucoma, bipolar disorder, and bleeding tendency. Milnacipran is likely to be a useful late antidepressant option in treatment-resistant patients, as well as those with chronic pain, anergia and hypersomnia.

To evaluate whether a workshop on family systems delivered to medical students could improve participants’ understanding of families from a systemic point of view and help them recognise and address systemic issues that may be affecting their patients.

Fifth year (senior) medical students (n = 36) from the University of Auckland participated in a 90-min workshop about family systems. Pre- and post-workshop, self-reported measures of knowledge and confidence were completed and qualitative feedback was also obtained from participants.

The workshop was well received and its interactive and role-play based nature were particularly appreciated. Participants reported gains in all explored areas of knowledge and understanding, suggesting that the workshop met its desired aims.

This workshop is an educationally effective and expedient way to equip medical students with some knowledge and understanding about family systems. It may benefit their future work with individual patients and families.

To explore trainee perception of what facilitates or delays completion of the RANZCP Scholarly Project (SP).

Of 182 currently registered New Zealand trainees, 33 (18%) completed an online questionnaire and three open-ended questions.

Most trainees agreed or strongly agreed that having protected time for research (87.5%) and access to an appropriate supervisor (87.9%) would facilitate the completion of their SP. Other college requirements were identified by most trainees (87.9%) as a factor delaying completion.

Identifying and protecting research time and ensuring adequate supervision appear essential to improve the uptake and completion of this training requirement.

This study explored trainee preparation for the Royal Australian and New Zealand College of Psychiatrists (RANZCP) written examinations. We examined the relationship between candidates’ prior psychiatry experience, preparation techniques and expenses, perceptions of the exam and a pass result. We also examined perceptions of well-being.

A web-based survey was sent to RANZCP trainees. The association between responses and exam outcome was analysed using SPSS Statistics 23.

A total of 23% (n = 38) of the cohort responded to the survey. Respondents studied for an average of 7.8 months for the essay-style exam and 4.4 months for the multiple-choice questions. The mean months of total psychiatry experience prior to sitting was 36.1 months. Every additional 50 hours of study increased odds of passing by 23%. Respondents who believed that exam preparation would affect outcome had an almost 4-fold higher odds of passing than those who did not. Ratings of well-being before release of results were also positively associated with passing.

Trainees are sitting the written exams with clinical experience commensurate with RANZCP recommendations. Total study hours and favourable perceptions of exam processes appear to be predictors of success.