Australian & New Zealand Journal of Psychiatry

Objectives: To describe all elderly patients hospitalised with principal and secondary diagnoses of depression, and to determine whether a relationship can be demonstrated between psychosocial stressors, physical illness and type of depression.

Method: A retrospective chart review of elderly patients admitted to a general hospital psychiatry ward over a 7-year period with principal or secondary diagnoses of depression was undertaken. Four broad diagnostic categories of depression were used: major depression, psychotic depression, minor depression, and organic depression. Chief outcome measures were: number of medical diagnostic categories, presence of psychosocial stressors, global clinical improvement, and length of stay.

Results: Of 228 patients admitted with depression (194 principal diagnoses and 34 secondary diagnoses), 100 had major depression, 47 psychotic depression, 48 minor depression and 33 organic depression. Psychiatric comorbidi-ty occurred in 70%, about half of which was due to organic brain syndrome. Patients with psychotic depression had the fewest medical problems and those with organic depression the most, while patients with minor depression had the highest rate of family and marital problems, comorbid personality dysfunction and suicide attempts. Patients with psychotic depression had the longest admissions, while those with minor depression had the shortest. Overall, 89% showed significant clinical improvement. Conclusions: Elderly inpatients have a wide spectrum of depressive disorders with different psychosocial, medical and treatment profiles. Future studies of depression in old age should include all patients with clinical depression.

Objective: To investigate whether depression measured at the time of treatment predicts relapse of alcohol dependence in the 6 months following treatment of alcohol-dependent men.

Method: Ninety-three subjects with moderate-severe alcohol dependence (DSM-Ill-R), recruited from a 3-week, abstinence-focused therapeutic program, were assessed for current and lifetime major depression using the SCID-P and baseline depressive symptoms using the SCL-90, and then followed up for 6 months. Drinking outcomes were based on multiple sources of data. Results: Relapse was not associated with either lifetime major depression, or baseline depressive symptoms; inadequate numbers of subjects with a current major depression precluded statistical analysis of this variable. Conclusions: Neither lifetime major depression, nor the degree of depressive symptoms in alcohol-dependent men at the time of treatment, compromise drinking outcomes in the 6 months following treatment.

Objective: To determine whether a predominantly summer-focussed pattern of seasonal affective disorder (SAD) exists in tropical northern Australia. Method: A mail survey containing a modified form of the Seasonal Pattern Assessment Questionnaire (SPAQ) was administered to 176 households in the city of Townsville (latitude: 19° south).

Results: Using previously reported screening criteria, 9% of respondents reported a degree of summer impairment indicative of SAD, while the incidence rate for winter SAD was 1.7%. This summer-winter ratio is typically reversed in more temperate latitudes.

Conclusions: Excessive heat and humidity were reported to be the two most influential environmental factors affecting mood and behaviour. It is likely that respondents meeting criteria for summer SAD represent the extreme end of a spectrum of summer-related mood and behaviour change that affects many individuals in northern Australia. Strategies for further clinical and epidemiological research on SAD in tropical climates are proposed.

Objective: This study aimed to describe in detail, using a retrospective approach, the prodromal symptoms in first-episode psychosis patients. This initial prodrome, the period of disturbance preceding a first psychotic episode, is potentially important for early intervention, identification of biological markers, and understanding the process of becoming psychotic. Method: A consecutive series of 21 first-episode patients was recruited from the Early Psychosis Prevention and Intervention Centre, a specialised service for young people aged between 16 and 30 with first-episode psychosis. Subjects were interviewed in the recovery phase after the acute episode, about the period leading up to the psychosis, using a combination of unstructured and semi-structured techniques.

Results: A wide variability of phenomena and sequence patterns was found, with symptoms being a mixture of attenuated psychotic symptoms, neurotic and mood-related symptoms, and behavioural changes. Symptoms were often disabling and some, such as suicidal thoughts, potentially life-threatening. Conclusions: The findings highlight the loss of information that has resulted from disregarding early phenomenological studies of the psychotic prodrome and instead focussing on behavioural features. The ground work has been laid for the development of better methodologies for assessing and measuring first psychotic prodromes with increased emphasis on experiential phenomena. This has the potential to lead to the early recognition and more accurate prediction of subsequent psychosis, as well as a deeper understanding of the neurobiology of the onset of psychotic disorder.

Objective: The objective of the present paper is to present comprehensive models of the current psychosocial morbidity of Australian Vietnam veterans. Seldom has research in this area attempted to ‘untangle’ direct and indirect influences on current functioning via possible pre-army, Vietnam and homecoming pathways.

Method: The Australian Vietnam Veterans' Health Study gathered data on a sample of 641 veterans throughout Australia drawn randomly from army Vietnam tour lists of the era. The data arose from interview and army records of the era, and fall into four temporal categories: pre-army, Vietnam service, homecoming after Vietnam, and current state. Path analysis models of the veterans' current psychological morbidities and social wellbeing are used to identify direct aetiological influences of earlier era constructs on current state, free of confounding by indirect (often selection) effects.

Results: Our results indicate that psychological morbidity (particularly post-traumatic stress disorder) is largely influenced by combat and poor homecoming experiences, although pre-military characteristics do play some direct roles in symptomatology. Social dysfunction measures show smaller effects of the Vietnam War, which may be accounted for by an indirect association with Vietnam-related psychological morbidity. Some social measures show evidence of compensatory influences of combat, high combat leading to social dysfunction because of morbidity, but simultaneously being associated with healthier social disposition (possibly because of increased ex-service activity).

Conclusions: For Australian Vietnam veterans, combat-related and homecoming effects persist on a range of psychosocial endpoints 20–30 years after exposure. These effects are not explicable in terms of veterans' pre-Vietnam characteristics.

Objective: Persistent difficulties have been identified in relation to confidentiality in mental health settings. The objective of the current investigation was to develop practical options enabling clinicians to negotiate this issue in a manner that is sensitive to families.

Method: A review of the international literature, the current legal and policy settings, and the needs of clients and their families was undertaken. Additional material was drawn from the authors' own practice and advocacy experience. Results: The literature and policies reviewed emphasised the importance of meaningful collaboration between clinicians and families. A close reading of the relevant legislation revealed possibilities for an interpretation of confidentiality that facilitates such collaboration. Options for negotiating the engagement phase which are consistent with meaningful collaboration were then developed.

Conclusion: Rather than assuming that confidentiality is an intransient problem, the authors conclude that dealing with the question of confidentiality sensitively presents clinicians with an opportunity to develop quality relationships with both clients and their families.

The concept of competency to consent to psychiatric treatment is discussed as a multi-faceted complex interaction involving: the developmental stage of the child and its effect on cognitive ability and rationality; their social environment and previous experience; their relationship with the professional as well as with their own family; the information presented to them about treatment as well as their understanding of that information; and their mental state at the time of deciding. All of these factors exist on a continuum or spectrum (i.e. in shades of grey and not in black and white) and therefore the application of rigid arbitrary limits is inappropriate. What is not in doubt is that the child deserves to be considered as an individual and its rights protected. The doctor's main duty is to the child, as the patient, and every opportunity to allow them to give proper informed consent must be provided. In the event of the child being found to be incompetent to consent, then the issue of proxy consent is also discussed, including the dangers of assuming that the parents will act in the child's best interests.

A paper based on a workshop presented to the Suicide Prevention Australia conference, ‘Suicide. Who Cares?’, on 15 March 1995 in Sydney

Objective: To present arguments for and against the provision of curriculum-based suicide prevention programs in schools.

Method: The authors developed their arguments independently, based on the available literature on school-based programs, prior to debating the topic at a national conference on suicide prevention.

Results: The rationale for school-based programs is that the school has the responsibility: to resolve problems that interfere with education; to teach health education; and to acknowledge a duty of care to parents and to the community as well as to youth. Primary prevention programs in schools are not aimed at so-called ‘at-risk’ students, but potential ‘helpers’, based on the knowledge that peers are a primary support for troubled adolescents. One measure of the efficacy of school-based prevention programs must be the extent to which there is an increase in the tendency for adolescents to turn to adults for help. There is ample evidence that increasing the tendency for adolescents to approach adults for help is achievable. The argument against such programs is that evidence from evaluation research suggests that they are ineffective, inefficient, not universally acceptable, and of questionable safety. Conclusions: Those persuaded by the positive argument will wish to see these programs adopted in all Australian secondary schools. Those persuaded by the negative argument will recommend that suicide prevention resources be allocated to activities other than school-based suicide education programs.

Objective: This paper presents the findings from a questionnaire-based survey of psychiatrists designed to elucidate the positive and negative aspects of group peer review and its perceived place in accountability procedures, and to provide information about how accountability through group peer review might be improved.

Method: Three hundred and eighty-eight psychiatrists were surveyed via mail-out questionnaire. Demographic data, details of groups, and perceptions of beneficial and detrimental effects of group peer review were sought from group participants and non-participants. Attitudes of participants were compared with those of non-participants. Features of groups related to satisfaction in participants were examined.

Results: The majority of the 170 respondents participating in groups regarded peer review as a means of maintaining and improving skills, sharing ideas and methods, receiving constructive criticism and feedback, of educational benefit and an important source of professional accountability. Non-participants, while less positive overall, responded equally that participation in peer review groups would be an effective response to accountability procedures. Potential detrimental effects and problems with the functioning of peer review groups were elucidated.

Conclusions: Group peer review contributes significantly to professional accountability and education in well-functioning groups. Further strategies for the facilitation of group functioning and for the processing of problems arising in group peer review need to be developed to optimise its contribution to the maintenance and improvement of professional standards.

Objective: This study sought to elucidate the contribution of peer review groups involving psychiatrists to quality improvement and quality care. Method: Audio-taped interviews of groups engaged in peer review were analysed using a qualitative methodology. Participants' views of the ways in which they experienced and conceptualised peer review were explored. Results: The views of participants in peer review groups were analysed, and categories evolved which identified differences in how they perceived the structure and function of group peer review.

Conclusions: Participants in the groups studied perceived peer review as a professional growth forum within a quality improvement framework providing critical review of treatment, continuing education, and a sense of collegiality. Boundaries of acceptable practice were tested and defined. At its best, participation in peer review groups enhanced reflective practice which achieved new understandings of clinical work. In this regard, peer review is seen as a highly desirable method for the maintenance of professional standards.

Objective: To describe a two-phase study of the structure of Australasian psychiatrist peer review groups.

Method (Phase one): Initially, information was sought from chairskoordinators of psychiatrist peer review groups regarding the nature and organisation of their group.

Results (Phase one): One hundred and three questionnaires were returned describing a number of models of peer review. Three principal models were identified: a teaching hospital model, a private practice model, and a private institution model.

Method (Phase two): The second-phase questionnaire sought information on the quality of the review, using six proposed standards developed by the Quality Assurance Committee of the Royal Australian and New Zealand College of Psychiatrists.

Results (Phase two): Many groups indicated that four of the proposed standards (those relating to documentation, having clear goals, reviewing actual clinical cases, and rigorous protection of confidentiality) were either already being followed or would be relatively easy to implement. The remaining two proposed standards (including structure, process and outcome dimensions of health care in the case discussion, and the use of explicit criteria) presented more difficulty.

Conclusion: The application of such standards to peer review group meetings should assist groups to provide a forum for presentation and evaluation of clinical work where participants know they will be challenged in an environment which is both supportive and educational.

Objective: To evaluate Queensland Health's recruitment campaign of 15 full-time psychiatrists to non-metropolitan areas between July 1992 and December 1993.

Method: A detailed 170-item Likert-type questionnaire was designed and mailed to all 15 psychiatrists. Thirteen questionnaires were completed and followed-up by a face to face interview.

Results: Findings indicate that most of those recruited were experienced senior specialists who came to the positions as result of personal contact and were attracted to non-metropolitan positions because of ‘lifestyle’ and ‘professional challenge’ variables. ‘Lifestyle’ and ‘professional’ variables were identified as major contributors to their retention. They reported that ‘bureaucracy’ and ‘social and family’ reasons would be the most likely cause of them considering leaving their current positions.

Conclusions: While the recruitment campaign was evaluated as successful, some aspects were clearly more influential than others. It was noted that factors which were likely to influence psychiatrists to leave non-metropolitan public sector positions were more ‘public’ than ‘non-metropolitan’ in nature.

This paper is an account of the principles and practices of treatment offered at the Cassel Hospital, London, with a particular focus on the Inpatient Families Unit. The Cassel Hospital is an internationally renowned therapeutic community, the operation of which is based on psychoanalytic principles and which has operated within the British National Health Service for nearly 50 years. An account of the historical development of the hospital is given as well as a description of its structure and function. The following three innovative structures are elaborated: a complex network within which patients can develop, Cassel-style nursing care, and nurse-therapist supervision. Theoretical underpinnings are outlined, which together with two case studies facilitate an appreciation of the capacity of the therapeutic network to foster the successful treatment of a range of severely disordered individuals and families. Such treatment may approach a level perhaps otherwise unattainable and which is widely applicable in the public hospital and clinic settings in Australia.

Objective: To discuss the ethical and clinical issues associated with the management of social breakdown in the elderly (SBE) in relation to the case of a 76-year-old recluse who was referred following community concerns about her living conditions and behaviour.

Method: Longitudinal assessment and management of the patient resulted in a diagnosis of schizophrenia and treatment with fluphenazine decanoate. Results: The patient responded to treatment and was returned home, after which a relationship was maintained by community services. Conclusions: A coherent and defensible position on both clinical and ethical grounds may be made in favour of intervention with SBE. Practical aspects of the process are suggested.

Objective: Fiji is a Pacific nation with roughly equal numbers of indigenous Fijians and Indians. Previous studies, using police and medical records, have suggested significant racial, regional, age and gender differences in suicidal behaviour. The objective of the present study is to use a unique data set (autopsy reports) in the evaluation of earlier reports and to identify groups at greater risk.

Method: Hanging and poisoning autopsy reports from two distinct regions were examined.

Results: The rate of autopsy (per 100 000 population per year) among Indians (19.5) is significantly greater (p<0.0001) than among Fijians (1.53). In the north, among the Indians, there are more autopsies in females (21.2) than males (16.8), and hanging constitutes 85% of total suicides, while in the Central and Eastern Divisions hanging constitutes only 58% of the total. These are regional influences. Among Fijians, the rates of hanging autopsy are significantly greater (p<0.001) in males (1.98) than females (0.40); however, among Indians there is no significant difference. This is a racial difference. Hanging remains the preferred option for all groups. The mean age at autopsy is 31.7. There is no significant difference between the mean ages of the races, the sexes or the regions. There is no significant difference between the mean age of poisoning (31.5) and hanging (31.8).

Conclusion: There is a significant racial difference in rates of suicide but the influences of region, age and method are relatively slight.

Objective: Post-stroke mania has rarely been noted and researched, and reported cases have mostly involved the non-dominant hemisphere. In this paper, we report a case of bipolar disorder secondary to a stroke over the dominant hemisphere.

Clinical picture: A 48-year-old, right-handed man had a cerebral infarct over the left temporal region. He became depressed after the stroke, and 4 months later developed a manic episode.

Treatment: The patient was treated with haloperidol and lorazepam. Outcome: The symptoms subsided within 2 months after treatment. Conclusions: It is premature to consider mania to be a syndrome of the right, or non-dominant, hemisphere. We suggest that further study focusing on specific anatomical regions, rather than laterality, will help to elucidate the interrelationship between mood and brain function.

Objective: This report identifies neuroleptic malignant syndrome (NMS) occurring on a steady state dosage of clozapine monotherapy. Clinical picture: An outpatient presented with a recent history of stiffness and soreness of his legs, dizziness, polydipsia, polyuria, abdominal and chest pains. After admission to a general hospital, further symptomatology was identified including: pallor, diaphoresis, nausea, confusion, agitation, decrease in normal reflexes, minimally reactive pupils and rigid limbs. Treatment: Intravenous (I/V) diazepam was administered but failed to decrease the agitation and confusion. He was sedated with the administered of IN drop-eradol, intubated and placed on a ventilator with circulatory supports for 4 days.

Outcome: On day five he was extubated and transfered to a medical ward. All laboratory values had returned to normal values by this time. The patient was subsequently discharged.

Conclusions: Neuroleptic malignant syndrome can occur at any stage of clozapine treatment, and the patient can be rechallenged after such an episode. This person was rechallenged and after 6 months of treatment has suffered no further recurrence of NMS.

Objective: To report the case of a Chinese refugee who presented with a brief reactive psychosis in the presence of significant stressors. Clinical picture: A 30-year-old Chinese refugee, who fled alleged torture and persecution in China, presented with an acute, severe, paranoid psychosis. Treatment and outcome: This patient's psychosis was exacerbated by involuntary hospitalisation and treatment. The withdrawal of restrictive measures, cessation of medications and attention to his social needs led to an improvement in his condition.

Conclusions: Involuntary treatment of a brief reactive psychosis in those who have been previously tortured may exacerbate the psychosis. Withdrawal of restrictions and advocacy for the patient may generate a therapeutic alliance with a positive outcome.

Objective: A case report of carrot addiction is presented with a review of the literature and comment on the role of beta carotene in addictive behaviour. Clinical Picture: The addiction occurred in a 49-year-old woman under conditions of stress due to marital problems, leading to a depressive illness and increased smoking. The patient maintained that the sensations of carrot craving and withdrawal were quite distinct from those associated with smoking.

Treatment: The patient was advised to record her daily carrot consumption. Outcome: The patient did not return for several months, but stopped eating carrots after an operation, at which time she also stopped smoking. Conclusion: Compusive carrot eating, regarded as a rare condition, has received scant documentation, unlike hypercarotenemia due to unusual diets or food fads. Nervousness, craving, insomnia, waterbrash and irritability are associated with withdrawal from excessive carrot eating. The basis for the addiction is believed to be beta carotene, found in carrots. Does carrot eating, an aggressively oral activity, merely act as a behavioural substitute for smoking? Or does beta carotene contain a chemical element that replicates the addictive component of nicotine? Further study of this unusual but intriguing addiction may reveal more about the basis of all addictions, with particular implications for the cessation of cigarette smoking.