Australian & New Zealand Journal of Psychiatry

Short-term psychodynamic psychotherapy (STPP) is a widely practised form of psychological intervention. Given that the Roth and Fonagy (1996) review concluded that there was a lack of confirming evidence for STPP, the current review is focused on studies published between 1996 and 2006 that evaluate the efficacy of STPP. As a result of a systematic literature review, 18 studies were found that met inclusion criteria consistent with those used by Roth and Fonagy (1996) for selection of studies, patient groupings and definition of therapeutic method. In general these studies add to an increasing body of evidence suggesting that STPP can be an effective psychological treatment for individuals experiencing mental health problems. Specifically, for depression STPP can be equal in effects to other psychological treatments and is significantly better than no treatment in the short term. Furthermore, emerging process data indicate that there is a significant relationship between the use of specific psychodynamic therapeutic techniques and the alleviation of depressive symptoms. Increasing evidence has emerged to support STPP as a treatment for generalized anxiety disorder, panic disorder and some personality disorders. There remains limited evidence for the use of STPP treatment for patients with anxiety disorders that relate more to stress. Very limited and inconclusive evidence currently exists to support STPP as a treatment for bipolar disorder, eating disorders and drug dependency. Future research needs to include broader assessment measures, long-term follow up, studies that maintain an identifiable focus, and research that includes a focus on psychotherapy process variables as they interact with outcomes.

The purpose of the present paper was to identify, from the voluminous literature on efficacy and safety in new-generation antidepressants (NGAs) with depressed children and adolescents, practical clinical strategies for acute phase treatment. To this end a pragmatic survey of studies and reviews was undertaken. Meta-analyses of randomized controlled trials of NGAs in depressed children and adolescents have noted a comparative lack of efficacy, and a weak but statistically significant increased risk of self-harm and suicidal thoughts. But NGA prescription rates and youth suicide rates are generally inversely related, and ensuing ‘black box’ warnings about NGAs, by deterring NGA prescribing, have possibly contributed to rising youth suicide rates. In moderate–severe depression, benefits for fluoxetine and possibly other NGAs demonstrably outweigh risks. NGAs are not present in adolescents who die by suicide. Concern about NGA risks must be balanced against risks of non-treatment. While mild depression entails regular review, psychoeducation, self-care strategies and psychological interventions, NGAs should be administered concurrently with psychological treatments if depression is moderate– to severe, or if mild depression persists. Patients should be warned about off-label status of NGAs in depression, serious side-effects such as ‘activation’, suicidality, emotional blunting and manic switches, the need for adherence and avoiding abrupt discontinuation. They should be monitored early and regularly. Better evidence is required regarding psychological treatments, clinical course, and clinical practice trends. In moderate–severe depression the risk of suicide if NGAs are not used may outweigh any risk of self-harm associated with them.

Objective: Abnormalities of the anterior cingulate cortex (ACC) have consistently been identified in obsessive–compulsive disorder (OCD), but very few studies have examined the biochemical basis of such changes. The purpose of the present study was to investigate how ACC biochemistry in OCD varies as a function of gender, hemisphere, subregion, and symptomatology.

Method: 3 T proton-magnetic resonance spectroscopy (MRS) was used to probe ACC biochemistry in 20 OCD patients (10 male, 10 female) and a comparable group of 26 healthy comparison subjects. Data were acquired from the left and right dorsal and rostral subregions of the ACC. Metabolites assessed included N-acetylaspartate (NAA), glutamate–glutamine (Glx), choline-containing compounds (Cho), creatine/phosphocreatine (Cr), and myoinositol-containing compounds (mI).

Results: Female OCD patients had significantly reduced levels of Glx in all but one subregion of the ACC when compared to matched controls. Levels of Glx were correlated with clinical measures of symptom severity in female but not male patients. State levels of anxiety and depression did not explain this association. In addition, both male and female OCD patients had relatively higher concentrations of mI in their right ACC (rostral and dorsal) compared with healthy controls. No other compounds had any statistically significant group differences, nor were the concentrations of any other compounds correlated with symptom measures.

Conclusions: To the authors’ knowledge this is the first study to demonstrate gender-specific neurochemical changes in OCD. Although these findings are tentative and require replication, they raise the possibility that MRS techniques may be of use in objectively monitoring patient progress and assessing the effectiveness of various treatments.

Objective: Neuroimaging studies have highlighted important issues related to structural and functional brain changes found in sufferers of psychological trauma that may influence their ability to synthesize, categorize, and integrate traumatic memories.

Methods: Literature review and critical analysis and synthesis.

Results: Traumatic memories are diagnostic symptoms of post-traumatic stress disorder (PTSD), and the dual representation theory posits separate memory systems subserving vivid re-experiencing (non-hippocampally dependent) versus declarative autobiographical memories of trauma (hippocampally dependent). But the psychopathological signs of trauma are not static over time, nor is the expression of traumatic memories. Multiple memory systems are activated simultaneously and in parallel on various occasions. Neural circuitry interaction is a crucial aspect in the development of a psychotherapeutic approach that may favour an integrative translation of the sensory fragments of the traumatic memory into a declarative memory system.

Conclusion: The relationship between neuroimaging findings and psychological approaches is discussed for greater efficacy in the treatment of psychologically traumatized patients.

Objectives: To understand and promote recovery from serious mental illnesses, it is important to study the perspectives of individuals who are coping with mental health problems. The aim of the present study was to examine identity-related themes in published self-narratives of family members and individuals with serious mental illness. It adds to the body of research addressing how identity affects the process of recovery and identifies potential opportunities for using published narratives to support individuals as they move toward positive identities that facilitate recovery.

Method: Forty-five personal accounts from individuals with severe mental illness, which were published in two prominent research journals between 1998 and 2003, were qualitatively analysed.

Results: Individuals with mental illness and their family members described a loss of self and identity that had to be overcome, or at least managed, for recovery to become possible. Writers described (i) a loss of self, (ii) the duality of (ill/well) selves, (iii) perceptions of normality, (iv) specific concerns about parenting and identity, and (v) hope and reconciliation.

Conclusions: Individuals’ stories of their experiences of severe mental illness describe severe challenges managing identity. Efforts to publish personal accounts that focus on strengths-based patient-centred stories, rather than on deficits, could be helpful to provide hope for patients. These published narratives highlight the importance of moving recovery and hope to the forefront among patient, family, and clinician groups. Increasing such information and role models can provide important resources to individuals working to redefine themselves and create a sense of self-worth and stable identity that will support productive, happy lives.

Objective: Schizophrenia is a complex disorder characterized by impairment in a number of domains, all of which contribute to disability. The aim of the present study was to investigate the relationships between cognitive function, symptoms and quality of life (QOL) in schizophrenia.

Method: This cross-sectional study measured cognition, positive and negative symptom severity, and quality of life (measured with the Quality of Life Scale) in 57 outpatients with schizophrenia. Correlations between the different measures were sought. Multiple regression analyses were used to develop models of the contributions of cognitive deficits and symptomatology to QOL.

Results: More severe positive and negative symptoms and cognitive impairment each correlated with poorer QOL. There was a moderate association between negative symptoms and cognition and a small association between positive symptoms and cognition. Age, gender, and drug and alcohol abuse did not significantly predict QOL. In the multiple regression analysis, entering the total cognition and total symptom scores produced a model that accounted for an additional 57% of the variance in QOL.

Conclusions: Improving quality of life for people with schizophrenia requires that positive and negative symptoms and cognition are each addressed as separate domains of impairment. But, given that these account for only 57% of the variance in QOL, other factors such as unemployment, poverty, social isolation and stigma may also be important.

Objective: Several large population-based studies have reported that otherwise-well individuals endorse items related to delusion-like experiences. The aim of the present study was to examine selected correlates of delusion-like experiences in a sample of non-psychotic individuals.

Method: Subjects (n=310) were screened with the Diagnostic Interview for Psychosis in order to exclude psychotic disorders. Delusion-like experiences were assessed with the Peters Delusional Inventory (PDI). Non-parametric statistics were used to assess the relationship between total PDI score and a range of demographic (age, sex, migrant status, paternal age), physical (minor physical anomalies) symptom-related variables (hallucinations, awareness of thought disorder) and family history of mental illness.

Results: The median (range) PDI score was 4 (0–26), while one-third of the subjects endorsed seven or more items. The presence of a family history of any psychiatric condition was significantly correlated with a higher PDI score. PDI score was significantly positively correlated with endorsement of hallucinations and awareness of thought disorder. PDI was not significantly associated with sex, family history of schizophrenia, paternal age, migrant status nor scores related to minor physical anomalies. There was a trend level association between younger age and higher PDI score.

Conclusion: Delusion-like experiences are relatively common in non-psychotic individuals. The association with a family history of mental disorders provides clues to the mechanisms underlying the profile of delusion-like experience.

Objective: Persons with psychiatric illness, especially depression and schizophrenia, are at relatively high risk of suicide, but there are few studies that look at the Asian population. The aim of the present study was to identify the risk period and risk factors for suicide in psychiatric patients in Singapore. The nature of psychiatric care that was provided, both inpatient and outpatient, was also explored.

Method: This is a case–control study of 123 patients who committed suicide from 2003 to 2004. Controls were 123 surviving patients who were individually matched for age, gender, principal diagnosis and calendar time.

Results: The most common principal diagnoses among the suicide subjects were schizophrenia (46.3%) and depression (26.8%). Numerous factors were associated with significantly increased suicide risk. Stepwise conditional logistic regression showed that the following three independent factors best predicted suicide: history of attempted suicide using highly lethal means; coexisting significant physical illness; and delusions. Suicides occur mainly soon after discharge and after an outpatient consult. Subgroup analyses were done to distinguish between subjects who suicided early and late following discharge.

Conclusions: Suicidal risk remains high in Singaporean psychiatric patients soon after discharge. They share some common risk factors for suicide identified in Western studies but the lower prevalence of substance abuse and comorbidity in Singaporean suicide subjects was one notable difference. The phenomena of suicides soon after discharge and outpatient review suggest the need for proper identification and more intensive follow up during this period.

Objective: Declining interest in psychiatry is an urgent public health issue and has been the subject of many studies. The purpose of the present paper was to survey the attitudes of senior medical students in order to explore reasons why psychiatry might be regarded as an attractive option as a career.

Method: Thirty-three students from an Australian university were asked during a written examination to consider why a psychiatric career might be an attractive choice for medical recruits. Key themes were identified and qualitatively analysed from the open-ended responses to the question: ‘On the basis of your clinical experience, consider why a psychiatric career is an attractive choice these days.’

Results: Thematic analysis indicated that the factors influencing decisions to specialize as a psychiatrist weighted financial and lifestyle advantages. The main drawcard profile was of challenging work that affords a good lifestyle and stimulating research opportunities. Other themes such as rewarding patient interaction, holistic care and variety were also raised.

Conclusion: Concern that the Australian psychiatric profession is failing to attract sufficient numbers of high-quality recruits is growing. While the majority of essays analysed in this account suggested that the students perceived psychiatry as an adequate career that affords the benefits of a balanced lifestyle, the constraining nature of the survey question compelled examinees to provide positive responses. Despite this bias, the responses are nonetheless revealing and contribute to understanding of the factors that may influence trainees to enter the field. On the whole, it would appear that the discipline is currently not exciting keen passions in medical students.

Objective: The findings regarding the validity of attention-deficit–hyperactivity disorder (ADHD) subtypes using neuropsychological functioning have been inconsistent; and no such study has been conducted in an ethnic Chinese population. The aim of the present paper was therefore to examine the validity of attention tasks in distinguishing the ADHD-combined type (ADHD-C) from the ADHD-inattention type (ADHD-I), as compared to children without ADHD in Taiwan.

Methods: Participants included 52 children with ADHD-C, 17 with ADHD-I, and 52 controls, aged 7–10years. The clinical diagnosis of DSM-IV ADHD was further confirmed by a standardized psychiatric interview. Four attention components were examined: sensory selection, response selection, capacity/focus, and sustained attention, using the Cancellation Test, Digit Span, Trail-Making Test (TMT), Continuous Performance Test (CPT), and Circle-Tracing Test. Behaviour symptoms were rated by the parents, teachers, and investigators.

Results: Compared to children without ADHD, children with ADHD scored significantly higher in parent-reported and investigator-rated behavioural symptoms, and performed worse in the four domains of attention. Multiple comparisons indicated that children with ADHD-C had a worse performance on most tests than children with ADHD-I, except that children with ADHD-I had more off-target errors on the TMT with alphanumeric sequencing than children with ADHD-C.

Conclusions: Attention tests can distinguish Taiwanese children with ADHD from those without ADHD, and these tests also demonstrate different profiles between the ADHD-C and ADHD-I groups. Further investigation on this topic should include the ADHD-hyperactivity–impulsivity subtype (ADHD-HI) and increase sample sizes of the children with ADHD-I and ADHD-HI. (ClinicalTrials.gov number, NCT00494819.)

Objective: Aggressive behaviour is common in young people admitted to child and adolescent inpatient services. Little is known about how physical aggression during admission influences patient outcomes. The aim of the present study was to identify predictors of aggression in a child and adolescent inpatient unit and examine differences in clinical outcomes between aggressive and non-aggressive patients.

Method: Episodes of aggression occurring within a child and adolescent inpatient unit were prospectively documented between October 2004 and December 2005. Patient factors (demographics, diagnoses, clinical history) were examined as predictors of aggression. Outcomes for admissions in which more than one episode of physical aggression occurred were compared to those in which no aggression occurred. Outcomes assessed were changes in symptom severity (as rated by the Health of the Nation Outcome Scales for Children and Adolescents) length of stay, and initiation of medications.

Results: A total of 134 patients were admitted during the study period (61.9% female, mean age=13.8years, SD=2.9); 31 patients (23.1%) exhibited physical aggression during admission and 20 of these exhibited more than one episode of physical aggression. Factors that predicted persistent physical aggression included history of aggression, use of medications at presentation and absence of self-harm. Persistent aggression was also associated with increased length of stay, but did not compromise improvements in clinical symptom ratings between admission and discharge or lead to increased medication prescribing

Conclusion: Contrary to hypotheses and existing research, aggression during admission does not appear to be a barrier to clinical improvement. Further research is necessary to clarify how aggressive children can receive the most benefit from inpatient admission while minimizing the risks to the patient and those around them.

Objective: To describe a patient who survived a suicidal act in which lethal means were used and who subsequently cooperated with psychiatric examination.

Method: Case report.

Results: A 22-year-old man jumped from a bridge into the water 49m below and survived. He was admitted to hospital for assessment. No psychiatric diagnosis could be made on either Axis I or II. He had misappropriated money and lost it gambling, and detection was imminent. He described his jumping as being the result of a sudden impulse. While he was falling he changed his mind and assumed an appropriate diving posture with the intention of preventing his death.

Conclusions: This is an example of a person performing a highly lethal suicide act, in the absence of Axis I or II disorder. Threat of disgrace and possible prosecution; and impulsivity were significant factors.