Australian & New Zealand Journal of Psychiatry

To provide guidance for the optimal administration of electroconvulsive therapy, in particular maintaining the high efficacy of electroconvulsive therapy while minimising cognitive side-effects, based on scientific evidence and supplemented by expert clinical consensus.

Articles and information were sourced from existing guidelines and the published literature. Information was revised and discussed by members of the working group of the Royal Australian and New Zealand College of Psychiatrists’ Section for Electroconvulsive Therapy and Neurostimulation, and findings were then formulated into consensus-based recommendations and guidance. The guidelines were subjected to rigorous successive consultation and external review within the Royal Australian and New Zealand College of Psychiatrists, involving the full Section for Electroconvulsive Therapy and Neurostimulation membership, and expert and clinical advisors and professional bodies with an interest in electroconvulsive therapy administration.

The Royal Australian and New Zealand College of Psychiatrists’ professional practice guidelines for the administration of electroconvulsive therapy provide up-to-date advice regarding the use of electroconvulsive therapy in clinical practice and are informed by evidence and clinical experience. The guidelines are intended for use by psychiatrists and also others with an interest in the administration of electroconvulsive therapy. The guidelines are not intended as a directive about clinical practice or instructions as to what must be done for a given patient, but provide guidance to facilitate best practice to help optimise outcomes for patients. The outcome is guidelines that strive to find the appropriate balance between promoting best evidence-based practice and acknowledging that electroconvulsive therapy is a continually evolving practice.

The guidelines provide up-to-date advice for psychiatrists to promote optimal standards of electroconvulsive therapy practice.

Cognitive remediation therapy is a moderately effective intervention for ameliorating cognitive deficits in individuals with schizophrenia-related disorders. With reports of considerable variability in individual response to cognitive remediation therapy, we need to better understand factors that influence cognitive remediation therapy efficacy to realise its potential. A systematic review was conducted to identify and evaluate predictors of cognitive outcome.

An electronic database search was conducted identifying peer-reviewed articles examining predictors of cognitive response to cognitive remediation therapy.

A total of 40 articles accounting for 1681 cognitive remediation therapy participants were included; 81 distinct predictors of cognitive response were identified. Data synthesis and discussion focused on 20 predictors examined a minimum three times in different studies. Few of the examined predictors of cognitive outcome following cognitive remediation therapy were significant when examined through systematic review. A strong trend was found for baseline cognition, with reasoning and problem solving and working memory being strongly predictive of within-domain improvement. Training task progress was the most notable cross-domain predictor of cognitive outcome.

It remains unclear why a large proportion of participants fail to realise cognitive benefit from cognitive remediation therapy. However, when considering only those variables where a majority of articles reported a statistically significant association with cognitive response to cognitive remediation therapy, three stand out: premorbid IQ, baseline cognition and training task progress. Each of these relates in some way to an individual’s capacity or potential for change. There is a need to consolidate investigation of potential predictors of response to cognitive remediation therapy, strengthening the evidence base through replication and collaboration.

Successive suicide prevention frameworks and action plans in Australia and internationally have called for improvements to mental health services and enhancement of workforce capacity. However, there is debate regarding the priorities for resource allocation and the optimal combination of mental health services to best prevent suicidal behaviour. This study investigates the potential impacts of service capacity improvements on the incidence of suicidal behaviour in the Australian context.

A system dynamics model was developed to investigate the optimal combination of (1) secondary (acute) mental health service capacity, (2) non-secondary (non-acute) mental health service capacity and (3) resources to re-engage those lost to services on the incidence of suicidal behaviour over the period 2018–2028 for the Greater Western Sydney (Australia) population catchment. The model captured population and behavioural dynamics and mental health service referral pathways and was validated using population survey and administrative data, evidence syntheses and an expert stakeholder group.

Findings suggest that 28% of attempted suicide and 29% of suicides could be averted over the forecast period based on a combination of increases in (1) hospital staffing (with training in trauma-informed care), (2) non-secondary health service capacity, (3) expansion of mental health assessment capacity and (4) re-engagement of at least 45% of individuals lost to services. Reduction in the number of available psychiatric beds by 15% had no substantial impact on the incidence of attempted suicide and suicide over the forecast period.

This study suggests that more than one-quarter of suicides and attempted suicides in the Greater Western Sydney population catchment could potentially be averted with a combination of increases to hospital staffing and non-secondary (non-acute) mental health care. Reductions in tertiary care services (e.g. psychiatric hospital beds) in combination with these increases would not adversely affect subsequent incidence of suicidal behaviour.

Bipolar disorder is associated with a decreased life expectancy of 8–12 years. Cardiovascular disease is the leading cause of excess mortality. For the first time, we investigated the Framingham 30-year risk score of cardiovascular disease in patients with newly diagnosed/first-episode bipolar disorder, their unaffected first-degree relatives and healthy individuals.

In a cross-sectional study, we compared the Framingham 30-year risk score of cardiovascular disease in 221 patients with newly diagnosed/first-episode bipolar disorder, 50 of their unaffected first-degree relatives and 119 healthy age- and sex-matched individuals with no personal or first-degree family history of affective disorder. Among patients with bipolar disorder, we further investigated medication- and illness-related variables associated with cardiovascular risk.

The 30-year risk of cardiovascular disease was 98.5% higher in patients with bipolar disorder (p = 0.017) and 85.4% higher in unaffected first-degree relatives (p = 0.042) compared with healthy individuals in models adjusted for age and sex. When categorizing participants in low cardiovascular risk without considering age and sex distribution among participants, 81% of patients were at low risk, versus 92% of unaffected relatives and 89% of healthy individuals. Of the patients 209 (94.6%) were diagnosed within the preceding 2 years. Smoking was more prevalent among patients with bipolar disorder (45.2%) and their unaffected first-degree relatives (20.4%) compared with healthy individuals (12.8%). Similarly, dyslipidemia was more common among patients with bipolar disorder compared with healthy individuals. Treatment with psychotropic medication with metabolic adverse effects was associated with higher 30-year cardiovascular disease risk score, whereas we did not find illness-related variables associated with cardiovascular risk among patients with bipolar disorder.

We found an enhanced cardiovascular disease risk score in patients with newly diagnosed bipolar disorder and their unaffected first-degree relatives, which points to a need for specific primary preventive interventions against smoking and dyslipidemia in these populations.

The Australian Institute of Health and Welfare has reported an increased rate of hospital-treated intentional self-harm in young females (2000–2012) in Australia. These reported increases arise from institutional data that are acknowledged to underestimate the true rate, although the degree of underestimation is not known.

To consider whether the reported increase in young females’ hospital-treated intentional self-harm is real or artefactual and specify the degree of institutional underestimation.

Averages for age- and gender-standardised event rates for hospital-treated intentional self-harm (national: Australian Institute of Health and Welfare; state: New South Wales Ministry of Health) were compared with sentinel hospital event rates for intentional self-poisoning (Hunter Area Toxicology Service, Calvary Mater Newcastle) in young people (15–24 years) for the period 2000–2012. A time series analysis of the event rates for the sentinel hospital was conducted.

The sentinel hospital event rates for young females of 444 per 100,000 were higher than the state (378 per 100,000) and national (331 per 100,000) rates. There was little difference in young male event rates – sentinel unit: 166; state: 166 and national: 153 per 100,000. The sentinel hospital rates showed no change over time for either gender.

There was no indication from the sentinel unit data of any increase in rates of intentional self-poisoning for young females. The sentinel and state rates were higher than the national rates, demonstrating the possible magnitude of underestimation of the national data. The reported increases in national rates of hospital-treated self-harm among young females might be due to artefactual factors, such as changes in clinical practice (greater proportion admitted), improved administrative coding of suicidal behaviours or possibly increased hospital presentations of community self-injury cases, but not intentional self-poisoning. A national system of sentinel units is needed for the accurate and timely monitoring of all hospital-treated self-harm.

Stepped care has been promoted for the management of mental disorders; however, there is no empirical evidence to support the cost-effectiveness of this approach for the treatment of anxiety disorders in youth.

This economic evaluation was conducted within a randomised controlled trial comparing stepped care to a validated, manualised treatment in 281 young people, aged 7–17, with a diagnosed anxiety disorder. Intervention costs were determined from therapist records. Administrative data on medication and medical service use were used to determine additional health care costs during the study period. Parents also completed a resource use questionnaire to collect medications, services not captured in administrative data and parental lost productivity. Outcomes included participant-completed quality of life, Child Health Utility – nine-dimension and parent-completed Assessment of Quality of Life – eight-dimension to calculate quality-adjusted life years. Mean costs and quality-adjusted life years were compared between groups at 12-month follow-up.

Intervention delivery costs were significantly less for stepped care from the societal perspective (mean difference −$198, 95% confidence interval −$353 to −$19). Total combined costs were less for stepped care from both societal (−$1334, 95% confidence interval −$2386 to $510) and health sector (−$563, 95% confidence interval −$1353 to $643) perspectives but did not differ significantly from the manualised treatment. Youth and parental quality-adjusted life years were not significantly different between groups. Sensitivity analysis indicated that the results were robust.

For youth with anxiety, this three-step model provided comparable outcomes and total health sector costs to a validated face-to-face programme. However, it was less costly to deliver from a societal perspective, making it an attractive option for some parents. Future economic evaluations comparing various models of stepped care to treatment as usual are recommended.

Disruptions in biological rhythms and sleep are a core aspect of mood disorders, with sleep and rhythm changes frequently occurring prior to and during mood episodes. Wrist-worn actigraphs are increasingly utilized to measure ambulatory activity rhythm and sleep patterns.

A comprehensive study using subjective and objective measures of sleep and biological rhythms was conducted in 111 participants (40 healthy volunteers [HC], 38 with major depressive disorder [MDD] and 33 with bipolar disorder [BD]). Participants completed 15-day actigraphy and first-morning urine samples to measure 6-sulfatoxymelatonin levels. Sleep and biological rhythm questionnaires were administered: Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN), Munich Chronotype Questionnaire (MCTQ), Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS). Actigraph data were analyzed for sleep and daily activity rhythms, light exposure and likelihood of transitioning between rest and activity states.

Mood groups had worse subjective sleep quality (PSQI) and biological rhythm disruption (BRIAN) and higher objective mean nighttime activity than controls. Participants with BD had longer total sleep time, higher circadian quotient and lower 6-sulfatoxymelatonin levels than HC group. The MDD group had longer sleep onset latency and higher daytime probability of transitioning from rest to activity than HCs. Mood groups displayed later mean timing of light exposure. Multiple linear regression analysis with BRIAN scores, circadian quotient, mean nighttime activity during rest and daytime probability of transitioning from activity to rest explained 43% of variance in quality-of-life scores. BRIAN scores, total sleep time and probability of transitioning from activity to rest explained 52% of variance in functioning (all p < 0.05).

Disruption in biological rhythms is associated with poorer functioning and quality of life in bipolar and MDD. Investigating biological rhythms and sleep using actigraphy variables, urinary 6-sulfatoxymelatonin and subjective measures provide evidence of widespread sleep and circadian system disruptions in mood disorders.