Australasian Psychiatry

This paper aims to explore how social media users represent themselves online, and to consider whether this process has inherent potential to impact upon the psyche of the individual.

Advanced thinking around social media may exist on an organizational level, but on an individual level there exists a need to catch up, as the psychological dimensions of going online are significant and deserve consideration. Inherent to the experience of using social media is the self selection of favorable material to represent the individual. This process is cumulative, and effectively creates a socially-derived and socially-driven, composite online image (‘social avatar’). Humans notably select their best aspects for presentation to others and the social avatar reflects this tendency, effectively facilitating the creation of a ‘gap’ between online image (representation) and offline identity (substance). The creation of a social avatar should therefore be an important and conscious consideration for all users of social media, not just those individuals already struggling with the task of integrating the multiple facets which make up modern personal identity. Social avatars appear to be an important factor in understanding the inherent potential for social media to affect the psyche/contribute to psychopathology within the individual.

To describe the emergence of, and myriad issues pertaining to, problematic internet use in childhood and youth. In this overview and appraisal of a uniquely 21st century affliction, the focus is on youth and less on young adult perspectives.

We employed relevant literature-search methodology though EMBASE, Psychinfo and Web of Science, utilising the key terms of PIU, internet addiction and youth mental health, and present a selection of the pioneering and important research developments both nationally and internationally. We focused on the literature from the past 10 years, but we also included relevant early developments in the field going back to the 1990s. We also made reference, where appropriate, to major considerations of relevance to the general public, where these were reported in reputable international news and media organisations. The authors utilised common internet search engines to access these news reports. It was found that the complex, novel and at times controversial concept of ‘problematic internet use’ (PIU) – often popularly dubbed ‘internet addiction’ – has attracted much public, media and research interest, particularly over the past decade. In common with many other afflictions that have a prominent ‘pop-cultural’ component, often the commentary and debate has been polarising, unclear and sensationalist. At times, more light than heat appears to be generated.

The formal assessment of a person’s capacity for making reasoned decisions is an infrequent and usually unappealing clinical task. The purpose of this paper is to dissect the task, consider the component parts, clarify those aspects that can be problematic and highlight those that remain so.

The paper reviews the concepts, terminologies and dilemmas around alcoholism, insight, lack of insight, denial, judgement, will, decisional capacity and competence.

Assessments of patients suffering from alcoholism (or any other dyscontrol problem such as deliberate self-harm, problem gambling or eating disorders) are likely to evoke unease because of the interweaving of potentially disputable phenomenological, clinical, ethical, semantic and legal aspects. Familiarity with the concepts and terms around decisional capacity helps to orientate clinicians in their work. There remain some particular conceptual issues that are in need of further scholarly attention.

Australian public mental health services have seen a rapid adoption of risk assessment into clinical practice over the past decade. It is timely to review the role of risk assessment in clinical practice, evidence for its validity and to explore its role in clinical decision-making.

There is little evidence to support the current form of risk assessment used in public mental health. The continued focus in risk may lead public psychiatrists into a bind where their specialist role is defined by a capacity that they do not fully possess. Further work is required to find ways of demonstrating our attention to the possibility of adverse outcomes whilst maintaining our skills and capacity to manage mental illness with complexity and balance within the limitations of rational decision-making.

Suicide bereavement research can help facilitate greater understanding of the impact of suicide and potential risks for others. As there is limited research on the experience of young people who lose a friend to suicide, the aim of this exploratory study was to consider specific psychological factors for such bereaved young people.

Ten young people who had experienced the suicide death of a friend completed self-report measures to assess levels of depression, anxiety, coping and prolonged grief.

Participants reported increased levels of stress, depression, reduced coping capacity and prolonged grief symptoms that have continued considerably beyond the death of their friend.

Psychological distress for young people bereaved by a friend’s suicide is of concern given the developmental changes and life transitions associated with this age group. Implications include the significant health and wellbeing challenges associated with suicide bereavement for young people. The outcomes support a more proactive response from mental health and support services.

The recovery paradigm is significantly influencing contemporary mental health services. This paper explores using a recovery orientation when introducing, prescribing, administering and monitoring medication as part of treatment in psychiatry.

Recovery is not ‘anti’ medication; however, a recovery-oriented position does require the adoption of an enabling and empowering approach to the use of medication. The cornerstone of this is shared decision-making that respects the person’s own lived experience and choice as well as the practitioner’s professional expertise. This paper suggests that by taking this path, relationships between psychiatrists, other clinicians and consumers will be enhanced.

To review the current role and comparative efficacy of short-acting intramuscular (IM) antipsychotics in the management of acute agitation, in current clinical practice.

The efficacy and tolerability of IM antipsychotics in the management of acute agitation in current clinical practice were reviewed in the Medline, PubMed, Cinahl Plus, Scopus-v.4 and PsycInfo databases.

The comparative efficacy of the rapidly-acting IM atypical antipsychotics (olanzapine, ziprasidone and aripiprazole) is similar to that of the typical antipsychotic, haloperidol. IM olanzapine and ziprasidone were associated with fewer extrapyramidal side-effects and had similar cardiac tolerability to IM haloperidol.

Further studies are required in the ongoing development of contemporary, evidence-based clinical guidelines in acute agitation, including head-to-head comparisons of currently utilized IM atypical antipsychotics, sequential treatment or combinations of medications.

This paper aims to ascertain predictors of the length of stay in a Psychiatric Emergency Care Centre (PECC).

Demographic and clinical characteristics were recorded retrospectively via file audit in 477 patients who were admitted to a PECC within a six-month period. Associations between these variables and length of stay were analysed using logistic regression.

Length of stay in the PECC was predicted by medical complications arising in the PECC, absconding behaviour, diagnosis of depression and being brought in by family members. Aggression within the PECC and previous contact with mental health services predicted a shorter stay.

Length of stay in the PECC is predicted by a number of variables that are different from those that predict length of stay in an acute psychiatric unit. A comprehensive assessment of these variables prior to admission may decrease the length of stay in the PECC and improve efficiency of acute psychiatric services.

To describe the organisational, clinical and pragmatic features of a GP liaison service established by the Division of Mental Health in the Darling Downs Hospital and Health Service catchment to facilitate the care of rural patients and improve communication between primary and specialist care.

The GP liaison service was created using funding from the Commonwealth STP initiative to provide weekly registrar clinics to primary care providers in the Darling Downs. The service was eagerly accepted by providers who saw patient benefits outweighing financial considerations. Expectations of a greater level of care than the assessment and advice provided reflects the large unmet need for mental health services in rural areas. GPs expressed enthusiasm for true collaborative care, such as case management overseen by the public mental health service but based at GP offices.

This paper aims to describe the growth of a regionally-based mental health team providing services to remote Indigenous communities in far north Queensland.

By drawing on their experience, the authors are able to identify factors supporting the development and sustained capacity of integrated mental health teams, working in challenging remote settings.

In view of the growing disease burden of mental disorders, we consider the pressing need to update medical school psychiatry education to better equip doctors to recognise and treat these conditions. Key challenges to the delivery of medical school mental health curricula, and possible directions for reform, are reviewed with the aims of stimulating collaboration and enhancing the efficiency across schools.

In Australia, medical school expansion provides opportunities to prepare many training doctors to meet growing mental health care needs. Despite this, published reviews of practice and curriculum models are notably lacking. Australia, unlike other countries, has yet to agree on a core curriculum in medical school psychiatry, with practices varying widely between schools. Curricula should equip doctors to better recognise and treat common mental disorders during early stages, as well as preparing some for specialist psychiatry training. High-quality, multidisciplinary teaching in varied clinical settings may boost teaching resources. Additionally, medical education provides opportunities to better equip doctors to take care of their own mental health. Key challenges are to achieve a consensus on core curricula across Australian medical schools, and an appropriate proportion of medical school curriculum time for mental disorders, relative to their complexity and large disease burden.

To consider the role of specialty trainees as clinical teachers of medical students in psychiatry.

We discuss the role of specialty trainees as teachers and approaches to improving their skills and capacity, giving examples from the local and international literature and our own experience as psychiatry medical educators.

Good clinical teaching is crucial for medical students’ learning but sharp increases in numbers combined with economic and workforce pressures have stretched capacity. Specialty trainees do much of the medical student teaching during their clinical placements but infrequently receive instruction on how to teach. The two common approaches to increasing capacity are, first, establishing education rotations for individual trainees and, second, providing workshops to improve trainees’ confidence and skill. Psychiatry trainees surveyed in New South Wales welcomed the role of teacher and the opportunity to improve their teaching capacity. Further support from supervisors, health services and medical schools is needed to assist trainees in their teaching role.

The role that trainees play as clinical teachers should be acknowledged and supported. Further development of research and scholarship in medical education is needed to determine how best to teach trainees to teach.

To explore the history of insulin coma therapy (ICT) in Australia.

The negative period between the wars came to an end with the discovery of the biological therapies, including ICT, a development of great interest to Australian psychiatrists. Melbourne psychiatrist Reg Ellery documented his use of ICT in 1937, but the evidence shows that he was beaten to it by Farran-Ridge and Reynolds at Mont Park. ICT was soon used at various centres, but phased out by the late fifties. A review follows of its use in Australia and a discussion of the issues involved. Doing ICT played a part in enhancing the professional status of Australian psychiatrists and was one of the factors that led to the establishment of the AAP in 1946.

This paper documents use of a historically accurate and psychiatrically relevant play written by a couple of visiting academics.

The high recognisability of first author Samuel Shem’s name was used to attract interest from both within the medical profession and the media, which was intrigued by the curiosity of a psychiatrist turning producer. Far-reaching publicity was achieved at no financial cost.

In our quest to improve the lives of our patients, we can often be swept up by the euphoria associated with new treatments. At times, our enthusiasm for new treatments can lead us to forget the fundamental principles of patient care and lose focus of an individual’s suffering and personal journey.

To illustrate the importance of understanding a patient’s predicament in the context of our own need to cure.

Oil on canvas (92 × 122cm).

By focusing on a centrally positioned patient who has hypothetically just had new electronic devices installed into her scalp and chest wall, I was able to see a weakened lady with a turbulent past attempting to protect herself with her jet black hair. Many around her remain oblivious to the storm. An observant medical student glances away from his textbook to see that all is not well outside the hospital walls.

Several perspectives are required to adequately assess the way that we treat patients. Contrary to our expectations, our treatments might hurt a bit.

We present a case of anti-N-methyl D-aspartate (NMDA) receptor encephalitis that illustrates the dilemma that psychiatrists face in evaluating patients with first episode psychosis.

The discovery that acute psychosis can be the presenting feature of autoimmune encephalitis (in particular encephalitis caused by anti-NMDA receptor antibodies) has both practical and theoretical consequences. First, this condition is an important, but often overlooked, differential diagnosis of first episode psychosis. Antibody testing is not currently part of routine screening, though delayed (or missed) diagnosis can lead to prolonged hospital stay, medical complications and incomplete or delayed recovery. Widespread screening of patients with first presentation psychosis for anti-NMDA receptor and anti-voltage-gated potassium channel (anti-VGKC) antibodies is warranted for a number of reasons: to expedite appropriate treatment, to determine the true proportion of patients with these conditions presenting as psychosis, and to help elucidate the neurochemical causes of psychosis.