Australasian Psychiatry

To overview candidate clinical features that support a bipolar II diagnosis.

Personal clinical and research-based observations are presented.

It is argued that clinical assessment should consider the nature of the depressive episodes as well as of the highs, search for a ‘trend break’ onset and a family history, and weight the absence of psychotic features in distinguishing the condition from a bipolar I condition.

This review argues for bipolar II disorder as differing categorically from bipolar I disorder, and details cross-sectional and longitudinal clinical features found useful in facilitating its diagnosis.

The aim is to overview a personal model for managing bipolar II disorder.

The model describes the author’s personal approach and observes the relative lack of an evidence base.

Key ‘macro’ and treatment component approaches are overviewed.

It is suggested that bipolar II disorder is categorically distinct from bipolar I, in lacking any psychotic features during contrasting mood states and thus allowing that its management should not necessarily extrapolate strategies used to manage bipolar I disorder. If valid, in addition to there being less of a need to prescribe antipsychotic drugs, the differing mood stabilizers may have quite differing gradients of efficacy across the bipolar I and II disorders.

The diagnosis of children with autism spectrum disorders (ASDs) is sometimes delayed until adolescence. This study tries to identify the symptoms in clients that initiated a referral to an autism team of an early intervention service providing psychiatric care for young people between the ages of 15 and 25 and who subsequently receive a new diagnosis of autism.

Thirty-one ASD assessments were carried out during a period of 3 years in an early intervention service in Australia. An attempt to identify the common presenting symptoms and trends in the referrals for ASD assessment within the service was made.

Most common presentation of adolescents getting referred for ASD assessment was with depressive symptoms followed by mixed anxiety and depression and primary psychotic symptoms. There was a significant gender difference, with a higher number of males getting referred for ASD assessment.

ASDs can go undetected during childhood and these clients can sometimes present during adolescence to mental health services for a psychiatric comorbidity. Regular training opportunities for clinicians dealing with them could improve the chances of ASDs being picked up during their episode of care at an early intervention service, thus optimizing their management.

The authors sought to identify characteristics associated with premorbid and postmorbid panic disorder onset in relation to heart failure (HF) onset, and examine the effect on unplanned hospital admissions.

In a two-stage screening process, 404 HF patients admitted to three hospitals in South Australia were referred for structured psychiatric interview when any of the following four criteria were met: (a) Patient Health Questionnaire ≥10; (b) Generalized Anxiety Disorder Questionnaire ≥ 7); (c) positive response to one-item panic attack screener; (d) or evidence of suicidality.

A total of 73 referred HF patients (age 60.6 ± 13.4, 47.9% female) were classified into three groups: premorbid panic disorder (27.4%), postmorbid panic disorder (24.7%), and no panic disorder (47.9%). Postmorbid panic disorder was associated with more psychiatric admissions and longer hospital stay in the 6 months prior to the index psychiatric assessment, and also in the 6 months after the index psychiatric assessment (all p <.05 unadjusted). In sensitivity analysis, years since panic disorder onset were associated with longer cardiac length of stay (β = .34, p = .03).

Panic disorder onset in relation to HF diagnosis was associated with discrete patterns of hospital admissions for cardiac and psychiatric causes.

This study investigates if the routine use of the urine drug screen offers any diagnostic or management benefit in the assessment and treatment of psychiatry patients in a suburban psychiatry emergency service.

Data was collected retrospectively from consecutive patients 18 years and above, who presented to a large suburban hospital emergency department and had a urine drug screen ordered in the emergency department. A total of 111 patients, (with mean age of participants being 34.9 years, SD 10.2 years, minimum 18 – maximum 62 years, 62.2% (69/111) were male) met the inclusion criteria.

The most common drug group identified was benzodiazepines (59.5%; 66/111), followed by cannabis (40.5%; 45/111). Other drugs were identified at much lower levels, including amphetamines (9.0%; 10/111), opiates (4.5%; 5/111) and methadone (0%; 0/111). For most individuals only one drug was detected (55.9%; 62/111), with equal numbers (18.9%) with either zero or two drugs identified by a urine drug screen. Fewer patients had three drugs on a urine drug screen (5.4%; 6/111) or four (0.9%; 1/111).

Qualitative urine drug screens provide limited additional information compared to history taking and has minimal impact on clinical management decisions in a psychiatry emergency service.

This paper provides an overview of mentalization-based therapy (MBT). Multiple strands of research evidence converge to suggest that affect dysregulation, impulsivity and unstable interpersonal relationships are core features of borderline personality disorder (BPD). The MBT approach to BPD attempts to provide a theoretically consistent way of conceptualising the inter-relationship of these features.

MBT makes mentalizing a core focus of therapy and was initially developed for the treatment of BPD in routine clinical services, delivered in group and individual modalities. This article provides a brief overview of mentalizing and its relevance to BPD, provides an overview of MBT and notes a number of current trends in MBT.

MBT provides clinicians with an empirically supported approach to BPD and its treatment.

Whilst mentalizing is viewed as an integrative framework for therapy, more knowledge is needed as to which of the therapies are of most benefit for individual patients.

The aim of this paper is to re-visit the therapeutic effectiveness of ‘no’.

Embedded within a philosophy of care, the use of ‘no’ benefits both parties in the therapeutic endeavour.

This paper aims to explore why staff, agencies and families, might be reluctant to use ‘no’ as a therapeutic manoeuvre.

Various factors contribute to this hesitancy and when understood and acknowledged, may serve to return the clinician to the task at hand.

To describe completeness and accuracy of recording medication changes in progress notes during psychiatric inpatient admissions.

A retrospective audit of records of 54 randomly selected psychiatric admissions at a metropolitan tertiary hospital. Medication changes recorded on National Inpatient Medication Chart (NIMC) were compared to documentation in the clinical progress records and assessed for completeness against seven quality criteria.

With between one and 32 medication changes per admission, a total of 519 changes were recorded in NIMCs. Just over half were documented in progress notes. Psychotropic and regular medications were more frequently charted than ‘other’ and ‘if required’ medications. Documentation was seldom comprehensive. Medication name was most frequently documented; desired therapeutic effect or potential adverse effects were rarely documented. Evidence of patient involvement in, and an explicit rationale for, a change were infrequently recorded.

Revealing substantial gaps in communication about medication changes during psychiatric admission, this audit sheds light on a previously undescribed source of medication error, warranting attention. Further research is needed to examine barriers to best practice, to support design and implementation of quality improvement activities but in the interim, attention should be addressed to development and articulation of content and procedures for documentation.

This study aimed to survey multidisciplinary mental health staff on their perceptions of risk assessment and management practices in a local health district in Sydney.

The research team developed the risk assessment and management survey (RAMS) which was distributed to staff across the district from November 2013 to January 2014.

A total of 340 RAMS were distributed and 164 were returned (48% response rate). There was considerable agreement that risk assessment and management is essential to maintaining safety and delivering good mental health care, and respondents reported high levels of confidence in their judgement when carrying out such practices. Respondents identified organisational pressure in relation to risk assessment and management but also felt supported. However, 65% of respondents considered that there ‘is good evidence that risk assessment and management practices are effective in reducing risk in mental health care’, when this is not the case.

The confidence that clinicians placed in risk assessment and management practices (despite an absence of evidence) is disconcerting. Given the dominance of risk assessment and management, health services mandating such practices have a duty to inform employees of the current evidence base for this approach in reducing risk.

Our aim was to determine the views and experiences of carers of people with severe mental illness in regard to Community Treatment Orders (CTOs).

Questionnaires were posted using the mailing lists of two well-established carer support organisations in Victoria. The questionnaires included information about the person with a mental illness, the carer and their experience of care (ECI) and knowledge of recovery (RKI).

In total, 278 questionnaires were sent and 63 returned, of which 62 provided valid data. Those who responded were predominantly female (90%) and older (mean age 63 years), and were the carer of a person with a severe and recurrent mental illness. Some 60% had experience of caring for a person on a CTO. Most felt the CTO had been of benefit, and in 89% the person relapsed and needed further treatment when the CTO was stopped.

Mental health legislation is shifting to bring a greater focus on rights, individual choice and autonomy in line with recovery-oriented care. This study describes the impact of severe mental illness and decisions in relation to CTOs on carers.

The Gender Dysphoria Clinic in Melbourne, Australia, assessed patient outcome by focusing on patients’ subjective evaluation of the healthcare services they received through the clinic.

A satisfaction survey, which was previously used in two established gender clinics in the US and UK, was adapted and then administered to consecutive patients who attended the Gender Dysphoria Clinic during a 1-month period.

A total of 127 surveys were available for analysis: 88% of patients reported being satisfied with the services they received. Patients’ perceived level of distress reduced significantly, following their involvement with the Gender Dysphoria Clinic. Feeling understood and heard in a non-judgmental manner by a specialist in the field of gender dysphoria was the most positive aspect of service provision. The most negative aspect of the clinic was a lengthy waiting list.

Although the majority of trans-and-gender-diverse patients attending the Gender Dysphoria Clinic were satisfied with the service they received, there is a need to identify strategies to facilitate timely access to the clinic.

Take into account patient views in developing a linkage intervention to the evidence-based Individual Placement and Support approach to Supported Employment (SE) for patients with schizophrenia on a mental health unit (MHU) who want to work in competitive employment.

Analysis of 20 once-off, face-to-face interviews, with informed consent, between author and voluntary MHU inpatients with schizophrenia about getting into SE from the MHU.

From the major category ‘patient ideas about SE linkage intervention from MHU’ the three themes of ‘patient choice’, ‘type of support’ and ‘start from the MHU’ emerged. The other major category, ‘patient attitude to the author’s proposed SE linkage intervention’, revealed the theme of ‘positive attitude’.

There may be enough interest from patients with schizophrenia on a MHU who want to work, to test a pilot of the author’s proposed voluntary SE linkage intervention.

A case is described pointing to the biological factors in gender identity and personality structure.

The history is presented of a transsexual patient who experienced a change of gender identity and personality following an episode of status epilepticus.

The patient presented as convincingly feminine and with features of Borderline Personality Disorder. She had an old brain injury. After a prolonged epileptic episode the Borderline features disappeared and the patient expressed a clearly male identity.

The findings are equivocal: they may be seen both as reflecting a change in a neurologically structured identity and as a resetting of psychosocially acquired characteristics.

In 2003 a revised RANZCP training program was implemented. This involved a revised training structure with Basic (years 1–3) and Advanced (years 4–5) requirements. All summative assessments occur during Basic Training and generalist or sub-specialty streams are available in Advanced Training. Trainees that started from2003 onwards have reached or exceeded the minimum time to attain Fellowship. This paper updates the original study to assess the progression of trainees through the elements of the training program and those that have attained Fellowship.

This paper examines the pathway and barriers to attaining Fellowship with a focus on assessments and time to complete.

Data were extracted for all trainees commencing training between December 2003 and February 2006. Items on assessments, rotations, breaks in training, part-time training, and other items were analysed. Time taken to complete mandatory training requirements and outcomes were the key elements evaluated.

For those who attained Fellowship, the median training time was 6.1 years. It was common for trainees to attain Fellowship in the minimum time of 5 years. Delaying the completion of assessments or examinations contributed to the expanded time to attain Fellowship Training, as did part-time training and breaks in training.

We aimed to evaluate perceptions of a Royal College of Psychiatrists promotional film among Malaysian medical students.

Year 3 (n=108) and Year 5 (n=108) students completed separate standard measures of attitudes to psychiatry: the ATP 30 and Balon scales, respectively. A questionnaire was also administered recording students’ socio-demographic information, career preferences, perceptions of the film’s effectiveness and its influence on career choice. Quantitative and qualitative analyses of responses were performed.

The overall response rate was 95.5%. Mean career preference ranking for psychiatry was higher for Year 5 than for Year 3 (p=0.025). For most Year 3 (64.8%) and Year 5 (58.3%) respondents the film conveyed a positive image of psychiatry. Fewer perceived it as influencing career choice: 31.4% for Year 3 and 27.2% for Year 5. Higher scores on both attitudinal scales correlated positively with increasing likelihood of students rating the film positively (Year 3: p=0.000; Year 5: p=0.003). Thematic content analysis suggested possible socio-cultural influences on students’ perceptions.

Despite conveying a positive image of psychiatry, promotional films may have limited impact in changing students’ attitudes towards psychiatry and in increasing interest in psychiatry as a career.

We aimed to examine the experiences of advanced trainees in forensic psychiatry as they practise testifying as expert witnesses in a mock court setting.

Five advanced trainees (including the first author) submitted court-ordered forensic reports in advance of attending the mock court. Senior colleagues had roles of Judge, prosecution and defence lawyers. House officers and medical students were summoned as jury. Over a year, each trainee had the experience of direct and cross-examination by opposing legal teams. Following the mock trial, each participant was given immediate feedback and subsequently asked to complete a semi-structured questionnaire.

The experience of participating in a mock court has learning value for advanced trainees specialising in forensic psychiatry in anticipation of giving evidence in a court of law. Constructive feedback enabled attendees to gain valuable education in a supportive setting. Of particular value was guidance in the use of technical language in presenting evidence in a court setting, knowledge of the breadth of questions that could be put forth to an expert witness, desensitisation training in an adversarial albeit simulated setting, and acquiring skills in staying calm under pressure.

The importance of a well-written report, good preparation and anxiety management were significant learning points.

To explore the medico-legal work of Melbourne psychiatrist Reg Ellery.

Ellery, a radical activist, attacked judges on the grounds that they could not be relied on to produce proper judgements or understand the social and psychiatric basis from which crime arose. Ellery’s views were strongly influenced by his support for communism, and he regarded the Soviet Union as a model society that should be emulated. Ellery paid the penalty of losing his hospital position. However, there is no evidence that this affected his medico-legal work, and he continued to assess forensic cases until the end of his career. Some of Ellery’s more interesting cases are discussed.