Australasian Psychiatry

This paper aims to explore the concept and determinants of successful ageing as they apply to psychiatrists as a group, and as they can be applied specifically to individuals.

Successful ageing is a heterogeneous, inclusive concept that is subjectively defined. No longer constrained by the notion of “super-ageing”, successful ageing can still be achieved in the face of physical and/or mental illness. Accordingly, it remains within the reach of most of us. It can, and should be, person-specific and individually defined, specific to one’s bio-psycho-social and occupational circumstances, and importantly, reserves. Successful professional ageing is predicated upon insight into signature strengths, with selection of realistic goal setting and substitution of new goals, given the dynamic nature of these constructs as we age. Other essential elements are generativity and self-care. Given that insight is key, taking a regular stock or inventory of our reserves across bio-psycho-social domains might be helpful. Importantly, for successful ageing, this needs to be suitably matched to the professional task and load. This lends itself to a renewable personal ageing plan, which should be systemically adopted with routine expectations of self-care and professional responsibility.

Psychiatrists appointed to National Health Service (NHS) consultant posts in the United Kingdom before a specific date in 1995 qualified for early retirement and this has implications for workforce planning.

The author reflects on the implications this has for ageing psychiatrists and for relationships between psychiatrists and patients and families using mental health services, from the perspective of a psychiatrist who took advantage of the opportunity to retire early from a consultant post in the NHS and to develop a new career.

Older psychiatrists continuing to practise after retirement from consultant roles may bring disadvantages and advantages.

Older psychiatrists may be a valuable resource for future mental health services, and they may be in a position to try out new ways of working which might be relevant to their younger colleagues in the uncertain future faced by mental health services at a time of austerity.

This paper sets out a process for the elective closure of a clinical practice. The details are described for a particular example of a practice closure. The common elements to all practice closures are identified. A range of other factors which may be relevant to other practice closure circumstances are also listed and the literature is referenced.

The closure of a clinical practice is a major stage in professional life and merits preparation, support and accessible resources.

This paper is a guide to the general psychiatric assessment of the late career medical practitioner (LCP) from a clinical viewpoint.

Late career is a specific developmental stage in medical practitioners, a time of transition towards retirement. The treating psychiatrist should be mindful of the welfare of the practitioner, the public and the profession during the assessment, which is conducted from a complex therapeutic and regulatory viewpoint. It is important to assess the physical, psychological and cognitive health of the LCP. Although rates of burnout, depression and suicidal ideation are lowest in Australian doctors over 60, only a small minority of LCPs over 75 are likely to perform at a cognitive level similar to that of younger colleagues. There are a number of therapeutic challenges, including the practitioner’s acceptance of their own ageing.

Age correlated changes in mental and physical capacity have contributed to increasing concerns about older physicians’ clinical competence. This paper explores the relationship between age and health in a clinical population referred for fitness for duty evaluations.

Fifty cases from an evaluation center performing fitness for duty evaluations were randomly selected. Cases were reviewed for referral reason, demographic information, diagnosis, and recommendations.

Age ranged from 28–70 (median age of 51, mode of 45).

Eighty-eight percent of cases had a diagnosed medical condition with potential cognitive sequellae.

While the literature supports performance concerns in aging practitioners, health independent of age, appears to be an important contributing factor. A screening process considering biopsychosocial reserve and professional load while applicable to older clinicians would optimally be implemented for physicians across their careerspan.

The objective of this study was to discuss some concerns that today’s psychiatrists are likely to experience in the later stages of their careers.

When changes associated with ageing begin to make their presence felt, there is a need to come to terms with them. For many psychiatrists this may generate a surprising creativity. Psychiatrists also need to come to terms with a paradigm change that has taken place in psychiatric practice. This paper, one of a series that captures a broad perspective on ageing, was solicited (by the Members Engagement Committee) to specifically capture the psychotherapist’s view of later life transitions.

The aim is to present recommendations of the Australian and New Zealand College of Anaesthetists (ANZCA) with respect to practice implications for ageing specialists, together with brief discussion of effects of ageing on professional medical capabilities and recommendations on preparing to retire from medical practice.

Practitioners should recognise that planning for retirement is part of good management of a medical career, and that the ageing process will inevitably compromise their ability to treat patients safely unless they retire at the appropriate time. Planning should include adequate financial preparation, and cultivation of interests and friends outside medicine. Practitioners should also realise that insight is likely to be compromised, so that they should seek colleagues who are trusted to advise them if/when they begin to lose competency. Lastly all practitioners should ensure that they consult a General Practitioner frequently, and that they have arranged all the proper legal instructions such as a Will, a Power of Attorney and an Advanced Health Directive.

The ANZCA recommendations concerning ageing specialists have wide application to all medical specialties, not just for anaesthetists, and therefore all Medical Colleges should generate their own specific recommendations for ageing practitioners and the general effects of fatigue particularly for aged practitioners.

The Royal Australasian College of Surgeons (RACS) has been innovative in developing core competencies, which provide a framework for assessing performance and a ‘Code of Conduct’, for the lifelong journey of all surgeons. The older surgeon may face significant challenges, having passed their peak, with a lower volume of cases, and potentially increased complications. They also face the challenges of retiring from active clinical practice with its logistical and psychological dilemmas. The RACS has, therefore, put in place several initiatives to deal with these dilemmas.

The Senior Surgeons’ Group, which conducts annual ‘Building Towards Retirement’ workshops, has been the driving force behind these initiatives. The group has a regular program in the RACS Annual Scientific Congress, including the multidisciplinary session ‘The ageing specialist - challenges for regulators: hypothetical’ which took place in 2014, and some of its members are part of a multidisciplinary team with an approach to adapting to ageing that encourages self-reflection and self-monitoring. It has also influenced the RACS Council to change the continuing professional development (CPD) regulations to include requirements for ageing surgeons regards health maintenance, peer reviews, and modified requirements to satisfy CPD completion. The RACS offers a variety of other opportunities for the ageing surgeon to remain active in college activities.

We offered guidance on the role of structural and functional neuroimaging modalities for the general psychiatrist and for trainees in the clinical setting.

We outlined the utility of neuroimaging modalities in the clinical setting, specifically with a view to understanding the pathophysiology of manifestations of disease.

Both structural and functional neuroimaging modalities have a clear role in diagnostic evaluation in the spectrum of neurodegenerative disorders.

Whilst the role of neuroimaging in patients with mood, anxiety and psychotic disorders is less clear, structural and functional imaging modalities have utility in the clinical setting in the form of diagnostic refinement and in understanding the pathophysiology of disorders, towards explaining manifestations and planning treatment.

To determine the prevalence and clinical correlations of catatonia in patients aged over 65 years who are referred to a consultation-liaison service within a regional area of Australia. Additionally, to examine if the use of standardised screening tools is likely to change the rate of diagnosis of catatonia within the consultation-liaison service.

One hundred and eight referrals from general hospital wards were assessed using the Bush-Francis Catatonia Screening Instrument (BFCSI) and associated examination; each consented patient was screened for catatonic symptoms. If two or more signs were present on the BFCSI, then severity was rated using the Bush-Francis Catatonia Rating Scale. These clinical characteristics were compared with their socio-demographic and medical data.

Prevalence of catatonia was 5.5%. The most common symptoms appeared to be rigidity, posturing and immobility (67% of cases), and were elicited through routine psychiatric examination.

Routine psychiatric history and examination are likely sufficient to elicit catatonic signs in a consultation-liaison setting. Standardised screening examination may be more suited for conducting research or for use when examining for catatonia in psychiatric inpatient settings.

To describe the nature of psychiatric morbidity in patients admitted to a critical care unit of a general hospital and referred to a consultation-liaison psychiatry service.

Analysis of clinical records on all patients admitted to a critical care unit and referred to consultation–liaison between 2010 to end of 2011. Descriptive statistics only are reported.

The referrals represented all age groups. Of those referred, 63.9% had a pre-existing psychiatric diagnosis and 64.7% had been admitted for intentional or accidental overdose.

Those identified to have a pre-existing mental illness and who had engaged in treatment were found to be inadequately supervised. They require more extended care and monitoring for suicidality and co-morbid physical conditions.

To detail a diagnostic dilemma of intentional hand amputation in a man with a history of substance misuse and associated psychosis, depression and traumatic brain injury and to highlight issues in joint psychiatric and surgical management of such a complex patient in a general hospital setting.

Deliberate limb self-amputation is a rare event with the majority of reported cases occurring during an episode of psychosis. This case illustrates the diagnostic utility of the literature supporting that a person who has self-inflicted amputation of a limb should be treated as psychotic until proven otherwise. The presence of a traumatic brain injury, with associated cognitive and psychosocial sequelae, affected diagnosis and management. Early and ongoing involvement of consultation-liaison psychiatry collaborating with a multidisciplinary general hospital team may improve mental and physical health outcomes for such patients.

To determine the incidence of clozapine-induced myocarditis and cardiomyopathy and identify risk factors.

A cohort of 129 patients initiated on clozapine at Toowoomba Mental Health Service from year 2000 until 2011 was examined to evaluate cases of myocarditis and cardiomyopathy. Risk factors were analysed using multivariable logistic regression.

The incidence of clozapine-induced myocarditis and cardiomyopathy was 3.88% and 4.65% (or 2.26 per 100 patient years), respectively. A significant association was identified between clozapine-induced myocarditis and SSRI use (p = 0.043). Subclinical cardiomyopathy was identified in the absence of symptoms in the majority of cases.

These results illustrate a high incidence of clozapine-induced myocarditis as well as cardiomyopathy, reinforcing the need for a standardised, mandatory monitoring scheme. Concomitant SSRI use as one such potential predictor merits further study.

We present a case of clozapine-related myocarditis, with a rising C-reactive protein as the only initial evidence supporting the diagnosis.

An otherwise healthy young male presenting with treatment-resistant schizophrenia was started on clozapine. Monitoring was performed.

At day 18 he developed fever, tachycardia and a raised C-reactive protein, while troponin levels and echocardiogram remained normal.

Current protocols monitoring for myocarditis have their limitations and can often only be used to support a presumptive diagnosis of myocarditis. In keeping with the current clozapine monitoring guidelines, we demonstrate that a rise in C-reactive protein levels can be a critical early sign of myocarditis warranting close monitoring and serious consideration for cessation of clozapine.

This paper describes the establishment of training in cognitive remediation for psychosis within a community mental health service.

Clinical staff working in the community of a mental health service were surveyed to ascertain their interest in cognitive aspects of psychosis and skills training in cognitive remediation (CR). Based on the results of the survey a tiered training programme was established with attendance figures reported for each level of training. Fidelity assessment was conducted on the five CR programmes operating.

Of 106 clinical staff working in the community with people diagnosed with a psychotic illness 51 completed the survey (48% response rate). The training needs varied with all 106 staff receiving the fundamental (mandatory) training and 51 staff receiving CR facilitator training. Thirty three percent of staff trained as facilitators were delivering CR.

Up skilling the mental health workforce to incorporate an understanding of the cognitive aspects of psychosis into care delivery can be facilitated by a tiered training structure. Fundamental training on the psychosocial aspects of psychosis can act as a platform for focussed CR skills based training. There is also a need for accessible therapy based supervision for staff wishing to develop competencies as CR therapists.

To give a contextualised personal account of the 30th Annual Congress of the Argentine Association of Psychiatrists.

Conference attendance and analysis of talks.

The congress demonstrated that Argentine psychiatry is held back by oppressive political regimes and by government underfunding. The drug companies and third-party payers are entering the vacuum.

Argentine trainees and consultants feel ill-prepared to meet the demands of the biomedical psychiatry.

To describe a case of a possible incipient Stevens–Johnson reaction while a patient had been on a stable dose of lamotrigine for several months and to consider the likely cause.

The history is recounted.

One likely cause implicates differing effective doses of lamotrigine across differing brands and raises quality control issues.

The patient’s severe reaction may reflect changing to a brand of lamotrigine that precipitously generated a higher serum level of lamotrigine.

To explore the condition of misophonia, its definition, possible neurological correlates, its associated morbidity, its possible psychiatric relevance and potential treatment.

Provision of an illustrative case vignette and a review of the limited literature.

Misophonia is a symptom associated with obsessive-compulsive disorder and anxiety disorders and may be a syndrome in itself associated with significant distress and avoidance. Treatments are not well validated.

Misophonia may be an under-recognised condition of psychiatric relevance.

One in four psychiatric beds in Australia are located in the private sector, and more than half of Australian psychiatrists undertake private work. However, nearly all medical student teaching in psychiatry takes place in public hospitals. This paper explores the learning opportunities in the private sector. We report the South Australian experience; medical students have been taught in Ramsay Health Care (SA) Mental Health facilities for more than 23 years.

Our experience demonstrates that clinical teaching in private hospitals is sustainable and well accepted by students, patients and clinicians. The private sector has the capacity to make a much greater contribution to medical student training in psychiatry.