Australasian Psychiatry

The differential diagnosis of psychotic symptoms is broad and extends beyond primary psychotic and affective disorders. We aim to illustrate that the chronology and phenomenological nature of hallucinatory symptoms may provide clues towards alternative diagnoses, such as hallucinogen persisting perceptual disorder (HPPD). We describe the resurgence of visual pseudo-hallucinations in a young woman in the context of previous substance-induced hallucinatory symptoms and a prior diagnosis of occipital lobe epilepsy. She presented a diagnostic challenge, saw several emergency and specialist doctors and attracted stigmatising diagnoses leading to anxiety and depressive symptoms. Her symptoms were finally recognised as HPPD, and she was treated appropriately with lamotrigine.

Patients with perceptual disturbance can present in various clinical settings, and HPPD is an under-recognised diagnostic possibility. Delayed or misdiagnosis prolongs profound functional impairment and social decline, and predisposes the patient to the development of anxiety and depression and related increased risk of suicide.

This paper reports outcomes of a clinical audit of smoke-free policy implementation within an Australian inpatient psychiatric setting. It aimed to evaluate assessment of smoking status and subsequent management of nicotine withdrawal, and investigate any patient factors influencing these processes.

A total of 67 medical case notes were retrospectively analysed for inpatients admitted to psychiatric units of a general hospital in South Australia, from July to September 2015. Patient demographic variables and information from the hospital’s Smoking Assessment and Management Form (SAMF) were recorded. Data analysis involved descriptive statistics and Chi-square tests of association between dependent variables (how the SAMF was completed) and independent variables (sex, voluntary status, diagnosis).

The SAMF was implemented for most patients (76.1%), with 64.71% completed within 24 hours of admission; though, many were incomplete. Nicotine dependence was not properly assessed for 42.3% of smokers; 69.23% were prescribed nicotine replacement therapy (NRT), despite most scoring moderate to high nicotine dependence. No statistically significant relationships were found between patient factors and form completion.

SAMF completion was timely for most patients; however, sections important for determining support actions remained largely incomplete, suggesting patients’ nicotine withdrawal is not being adequately addressed. More work is needed to improve inpatient staff’s assessment to ensure optimal care.

The objective of this study was to consider the implications of a recent Western Australia Court of Appeal decision in which an indigenous youth who had been sentenced for the manslaughter of his neonate child was later diagnosed with Fetal Alcohol Syndrome Disorder.

The increased use of the 2016 Australian guide to the diagnosis of fetal alcohol spectrum disorder should be encouraged to enable clinicians to not only diagnose and manage Fetal Alcohol Syndrome Disorder, but also counsel families to prevent it.

The aim of this study was to highlight that concurrent administration of the common lipid-lowering agent fenofibrate may lead to false-positive amphetamine results in often-used immunoassay-based urine drug screens. It also aimed to show that there are significant moral and clinical challenges associated with the interpretation of such results amongst psychiatric inpatients.

It is evident that different pathology laboratories may utilise different commercial urine drug-screen immunoassays in their toxicology analysis, with variability in the test specificities. Despite the relatively high prevalence of substance misuse in the population of psychiatric inpatients, there exists a need for increased vigilance towards the possibility of false-positive amphetamine results owing to likely cross-reactivity of fenofibrate with the test reagents. In cases where there is uncertainty when correlating clinically, or where false positives are suspected, gold-standard urine-sample analysis by mass spectrometry should be considered, particularly when the consequences for patients may include restrictive measures.

On the basis of the experience of the Netherlands, this critical commentary will argue why activity-based funding (ABF) in mental health care is a disastrous path that Australia should not take.

ABF leads to an exponential growth in health care spending as it encourages diagnostic inflation and overproductivity. It also leads to fraud and an increased bureaucracy that goes hand in hand with demoralisation among health workers. And finally, the increasing treatment claims leads to the reintroduction of productivity limitations, waiting lists and ultimately austerity measures in order to halt the untamed growth of spending.

This article explores the relevance of gossip and rumour to health organisations and presents what limited empirical research is available specific to the management of gossip and rumour in health organisations.

The concept of a sentinel function for gossip and rumour in health organisations is proposed as a topic worthy of further research.

The aim of this study was to determine the rates of patient aggression in a psychiatric unit over 12 months and to determine underlying causes, notably the role of substances.

A retrospective file audit was undertaken of all patients admitted to St Vincent’s psychiatric unit (Melbourne, Australia) in the first half of 2013 and 2014 involved in an aggressive incident. Patient information included demographics, psychiatric, substance and aggression history. The setting and context of aggression and associated mental state findings were also reviewed.

There were 26 aggressive incidents in 2013 and 63 in 2014, perpetrated by 11 and 34 patients respectively. No significant differences were found between the groups’ baseline demographics. The 2014 cohort was significantly more likely to have substance use history (odds ratio (OR) 4.83) and have made threats to staff (OR 4.07) but significantly less likely to be distracted by internal stimuli (OR 0.05). There were also (not statistically significant) trends for the 2014 cohort; they were more likely to report a history of alcohol use (OR 3.9); be accompanied to emergency department by police (OR 2.95) and have leave prior to aggression (χ² = 7.37).

Aggressive incidents more than doubled over 12 months. Substance use appeared to be a major factor associated with aggression. These findings have implications for service provision and training. Further research is needed to better understand and manage substances in psychiatric settings.

To explore a contradiction between evidence suggesting community treatment order (CTO) ineffectiveness and clinical experience.

The literature pertaining to CTOs actually provides an evidence base for both positions. The headline that three randomised controlled trials and subsequent meta-analyses fail to demonstrate significant differences between groups reflects selection bias. A case may still be made for CTOs.

To examine compliance with routine metabolic monitoring at four rehabilitation facilities within the Metro South Addiction and Mental Health Services in Queensland.

A retrospective chart audit was undertaken on 63 residents of rehabilitation facilities with electronic health records from 1 October 2014 to 30 March 2015.

Evidence of any metabolic monitoring was recorded for 87% of residents. Compliance rates differed for monitoring waist circumference (97%), blood pressure (97%), high-density lipoprotein (79%), triglycerides (81%) and plasma glucose (83%). Evidence of communication with residents and primary healthcare providers were each found in 41% of the sample.

In current clinical practice, metabolic monitoring is high for residents of rehabilitation facilities in Queensland with serious mental illness. However, many residents do not receive adequate communication regarding their results and, disturbingly, results are not forwarded to their primary healthcare providers. This can result in people not receiving treatment for modifiable factors of metabolic syndrome.

This article aims to draw mental health clinicians’ attention to the connections between nutrition and mental health, and the roles that Accredited Practising Dietitians play in improving mental and physical health through dietary change.

Selective narrative review.

Unhealthy dietary practices are common in high prevalence and severe mental illness. Epidemiological evidence demonstrates that nutrients and dietary patterns impact on mental health. In addition, poor physical health is well documented in people with mental illness and the greatest contributor to the mortality gap. Dietary intervention studies demonstrate improved mental and physical health outcomes. Accredited Practising Dietitians translate nutrition science into practical advice to improve the nutritional status of patients with mental illness, and prevent and manage comorbidities in a variety of care settings.

Medical Nutrition Therapy offers opportunities to improve the physical and mental health of people living with mental illness.

There is an increased rate of sudden cardiac death (SCD) in mental health patients. Some antipsychotic medications are known to prolong the QT interval, thus increasing a patient’s risk of SCD via the arrhythmia, torsades de pointes (TdP). Our aim was to evaluate assessment for QT prolongation within a public inpatient mental health facility by auditing electrocardiograph (ECG) use.

We reviewed records of all mental health inpatient admissions to a public emergency mental health inpatient unit between 1 January 2016 and 11 February 2016. ECG availability was noted and QT interval was manually measured and assessed for risk of TdP using the QT nomogram when present. Demographic information and medication use was collected.

Of 263 mental health inpatient admissions, 50 (19%) presentations had an ECG. A total of four (8%) had a prolonged QT interval. Of the 50 patients with an ECG, 12 (24%) were taking medication known to prolong the QT interval.

There was very limited risk assessment for QT prolongation in a public hospital psychiatric inpatient unit, with less than 20% of patients having an ECG performed. Our study supports an association between QT-prolonging drugs and a clinically significant prolonged QT interval; however, a larger study with routine ECG screening is required.

The objective of the current study was to examine the pathology test utilisation of 25-hydroxyvitamin D (25(OH)D) within an Australian inpatient psychiatric setting.

A retrospective audit of 300 random hospital files of those admitted as inpatients between Nov 2014 and Nov 2015 was undertaken. Data was quantitatively analysed and described.

The number of inpatients who had a vitamin D determination during their admission was 37/300 (12.33%). The mean vitamin D level of those tested was 51.63 nmol/l. Of those that were tested, 18/37 (48.6%) were mildly to moderately deficient. There was a statistically significant difference in age and length of stay between those that were and were not tested for vitamin D levels, p-value <0.001 and 0.017, respectively. In addition, a simple linear regression indicated a weak association between length of stay and vitamin D levels.

This audit highlights vitamin D screening inadequacy. More research is recommended to establish tangible benefits of supplementation, while local practice provides valuable data for education and policy purposes.

Several studies have demonstrated a link between post-traumatic stress disorder and myocardial infarction. We aim to determine what phenotypic features or symptom profile associated with cardiovascular disease may help with early detection and intervention.

This is a cross-sectional study. The study population comprises trauma-exposed Vietnam War veterans.

Variables significantly associated with myocardial infarction from the bivariate analysis were avoidance memories, avoidance reminders and sleep disturbance. These variables were put into a logistic regression with known risk factors for myocardial infarction. Only sleep disturbance retained its effect, with a p-value of 0.015.

It is concluded that sleep disturbance may be a modifiable risk factor in the treatment and prevention of myocardial infarction.

To teach psychiatric case formulation; to build a repertoire of patterns that can be reused as building blocks in constructing case formulations.

Pattern-based Formulation.

Demonstration of a case formulation and introducing three patterns.

The demonstration will assist learning case formulation using the Pattern-based Formulation, while the three patterns introduced can be reused when formulating relevant cases.

This paper seeks to explore the application of neurobiology to further understanding the importance of developing, refining and modelling good bedside manner in psychiatry. The concept of a social synapse is used as a framework to understand the impact of verbal and non-verbal information that crosses between two attuned individuals. Research shows that widely distributed cortical and subcortical networks are involved in processing of social information and the perception of safety.

Good bedside manner is proposed as the ability of a clinician to navigate the social synapse and make a patient feel at ease. Findings from neurobiology suggest that good bedside manner needs to be a more considered component of effective psychiatric health care.

This study aims to examine the potential nature of an ongoing paradigm shift in psychiatry that has been suggested to be occurring.

New findings in traumatology and neuroscience do form a potential platform for a paradigm shift. Prior conflicting paradigms are suggested to be due to biases arising from mental structures themselves. A new wholist perspective is proposed, which makes sense of and incorporates previous paradigms, and coheres recent understanding of right- and left-brain functioning and biopsychosocial traumatic processes and their ramifications. The perspective makes sense of the great variety of post-traumatic manifestations ranging from somatic to meaning-making dysfunctions. The wholist perspective may well be an important step in solidifying a fresh paradigmatic perspective in psychiatry.

This article discusses Lady Macbeth’s famous sleepwalking scene from the Shakespearean tragedy, and how it became used as a template for the formulation of obsessive-compulsive disorder.

Psychoanalysis maintained its role in understanding the condition, despite the lack of evidence base and the repeated finding from many therapists of a failure to control symptomatology. It is suggested that psychodynamic psychotherapy suffered from a failure to recognise what components of its practice were aesthetically attractive concepts rather than evidence-based medicine and outcome measures, and is an important issue in considering its future directions.

The ordinary, ongoing sense of personal existing, variously called higher order consciousness, mind, or self, is disintegrated, constricted and distorted in those who have suffered repetitive psychological traumata. Their speech has the form of a ‘chronicle’, literal and asymbolic. This paper offers a condensed rationale for a relational approach to this, so far, neglected problem.

A restorative and generative kind of relatedness is ‘natural’, the propensity for it being given to us by our biological heritage. Its first form is a game between babies and caregivers, a ‘proto-conversation’. Principles derived from this, and related developmental behaviours, guide a form of therapeutic relatedness consisting of an interactive, to-and-fro ‘patterning’ of verbal ‘pictures’, or analogues, of the subject’s immediate experience. The analogue is the first form of symbol, the use of which is the hallmark of the human.

Depression is a mental disorder, affecting the quality of life. Our study explores the efficacy of Pranic Healing (PH), as an adjuvant therapy in treating depression

In this randomised double-blind controlled trial, 52 participants with a mean age of 34.4 years, with mild to moderate depression were assessed using the Hamilton Depression Rating (HAM-D) scale during the 5-week study. Both Medication + PH (MedPH) and Medication + Mock PH (MedMockPH) groups comprising 26 members received Pranic and mock healing lasting 20 minutes per session respectively once a week for 4 weeks, along with the antidepressant drug.

The average decrease in HAM-D score in MedPH was median 11 (Interquartile Range (IQR) 7–12) and was significantly higher compared with the MedMockPH group median 6.5 (IQR 3–9). At pre-assessment, both groups had 8 cases of mild and 18 cases of moderate depression. At post-assessment, HAM-D showed that the improvement in depression category was seen in 69.2% of participants in the MedMockPH group and 100% in MedPH group.

These results give first the evidence that PH can aid as an adjuvant therapy for depressed people.

The objective of this study was to review the clinical significance of the experience of chronic emptiness in borderline personality disorder (BPD).

A systematic search of the literature was conducted using MEDLINE and PubMed, employing search terms including ‘emptiness’, ‘personality disorder’ and ‘borderline personality disorder’. The most relevant English-language articles and books were selected for this review.

Published literature and clinical experience suggest that chronic emptiness represents a substantial component of the symptom burden experienced by people with BPD, contributes to functional impairment and may distinguish BPD from other disorders such as major depressive disorder.

Further research will elucidate the significance of chronic emptiness with regard to diagnosis, prognosis and treatment of BPD.

Brexpiprazole is a new dopamine partial agonist antipsychotic in the same class as aripiprazole. This paper will briefly review brexpiprazole and compare it with aripiprazole.

Brexpiprazole and aripiprazole are both partial agonists at dopamine D₂, and serotonin 5-HT_1A and antagonists at serotonin 5-HT_2A and noradrenergic α_1B receptors. However, the two drugs are significantly different in potencies at various receptors; neurochemical profiles predict that brexpiprazole may be comparable with aripiprazole in its antipsychotic efficacy but may cause less akathisia, extrapyramidal side effects (EPS) and activation. In pivotal trials brexpiprazole demonstrated antipsychotic efficacy in short and long-term studies; it was also found to be an effective adjunct in patients with major depression resistant to antidepressants. Akathisia can occur early in treatment with brexpiprazole, as can minor weight gain and prolactin elevation. Indirect data extrapolations from pivotal studies suggest that brexpiprazole and aripiprazole have comparable efficacy but brexpiprazole may cause less akathisia. Like aripiprazole, brexpiprazole has been approved in the USA for use in schizophrenia and antidepressant-resistant depression. Although much more clinical experience is needed, brexpiprazole appears to be distinct from aripiprazole and a promising new ‘metabolically-friendly’ antipsychotic option for treatment of psychoses and mood disorders.

The objective of this study was to explore the concept of mindset for psychiatrists who are considering stepping into the leadership arena.

Qualitative themes were extracted from dialogue on leadership development at a Royal Australian and New Zealand College of Psychiatrists forum for early career psychiatrists.

Three key themes were identified: adapting to a professional identity as psychiatrists; developing a mindset for leadership; and acting intentionally to seek opportunities for leadership.

Shifts in professional identity occur in the transition from trainee to specialist as early career psychiatrists become increasingly aware of broad systemic factors in clinical care. The concept of a mindset, distinct from a skillset of knowledge and expertise, may be an emergent quality for psychiatrists who are seeking to develop their leadership potential.

To understand whether foundation trainees change their career intentions during psychiatry placements and explore what factors influence such changes.

Over a two-year period, foundation trainees completed questionnaires at the beginning, middle and end of their four-month placement. There were two questions, the first as to how likely they were to pursue a career in psychiatry and the second openly asked them to elaborate on their reasons.

Twenty-one out of 41 eligible trainees returned all three questionnaires. The number of trainees ‘highly likely’ to choose psychiatry increased over the four-month period, from 4.5% to 19%. The number of trainees ‘highly unlikely’ to choose psychiatry decreased, from 27.3% to 9.5%. An increasingly positive intention towards a psychiatry career appeared to relate to enjoyment of the placement and the quality of supervision. The most common reason for not choosing psychiatry was a pre-existing interest in another specialty.

Undertaking a psychiatry placement during the foundation programme continues to increase the likelihood of a positive attitude towards psychiatry as a career. The findings of our study suggest good practice in providing foundation placements in psychiatry includes identifying medical school experience, enjoyment, quality weekly supervision and mindful experiential design of placements.