Australasian Psychiatry

This paper provides an overview for general and forensic psychiatrists of the complexity and challenge of working in the civil medico-legal arena. It covers expert evidence, ethics, core concepts in civil forensic psychiatry and report writing.

Civil forensic psychiatry is an important sub-speciality component of forensic psychiatry that requires specific skills, knowledge and the ability to assist legal bodies in determining the significance of psychiatric issues.

This paper describes the main areas of civil forensic psychiatry (FP) and the skills required by psychiatric experts. Some specific areas of civil FP are discussed, including tort law reform, reliability of psychiatric evidence, contentious psychiatric disorders, and the many domains of civil FP.

Civil FP is an important sub-specialty component of forensic psychiatry that requires greater emphasis in the training and continuing education of psychiatrists. A process of accrediting psychiatrists as having competency in advanced civil FP may be of value.

This is the third in a series of papers on Civil Forensic Psychiatry and provides practical advice for forensic psychiatrists, general psychiatrists and trainees who are expanding or contemplating a medico-legal aspect to their practice.

Attention to the practice setting, office layout, recording of information, management of documentation, screening of briefs and proper timetabling can improve safety, quality, reliability and workload manageability.

Readmission rates are a routinely used measure of patient and service outcomes, potentially improved by discharge planning. This pilot study aimed to develop a discharge checklist for psychiatric inpatients, exploring its feasibility, applicability, and impact on readmission rates.

The study used a quasi-experimental, pre–post intervention design. The checklist was designed from an evidence-based literature review, and introduced for a three-month period, comparing 28-day readmission rates with the previous three months using interrupted time series analysis.

Checklists were completed for 80% of patients in the trial period, with 100% completion of checklist items. Demographic and clinical details for pre- and post-intervention groups were closely aligned. There was a small, but statistically non-significant, reduction in readmission rates.

There was a high rate of checklist completion. The lack of significant reductions in readmission rates supports more development of the checklist application and design before a longer implementation period and re-evaluation.

The study aimed to evaluate the attitudes of patients and staff in relation to the potential benefits and risks of allowing psychiatric inpatients controlled access to personal electronic devices (PEDs), and to document a snapshot audit of practice within the mental health inpatient units of New South Wales, Australia.

Psychiatric inpatients and staff at Royal North Shore Hospital’s Mental Health inpatient units were surveyed, and an audit of the policies of the psychiatric inpatients of New South Wales was undertaken.

Access to PEDs is denied in 85% of New South Wales psychiatric inpatient units. While patients and staff appear to concur on the risks of access to PEDs and the need for risk assessment and rules, compared to patients, staff appear to underestimate the importance of PEDs to maintaining social connection and recovery.

This study may assist in the formulation of local policy and procedure to allow a more recovery-oriented approach to the question of whether patients should have access to their PEDs while in hospital.

Multidisciplinary teams in mental health receive limited guidance, leading to inconsistent practices. We undertook a systematic review of the characteristics and practices of multidisciplinary team reviews for patients with severe mental illness or in relevant mental health service settings.

Sources published since 2000 were located via academic database and web searches. Results were synthesised narratively.

A total of 14 sources were analysed. Important characteristics and practices identified included routine monitoring and evaluation, good communication, equality between team members, and clear documentation practices. Success factors included defined leadership and clear team goals. Four sources described considerations for patients with complex clinical needs, including allocating sufficient time for discussion, maintaining connections with community providers, and ensuring culturally sensitive practices.

No single best practice model was found, due to variations in team caseload, casemix, and resourcing levels. However, key ingredients for success were proposed. Sources were mostly descriptive; there remains a lack of evidence-based guidance regarding multidisciplinary team review characteristics and practices.

This study examined the patterns of direct observation of patients by nursing staff (‘nurse specials’) and compared those required for mental health/drug health (MH/DH)-related presentations to other patient groups in different care settings.

A retrospective review of nurse special shifts requested during the 2014 calendar year at an urban teaching hospital.

Hospital-wide 14,021 8-hour nursing shifts were ordered for special observation of patients, an average of 39 per day. Of these, 30% were requested for MH/DH-related presentations, with the majority (70%) required for medically unstable patients. However, of the 1917 shifts required in the emergency department, 1841 (96%) were for MH/DH presentations compared to 76 (4%) for patients with unrelated medical conditions (odds ratio 98.2; 95% confidence interval 77.71–124.06, P<0.0001).

In contrast to the rest of the hospital, emergency department-based nurse special requests were significantly more likely to be for MH/DH presentations. This figure represents a considerable staff and financial burden and may be reduced by diversion or more rapid transfer of such presentations to an appropriate inpatient ward.

To evaluate the psychometric properties of the Beck Depression Inventory (BDI) and Cognitive Depression Index (CDI) as a potential screening tool for major depression in haemodialysis (HD) patients.

Forty-five HD patients completed both the BDI/CDI and diagnostic interview. The interview was conducted by two experienced clinicians and was based on DSM-IV criteria. The sensitivity, specificity and positive (PPV) and negative (NPV) predictive values were then calculated.

A diagnosis of depression was found in 6 of the 45 participants (13.3%). Optimal cut-offs were ≥18 for the BDI (sensitivity 1.0, specificity 0.90, PPV 0.60, NPV 1.0) and ≥11 for the CDI (sensitivity 1.0, specificity 0.92, PPV 0.67, NPV 1.0).

Both the BDI and CDI were shown to be acceptable screening tools for depression in this population of chronic HD patients. The recommended cut-off scores for both scales are higher than those suggested for the general population and slightly higher than previously found in the chronic kidney disease literature, suggesting that altered thresholds are required when using these screening tools amongst HD patients.

This study aims to describe the impact of a mental health assertive community treatment prison model of care (PMOC) on improving the ability to identify prisoner needs, provide interventions and monitor their efficacy.

We carried out a file review across five prisons of referrals in the year before the implementation of the PMOC in 2010 (n = 423) compared with referrals in the year after (n = 477).

Some improvements in the identification of needs and providing interventions were detected. There was increased use of medication management and clinically significant improvement in addressing engagement with families. Monthly multi-disciplinary team face-to-face contact improved.

Meeting the needs of mentally ill prisoners is challenged by the complexity of the custodial environment. Improvements made resulted from changing the model of care, rather than adding new resources.

To compare by ethnicity the rates of apparent new referrals and admissions to mental health services for selected major diagnostic groupings.

Using a Ministry of Health database covering all referrals and admissions to New Zealand’s Mental Health services in 2014 and who had not been patients in the preceding six years, population adjusted rates of presentation were calculated and compared across the two major New Zealand ethnic groupings.

Population corrected rates of apparently new cases of schizophrenia are more than twice as common in Māori as in non-Māori. Major depression is also significantly more common in Māori. That same trend was not evident for bipolar patients.

These ethnically associated apparent differences in the rates of schizophrenia and depression need both confirmation and explanation.

The purpose of this research was to compare the current status of assessment and intervention for New Zealand children and adolescents who have autism spectrum disorder (ASD) with recommendations outlined in the 2008 New Zealand ASD Guideline.

ASD coordinators and New Zealand District Health Board (DHB) staff working with children and adolescents who have ASD were electronically surveyed.

Responses were received from 32 staff in 17 (85%) surveyed DHBs. Positive findings included the presence of ASD coordinators in 85% of DHBs, clear pathways for management in 73.1% of DHBs and good communications between paediatric, psychiatric and educational teams in some DHBs regions. Areas for improvement included wait times to assessment, access to longer-term support and intervention for families, and training for staff in ASD and cultural issues.

Since the launch of the NZ ASD Guidelines, significant progress has been made. However, further work is needed to ensure services for children and adolescents with ASD are accessible, well-coordinated and focussed on both assessment and intervention.

The aim of this study was to report on a half-day multi-stakeholder symposium on community treatment orders (CTOs) hosted by the Melbourne Social Equity Institute (MSEI), which identified research gaps and opportunities, and produced an agreed agenda for future CTO research.

The MSEI convened a symposium for 22 experts in CTO research to discuss research priorities in this field in Australasia. An independent moderator elicited views and recommendations and produced a report detailing possible research projects.

Research on CTOs is contentious and there is a need to gather and examine information regarding both their use and utility. Due to the complexities involved, it was agreed that research should be undertaken in partnership with persons with had lived experience of mental health problems, clinicians, policymakers and other interdisciplinary stakeholders. Five key areas for future investigation were identified.

The issues and recommendations arising from the symposium should shape the scope, nature and conduct of future research directions in the field.

The aim of this study is to provide an opinion paper reviewing the role of depot or long-acting injectable (LAI) antipsychotic medications, with comments on individual newer LAIs such aripiprazole maintena and paliperidone palmitate. In particular, we share our recent experience of using paliperidone three-monthly LAI. We also reflect on the associated benefits and potential harms of LAIs, and when they may be used.

LAI antipsychotics are an important and arguably under-utilised therapeutic option, particularly where medication adherence is a priority, and where an informed patient opts for this formulation. Paliperidone is the first three-monthly LAI antipsychotic, and as such represents a significant advance in the range of treatment choices.

To determine the average duration of treatment at a community-based anxiety disorders clinic.

Data were collected on primary disorder, the presence of co-occurring disorders and treatment length (both in terms of number of sessions and weeks of therapy) for 248 consecutive clients.

The mean number of sessions was 13, and average treatment length was 29 weeks. There was substantial variation in treatment duration (range for number of sessions = 1–128, range for treatment duration = 0–186 weeks).

Clients with anxiety disorders were often treated in relatively few sessions, in line with randomised controlled trials (RCTs). However, a number of clients required many more sessions and were treated for a longer period of time than clients in RCTs. Health services should be cautious in mandating limits to therapy duration for anxiety disorders given the wide range in the duration of treatment for clients in our sample.

Our objective was to report and describe a case of quetiapine-induced dystonia in an older lady with psychosis. Quetiapine is a second-generation antipsychotic and known to be rare in causing extrapyramidal side effects with rates similar to placebo.

There have been few documented cases of quetiapine-induced dystonia. It is important to be vigilant and consider the development of dystonia in patients who may not fit the typical risk profile.

Previous reports have found the incidence of gender dysphoria in Klinefelter’s patients greater than in the general male population.

A cohort of patients with gender dysphoria was reviewed.

Of the 220 patients with gender dysphoria, three had Klinefelter’s syndrome.

These three reports are further examples of gender dysphoria in Klinefelter’s syndrome. The role of biological factors in gender identity is affirmed. Caution is urged in prescribing testosterone.

The objective of this study is to determine if pattern-based formulation (PBF) can accurately contribute to case formulation.

The application of three PBFs accurately contributed to the development of this patient’s case formulation. The case formulation demonstrated here, and the patterns introduced in this paper, will serve as educational materials for teaching psychiatric case formulation.