Australasian Psychiatry

There are increasing demands on emergency psychiatrists with higher numbers of mental health presentations, and longer stays in emergency departments (EDs). Australia, like other English speaking countries, funds considerably lower numbers of psychiatric beds than average for Organisation for Economic Co-operation and Development (OECD) countries. Consequently, acute bed occupancy is high, and a bed is frequently unavailable when a person needs admission. Patients with serious mental illness can wait days in busy and overstimulating EDs, become agitated and assaultive, and then require chemical and physical restraint. All patients have a right to safe high quality care, but the paucity of beds deprives patients of this right. The Australasian College of Emergency Medicine recommends reporting ED access block to health ministers, and human rights and/or health rights commissioners, and recommends increased funding for inpatient psychiatric care, emergency mental health and after-hours community services, together with more alcohol and other drug programs.

It is challenging for emergency physicians and psychiatrists to provide optimal care for acutely unwell patients who stay extended periods in the ED. Increasing the availability of inpatient care must be considered as part of a comprehensive solution for minimising ED lengths of stay in Australia.

The aim of this study is to understand better the service implications of patients presenting to an inner city Australian Emergency Department (ED) and Acute Psychiatric Inpatient Service (AIS) with a history of recent crystal methamphetamine use.

An audit was taken of all patients with recent crystal methamphetamine use presenting to St Vincent’s Hospital Melbourne ED and AIS over the month of September 2017. Recorded information included patient demographics, diagnosis, aggressive episodes, restrictive interventions and other risk incidents.

Methamphetamine was related to 21.7% of AIS admissions. Of these individuals, half were involved in aggression towards staff. In the ED, 65.7% of patients with amphetamine use were aggressive to staff and 50% were aggressive towards other patients. There were high rates of physical (69.2%) and mechanical restraint (61.5%) in the ED setting. Methamphetamine use in the AIS was commonly associated with enduring psychotic disorders, whilst those managed exclusively in the ED were most commonly in an acute intoxicated state.

Methamphetamine use presents a significant challenge to EDs and acute mental health services. Additional resources are required to manage these patients and their impact on the health system needs to be factored into future service planning.

The aim of this study was to assess the outcomes for people following intervention by a police–mental health co-responder team.

Individuals seen by the co-responder team were followed for 2 weeks to monitor subsequent emergency department presentations and inpatient admissions.

Of the 122 people who had direct contact with the co-responder team, 82 (67.2%) remained at their residence, 35 (28.7%) were transported to the emergency department (ED) and 5 (4.1%) were taken into custody by police. The 82 people who remained at home following initial assessment were followed-up for 2 weeks. During this time 10 (12.2%) presented to ED and 3 of these (3.7%) were subsequently admitted to hospital.

Interventions provided through the co-responder team were capable not only of resolving the immediate crisis for the majority of people, but were also likely to divert people away from ED and inpatient treatment in the immediate term.

The study describes the implementation and adaptation of a brief intervention model as routine clinical practice in an acute care service.

An action research process informed the evaluation and design of the intervention.

The model’s theoretical framework enhanced clinical practice and benefited consumers, though it was too rigid to be implemented in an acute care setting, so was adapted to suit this environment.

This paper highlights the value in realigning practice with fundamental engagement principles to improve practice outcomes.

To perform a clinical and risk audit of private hospital inpatients staying in hospital at least 21 days.

Of 492 admissions for ≥21 days in 2016, 40 were randomly selected for audit. Characteristics, illness severity and course using the Clinical Global Impression severity (CGI-S) subscale and improvement (CGI-I) subscale, and clinical risk profiles were ascertained at admission, day 15 and discharge by two psychiatrists.

The cases were 65% female, age 50.0±16.2 years (range 24–86), 43% in relationships, and 28% on disability support. The length of stay was 29±7 days. On admission 88% were severely or markedly ill on the CGI-S subscale. Thirty-nine of 40 cases had ≥3 psychiatric diagnoses: 93% depression, 48% bipolar, 15% schizophrenia. High risk was present in suicide risk (48%), illness-induced dysfunction risk (78%) and physical risk (28%). By day 15, 63% were not improved or marginally worse. Suicide ratings were unimproved. By the time of discharge, illness severity and risk ratings were significantly reduced.

Private hospital inpatients staying ≥21 days were predominantly female and had severe, diagnostically complex illnesses and high risk ratings. Most were still seriously unwell after 15 days. Patients improved significantly by the time of discharge (though were by no means recovered), indicating that the duration of hospitalisation was appropriate.

To evaluate the therapeutic security characteristics of the secure forensic mental health inpatient units in New South Wales, Australia.

This study evaluated all eight secure inpatient units in New South Wales using a validated tool, the Security Needs Assessment Profile.

A pattern of decreasing therapeutic security across the secure units was found, consistent with their intended security levels, from high security through to open security. However, important inconsistencies across and between levels of security were highlighted.

This study clarifies the therapeutic security structure of the New South Wales forensic mental health service, which is an essential first step in service development and reform.

The objective of this study was to present an assessment of Australia’s mental health system performance, within its social context, by comparison with other countries.

A review of existing literature and databases from both Australia and overseas was undertaken. Systems permitting international comparison of mental health and its social context are few. The review is limited in scope.

Although Australia was one of the first nations to develop and adopt a national mental health policy (in 1992), the data that are available suggest that we are not World leaders across the identified domains.

While international benchmarking can play an important role in fostering quality improvement, there are only limited mental health or social system performance data sources to utilise. It would be desirable for a more systematic international process to be established to review existing approaches and design a new multilateral strategy. It would be important that this new strategy reflected the full experience of mental health and its broader social context.

This article draws attention to an initiative aimed at benefiting colleagues in developing countries, through financial and/or moral support. It describes an attempt to engage The Royal College of Australian and New Zealand Psychiatrists (‘the College’) in supporting this philanthropic activity. It further aims to attract interest from the College and fellows in contributing to international philanthropy.

Doubling provides a credible model for facilitating better mental health care in situations where there are trained staff but inadequate resources. The College’s resistance to engagement with this project may represent a missed opportunity for philanthropic support.

Development of a Mental Health Quality and Safety Framework with co-designed priority areas for improvement.

A qualitative and inductive approach was utilised, including a literature search, consultations with staff and focus groups with consumers and carers.

Thematic analysis resulted in 32 categories, grouped into seven key themes. Combined with the evidence base, these were distilled into component parts of the Framework.

A change in strategy and culture is required, balancing a traditionally centralised top-down approach to health care governance and improvement, with a complementary localised bottom-up model that embeds improvement science principles involving frontline staff, consumers and carers. This Framework, that centres on patient safety and quality improvement, in combination with a corresponding cultural change, can enhance clinical outcomes, service efficiency, staff morale and staff retention rates.

Allocation of transgender patients to single-sex mental health wards in Australasia can be a complex and challenging decision in the absence of adequate awareness, education and policy that prioritize consumer safety and preference. It is a point of care that can go wrong for a transgender person. We examine relevant literature, law and existing principles of care and offer an approach.

Transgender individuals experience an excess health burden and have difficulties that are poorly understood by many health practitioners. This is partly the result of both informational and institutional biases. Relevant legal frameworks, while supportive, are still to be translated into policy. We suggest a framework that canvasses the needs of various stakeholders and considers them equally in the decision-making process.

This paper reviews the history of electroconvulsive therapy (ECT) with an emphasis on the Australian context over the past 30 years. The review includes data collection, the contribution of the RANZCP, and changes in legislation.

ECT remains the most effective treatment for severe depression. Since the 1950s efforts have been made to make it more effective, tolerable and acceptable. Over the same period, significant social and political forces have acted to have the practice of ECT restricted or banned. Psychiatrists, through the RANZCP and other bodies, have the responsibility to promote quality ECT practice, advocate for patients, carers, and clinicians, counter inaccurate negative portrayals, and lobby for balanced legislation for ECT and other neurostimulation.

A lack of compassion for oneself, or harsh self-criticism, is associated with a range of psychiatric disorders including borderline personality disorder (BPD). Personal recovery in the context of a mental illness such as BPD involves building a life that is subjectively meaningful and satisfying. Limited self-compassion or harsh self-criticism may be an impediment to recovery from BPD. The association between self-compassion and recovery and self- criticism and recovery were examined.

Nineteen individuals diagnosed with BPD completed the Neff Self-Compassion Scale, the Forms of Self-Criticising/Attacking and Self-Reassuring Scale and the Recovery Assessment Scale at a single time point.

There was a strong positive correlation between self-compassion and recovery (r = 0.75) and a strong negative correlation (rho = −0.67) between self- criticism and recovery.

Although preliminary in nature, these results suggest the importance of fostering self-compassion and working to address self-criticism within clinical interventions supporting recovery from BPD.

To review and highlight the clinical significance of the symptom ‘fear of abandonment’ in borderline personality disorder (BPD).

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

Fear of abandonment is widely recognised as a core symptom in BPD; a biopsychosocial explanation for the occurrence of the symptom is presented. While fear of abandonment may differ in its clinical presentation, it has a significant impact on therapeutic engagement, suicidal behaviour and non-suicidal self-injury, clinical management and prognosis. Most evidence based psychotherapies for BPD address the phenomenon of fear of abandonment; however, the lack of specifically targeted treatment interventions is disproportionate to its prominence and clinical significance.

Given its defining role in BPD, we recommend fear of abandonment as an important subject of future research and a specific therapy target.

Examine knowledge, opinions and practices of psychiatrists and trainees in responding to domestic violence (DV).

Online survey including two sub-scales from PREMIS (Physician Readiness to Manage Intimate Partner Violence Survey): knowledge (10 items) and preparedness (10 items).

Of psychiatrists completing the survey (216), 47% had received less than 2 hours of training in DV. PREMIS findings showed moderate knowledge of, and preparedness to deal with, DV. Participants with more clinical experience had significantly more knowledge and preparedness to deal with DV.

Findings suggest more training in DV for psychiatrists is needed.

To consider whether consensus exists in recommendations for managing bipolar mixed states published in recent reviews and treatment guidelines, and to summarise what might be their best management.

Limitations to and changes in the definition of mixed states compromise diagnosis and management. The striking comparison between DSM-IV and DSM-5 criteria sets risks under-diagnosis and over-diagnosis. Current reviews and guidelines offer limited evidence to guide treatment; however, management should involve addressing the contribution of any antidepressant medication, and the introduction of a second-generation antipsychotic medication to stabilise the condition.

To question the status of the randomised controlled trial (RCT) in the hierarchy of evidence.

The RCT provides important and clinically relevant information, particularly in psychopharmacology. However, and as with other methodologies, RCTs too are flawed and automatic abdication to their conclusions, especially in complex social interventions, is unwise. A clinical example with conflicting and polarising views, each with their evidence base, is described alongside a suggested clinical strategy for resolving differences of opinion.

This paper describes, from the personal perspective of a mid-career researcher, principles and advice regarding the development of an embedded clinical psychiatric research program within a medical school and public sector mental health service. From this experience, some general principles are drawn.

Through careful strategic planning, together with collaboration with the mental health service, it is possible to bootstrap and develop an embedded clinical research program.

To assess Australian psychiatrists’ and psychiatry trainees’ knowledge about and attitudes towards medicinal cannabinoids, given the recent relaxation of cannabinoid-prescribing laws in Australia.

All Australian members of the Royal Australian and New Zealand College of Psychiatrists were invited to participate in an anonymous, 64-item online questionnaire, through Royal Australian and New Zealand College of Psychiatrists’ newsletters. The questionnaire ran for a 10-week period from March to May 2017. Participants were asked about their knowledge of the evidence for and against prescribing pharmaceutical-grade cannabidiol and tetrahydrocannabinol, and their concerns about prescribing medicinal cannabinoids.

In total, 88 doctors responded to the survey, with 55 completing all items (23 psychiatrists, 32 trainees). Overall, 54% of respondents would prescribe medicinal cannabinoids if it was legal to do so. Participants believed there was evidence for the use of cannabidiol and tetrahydrocannabinol in treating childhood epilepsy, chronic pain, and nausea and vomiting. They were most concerned about medicinal cannabinoids leading to psychotic symptoms, addiction and dependence, apathy and recreational use.

Our sample of Australian psychiatrists and trainees were aware of the main clinical indications for medicinal cannabinoids, but were poor at differentiating between the indications for cannabidiol versus tetrahydrocannabinol. Further education about medicinal cannabinoids appears necessary.

To demonstrate how the Pattern-based Formulation can be used to integrate biological, psychological and sociocultural factors in constructing the case formulation in a patient who developed schizophrenia and post-psychotic depression.

Three new patterns are introduced and used to construct a comprehensive case formulation. This expands the suite of patterns in the pattern-based method of psychiatric case formulation, and further demonstrates its broad utility as an educational resource in psychiatry training.