Australasian Psychiatry

To review selected literature available on trainee welfare and reflect on our own experiences to provide practical advice to our colleagues and suggest strategies to enhance trainee welfare.

Promoting the welfare of psychiatry trainees requires a three-pronged approach. We must care for ourselves through individual strategies; we must advocate for optimization of the systems we work in to minimize modifiable factors associated with burnout; and we must continue on the perennial challenge of culture change to reduce stigma around stress and mental illness and promote a healthier workplace.

To explore key sources of stress experienced during training by psychiatry registrars and identify which coping strategies they found helpful or unhelpful.

We used three data sources: a) ‘stress’ vignettes written by Stage 3 trainees; b) minutes of regular registrar meetings; c) focus groups. We analysed these using abbreviated grounded theory, generating themes.

The main sources of stress during training were disempowerment, adverse events, difficult supervision and cultural perspectives. Other themes included difficulties in after-hours work, and organisational issues. Stressors may differ in impact according to training stage. Peer support and a good supervisory relationship reduced stress. Conversely, a poor supervisory relationship compounded stress. Trainees were motivated to address modifiable problems.

A variety of stressors influence training at all stages. Trainees, the College and employers each have a role in promoting trainee welfare. Interlinking cultural dimensions are not currently addressed in the training curriculum and require attention. A good supervisory relationship can buffer many stressors for trainees.

Healthcare professionals including psychiatry trainees experience high amounts of occupational stress. This pilot study aims to assess the impacts and feasibility of a mindfulness-based intervention program as an occupational intervention in a metropolitan hospital.

Psychiatry trainees participated in an mindfulness-based intervention training program consisting of 1-h weekly sessions over 8 weeks. Levels of psychological distress and mindfulness were measured pre and post-intervention. Qualitative data through an open-ended feedback survey were also collected.

There was an improved level of mindfulness and a decreased level of burnout among trainees post-intervention. Advantages of the program included having a compassionate facilitator and the program being tailored to healthcare staff. Limiting factors included time restraints and clinical responsibilities.

Psychiatry trainees can benefit from an occupational MBI program. This can positively impact their health as well as improve their work performance. A number of factors important for implementation of a mindfulness-based intervention program were also identified.

The use of formal supervision contracts has been strongly advocated across non-medical mental health professions. However, the use of such agreements is not a feature of the RANZCP Competency-Based Fellowship Program. This paper critically examines the evidence to support the use of formal supervision contracts.

A systematic review of empirical studies relating to the outcomes of supervision contracts was completed. Included records were subject to quality appraisal.

Two studies met the inclusion criteria; both were assessed to be of poor quality. One study found improved supervision effectiveness associated with the use of supervision contracts, and the other found no significant differences associated with formal contracting.

Despite strong advocacy, limited empirical evidence was found to support the value of formal supervision contracts across mental health professions.

PROSPERO registration - PROSPERO 2018 CRD42018104142

A mentoring programme was established in South Australia in 2014 by psychiatry trainees, with the goal of reducing stress and burnout amongst first-year trainees. All first-year trainees are offered the opportunity to have a senior trainee as a mentor. This article describes the mentoring programme, presents feedback from participants and identifies areas for further development.

The majority (72/76) of first-year trainees entering psychiatry training in South Australia from 2014–2018 were allocated a mentor. Surveys were sent out in 2014, 2015 and 2017. Twenty of 42 (48%) mentors and 17 of 42 (40%) of mentees completed a 10-item questionnaire, with free text responses.

Mentee feedback was mostly positive, reporting that mentors offered them reassurance and support. The most common challenges were advice about training, managing work-life balance and issues with supervision. The main barrier to the mentoring programme was lack of time to meet. Mentors identified that they would have liked more training in mentoring.

The trainee mentoring programme has been a useful initiative. As consultant psychiatrists are likely to provide mentoring for more junior colleagues, the authors propose that training in mentoring should be part of the Royal Australian and New Zealand College of Psychiatrists education programme.

This literature review aimed to outline the evidence regarding the outcomes of formal mentoring programs for training psychiatrists.

An electronic search of Ovid MEDLINE, EMBASE, Ovid PsycINFO and The Cochrane Library was conducted.

A total of 17 articles fulfilled inclusion criteria. Positive outcomes of mentorship include promotion of research, perpetuation of further mentorship, increased perceived support and enhancement of teaching skills. One article reported a negative outcome.

Current evidence regarding mentorship in psychiatry is limited and there is a lack of clarity regarding the relationship between positive outcomes and mentorship. Components of the included programs may act as confounders. Mentorship, protected teaching time, and didactic teaching may be important to encourage research. Other potential benefits of mentorship include enhanced career guidance, perceived support, and enriched teaching skills.

We examined current pathways of training for junior clinical academic psychiatrists in Australia. An initiative of the School of Psychiatry, University of New South Wales, is described from the perspective of two junior clinical academics.

Australia has limited defined clinical academic pathways for psychiatrists when compared internationally. Numerous challenges for junior psychiatrists entering academia include tensions between clinical and academic roles, reduced remuneration, difficulty building a competitive track record and a scarcity of funding. Potential solutions lie with universities and local health districts partnering to fund clinical academic roles and offering flexible entry points across specialty training. Fostering research engagement in junior psychiatrists will develop the next generation of clinical academics with benefit for clinical and academic domains.

To capture the voices of psychiatrists as they reflect on challenges at the early stages of the career trajectory.

Early career psychiatrists contributed reflections that identified various challenges in the transition from trainee to consultant psychiatrist.

Common difficulties included negotiating role transition and conflict. Specific events had deep impact such as involvement with a patient who had committed suicide.

Challenges in the early career stage as a consultant psychiatrist may have lasting or career defining impact. Written reflection is a valuable tool that can impart collective learning, provide validation and engender support among peers.

Doctors are known to have poor mental health compared with the general population. Psychiatrists are exposed to a number of unique stressors that may increase the risk of poor mental health. The aim of this study was to undertake a meta-analysis of burnout rates in psychiatrists.

Electronic databases (including MEDLINE, PsycINFO and Embase) were searched. Only studies published since 1999 and using the 22-item Maslach Burnout Inventory were included in the analysis. A meta-analysis was conducted using the Comprehensive Meta-Analysis software.

A total of 11 studies, across nine publications, were included in the final analysis. Studies were significantly heterogenous but there was no indication of publication bias. The pooled mean for emotional exhaustion was 22.03 (95% confidence interval (CI): 19.71–24.34, tau = 3.74). For depersonalisation, the pooled mean was 7.41 (95% CI: 5.91–8.90, tau = 2.45). The pooled mean for personal accomplishment was 30.00 (95% CI: 24.75–35.27, tau = 8.87).

The high level of psychiatrist emotional exhaustion is a significant concern. Further research is needed to consider the role of modifiable risk factors in the aetiology of psychiatrist burnout.

To evaluate the effectiveness of a workshop intervention to promote wellbeing for Australian physician trainees using a randomized-controlled design.

Participants were randomly assigned into intervention and control groups. The intervention group attended a half-day workshop. Outcome measures included depression anxiety stress scale, professional quality of life scale and alcohol use disorders identification test. Demographic and work/life factors were measured. Measurements were recorded at baseline, 3 and 6 months, and the workshop was evaluated by participants.

High rates of burnout (76%) and secondary traumatic stress (91%) were detected among study participants and around half met screening criteria for depression (52%), anxiety (46%) and stress (50%) at baseline. Workshop evaluations showed that participants agreed that the training was relevant to their needs (96%) and met their expectations (92%). There was a small reduction in alcohol use, depression and burnout in the intervention group compared with the control group at 6 months, but these changes did not reach statistical significance.

High rates of psychological morbidity detected in the study suggest that physician trainees are a vulnerable group who may benefit from initiatives that promote wellbeing and changes in the workplace to reduce distress.

To explore the relevance and adaptability of the Optimal Health Program for mental and primary healthcare providers in Malaysia.

Evaluate stakeholder engagement and training programme for psychiatrists, family medicine specialists, public health specialists, physicians, clinical psychologists, counsellors, and representatives from a patient support group. Evaluate the programme for applicability, as well as participant’s knowledge and confidence in using key components.

The training was very well received in terms of content, training materials and facilitation style. Development of culturally specific materials will be needed. Improvement in the self-rating measurement for knowledge and confidence in using key Optimal Health Program components was reported at the completion of the 2-day training.

The Optimal Health Program has potential as a comprehensive socio-culturally responsive self-management programme that is relevant within mental health services and adaptable for task-sharing of mental health care in Malaysia.

Self-awareness is essential for combating burnout, promoting self-care, and wellbeing in health professionals. This article examines modern day roadblocks to developing this skill in medical practice and highlights some simple solutions for consideration.

The capacity for self-awareness is essential to the modern-day physician seeking a long and fulfilling career. Mindfulness meditation and reflective writing are two simple, proven methods that can be easily implemented into medical training.

We aimed to report substance use across a five-year period in individuals admitted to an acute mental health unit, utilizing data from a routine clinical measure, diagnoses, and findings related to gender, ethnicity and the implementation of a new dual-diagnosis policy.

Data was extracted from the electronic records of 2118 individuals who had consecutive admissions to the acute inpatient unit. Analysis focused on demographic and diagnosis variables and the drug and alcohol question in the Health of the Nations Outcome Scale.

Some 57.6% of the sample was in the at-risk drug and alcohol category. Male and indigenous inpatients were most at risk. More than 50% of patients with schizophrenia, anxiety and personality disorders were deemed at-risk. Following implementation of the dual-diagnosis policy, recorded primary and secondary substance use disorder (SUD) diagnoses significantly increased.

The study replicated previous findings of a high proportion of patients with co-morbid drug and alcohol use. In this sample it seems likely that the dual-diagnosis policy and related activities increased the rate of SUD diagnoses recorded, although it is likely to still be under-reported.

Smoking rates in people with mental illness in Australia remain alarmingly high whilst they have been declining in the general population. This study reviews a smoking cessation programme in a mental health service, as a pilot for future studies and program development. We aim to assess the effectiveness of this intervention and the ease of implementation after upskilling the clinical workforce.

Part A – a retrospective analysis of patients attending the Smokers’ Clinic, (n = 44) over a period of 18 months. Part B – survey of ease of implementation and change in practice of the resident medical officers (RMOs; n = 8) following their clinical placement.

For the entire clinic population, the mean reduction in expired carbon monoxide was approximately 43%, with 34% of patients achieving abstinence. Females were 3.4 times more likely to be successful than males. Seventy-five per cent of RMOs found learning about nicotine dependence and smoking cessation ‘easy’, and 88% continued to offer smoking cessation after their placement.

The Smokers’ Clinic was successful in helping tobacco smokers with mental illness to reduce or cease smoking. Specialist skill and experience is not required to manage smoking cessation in a mental health setting.

Synthetic cannabinoid use disorder is emerging as a significant clinical issue. This article provides the general psychiatrist with an overview of the physical and psychiatric adverse effects of chronic synthetic cannabinoid use, as well as specific clinical responses.

We performed electronic searches of Ovid MEDLINE and Ovid Embase to identify key articles, of all methodological designs, published up to June 2018.

The available evidence suggests that, compared to cannabis, use of synthetic cannabinoids is associated with the more rapid development of dependence, increased psychiatric risks and complex withdrawal, and serious physical adverse effects that include seizures, cardiotoxicity and death, denoting a potential need for more intensive management.

When synthetic cannabinoid use is identified, along with management of acute physical and psychiatric adverse effects, psychotherapeutic strategies to reduce use and/or harm are recommended.

To describe the baseline characteristics, treatment and retention in patients electively admitted for gamma-hydroxybutyrate (GHB) withdrawal management.

All patients admitted between July 2010 to June 2016 who used GHB two or more times per week with a minimum duration of 3 months were identified and data extracted by file review.

Twelve cases satisfied the inclusion criteria, of whom 50% were female; 75% were using GHB daily, with an average daily amount of 16 ml. Average duration of use was 60 months. All subjects were using amphetamine type stimulants and nicotine. Psychiatric comorbidity and unintentional overdose were common; 50% completed treatment. Medications used included diazepam and neuroleptic. Two patients completed withdrawal with no medications. No subject using greater than 90 ml GHB in the preceding week completed treatment. Pattern of GHB use did not predict medication requirements during withdrawal management.

There were low numbers attending for elective treatment for GHB use. Heavier GHB use predicted poor treatment retention. Polysubstance use and psychiatric co-morbidities need consideration in treatment planning.

This paper outlines the use of psychodynamic psychotherapy as an adjunct to treatment as usual for addressing challenging behaviours in a patient with schizophrenia under the care of a community mental health team (CMHT) in South Australia.

Ms P suffered from schizophrenia and demonstrated challenging behaviours in the context of being administered depot medication under a community treatment order (CTO). Multiple attempts at addressing non-compliance and consistently disruptive behaviour through conventional methods had failed. Consequently, the novel approach of fortnightly psychodynamic psychotherapy sessions was trialled for 5 months, augmenting treatment as usual.

Psychodynamic psychotherapy proved effective for this patient. With treatment, she showed an improved compliance and overall engagement. Additionally, consequent to regularly receiving medication, her mental state improved and hospitalisations decreased.

Further research could lead to a better understanding of how and in what contexts, psychodynamic therapy and psychodynamic thinking can be utilised in the public health system.

Mindfulness is a proven treatment in clinical settings. Our objective was to examine the feasibility and effect of a mindfulness-training program on the mental resilience and emotional intelligence of amateur basketball players.

This was a parallel-group, pre- and post- test, randomised controlled trial. Thirty male amateur male basketball players from Tehran, Iran, were assigned randomly into experimental and control groups (n = 15 each). Outcomes were measured using the mindfulness sport inventory, mental toughness (MT) questionnaire and emotional intelligence questionnaire. Data were analysed using ANCOVA and MANCOVA.

Mindfulness scores were significantly greater in the intervention group than in the controls following training. The intervention also increased overall MT and all of the component sub scores. The same applied to emotional intelligence and all of its components.

These findings may have implications on sport mindfulness training in increasing the MT and emotional intelligence of athletes.

This study aimed to explore the effects of a four-week course of transcranial magnetic stimulation (TMS) on the following symptoms of major depressive episode (MDE): mood, work activities, health concerns, guilt, anxiety and retardation.

Patients underwent 20 daily sessions of 10 Hz TMS (two sets of 10 daily treatments separated by two days of rest). The six-item Hamilton Depression Rating Scale (HAMD-6) was administered before and after treatment. Remission was operationalised as a HAMD-6 score of <4. Descriptive statistics and t-tests were used to compare pre/post scores on HAMD-6 subscales, and logistic regression was used to understand symptoms that predicted remission/non-remission.

There were 104 participants (79 female; 76%), with a mean age of 44.6 years (SD=15.7 years). There was a significant improvement in the whole sample and in remitters (n=70) on all subscales. However, those who failed to remit did not achieve significant reductions in ‘health concerns’ and ‘retardation’. There were no difference in age and sex between remitters and non-remitters. Also, there were no significant differences between the remitters and non-remitters on the pretreatment depression symptom profiles. No predictors of response were identified, as expected.

TMS has the ability to reduce all listed MDE symptoms. No pretreatment MDE symptom profile was identified which might carry prognostic value.

Neurocognitive assessment and feedback to a young adult inpatient.

Computerised neurocognitive assessment and feedback.

A collaborative process of personalised intervention.

Personalised feedback in this setting can be employed as a management tool to identify and prioritise care.

The aim of this study was to introduce new approaches to conduct qualitative research that may provide valuable insight into issues related to education, training and patient care in psychiatry.

A variety of data-collection tools is available for researchers and practitioners in psychiatry. These can be used independently or in conjunction with other quantitative and qualitative methods.