Australasian Psychiatry

Digital mental health services offer innovative ways for individuals to access services but are not without risk. Our objective was to develop National Safety and Quality Digital Mental Health (NSQDMH) Standards that improve the quality of digital mental health service provision and protect service users from harm.

The NSQDMH Standards were developed by adapting the National Safety and Quality Health Service (NSQHS) Standards and adding components highlighted through a national consultation process as critical to the safety and quality of services. Further public consultation and pilot testing assisted in refining the NSQDMH Standards.

The NSQDMH Standards comprise three standards—Clinical and Technical Governance, Partnering with Consumers, and Model of Care—and were launched in November 2020.

The NSQDMH Standards provide a quality assurance mechanism to improve digital mental health care in Australia.

For psychiatrists and trainees, to reflect upon adverse managerial reactions to healthcare advocacy about patient care and safety, drawing upon examples from general healthcare settings, and to share approaches to addressing these reactions.

Psychiatrists and trainees engaging in healthcare advocacy may face adverse responses from healthcare management, with personal and professional consequences. Advocates need to consider counterstrategies to negative actions by management that may include workplace incivility, bullying and harassment. Health advocacy is more effective within a network of peers, patients and the broader community, including medico-political professional organisations, such as the Australian Medical Association, Royal Australian and New Zealand College of Psychiatrists, and Unions. These organisations should advocate openness to doctors highlighting healthcare safety and quality, as well as prevention of workplace bullying.

To provide a clinical update for psychiatrists and trainees on psychiatric workforce-planning in the Australasian context.

There is a lack of detailed evidence regarding effective psychiatric workforce planning. Planning may be based on a foundation of psychiatrist-to-population ratios. This would be modified by needs assessment, understanding of service models and existing service demand. Given that it has recently expressed significant concerns about workforce shortages, the RANZCP should lead development of an independent Australasian psychiatric workforce planning model to inform policy advice to governments.

Australian youth mental health services have received significant funding over the past 15 years. We analysed data on hospitalisation due to intentional self-harm to determine whether increased youth services were associated with reduction in a key indicator of youth population mental health.

Trends in national self-harm hospitalisation data from 2008 to 2019 for youth (<25 years) and adults (>25 years) were analysed using joinpoint regression.

Rates of hospitalisation due to intentional self-harm increased significantly in both male (1.1% per annum, 95% CI [0.2%, 1.9%]) and female (3.0% per annum, 95% CI [0.9%, 5.1%]) youth aged <25 years between 2008 and 2019. Female youth had higher rates of hospitalisation than males, and there were average annual increases of 9.1% (95% CI [2.4%, 16.3%]) and 4.0% (95% CI [0.1%, 7.9%]), and absolute increases of 120% and 47.9%, in the rate of hospitalisation of females aged 0–14 and 15–19, respectively. In contrast, there was no overall change in adults (>25 years).

Rates of hospitalisation due to intentional self-harm in Australian youth have increased despite significant investment in youth mental health services. This result could be attributable to several sociocultural factors and suggests a critical need for more hospital-based emergency youth mental health services.

To provide an overview of specific aspects of historical and possible future trajectories of psychiatry.

Psychiatric treatments alleviate suffering, promote physical health, and are associated with increased longevity. As the biological underpinnings of mental illnesses are slowly uncovered, they generally cease to be primarily part of psychiatry (e.g. epilepsy, anti-NMDA receptor encephalitis). If this process continues, the biological basis of all symptom-based ‘mental illnesses’ might be described, and psychiatry absorbed into neurology and other disciplines. This will be a positive development if it provides better treatment for mental illness and psychiatric symptoms in other conditions, which is psychiatry’s sole concern. Psychiatry’s own survival as a distinct discipline is irrelevant if other disciplines can do the job better, possibly in collaboration. Given the tiny impact of neuroscience on psychiatry to date, the disappearance of psychiatry is unlikely to occur anytime soon, if ever. It is possible that human psychological functioning and psychiatric suffering are sufficiently complex and changeable as to defy complete, fine-grained, neuroscientific explanation. This would leave a role for psychiatry indefinitely, treating the immensely disabling, biologically unexplained clusters of symptoms that we currently call ‘mental illnesses’, increasingly in collaboration with, or absorbed within, other disciplines in medicine.

To provide a rapid clinical update on casemix, average length of stay, and the effectiveness of Australian private psychiatric hospitals.

We conducted a descriptive analysis of the publicly available patient data from the Australian Private Hospitals Association Private Psychiatric Hospitals Data Reporting and Analysis Service website, from 2015–2016 to 2019–2020. This was compared with corresponding reporting on public and private hospitals from the Australian Institute of Health and Welfare, and Australian Mental Health Outcomes and Classification Network.

In 2019–2020, there were 72 private psychiatric hospitals in Australia with 3582 acute beds. There were 42,942 inpatients with 1,286,470 days of care, and a mean length of stay 19.6 days (SD 13.9) for the financial year 2019–2020. The main diagnoses were major affective and other mood disorders (49%), and alcohol and other substance abuse disorders (21%). Clinician-rated outcome measures, that is, the HoNOS, showed an improvement effect size of 1.64, while the patient-rated MHQ-14 showed an improvement effect size of 1.18. Results are similar for previous years.

Private psychiatric hospitals provide substantial, effective psychiatric care.

We sought to assess the attitudes of ACT public psychiatry doctors towards the financial and criminal penalties in the ACT Mental Health Act 2015.

Baseline attitude was surveyed with an 11-item 5-point Likert scale. Education was then provided about the offences outlined in the Act and the associated penalties. The same initial survey was then repeated. Primary outcomes were changes in attitude pre- and post- information, and secondarily data was explored for differences related to gender and seniority.

Forty-nine percent of 89 eligible public mental health system doctors responded. The majority of the survey respondents were female (59%). Provision of information resulted in a significant improvement in understanding of liabilities (2.80 (SD 1.14) versus 3.58 (SD 0.93), t(39) = 4.06, p < 0.001). Gender had no significant impact on scores. Senior staff were less legally secure and less satisfied with the Mental Health Act pre-information being provided. With regards to notification penalties, with education, junior staff became more secure and seniors less so.

Information provision improves understanding of the penalties under the Mental Health Act 2015. Having a senior role predicts lower satisfaction with the penalties in the Act.

This aim of this qualitative study was to explore the experiences of clinicians involved with inquiries into the mental health care of patients who were perpetrators of homicide in New Zealand.

Our purposive sample comprised ten clinicians working in New Zealand district health board mental health services. These clinicians were individually interviewed. Interviews were audio-recorded, transcribed and thematically analysed. The coding framework was checked and peer reviewed by an independent researcher.

Five themes were identified: the inquiry process; emotional burden; impact on team dynamics; changes to individual clinical practice; and perceptions of inquiries being influenced by organisational culture. Clinicians involved with inquiries reported significant anxiety and disrupted multidisciplinary team dynamics. Some participants found inquiries led to changes to their clinical practice and perceived that a punitive organisational culture limited learning.

Clinicians perceived inquiries as threatening, anxiety provoking and primarily concerned with protecting organisational interests. Communication of the inquiry process and ensuring inquiry findings are disseminated may enhance clinicians’ experiences of inquiries and facilitate their participation and their reflection on changes to clinical practice that could contribute to improving services. Support for clinicians and multidisciplinary teams should be emphasised by the commissioning agency.

We compared the quality of the written informed consent forms for electroconvulsive therapy (ECT) in Australian jurisdictions.

For this comparative audit-type study, a checklist was developed to compare informed consent forms from different jurisdictions. The main information sources for consent forms were government health department websites and Google. The directors of clinical services were contacted if a consent form was not available through a web source.

Majority of the informed consent forms covered information about ECT, general anaesthesia and alternative treatments, supports available for decision making, and a reference to the right to withdraw consent. Missing information affected information areas such as likely outcome if no ECT, lack of guaranteed response and cultural and linguistic supports.

A standardised consent form that can be used across all jurisdictions can help improve the ECT practice.

To evaluate the medical assessments of involuntary community patients in a regional mental health service, determine the compliance with requirements under Queensland’s Mental Health Act 2016 (the Act) to regularly review orders and assess patients’ mental capacity.

We audited 183 patient records on community treatment authorities (CTAs) to determine whether medical assessments undertaken under the Act included consideration of the person’s capacity, and regular reviews by an authorised doctor as required^1s205.

The audit revealed that 51% of the CTA patients did not comply with legal requirements either to complete a capacity assessment and/or be medically assessed within three months of the last review.

Over 50% of medical assessments did not comply with the legislative requirements to record capacity assessments and review involuntary treatment on at least a three-month basis. However, when the treatment criteria were met, it did not appear to be a basis for CTA revocation. Further research may help determine whether the Mental Health Review Tribunal (Tribunal) could play a greater role in overseeing compliance with the new legislative requirements or if other clinical oversight mechanisms would be appropriate to improve the assessment process.

To examine the history of Fremantle, Western Australia’s first purpose-built asylum.

A range of primary sources were consulted.

Fremantle was opened in 1865 to house inmates away from the populace and for the most part under the care of Dr HC Barnett. Attendants as well as inmates were occupied with work roles that kept the asylum functioning cost effectively.

Within 15 years, the structure was neglected and overcrowded. Changes to the Penal Servitude Act limiting convict transportation, petty crime and a need to manage its proliferation resulted in large numbers of people being incarcerated at Fremantle.

To provide a biography of G Vernon Davies who took up a career in old age psychiatry in 1955 at the age of 67 at Mont Park Hospital in an era when there few psychiatrists working in the field.

In the 1950s and 1960s, Vernon Davies worked as an old age psychiatrist and published papers containing sensible practical advice informed by contemporary research and experience, broadly applicable to both primary and secondary care, presented in a compassionate and empathetic manner. His clinical research in old age psychiatry resulted in the first doctoral degree in psychiatry awarded at the University of Melbourne at the age of 79. Before commencing old age psychiatry, he served in the Australian Army Medical Corps as a Regimental Medical Officer and received the Distinguished Service Order. He spent 3 years as a medical missionary in the New Hebrides before settling at Wangaratta where he worked as a physician for over 30 years. He contributed to his local community in a broad range of activities. Vernon Davies is an Australian pioneer of old age psychiatry.

The Australian federal government introduced additional Medicare Benefits Schedule (MBS) telehealth-items to facilitate care by private psychiatrists during the COVID-19 pandemic.

We analysed private psychiatrists’ uptake of video and telephone-telehealth, as well as total (telehealth and face-to-face) consultations for April 2020–April 2021. We compare these to face-to-face consultations for April 2018–April 2019. MBS-Item service data were extracted for COVID-19-psychiatrist-video- and telephone-telehealth item numbers and compared with face-to-face consultations for the whole of Australia.

Psychiatric consultation numbers (telehealth and face-to-face) were 13% higher during the first year of the pandemic compared with 2018–2019, with telehealth accounting for 40% of this total. Face-to-face consultations were 65% of the comparative number of 2018–2019 consultations. There was substantial usage of telehealth consultations during 2020–2021. The majority of telehealth involved short telephone consultations of ⩽15–30 min, while video was used more, in longer consultations.

Private psychiatrists and patients continued using the new telehealth-items during 2020–2021. This compensated for decreases in face-to-face consultations and resulted in an overall increase in the total patient contacts compared to 2018–2019.

This longitudinal study examined changes in psychological outcomes of perioperative frontline healthcare workers at one of Australia’s most COVID-19 affected hospitals, following the surge and decline of a pandemic wave.

A single-centred longitudinal online survey was conducted between 26 May and 17 November 2020. Recruitment was via poster advertisement and email invitation. The survey was sent out every 4 weeks, resulting in seven time-points.

In total, 385 survey results were analysed from 193 staff (about 64% response rate), 72 (37%) of whom completed the survey more than once. The prevalence of moderate-to-severe anxiety and depressive symptoms peaked at 27% and 25%, respectively, during the pandemic surge. Up to 35% displayed post-traumatic stress disorder (PTSD) symptoms. Although not statistically significant, the trend of depressive and PTSD symptoms worsened over time, especially among females and anaesthetic/surgical trainees, despite subsidence of the pandemic curve. Technicians and anaesthetic/scrub nurses were the at-risk groups with worst psychological outcomes.

We found persistent mental health impacts on frontline perioperative HCWs despite subsidence of the pandemic wave. Further research is needed to determine the extent and trajectory of such impacts with larger sample sizes to determine generalisability to frontline HCWs in general.

In this study, we aimed to identify service user demographic and clinical characteristics of an acute mental health service in South Auckland during the first New Zealand coronavirus-related lockdown.

We conducted a clinical audit of a sample of service users presenting to a district health board's acute adult mental health service during New Zealand’s level-4 lockdown in 2020 and made comparisons to a sample from 2019. We identified demographic factors, living situation, mode of referral, mode of assessment, diagnosis, substance use, risks, stressors, use of mental health act legislation and follow-up.

During the first level-4 lockdown fewer Ma¯ori were assessed, police referrals increased, specific stressors related to confinement were identified and there was an increase in risks relating to self-harm and harm to others.

Service users had unique stressors and changing patterns of presentation during the level-4 New Zealand lockdown. In response to the changing needs of service users during a pandemic, we recommend optimising telehealth, enhancing connections with other essential services, development of digital interventions and care for frontline staff.

The COVID-19 pandemic may cause a major mental health impact. We aimed to identify demographic or clinical factors associated with psychiatric admissions where COVID-19 was attributed to contribute to mental state, compared to admissions which did not.

A retrospective cohort study was undertaken of inpatients admitted to Northern Psychiatric Unit 1, Northern Hospital in Melbourne, Victoria, Australia during 27/02/2020 to 08/07/2020. Data were extracted for participants who identified COVID-19 as a stressor compared to participants who did not. Fisher’s exact test and Mann-Whitley rank sum test were used.

Thirty six of 242 inpatients reported the COVID-19 pandemic contributed to mental ill health and subsequent admission. Reasons given included social isolation, generalized distress about the pandemic, barriers to support services, disruption to daily routine, impact on employment, media coverage, re-traumatization, cancelled ECT sessions, loss of loved ones, and increased drug use during the lockdown. Chronic medical conditions or psychiatric multimorbidity were positively associated and smoking status was negatively associated with reporting the COVID-19 pandemic as a contributor to mental ill health.

Screening and identifying vulnerable populations during and after the global disaster is vital for timely and appropriate interventions to reduce the impact of the pandemic worldwide.

The aim of this study was to investigate the well-being of people with severe borderline personality disorder (BPD) during the first wave of COVID-19 social restrictions.

Clients of an outpatient specialist personality disorder clinic (n = 77) were invited to the study. An online survey was conducted including a range of open-ended questions exploring well-being and the Coronavirus Anxiety Scale (CAS) which assesses ‘coronaphobia’. Qualitative data were analysed using inductive content analysis with NVivo software. CAS data were analysed descriptively using SPSS version 25.

Thirty-six surveys were completed (48% response rate). Many participants experienced significant challenges to their overall well-being during lockdown although some reported improvements in psychosocial functioning. Three participants (8.3%) experienced clinically significant ‘coronaphobia’.

The self-reported physical and mental health of participants with BPD demonstrated resilience, suggesting that the capacity to maintain treatment via telehealth helped to mitigate many of the adverse aspects of social restrictions. This study was conducted during the first wave of social restrictions; subsequent studies will reveal longer-term effects of extended community lockdowns.

Victoria has low numbers of general adult psychiatric beds per capita by Australian and international standards. Hospital key performance indicators (KPIs) such as bed occupancy rates, emergency department waiting times and inpatient lengths of stay are proximal measures of the effects any shortfall in beds. We investigate the real-world performance of Victorian hospitals during the first year of the COVID-19 pandemic and the extended lockdowns in 2020.

The Victorian inpatient psychiatric system is characterised by high bed occupancies in many regions, extended stays in emergency departments awaiting a bed, and short inpatient lengths of stay, except for patients with excessively long stays on acute units (over 35 days) who are unable to be admitted to non-acute facilities. At the end of 2020, bed occupancies were high (above 90%) in 10 regions, with three regions having bed occupancies over 100%. However, state-wide average bed occupancy improved between 2019 (94%) and 2020 (88%). Other KPIs remained steady because acute hospitals did not experience the expected pandemic mental health demand-surge. For a more complete picture of the impact of the pandemic, Australia needs interconnected, centralised data systems.

Sudden cardiac death (SCD) is a significant cause for increased mortality in people with schizophrenia and schizoaffective disorders. Cardiac arrhythmia is one cause of SCD. Electrocardiographic (ECG) abnormalities predictive of arrhythmias are associated with antipsychotic drug use.

This chart audit examined the types and frequency of ECG abnormalities (ECG-Abs) in 169 patients with schizophrenia and schizoaffective disorder in a long-stay inpatient unit. We examined the association of ECG-Abs with demographic details and psychotropic drug prescription using chi-square test, Fisher’s Exact test, independent two-sample t-test, Pearson’s correlation, and one-way ANOVA.

Eighty-eight patients (52.1%) recorded at least one ECG-Ab, and 20.7% had two or more ECG-Abs. The use of multiple antipsychotics, with or without other psychotropic drugs, did not associate significantly with the presence or number of ECG-Abs.

A significant proportion of patients with schizophrenia and schizoaffective disorder have ECG-Abs other than prolonged QTc interval, which can predispose them to cardiac arrhythmias. The abnormalities were not limited to patients on psychotropic polypharmacy. ECG evaluation is indicated for all patients and should consider various electrical abnormalities to identify arrhythmia risk.

The stressful nature of the intensive care unit (ICU) environment is increasingly well characterised. The aim of this paper was to explore modifiers, coping strategies and support pathways identified by experienced Intensivists, in response to these stressors.

Prospective qualitative study employing interviews with Intensivists in two countries. Participants were asked how they mitigated their emotional responses to the stressors of the ICU. Audio-recordings were transcribed and analysed by all researchers who agreed upon emerging themes and subthemes.

A wide range of strategies were reported. Although several participants had sought professional help and all supported its utility, few disclosed accessing such help to others indicating stigma. Many felt a sense of responsibility for the well-being of other staff but identified barriers that suggest alternate support pathways are required. Further implications of these findings to training considerations are described.

Several approaches were described as regularly employed by Intensivists to mitigate ICU environmental stressors. Intensivists perceive themselves to have limited training to provide support to others; they also perceive stigma in seeking professional help.

This cross-sectional survey aimed to establish the views and intentions of New Zealand (NZ) psychiatrists regarding their role as competence assessors in the NZ End of Life Choice Act (‘Act’). Some questions were replicated from a pre-existing Ministry of Health workforce survey regarding the Act, for comparative analysis between psychiatrists and other health professionals.

The survey was disseminated via email to all NZ psychiatrists registered with the Royal Australia and NZ College of Psychiatry and promoted by snowballing methods to reach non-members.

There were similar (moderate) levels of understanding of the Act, compared to other health professionals. Psychiatrists show similar levels of support for assisted dying as other health professionals (55% and 47%, respectively), however psychiatrists are significantly less likely to be willing to provide assisted dying services than other health professionals. Concerns were raised regarding the challenges faced by psychiatrists and need for more clarity around the psychiatrist’s role.

Few NZ psychiatrists were willing to be involved with the Act. There was a perceived lack of information around a psychiatrist’s role, responsibilities and legal protections. Further guidance is needed regarding the concept of capacity in assisted dying and the factors that challenge these assessments.

The aim of this project was to evaluate the experiences of Royal Australian and New Zealand College of Psychiatrists (RANZCP) trainees in a regional centre who participated in a psychodynamic psychotherapy written case supervision group with three co-supervisors.

A web-based survey was sent to RANZCP trainees. Descriptive statistics were performed, and written feedback was analysed.

A total of 8 of 10 eligible trainees completed the survey. All respondents stated that the group met their training needs. The average rating of feeling understood by supervisors was 91 (maximum 100). Positive feedback was received about the variety and breadth of experience provided by the co-supervisors. Trainees felt that 1:1 supervision was important to complement group supervision.

The supervision group model with three co-supervisors is competently meeting the training needs of RANZCP trainees as well as providing a deep learning experience. This model may be of use in other services, particularly in regional settings.

To explore the theme identified by Bagster et al.¹ in their selective psychiatric literature review that formulation can appear daunting.

Formulation is understandably daunting, even though it occurs in all human encounters. The plural nature of mental symptoms is such that anxiety-provoking intuitive judgement is required at all points in both the process and explication of formulation, a type of instinctive guessing. There are no rules for this, because the laws of vertical integration of systems are not established. Guidelines are more appropriate than ‘instructions’. Much of the wider mental health and clinical reasoning literature addresses intuitive judgement, but the current psychiatric literature tends to focus on pattern recognition as a deliberative cognitive act of Type 2 processes. Arguably this reductionism adds to the dauntingness. Anxiety detected about the intuitive judgement involved can be addressed in supervision, taking into account the psychological mindedness of the trainee.