Literature Flashcards
Relapse rates of MDD within 12 months of ECT cessation in TR MDD
50%
Lithium in TR MDD
Adjuvant agent best supported by clinical trials for use
Rasmussen KG 2015
Lithium for post ECT depressive relapse prevention
?optimal target blood level,
duration of use and concomitant antidepressant use
Decriminalisation of mentally ill in terms of EEO. The problem with EEA
Paul Brown AP 2015 The current decriminalisation is the term which I apply to the relatively novel practice of police officers (and ambulance officers) who, under various state mental health acts, deposit the dangerously mentally ill at emergency departments. The point about the EEO is that it is a first-order solution to a problem that requires a second-order solution. The latter is usually couched in economic terms. Meantime, the police are currently the arbiters of diagnosis of much mental illness. Perhaps we should be providing them with more training?!
Kerry Dawes re medical students in private practicw
Interestingly, we found that those students placed in the private facility reported a much more positive view of psychiatry as a profession and a more optimistic outlook for those with mental health problems than those placed in the public sector. This is an area that needs further evaluation. Reference 1. Galletly CA, Turnbull C and Goldney R. Medical student teaching in the private sector – An overlooked opportunity? Australas Psychiatry 2016; 24: 198-200.
AP polypharmacy
Antipsychotic polypharmacy (APP), the concurrent use of two or more antipsychotics, is generally debated, discouraged and still likely implausible. It implies total higher-than-required D2 blocking doses (>60% for antipsychotic efficacy) with: •• Lack of evidence base •• Greater side-effects burden •• Possible drug interactions •• Jeopardizing treatment adherence •• Added costs.
Patrick et al.1 reviewed the literature and found three out of four double blind studies, and nine out of 13 open-label trials showing combination therapy was effective in reducing symptomatology ostensibly in clozapine partial responders.
As Goff and Dixon4 put it, polypharmacy
does not produce side effects;
it is the specific drugs and doses that
matter.
A meta-analysis of 19 studies by Correll and Gallego3 found a significant advantage for antipsychotic polypharmacy relative to monotherapy as regards efficacy and all-cause discontinuation, notably when clozapine was included and when used simultaneously rather than sequentially
It then behooves clinicians to neither refrain from APP nor to have an allopathic compulsion to go for heroic combos from the outset. Sound clinical judgment/acumen would dictate when APP might be well reasoned, and as Stahl famously put it: ‘never say never but never say always!’
Development of community care unit
The process of deinstitutionalisation across the
developed world began in the 1950s leading to
downsizing and closing of asylums.1
In Victoria,
non-governmental organisations (NGOs) managed halfway
houses or hostels built to allow patients discharged
from such asylums to adapt to living in the community.
A 10-bed residential rehabilitation unit separate to the
halfway houses or hostels with 24 hour on-site clinical
staffing was established in 1988. This became the
state’s first community care unit (CCU). Over time several
CCUs were established as part of Australian mental
health strategy (1992).
They were developed as purpose
built cluster housing developments, modelled on the
concept developed in the United Kingdom of locating
the ‘ward in the community’.
There has been limited research into CRCs, and of CCUs, since the deinstitutionalization period. Comprehensive evaluation of the processes and outcomes of these services is needed to guide best practice.
Recovery approach
“gaining and retaining
hope; understanding of one’s abilities and limitations;
engagement in an active life; personal autonomy; social
identity; meaning and purpose in life; and a positive
sense of self.” NSW consumer advisory group 2009
Recovery focus is about strengths based and wellness oriented approach. Enable people to live meaningful lives in the community
The key principle underlying the model of care is to
place the consumer at the centre, and recognise the
unique physical, emotional, social, cultural and spiritual
dimensions of each individual and empower and support
them to make decisions about their treatment and
recovery. The concept of increased patient autonomy as
part of recovery-oriented care has required a whole new
staff culture to be created.
Application for research
Research projects require review of both ethical and
scientific acceptability, and compliance with local
research governance prerequisites. For the former,
either the Application Form for Ethical and Scientific
Review of Low and Negligible Risk Research (LNR) or
the National Ethics Application Form is used.
Contacting the Executive Officer of the Human
Research Ethics Committee (HREC) for advice regarding
appropriate selection of forms and HREC was
informative and easy.4 The LNR is used where the risk
to participants does not exceed inconvenience or discomfort
as formally defined.5 Low and negligible risk
research is eligible for expedited HREC review.
Research governance pertains to an institution’s consideration
of pragmatic issues such as experience of researchers
and accountability. A relevant Site Specific Assessment
form must be submitted to the research governance officer
of the participating institution. Approval from the
Scholarly Project Branch Training Committee (BTC) can
then be sought.
Pharmakokinetic and pharmacodynamic failures in TR schizophrenia
All of these aspects need to be factored in the differential diagnosis. Failure to do so might result in the hasty changes of medications to the detriment of patients.
Pharmakokinetic-> absorption, distribution, metabolism
Pharmacodynamic-> at receptor, supersentivity. Drug-drug interactions
Dopamine
supersensitivity has been tied to
substance use, social isolation, organicity and genetic polymorphisms. Pharmacodynamic
relapse might also be related to
antipsychotic tachyphylaxis with
continuous treatment
Aripirazole- high affinity, can displace other antipsychotics. Then acts like a partial agonist, reducing overall activity. May see a relapse.
Job satisfaction for psychiatrists Rostein et al 2017 AP
> 80% of respondents experienced overall job satisfaction
would like to see changed, participants raised issues
related to patient variety, administration, work hours,
workplace safety, training and job satisfaction. Some
respondents indicated a desire for increased variety in
patient diagnoses, more psychotherapy, research and
academic work. Excessive paperwork, including form
filling and meeting KPI (key performance indicator) targets,
was viewed negatively by many respondents who
saw these activities as detracting from clinical work. A
number of respondents indicated they would prefer
reduced working hours and less overtime, and a significant
number had concerns relating to safety in the workplace.
Safety was a particular concern in the acute public
sector. Training issues included limited choice of rotations
and diversity of experiences, length of training and
difficulties balancing service needs and training commitments.
“Too much work, too little time” number one stressor
stress of training examinations Rostein et al
For trainee psychiatrists
74.5% found examinations moderately/
extremely stressful and 88.1% of trainees found training
hurdles moderately/extremely stressful
It is imperative
for the College to continue its work towards optimising
the health and well-being of its members.
bullying in the workplace
In 2015 the Australian Medical
Association (AMA) revised their position statement on
workplace bullying and harassment and noted a ‘culture
of bullying and harassment that has, over time,
become pervasive and institutionalised in some areas
of medicine’.
Karasek’s model of job strain
Karasek’s model of job strain which considers the
balance between demands on the employee and their
degree of autonomy
work life balance for psychiatrsists Evans et al
Previous research has suggested that doctors have higher
rates of mental illness, marital dissatisfaction, substance
misuse, and suicide.8,10 It has been argued that medicine
is a “challenging career where a stoic work ethic is the
dominant culture, and personal needs are secondary to
the needs of both patients and employers.”11 However,
this ignores the fact that “a critical element contributing
to the stress that many conscientious doctors experience
is internal.”12 Our research demonstrated that both
internal and external factors impact on WLB.
Furthermore, past research shows that doctors find it
hard to seek help when ill.10 Thus, we can infer that
addressing stress and burnout in doctors is likely to be a
complex undertaking.
Kahneman D.
Blaming the external environment may be
more comfortable than reflecting on internal motivation
and thinking: “It is much easier, as well as far more
enjoyable, to identify and label the mistakes of others than to recognise our own.”
Reconciliation
Action Plan 2016–2018
The launch highlighted the importance of reconciliation and engagement with Aboriginal and Torres Strait Islander peoples, as well as the RANZCP’s continuing vision to contribute to the reduction of inequality in mental health outcomes for Aboriginal and Torres Strait Islander people.
neuromodulation techniques S Hussain 2017 AP
In summary, evidence is mounting regarding the validity
of the potential novel neuromodulation techniques.
Therefore, it is crucial to adopt a balanced strategy to support
research in neuromodulation and maintaining
healthy optimism. Furthermore, it is prudent to assert the
learnt morals from history to refrain from adopting a
defensive or reductionist attitude towards or against any
of these approaches in a way that restricts innovation and
further development of treatment modalities and deprives
patients from what can be life-saving treatments.
self-illusion psychotherapy Steve Stankevicius
Our usual experience of the self is an illusion. Rather than a discrete entity, it is a network of processes
that maintains apparent irreducible unity via alterations of perceptions, beliefs, intentions and memories
William James conceptualised the self as consisting
of two components: the minimal self (moment-tomoment)
and the narrative self (extended in time).
Indeed, illusion
is defined as “the perception of something
objectively
existing in such a way as to cause misinterpretation
of its actual nature”.
Selfgenerating
elements, including memories, beliefs, intentions
and invariant representation, can be conceptualised
as the partial circles of the Kanizsa square illusion.
Memories support the self, but are also constrained and shaped by the self. Memory-self system
Invariant representation involves
cortical processes that shape our perceptions by constantly
creating predictions about what is coming next.
Since these predictions are formed by factors such as our
memories and emotional state, they are dependent on
the self, and in turn reinforce the self
Indeed, we should remember that
the forces of evolution by natural selection have not
necessarily favoured continually happy organisms, but
coherent beings able of constructing and executing an
aligned set of plans in order to survive and reproduce in
a hostile environment.
Cognitive dissonance can be utilised in psychotherapy
to achieve therapeutic gains. For example, behavioural
therapy encourages a patient to repeatedly act in a way
that contradicts self-orientated beliefs; discordance that
motivates revision of incongruent beliefs
Early findings from diffusion tensor
imaging and functional magnetic resonance imaging
studies have shown that some forms of psychotherapy
and mindfulness result in significant changes in white
matter and functional network efficiency of the brain
The self is an illusion from neuroscientific, philosophical
and experiential perspectives. Rather than a unitary
and pervading inner subject of thought and experience,
it is a complex network of perceptions, beliefs, intentions
and memories. Though it is an illusion, the self
provides a “center of gravity” around which these facets
are moulded to maintain individual coherence.23 This
unity allows one to experience, predict and interact with
the world efficiently.
conversational model psychotherapy Korner et al
Conversational Model Therapy remains an important evidence-based option in fostering recovery
and growth for many patients with traumatic disruptions and restrictions of self. It is one of an emerging group of
relational psychotherapies, broadly reflecting a change from a one person to a two person (intersubjective) psychological
paradigm in psychotherapy.
Russel Meares
It has demonstrated
maintenance of progress with long-term followup;
6,7 replication of findings with a different cohort;8
and cost-effectiveness
sustained improvement has been demonstrated
five years after completion of therapy
The essential forms
of intervention are seen to be analogues of a healthy
developmental relationship and involve the communicative
responses of ‘coupling’ (staying close to what is given
by the patient); ‘amplifying’ (building on what is most
alive); and ‘empathic representation’ (sharing what has
been understood in a tentative, collaborative way that
gives priority to the patient’s view). Where a patient is
engaged with the therapist in a medium- to long-term
therapy, the therapist will contribute to disjunctions and
will need to work on repair, which, if done adequately, is
often an opportunity for therapeutic growth
Suckling infant Henry moore
From 1920 onwards, Moore deconstructed the Palaeolithic
Venus figurines, before moving to the mother–infant
motif – a fundamental obsession throughout
his life.5 His
confronting sculpture Suckling Child (1927) intuitively
captures the essence of Klein’s theories, visually evoking
the ‘paranoid schizoid’ position. Suckling Child is a baby’s
perception of the mother as breast only (part object) existing
for the baby’s immediate gratification. The mother
(whole object) is almost obliterated (Figure 2).
Psychotherapy registrar position
This psychotherapy registrar position is a novel role that provides an opportunity to work in an intensive
and sustained way with patients and within multidisciplinary teams whilst being supported by supervision and
a rich teaching milieu. It offers experience of psychotherapeutic work not usually available in public mental health
services. It thus assists the development of psychotherapeutic skills that are likely to enhance the future practice of
those undertaking the role.
concept of mental wealth
The term was coined by
Beddington and colleagues,1 who showed that economic
and social capital builds to a peak in early adult
life. Seventy-five per cent of mental illness emerges
prior to or during this period and poses the greatest
threat to economic and social development of nations.
So prevention, early intervention and effective treatment
for children and emerging adults are the keys to
safeguarding ‘mental wealth’.
We continue to suffer
from serious underinvestment in direct and proactive
mental health care, and this is costing the Australian
economy tens of billions annually through huge downstream
productivity and welfare costs.
Implementation science is concerned with the translation
of the best currently available evidence into clinical
practice. The evidence-based
paradigm has been misused by vested interests through
the tactic of raising the bar and demanding ever-perfect
evidence to block an overdue reform.
This is otherwise
known as ‘clutching at flaws’. Reform can never depend
on perfect evidence. The perfect is the enemy of the
good and so we must make decisions now on the best
available evidence, and just as importantly know how to
implement these decisions in the face of inertia, discrimination
against mental health in funding allocations,
and predictable undermining by vested interests. What
is clear is that the ‘right’ reasons, such as relieving suffering,
reducing disability and the logic of making the latest
scientific advances available to patients in a reliable
and equitable manner, are necessary, but nowhere near
sufficient.
impact of headspace Pat McGorry
So
headspace represents a new entrance hall and front
room of our health system, not a total solution. For full
effect and to transform outcomes, prevention and early
detection programs, novel, technology-assisted ‘onramps’,
and the addition of other spaces in the building,
where more specialized expertise can be accessed, need
to be built. The advent of headspace has further exposed
the latter gap. This is preventing the waiting list for specialized
care being hidden or denied, and will force state
and federal governments to fund this gap.
In 10 years,
more than 270,000 young Australians have received help
and treatment through headspace services. The report
was overwhelmingly positive and highlighted significant
successes achieved by headspace, and top of the list was
the improved access, engagement and satisfaction.
The ‘soft entry’ approach of headspace favours
simple solutions with minimal professional input for
those who do not need this. It also means that those with
emerging complex disorders can be fast tracked into
stepped care and preemptive care
propaganda
information, especially of a biased or misleading nature, used to promote a political cause or point of view.
dissociation and hallucinations
- Experiences varied from external, pervasive, distressing,
uncontrollable voices to those occurring
in the internal subjective space and retaining
insight. - Diagnosis was a poorer predictor of the experience
of trauma intrusive hallucinations than previous
childhood sexual abuse and derealisation/ depersonalisation
scores. - The higher rates of derealisation/depersonalisation
in trauma intrusive hallucinations suggests
that a state of dissociation may be a mediating
factor.
tackling society’s image of psychiatry
As Hopson (2014, p.178) writes, “Psychiatrists should pay thoughtful attention to the task of persuading society that they are healers and not torturers, criminals, sexual predators, charlatans and money-grubbing madmen”. They can so persuade by advocacy and education, but also – and perhaps more importantly – by their own professional integrity, compassionate patient care, and scientifically robust practice of psychiatry.
trauma and BPD
In a large sample, Zanarini and colleagues found that
85% of BPD sufferers had experienced childhood
trauma,12 with associated insecure attachment commonly
associated with such trauma.
trauma and neuro changes
It is now well-established that childhood maltreatment
coupled with genetic vulnerability evokes a stress
response that can promote pathophysiological processes.
19 This results in disruptions in neuroendocrine,
neurochemical and neuroimmunological systems with
feedback system loops between all of the critical central
nervous system anatomical and neurochemical pathways.
20 Childhood maltreatment can trigger major neurobiological
destabilisation, with major disruption of
hypothalamic–pituitary–adrenal (HPA) axis functioning
and cortisol production.21 Although direct mechanisms
are yet to be defined, studies have highlighted epigenetic
modifications to be the environmental/gene link.
cPTSD and BPD
The term ‘complex PTSD’ may be less stigmatising
and opens the possibility of developing and applying
more trauma-informed treatment strategies.
role of trauma in BPD understated. Stigmatising
A lot of overlap
self harm
Self-harm is defined as the deliberate,
direct injury of one’s own body tissues, usually without
suicidal
intent, although self-harming behaviour may
be life-threatening
Belief in Jinn
Beliefs about jinn possession are common and widespread
in some countries,1, 2 but often unfamiliar to clinicians
in Australia. Jinn possession phenomena are
most frequently observed in migrants from Pakistan,
Bangladesh, the Middle East, North Africa, and other
parts of the Islamic world.3 According to Islamic beliefs,
jinn are spiritual creatures created by Allah, who live
alongside humans but cannot be seen. It is written in the
Qur’an that humans are created from clay, and jinn are
created from the flame of smokeless fire. Jinn possession
refers to the belief that a jinn has entered a person’s
body, to control or influence them against their will. A
better understanding of these beliefs would help
Australian clinicians to formulate a more accurate diagnosis
and strengthen the therapeutic alliance with
Muslim patients.
infant of psychotherapy Newman
The infant of psychotherapy exists on
two levels: first, the infantile experience of the adult in
therapy where psychotherapeutic processes are important
in recreating a narrative of early experience and
promoting understanding of the psychological impasses
that emerge from infantile experience; second, the
infant of transgenerational processes where a parent’s
own infantile experiences of being parented influence
themselves in their relationship with their infant.
the beginnings of the self
From a psychological
perspective the earliest origins of the Self are in
parental recognition of the infant and acknowledgement
of the infant’s mind, described as parental reflective
functioning or the recognition of the interiority of
the infant. Psychoanalysis has focused on the process of
coming to form a relationship with the infant and
acknowledgement of the infant’s psychological separateness.
From a neurobiological point of view this acknowledgement
of the Self of the infant also implies that the
parent has the capacity to both label and process the
infant’s affective communication. Neurobiological
approaches to the understanding of the complex task of
parental affect recognition are emerging which provide
the beginnings of a model of the neurodevelopment of
affective regulation.6
Neurobiologically this might be described as the way in
which the carer operates to maintain the infant in an
optimal level of neurophysiological arousal, and based
on their sensitive attunement and reading of the infant’s
state this is modulated and regulated
concept of resilience
The concept of resilience provides an overarching concept
for thinking about the capacity to regulate both
stress and emotional experience and those emergent
capacities for self-regulation
Importantly it is also seen as a
neurological capacity for affective regulation, stress regulation
and for empathic functioning which develop in
a relational context.8 From the perspective of attachment
theory, resilience can be seen as referring to the
capacity to use relationships with others for self-regulation
and for maintaining a sense of cohesion. In this
way, the concept of resilience is one example of an integrative
psychological and neurodevelopmental construct
and one which is useful in terms of describing
factors on several levels which shape an individual’s psychological
functioning. Resilience
mirroring
Within the psychoanalytic tradition Winnicott’s
concept of maternal mirroring has described this in
some detail and integrating this with more recent concepts
of mutual regulation from a neurological point of
view has provided elaboration of the importance of
sequences of mutual relationships.
forced smoking cessation , caffeine consideration
The consumption of caffeinated products (e.g. coffee, tea, cola) is common amongst people with mental illnesses, a concern because caffeine is also a substrate for the CYP1A2 enzyme.5 Enforced smoking abstinence may diminish caffeine metabolism, and if intake is not modulated symptoms of caffeine toxicity (e.g. restlessness, anxiety, sleep disturbance, gastrointestinal disturbance, diaphoresis and tachycardia) may ensue. Ironically, these may be interpreted as signs of nicotine withdrawal, or an exacerbation of the symptoms of mental illness.
Research Domain Criteria initiative
The Research Domain Criteria (RDoC) project is an initiative being developed by US National Institute of Mental Health. In contrast to the Diagnostic and Statistical Manual of Mental Disorders maintained by the American Psychiatric Association, RDoC aims to be a biologically-valid framework for understanding mental disorders: “RDoC is an attempt to create a new kind of taxonomy for mental disorders by bringing the power of modern research approaches in genetics, neuroscience, and behavioral science to the problem of mental illness.
To clarify the underlying causes of mental disorders, it will be necessary to define, measure, and link basic biological and behavioral components of normal and abnormal functioning. This effort will require integration of genetic, neuroscience, imaging, behavioral, and clinical studies. By linking basic biological and behavioral components, it will become possible to construct valid, reliable phenotypes (measurable traits or characteristics) for mental disorders.
in defense of DSM
As Prof Frances puts it in an essay on the topic called Psychiatric Diagnosis: “Our classification of mental disorders is no more than a collection of fallible and limited constructs that seek but never find an elusive truth. Nevertheless, this is our best current way of defining and communicating about mental disorders.
“Despite all its epistemological, scientific and even clinical failings, the DSM incorporates a great deal of practical knowledge in a convenient and useful format. It does its job reasonably well when it is applied properly and when its limitations are understood. One must strike a proper balance.
It is also easy to forget how open to doubt psychiatric diagnoses were in the past. In a landmark 1973 paper by David Rosenhan (On Being Sane in Insane Places), eight people with no history of mental illness feigned symptoms in order to gain admission to mental health facilities. As soon as they did gain entry they then stopped feigning any symptoms, yet none of the staff noticed any change in their behaviour. Embarrassingly enough, many other patients did suspect that these people were “not crazy”.
Another study from 1971 found that psychiatrists were unable to come to a shared diagnostic conclusion when studying the same patients on videotape.
Therefore any improvement in the diagnostic framework for mental health, however imprecise it may be, should never be taken for granted.
criticisms of DSM
In their letter, a group of psychiatrists argued that they were “concerned about the lowering of diagnostic thresholds for multiple disorder categories, about the introduction of disorders that may lead to inappropriate medical treatment of vulnerable populations, and about specific proposals that appear to lack empirical grounding
henry barnett
“no kind of deception should be practised towards patients”
violence and neuropsychological deficits
Cognitive deficits have long been considered a core component of psychotic disorders. In this line, it has been supported that aggression levels differentiate primarily due to the varying levels of deficits in cognition, as researchers have found that cognitive tasks are valuable in predicting aggression and its management. 2
tripartite mission
research
teaching
clinical practice
doctor as teacher
There is a long tradition of doctors as educators. Indeed,
the word ‘doctor’ is derived from the Latin docere, which
means ‘to teach’.
competent medical educators
medical knowledge, learner centredness, interpersonal and communication skills, professionalism and role modelline, practice based reflection, system based practice
MHA and RANZCP position
Provide adequate resources to ensure that effective, culturally- informed alternatives to involuntary treatment can be provided to all who need them - in particular, Aboriginal and Torres Strait Islander peoples and Māori.
Ensure that health services have the resources to provide early identification and treatment of mental health conditions, allowing compulsory treatment to be reduced in a safe and clinically sound manner.
UN Principles for the Protection of Persons with Mental Illness 1991, as opposed to the more recent Convention on the Rights of Persons with Disabilities (CRPD). The CRPD conceives of ‘disability’ as the product of interaction with social/environmental barriers, as opposed to a deficiency or deviation from the norm.
Although the CRPD Committee calls for the abolition of MHAs and forensic patient legislation, this is unlikely to occur in the foreseeable future, but the CRPD is helping to drive law reform that emphasises recovery, decision-making capacity and supported decision making
Specifically, article
12 of the CRDP calls for state parties to replace the
paternalistic ‘best interests’ or ‘harm minimization’
model with a rights-driven ‘supported decision-making’
model in which a person makes treatment decisions
for themselves, with support where required.5
Given the gaping chasm between the two models, currently,
even the most progressive of Australian jurisdictions
have ‘substituted decision-making’ models in
which clinicians or tribunals may make treatment decisions
on the patient’s behalf in specific circumstances.
bloom’s taxonomy for formulation
- Identification and demographic details of the case Factual Remembering and
understanding - Case summary – key factors in the history and thematic
analysis
Factual Understanding and applying
2.1. Identification of stressors – trigger, contributory or
maintenance stressors
Factual Analysing
2.2. Identification of personal factors (i.e. historical features,
developmental, personality, vulnerability, coping strategies,
social support access, etc.)
Conceptual Analysing - Relationship between stresses, personal factors and
presenting features – i.e. hypothesis development using
psychological or developmental theories
Conceptual and
metacognitive
Analysing and synthesising
(creating) - Prognostication and evaluation of information and hypotheses Conceptual, procedural
and metacognitive
Evaluating
psychiatric advanced directives
While the requirement to provide reasons encourages
clinicians to make reasonably considered decisions,
without specific guidelines in place, such determinations
are likely to have a degree of subjectivity that renders
them poor safeguards of patient autonomy.
clinicians in QLD can override decisions in PAD
supervision in training
In obtaining value from supervision, the active role of the supervisee in seeking feedback, finding
value in criticism and building autonomy is emphasised. Additionally, the importance of exploring what value a
supervisor can offer and maintaining realistic expectations is considered. Trainees can benefit from taking an active
role in planning and managing their supervision to maximise their learning.
suvorexant
Suvorexant has not been trialled against other hypnotics, is expensive and its utility for insomnia in
patients with psychiatric disorders is unknown. Currently, use of suvorexant could be considered where more established
treatments are inappropriate
shared decision making
SDM is central to the
recovery model, the adoption of which has led to a
growing emphasis on the role of patients as active participants
in their healthcare. This approach respects the
contributions of both the patient with lived experience
and knowledge of their goals, values and life situation,
alongside the health professional with their training and
role in educating the patient.
reduced symptoms, improved selfesteem,
increased service satisfaction and improved
treatment adherence
barriers: Patient factors include things that impact on patients’
confidence in contributing to decisions about their
health such as lower levels of education, lower income,
limited access to information, self-stigma, current symptoms
of illness, feelings of powerlessness, lack of trust in
health professionals as well as cultural attitudes
- Preparation (history, problem analysis)
- Goal talk (identify discussion partner, identify
patient values and goals of care) - Choice talk (summarise and offer choice, patient
formulates treatment aims) - Option talk (personalised treatment aims are discussed)
- Decision talk (focus on preferences, connect to
patient values, goals of care and treatment aims,
decide) - Evaluation (evaluate the SDM process, prepare a
treatment plan)9
capacity adjusted approach shared decision making older people
A capacity-adjusted approach to
SDM has been proposed for older people with cognitive
impairment.10 This involves (1) inviting support persons
to attend consultations, (2) providing tailored decision
aids and coaching for patients and families, and (3) integrating
capacity-adjusted SDM into the regular workflow.
does early intervention prevent chronic psychosis. A question for the Victorian Royal Commission into mental health
Allison et al 2019
Victoria has highest spending per capita on youth mental health
Early intervention psychosis reforms inprove function while individuals in the program, but lack of evidence to suggest prevents chronic psychosis
Vic has lowest spending in adult services, few beds, few community contract. Does youth mental health services reduce service requirements in midlife when prevalence and burden of mental illness reach its peak?
Vic youth progrmmes unlikely to reduce the idlife prevalence and disease burden of schizophrenia
EPPIC- 75% did not recover, only a 1/4 achieved both symptomatic remission and social/vocational recovery
ECT titration Rosenman ANZJP 2019
Seizure threshold titration in electroconvulsive therapy is not a proven technique of dose optimisation. It
is widely held and practiced; its benefit and harmlessness assumed but unproven. It is a prematurely settled answer to an
unsettled question that discourages further enquiry. It is an example of how practices, assumed scientific, enter medicine
by obscure paths
what we know about school shooters
Newman and Fox (2009) identified five necessary conditions, although they are not regarded as sufficient to culminate in a shooting. These are •• Marginalisation; •• Psycho-social problems; •• Cultural script; •• Availability of guns; •• Failure in prevention and surveillance systems.
eight warning behaviorus in school shooters indicating possible threat
•• Pathway warning behaviours. Behaviour is part of research, planning, preparation or implementation of an attack. •• Fixation warning behaviours. Indicating pathological preoccupation with a person or cause. •• Identification warning behaviour. Identification with militaria, warriors, previous attackers. •• Novel aggression warning behaviour. Violence unrelated to attack behaviour, committed for the first time, as the perpetrator tests out their ability to do the violent act. •• Energy burst warning behaviour. Increasing frequency or variety of activities related to the target. •• Leakage warning behaviour. Communication to a third party (intentional or not) of intent to do harm to a target. •• Directly communicated threat. Communication of a direct threat to the target or law enforcement. •• Last resort warning behaviour. Increasing desperation or distress through declaration in word or deed.
Conducting a medico-legal assessment
- Determine patient’s understanding of the request
- Consent
- Explain the purpose, the form of the interview, privacy, availability of breaks/refreshments
- Confidentiality not confined to the usual standard of doctor-patient
- Professional, neutrality, duty of care
- Should not be providing routine treatment.