Showing papers in "Australasian Psychiatry in 1996"

The centre for young people's mental health: Blending epidemiology and developmental psychiatry

Abstract: (1996). The Centre for Young People's Mental Health: Blending Epidemiology and Developmental Psychiatry. Australasian Psychiatry: Vol. 4, No. 5, pp. 243-247.

Outcome Measurement: Sharing Experiences in Australia

Abstract: There is growing attention to evidence-based medicine both in informing medical education and in guiding clinical practice. The result is increasing emphasis on evaluating treatment efficacy, the structure of health care delivery, the allocation of the health dollar and the application of information technology to these tasks. Implications are emerging for psychiatric care in Australia from everyday clinical practices to the political level. Collective experience in this area, as discussed at a conference forum in Sydney [1], is summarized in this paper. This information is presented to stimulate thought, foster comparisons and encourage a synthesis of clinical, administrative and political directions in this field.

A Pilot Study of the Health of the Nation Outcome Scale as a Measurement of Outcome in a Private Psychiatric Hospital

Abstract: In this era of increasing accountability in health care there is a need for an easily administered reliable instrument to assess the outcome of patients treated for psychiatric illness. This need has been reviewed comprehensively by Andrews et al [1]. One of the several instruments they recommended was the Health of the Nation Outcome Scale instrument (HoNOS) [2,3]. This paper describes the introduction of the HoNOS in a private hospital setting.

Identity, Conflict and the Search for Nationhood

Abstract: katoa i runga i te tino miham o tenei huihuinga. Tena hoki koutou, i whakanuitia mai ki tenei whakaritenga. Anei nga takuta hinengaro o te motu, whiti atu ki Poi Hakena, ki Ahitereiria whanui, me etahi o nga moutere o te Moana-Nui-aKiwa. KO te kaupapa e mauria mai e ratou ko te hauora h i n e n p , a ko te tino take, ko te oranga tangata. Heoi an0 tens koutou i tae mai i tenei PO ki te tautoko, ki te tutaki tatou ki a tatou. Kia ora an0 tatou [I]. Engari ko tatou nei o te hunga ora, tena tatou

Culture and Mental Health in Burma

Abstract: CULTURAL CONTEXT The help-seeking behaviour of a Burmese patient, as in other parts of Asia, may be influenced by a number of culturally determined factors such as difEculty in complaining to a doctor about close relationships, the social construction of illness, which is usually determined by various folk beliefs, and expectations of the doctor or the healer, which are congruent with the concepts of illness that are held. As Kleinman has noted among non-Western societies [2], Burmese patients commonly use somatic symptoms to communicate their feelings of depression or anxiety. Although Buddhism, the dominant religion in Burmese society, has an enormous impact on the way of life in general, the Burmese patient’s perception of mental illness is much influenced by the preexisting Burmese supernatural beliefs related to a number of cults such as the worship of Nats (supernatural spirits), astrology and the practice of alchemy. This means that the treatment of disordered persons by traditional healers usually involves a process of overcoming malevolent spirits and other intervening forces. There are both similarities and differences between the criteria and methods for assessing Dr Raymond l in t Way Registrar Canberra Hapital ACT 2605 psychopathology used by traditional folk healers in the indigenous system and those employed by Western psychiatry. Some behaviour considered pathological by psychiatry may be considered ‘normal’ by Burmese and thought of as ‘Nut (spirit) possession’. Other behaviour may be regarded by both cultures as pathological but may be attributed to different causes. In the Burmese folk practices of the quasi-Buddhist sects (guings), exorcists are widely used to expel harmful supernatural beings h m the bodies of their victims with the assistance of benevolent beings. If an exorcism is followed by a return to normal behaviour, the ceremony is assumed to have been successful. Melford Spiro’s study [3] in Yegyi, a small village near Mandalay, pointed out some similarities between the Burmese exorcistic seance and the minimum definition of ‘psychotherapy’ given by Jerome Frank: . . . a form of help-giving in which a trained, socially sanctioned healer tries to relieve a sufferer’s distress by facilitating certain changes in his feelings, attitudes and behavior thnough the performance of certain activities with him, often with the participation of a group . . . [4]

Society, Trauma, amd Dissociation:

Abstract: The current official nosological status 1 of dissociative disorders could be said to be reflected by their location in DSM-W, sandwiched between factitious and sexual disorders. Three papers seeking to demystdy dissociative disorders and present a balanced scientific view were presented and discussed at a symposium at the RANZCP Wellington Conference 1996, entitled Society, Trauma, and Dissociation. They are integrated and summarized in this paper. Middleton chaired the session and later presented a discussion on the mental health ethos in which recognition and management of dissociation occurs. Butler analysed socio-cultural factors in the diagnosis and treatment of post-traumatic dissociation, and Driscoll surveyed dissociative responses in childhood. Brown integrated and discussed these papers and the issues which they elicited and also provided a Janetian perspective.

Public Sector psychiatry towards 2000. Isewroles and Challenges: Technician or Clinician?

Abstract: e Commonwealth and State Th governments have released mental health policies which are and will continue to impact on the public sector psychiatrist. What the implications of these policies are for the psychiatrist role and function is not clear, and this has potential for discomfort and distress for individuals striving to do more within the same or limited resources. As there are fewer psychiatrists now willing to remain within the public sector, it is im ortant to define the

Australasian Psychiatry and Euthanasia: Ranzcp Section of Consultation-Liaison Psychiatry's Working Group on Euthanasia

Abstract: In May 1995, the Northern Territory of Australia became the first legislative jurisdiction in the world to introduce legislation specifically sanctioning active voluntary euthanasia. Shortly after the introduction of the legislation many of Australia's political leaders announced that they would support similar legislation in their jurisdictions and there nave already been attempts to pass such legislation elsewhere in Australia and in New Zealand.

Personality Disorder or the Snark Still at Large

Abstract: WHAT IS PERSONALITY? Self-evidently one cannot have a personality disorder unless one has a personality to be disordered. What then is a personality? In your acquaintance there are people you think of in particular ways. Here is someone you regard as pleasant and mature; here on the other hand is someone whom you perceive as an abrasive skin-flint. I believe that I could produce many adjectives that you could relate to particular individuals. If we reflect a little it can be seen that there are some difficulties in such assessments. The first is that people behave inconstantly. I have seen home movies of Adolf Hitler patting small children on the head quite warmly and when Hugh Walpole met Adolf Hitler in 1925 he wrote: ‘Tears poured down his cheeks. I thought him fearfully ill-educated and quite tenth-rate pathetic. I felt rather maternal towards him’. We all know or have read of pillars of rectitude and religion who have gone to gaol for doing wicked things. People change. Another important obstacle in the way of making accurate judgements about people is that much of our behaviour is determined by the environment in which we happen to find ourselves at a particular time. For example, there are programs in prisons which produce major changes in the behaviour of the prisoners while they remain in prison and yet have no effect at all on their p s t discharge behaviour. A third difficulty is that being observed is likely to change our behaviour. It is an old observation that people driving automobiles without accompanying passengers tend to pick their noses when they think no one is watching one sees Dr John Ellnrd The Ellard Practice criminally inclined can be quite selective in doing what they do depending on where they are. We can all be on our best behaviour when it is necessary. And what of the observers? Each of US is located securely or insecurely in a carapace of beliefs, social conditioning and personal history which sign&antly determine not only what we do, but also what we see and the judgements we make. One imagines that the officers of the Inquisition, as they piled up the faggots for the burning of the next heretic, saw each other as admirable and well-intentioned people. I shall return to the problem of the observer when we come to discuss personality disorder itself. However, I cannot forebear from mentioning that particular form of naivety which believes that if one writes one’s questions down on a piece of paper and causes the persons being investigated to write their answers, or tick boxes, one achieves ‘objectivity’. In all this confusion and uncertainty some factors remain relatively constant. For example, while there is debate over the exact nature of intelligence and how many intelligences there are, there is no doubt that some people are relatively bright and some are relatively dull. These individual differences remain unless some new factor such as cerebro-vascular disease intervenes. Again, if a man is very large and muscular, or a woman is particularly beautiful, these qualities are likely to produce reasonably constant influences on their personalities, at least while they are undiminished. Personality and temperament are two much used words. I can offer you no clear distinction between them which is not surprising since I can define neither of them. However since Chess & Thomas’s work in the 1970s [1] there has been much written, spoken and done about the notion of inherited differences in temperament. Since we agree that there is a genetic and biological substrate to personality one might look there for some relatively constant elements in its construction. You will understand that I am not talking of specific abnormalities, such as attention deficit disorder with hyperactivity, but of individual differences in what we might call the nonnal equipment. Once more the difficulties in assessment are profound. Mothers do not always see their children through unbiased eyes and mothers and fathers do not always see them in the same light. It is not easy to distinguish between the child’s basic temperament, and behaviour which is a product of the child’s constitution and the responses of those who

The Myth of ‘Eclecticism’ in Psychiatry

Abstract: f we say, as people often do [1,2], that psychiatry is an eclectic field, what exactly are we saying? The immediate implication is that practitioners can pick and choose, more or less as they see fit, fkm what is on offer within the field and, quite likely, from outside as well. If so, this would be a strange form of science [3], but eclectics may retreat Gom this charge, saying that psychiatry isn’t a science. To some, this is not a handicap [4]; to others, it is a definite weakness [5]. In a practical field such as ours, one can be eclectic in three distinct areas: in theory, in research and in the practice of getting people better. Taking each of these areas in turn, I wish to consider the implications of espousing eclecticism within psychiatry.

Aboriginal Communities and Suicide

Abstract: Collective despair, or collective lack of hope, will lead us to collective suicide. This type of suicide can take many forms, foreshadowed by many possible signs: identity crisis, loss of pride, every kind of dependence, denial of our customs and traditions, degradation of our environment, weakening of our language, abandonment of our struggle for our Aboriginal rights, our autonomy and our culture, uncaring acceptance of violence, passive acknowledgment of lack of work and unemployment, corruption of our morals, tolerance of drugs and idleness, parental surrendering of responsibilities, lack of respect for elders, envy of those who try to keep their heads up and who might succeed, and so on.

The National Mental Health Strategy: Is it Making Any Difference?

Abstract: In April 1992, the Health Ministers of all Australian states, territories and the Commonwealth endorsed, for the first time, a National Mental Health Policy.

American Psychiatry: An Unexpected, Undesired and Unplanned Reform

Abstract: There are surprising parallels between Australian and US psychiatry. There have been similar tiers of services, state hospitals, private fee for service and federally-funded provision, and even similar attempts to ‘cost-shift’ between sectors. The similarities and size and energy of American psychiatry means that the effect of changes there are felt in other countries. especially in Australia. Those of us who pmfit from the intellectual goods produced by the US may profit from understanding the changes.

Asia-Pacific Forum for International Mental Health Co-Operation

Abstract: a high priority on the national social and economic development agendas of countries in the region. legislation, policies and strategic plans that are consistent with national culture and national priorities for social and economic development mental health, consistent with strategies developed by international organisations (e.g. World Health Organization, World Psychiatric Association).

Post-Traumatic Stress Disorder: A Comment on the Value of ‘Mixed Trauma’ Treatment Groups

Abstract: (1996). Post-Traumatic Stress Disorder: A Comment on the Value of ‘Mixed Trauma’ Treatment Groups. Australasian Psychiatry: Vol. 4, No. 5, pp. 258-259.

A Proposal for a Local Resource Allocation Formula for Mental Health Services

Abstract: BACKGROUND ealth and Community Services H Victoria has been working for two years on a new way of allocating mental health funds to the health regions in Victoria. This follows the lead of countries such as the UK and the USA, where resources for public mental health services are often allocated to areas on the basis of such proxy indicators of psychiatric morbidity. The form this development is taking in Victoria is of a formula which includes weightings for: socio-economic disadvantage, the age, sex and marital status structure of the population, aboriginal populations, a discount for private activity, then costing allowances for persons of non-English speaking backgrounds, and for rurality. An early version of the formula was presented in 1994 [l]. A revised version of this is to guide resource allocation for financial year 1996-97, but many of the principles of the first paper are to be retained. There is a logic to allocating resources to populations down to quite small geographical units on similar principles. However the complexity of the formula as presented to the State means it is unlikely to prove suitable for use below a certain critical total population size. There follows a need for a simpler version of such a formula, based on similar principles but capable of being derived from data which is readily accessible and without undue computational demands. This paper will set out a proposal for such a formula. By way of example, sample output will be given for an area roughly coterminus with the Western Network Hospital Services of Metropolitan Melbourne. The intent is to present a formula which can be relatively easily calculated with requirements limited to a spreadsheet and access to census data in computerised form. THE VICTORIAN STATE FORMULA AND THE LOCAL FORMITLA: PRINCIPLES AND RANGE CONSIDERATIONS In the State formula the principle has been adopted of deriving a factor from the centile scores for the distribution across the State, and that principle has guided development of factors for this formula. This is a convenient way of transforming an ordinal scale into a ratio scale. The statistically minded may find the properties of this transform intriguing. It will ensure that the rank ordering of allocation is correctly retained from the source data. Whether or not the intervals for allocation achieved by this process are exactly appropriate would require an extensive research project, of which the Colorado Social Health Survey is an example [Z].

Euthanasia and the Death of Freud

Abstract: The practice of medicine confronts the practitioner with many sad, urgent and cruel happenings. No case is quite like another, and there are decisions to be made when all the Possible answers are t...

Intellectual Disabiliix Sexuality and HIV infection

Abstract: Lecturer in Psychiatry of Intellectual Disability The University of Melbourne Department of PsychSt Vincent’s Hospital F i m y VIC 3065 ociety has always had an uneasy and S ambivalent relationship with those of its members burdened by low intelligence levels combined with reduced personal and social functioning. Persons with an intellectual (developmental) disability the current jargon designation for this group continue to be disempowered, stigmatised, abused and neglected. That such attitudes and problems have persisted through the centuries up until this day is beyond dispute. As early as the thirteenth century, the Statute of Prerogatives in the Common Law jurisdiction removed the right to inheritance for this group and hence arose the potential for disempowerment and exploitation. The sinister Eugenics movement of the mid-nineteenth century, utilising pseudo-scientific reasoning and drawing upon the work of Charles Darwin, gave questionable credibility and respectability to discrimination against the intellectually disabled. It is sobering to realise that in this century Nazi philosophy and the ideas of Winston Churchill concerning the intellectually disabled were not all that dissimilar. The processes of deinstitutionalisation and integration together with the philosophy of normalisation, all key elements of current community care of the intellectually disabled, may never produce sigdcant and lasting changes in social attitudes and prejudice. As might be expected, it is in the area of sexuality that hostility and ignorance both from lay and professional persons become overtly manifest. Consider this quotation fmm a lecture delivered by a eugenics ‘expert’ to the prestigious Massachusetts Medical Society in 1912 [l]: ‘. . . the feeble minded are a parasitic, predatory class, never capable of self support or of managing their own affairs . . . feeble minded women am almost invariably immoral, and if at large usually become carriers of venereal disease or give birth to children who are as defective as themselves. The feeble minded woman who marries is twice as proWc as the normal woman . . . The feeble minded person especially the high grade imbecile is a potential criminal, needing only the proper environment and opportunity for the development and expression of his criminal tendencies. The unrecognised imbecile is a most dangerous element in the community.’ Obviously a fairly spirited delivery to an apparently accepting audience! No doubt there are some readers of this article who may secretly share to some degree the sentiments expressed above. It has only been in the last decade in Australia that mutine sterilisation of intellectually disabled women has ceased and the perceived ’right’ of parents of intellectually disabled minors to order such procedures has been clarified by the Family Court. Onto this backpund of a socially disadvantaged and negatively stereotyped group, must be painted the spectre of H N infection. Mercifully thus far, the reported infection rate of HIV infection in intellectually disabled populations is extremely low. However, the cases which have been reported raise concerns about issues of personal freedoms and rights and appropriate management.

Resourcing Mental Health Services in Australia and New Zealand

Abstract: ere are essentially three parties in ?”” the delivery of health services. The first party is the consumer (the patient) who requires services and therefore (at least in theory) sets the demand. The second party is the service provider (health professionals, hospitals and community agencies [NGOs]). The third party is the person or organisation who pays the bill for the services (governments, health insurance companies and the patient when ‘out of pocket’ expenses are incurred). Changes are being made in both Australia and New Zealand in the ways in which funding for health services flow between these parties. This paper briefly summarises some of these changes with specific reference to mental health. The amount of funding a country allocates to mental health is determined by how economically healthy it is (e.g. the size of its gross domestic product [GDP]), the proportion of the GDP spent on health, and the proportion of the health budget spent on mental health. In Australia health gets just over 8% of the GDP compared with 7.7% in New Zealand, just over 6% in the United Kingdom, over 8% in Germany, % in France and 13% in the United States [l]. In Australia, expenditure on health is made up of allocations provided from Commonwealth and State taxes, payments made by health insurance and related funds (e.g. workers’ compensation funds) and money paid directly by consumem to health providers that is not reimbursed in any way (‘out of pocket’ expenses). In New Zealand, expenditure on health comes from tax allocations, a small contribution from ACC funds, some local funding, and direct payments from consumers to providers. ACC is a social insurance scheme which covers accident compensation, medical treatment, rehabilitation and injury prevention. Public funding made up about 77.2% of all health funding in 1994 (having decreased from 88% in 1980 and 80.6% in 1991) [2]. The international mean for public funding for health is 74.8%. In 1993/94 $1.56 billion was spent on mental health in Australia (4.6% of the overall Australian health expenditure). In New Zealand in 1993194 $312.4 million was spent on mental health by the Regional Health Authorities (7.8% of public health expenditure excluding primary health and pharmaceuticals) [3]. The United Kingdom spends 10% of health budget on mental health services [l]. However these international comparisons are not all that meaningful because of the differences in what is included in mental health. Services such as vocational rehabilitation, social support, housing, etc. for psychiatric patients are, in some countries, counted as health expenditure while in others they are counted in different government portfolios. Of the $1.56 billion spent on mental health services in Australia, 63% ($981 million) was provided by States and Territories to fund public sector services, 30% ($465 million) by the Commonwealth to provide rebates to private psychiatrists and general practitioners and subsidies for the Pharmaceutical Benefits Scheme (F‘BS). The remainder ($113 million) is contributed by private health insurance funds to patients in private hospitals. An estimate of ‘out of pocket’ expenses incurred directly by consumers is not available.

New Issues in Refractory Depression

Abstract: t the recent XXth Congress of the 4 Collegium Internationale NeuroPsychopharmacologicum (CINP) in Melbourne, a half day program was devoted to the presentation and discussion of new developments in the treatment of Refractory Depression. This article presents an overview of some of the key issues that arose at that symposium. It refers particularly to Dr Martin B Keller’s paper on long-term issues and my own presentation about the implications of comorbidity for the treatment of depression. It also summarizes promising new data on venlafaxine, the world’s first serotonin and noradrenaline reuptake inhibitor (SNRI), presented by Dr Claude de Montigny. recurrence [3]. Other patients who may need maintenance therapy include those with double depression, a family history of affective disorder, poor symptom control during continuation therapy, a comorbid disorder or substance abuse.

Admission Protocols in the Management of Hospital Recidivism

Abstract: significant factor in the shift toward A community treatment of psychiatric disorder was widespread awareness of the ‘revolving door’ phenomenon and the apparent powerlessness of mental hospitals to deal with it. This mental hospital recidivism meant that a relatively small number of patients was using an excessive proportion of available resources [l]. It is not yet clear if the move toward community psychiatric treatment has resolved this problem. Most of the literature in the area is from the United States, where non-compliance with treatment and denial of illness appear to be the most potent contributors to hospital recidivism in the era of community psychiatric treatment [2,3]. Similar findings have emerged from the United Kingdom [4] and Australia [5,6], although in the Australian study relationship problems linked with personality disorder were prominent also. There is a consensus that hospital recidivists generally make little use of community psychiatric services, limiting the role of conventional case management in dealing with what Casper [3] describes as a ‘complex multifaceted problem’ that requires a range of innovative treatment programs. Pending the development of such programs, the South Australian Mental Health Service uses admission protocols to help manage hospital recidivism. This system is well developed and, as far as we could determine by reviewing the literature, unique. It is based on the idea that when hospital recidivists present for admission, crucial background information about them must be readily available. Only in this way can a balanced judgement be made. Even in well-designed community mental health systems, case notes may not be immediately available, and staff

Towards the Best Public Health Response to Horrendous Events

Abstract: The recent shootings at Port Arthur have highlighted trends throughout the Western World to extend debriefing and post-event counselling to the local community and secondary victims of such tragedies as well as the primary victims and emergency personnel involved. The cost of providing this extended service is not inconsiderable. There is little research that confirms effectiveness of such debriefing [1-4] and even some that points to possible long-term harm [5]. It is important to reconsider the most effective, post-event response from public health authorities.

Writing Discharge Summaries: A Useless Chore?

Abstract: (1996). Writing Discharge Summaries: A Useless Chore? Australasian Psychiatry: Vol. 4, No. 4, pp. 204-205.

A Community Consultation Clinic in a Paediatric Hospital

Abstract: he prevalence of childhood T psychiatric disorders in the community has been estimated at around 20%, with 1 4 % seeking any kind of help [l]. For every child with a diagnosable disorder, there are several who have transient or subclinical mental health difficulties, or exposure to risk factors. Newer, pragmatic and more creative programs are required for these children without necessarily increasing the budget. Consultation helps strengthen the skills of primary health workers, by offering advice on case management, without assuming responsibility for the case.