Anne P. F. Wand

Does the ‘hikikomori’ syndrome of social withdrawal exist outside Japan? A preliminary international investigation

PurposeTo explore whether the ‘hikikomori’ syndrome (social withdrawal) described in Japan exists in other countries, and if so, how patients with the syndrome are diagnosed and treated.MethodsTwo hikikomori case vignettes were sent to psychiatrists in Australia, Bangladesh, India, Iran, Japan, Korea, Taiwan, Thailand and the USA. Participants rated the syndrome’s prevalence in their country, etiology, diagnosis, suicide risk, and treatment.ResultsOut of 247 responses to the questionnaire (123 from Japan and 124 from other countries), 239 were enrolled in the analysis. Respondents’ felt the hikikomori syndrome is seen in all countries examined and especially in urban areas. Biopsychosocial, cultural, and environmental factors were all listed as probable causes of hikikomori, and differences among countries were not significant. Japanese psychiatrists suggested treatment in outpatient wards and some did not think that psychiatric treatment is necessary. Psychiatrists in other countries opted for more active treatment such as hospitalization.ConclusionsPatients with the hikikomori syndrome are perceived as occurring across a variety of cultures by psychiatrists in multiple countries. Our results provide a rational basis for study of the existence and epidemiology of hikikomori in clinical or community populations in international settings.

The effectiveness of consultation-liaison psychiatry in the general hospital setting: A systematic review

OBJECTIVE The aim of this study was to review how the effectiveness of consultation liaison psychiatry (CLP) services has been measured and to evaluate the strength of the evidence for effectiveness. METHODS Systematic review of medical databases using broad search terms as well as expert opinion was sought. The literature search was restricted to studies of general, whole-of-hospital inpatient CLP services. RESULTS Forty articles were found and grouped into five measurements of effectiveness: cost effectiveness including length of stay, concordance, staff and patient feedback, and follow-up outcome studies. All measurements contributed to the evaluation of CLP services, but no one measure in isolation could adequately cover the multifaceted roles of CLP. Concordance was the only measurement with an established, consistent approach for evaluation. Cost effectiveness and follow-up outcome studies were the only measures with levels of evidence above four, however the three follow-up outcome studies reported conflicting results. Subjective evidence derived from patient and staff feedback is important but presently lacking due to methodological problems. The effectiveness of CLP services was demonstrated by cost-effectiveness, earlier referrals to CLP predicting shorter length of stay, and concordance with some management recommendations. CONCLUSION There is evidence that some CLP services are cost-effective and reduce length of stay when involved early and that referrers follow certain recommendations. However, many studies had disparate results and were methodologically flawed. Future research should focus on standardising patient and staff feedback, and short-term patient outcomes.

A multifaceted educational intervention to prevent delirium in older inpatients: A before and after study

BACKGROUND Systematically targeting modifiable risk factors for delirium may reduce its incidence. However, research interventions have not become part of routine clinical practice. Particular approaches to the education of clinical staff may improve their practice and patient outcomes. OBJECTIVES To evaluate the effectiveness of a multifaceted educational program in preventing delirium in hospitalised older patients and improving staff practice, knowledge and confidence. DESIGN A before and after study. SETTING A 22-bed general medical ward of a district hospital in Sydney, Australia. PARTICIPANTS Patients were aged 65 years and over and not delirious upon admission. Of 568 eligible patients, 129 were recruited pre-intervention (3 withdrew initial consent) and 129 patients post-intervention. METHODS Prior to the intervention, in order to establish a baseline, patients were assessed early after admission and again at discharge. The intervention was a one-hour lecture on delirium focusing on prevention for medical and nursing staff followed by weekly interactive tutorials with delirium resource staff and ward modifications. Following the initial education session, data were gathered in a second group of medical ward patients at the same time-points to ascertain the effectiveness of the intervention. Pre and post-intervention data were analysed to determine change in staff objective knowledge and self-ratings of confidence and clinical practice in relation to delirium. The main outcome measures were incident delirium and change in staff practice, confidence and knowledge. RESULTS The mean age of patients was 81. The pre and post-intervention groups were comparable, aside from greater co morbidity in the pre-intervention group (F(1, 253)=9.20, p=0.003). Post-intervention there was a significant reduction in incident delirium (19% vs. 10.1%, X(2)=4.14, p=0.042), and improved function on discharge (mean improvement 5.3 points, p<0.001, SD 13.31, 95% CI -7.61 to -2.97). Staff objective knowledge of delirium improved post-intervention and their confidence assessing and managing delirious patients. Staff addressed more risk factors for delirium post-intervention (8.1 vs. 9.8, F(1, 253)=73.44, p<0.001). CONCLUSIONS A low-cost educational intervention reduced the incidence of delirium and improved function in older medical patients and staff knowledge and practice addressing risk factors for delirium. The program is readily transferable to other settings, but requires replication due to limitations of the before and after design.

Introducing the concept of modern depression in Japan; an international case vignette survey

AIM Japanese psychiatrists have increasingly reported patients with depression that does not seem to fit the criteria of the ICD-10 and the DSM-IV, and which has recently been called modern type depression (MTD). We explored whether MTD is frequently seen in Japan and also in other countries, and if so, how patients with MTD are diagnosed and treated. METHODS The questionnaires, with two case vignettes (traditional type depression (TTD) and MTD), were sent to psychiatrists in Australia, Bangladesh, India, Iran, Japan, Korea, Taiwan, Thailand and the USA. Participants rated their opinions about each cases prevalence in their country, etiology, diagnosis, suicide risk, and treatment using Likert scales. RESULTS Out of 247 responses (123 from Japan and 124 from other countries), two hundred thirty-nine valid responses were received. MTD was recognized in all participating countries, and especially in urban areas. Generally, the factor of personality was regarded as the most probable cause of MTD. Whereas about 90% of Japanese psychiatrists applied the ICD/DSM criteria to TTD, only about 60% applied the criteria to MTD. CONCLUSION Our results indicate that Japans MTD seems to be occurring in many other countries, and that the present ICD/DSM criteria may not be sufficient to diagnose MTD. Therefore, it could be an important candidate for a new international diagnostic criterion as a subtype of depression. A clear diagnostic framework and consensus on the interventions to treat MTD would be valuable. Further clinical, psychopathological and international epidemiological studies are needed to confirm our preliminary findings of MTD.

‘Admit voluntary, schedule if tries to leave’: placing Mental Health Acts in the context of mental health law and human rights

Objectives: Most postgraduate training for clinicians in Australia and New Zealand regarding mental health legislation focuses on the relevant Mental Health Acts (MHAs) rather than the broader principles of mental health law. Key concepts include treatment in the least restrictive environment, voluntary access to mental health services, treatability, reciprocity and due process. Lack of awareness of these principles may result in a more risk-averse interpretation of MHAs, which is inconsistent with the spirit of mental health law and the promotion of human rights. The aim of this paper is to present some fundamental principles of mental health law, which are essential to proper clinical application of MHAs, and to demonstrate why they should form part of the curriculum for psychiatry training and continuing professional development for psychiatrists. Conclusions: A sound understanding of the principles of mental health law is essential for all clinicians who may be enacting aspects of MHAs. This provides the necessary platform to safeguard human rights and optimise the care of people with a mental illness.

Issues in the evaluation and treatment of anxiety and depression in migrant women in the perinatal period

Objectives: Perinatal depression and anxiety are prevalent in migrant women. The main aims of this literature review were to understand the psychosocial determinants of depression and anxiety in migrant women antenatally and to explore common clinical presentations. In addition, we aimed to identify barriers and facilitating factors for help-seeking and treatment, in order to identify directions for service development and improvement. Methods: A review of the literature was performed using electronic databases. Results: Depression and anxiety are over represented in migrant women in the perinatal period. Somatic symptoms are common presentations for emotional distress. An identified difficulty is a perceived lack of support, often as a result of cultural dislocation and social isolation. Significant barriers to help-seeking include the perception that limited assistance is available and reluctance to share personal information with an unknown clinician. Preferred therapeutic approaches include the use of clinical consultants from the same or similar culture, as well as practical and emotional support rather than medical management of symptoms. Conclusion: Clinicians should be aware of psychosocial issues in this vulnerable population. Group programmes with a focus on education about mental and physical health, available supports, and socialisation are effective in engaging and assisting pregnant migrant women.

Validating the 4A's test in screening for delirium in a culturally diverse geriatric inpatient population

To measure the diagnostic accuracy of the 4As test in screening for delirium in geriatric inpatients from culturally diverse backgrounds.

Relationship between timeliness of contact and length of stay in older and younger patients of a consultation-liaison psychiatry service.

Aim and methods The aims were to determine whether the timeliness of contact with a consultation-liaison psychiatry (CLP) service is associated with shorter lengths of stay (LOS), whether this relationship persists for stays greater than 4 days and whether this association varies with age. The length of stay was correlated with the time from admission to contact with the service (the referral lag (REFLAG)), and the REFLAG’s proportion of length of stay (REFLAG/LOS) for all 140 in-patients, those with stays greater than 4 days, and for those under and over 65 years. Results The length of stay was significantly correlated with referral lag and logREFLAG/logLOS for all patients and for patients with stays greater than 4 days. The correlations remained significant for both age groups, but were stronger in the younger group. Clinical implications Timeliness of contact with CLP was associated with shorter length of stay, particularly in younger patients. Psychiatric factors influencing length of stay in older patients should be studied by CLP services.

Considering culture in the psychiatric assessment of Aboriginal and Torres Strait Islander peoples

Abstract There is little information about referrals of Aboriginal and Torres Strait Islander peoples to general hospital psychiatry services. Even less is known about how culture is incorporated into their psychiatric assessment and management plans. This is important as culture is a fundamental aspect of the social and emotional health and wellbeing of Indigenous Australians. Consultation-liaison psychiatry services are referred patients admitted to the general hospital or Emergency Department. This study was conducted to evaluate whether and how culture is incorporated into the psychiatric assessment and management of Aboriginal and Torres Strait Islander peoples referred to a consultationliaison psychiatry service. Thematic analysis, with a particular focus on cultural references, was used to retrospectively evaluate forty referrals. Results derived from the data analysis were verified by independent analysis of a subset of files by a former Clinical Nurse Consultant in Aboriginal mental health and consultations with Aboriginal Health Workers. Culture was often only indirectly and infrequently documented in the consultation-liaison clinician’s assessment. The clinician demonstrated that culture was considered through direct references; patterns of communication; diagnostic labels; identification of strengths and resilience; and by the involvement of the Aboriginal Health Worker. Culture should be routinely included in psychiatric assessments of Indigenous Australians. Placing the patient in context using a detailed psychiatric formulation may be more informative and helpful for both the patient and referrer than a diagnosis alone. Aboriginal Health Workers may contribute to care in this setting, including by assisting consultation-liaison clinicians to communicate effectively and to deliver more holistic care. However, more attention must be given to formally defining the role of Aboriginal Health Workers and developing true partnerships with clinicians.

Comparison of consultation–liaison psychiatry services for inner-city, district or regional general hospitals using a common tool: Does one size fit all?

OBJECTIVE Consultation-liaison psychiatry (CLP) services vary in terms of structure, function and responsiveness. It is not known whether evaluation measurements can be meaningfully compared across different CLP services to assess value and efficiency. The aim was to develop and test a common tool for measuring process and outcome measures in CLP. METHODS A data collection tool was developed using the literature and consultation with CLP clinicians. The tool was used to prospectively gather referral data, response times, health utilisation data and functional outcomes for individuals referred over seven months to three different CLP teams, servicing inner city, district and regional areas. RESULTS The structure, staffing, liaison attachments and scope of practice varied between the services. The regional CLP service attended seven hospitals and had the highest referral rate and largest inpatient population pool. The three services received referrals for similar reasons and made similar diagnoses. Multimodal management was the norm, and CLP facilitated follow-up arrangements upon discharge. Only the district CLP service saw all emergency referrals within an hour. Age and need for an interpreter did not affect response times. CONCLUSION Despite local differences in geography, CLP roles, hospital and community mental health service pathways and patient populations, the CLP data collection tool was applicable across sites. Staff resourcing and referral demand are key determinants of CLP response times.