David Ash

Evidence-based medicine evaluation of electrophysiological studies of the anxiety disorders.

We provide a systematic, evidence-based medicine (EBM) review of the field of electrophysiology in the anxiety disorders. Presently, electrophysiological studies of anxiety focus primarily on etiological aspects of brain dysfunction. The review highlights many functional similarities across studies, but also identifies patterns that clearly differentiate disorder classifications. Such measures offer clinical utility as reliable and objective indicators of brain dysfunction in individuals and indicate potential as biomarkers for the improvement of diagnostic specificity and for informing treatment decisions and prognostic assessments. Common to most of the anxiety disorders is basal instability in cortical arousal, as reflected in measures of quantitative electroencephalography (qEEG). Resting electroencephalographic (EEG) measures tend to correlate with symptom sub-patterns and be exacerbated by condition-specific stimulation. Also common to most of the anxiety disorders are condition-specific difficulties with sensory gating and the allocation and deployment of attention. These are clearly evident from evoked potential (EP) and event-related potential (ERP) electrical measures of information processing in obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD) and the phobias. Other ERP measures clearly differentiate the disorders. However, there is considerable variation across studies, with inclusion and exclusion criteria, medication status and control group selection not standardized within condition or across studies. Study numbers generally preclude analysis for confound removal or for the derivation of diagnostic biomarker patterns at this time. The current trend towards development of databases of brain and cognitive function is likely to obviate these difficulties. In particular, electrophysiological measures of function are likely to play a significant role in the development and subsequent adaptations of DSM-V and assist critically in securing improvements in nosological and treatment specificity.

Five-year review of absconding in three acute psychiatric inpatient wards in Australia

Absconding, where patients under an involuntary mental health order leave hospital without permission, can result in patient harm and emotional and professional implications for nursing staff. However, Australian data to drive nursing interventions remain sparse. The purpose of this retrospective study was to investigate absconding in three acute care wards from January 2006 to June 2010, in order to determine absconding rates, compare patients who did and did not abscond, and to examine incidents. The absconding rate was 17.22 incidents per 100 involuntary admissions (12.09% of patients), with no significant change over time. Being male, young, diagnosed with a schizophrenia or substance-use disorder, and having a longer hospital stay were predictive of absconding. Aboriginal and Torres Strait Islander patients had higher odds of absconding than Caucasian Australians. Over 25% of absconding patients did so multiple times. Patients absconded early in admission. More incidents occurred earlier in the year, during summer and autumn, and later in the week, and few incidents occurred early in the morning. Almost 60% of incidents lasted ≤24 hours. Formulation of prospective interventions considering population demographic factors and person-specific concerns are required for evidence-based nursing management of the risks of absconding and effective incident handling when they do occur.

Early recognition of anti-N-methyl D-aspartate (NMDA) receptor encephalitis presenting as acute psychosis

Objective: We present a case of anti-N-methyl D-aspartate (NMDA) receptor encephalitis that illustrates the dilemma that psychiatrists face in evaluating patients with first episode psychosis. Conclusions: The discovery that acute psychosis can be the presenting feature of autoimmune encephalitis (in particular encephalitis caused by anti-NMDA receptor antibodies) has both practical and theoretical consequences. First, this condition is an important, but often overlooked, differential diagnosis of first episode psychosis. Antibody testing is not currently part of routine screening, though delayed (or missed) diagnosis can lead to prolonged hospital stay, medical complications and incomplete or delayed recovery. Widespread screening of patients with first presentation psychosis for anti-NMDA receptor and anti-voltage-gated potassium channel (anti-VGKC) antibodies is warranted for a number of reasons: to expedite appropriate treatment, to determine the true proportion of patients with these conditions presenting as psychosis, and to help elucidate the neurochemical causes of psychosis.

Crisis Beds: the Interface Between the Hospital and the Community

The main role of the crisis unit at a state psychiatric hospital was found to be the provision of brief hospitalisation for patients with adjustment disorders and person ality disorders. The four bed crisis unit treated 14% of all patients admitted to the hospital, with an average length of stay less than three days. A study of 78 crisis unit patients found that 77% were able to be discharged directly to the community, and only 18% were readmitted during the following six months.

School Shootings – ‘It wouldn’t happen here’?:

Australian & New Zealand Journal of Psychiatry, 52(5) Recent events, including the arrest of two teenage school pupils in rural South Australia charged with weapons offences but reportedly planning a school attack, and the tragic death of 17 pupils at Marjory Stoneman Douglas High School in Florida, have reawakened awareness of these rare, but devastating, events. These events also highlight the possibility that a school shooting might be successfully carried out in Australia or New Zealand. In New Zealand in 1923, a father shot and killed two pupils at his children’s school, wounding the school master and five other children. Accounts suggest he had a grievance towards the school and was known in the community for persecutory ideas. In 1999, Jonathan Horrocks killed one and injured another in a shooting in a bar at La Trobe University, Melbourne. He was restrained from harming others. He reportedly held a grudge, having been sacked earlier that year on suspicion of theft. He received a life sentence with a minimum term of 23 years. In 2002, Huan Yun Xiang killed two and injured five at Monash University, Melbourne. The attack was reportedly driven by persecutory delusions centred on another student, who was one of the two to die. A mental impairment defence was accepted by the jury, and Xiang was admitted to a forensic hospital. In Australia, there have been three other incidents of students using firearms or explosives on school grounds, without fatalities. The literature on school shootings (Langman, 2015) is generally restricted to circumstances where the perpetrator is a current, or recent, pupil at the school or University and attends with the specific intention of committing a massacre, rather than gun violence in schools generally. Applying this definition, the NZ and La Trobe cases would not be categorised as typical ‘school shootings’. School shootings comprise part of a group best termed lone actor mass killers.

Recovery-based services in a psychiatric intensive care unit – the consumer perspective

Objective: To describe the implementation of recovery-based practice into a psychiatric intensive care unit, and report change in seclusion rates over the period when these changes were introduced (2011–2013). Method: Recovery-based practices including collaborative care, safety care plans, a comfort room, and debriefing after coercive interventions were introduced. A carer consultant was employed. A restraint and seclusion review committee, chaired by a peer worker, was established. A consumer exit interview was introduced and these data were collected, reviewed by staff and the peer worker and used to improve the ward environment. Rates of seclusion were measured during the period when recovery-based practices were introduced. Results: Consumer feedback indicated that positive aspects of the psychiatric intensive care unit included approachable, helpful staff and completion of a safety care plan. Negative aspects included lack of involvement in decisions about admission and about medications, the non-smoking policy, and being placed in seclusion or restraint. There was a significant reduction in the number of consumers secluded and the total number of seclusions. Conclusions: Recovery principles can be successfully introduced in a psychiatric intensive care unit environment. Introduction of recovery based practice was associated with a reduction in seclusion.

Challenges in psychiatric classification: the case of generalized anxiety disorder.

Objective: This paper aims to describe some of the challenges in psychiatric classification, using generalized anxiety disorder (GAD) as an example. A range of different conceptualizations of GAD are presented. Some are based on theoretical formulations, while others draw on epidemiological data. Each has merit, but also deficiencies. The evolution of diagnostic criteria is not simply a theoretical exercise, but reflects assumptions about the nature of the underlying pathology and the relationships between different disorders. Furthermore, these criteria determine which subjects are included in research and in clinical trials, so they shape the further development of psychiatric classification systems. Conclusion: The controversies about the classification of GAD illustrate the complexities and challenges of developing a valid classification system for psychiatric disorders.

Self‐reported forensic histories amongst patients admitted to an acute psychiatric unit

This study was undertaken to investigate the rates of forensic histories of people admitted to an acute psychiatric unit, in the public mental health system of South Australia. The study was conducted using individual interviews by research team members, relying on self‐report of forensic contact Data were collected from 83% of the patients admitted to the unit over a three month period (n = 119). The study shows a high number (24%) of patients admitted to an acute ward had charges pending and 36% admitted to previous convictions. Some of the charges and convictions appeared to relate to behaviour which had occurred as a result of mental illness. There was a significant association between substance abuse, impending court cases and previous convictions.

Electroconvulsive therapy for the neurological and psychiatric manifestations of multiple system atrophy.

A 64-year-old businesswoman was admitted with treatment-resistant depression and multiple system atrophy (MSA). Three years earlier she had been diagnosed with MSA (parkinsonian type) with symptoms including slow gait, postural instability with falls, and symmetrical rigidity and bradykinesia of the limbs. She had autonomic involvement with hyperhydrosis, constipation and urinary frequency. Dopamine transporter imaging of the brain had shown symmetrical reduction in dopamine transporter binding in the striatum. She had become depressed as her physical health declined. She had difficulty running her business, slept poorly and lost weight. She became increasingly anxious and fixated on her somatic symptoms. She distrusted medications, which she alleged worsened her symptoms. She took levodopa and pramipexole intermittently in small doses. These medications were poorly tolerated and did not improve her motor function. Numerous antidepressant medications were unhelpful. On admission she was severely depressed, spending most of her time in bed. Her mobility was poor with a slow unsteady gait and she required assistance with activities of daily living (ADLs). She had urgency urinary incontinence. She began standard pulse width (SPW) right unilateral electroconvulsive therapy (ECT) three times per week. By the sixth treatment there was obvious improvement in her mental state and neurological function. She became more reactive, less fixated on her physical symptoms and more engaged with staff. She gained independence with ADLs, her mobility improved, and her urinary incontinence decreased. Having previously refused medication she now accepted daily levodopa. After the eleventh ECT treatment she had some memory impairment. Treatment was withheld but after 4 days it was evident that she was deteriorating. ECT was resumed with good effect, and she had a total of 18 treatments. The marked improvement in both depression and MSA with ECT was the first time this patient had responded to any intervention. MSA is a rare neurodegenerative disorder frequently complicated by depression (Tison et al., 2006). The most common treatment is selective serotonin reuptake inhibitors. ECT has been used for the treatment of depressive and motor symptoms in Parkinson’s disease (Hooten et al., 1998), but there are only a few reports of its use in MSA (Husain et al., 2013). This case suggests that unilateral SPW ECT can produce clinically significant improvements in patients with depression associated with MSA of the parkinsonian type. The improvement in her physical symptoms may have been due to the ECT, or could have been related to improved medication compliance. Maintenance ECT may be required to avoid relapse.

Metabolic health of people admitted to a psychiatric intensive care unit in adelaide, South australia.

To the Editor: People with psychiatric disorders have high rates of comorbid obesity, cardiovascular disease, metabolic syndrome, and diabetes. These disorders are associated with poor quality of life and premature mortality.1 Lifestyle factors including poverty, poor diet, and lack of exercise contribute to physical comorbidity. In addition, many psychotropic drugs, including some of the atypical antipsychotics, mood stabilizers, and antidepressants, are associated with weight gain and increased risk of metabolic syndrome. A recent voluntary screening program for public mental health patients in the United States2 found high rates of obesity, hypertension, and elevated cholesterol, glucose, and triglycerides. John and colleagues3 found that 54% of Australians attending community mental health clinics met International Diabetes Federation criteria for metabolic syndrome, compared to rates of 13.4%–30.7% in the general Australian population.4 However, few data are available concerning the metabolic profiles of people admitted acutely to hospital with severe psychiatric disorders. We assessed a range of metabolic parameters in patients admitted involuntarily to a 10-bed, closed psychiatric intensive care unit. This service managed the most severely behaviorally disturbed patients from a catchment population of approximately 750,000 people in Adelaide, South Australia. Method. One hundred nineteen consecutive patients were admitted during the study period. Fourteen patients refused measurement of body mass index (BMI) or venipuncture; data for the remaining 105 patients are included in the analysis. This study conformed to the ethical criteria of the Australian National Health and Medical Research Council (2003).5 Results. The patients’ mean age was 35.21 years (SD = 10.62), and 67% were male. Men were significantly younger, on average, than the women (t = 5.15, df = 103, P < .001). Thirteen subjects (12%) were Aboriginal. The most common clinical diagnosis (DSM-IV criteria) was nonaffective psychosis (67%, n = 70), followed by bipolar disorder (21%, n = 22). The mean BMI was 27 (SD = 6.14), with 4 subjects (3.8%) being underweight (BMI 30). The mean BMI did not significantly differ between men (mean = 26.9, SD = 6.25) and women (mean = 27.3, SD = 6.0). Standard laboratory criteria (Institute of Medical and Veterinary Science, Adelaide, South Australia6) were utilized to interpret the blood results. The mean fasting blood glucose level was 4.9 mg/dL, and 25 subjects (23.8%) had an elevated fasting glucose level (> 5.5 mg/dL). The mean fasting cholesterol level was 4.43 mmol/L (SD = 1.34), with 16 patients (15.2%) having borderline high cholesterol (5.18–6.18 mmol/L) and a further 9 (8.6%) classified as having high cholesterol (> 6.19 mmol/L). The mean triglyceride level for the sample was 1.85 (SD = 1.20), with 43 (43.9%) having elevated triglycerides (≥ 1.6 mmol/L). The mean low-density lipoprotein cholesterol (LDL) level was 2.56 (SD = 0.91) mmol/L, and 17 patients (16.1%) had elevated LDL ≥ 2.6 mmol/L. The mean high-density lipoprotein cholesterol (HDL) level was 1.19 (SD = 0.32) mmol/L. Men had significantly lower HDL (t = 2.49, df = 96, P = .015). For each unit increase in HDL, BMI decreased by 4.49 (P = .019). There was a mean weight gain of 2.45 kg during hospitalization. The mean length of stay was 11.6 days, so patients gained a mean of 0.22 kg/d. Contributing factors include the lack of opportunity to exercise and a policy of allowing patients to purchase confectionery, chips, and soft drinks. Ninety percent of our sample (n = 95) were treated with olanzapine, clozapine, and/or sodium valproate. The mean weight gain was greater for patients treated with these medications, although these differences did not reach significance. However, other medications with a more favorable metabolic profile are clearly preferable, even in the acute setting. Our study shows that about 60% of these acutely unwell patients are overweight or obese, almost half have elevated triglycerides, and a quarter have elevated fasting blood glucose and elevated cholesterol. These rates are very similar to rates in the healthy Australian population.7,8 Compared to the US sample studied by Correll et al,2 our patients had lower rates of obesity, and a smaller proportion had elevated fasting glucose and triglyceride levels. This finding may reflect population level differences between the United States9 and Australia.8 The participants in this study tend to be excluded from most research, as they are involuntary and behaviorally disturbed and often do not have capacity to give informed consent. It is essential that service level studies are undertaken to provide basic information about their rates of physical comorbidity. It does appear that these acutely admitted patients, many of whom were not receiving treatment prior to admission, have about the same level of cardiometabolic risk as the general population. From a metabolic perspective, they are healthier than people engaged in ongoing psychiatric treatment.2,3 This is consistent with the findings of Foley and Morley,10 who reported that, prior to treatment, first-episode psychosis patients had normal levels of cardiovascular risk, assessed using weight or metabolic indices, but their risk increased after first exposure to any antipsychotic drug. Selecting medications that do not exacerbate cardiometabolic risk is important in this population. While in the short-term treatment of acute behavioral disturbance the sedative properties of a drug may outweigh the metabolic risks, consideration should be given to switching to a drug with a more favorable metabolic profile prior to discharge. It is also important that patients with metabolic measures requiring treatment receive the same level of general medical care as other members of the community.