Frances Dark

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders.

Objectives: This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function. Methods: The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups. Results: The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice. Conclusions: This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.

The therapeutic alliance: the key to effective patient outcome? A descriptive review of the evidence in community mental health case management

Objective: The aim of this review was to examine the level of evidence supporting the assumed link between a positive therapeutic alliance among patients and case managers and effective outcome for patients with a mental illness who are managed in community mental health services. Method: MedLine, PsychINFO and Social Sciences Index search of articles from 1986 to 2001 returned 84 articles and two texts. Inclusion criteria were the use of validated measures and relevance to psychiatry and community case management. Results: A definite correlation exists in the psychotherapy literature between the therapeutic relationship and improved outcomes, with its potential as a prognostic indicator acknowledged. Attempts to apply the concept to patients outside the field of psychotherapy have been slow, although expansion of the concept to other forms of change-inducing therapy was a current trend. Issues of definition, quantification and measurement of the relationship caused rigorous debate in the literature. Case management research demonstrating the importance of the therapeutic relationship and ‘goodness-of-fit’ between patients and case managers was sparse with no published Australian studies. Conclusions: The level of evidence supporting the link between the therapeutic alliance of patients with mental illness and improved outcomes although sparse is encouraging. It indicates the potential of the alliance as a predictor of outcome for patients engaged in case management services in community mental health. Research to determine the role and effectiveness of the alliance in the patient/case manager dyad is needed to define this potential. Effectiveness of clinical practice in the case management field could be enhanced if research findings confirmed the genesis and value of the alliance in case management. Focus on relationship strategies as a clinical tool gives the clinician and service provider a potential vehicle for promoting partnerships with the seriously mentally ill person in managing their illness and optimizing their strengths in the community.

Pathological Laughing and Crying

Objective: To review the clinical features, neurobiological correlates and treatment of pathological laughing and crying. Method: Selective literature review. Results: Attacks of involuntary, irresistible laughing or crying have long been recognised as sequelae of brain damage. There is controversy about the clinical features of these attacks, the stimuli that provoke them and their relation to affective disorder. The pathophysiology of pathological laughing and crying is still unclear. It can occur in the presence of focal as well as diffuse brain disease. Treatment with antidepressant medications has been found to be of benefit in patients with cerebrovascular disease and multiple sclerosis. Conclusions: Clinicians should remain vigilant for these symptoms, and offer effective treatments, such as antidepressants, where indicated. Further research is needed to delineate the underlying neurobiological correlates of pathological laughing and crying. The efficacy of both pharmacological and non-pharmacological interventions requires critical evaluation.

Posttraumatic stress disorder: an exploratory study examining rates of trauma and PTSD and its effect on client outcomes in community mental health

BackgroundRates of trauma and Posttraumatic Stress Disorder (PTSD) were examined in order to compare the profile in clients of an Australian Public Mental Health Service with that reported in the international literature for clients with major mental illness and to explore the effect of this on client health outcomes. Potential factors contributing to increased levels of trauma/PTSD in this group of clients and the issue of causality between PTSD and subsequent mental illness was also explored.MethodsA convenience sample of 29 clients was screened for trauma and PTSD using the Posttraumatic Stress Diagnostic Scale™ (PDS) and selected outcome measures. Paired and independent samples t-test and ANOVA were applied to the data.ResultsHigh levels of undocumented trauma and PTSD were found. Twenty clients, (74%) reported exposure to multiple traumatic events; 33.3% (9) met DSM IV diagnostic criteria for PTSD. Significant difference was found for PTSD symptomatology, severity and impairment and for client and clinician-rated scores of Quality of Life (QOL) outcomes in the PTSD group. No effect for PTSD symptomatology on the Working Alliance (WA) was found. Factors that may influence higher rates of PTSD in this group were identified and included issues associated with the population studied, the predominance of assaultive violence found, and vulnerability and risks factors associated with re-traumatisation within the social and treating environments.ConclusionA similar trauma and PTSD profile to that reported in the international literature, including greater levels of trauma and PTSD and a poorer QOL, was found in this small sample of clients. It is postulated that the increased levels of trauma/PTSD as reported for persons with major mental illness, including those found in the current study, are primarily related to the characteristics of the population that access public mainstream psychiatric services and that these factors have specific implications for service delivery, and raise issues of efficiency and effectiveness of resource use in achieving successful outcomes in public mental health services for clients with co-morbid PTSD. Further research with a more rigorous design is needed to test these preliminary findings within Australian Community Mental Health Services.

Apolipoprotein E genotype does not affect the age of onset of dementia in families with defined tau mutations

We have assessed whether apolipoprotein E (ApoE) genotype influences the age of onset of dementia in a series of families with frontal temporal dementia with defined mutations in the tau gene. In contrast to the situation in Alzheimers disease (AD), we could find no evidence that the age of onset of disease was influenced by the ApoE genotype.

A Family with Autosomal Dominant, Non-Alzheimer's Presenile Dementia

Objective:A rare family pedigree is described with a multigenerational history of an early onset, non-Alzheimers dementia consistent with autosomal dominant inheritance. Information on five generations, with 26 suspected or proven cases of dementia, are presented. Method:Previous work on the family was collated and verified. The pedigree was updated. Thirty-three family members agreed to be interviewed for the present study. Standardised clinical information was obtained using the Cambridge Mental Disorders of the Elderly Examination (CAMDEX) National Adult Reading Test (NART), vocabulary and digit substitution subscales of the Wechster adult intelligence scale — revised edition (WARS-R). Abbot samples were taken for biochemical and genetic analysis. Results:Fifteen males and 11 females have been affected. The age of onset of dementia in those for whom data were available (n = 12) ranged from 39 to 64 years with a mean of 53 years. The duration of illness ranged from 4 to 14 years and the age at death ranged from 49 to 69 years (mean 62 years). Autopsy data exist for nine cases. In one case the neuropathology was consistent with Alzheimers disease. In two cases the diagnosis of Picks disease was made on the basis of frontal or frontal/temporal lobe atrophy without Pick bodies or cells. One case diagnosed as Picks disease had frontal/temporal lobe atrophy with cells resembling Picks bodies. In the five remaining cases there were no distinctive neuropathological features to differentiate the type of dementia. Conclusions:The importance of recognising familial dementia, collating information on multiple generations and prospectively collecting standardised data is discussed.

Thought Disorder and Executive Ability

A neurocognitive model of thought disorder is proposed that links: (1) impaired ability to establish set with poverty of speech; (2) impaired ability to maintain set with positive thought disorder; and (3) impaired ability to shift sets with perseveration in speech. The aim of this study is to examine performance on tests sensitive to set ability in patients prone to thought disorder. Patients with schizophrenia (n = 36), mania (n = 18) and a well control group (n = 20) were assessed on two occasions separated by 4 weeks. Testing included: a free speech sample, Controlled Oral Word Association test, Stroop test, Wisconsin Card Sort test, and the Trail Making test. Impaired ability to maintain set in the face of interference was correlated with positive thought disorder, impaired ability to establish set was correlated with poverty of speech, and impaired ability to shift set was associated with perseveration in speech. The associations between impaired set ability and types of thought disorder support a neurocognitive model implicating impaired executive ability in the pathogenesis of thought disorder.

Longitudinal comparative evaluation of the equivalence of an integrated peer-support and clinical staffing model for residential mental health rehabilitation: a mixed methods protocol incorporating multiple stakeholder perspectives.

BackgroundA novel staffing model integrating peer support workers and clinical staff within a unified team is being trialled at community based residential rehabilitation units in Australia. A mixed-methods protocol for the longitudinal evaluation of the outcomes, expectations and experiences of care by consumers and staff under this staffing model in two units will be compared to one unit operating a traditional clinical staffing. The study is unique with regards to the context, the longitudinal approach and consideration of multiple stakeholder perspectives.Methods/designThe longitudinal mixed methods design integrates a quantitative evaluation of the outcomes of care for consumers at three residential rehabilitation units with an applied qualitative research methodology. The quantitative component utilizes a prospective cohort design to explore whether equivalent outcomes are achieved through engagement at residential rehabilitation units operating integrated and clinical staffing models. Comparative data will be available from the time of admission, discharge and 12-month period post-discharge from the units. Additionally, retrospective data for the 12-month period prior to admission will be utilized to consider changes in functioning pre and post engagement with residential rehabilitation care. The primary outcome will be change in psychosocial functioning, assessed using the total score on the Health of the Nation Outcome Scales (HoNOS). Planned secondary outcomes will include changes in symptomatology, disability, recovery orientation, carer quality of life, emergency department presentations, psychiatric inpatient bed days, and psychological distress and wellbeing. Planned analyses will include: cohort description; hierarchical linear regression modelling of the predictors of change in HoNOS following CCU care; and descriptive comparisons of the costs associated with the two staffing models. The qualitative component utilizes a pragmatic approach to grounded theory, with collection of data from consumers and staff at multiple time points exploring their expectations, experiences and reflections on the care provided by these services.DiscussionIt is expected that the new knowledge gained through this study will guide the adaptation of these and similar services. For example, if differential outcomes are achieved for consumers under the integrated and clinical staffing models this may inform staffing guidelines.

Improving the social cognitive deficits of schizophrenia: a community trial of Social Cognition and Interaction Training (SCIT).

Objective: Social Cognition and Interaction Training (SCIT) is a Cognitive and Behavioural Therapy (CBT) informed group therapy with an emerging evidence base in addressing the social cognitive deficits associated with schizophrenia. This paper evaluates the application of this therapy within a community public mental health setting in Australia. Method: A mixed methods approach to the evaluation was undertaken, including survey data and thematic analysis. Results: Considerable challenges were met in the trial of SCIT in this ‘real-world’ setting. The qualitative data suggested that at least a subset of participants viewed the program as valuable and relevant to their needs. Conclusions: Further research is required to realise the benefits of SCIT found in research settings, in the real world of public community psychiatric practice.

Integrated staffing model for residential mental health rehabilitation

Purpose – A novel integrated staffing model for community-based residential rehabilitation services is described. The purpose of this paper is to achieve synergistic gains through meaningful integration of peer support and clinical workers within rehabilitation teams. Key features include the majority of roles within the team being held by persons with a lived experience of mental illness, the active collaboration between peer and clinical workers throughout all stages of a consumer’s rehabilitation journey, and an organizational structure that legitimizes and emphasizes the importance of peer work within public mental health service delivery. This staffing model is not anticipated to alter the core rehabilitation function and service models. Design/methodology/approach – The emergence of the integrated staffing model is described with reference to the policy and planning context, the evidence base for peer support, and the organizational setting. A conceptual and contextualized description of the staffin...