Garry Walter

Psychosocial Treatments for People with Co-occurring Severe Mental Illnesses and Substance Use Disorders (Dual Diagnosis): A Review of Empirical Evidence

&NA; Considerable research documents the health consequences of psychosis and co‐occurring substance use disorders. Results of randomized controlled trials assessing the effectiveness of psychosocial interventions for persons with dual diagnoses are equivocal but encouraging. Many studies are hampered by small, heterogeneous samples, high attrition rates, short follow‐up periods, and unclear description of treatment components. The treatments available for this group of patients (which can be tailored to individual needs) include motivational interviewing, cognitive‐behavioral therapy, contingency management, relapse prevention, case management, and skills training. Regardless of whether services follow integrated or parallel models, they should be well coordinated, take a team approach, be multidisciplinary, have specialist‐trained personnel (including 24‐hour access), include a range of program types, and provide for long‐term follow‐up. Interventions for substance reduction may need to be further developed and adapted for people with serious mental illnesses. Further quality trials in this area will contribute to the growing body of data of effective interventions.

Clinical practice recommendations for bipolar disorder

Objective:  To provide clinically relevant evidence‐based recommendations for the management of bipolar disorder in adults that are informative, easy to assimilate and facilitate clinical decision‐making.

Characteristics of Adolescents with School Refusal

Objective: To describe the characteristics of young people presenting with school refusal to a child and adolescent psychiatric unit and examine differences between those admitted for inpatient treatment and the rest. Method: One hundred and ninety-two adolescents who had been assessed or treated for school refusal between 1994 and 1998 at the Rivendell Unit, Sydney, Australia were identified. An instrument was developed and used to gather data from files. Diagnoses were made by the consensus of two of the investigators using DSM IV criteria from all sources of information. Results: The commencement of school refusal generally occurred in the first 2 years of high school. School refusers had a high prevalence not only of anxiety, but also of mood and disruptive behaviour disorders. A family history of psychiatric illness was present in over half the sample. There were no differences between those subsequently admitted as inpatients and the rest in terms of symptom scores, family composition, family conflict, family separation or history of abuse. Those admitted for inpatient treatment were more likely to have a diagnosis of mood disorders and comorbid diagnoses and to have a maternal history of psychiatric illness. Conclusions: School refusal in adolescence can be a symptom of a variety of disorders, particularly anxiety and mood disorder. Treatment programs need to be geared to the range of diagnoses which occur in this patient group and to the various circumstances associated with the onset of the problem.

The Impact Factor: Time for Change

Objective: The Impact Factor (IF) has received virtually no attention in the psychiatric literature, despite its long-term use, expanding influence and evidence of misapplication. We examine the IFs validity as a measure of a papers scientific worth, and consider alternative ways to conduct such an appraisal. Method: We explored medical databases and websites, and conferred with acknowledged experts on the subject. Results: Irremediable problems, both conceptual and technical, make the IF a flawed measure. The notion that citations vouch for the quality of an article is questionable. Moreover, the IFs vulnerability to misuse in domains such as academic promotion and research grant assessment is a serious development. Conclusion: The IF (and all measures derived from it) should be abandoned. A ‘return to basics’ in evaluating published work is overdue. As seductive as a simple formula is to assess quality, shortcuts are unavailable and unlikely to be useful. Publishing a short-list of papers annually, judged as objectively as possible by peers to merit special attention, may be a more meaningful option. Conceivably, every psychiatric journal could participate in this cyclical exercise, leading to a ‘grand short-list’. This could be made readily available to all professionals, both researchers and clinicians, by being posted on a suitable website. Since peer review has a long-standing role in scientific publishing, our proposal is essentially an extension of that process.

Clinical practice recommendations for depression

Objective:  To provide clinically relevant evidence‐based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making.

Psychosocial treatments for people with co‐occurring severe mental illness and substance misuse: systematic review

AIM This study is a report of a systematic review to assess current evidence for the efficacy of psychosocial interventions for reducing substance use, as well as improving mental state and encouraging treatment retention, among people with dual diagnosis. BACKGROUND Substance misuse by people with a severe mental illness is common and of concern because of its many adverse consequences and lack of evidence for effective psychosocial interventions. DATA SOURCES Several electronic databases were searched to identify studies published between January 1990 and February 2008. Additional searches were conducted by means of reference lists and contact with authors. REVIEW METHODS Results from studies using meta-analysis, randomized and non-randomized trials assessing any psychosocial intervention for people with a severe mental illness and substance misuse were included. RESULTS Fifty-four studies were included: one systematic review with meta-analysis, 30 randomized controlled trials and 23 non-experimental studies. Although some inconsistencies were apparent, results showed that motivational interviewing had the most quality evidence for reducing substance use over the short term and, when combined with cognitive behavioural therapy, improvements in mental state were also apparent. Cognitive behavioural therapy alone showed little consistent support. Support was found for long-term integrated residential programmes; however, the evidence is of lesser quality. Contingency management shows promise, but there were few studies assessing this intervention. CONCLUSION These results indicate the importance of motivational interviewing in psychiatric settings for the reduction of substance use, at least in the short term. Further quality research should target particular diagnoses and substance use, as some interventions may work better for some subgroups.

Combating psychiatric stigma: An overview of contemporary initiatives

Psychiatric stigma is the false and unjustified association of individuals who have a mental illness, their families, friends and service providers with something shameful. It is often deeply hurtful. Sometimes fanned by the media, the ever-glowing coals and brand of stigma foster hostility in the community and negative discrimination by services and employer. Stigma stirs up fears and discourages people who suspect they may have a mental illness from seeking appropriate and timely help. The following paper summarises recent initiatives to counter psychiatric stigma that are relevant to or emanate from Australia and New Zealand.

The portrayal of ECT in American movies.

Objective To describe the portrayal of electroconvulsive therapy (ECT) in American films. This has not been systematically studied previously, despite some notorious ECT scenes in the history of American cinema and the impact of films on audiences. Method All movies depicting or making reference to ECT were identified from a number of sources. Available movies were viewed on at least two occasions. Results 22 films, beginning with The Snake Pit and ending with Requiem for a Dream, portraying or making reference to ECT were made between 1948 and 2000. 20 (91%) of these movies were obtained and viewed. Conclusion Having commenced its movie career as a severe but helpful remedy for personal distress, ECT on film has become a progressively more negative and cruel treatment, leaving the impression of a brutal, harmful, and abusive maneuver with no therapeutic benefit.

Psychiatry and the Hirsch h-index: The Relationship Between Journal Impact Factors and Accrued Citations

&NA; There is considerable debate on the use and abuse of journal impact factors and on selecting the most appropriate indicator to assess research outcome for an individual or group of scientists. Internet searches using Web of Science and Scopus were conducted to retrieve citation data for an individual in order to calculate nine variants of Hirschs h‐index. Citations to articles published in a wide range of psychiatric journals in the periods 1995–99 and 2000–05 were analyzed using Web of Science. Comparisons were made between journal impact factor, h‐index of citations from publication to 2008, and the proportion of articles cited at least 30 or 50 times. For up to 14 years post‐publication, there was a strong positive relationship between journal impact factor and h‐index for citations received. Journal impact factor was also compared to the percentage of articles cited at least 30 or 50 times—a comparison that showed wide variations between journals with similar impact factors. This study found that 40%–50% of the articles published in the top ten psychiatry journals ranked by impact factor acquire 30 to 50 citations within ten to fifteen years. Despite certain flaws and weaknesses, the h‐index provides a better way to assess long‐term performance of articles or authors than using a journals impact factor, and it provides an alternative way to assess a journals long‐term ranking.

An epidemiological study of the use of ECT in adolescents

OBJECTIVE There is little knowledge about the use of electroconvulsive therapy (ECT) in adolescents. Given the prevalence and severity of psychiatric disorders in this age group, it is important to determine the frequency, indications, effectiveness, and side effects of ECT. METHOD Persons younger than 19 years who received ECT between 1990 and 1996 in the Australian state of New South Wales were identified. Detailed information about diagnosis, treatment, and outcome was then obtained. RESULTS Forty-two patients aged 14 to 18 years underwent a total of 49 courses comprising 450 ECTs (0.93% of all treatments given to all persons). Marked improvement or resolution of symptoms occurred in half of the completed courses. Mood disorders derived most benefit from ECT. Side effects were transient and minor. Prolonged seizures were observed in 0.4% of treatments. Comorbid personality disorder predicted poorer response, and the anesthetic propofol was associated with shorter seizures. CONCLUSIONS Although ECT is an effective treatment for some mental disorders in adolescents and has few side effects, it is seldom used. Indications, response, and unwanted effects were similar to those observed in adults. The use of propofol may reduce the risk of prolonged seizures.