Graham Mellsop

Lifetime suicide risk in major depression: sex and age determinants

BACKGROUND Recent work has demonstrated that the lifetime suicide risk for patients with DSM IV Major Depression cannot mathematically approximate the accepted figure of 15%. Gender and age significantly affect both the prevalence of major depression and suicide risk. METHODS Gender and age stratified calculations were made on the entire population of the USA in 1994 using a mathematical algorithm. Sex specific corrections for under-reporting were incorporated into the design. RESULTS The lifetime suicide risks for men and women were 7% and 1%, respectively. The combined risk was 3.4%. The male:female ratio for suicide risk in major depression was 10:1 for youths under 25, and 5.6:1 for adults. CONCLUSIONS Suicide in major depression is predominantly a male problem, although complacency towards female sufferers is to be avoided. Diagnosis of major depression is of limited help in predicting suicide risk compared to case specific factors. The male experience of depression that leads to suicide is often not identified as a legitimate medical complaint by either sufferers or professionals. Increasing help-accessing by males is a priority. CLINICAL IMPLICATIONS Patients with a history of hospitalisation; comorbidity, especially for substance abuse; and who are male, require greater vigilance for suicide risk. It may be that for males the threshold for diagnosing and treating major depression needs to be lowered. LIMITATIONS This research is based on a mathematical algorithm to approximate a life-long longitudinal study that identifies community cases of depression. Our findings therefore rely on the validity of the statistics used. Extrapolation is limited to populations with an actual suicide rate of 17/100,000 or less and a lifetime prevalence of major depression of 17% or more.

A study of the use of seclusion in an acute psychiatric service

Objective: In recent years, increased attention has been paid to significantly restrictive practices taking place in psychiatric services in New Zealand. The aim of this study was to prospectively examine the frequency of use of seclusion and the factors associated with its use in the acute general adult psychiatric wards serving the Waikato area. Methods: Information on the use of seclusion and relevant demographic data were collected over a 9-month period in 2000. The patterns of locked seclusion use and the characteristics of patients who had been secluded were examined. Analysis compared patients requiring one or more episode of seclusion (n = 84) with those never secluded (n = 455). Results: Of a total of 539 patients admitted to the general adult unit during our study period, 84 (16%) were secluded in 129 seclusion episodes. About two-thirds of the seclusion events were initiated in the first week of the patients admission, and three-quarters of secluded patients had only one episode. The median duration of seclusion was 14 hours. Comparison of gender and race revealed significant differences between the groups. Diagnosis, but not age, had a significant effect on whether a patient would be secluded. Seclusion was mainly associated with risk of, or actual, violence toward staff, patients or property. Conclusions: This study shows that seclusion is regularly practiced in the psychiatric wards of the Waikato area. In the majority of cases, its use was related to actual or threatened violence. Male, non-European patients and patients with certain diagnoses were at particular risk for seclusion. More research is required to examine the most effective use of seclusion and also the development and use of alternative strategies in controlling aggressive behaviour.

Stigma and quality of life as experienced by people with mental illness

Objectives: The aim of this study was to assess the extent to which people with mental illness in a New Zealand setting encounter stigma and discrimination and to examine their satisfaction with quality of life. Method: Patients under the care of a range of community mental health services were invited to participate in a survey. Fifty-three females and 47 males completed questionnaires concerning stigma, discrimination and quality of life. Demographic and diagnostic characteristics were also recorded. Results: The majority of participants reported experiencing stigma and discrimination in a variety of contexts. In association with this, they had experienced dissatisfaction with their quality of life in a number of areas. Conclusions: The experience of stigma and dissatisfaction with quality of life among people with mental illness is common. This has implications for clinical assessment and management.

Alcoholism and Psychiatric Disorder

Over the past 50 years the relationship between alcoholism and psychiatric disorders, such as depression, anxiety and schizophrenia, has been the subject of a great deal of research. Psychiatric problems have been seen as both a cause and a result of alcoholism. Whatever the relation between alcoholism and psychiatric disorder is, it may have significance for the development of differentially effective treatment strategies. Several authors have argued that the presence and nature of psychiatric symptoms should form the basis of a classification system for alcoholics. Given the potential rewards of such a system for both understanding the aetiology of alcoholism and developing effective treatment strategies, it is important to have a clear picture of the nature and extent of this relationship. This paper reviews critically the published studies of the association between alcoholism and psychiatric disorder and outlines directions for future research.

The Contributions of Culture and Ethnicity To New Zealand Mental Health Research Findings

Background & material: In the last five years a number of studies have been conducted in specialist psychiatric and primary care populations in New Zealand which have allowed comparisons in terms of clinical phenomena and therapeutic experiences between Mâori (the indigenous people of New Zealand) and non-Mâori. These studies were reviewed in terms of the methodology used, their major findings and their implications. Discussion: In specialist psychiatric services Mâori were more likely to present with hallucinations and/or aggression and less likely to present with depression and/or episodes of self-harm. They were overly represented in those with schizophrenia. Mâori were more likely to be involved in acts of aggression and to be secluded, and an equivalent episode of care for Mâori appeared to be significantly more costly than for non Mâori. Other studies, conducted in prison and community-based samples, suggested that Mâori were less likely to access care and, when given a diagnosis of depression, less likely to be prescribed anti-depressant medication. The rates of depression were significantly higher in Mâori (women) and Mâori were also overly represented in those with anxiety and substance misuse disorders. These differences remained even after the sample was standardised for socio-economic status. Further exploration of the genesis and implications of these findings, derived from a strong and relatively well-defined indigenous people, may usefully inform the more general issues of culture and its significance for diagnosis, classification and service use. Conclusions: While the methodologies used and the actual results gained differed across studies, there do seem to be differences in phenomenological profiles at presentation, in the diagnostic patterns, the cost of care, and the therapeutic experiences between Mâori and non-Mâori New Zealanders. These differences may reflect actual differences between certain ethnic groups, which then explain the differences in the experiences of those users, or they may reflect inadequacies on the parts of non-Mâori clinicians, their diagnostic tools and the services in which they operate, in catering for Mâori patients.

Patient and staff perspectives on the use of seclusion

Objectives: This paper investigates the perceptions and experience of patients and staff on the use of seclusion in psychiatric services. Method: A purpose designed questionnaire was distributed to staff and patients in a general adult mental health service. Results: Staff and patients both attributed more negative than positive feelings to patients’ experience of seclusion. Conclusions: Monitoring and evaluation of the use of seclusion may be insufficient to prevent or ameliorate its emotional impact. More comfortable alternatives to seclusion need to be utilized whenever possible.

Pōwhiri process in mental health research.

Within the health research context, indigenous people globally have a commitment to provide their own solutions. Māori, the indigenous people of Aotearoa (New Zealand) value the traditional Pōwhiri process of engagement and participation in mental health research. The practices and protocols within the Pōwhiri process (use in the Doctorate of Philosophy (2010) and Auckland University) are premised on the notion of respect and positive relationships between the tangata whenua (hosts or research participants) and manuwhiri (guests or researchers). This paper briefly describes the Pōwhiri process, which may be a model applicable to research with other indigenous cultures.

Involuntary admission and treatment of patients with mental disorder

Despite the efforts of the World Health Organization to internationally standardize strategies for mental-health care delivery, the rules and regulations for involuntary admission and treatment of patients with mental disorder still differ markedly across countries. This review was undertaken to describe the regulations and mental-health laws from diverse countries and districts of Europe (UK, Austria, Denmark, France, Germany, Italy, Ireland, and Norway), the Americas (Canada, USA, and Brazil), Australasia (Australia and New Zealand), and Asia (Japan and China). We outline the criteria and procedures for involuntary admission to psychiatric hospitals and to community services, illustrate the key features of laws related to these issues, and discuss their implications for contemporary psychiatric practice. This review may help to standardize the introduction of legislation that allows involuntary admission and treatment of patients with mental disorders in the mainland of China, and contribute to improved mental-health care. In this review, involuntary admission or treatment does not include the placement of mentally-ill offenders, or any other aspect of forensic psychiatry.

Why academic psychiatry is endangered.

Australian & New Zealand Journal of Psychiatry, 49(1) Across the developed world, recruitment into all areas of academic medicine has declined, not least psychiatry. For Australia and New Zealand, this will have a serious impact on undergraduate teaching, on postgraduate training and on our continuing contribution to research. In the UK, the Academy of Medical Sciences became sufficiently concerned about the situation in academic psychiatry to deploy a high-level working group to find ways of strengthening it. In America, the National Institute of Mental Health concluded that a decline in the psychiatrist-researcher workforce was ‘harming public needs’ (Institute of Medicine, 2005). It subsequently appointed a National Psychiatry Training Council to seek ways to improve the situation. In Australia and New Zealand, recruitment into academic psychiatry is in the same precarious state, although paradoxically this is occurring at a time when the knowledge base is undergoing unprecedented expansion. We believe that the specialty suffers from an unfavourable image among young graduates who see it as Why academic psychiatry is endangered

Review of psychiatric services to mentally disordered offenders around the Pacific Rim

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in‐reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial (“disability”) are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic services.