Marina Vamos

Effects of Methylphenidate in Normal Adults with Reference to Drug Action in Hyperactivity

Methylphenidate was administered to each of 12 adult volunteers in a double-blind, placebo-controlled, crossover study for purposes of comparison with previous studies in hyperactive children. Statistically significant changes occurred only on a minority of measures, but the results were generally in the direction of facilitated performance, reduced physical activity and increased emotional responsivity. As these results are similar to those in hyperactive and normal children, this appears to support the contention that stimulant drug effects in hyperactive children are not paradoxical or atypical.

‘We didn’t have a clue’: Family caregivers’ experiences of the communication of a diagnosis of schizophrenia

Background: Despite widespread acceptance of the principle that patients should be informed about their diagnosis, many clinicians are reluctant to provide a diagnosis of schizophrenia. This study examines family caregivers’ experiences of the communication of a schizophrenia diagnosis and related information. Methods: A generic qualitative methodological approach was used. In all, 13 family caregivers were recruited in regional New South Wales, Australia. Semi-structured interviews were used to explore their experiences and perceptions of discussing the diagnosis, prognosis and treatment of schizophrenia with mental health professionals. Interviews were recorded, transcribed, codes generated and thematic analysis undertaken. Results: Family caregivers described long and difficult pathways to being given a diagnosis, haphazard means of finding out the diagnosis, high unmet needs for information, exclusion from the medical care process and problematic communication and general interactions with mental health clinicians. Caregivers were unanimous about the importance of receiving a timely diagnosis, for them and their relative with schizophrenia. Conclusion: Family caregivers are an integral part of the mental health-care system, and they should be included early in discussions of diagnosis and treatment of a person with schizophrenia. Their perspectives on communicating a diagnosis of schizophrenia provide important information for communication skills training of psychiatrists and other mental health professionals.

Improving Clinician Competency in Communication About Schizophrenia: a Pilot Educational Program for Psychiatry Trainees

ObjectiveImportant gaps are observed in clinicians’ communication with patients and families about psychiatric disorders such as schizophrenia. Communication skills can be taught, and models for education in these skills have been developed in other fields of medicine, such as oncology, providing a framework for training communication skills relevant to psychiatric practice. This study evaluated a pilot communication skills education program for psychiatry trainees, focusing on discussing schizophrenia diagnosis and prognosis.MethodCommunication skills training modules were developed based on an existing theoretical framework (ComSkil), adapted for discussing a schizophrenia diagnosis and prognosis. Pre-post training rating of self-reported confidence in a range of communication tasks was obtained, along with trainee views on the training methods.ResultsThirty-eight participants completed the training. Significant improvements in confidence were reported post training for discussing schizophrenia prognosis, including an increased capacity to critically evaluate their own communication skills. Participants reported high levels of satisfaction with the program.ConclusionThis preliminary study provides support for the translation of a well-established educational model to psychiatric training addressing core clinical communication tasks and provides the foundation for the development of a more comprehensive evaluation and an extended curriculum regarding other aspects of care for patients with schizophrenia: ongoing management and recovery, dealing with conflict, and conducting a family interview.

Contextual barriers to discussing a schizophrenia diagnosis with patients and families: need for leadership and teamwork training in psychiatry.

ObjectiveThis research sought to gain insight into the processes used by clinicians to discuss a schizophrenia diagnosis with patients/families, with the aim of informing the development of a communications skills training program.MethodsA generic qualitative methodological approach was used. Sixteen mental health clinicians were recruited. Semi-structured individual interviews were used to explore their perceptions and experiences communicating a schizophrenia diagnosis. Interviews were recorded, transcribed, and thematic analysis undertaken.ResultsThere were five key themes relating to the process of communication about a diagnosis of schizophrenia: (1) orientation to patient care, (2) planning of communication, (3) the impact of team leadership and inter/intra-professional functioning on communication tasks, (4) the roles of different clinicians in communicating about diagnosis and treatment, and (5) time and resource deficiencies. Despite expressing care and concern for vulnerable patients and embracing the concept of multidisciplinary teams, communicating diagnostic information to patients and families was generally unplanned for, with little consistency regarding leadership approaches, or how the team communicated diagnostic information to the patient and family. This contributed to tensions between different team members.ConclusionThe findings demonstrated a number of issues compromising good communication around a schizophrenia diagnosis, both in terms of clinician skill and clinical context, and support the importance of education and training for all members of the multidisciplinary team about their role in the communication process.

Hunter New England Training (HNET): how to effect culture change in a psychiatry medical workforce

Objective: It is now recognized that education and training are at the core of quality systems in health care. In this paper we discuss the processes and drivers that underpinned the development of high quality education and training programs and placements for all junior doctors. The early identification and development of doctors interested in psychiatry as a career, engagement and co-operation with the broader junior doctor network and the creation of teaching opportunities for trainees that was linked to their stage of development were identified as key to the success of the program. Conclusions: Targeted, high quality education programs and clinical placements coupled with strategic development of workforce has reduced staff turn over, led to the stabilization of the medical workforce and created a culture where learning and supervision are highly valued.

Psychotherapy in the Medically Ill: A Commentary

OBJECTIVE To overview the field of psychotherapy in the medically ill. Rather than attempting a systematic review of this very extensive area, the article seeks to capture some of the main threads and issues of importance. METHOD The subject is looked at under four headings: (i) which illnesses have attracted research interest in psychotherapy; (ii) which outcome measures have been chosen; (iii) which modes of intervention have been used; and (iv) finally a review of the methodology and the results obtained. RESULTS Some illnesses have attracted much more psychotherapeutic interest than others; the differences are haphazard. Outcome measures on the whole have focused on coping with illness and psychological distress, with a smaller number looking at disease outcome. Only short-term changes have been sought in the main. The most commonly used modalities of therapy have been cognitive-behavioural; additionally, supportive information-giving and group therapy have been trialled. Benefit in terms of all these have been reported, but the majority of studies are weakened by major methodological shortcomings. CONCLUSION There is an overall paucity of well-designed studies that clearly demonstrate psychotherapy as an efficacious treatment in the medically ill. The field is hampered by the lack of a clear conceptual thread recognizing the long-term and diverse experience of patients with medical illness and relating this to the question of the part psychotherapy should play. Future work needs to concentrate on appropriate selection of patients who might benefit, as well as including a wider range of more clinically relevant outcome measures and more stringent methodology.

Organ transplantation and magical thinking

Organ transplantation can provide important treatment benefits in a variety of situations. While a number of live donor procedures are now possible, procurement of organs from dead donors remains the mainstay of transplant programmes. However, cadaveric donation rates remain much lower than anticipated, and some patients who receive organs struggle to adapt to their new body. The reasons for this are not entirely explained by rational or logical means. This paper uses concepts drawn from magical thinking to try to explain some of the less apparent issues at play within the process of cadaveric organ transplantation, including both the donation and receiving of organs. Three themes are explored as potentially relevant: superstitions and rituals around death and the dead body, incorporation and the meanings attached to the transplanted organ, and survivor guilt. All three are shown to be relevant for some part of the transplantation process in at least a minority of cases. It is therefore suggested that focusing not only on the logical and scientific, but also on the ambiguous and magical may enhance the organ donation process and thus increase donation rates and the psychological adjustment of transplant recipients.

Physician-assisted suicide: saying what we mean and meaning what we say.

Australian & New Zealand Journal of Psychiatry, 46(2) Entering an arena where so many distinguished commentators have already slugged it out is a daunting task. So rather than attempting to weigh arguments for and against, this discussion will confine itself to analysing and elucidating some of the linguistic underpinnings of the debate – the ways in which the notion of physician-assisted suicide is framed. Framing, says Goffman, is the process by which we provide background understanding, and structure meaning of events – particularly social ones (Goffman, 1974). The most fundamental way we do this is linguistically. The categorisation of words creates instant bias toward one interpretation or another. Thus the words we choose not only reflect what we are trying to say, but also control meaning in and of themselves (Somerville, 2003; Tucker and Steele, 2007). If we begin by looking at the ways we typically frame death and dying, we find that there have been quite profound changes over time. Obituaries, the news reports of death, make sense of death by creating a narrative about the person who has died. They present what is important and noteworthy in a manner intended to provide structure and comfort to those left behind. But while their function and significance has not changed, their content has. In a comparative analysis of obituaries appearing in The New York Times over three periods, Phillips (2007) notes significant differences. While in 1899 and 1959 obituaries typically described the process of dying, including the place and time of death and the details of comfort, pain, symptoms and other biological facts, notices from more recent years emphasise a warrior metaphor – the ability to control the circumstances of death, to fight a battle against it, claiming autonomy and agency for the dead person. When we thus discuss the dead as if they were still living, we avoid the distress of death, and move from the reality of our mourning – as Haussamen puts it, ‘language squirms to avoid the finality of death’ (Haussamen, 1998). While death cannot be conquered, it can be pushed aside and marginalised in its cultural expression. However, one can only speculate whether this death denial may have consequences. Might it, for example, lead to an under-estimation of the true need for palliative care resourcing (Emanuel and Emanuel, 1998; Somerville, 2003)? Furthermore, the pretence of control has led to some very strange linguistic frames. For example, it is now commonplace to use the expression ‘the right to die’ – as if one had any choice about the matter! In a recent example of this, Babylon and MonkTurner (2006) posed the question ‘Should incurable patients be allowed to die?’ The image is almost reminiscent of King Canute – a stern-faced, single-minded committee opposing the incoming tide of death. This brings us to the biggest linguistic trick of all. The word ‘euthanasia’ (a good death) appears to promise what we all hope for. Indeed, one might think it the mantra for palliative care – a death that is ‘free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients’ and families’ wishes; and reasonably consistent with clinical, cultural and ethical standards’ (Field and Cassel, 1997). But to imply that this is what euthanasia means is to leave out the most essential part. Euthanasia is in fact a new word for the act of killing. We are not talking about care for the dying, but the killing of a consenting adult (Callahan, 1997). Sulmasy (1998) claims the word euthanasia is a deceptive euphemism and argues that an unambiguous definition for what is being proposed should be an essential first step towards critical analysis of the practice. He proposes ‘euthanasia’ should be clearly described as: ‘An act in which an agent creates a new, lethal pathophysiological state with the specific intention in acting thereby causing a person’s death’. Euphemisms can be dangerous. While to say somebody ‘passed away’ rather than died may be no more than an avoidant figure of speech, at worst cultivating the denial of death and dying, using the term ‘euthanasia’ may cause actual harm. It may ‘disguise a practice which one might abhor if it were given another name’ (Mitchell, 1999–2000). It is difficult at this point not to recall that it was this precise euphemism Physician-assisted suicide: Saying what we mean and meaning what we say

Coming on board: the assessment of overseas trained psychiatrists by the Royal Australian and New Zealand College of Psychiatrists

Objective: The aim of this paper was to investigate key concerns of overseas trained psychiatrists (OTPs) in Australia and New Zealand surrounding the assessment of their qualifications and their experience of the Fellowship examination process. Method: A survey of OTPs progressing towards Fellowship of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) was conducted using an online survey instrument. The survey aimed to explore OTPs’ views regarding the key issues encountered in their progression to Fellowship and to gauge their level of satisfaction with a range of RANZCP support initiatives. Results: Important areas of concern were elicited across a variety of domains, including the examination process itself, issues around immigration, and differences in professional culture and language. The message to the RANZCP was that there were still important areas of dissatisfaction relating to measures taken to address these concerns. Conclusions: The authors recommend specific courses of action to address areas where more support is required, and suggest additional areas where more research is needed.

Communication skills in psychiatry training

Objective: Mental health clinicians can experience problems communicating distressing diagnostic information to patients and their families, especially about severe mental illnesses such as schizophrenia. Evidence suggests that interpersonal communication skills can be effectively taught, as has been demonstrated in the specialty of oncology. However, very little literature exists with respect to interpersonal communication skills training for psychiatry. This paper provides an overview of the communication skills training literature. Conclusions: The report reveals significant gaps exist and highlights the need for advanced communication skills training for mental health clinicians, particularly about communicating a diagnosis and/or prognosis of schizophrenia. A new communication skills training framework for psychiatry is described, based on that used in oncology as a model. This model promotes applied skills and processes that are easily adapted for use in psychiatry, providing an effective platform for the development of similar training programs for psychiatric clinical practice.