Neeraj Gill

Incidence and risk factors for clozapine-induced myocarditis and cardiomyopathy at a regional mental health service in Australia

Objective: To determine the incidence of clozapine-induced myocarditis and cardiomyopathy and identify risk factors. Method: A cohort of 129 patients initiated on clozapine at Toowoomba Mental Health Service from year 2000 until 2011 was examined to evaluate cases of myocarditis and cardiomyopathy. Risk factors were analysed using multivariable logistic regression. Results: The incidence of clozapine-induced myocarditis and cardiomyopathy was 3.88% and 4.65% (or 2.26 per 100 patient years), respectively. A significant association was identified between clozapine-induced myocarditis and SSRI use (p = 0.043). Subclinical cardiomyopathy was identified in the absence of symptoms in the majority of cases. Conclusions: These results illustrate a high incidence of clozapine-induced myocarditis as well as cardiomyopathy, reinforcing the need for a standardised, mandatory monitoring scheme. Concomitant SSRI use as one such potential predictor merits further study.

Common mental disorders among Indigenous people living in regional, remote and metropolitan Australia: a cross-sectional study

Objective To determine, using face-to-face diagnostic interviews, the prevalence of common mental disorders (CMD) in a cohort of adult Indigenous Australians, the cultural acceptability of the interviews, the rates of comorbid CMD and concordance with psychiatrists’ diagnoses. Design Cross-sectional study July 2014–November 2016. Psychologists conducted Structured Clinical Interviews for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Axis I Disorders (SCID-I) (n=544). Psychiatrists interviewed a subsample (n=78). Setting Four Aboriginal Medical Services and the general community located in urban, regional and remote areas of Southern Queensland and two Aboriginal Reserves located in New South Wales. Participants Indigenous Australian adults. Outcome measures Cultural acceptability of SCID-I interviews, standardised rates of CMD, comorbid CMD and concordance with psychiatrist diagnoses. Results Participants reported that the SCID-I interviews were generally culturally acceptable. Standardised rates (95% CI) of current mood, anxiety, substance use and any mental disorder were 16.2% (12.2% to 20.2%), 29.2% (24.2% to 34.1%), 12.4% (8.8% to 16.1%) and 42.2% (38.8% to 47.7%), respectively—6.7-fold, 3.8-fold, 6.9-fold and 4.2-fold higher, respectively, than those of the Australian population. Differences between this Indigenous cohort and the Australian population were less marked for 12-month (2.4-fold) and lifetime prevalence (1.3-fold). Comorbid mental disorder was threefold to fourfold higher. In subgroups living on traditional lands in Indigenous reserves and in remote areas, the rate was half that of those living in mainstream communities. Moderate-to-good concordance with psychiatrist diagnoses was found. Conclusions The prevalence of current CMD in this Indigenous population is substantially higher than previous estimates. The lower relative rates of non-current disorders are consistent with underdiagnosis of previous events. The lower rates among Reserve and remote area residents point to the importance of Indigenous peoples’ connection to their traditional lands and culture, and a potentially important protective factor. A larger study with random sampling is required to determine the population prevalence of CMD in Indigenous Australians.

Understanding existing community networks for volunteer suicide intervention trainees – preliminary findings from trainees undertaking an Indigenous suicide intervention training program developed in partnership with Indigenous communities

The fictional artificial intelligence (AI) computer, HAL (Heuristically programmed ALgorithmic computer) 9000, spaceship Discovery One’s computer, plays a pivotal role in director Stanley Kubrick’s ground-breaking 1968 film, 2001: A Space Odyssey. The screenplay by science fiction writer Arthur C. Clarke and Kubrick, depicting HAL 9000 gradually breaking down, serves as an early example of an AI model of schizophrenia with computational models now being used to investigate illness mechanisms in schizophrenia (Hoffman et al., 2011). Mental illness is a recurring theme in Kubrick’s films and they feature a number of central characters affected by it: Alex DeLarge in A Clockwork Orange, Jack Torrance in The Shining and Leonard Lawrence in Full Metal Jacket. HAL 9000 is able to perform many human-like functions such as speech, speech recognition, facial recognition, lip reading, interpreting emotion and behaviours, automated reasoning and playing chess. HAL 9000 breaks down after being unable to resolve an internal conflict as it has been programmed to relay information to crew members accurately but has orders specific to that particular mission to withhold information from the crew. Toward a Theory of Schizophrenia (Bateson et al., 1956) was published in 1956, just 12 years prior to the release of the film. The situation HAL 9000 is in with Discovery One’s crew appears to be a double bind similar to that described by Bateson et al. HAL 9000 does not immediately malfunction but starts to develop problems approximately 9 years after production showing minor malfunctions such as incorrectly identifying a particular chess move using descriptive notation in a game which it plays with crewmember Dr Frank Poole. A fault with the spaceship’s communications antenna is also mistakenly reported. These can be seen as an AI version of a schizophrenic prodromal state in which cognitive impairment is often observed. The crew gradually realise the computer is malfunctioning and faced with the threat of disconnection and hence loss of control; HAL 9000 reasons that with the crew dead it can continue to operate while concealing its malfunction from mission support staff on Earth and sets about killing them. Is this the violence sometimes seen subsequent to threat/controloverride delusions? Of the five astronauts, only Dr David Bowman survives and eventually shuts the computer down by removing its memory terminals, one by one. The computer’s last words are a rendition of the song ‘Daisy Bell (Bicycle Built for Two)’, which includes the line ‘I’m half crazy’, possibly signifying a full-blown psychotic break. If all this seems far fetched and merely the stuff of science fiction, then one only needs to consider flight QF72 from Singapore to Perth on 7 October 2008. Incorrect data on measures such as airspeed and angle of attack (a critical parameter used to control an aircraft’s pitch) were sent by one of the Qantas Airbus A330’s three air-data computers to other systems on the plane. One of the three flight control primary computers (known as PRIMs) then reacted to the angle-of-attack data by commanding the plane to nosedive repeatedly. This is analogous to a person suffering from schizophrenia whereby they are making, sometimes life changing, decisions affecting them and others based on faulty input data such as delusions and hallucinations. Injuries occurred to 119 passengers and crew, 12 of these suffering serious injuries, and at least two long serving flight crew, including Captain Kevin Sullivan, a former United Sates Navy fighter pilot, developed posttraumatic stress disorder. O’Sullivan (2017) stated,

An Australian Indigenous community-led suicide intervention skills training program: community consultation findings

BackgroundLittle is known of the appropriateness of existing gatekeeper suicide prevention programs for Indigenous communities. Despite the high rates of Indigenous suicide in Australia, especially among Indigenous youth, it is unclear how effective existing suicide prevention programs are in providing appropriate management of Indigenous people at risk of suicide.MethodsIn-depth, semi-structured interviews and focus groups were conducted with Indigenous communities in rural and regional areas of Southern Queensland. Thematic analysis was performed on the gathered information.ResultsExisting programs were time-intensive and included content irrelevant to Indigenous people. There was inconsistency in the content and delivery of gatekeeper training. Programs were also not sustainable for rural and regional Indigenous communities.ConclusionsAppropriate programs should be practical, relevant, and sustainable across all Indigenous communities, with a focus on the social, emotional, cultural and spiritual underpinnings of community wellbeing. Programs need to be developed in thorough consultation with Indigenous communities. Indigenous-led suicide intervention training programs are needed to mitigate the increasing rates of suicide experienced by Indigenous peoples living in rural and remote locations.

The feasibility of the structured clinical interview for diagnostic and statistical manual of mental disorders (SCID-I) as a practical and culturally appropriate method of diagnosing mental disorders in indigenous Australians

Background: Problem drinking is a worldwide concern and is often a comorbid health problem for psychiatric illness. With the rising trend in e-mental health interventions, the advancement of smartphone technology has ushered in an era where smartphone applications can be used for behavioural intervention in problem drinking. Objectives: The aim of the study is to contribute towards the development of a novel smartphone application for use with problem drinkers based on behavioural modification principles. Methods: Seven postgraduate students in the School of Health Professions at Murdoch University were interviewed about the use of a novel smartphone application for behavioural intervention with problem drinking and the interview transcripts were subjected to thematic analysis. Findings: Themes that emerged include: accessibility, milestones and commitment. Conclusions: These findings shed light on the development of a novel e-mental health intervention for problem drinking. The implications for clients from diverse cultures and various age groups are discussed.Background: The last 10 years has seen considerable progress in relation to seclusion data development and reduction initiatives in Australia. Part of the success has been the use of a standardized definition and national collection of data for benchmarking and quality improvement. The National Seclusion and Restraint Reduction Project has encouraged services and individuals to reconsider their practices, and there has been a flurry of activity at local, state and national levels. Objectives: This paper describes that journey presents data from the national collection and looks at the future intentions of the Project. Findings: The acute mental health units have progressively reduced their use of seclusion in the last 6 years from 13.8 episodes per 1000 bed days in 2009–2010 to 8.0 in 2013–2014. Despite this, an average of 5% of people admitted to specialized services still experience an episode of seclusion, and there are considerable variations across sites and age ranges. There have also been some remarkable successes, particularly when consumers have been actively involved in the response. Conclusions: The call for ‘recovery’ challenges us to think about many other forms of restrictive practice. We are at various stages in the development of national measures of physical and mechanical restraints, continuing involuntary treatment and acute injectable medications. As seclusion once was, much of this has been considered necessary for safety or to get a good outcome. Is this true and what does the future hold?

Human Rights Based Mental Health Care - Legislation and Practice

Background: Natural disasters affect the health and wellbeing of adults throughout the world. There is some debate in the literature as to whether older persons have increased risk of mental health outcomes after exposure to natural disasters when compared to younger adults. To date, no systematic review has evaluated this. Objectives: We aimed to synthesise the available evidence on the impact of natural disasters on the mental health and psychological distress experienced by older adults. Methods: A meta-analysis was conducted on papers identified through a systematic review. The primary outcomes measured were post-traumatic stress disorder (PTSD), depression, anxiety disorders, and adjustment disorder. Findings: We identified six papers with sufficient data for a random effects meta-analysis. Older adults were 2.11 times more likely to experience PTSD symptoms when exposed to natural disasters when compared to younger adults. Conclusions: Recent decades have seen a global rise in the numbers of older adults affected by natural disasters, implying that an increasing number of the older adults will find themselves “in harm’s way” amid community disruption and distress. Mental health service providers need to be prepared to meet the mental health needs of older persons, and be particularly vigilant after natural disasters to ensure, in particular, early detection and management of PTSD.Abstract of a poster presentation at the RANZCP 2015 Congress, Brisbane, Australia, 3-7 May 2015. Disciplines Medicine and Health Sciences | Social and Behavioral Sciences Publication Details Dawes, K., Lethbridge, A. & Pai, N. (2015). Does clinical placement location affect medical student exam performance in psychiatry?. Australian and New Zealand Journal of Psychiatry, 49 (Suppl. 1), 107-108. This journal article is available at Research Online: http://ro.uow.edu.au/smhpapers/2780 Poster Presentations RANZCP 2015 CONGRESs, Brisbane Convention and Exhibition Centre, 3–7 May 2015 Does Clinical Placement Location Affect Medical Student Exam Performance in Psychiatry? K Dawes, A Lethbridge, N Pai University of Wollongong, Wollongong, Australia Background: One of the many challenges in managing student clinical placements is trying to ensure equity of opportunity and experience in regards to meeting the curriculum objectives. Students often complain that they have been disadvantaged by their clinical placement due to variations in patient population and acuity, the availability of consultants, registrars and other health care staff to guide learning, and the presence of other students from all disciplines who compete for opportunities. Objectives: To identify if there is a relationship between psychiatry placement location in the Illawarra Shoalhaven Local Health District (ISLHD) and end of year psychiatry exam results for medical students from the University of Wollongong. Methods: We compared psychiatry oral and written exam results for six cohorts of students, from 2009 to 2014, across four different placement locations in the ISLHD (N = 450) using one-way multivariate analysis of variance. Findings: The multivariate effect of placement location was not significant (Pillai’s Trace = .013, F(6,892) = .994, p = .428). Univariate ANOVAs on the individual outcome variables were also non-significant (written exam scores, F(3, 446) = 1.373, p = .250; oral exam scores F(3,446) = .789, p = .501). Conclusions: Maintaining the quality and consistency of clinical placements will always be a challenge due to limited and varied opportunities, student numbers, and the dynamic nature of both the workforce and the patient populations. However, based on our findings, within our region there is no difference in placement location in regards to end of year psychiatry exam results.Background Australia and New Zealand both have mandated systems for routine outcome measurement within public mental health services. A comprehensive 2014 review of the Australian system highlighted both support for routine outcome measurement and a need to spread good practice in the use of the mandated measures in practice. At the same time, the mandated measures are under evaluation in Australia for inclusion within activity based funding processes. The RANZCP has completed two online modules to assist trainees in improving their knowledge and skills in this important area of practice.

Between the idea and the reality: GP liaison in a rural setting

Objectives: To describe the organisational, clinical and pragmatic features of a GP liaison service established by the Division of Mental Health in the Darling Downs Hospital and Health Service catchment to facilitate the care of rural patients and improve communication between primary and specialist care. Conclusions: The GP liaison service was created using funding from the Commonwealth STP initiative to provide weekly registrar clinics to primary care providers in the Darling Downs. The service was eagerly accepted by providers who saw patient benefits outweighing financial considerations. Expectations of a greater level of care than the assessment and advice provided reflects the large unmet need for mental health services in rural areas. GPs expressed enthusiasm for true collaborative care, such as case management overseen by the public mental health service but based at GP offices.