Pete M. Ellis

Prospectively Ascertained Child Maltreatment and Its Association With DSM-IV Mental Disorders in Young Adults

CONTEXT Evidence for an association between child maltreatment and later psychopathology heavily relies on retrospective reports of maltreatment. The few studies using prospective ascertainment of child maltreatment show weaker associations, raising the possibility that it is not maltreatment, but rather the memory of maltreatment, that raises the risk of later mental disorders. OBJECTIVES To estimate associations between prospectively ascertained child maltreatment and a wide range of subsequently measured DSM-IV mental disorders and to show the influence of retrospectively reported maltreatment in the comparison group on these associations. DESIGN Retrospective cohort study. SETTING Nationally representative New Zealand community. PARTICIPANTS Respondents aged 16 to 27 years (n = 2144) from a mental health survey, 221 of whom were identified as having records on a national child protection agency database. MAIN OUTCOME MEASURES Twelve-month and lifetime prevalence of individual DSM-IV mood, anxiety, and substance use disorders, and disorder groups assessed with the World Health Organization Composite International Diagnostic Interview. RESULTS After adjusting for demographic and socioeconomic correlates, child protection agency history was associated with several individual mental disorders, mental disorder comorbidity, and all mental disorder groups, both 12-month and lifetime. Odds of 12-month posttraumatic stress disorder were 5.12 (95% confidence interval [CI], 2.42-10.83); of any 12-month mood disorder, 1.86 (95% CI, 1.12-3.08); of any anxiety disorder, 2.41 (95% CI, 1.47-3.97); and of any substance use disorder, 1.71 (95% CI, 1.01-2.88). These associations increased in magnitude when those who retrospectively reported child maltreatment were removed from the comparison group. CONCLUSIONS Prospectively ascertained child maltreatment is significantly associated with a range of subsequent mood, anxiety, and substance use disorders, indicating that maltreatment, not just the memory of maltreatment, is associated with subsequent psychopathology. There is a need for both targeted mental health interventions with the present and past clients of child welfare agencies and for concerted population-level strategies to meet the needs of the many other children who experience maltreatment.

Privacy, professionalism and Facebook: a dilemma for young doctors

Medical Education 2010: 44: 805–813

Childhood maltreatment and DSM-IV adult mental disorders: Comparison of prospective and retrospective findings

BACKGROUND Prior research reports stronger associations between childhood maltreatment and adult psychopathology when maltreatment is assessed retrospectively compared with prospectively, casting doubt on the mental health risk conferred by maltreatment and on the validity of retrospective reports. AIMS To investigate associations of psychopathology with prospective v. retrospective maltreatment ascertainment. METHOD A nationally representative sample of respondents aged 16-27 years (n = 1413) in New Zealand completed a retrospective assessment of maltreatment and DSM-IV mental disorders. Survey data were linked with a national child protection database to identify respondents with maltreatment records (prospective ascertainment). RESULTS Childhood maltreatment was associated with elevated odds of mood, anxiety and drug disorders (odds ratios = 2.1-4.1), with no difference in association strength between prospective and retrospective groups. Prospectively ascertained maltreatment predicted unfavourable depression course involving early onset, chronicity and impairment. CONCLUSIONS Prospectively and retrospectively assessed maltreatment elevated the risk of psychopathology to a similar degree. Prospectively ascertained maltreatment predicted a more unfavourable depression course.

The oral examination: a study of academic and non-academic factors

Summary. The oral examination in psychiatry for final‐year medical students at Wellington and Dunedin School of Medicine, University of Otago, was studied. Between December 1989 and April 1990, 40 medical students were videorecorded during such an examination. The transcripts of the recording of each oral, and at a later date the videorecordings, were individually scored by a panel of six research psychiatrists who were experienced examiners. In addition verbal and non‐verbal behaviour was rated using visual analogue scales and the students completed personality and anxiety questionnaires. There was a low level of agreement between research psychiatrists in the allocation of oral marks. The oral score was positively associated with the level of confidence of the student and negatively with anxiety in men.

Evidence-based guidelines: response to Professor Gordon Parker's critique

Objective: To clarify the development of the ‘Australian and New Zealand clinical practice guidelines for the treatment of depression’ and to discuss the critique of these guidelines. Method: Consideration of international practice in evidence-based medicine and rebuttal of criticisms. Results: We agree with Professor Gordon Parker on fundamental issues in the treatment of depression. His main criticisms reflect his concerns about the classification of depression. We consider that many of his detailed criticisms reflect a difference of opinion on how data should be evaluated or interpreted. Conclusions: The guideline for the treatment of depression makes sound recommendations, in agreement with comparable guidelines from the US and the UK.

Clozapine-treated Patients Have Marked Gastrointestinal Hypomotility, the Probable Basis of Life-threatening Gastrointestinal Complications: A Cross Sectional Study.

Background Gastrointestinal side effects are particularly common with clozapine and occur with other antipsychotics, ranging from mild constipation to fatal bowel obstruction and/or ischemia. While this adverse-effect spectrum has been attributed to ‘gastrointestinal hypomotility’, gastrointestinal transit times in antipsychotic-treated patients have not previously been measured, making this mechanism speculative. Methods Using standardized radiopaque marker (‘Metcalf’) methods we established colonic transit times of antipsychotic-treated psychiatric inpatients and compared them with population normative values. We analyzed results by antipsychotic type, antipsychotic dose equivalent, anticholinergic load, duration of treatment, gender, ethnicity, and age. Outcomes For patients not prescribed clozapine, median colonic transit time was 23 h. For patients prescribed clozapine, median transit time was 104.5 h, over four times longer than those on other antipsychotics or normative values (p < 0.0001). Eighty percent of clozapine-treated patients had colonic hypomotility, compared with none of those prescribed other antipsychotics (olanzapine, risperidone, paliperidone aripiprazole, zuclopenthixol or haloperidol). In the clozapine group, right colon, left colon and rectosigmoid transit times were all markedly abnormal suggesting pan-colonic pathology. Hypomotility occurred irrespective of gender, age, ethnicity, or length of clozapine treatment. Transit times were positively correlated with clozapine plasma level (rho = 0.451, p = 0.045), but not with duration of treatment, total antipsychotic load or demographic factors. Interpretation Clozapine, unlike the other antipsychotics examined, causes marked gastrointestinal hypomotility, as previously hypothesized. Pre-emptive laxative treatment is recommended when starting clozapine.

Recovery of evidence‐based practice

Consumer recovery is now enshrined in the national mental health policy of many countries. If this construct, which stems from the consumer/user/survivor movement, is truly to be the official and formal goal of mental health services, then it must be the yardstick against which evidence-based practice (EBP) is judged. From a consumer-recovery perspective, this paper re-examines aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence associated with EBP, those previously having been identified as deficient and in need of expansion. One of the significant differences between previous investigations and the present study is that the work, writing, perspectives, and advocacy of the consumer movement has developed to such a degree that we now have a much more extensive body of material upon which to critique EBP and inform and support the expansion of EBP. Our examination reinforces previous findings and the ongoing need for expansion. The consumer recovery-focused direction, resources, frameworks, and approaches identified through the present paper should be used to expand the aspects of services chosen for study, methodologies, outcomes measures, and standards of evidence. This expansion will ultimately enable services to practice in a manner consistent with the key characteristics of supporting personal recovery.

A population study of childhood maltreatment and asthma diagnosis: differential associations between child protection database versus retrospective self-reported data.

Objective Despite growing evidence from longitudinal studies of a link between early-life stress and the development of asthma, very few of these examine one of the most severe types of early-life stress: childhood maltreatment. Cross-sectional studies on this topic have relied on retrospective self-reports of maltreatment. This study investigates associations between childhood maltreatment indicated by child protection agency records versus self-reports and lifetime asthma diagnosis in young adults, adjusting for socioeconomic status and mental disorders. Methods A nationally representative general population survey of DSM-IV mental disorders in New Zealand (n = 12,992) obtained information on lifetime diagnoses of chronic physical conditions. Information from a subsample of survey respondents aged 16 to 27 years (n = 1413) was linked with a national child protection database to identify respondents with a history of agency involvement, which was used as a proxy for childhood maltreatment. Retrospective reports of maltreatment were also obtained. Results Child protection agency history was associated with elevated odds (odds ratio = 2.88 [95% confidence interval = 1.7–4.74]) of a lifetime diagnosis of asthma. After adjusting for a variety of indicators of socioeconomic status, lifetime mental disorders, lifetime smoking, and body mass index, this association remained significantly elevated (odds ratio = 2.26 [95% confidence interval = 1.33–3.83]). Retrospectively self-reported maltreatment in childhood was not associated with asthma. Conclusions Childhood maltreatment was associated with elevated odds of asthma diagnosis. These findings are consistent with the possibility that early-life stress may be one of the environmental factors that increase the risk of asthma in genetically vulnerable individuals. Abbreviations CI = confidence interval HPA = hypothalamic-pituitary-adrenal

Estimating the prevalence of schizophrenia among New Zealand Maori: a capture–recapture approach

Objective: The aim of the present study was to estimate the 12 month prevalence of schizophrenia in the Māori population of New Zealand. Method: Mental health data from two national sources were obtained for the period 2000–2003. A simple count of unique individuals with schizophrenia was used to estimate contact prevalence and a four-list capture–recapture procedure to estimate population prevalence. Results: Contact prevalence was significantly lower than the estimated population prevalence for both groups. The estimated 12 month prevalence of schizophrenia for Māori (0.97%) was significantly higher than for non-Māori (0.32%), even after adjustment for age, case under-ascertainment, and socioeconomic deprivation. Conclusions: The prevalence of schizophrenia among Māori appears to be elevated, although limitations in diagnostic reliability and recording of ethnicity must be considered. This adds further evidence of worldwide variation in the prevalence of schizophrenia. Capture–recapture provides a reliable cost-effective alternative to epidemiological surveys for estimating the prevalence of low-prevalence disorders such as schizophrenia.

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