The Right to Equal Health: Best Practice Priorities for Māori with Bipolar Disorder from Staff Focus Groups

Bipolar disorder (BD) is a serious mental health condition that is clinically complex to monitor and manage. While best practice guidelines exist, they vary internationally lacking consensus. Indigenous peoples, including Māori in New Zealand, experience higher community rates of BD. While New Zealand practice guidelines recommend providing culturally responsive care to Māori, studies show that Māori do not receive best practice. This qualitative study aimed to share the evidence about patterns of health service use and Māori patient experiences with focus group participants involved in the design and delivery of BD services, to discuss and develop guidelines for best practice for Māori with BD and address areas of unmet need. Three focus groups were conducted with 22 participants involved in the delivery of services to Māori with BD across three sites. Willing participants were sent background information and three focus group questions framed to elicit priority solutions to improve clinical, structural and organisational features of mental health service delivery for Māori patients with BD and their whānau (family). The nominal group technique was used to synthesise responses, and then develop a prioritised list of proposed solutions. Results identified system-level changes required at the clinical, structural and organisational levels of healthcare. Findings further evidence the need for healthcare reform in New Zealand, to be responsive to Māori with BD.

Presence of alcohol and other drug use within youth mental health presentations to the emergency department: A single-site retrospective observational study

OBJECTIVE

Youth mental health is a growing issue, which can be worsened by alcohol and other drug (AOD) use. The present study aimed to characterise the association of AOD use in youth presenting to an ED with a mental health crisis.

METHODS

A retrospective observational study of paediatric patients presenting with mental health concerns to a tertiary ED in New Zealand in 2019-2020, with an examination of use of alcohol or other drugs before presentation.

RESULTS

There were 842 ED presentations, made up of 491 unique individuals, examined from the 2-year period. Overdose (63.1%) was the most common reason for presentation, with 39.9% of overdoses involving prescription-only medications, 36.7% over-the-counter, and 20.0% a combination. Seventy-four (8.8%) presentations had documented use of alcohol or other drugs (excluding those taken in overdose) before arrival, with alcohol (51 presentations), followed by cannabis (19 presentations), being the most commonly recorded drugs used. Concurrent AOD use was not associated with any significant difference in triage, length of stay or admission status.

CONCLUSION

In New Zealand, it is not legal to sell alcohol to persons under 18 years; however, this was the most commonly identified drug impacting on youth mental health presentations. There is a known association between alcohol use and adverse mental health symptoms; therefore, efforts to decrease access to alcohol in this age group must continue, and harm reduction interventions to reduce clinically significant overdoses recommended.

The Aotearoa New Zealand doctor shortage: current context and strategies for retention

The international migration of health professionals has been an ongoing issue with the medical workforce in Aotearoa New Zealand. There are many reasons why New Zealand-trained doctors choose to leave. Often it has been to gain overseas experience, with many eventually returning to New Zealand; however, this has now changed, with increasing numbers not returning. Little has been done to combat this developing problem, amidst an increasingly competitive global market for health professionals. There is public and political concern about the current shortage and uneven distribution of doctors, particularly because this has fostered unsustainable working conditions, which diminishes the provision of safe healthcare in this country. This article examines the context behind the migration of New Zealand-trained doctors and proposes several strategies for retention as potential solutions to the underlying problem.

Parental acceptance of silver fluoride as a treatment option for carious lesions among South African children with special health care needs

Providing dental care for children with neurological special health care needs, including Down syndrome, Cerebral palsy and Autism spectrum disorders, is challenging. They often require repeat exposure to sedation or general anaesthesia for routine dental care. 51 parents of children with special needs completed a questionnaire regarding the acceptance of Silver Fluoride as a treatment option.

Background

Silver Diamine Fluoride has become popular as a minimally invasive treatment option for providing oral health care to young or uncooperative children. Silver Fluoride (SF) is a newer development with similar but improved properties. The aim was to determine the acceptance of SDF/SF as treatment option for Children with Special Health Care Needs (CSHCN), including Down Syndrome, Autism Spectrum Disorder and Cerebral Palsy.

Methods

51 Parents of CSHCN completed a questionnaire on the overall acceptance of SF; aesthetic concerns related to the location of application; the use of SDF as an alternative to general anesthesia; and the composition of SF.

Results

The use of SF on posterior teeth were more acceptable (70.59%) as opposed to its application to anterior teeth (50.98%). Parents generally agreed/ strongly agreed to the use of SF to reduce infection and pain (82%); to avoid treatment under GA (26.70%); and to avoid an injection (78%). 64% of parents indicated their agreement in using SF because it has a reduced cost when compared to a conventional restoration. Majority of parents were in agreement to use SF even if it contains Fluoride (84%) and Silver (78%).

Conclusion

The use of SF, as treatment option for caries, was well accepted by South African parents of CSHCN. Shared decision making should be applied when considering SF as treatment option for CSHCN.

Polypharmacy in the treatment of people diagnosed with borderline personality disorder: repeated cross-sectional study using New Zealand's national databases

BACKGROUND

There is insufficient evidence to support the pharmacological treatment of borderline personality disorder. However, previous out-patient cohorts have described high rates of polypharmacy in this group. So far, there have been no national studies that have considered polypharmacy in borderline personality disorder.

AIMS

To describe psychotropic polypharmacy in people with borderline personality disorder in New Zealand.

METHOD

New Zealand's national databases have been used to link psychotropic medication dispensing data and diagnostic data for borderline personality disorder. Annual dispensing data for 2014 and 2019 have been compared.

RESULTS

Fifty percent of people with borderline personality disorder who were dispensed medications had three or more psychotropic medications in 2014. This increased to 55.9% in 2019 (P < 0.001). Those on seven or more psychotropics increased from 8.4 to 10.7% (P < 0.023). Quetiapine was the most dispensed psychotropic medication, being given to 53.8% of people dispensed medication with borderline personality disorder in 2019. Lorazepam dispensing showed the largest increase, going from 15.5 to 26.7% between 2014 and 2019 (P < 0.001).

CONCLUSIONS

There is a large burden of psychotropic polypharmacy in people with borderline personality disorder. This is concerning because of the lack of evidence regarding the efficacy of these medications in this group.

Indigenous suicide rates in the United States, Australia and New Zealand between 2006 and 2019

OBJECTIVE

Indigenous suicide prevention is an important focus for national health policies. Indigenous suicide rates in formerly colonial English-speaking countries such as the United States, Australia and New Zealand are considerably higher than the general population, particularly in young males. Given the similarities in their sociocultural history, a time series analysis was conducted to assess recent sex and age trends of suicide in the Indigenous and general populations in the United States, Australia and New Zealand.

METHODS

Using the number of deaths by intentional self-harm and estimated resident population, suicide incidence rates were calculated for the years 2006-2019 and stratified by Indigenous status, year, time period, sex and age group (above 15 years). Incidence rates were plotted. Using the Poisson regression model, calculated suicide incidence rate ratios were used to make comparisons for sex and age.

RESULTS

Across all countries studied, Indigenous suicide rates have increased over time, with Indigenous males having higher suicide rates than Indigenous females. However, the increase in Indigenous female suicides was greater than that for Indigenous males in Australia and New Zealand. Indigenous males aged 15-44 years have the highest suicide rates across all countries.

CONCLUSION

Indigenous suicide rates have remained consistently high in the United States, Australia and New Zealand, with Indigenous males aged 15-44 years showing the highest rate. However, suicide rates for Indigenous females in Australia and New Zealand are increasing more rapidly than males. Given this, it is critical that further research is dedicated to understanding and addressing the issues driving this problem, particularly in youth.

Difficult decision-making in major depressive disorder: Practical guidance based on clinical research and experience

OBJECTIVES

To extend current published guidance regarding the management of major depression in clinical practice, by examining complex cases that reflect real-world patients, and to integrate evidence and experience into recommendations.

METHODS

The authors who contributed to recently published clinical practice guidelines were invited to identify important gaps in extant guidance. Drawing on clinical experience and shared knowledge, they then generated four fictional case studies to illustrate the real-world complexities of managing mood disorders. The cases focussed specifically on issues that are not usually addressed in clinical practice guidelines.

RESULTS

The four cases are discussed in detail and each case is summarised using a life chart and accompanying information. The four cases reflect important real-world challenges that clinicians face when managing mood disorders in day-to-day clinical practice. To partly standardise the presentation of each case and for ease of reference we provide a Time Line, History Box and Management Chart, along with a synopsis where relevant. Discussion and formulation of the cases illustrate how to manage the complexities of each case and provide one possible pathway to achieving functional recovery.

CONCLUSION

These cases draw on the combined clinical experience of the authors and illustrate how to approach diagnostic decision-making when treating major depressive disorder and having to contend with complex presentations. The cases are designed to stimulate discussion and provide a real-world context for the formulation of mood disorders.

A Randomized Controlled Trial of Mindfulness in Recovery from Colorectal Cancer

OBJECTIVE

This study examined whether a 4-week group-based mindfulness intervention would be superior in reducing psychological distress in colorectal cancer (CRC) patients compared to a psychoeducation and cognitive behavioural skills learning support active control group.

METHODS

Patients with CRC were randomized via Computerised Permuted Block Randomisation to mindfulness or active control groups (2-h weekly sessions over 4 weeks). Outcomes were measured pre-intervention, and 8 weeks and 6 months post-baseline. The primary outcome was psychological distress measured by the Hospital Anxiety and Depression Scale. Secondary outcomes were generic quality of life (QoL), disease specific QoL, mindfulness, and intervention credibility and acceptability.

RESULTS

Sixty-eight participants were randomized to mindfulness (n=35) or active control group (n=33). Uptake of potentially eligible patients consenting was low (28.0%) and the dropout rate was 33.8%. Depression scores were reduced in both groups at week 8 (P=0.020). Control participants had greater improvement in generic mental QoL scores at week 8 than mindfulness (P=0.023). In disease specific QoL, there was reduction in impotence symptom in the mindfulness group (P=0.022) and reduction in faecal incontinence in the control group (P=0.019). The embarrassment symptom had a significantly lower increase in the mindfulness group at week 8 compared to the control group (P=0.009). Both groups rated the treatments as credible and acceptable.

CONCLUSIONS

Mindfulness was not superior to the active control group in terms of alleviating psychological distress but both treatments were associated with some improvements in depression. There was low uptake of both interventions. (Trial registration number: ACTRN12616001033437).

The management of depression: the evidence speaks for itself

Comparing the recommendations of two recently published national clinical practice guidelines for depression, this editorial highlights the concordance of advice concerning the selection and sequencing of therapies. Lifestyle and psychological interventions feature prominently and there is broad agreement regarding medication choice and optimisation strategies. The guidelines are therefore a useful resource.

Positioning of psychodynamic psychotherapy in the treatment of depression: A comparison of the RANZCP 2020 and NICE 2022 guidelines

OBJECTIVE

To compare the 2022 NICE guidelines (NG222) and 2020 RANZCP clinical practice guidelines (MDcpg²⁰²⁰) recommendations for the treatment of depression using psychodynamic psychotherapy.

CONCLUSIONS

Both guidelines recommend psychological interventions first-line. However, only short-term psychodynamic psychotherapy (STPP) is recommended, and in the NG222 it is ranked last for less severe depression and 7th for more severe depression. In contrast, cognitive behavioural therapy and behavioural activation are deemed the more clinically effective and cost-effective psychological therapies. And antidepressants play a significant role - largely in more severe depression.

Adolescent borderline personality disorder: Does early intervention 'bend the curve'?

OBJECTIVE

The Global Alliance for Prevention and Early Intervention for Borderline Personality Disorder (BPD) proposed a major change for youth mental health services. The Alliance recommended that early detection and specialised treatment for youth BPD becomes a major focus of their clinical activities. Since structured psychotherapies for BPD are complex and lengthy, this proposal has significant implications for youth policy, planning and resource allocation. Our commentary addresses whether BPD is diagnosable and treatable in youth, and whether early intervention results in longer-term benefits.

CONCLUSION

People diagnosed with BPD are highly heterogeneous and experience high levels of comorbidity. The low quality of the evidence for the treatment of BPD in adolescence limits our ability to develop evidence-based guidelines. Accordingly, there is no clear case for BPD early intervention as a major component of youth mental health services. The introduction of ICD-11 classification system may facilitate further empirical studies of personality disorders in adolescence and emerging adulthood.

Pathways to post-traumatic growth and post-traumatic stress following the Canterbury earthquakes in a cohort of 40-year-olds

OBJECTIVE

To report on post-traumatic growth and post-traumatic stress following the Canterbury earthquakes and to quantify the relationships between exposure to the earthquakes, post-traumatic growth and post-traumatic stress.

METHOD

The Christchurch Health and Development Study is a longitudinal birth cohort study of New Zealanders aged 40 years at the time of latest assessment in 2017. A total of 455 participants were exposed to the Canterbury earthquakes and assessed in 2012 and 2017. Post-traumatic growth was measured in 2017 using the Post-traumatic Growth Inventory. Earthquake-related post-traumatic stress was measured in 2012 using post-traumatic stress disorder items from the Diagnostic Interview Schedule. Post-traumatic growth and post-traumatic stress were modelled using measures of earthquake impact and subjective measures of earthquake consequences (peri-traumatic stress and disruption distress).

RESULTS

There was an indirect relationship between earthquake impact and post-traumatic growth. This was mediated via disruption distress. There was also an indirect relationship between earthquake impact and post-traumatic stress. This was mediated via peri-traumatic stress and disruption distress. Post-traumatic growth and post-traumatic stress were not significantly related.

CONCLUSIONS

Measurement of post-traumatic growth and post-traumatic stress is required for a holistic understanding of disaster consequences. Subjective assessment of distress following disasters is required to predict their psychological effects.

Suicide amongst doctors

Nil.

Clinical Implications of ICD-11 for Diagnosing and Treating Personality Disorders

PURPOSE OF REVIEW

The International Classification of Diseases 11th revision (ICD-11) introduced a new approach to personality disorders and related traits. This paper reviews recent literature on the assessment of ICD-11 personality disorders and implications for clinical diagnosis, decision-making, and treatment.

RECENT FINDINGS

We reviewed findings on two measures developed for the ICD-11 model of personality dysfunction and six inventories for the ICD-11 trait specifiers. The psychometric qualities of these tools are promising, and they allow for both rapid screening and fine-grained assessment. Implications for clinical diagnosis and treatment of personality disorders are reviewed including utility for forensic practice. Based on evidence and our experience, we provide some recommendations for severity- and trait-informed interventions. Initial evidence supports the available instruments for assessing ICD-11 personality disorders. More research is needed including development of clinician-rating forms and diagnostic interviews as well as treatment protocols and trials based on the new ICD-11 classification.

An Evidence-Based Perspective on The 2020 Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines

OBJECTIVE

To rebut the claims made in an opinion piece by Anaf and colleagues regarding the recommendations for psychotherapy within the 2020 RANZCP Mood Disorders Clinical Practice Guidelines (CPG).

CONCLUSIONS

The CPG attaches importance to psychological interventions and recommends their administration as first-line in the treatment of depression. The concerns raised by Anaf and colleagues have no basis and are readily dismissed by referring to the guidelines. Therefore, we strongly encourage clinicians to formulate their own views by reading the guidelines for themselves.

Guidelines for the management of psychosis in the context of mood disorders

Psychotic episodes occur in a substantial proportion of patients suffering from major mood disorders (both unipolar and bipolar) at some point in their lives. The nature of these episodes is less well understood than the more common, non-psychotic periods of illness and hence their management is also less sophisticated. This is a concern because the risk of suicide is particularly high in this subtype of mood disorder and comorbidity is far more common. In some cases psychotic symptoms may be signs of a comorbid illness but the relationship of psychotic mood to other forms of psychosis and in particular its interactions with schizophrenia is poorly understood. Therefore, our targeted review draws upon extant research and our combined experience to provide clinical context and a framework for the management of these disorders in real-world practice - taking into consideration both biological and psychological interventions.

A randomised controlled trial of psychotherapy and cognitive remediation to target cognition in mood disorders

OBJECTIVE

To examine the impact of a treatment package combining Interpersonal and Social Rhythm Therapy (IPSRT) and cognitive remediation (CR), vs IPSRT alone, on cognition, functioning, and mood disturbance outcomes in mood disorders.

METHODS

A pragmatic randomised controlled trial in adults with bipolar disorder (BD) or major depressive disorder (MDD), recently discharged from mental health services in Christchurch, New Zealand, with subjective cognitive difficulties. Individuals were randomised to a 12-month course of IPSRT with CR (IPSRT-CR), or without CR (IPSRT). In IPSRT-CR, CR was incorporated into therapy sessions from approximately session 5 and continued for 12 sessions. The primary outcome was change in Global Cognition (baseline to 12 months).

RESULTS

Sixty-eight individuals (BD n = 26, MDD n = 42; full/partial remission n = 39) were randomised to receive IPSRT-CR or IPSRT (both n = 34). Across treatment arms, individuals received an average of 23 IPSRT sessions. Change in Global Cognition did not differ between arms from baseline to treatment-end (12 months). Psychosocial functioning and longitudinal depression symptoms improved significantly more in the IPSRT compared with IPSRT-CR arm over 12 months, and all measures of functioning and mood symptoms showed moderate effect size differences favouring IPSRT (0.41-0.60). At 18 months, small to moderate, non-significant benefits (0.26-0.47) of IPSRT vs IPSRT-CR were found on functioning and mood outcomes.

CONCLUSIONS

Combining two psychological therapies to target symptomatic and cognitive/functional recovery may reduce the effect of IPSRT, which has implications for treatment planning in clinical practice and for CR trials in mood disorders.

Randomised controlled trial of Interpersonal and Social Rhythm Therapy and group-based Cognitive Remediation versus Interpersonal and Social Rhythm Therapy alone for mood disorders: study protocol

BACKGROUND

Individuals with mood disorders frequently experience cognitive impairment, which impacts on the long-term trajectory of the disorders, including being associated with persisting difficulties in occupational and psychosocial functioning, residual mood symptoms, and relapse. Current first-line treatments for mood disorders do little to improve cognitive function. Targeting cognition in clinical research is thus considered a priority. This protocol outlines a prospectively-registered randomised controlled trial (RCT) which examines the impact of adding group-based Cognitive Remediation (CR) to Interpersonal and Social Rhythm Therapy (IPSRT-CR) for individuals with mood disorders.

METHODS

This is a pragmatic, two-arm, single-blinded RCT comparing IPSRT-CR with IPSRT alone for adults (n = 100) with mood disorders (Major Depressive Disorder or Bipolar Disorder) with subjective cognitive difficulties, on discharge from Specialist Mental Health Services in Christchurch, New Zealand. Both treatment arms will receive a 12-month course of individual IPSRT (full dose = 24 sessions). At 6 months, randomisation to receive, or not, an 8-week group-based CR programme (Action-based Cognitive Remediation - New Zealand) will occur. The primary outcome will be change in Global Cognition between 6 and 12 months (treatment-end) in IPSRT-CR versus IPSRT alone. Secondary outcomes will be change in cognitive, functional, and mood outcomes at 6, 12, 18, and 24 months from baseline and exploratory outcomes include change in quality of life, medication adherence, rumination, and inflammatory markers between treatment arms. Outcome analyses will use an intention-to-treat approach. Sub-group analyses will assess the impact of baseline features on CR treatment response. Participants' experiences of their mood disorder, including treatment, will be examined using qualitative analysis.

DISCUSSION

This will be the first RCT to combine group-based CR with an evidence-based psychotherapy for adults with mood disorders. The trial may provide valuable information regarding how we can help promote long-term recovery from mood disorders. Many issues have been considered in developing this protocol, including: recruitment of the spectrum of mood disorders, screening for cognitive impairment, dose and timing of the CR intervention, choice of comparator treatment, and choice of outcome measures.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, ACTRN12619001080112 . Registered on 6 August 2019.

Galenic syndromes: combinations of mental state and personality disorders too closely entwined to be separated

Many mental disorders are linked to personality, but this is rarely recognised in clinical practice. It is suggested here that when the links are very close, the two can be joined. Galenic syndromes are so named because Galen was the first physician to recognise the links between personality and disease.

Initial assessment of patients with putative functional disorders in medical settings

Patients presenting with symptoms suggestive of functional disorder are very frequent in practice. While it is always necessary to exclude treatable organic pathology, there are important clues in the presentation that can help the clinician. In particular, it is important to identify pathological health anxiety early in assessment, as failure to do so may lead to unnecessary investigations and the dangerous path of reinforcing reassurance. Because full assessment of functional symptoms takes time, it is suggested that a clinical support nurse with some training in psychological management should be available to guide the management of the patients with these disorders. Such support nurses, based in the clinic, offer a seamless way of providing care that is not achieved by external referral to psychologists or equivalent staff.

Profiling rTMS: A critical response

This article is a detailed response to the criticisms levelled by the authors of an accompanying viewpoint, which claims that the positioning of repetitive transcranial magnetic stimulation (rTMS) in the 2020 Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for the management mood disorders (MDcpg²⁰²⁰) is incorrect. We, the authors of the MDcpg²⁰²⁰, strongly refute these assertions and argue that first we have determined the positioning of rTMS using the same criteria as those applied to other treatments for depression. Second, in accordance with National Health and Medical Research Council (NHMRC) guidelines, the processes by which we have developed the MDcpg²⁰²⁰ have been guided by best practice and have been overseen throughout by the RANZCP. Third, our objective and detailed examination of the relevant research has shown that the evidence needed to support the positioning of rTMS alongside standard therapies for depression is severely deficient. And therefore, as a consequence, we set out clearly both our logic and reasoning with respect to interpreting rTMS data and outline our evidence-informed position in which rTMS remains a potential alternative therapy that can be considered in certain clinical circumstances once both suitable psychological and pharmacological treatments have been trialled. We also discuss why, until further research is conducted, rTMS is perhaps best regarded as an experimental therapy and an investigational tool, and to assist in this regard, we propose a framework for consideration by those conducting rTMS studies in the future. Thus, based on current knowledge, we conclude that rTMS does not have a sufficient evidence base to warrant recognition as a standard therapy for depression alongside established treatments such as psychological interventions, pharmacotherapy, and electroconvulsive therapy. Furthermore, there is no clinical profile for depressed patients that might benefit from rTMS and therefore tolerability alone is not good enough reason to promote rTMS in the management of major depression.

Impact of burnout on empathy

AIM

Burnout has a damaging effect on both the wellbeing of medical professionals and patients alike. Empathy is an important part of the therapeutic relationship and could be damaged by burnout. We aimed to describe the prevalence of burnout, assess levels of empathy and explore the relationship between burnout and empathy among senior medical officers (SMOs). We hypothesised that there would be a negative correlation between empathy and burnout.

METHOD

This was a cross-sectional observational study involving SMOs from a variety of specialities. The focus is on SMOs with relatively prolonged contact times with patients. Email invitations were sent out requesting participation in an electronic survey on the QuestionPro platform. The survey comprised 42 questions enquiring about demographics, empathy (Jefferson Scale of Physician Empathy) and burnout (Copenhagen Burnout Inventory). Correlational analyses were performed.

RESULTS

Three hundred and fourteen invitations were sent out and 178 responses were received (56.7% response rate). Forty-five percent of SMOs surveyed were experiencing high levels of personal burnout. There was a statistically significant negative correlation between empathy and patient-related burnout (p=0.018).

CONCLUSIONS

The results show high levels of personal burnout among SMOs and suggest that empathy reduces as patient-related burnout increases. The nature of this relationship is a complex one, and other contributing variables should be considered.

Functional neurological disorders presenting as emergencies to secondary care

BACKGROUND

Functional neurological disorders (FND) represent a significant proportion of presentations to outpatient adult neurology services. There is little information relating to patients presenting to acute inpatient care.

METHODS

We identified patients presenting as acute admissions with FND to Christchurch Hospital, Christchurch, New Zealand, from 2016 to 2018. We analyzed relevant demographic and clinical data from electronic records and measured incidence of presentation to secondary care and healthcare utilization.

RESULTS

One hundred sixty-two patients presented on 173 occasions with FND, representing 9% of all admissions to the neurology service during the 3-year study period. The mean age was 40 (SD 17) years, 111 (69%) patients were female and the median length of stay was 3 (IQR 2-4) days. A total of 92 computed tomography brain scans, 77 magnetic resonance imaging brain scans and 42 electroencephalograms were carried out. On 22 (13%) occasions, patients were referred for outpatient psychological therapy. In the 3 years prior to each patient's last presentation in the study period, these 162 patients had a total of 671 presentations to the emergency department. Healthcare demand did not decrease after the index admission. The rate of acute inpatient admission for FND was 10 per 100,000 per year for the total Christchurch Hospital catchment, 6/100,000/year in rural areas, and 11/100,000/year in urban areas.

CONCLUSION

FND represented almost 1 in 10 acute neurology admissions with significant inpatient healthcare resource utilization.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

The 2020 Royal Australian and New Zealand College of psychiatrists clinical practice guidelines for mood disorders: Bipolar disorder summary

OBJECTIVES

To provide a succinct, clinically useful summary of the management of bipolar disorder, based on the 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (MDcpg²⁰²⁰ ).

METHODS

To develop the MDcpg²⁰²⁰ , the mood disorders committee conducted an extensive review of the available literature to develop evidence-based recommendations (EBR) based on National Health and Medical Research Council (NHMRC) guidelines. In the MDcpg²⁰²⁰ , these recommendations sit alongside consensus-based recommendations (CBR) that were derived from extensive deliberations of the mood disorders committee, drawing on their expertise and clinical experience. This guideline summary is an abridged version that focuses on bipolar disorder. In collaboration with international experts in the field, it synthesises the key recommendations made in relation to the diagnosis and management of bipolar disorder.

RESULTS

The bipolar disorder summary provides a systematic approach to diagnosis, and a logical clinical framework for management. It addresses the acute phases of bipolar disorder (mania, depression and mixed states) and its longer-term management (maintenance and prophylaxis). For each phase it begins with Actions, which include important strategies that should be implemented from the outset wherever possible. These include for example, lifestyle changes, psychoeducation and psychological interventions. In each phase, the summary advocates the use of Choice medications for pharmacotherapy, which are then used in combinations along with additional Alternatives to manage acute symptoms or maintain mood stability and provide prophylaxis. The summary also recommends the use of electroconvulsive therapy (ECT) for each of the acute phases but not for maintenance therapy. Finally, it briefly considers bipolar disorder in children and its overlap in adults with borderline personality disorder.

CONCLUSIONS

The bipolar disorder summary provides up to date guidance regarding the management of bipolar disorder, as set out in the MDcpg²⁰²⁰ . The recommendations are informed by evidence and clinical expertise and experience. The summary is intended for use by psychiatrists, psychologists and primary care physicians but will be of interest to anyone involved in the management of patients with bipolar disorder.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders: Major depression summary

OBJECTIVES

To provide a succinct, clinically useful summary of the management of major depression, based on the 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (MDcpg²⁰²⁰ ).

METHODS

To develop the MDcpg²⁰²⁰ , the mood disorders committee conducted an extensive review of the available literature to develop evidence-based recommendations (EBR) based on National Health and Medical Research Council (NHMRC) guidelines. In the MDcpg²⁰²⁰ , these recommendations sit alongside consensus-based recommendations (CBR) that were derived from extensive deliberations of the mood disorders committee, drawing on their expertise and clinical experience. This guideline summary is an abridged version that focuses on major depression. In collaboration with international experts in the field, it synthesises the key recommendations made in relation to the diagnosis and management of major depression.

RESULTS

The depression summary provides a systematic approach to diagnosis, and a logical clinical framework for management. The latter begins with Actions, which include important strategies that should be implemented from the outset. These include lifestyle changes, psychoeducation and psychological interventions. The summary advocates the use of antidepressants in the management of depression as Choices and nominates seven medications that can be trialled as clinically indicated before moving to Alternatives for managing depression. Subsequent strategies regarding Medication include Increasing Dose, Augmenting and Switching (MIDAS). The summary also recommends the use of electroconvulsive therapy (ECT), and discusses how to approach non-response.

CONCLUSIONS

The major depression summary provides up to date guidance regarding the management of major depressive disorder, as set out in the MDcpg²⁰²⁰ . The recommendations are informed by research evidence in conjunction with clinical expertise and experience. The summary is intended for use by psychiatrists, psychologists and primary care physicians, but will be of interest to all clinicians and carers involved in the management of patients with depressive disorders.

Gender and mental health service use in bipolar disorder: national cohort study

BACKGROUND

Despite evidence of gender differences in bipolar disorder characteristics and comorbidity, there is little research on the differences in treatment and service use between men and women with bipolar disorder.

AIMS

To use routine data to describe specialist mental health service contact for bipolar disorder, including in-patient, community and support service contacts; to compare clinical characteristics and mental health service use between men and women in contact with secondary services for bipolar disorder.

METHOD

Cross-sectional analysis of mental health patients with bipolar disorder in New Zealand, based on complete national routine health data.

RESULTS

A total of 3639 individuals were in contact with specialist mental health services with a current diagnosis of bipolar disorder in 2015. Of these 58% were women and 46% were aged 45 and over. The 1-year prevalence rate of bipolar disorder leading to contact with specialist mental health services was 1.56 (95% CI 1.50-1.63) per 100 000 women and 1.20 (95% CI 1.14-1.26) per 100 000 men. Rates of bipolar disorder leading to service contact were 30% higher in women than men (rate ratio 1.30, 95% CI 1.22-1.39). The majority (68%) had a diagnosis of bipolar I disorder. Women were more likely to receive only out-patient treatment and have comorbid anxiety whereas more men had substance use disorder, were convicted for crimes when unwell, received compulsory treatment orders and received in-patient treatment.

CONCLUSIONS

Although the prevalence of bipolar disorder is equal between men and women in the population, women were more likely to have contact with specialist services for bipolar disorder but had a lower intensity of service interaction.

The physical health of Māori with bipolar disorder

AIMS

There is very little empirical evidence about the relationship between severe mental illness and the physical health of Indigenous peoples. This paper aims to compare the physical health of Māori and non-Māori with a diagnosis of bipolar disorder in contact with NZ mental health services.

METHODS

A cohort of Māori and non-Māori with a current bipolar disorder diagnosis at 1 January 2010 were identified from routine mental health services data and followed up for non-psychiatric hospital admissions and deaths over the subsequent 5 years.

RESULTS

Māori with bipolar disorder had a higher level of morbidity and a higher risk of death from natural causes compared to non-Māori with the same diagnosis, indicating higher levels of physical health need. The rate of medical and surgical hospitalisation was not higher among Māori compared to non-Māori (as might be expected given increased health needs) which suggests under-treatment of physical health conditions in this group may be a factor in the observed higher risk of mortality from natural causes for Māori.

CONCLUSION

This study provides the first indication that systemic factors which cause health inequities between Māori and non-Māori are compounded for Māori living with severe mental illness. Further exploration of other diagnostic groups and subgroups is needed to understand the best approach to reducing these inequalities.