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In this paper, we argue that risk assessment should be considered a part of daily clinical psychiatric practice. We discuss the advantages and disadvantages of various risk assessment procedures. In the event that a high risk for violence is present, we advise on strategies for discharging our duty to protect the public. Finally, by way of an illustrative case, we apply theory to practice and discuss the issues of risk management and risk reduction essential to a modern approach to psychiatry. [ABSTRACT FROM AUTHOR]

Objective: Growing awareness of the psychological effects of trauma has emphasized the need for clinicians across a range of practice settings to be aware of evidence-based treatment options for posttraumatic stress disorder (PTSD). The purpose of this article is to review the available empirical data on pharmacological approaches to PTSD and to provide recommendations for clinical practice. Method: Although a comprehensive search of PsychInfo and Medline databases revealed a multitude of case reports and open-label trials, this paper focuses primarily on evidence obtained from randomized controlled trials to determine the most effective pharmacological treatments for PTSD. Results: The research data overwhelmingly supports antidepressant medication as the first-line pharmacotherapy for PTSD, with selective serotonin re-uptake inhibitors having the strongest body of empirical support. Other medications, and with care, combination pharmacotherapy, may also have a role in the management of certain presentations. Cautions for clinicians in treating this complex disorder are provided. Conclusions: Despite a substantial increase in the amount and quality of research into pharmacological treatments for PTSD in recent years, there is still a pressing need for more data to guide routine clinical practice. In particular, future research regarding the psychobiological basis of PTSD may guide the development of a PTSD-specific drug, designed to treat the unique characteristics of this disorder. Australian and New Zealand Journal of Psychiatry 2005; 39:674–682 [ABSTRACT FROM AUTHOR]

Objective : Increasing awareness of how missing data affects the analysis of clinical and public health interventions has led to increasing numbers of missing data procedures. There is little advice regarding which procedures should be selected under different circumstances. This paper compares six popular procedures: listwise deletion, item mean substitution, person mean substitution at two levels, regression imputation and hot deck imputation. Method : Using a complete dataset, each was examined under a variety of sample sizes and differing levels of missing data. The criteria were the true t-values for the entire sample. Results : The results suggest important differences. If missing data are from a scale where about half the items are present, hot deck imputation or person mean substitution are best. Because person mean substitution is computationally simpler, similar in its efficiency, advocated by other researchers and more likely to be an option on statistical software packages, it is the method of choice. If the missing data are from a scale where more than half the items are missing, or with single-item measures, then hot deck imputation is recommended. The findings also showed that listwise deletion and item mean substitution performed poorly. Conclusions : Person mean and hot deck imputation are preferred. Since listwise deletion and item mean substitution performed poorly, yet are the most widely reported methods, the findings have broad implications. Australian and New Zealand Journal of Psychiatry 2005; 39:583–590 [ABSTRACT FROM AUTHOR]

Objective : This paper compares six missing data methods that can be used for carrying out statistical tests on repeated measures data: listwise deletion, last value carried forward (LVCF), standardized score imputation, regression and two versions of a closest match method. Method : The efficacy of each was investigated under a variety of sample sizes and with differing levels of missingness. Randomly selected samples from a dataset (n = 804) were used to compare the methods using t-tests. Efficacy was defined as the closeness of the estimated t-values to the true t-values from the complete dataset. Results : The results suggest a reliable and efficacious basis for imputation method for repeated measures data is to substitute a missing datum with a value from another individual who has the closest scores on the same variable measured at other timepoints, or the average value of four individuals who have the closest scores on the same variable at other timepoints. The LVCF and standardized score methods performed relatively poorly, which is of concern since these are often recommended. Listwise deletion was also an inefficient missing data method. Conclusions : Researchers should consider using closest match missing data imputation. Since listwise deletion performed poorly, is widely reported and is the default method in many statistical software packages, the findings have broad implications. Australian and New Zealand Journal of Psychiatry 2005; 39:575–582 [ABSTRACT FROM AUTHOR]

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge.A comprehensive literature review (1990−2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process.This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3−5 years following diagnosis since course of illness is strongly influenced by what occurs in this‘critical period’. Patients should not have to‘prove chronicity’ before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no specialist involvement, while very common, is not regarded as an acceptable standard of care. Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved. [ABSTRACT FROM AUTHOR]

Objectives: Our objectives were as follows: 1) to survey the literature on motivational interviewing (MI), ‘a client-centered yet directive method for enhancing intrinsic motivation to change by exploring and resolving client ambivalence’ and a well-established method of brief intervention, especially in the field of addictions treatment; 2) to review hypotheses about its mode of action; and 3) to discuss its possible impact on clinical psychiatry, in particular, on teaching communications skills. Method: Literature reviews and metaanalyses of numerous clinical trials of MI for addictions treatment have already been published and are briefly summarized. So far, no literature survey exists for MI applied to psychiatric patients. This review is limited to a synthesis of the articles relevant to psychiatry and to comments based on our team's experiences with MI. Results: There is no evidence that MI achieves better results than other established techniques for treating addictions; it may simply work faster. The explanation for the method's rapid effectiveness remains speculative. Outcomes concerning the application of MI to psychiatric patients, although preliminary, are promising. Methods of assessing the integrity of MI treatment are more developed than in most psychotherapies, which permits the learning progress of trainees to be measured. Conclusions: MI offers a complement to usual psychiatric procedures. It may be worthwhile to teach it, not only for addictions but also for other broad treatment issues, such as enhancing patients' medication compliance and professionals' communication skills. Questions remain concerning MI's feasibility in psychiatry settings. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Psychiatry is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Canadian Journal of Psychiatry is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives: Psychiatrists use biopsychosocial models in identifying aetiological factors in assessing their patients and similar approaches in planning management. Models in decision making will be influenced by previous experience, training, age and gender, among other factors. Critical thinking and evidence base are both important components in the process of reaching clinical decisions. Expected outcome of treatment may be another factor. The way we think influences our decision making, clinical or otherwise. With patients expecting and taking larger roles in their own management, there needs to be a shift towards patient-centred care in decision making. Conclusions: Further exploration in how clinical decisions are made by psychiatrists is necessary. An understanding of the manner in which therapeutic alliances are formed between the clinician and the patient is necessary to understand decision making. [ABSTRACT FROM AUTHOR]