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Objective: The aim of this paper is to describe the circumstances surrounding the only paper published in Australia by Sigmund Freud – his only publication in the Southern Hemisphere – in 1911. Conclusions: The invitations in 1911 from a Sydney psychoanalysis study group to Sigmund Freud, Carl Jung and Havelock Ellis to present papers at the Australasian Medical Congress, came at a time when the world was barely aware of Freud’s new psychology, and well in advance of many other countries. Sparring by Freud and Jung over a joint presentation was evident in the respective papers they sent, and they soon parted. A review of other papers presented at the congress indicates that Australian psychiatry, notwithstanding its slow progress, was well informed on recent developments, which was to manifest with biological treatments, as well as with the establishment of psychoanalysis. Despite its distance from Vienna, Australia seemed to have a special place in Freud’s mind that was to surface in various ways over the years, not least in Totem and Taboo. [ABSTRACT FROM AUTHOR]

Objective: This paper describes the initial development of a mental health rehabilitation curriculum for Australian mental health settings and for psychiatrists and trainees wishing to develop specialist skills in mental health rehabilitation. Method: Members of the Section of Social Cultural and Rehabilitation Psychiatry (SSCRP) established an expert working group under the auspices of the RANZCP. Existing college training resources were reviewed, and a gap analysis was conducted to guide development of new training modules. Results: A tiered curriculum structure was created that allows a staged development of rehabilitation knowledge, skills and attitudes required to be a specialist in mental health rehabilitation. An introductory module was developed to establish the principles of modern mental health rehabilitation. Most of the curriculum was based on existing resources that are relevant to rehabilitation practice. Finalisation of a draft for review was undertaken with the assistance of the RANZCP education project advisors and curriculum experts. Conclusions: As a national body responsible for training psychiatric registrars and maintenance of training for psychiatrists, the RANZCP is well situated to train the specialist medical mental health workforce required to lead rehabilitation services in Australia. The RANZCP mental health rehabilitation curriculum will provide a platform to train the skilled workforce that will enable these services to be fully realised. [ABSTRACT FROM AUTHOR]

Objective: In Australia and internationally, psychiatry has struggled to fill training places to keep up with demand for service. The objective of this study was to review the components of psychiatry terms and placements that determine a positive experience and potentially influence interest in vocational training in psychiatry.Method: A literature review and narrative synthesis was undertaken on 20 papers identified as meeting inclusion criteria.Results: The top themes contributing to positive experiences during the psychiatry term were: receiving high quality supervision; supported autonomy; and witnessing patient recovery. There was a paucity of Australian literature preventing investigation of the Australian context alone.Conclusions: There is a need to better understand how the junior doctor and medical student psychiatry experience influences perceptions of psychiatry and intention to specialise, especially in the Australian context. [ABSTRACT FROM AUTHOR]

Objective: Junior doctors have high rates of burnout resulting in downstream impacts on patient care. The aim of this study is to capture cross-sectional data on a cohort of psychiatry trainees. These data will be used to inform a wider project investigating psychiatry trainee mental health and wellbeing. Method: This paper reports on the 2019 baseline data of psychiatry trainees enrolled in a formal education course at the University of Sydney, Australia. The data were collected with an online survey using a range of validated mental health and wellbeing scales. This descriptive study involved psychiatry trainees as co-designers. Results: Our research findings are in keeping with the existing literature on the poor mental health and wellbeing of doctors with significantly higher levels of anxiety and exhaustion found in female trainees and carers. Despite this, the cohort had high scores on the flourishing scale. Conclusions: Concern around the wellbeing of junior doctors in Australia appears justified. We need to move beyond focussing on individual action to systems-based approaches to improving wellbeing and ongoing sustainability of the psychiatry trainee workforce in NSW. [ABSTRACT FROM AUTHOR]

Objective: This paper considers reasons that may be contributing to the unusual synchronicity of five vacancies for Chairs/Heads of Department of Psychiatry in the Group of Eight University Medical Schools in March 2019.Conclusion: University psychiatric departmental head vacancies arise from a number of factors: challenges and limitations in public sector psychiatry and universities; structural problems with such appointments; lack of a developmental pipeline for academic psychiatry; and other attractive alternative options, such as private practice. [ABSTRACT FROM AUTHOR]

Objective: This paper outlines the current psychiatry workforce shortages experienced by rural and remote communities in Australia and argues that postgraduate training in psychiatry may play a role in rectifying these healthcare access inequities.Conclusion: Funding for postgraduate medical specialist training in Australia is undergoing a shift away from solely metropolitan-centric training schemes, based on substantial evidence over the past two decades in undergraduate medical training. Psychiatry is well placed to lead the development of dedicated postgraduate rural training pathways to enhance recruitment and retention of an urgently required rural and remote psychiatry workforce. [ABSTRACT FROM AUTHOR]

Objective: The physical health and well-being of mental health patients have been a concern to health professionals for many years. However, very few positive gains have been made to address this problem. This paper outlines the efforts of the Inner North Brisbane Mental Health Service, Royal Brisbane and Women’s Hospital, to design and implement a structured educational programme, aimed at addressing and encouraging healthy lifestyle behaviours in its community mental health service recipients. Methods: Three programme modules were designed, addressing the topics of Nutrition and Healthy Eating, Physical Health, and Community Based Activities and Interests. Referral of patients to the programme was by their case manager or doctor. At the conclusion of each module, participants were asked to complete a satisfaction survey evaluating the programmes. The survey also gathered feedback regarding any suggestions and/or recommendations to improve content suitability and relevance. Results: Since commencing the Healthy Living Program, each module has been conducted at least twice, the topic of Healthy Eating receiving the most referrals and therefore conducted most frequently. To date, 35 satisfaction surveys have been evaluated. The overwhelming majority of respondents offered very positive feedback about the programme, most being able to identify some healthy lifestyle changes they planned to make in response to programme attendance. Conclusions: This paper highlights the importance of incorporating healthy lifestyle programmes into mental health service delivery. The majority of patients who have attended the Healthy Living Program have indicated satisfaction with the content, but as yet information pertaining to long-term lifestyle change has not been collated. The next phase aims to examine whether the programme attendance has more long-term outcomes in improving health and well-being and promoting healthy behaviour change of mental health service recipients. [ABSTRACT FROM AUTHOR]

Objective: This paper aims to analyse in a philosophically informed way the recent National Institute of Mental Health proposal for the Research Domain Criteria (RDoC) framework.Conclusion: Current classification systems have helped unify psychiatry and the conditions that it is most concerned with. However, by relying too much on syndromes and symptoms, they too often do not define stable constructs. As a result, inclusions and removals from the manuals are not always backed by sound reasons. The RDoC framework is an important move towards ameliorating matters. This paper argues that it improves the current situation by re-referencing constructs to physical properties (biomarkers for disorders, for example), by allowing theoretical levels within the framework, and by treating psychiatry as a special case of the cognitive sciences. [ABSTRACT FROM AUTHOR]

Objective: The Mark Sheldon Remote Mental Health Team provides psychiatric services to 29 communities in very remote Central Australia. This study evaluated Mark Sheldon Remote Mental Health Team patient demographics, diagnoses and clinical management. Methods: A retrospective cross-sectional review was performed for January 2020. Variables included age, sex, Indigenous status, diagnosis, legal status, medication class and route of administration. Results: A total of 180 patients were identified (85.6% Indigenous, 53.3% male). Schizophrenia and delusional disorders were most common (41.1%). A small proportion of patients (2.8%) were involuntary. Psychotropic medication was commonly prescribed (77.4%) with a low threshold for anti-psychotic depot use (51.5%). Oral medication rates varied according to class. Conclusions: This study provided insights into the demographic and clinical profile of a unique population. The findings will help to optimise patient management in very remote Central Australia and serve as a foundation for similar evaluations and comparisons with other remote psychiatric services. [ABSTRACT FROM AUTHOR]

Objectives: To provide a brief biography of Dr Richard Greenup and to explore the legacy he has left to one of Australia's longest operating psychiatric services. Methods: This history was obtained by consulting staff working within Cumberland Hospital, New South Wales and by examining primary and secondary sources. Results: Greenup was the second surgeon superintendent of 'The Parramatta Lunatic Asylum' from 1852 until 1866 when he was fatally stabbed with a pair of scissors by a patient. Greenup was involved in establishing The University of Sydney and advocated for expanded and improved services for people diagnosed with mental disorders. Conclusions: Greenup recognised the needs of the mentally ill and sought to address similar social and demographic determinants of health to those that we face today. The challenges he faced, and his tragic end remind us of the importance of delivering patient-centred care whilst being mindful of associated risks. [ABSTRACT FROM AUTHOR]

Objectives: Clinical directors established research-led healthcare by combining research, teaching and clinical excellence within the teaching hospitals. This research culture created high clinical standards, which benefited patients, the workforce and healthcare organisations. The current paper explores this research leadership role for clinical directors. It reviews studies arising from the theory of expert leadership, which focuses on the relationship between a leader's core knowledge and organisational performance. More specifically, we examine the expert leader's research track record, the associations with their organisation's performance, and the influence of research activity on clinical excellence.Conclusion: Distinguished researchers still lead the most prestigious teaching hospitals and the most trusted departments of psychiatry in the United States where the clinical directorate structure originated. It is also known that good scholars can improve research output when appointed to leadership positions. This suggests that the clinical director's research track record should be a consideration at a time when research is being embedded in Australia's local health networks. A clinical director's leadership may influence the research performance of their department and contribute to the quality of mental healthcare. [ABSTRACT FROM AUTHOR]

Objective: To examine the relationship between academic psychiatry and the pharmaceutical industry, focusing on a partnership between academics in Melbourne and Eli Lilly and Company (Lilly Melbourne Academic Psychiatry).Conclusions: Relationships between the pharmaceutical industry and the medical profession (including psychiatry) are under scrutiny as never before. Despite the complex nature of the relationship, the present paper argues that partnerships with external corporations such as pharmaceutical companies are of increasing importance for academic departments of psychiatry and research institutes, in environments in which core funding for tertiary institutes is being reduced. The partnership between Melbourne psychiatric academics and Eli Lilly and Company shows that benefits accrue to both parties, and suggests that there is a worthwhile place for other industry- academic collaborations of a similar nature in Australia. [ABSTRACT FROM AUTHOR]

Objective: In response to the identified need for up-skilling in psychiatry for rural and remote general practitioners, a series of workshops has been designed and delivered to medical and nursing staff in South Australia. In this paper one such workshop is described, dealing with acute psychiatric care. Quantitative and qualitative evaluations of the workshop are reported on, and recommendations are made for future training programmes.Conclusions: The workshop was well received and increased participants' knowledge about the management of acute psychiatric presentations. Qualitative data indicate that the pharmacological management and neurobiology of psychiatric illness was interesting but difficult for some participants, and further training in these areas may be appropriate in future workshops. Inclusion of all professional stakeholders in future training is recommended, including students, to promote interest in working in rural and remote health. Participants considered networking with colleagues as an important benefit of the workshop. Targeted training in psychiatry may be needed for overseas-trained doctors. Further, rigorous research is needed to evaluate the long-term benefits of up-skilling workshops, and to inform funding bodies as to where resources might be most effectively channelled. [ABSTRACT FROM AUTHOR]

Objective: To report the views of Australasian Psychiatry readers about pharmaceutical industry involvement in CME activities. Method: A discussion paper and fax-back survey form in a previous issue of Australasian Psychiatry sought views on specific areas of possible risk and several different strategic approaches which may be taken. Results: 182 responses were received from a wide cross section of College Fellows. Views on our current strategy (prohibition) were highly polarised and weakly associated with gender, years since fellowship and state. There was strong support for declaration, engagement and education strategies. Conclusions: There is much concern about the issue. Declaration, engagement and education strategies should be further developed. [ABSTRACT FROM AUTHOR]

The new RANZCP guidelines for the treatment of schizophrenia and related disorders highlights what we know works. In this paper, we examine why patients so often fail to benefit from this knowledge and why clinical practice falls so far short of the recommended standard. Instead of the continuous improvement that we expect of health care in general, in psychiatry we face an accelerating decline in systems of care. There has been a sustained underinvestment in public mental health care and a shared failure by State and Federal governments to construct and commit to a governance and funding model that can deliver the standard of care that is available in other major non-communicable diseases, and which we know is equally possible for severe mental illness. This paper sets out some of the reasons for the poor quality of care received by many people with schizophrenia and related disorders in Australia, and describes ways that care could be improved. In particular, we recommend an explicit statement of what constitutes an adequate standard of care, for people at all stages of these illnesses. This would help provide transparency about whether the care provided by mental health services achieves these benchmarks, and enable publication of results comparing the performance of different states and regional services. Patients and families, as well as professional, consumer and carer organizations would then be able to see clearly where the deficits are and demand resources and care that match the recommendations. [ABSTRACT FROM AUTHOR]

Objective: There has been a growing interest in psychiatry enrichment programmes such as summer schools and institutes for medical students in the last 10 years. Evaluation of enrichment programmes shows that they can be an effective method of increasing students' interest in psychiatry as a career. However, despite initial enthusiasm and motivation within an academic department, establishing a programme can be a daunting task. The aim of this paper is to provide a background of how to establish and implement a psychiatry summer school or institute. The steps that can be taken to establish and implement a psychiatry enrichment programme such as a summer school or institute are described and discussed. This includes how to structure a programme, content to include, costs and budget, programme promotion, selection of students and programme evaluation.Conclusion: Establishing an enrichment programme can provide academic departments of psychiatry with the opportunity to demonstrate excellence and innovation in teaching and positively promote psychiatry to students and other non-medical academics involved in medical education. For students interested in psychiatry, enrichment programmes have the potential to extend interest and knowledge beyond the curriculum and encourage serious consideration of psychiatry as a career. [ABSTRACT FROM AUTHOR]

Objective: To provide reflection on career opportunities, benefits and challenges, with regard to commencing private practice psychiatry in Australia. Conclusions: There are varied opportunities for a career in private practice psychiatry. Private practice has benefits and challenges, distinct from public sector psychiatry; with moderately greater professional autonomy, facilitating the provision of expert mental healthcare for the community. [ABSTRACT FROM AUTHOR]

Objective: The objective of this article is to present a decision aid in the form of a flowchart, designed to assist psychiatrists in navigating the challenges of off-label medication use. This tool is believed to be the only one currently available that combines guidance from medical indemnity insurers, RANZCP guidelines, CATG frameworks, and relevant legislation to provide a practical guide for everyday psychiatric practice. Conclusions: There are clinical, legal, ethical, and financial considerations to take into account each time an off-label prescription is ordered. There is no legal barrier to prevent psychiatrists from prescribing off-label in Australia and New Zealand. The medication should be utilised if it is in the best interests of the patient. However, practitioners must be able to defend the rationale for their off-label medication use with evidence of sound quality. Off-label use medication use can lead to improved patient outcomes and quality of life. On the other hand, poor practice in off-label prescribing can result in adverse events, patient harm, legal implications, and damage to professional reputation. By evaluating available evidence, considering patient characteristics, obtaining informed consent, and documenting the rationale for off-label use, clinical decision-making can be enhanced whilst mitigating the risks associated with off-label prescribing. [ABSTRACT FROM AUTHOR]

Objective: The Claassen Institute of Psychiatry for Medical Students (the Institute) is an innovative enrichment programme aimed at attracting medical students to psychiatry. This paper reports on the effectiveness of the Institute as a strategy to increase interest in psychiatry as a career, and the career pathways of students who have attended since 2008.Method: Students completed a baseline questionnaire on day 1 and the final day of the Institute. A follow-up survey was administered electronically to ex-Institute students to determine their career pathways and current level of interest in psychiatry.Results: Since 2008, 117 students have attended the Institute. There was a significant increase in those 'definitely' considering a career in psychiatry from 57% at baseline to 77% at the end of the week. Eighty-nine ex-Institute students were invited to participate in the follow-up survey, and of these 21% were currently psychiatry trainees.Conclusion: The Institute has been successful in encouraging medical students to pursue a career in psychiatry. Enrichment programmes are emerging as an effective recruitment strategy and will assist in future-proofing the psychiatric workforce in decades to come. [ABSTRACT FROM AUTHOR]

Objective: To determine bulk billing rates, and mean, median, and 10th and 90th centile fees for outpatient consultations with a psychiatrist in Australia in 2019, by state or territory. Method: Medicare claims data for bulk billing rates and the mean, median, and 10th and 90th centile for fees charged in Australia in 2019 were requested, for item numbers for initial and ongoing consultations. Results: There were high rates of bulk billing overall. Initial consultations were more likely to be bulk billed. There was variation in fees between states and territories. Fees were highest in the Australian Capital Territory. Conclusion: There is variation in fees and bulk billing rates for outpatient consultations with a psychiatrist. Fees tend to be higher in states or territories with higher median personal income. Psychiatrists were more likely to bulk bill for initial consultations, with the exception of the Northern Territory. High rates of bulk billing may indicate psychiatrists are absorbing increasing costs of service provision. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper is to provide an overview of the rationale behind the expansion of specialist psychiatry training positions outside of major public teaching hospitals, as expounded by the Australian Federal Government's Expanded Settings for Specialist Training (ESST) Program. Conclusion: Alternative training settings are required to help address the anticipated growth in numbers of medical graduates and to meet the need of psychiatry trainees for greater experience in treating high prevalence mental disorders. To progress the expansion of training settings within psychiatry, it is essential that comprehensive consultation be undertaken to understand the implications of this program for trainees, existing training facilities and expanded setting providers to ensure that all stakeholders, including patients and carers, derive benefit. [ABSTRACT FROM AUTHOR]

Objective: Recruitment of medical graduates into psychiatry has become a growing issue over the last few decades. This paper describes the implementation of an innovative program, based on a Canadian concept, that aimed to promote psychiatry as a career choice to medical students, to immerse them in the 'world of psychiatry', and introduce them to potential mentors. The University of Western Australia Institute of Psychiatry for Medical Students was a week-long program that provided medical students with an opportunity to participate in a diverse agenda of interactive seminars on a range of psychiatric subspecialties and the neurosciences. Students were also able to attend elective sessions and meet registrars and psychiatrists on an informal basis. Lunches and social events were also provided. Conclusion: Twenty-one students attended the inaugural Institute. Twenty-seven speakers contributed to the morning seminars and there were 17 clinical elective site visits. Feedback from students was positive and the week was rated highly, both in terms of its organization and from an academic perspective. It is planned to run the Institute annually and, in time, it is hoped that it will increase the numbers of students who choose psychiatry as a career option. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper was to identify factors that impact on career choice in order to promote careers in psychiatry to medical graduates. Method: Royal Australian and New Zealand College of Psychiatrists (RANZCP) psychiatry trainees were invited by email to complete an online survey on career planning. The survey included open-ended questions about the reasons for choosing psychiatry and satisfaction with career opportunities in psychiatry. Responses were analysed for main themes. Results: Of the 267 trainees who participated, 84% were currently training in Australia and 16% were training in New Zealand. The reasons given by trainees for choosing psychiatry varied. Over two-thirds of trainees highlighted a general interest in the area or enjoyment of their experience of psychiatry. Trainees also frequently mentioned work-life balance (29%), patient contact (20%), challenge and complexity (17%), helping people (16%), and the holistic perspective (15%) as reasons for choosing psychiatry. Over 80% of trainees reported being satisfied with their choice of medical specialization and were positive about the career opportunities that psychiatry offers. Conclusion: This study highlighted a number of factors that impact on career choice and satisfaction with career choice. Promotional materials should utilize these factors in order to more effectively promote careers in psychiatry. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper is to provide an overview of the history and activities of the RANZCP Section of Addiction Psychiatry, as well as its current challenges and opportunities. Conclusions: From initial exclusion to an active and growing membership, the Section of Addiction Psychiatry continues to ensure that problematic substance use and gambling remain core issues within Australasian psychiatry. In addition to commenting and contributing to ongoing clinical and policy initiatives, the Section has recently introduced an advanced training curriculum and maintains a strong partnership with the relatively new Australasian Chapter of Addiction Medicine. Its active input into education, training, media and policy development within the College guarantees that psychiatry is represented within the addiction field, and that tomorrow's psychiatrists are competent to assess and treat comorbid addiction issues. [ABSTRACT FROM AUTHOR]

Objective: Difficulties recruiting and retaining adequate numbers of mental health nurses have been extensively documented in the Australian literature. The continued increase in the average age of practicing mental health nurses has intensified concerns that a workforce crisis is rapidly approaching. Despite the urgency of this situation, there has been no comprehensive, co-ordinated collection of labour force data. The aim of this paper is to synthesise and present labour force data gathered from various official sources to more clearly identify and articulate the nature and extent of the problem. Method: Relevant labour force data was obtained from reports produced by the Australian Institute of Health and Welfare and the Victorian Department of Human Services. Information was collated, synthesised and, in some cases, re-analysed to provide a clearer picture of the current national and Victorian mental health nursing labour force, as well as requirement and supply projections. Results: Findings are consistent with conclusions in the available literature but suggest that the magnitude of the problem is likely to be greater than previously anticipated. Conclusions: The systematic and coordinated collection of mental health nursing labour force data is crucial in order that appropriate interventions can be implemented and evaluated. [ABSTRACT FROM AUTHOR]

Objective: Based on evidence obtained from recent Australian psychiatric patient surveys, a need to include the spiritual and religious dimension of patients in their psychiatric care has been identified. This paper aims to review the evidence for this need and to suggest the parameters in which this dimension might be applied. Methods: The phenomenology of spirituality and its relevance to psychiatry is considered, the concept of the psychiatrist and the clinician as a healer visited, and the evidence for the need for spirituality and religiosity for patients examined. Results: Patients’ spiritual needs should be addressed at different levels. Using previous data and experience, the authors suggest what psychiatrists might and might not do, in order that these issues are attended to in an ethical and sensitive manner. Conclusions: In considering the spiritual dimension of the patient, the psychiatrist is able to send an important message that he or she is concerned with the whole person, a message that enhances the patient–physician relationship. This, in turn, is likely to increase the therapeutic impact of psychiatrists’ interventions. [ABSTRACT FROM AUTHOR]

Objective: From the early 1990s there has been a growing awareness in Australia of dissociative processes and dissociative disorders. The objective in this paper is to provide a selective overview of the context and process of treatment based on the substantive dissociative disorders literature, ongoing clinical experience and research, and over 8 years as director of a trauma and dissociation unit at Belmont Hospital, Brisbane.Conclusions: The construct of individual selfhood is of direct relevance in illustrating the psychological damage sustained by patients who have relied on dissociative defences to survive, and in highlighting issues and areas that are a particular focus of informed treatment. [ABSTRACT FROM AUTHOR]

Discusses the proposed Maintenance of Professional Standards (MOPS) program for 2001 of the Royal Australian and New Zealand College of Psychiatrists. Removal of categories in educational meetings; Change in program activities for clinical and non-clinical practice; Focus on quality improvement and incorporation of peer review; Contribution of peer review groups; Papers relevant to quality improvement in psychiatry.

Objective: To explore psychiatry in Islam, with a view to informing Western psychiatrists working with Islamic patients, and Islamic medical students studying in Western countries.Methods: The first necessary step was to acquire some understanding of Islam, Sharia and Sharia law, as the basis on which the available psychiatric literature was considered. Standard textbooks on Islam and English-language papers in the psychiatric literature were examined. Discussions with knowledgeable Muslim people were conducted.Results: Islam shares roots with the other Abrahamic, monotheistic religions: Judaism and Christianity. A central issues is unity: the unity of God, unity with God and unity within the Islamic community. Islam is more than a religion, because it informs all aspects of behaviour and has been described as 'a comprehensive way of life'. Individualism is less important than the welfare of the community. The Sharia is a list of rules and regulations derived from authentic sources. Psychiatric services in Islam, according to Western standards, are somewhat limited. This issue is being addressed through epidemiological studies, provision of new services and policy development. Although mental health legislation is not universal, forensic psychiatry has a role, in many ways similar to that in the West.Conclusion: Islam is based on unity and core values of compassion, justice and benevolence. Islamic psychiatry has a proud early history, and advances are occurring. There is an opportunity for the profession of psychiatry to bridge religious, ethnic and cultural boundaries. [ABSTRACT FROM AUTHOR]

Reports that a Royal Australian and New Zealand College of Psychiatrists (RANZCP) discussion paper has identified a number of strategies to address the shortage of psychiatrists and the recruitment of trainee psychiatrists. Paper presented by RANZCP to the Australian Department of Health and Aging; Commitment of the RANZCP to developing effective partnerships with a range of mental health professions.

Developments in public mental health policy in Australia and a renewed focus on the preventative importance of the early postnatal years have recently brought perinatal mental health to the fore. The present paper aims to explore the meaning of ‘perinatal mental health’ and its relevance to psychiatry, and to examine the opportunities and challenges currently facing Australian psychiatrists in the provision of services in the perinatal period. The definition of ‘perinatal mental health’ is discussed and the impact of maternal mental illness arising in the ‘perinatal’ period on offspring outcomes and early intervention endeavours are reviewed. Recent Australian developments in public health policy are outlined. The use of the term ‘ perinatal’ highlights the importance of considering the mental health needs of both parents and infants from conception and through the developmentally critical first 2 years of life. The relevance of a perinatal approach is supported by a literature demonstrating that maternal mental illness arising at this time can adversely affect offspring mental health outcomes. Early intervention programmes targeted at well-defined ‘high risk’ families in the perinatal period may be of value in terms of reducing this morbidity but remain to be replicated. Although the 2nd National Mental Health Plan and other recent Australian health policy initiatives support the belief that good mental health care in the perinatal period is critical to the mental health of future generations, such care provision remains fragmented and often difficult to access. Innovative developments in public health policy and models of service provision are beginning to address these shortcomings. An understanding of the conceptual and empirical underpinnings of ‘perinatal mental health’ is essential if there is to be a shift towards an integrated approach to mental health service provision and better access for vulnerable families at this time. As psychiatrists, we have much to contribute to early identification and intervention strategies and the integration of these services with those provided by primary health-care professionals in the perinatal period. [ABSTRACT FROM AUTHOR]

Objective: In Australia, mental health services are delivered by a complex web of public- and private-sector providers. There is a growing recognition that linkages between these groups are not optimal, and a concern that this may lead to poor outcomes. This paper illustrates a conceptual framework for developing, implementing and evaluating programmes concerned with linkages. Method: Drawing on theoretical and practical literature, this paper identifies different levels of integration, issues in evaluating programmes to address poor linkages, and features of useful evaluations. Within this context, it describes the method by which the Public and Private Partnerships in Mental Health Project (Partnership Project) is being evaluated. Conducted by St Vincent’s Mental Health Service and The Melbourne Clinic, this is one of several Demonstration Projects in Integrated Mental Health Care funded under the National Mental Health Strategy. Results: Collaboration is hard to conceptualize and collaborative programmes usually have many players and components, and tend to operate within already-complex systems. This creates difficulties for evaluation, in terms of what to measure, how to measure it, and how to interpret findings. In spite of these difficulties, the illustrative example demonstrates a model for evaluating collaborative programmes that is currently working well because it is strongly conceptualized, descriptive, comparative, constructively sceptical, positioned from the bottom up, and collaborative. Conclusions: This model, or aspects of it, could be extended to the evaluation of other mental health programmes and services that have collaborative elements. [ABSTRACT FROM AUTHOR]

Objective: This paper challenges the adversarial judicial model of the Mental Health Review Tribunal. Following a brief history of the adversarial legal system, it questions the impact of imposing a legal environment on the mentally ill and on the traditional doctor/patient relationship. It also examines issues of poor communication and excessive bureaucracy. Conclusions: The current legal process is inhumane, outdated, and inefficient. There is room for lateral thinking into developing a more appropriate and contemporary model to address issues of civil liberties and medical treatment for the mentally ill. One possible model could be made up of a non-judicial and independent team with appropriately trained staff, recruited from more ‘caring’ professions, with well-defined, but discretionary legal powers. [ABSTRACT FROM AUTHOR]

Objectives: Following a very rapid and significant uptake of metropolitan telepsychiatry in private practice in Australia during COVID-19, practical questions remain: How long should psychiatrists continue telepsychiatry? Are there benefits of continuing: reduced COVID-19 risks to patient and psychiatrist, and flexibility of appointments? Will the Medicare Benefits Schedule (MBS) telehealth items be retained? How does metropolitan telepsychiatry fit into the overall mix of public and private services? This is an important debate.Conclusions: Private psychiatrists may continue to offer the majority of care, where practical, via telepsychiatry to reduce COVID-19 exposure risks, as well as allow for the realities of practice management for pandemic public health measures. However, consideration has to be given to the potential drawbacks for patients with sight, hearing and illness-related disabilities or risks, when in-person consultation is required. There are also risks: some patients may not benefit from telepsychiatry due to the nature of their illness, and will patients feel rapport is lost? However, the retention of COVID-19 MBS telehealth items is needed for ongoing flexible and comprehensive private practice psychiatry. [ABSTRACT FROM AUTHOR]

Objective: The generalist psychiatrist is recognised in Australia as a specialist in the management of addiction. However, generalist training does not adequately prepare psychiatrists to take on this expert role. This problem is exacerbated by the lack of consensus around core competencies and training pathways. This article conceptualises the status of addiction training in generalist psychiatry training, outlines current gaps and worrying trends and provides suggestions for how these can be addressed. Conclusion: Limited international leadership in the field provides an opportunity for psychiatry training in Australia and New Zealand to set a gold standard for training general psychiatrists to hold core competencies in addiction psychiatry. Key strategies will include: the identification and monitoring of addiction rotations; providing a formal training module in addiction; specifying a set proportion of addiction exam questions; and obtain consensus on core competencies. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic trends herald what many describe as the Asian Century, whereby Asian economic, political and cultural influence is in global ascendency. Broadening relevant ties between Australia and Asia is evident and logical and may include strengthening alliances in mental health systems. Aim: We argue the importance of strengthening Asian mental health systems and some of the roles Australian mental health workers could have in promoting strengthening the Asian mental health system. Methods: This paper is a narrative review which sources data from reputable search databases. Results: A well-articulated Australian strategy to support strengthening the mental health system in Asia is lacking. While there are active initiatives operating in this space, these remain fragmented and underdeveloped. Coordinated, collaborative and culturally respectful efforts to enhance health education, research, policy, leadership and development assistance are key opportunities. Conclusion: Psychiatrists and other mental health professionals have a unique opportunity to contribute to improved mental health outcomes in Asia. [ABSTRACT FROM AUTHOR]

The article comments on the key role of the Royal Australian and New Zealand College of Psychiatrists on the promotion of psychiatry as a profession and the development of policy on mental health in 2006. Key issues discussed include initiatives by the college to establish itself as a leader in the development of mental health policies in Australia and New Zealand.

Objective: For psychiatrists and trainees, to reflect upon adverse managerial reactions to healthcare advocacy about patient care and safety, drawing upon examples from general healthcare settings, and to share approaches to addressing these reactions.Conclusions: Psychiatrists and trainees engaging in healthcare advocacy may face adverse responses from healthcare management, with personal and professional consequences. Advocates need to consider counterstrategies to negative actions by management that may include workplace incivility, bullying and harassment. Health advocacy is more effective within a network of peers, patients and the broader community, including medico-political professional organisations, such as the Australian Medical Association, Royal Australian and New Zealand College of Psychiatrists, and Unions. These organisations should advocate openness to doctors highlighting healthcare safety and quality, as well as prevention of workplace bullying. [ABSTRACT FROM AUTHOR]

The article explores the use of recovery orientation, medication, and shared responsibility in contemporary mental health services in Australia. It highlights the importance of improving the relationships between psychiatrists, other clinicians and consumers as well as the influence of the personal recovery paradigm in mental health. Challenges in clinical practice are mentioned.

The article examines the history of insulin coma therapy (ICT) in Australia. It highlights the discovery of several biological therapies such as ICT, which is noted to be a development of great interest to psychiatrists in the country. Information about the administration of ICT as well as the positive response to hypoglyaemia in a patient is provided.

Pro re nata (PRN; 'as needed') medication is an archetypal mainstay for managing acute psychiatric inpatient symptoms and behaviours. Psychiatric and mental health nursing practices have circumnavigated the development of a uniform medical-ethical standard for the administration of PRN psychotropic medication. This paper examines the evidence for administration of PRN psychotropic medications and, in the context of evidence-based best practice, current mental health policy and professional ethics, proposes a standardized Australian PRN administration protocol. The procedures and circumstances leading to a nurse administering psychotropic PRN medication are divided into five simple steps, namely (i) medical prescription; (ii) nurse evaluation of patient indications for an intervention; (iii) nurse consideration of therapeutic options; (iv) obtaining patient informed consent; and (v) documentation of outcomes of PRN administration. The literature associated with each step is reviewed, along with national and international professional ethics, guidelines and patient rights documents pertaining to the care of mental health patients. Recommendations for best-practise care are discussed for each step. There is a lacuna of published evidence supporting the use of PRN medications in psychiatric inpatients. Yet there is published evidence that PRN medications are associated with increased risks of morbidity, inappropriate use, may result in above-recommended dosages or polypharmacy, and complicate the assessment of efficacy of regular scheduled medicines. Alternative non-pharmacological treatment options to PRN medication are effective and associated with fewer side-effects. There are no national explicit standards, operational criteria or quality assurance for the use of PRN medication in inpatient psychiatric units. Contemporary PRN practices are largely unregulated and driven by essentially anecdotal evidence, leaving the clinicians and the service open to claims of poor accountability and misuse (intentional and unintentional) of psychotropic medications. Development of best practice guidelines for the use of PRN administration is essential. [ABSTRACT FROM AUTHOR]

Objective: Declining interest in psychiatry is an urgent public health issue and has been the subject of many studies. The purpose of the present paper was to survey the attitudes of senior medical students in order to explore reasons why psychiatry might be regarded as an attractive option as a career. Method: Thirty-three students from an Australian university were asked during a written examination to consider why a psychiatric career might be an attractive choice for medical recruits. Key themes were identified and qualitatively analysed from the open-ended responses to the question: 'On the basis of your clinical experience, consider why a psychiatric career is an attractive choice these days.' Results: Thematic analysis indicated that the factors influencing decisions to specialize as a psychiatrist weighted financial and lifestyle advantages. The main drawcard profile was of challenging work that affords a good lifestyle and stimulating research opportunities. Other themes such as rewarding patient interaction, holistic care and variety were also raised. Conclusion: Concern that the Australian psychiatric profession is failing to attract sufficient numbers of high-quality recruits is growing. While the majority of essays analysed in this account suggested that the students perceived psychiatry as an adequate career that affords the benefits of a balanced lifestyle, the constraining nature of the survey question compelled examinees to provide positive responses. Despite this bias, the responses are nonetheless revealing and contribute to understanding of the factors that may influence trainees to enter the field. On the whole, it would appear that the discipline is currently not exciting keen passions in medical students. [ABSTRACT FROM AUTHOR]

Court diversion schemes have been running for a decade in New Zealand and are increasing in number in Australia. This paper aims to give an international and historical context to these developments, by reference to psychiatric initiatives at courts in the US and in England and Wales. From a review of the specialist literature, an account is given of three forms of psychiatric intervention in courts over the last 90 years: court psychiatric clinics and mental health courts in the US, and court diversion schemes in England and Wales. High levels of psychiatric morbidity among prisoners, coupled with a continuing increase in prisoner numbers, demonstrate the need for systems for dealing with mentally ill people who come before the courts. Court diversion in England and Wales developed as part of a system where the mentally ill who are found guilty are sent to hospital in lieu of any other sentence. Its focus is on a form of psychiatric triage, and its ethos is the health of the patient. Court psychiatric clinics in the US grew up as an alternative to assessment in prison. Their focus has been on full psychiatric evaluation in an insanity and incompetence jurisdiction. The ethos has been that of serving the court. Mental health courts are heavily influenced by ideas of therapeutic jurisprudence, and their emphasis has been on a judge holding minor offenders in community care through the threat of judicial sanction. Experience in England and Wales has shown that court diversion can be a powerful and effective intervention. In order for it to function properly, those running court schemes need direct admission rights to psychiatric beds, both open and locked. Court diversion schemes are best as part of a spectrum of services to police stations, courts and prisons, which involved both general and forensic psychiatrists. [ABSTRACT FROM AUTHOR]

Objective: To report on economic studies of Australian mental health issues. Conclusion: Although the international literature on the economics of mental health issues is increasing, and although many Australian studies exist on one comorbid condition of mental illness, namely substance abuse, there are very few empirical studies by economists of Australia’s mental health issues. [ABSTRACT FROM AUTHOR]

Objectives: This paper reports on changes, over time and between states, in the use of electroconvulsive therapy (ECT) in the private psychiatric sector in Australia between 1984 and 2004. Method: Data for ECT services, and all specialist psychiatry services provided under the Medicare system, have been analysed in absolute numbers and as utilization rates. Results: Changes in the use of ECT over time are different from other services provided by private psychiatrists. As in other countries, the use of ECT initially declined in period studied but has increased in recent years. In addition, there is a clear pattern of differential use of ECT between the states and territories. Conclusions: This descriptive study cannot ‘explain’ the results obtained: other data, incorporated into an explanatory model using regression analysis, are needed to determine the factors underlying the utilization patterns obtained in this study. Thus, further work is needed. Furthermore, it is important to analyse data at a lower level of geographical aggregation than that of the state/territory: this (state/territory) aggregation conceals differences in utilization between metropolitan, minor city, rural and remote regions of the country. [ABSTRACT FROM AUTHOR]

Objective: To discuss the prevalence of blood-borne viral and sexually transmissible infections among psychiatric populations, as well as current treatment approaches, both locally and internationally. Method: In this paper, we outline available epidemiological data, as well as interventions designed to target infectious disease risk among those with serious mental illness. Results: Within Australia, the prevalence of blood-borne viral and sexually transmissible infections among at-risk populations remains unacceptably high despite a number of successful harm reduction and prevention strategies. Although the highest rates of new infections occur among young people aged 15–29 years, recent research suggests that psychiatric populations are also at significant risk. However, despite increased rates, there is currently no coordinated strategy to educate, test and reduce disease risk among people suffering with mental illness within Australia. Conclusions: Although further epidemiological research at a local level is needed, interventions specifically targeting psychiatric populations and younger cohorts in particular, are essential. This will require multidisciplinary, collaborative service development, incorporating mental health, substance use and infectious disease specialists. [ABSTRACT FROM AUTHOR]

Objective: In Nazi-occupied Europe, substantial numbers of psychiatrists murdered their patients while many other psychiatrists were complicit with their actions. This paper addresses their motivations and actions, and with particular reference to Australia, explores issues of contemporary relevance. Methods: The events are reviewed in their historical context using mainly secondary sources. Results: The assumption that the term ‘Nazi’ denotes a closed and unrepeatable chapter is questioned. As with the Holocaust that followed, medical killing of psychiatric patients was an open secret with gradations of collective knowing. Perpetrators were impelled by pressure from peers and superiors, unquestioning obedience, racist ideology and careerism. Perpe­trators and bystanders’ denial was facilitated by use of deceptive language, bureaucratic and technical proficiency, and notions such as ‘a greater cause’ or ‘sacred mission’. Dissociation and numbing were common. Psychiatrists were the main medical speciality involved because Nazi race and eugenic ideology (accepted by many psychiatrists) targeted mentally ill people for sterilization and euthanasia, and because psychiatrists were state-controlled and tended to objectify patients. Few psychiatrists resisted. Implications: Nazi psychiatry raises questions about medical ethics, stigma and mental illness, scientific ‘fashions’, psychiatry's relations with government, and psychiatrists’ perceived core business. Psychiatric resistance to future similar threats should be based on commemoration, broad-based education and reflection on cultural values, strong partnerships between psychiatrists and patients, and willingness to question publicly policies and attitudes that disadvantage and stigmatize groups. The principle fundamental to all these practices is an orientation to people as subjects rather than objects. [ABSTRACT FROM AUTHOR]

Objective: To provide a review of my personal exposure to the Medical Psychiatric (Medical Psy) Liaison Group in Rochester during the tenure of a National Health of Medical Reseach Council Travelling Fellowship in the Clinical Sciences from June 1975 to March 1977. Method: A personal reminiscence and review of a number of papers by George Engel. Results: The Medical Psy Liaison Group had been developed by George Engel in 1946. My experiences were coloured by the fact that Engel had recently stepped down as Head and tensions in the structure and function of the group were obvious. Conclusion: My personal experience with Engel, the Medical Psy Liaison Group, Rochester psychiatry and my exposure to American psychiatry all had major influences on my subsequent career but perhaps not in a way that I might have expected when I went to Rochester. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper is to outline the opportunities and dangers the chronic fatigue syndrome (CFS) issue presents to Australian psychiatry. Method: The scientific literature of the last 50 years on CFS in adults was reviewed and samples of recent media portrayals of CFS in the UK and Australia were collected. The author has worked in both the UK and Australia managing adult CFS patients in specialist outpatient consultation–liaison (C–L) psychiatry settings. Results: Chronic fatigue syndrome has been at the heart of an acrimonious debate in the UK, both within the medical profession and in the wider community. UK psychiatry has been drawn into the debate, at times being the target of strong and potentially damaging criticism, yet UK psychiatry, especially the C–L subspecialty, has played a crucial role in clarifying appropriate research questions and in devising management strategies. The issue has served to enhance and broaden psychiatry’s perceived research and clinical role at the important medicine–psychiatry interface in that country. Conclusions: Handled properly, the CFS issue offers Australian psychiatry, especially C–L psychiatry, an opportunity to make a useful contribution to patient care in a clinically difficult and contentious area, while at the same time serving to help broaden psychiatry’s scope in the Australian medical landscape. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper is to inform psychiatrists about the basic priniciples, terminology, schools of thought, efficacy, safety and regulatory issues regarding herbal treatments for mental illness. Method: Information was obtained by computerised and manual searching of medical and botanical data bases, and by discussions with experts in herbal medicine and regulatory aspects of the pharmaceutical industry. Results: Herbal medicines are commonly used in developed and developing countries for psychiatric illness. The main schools of herbal medicine in Australia are Western herbal medicine, traditional Chinese medicine and ‘Ayurveda’ (Indian herbal medicine). Herbs used for psychiatric or neurological disorders are termed ‘nervines’. Three nervines which have attracted considerable attention recently are St John’s Wort, Gingko biloba and Valeriana officinalis. In Australia, most herbal drugs are classed as ‘listed drugs’ which are required to satisfy less rigorous safety and efficacy criteria than ‘registered drugs’. The popularity of herbal remedies has a number of clinical and research implications for psychiatry. Conclusions: Psychiatrists should not endorse treatments that are unsupported by sound research, nor remain ignorant about alternative approaches to mental illness. The extent of use of herbal treatments for mental illness suggests that psychiatrists should become more knowledgeable about developments in this area. [ABSTRACT FROM AUTHOR]