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Objective: To describe implementation of the Pathways to Community Living Initiative (PCLI) within an Older People's Mental Health (OPMH) service., Method: A retrospective observational study was conducted. Implementation comprised partnership with a specialist Residential Aged Care Facility (RACF). Data were obtained from Clinical Advisory Committee (CAC) discussion and minutes, the PCLI database, and consumer medical records., Results: Eighteen consumers were accepted onto the program between April 2019 and March 2023. Their PCLI and rating scale outcomes alongside interventions facilitating placements are described. Interventions included OPMH case management, wide-reaching liaison, and inservices. Challenges included communication, confusion regarding roles, and differing views on capacity to accommodate complex consumers. Solutions included streamlining communication, including clinical updates in the CAC, facility appointment of a lead PCLI-nurse, and targeted RACF education., Conclusions: Considered interventions strengthened the OPMH and specialist RACF partnership over time. Clarification of professional roles and intersection with other services was crucial. Successful placement for PCLI consumers required consideration of personalised needs and existing resident mix, liaison with stakeholders, and targeted staff training. These strategies may apply to other health services implementing similar initiatives supporting community placements for OPMH consumers with complex needs., Competing Interests: DisclosureThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The four authors receive a part- or full-time salary for their PCLI roles, remitted by the Sydney Local Health District. There are no limitations on their clinical research or reporting. The authors received no financial or non-financial benefits from the research.

Introduction: People living with young-onset dementia and their care-partners are at risk of a range of adverse mental health outcomes and social isolation. There are few interventions aimed at supporting couples affected by young-onset dementia, which poses unique psychosocial challenges for younger people., Methodology: This pre-post interventional mixed methods pilot study aimed to assess the feasibility and acceptability of an online group program for people with young-onset dementia and their care-partners living at home in Australia. The Music And Psychology and Social connections (MAPS) program aimed to address: (1) the challenges and changes associated with young-onset dementia; and (2) coping and wellbeing. The program involved six weekly two-hour sessions co-facilitated by a psychologist and music therapist, and a private Facebook group. The primary outcomes of feasibility and acceptability were assessed through a post-program focus group, separate individual feedback sessions with each couple, and a program evaluation questionnaire. Thematic analysis was conducted on the focus group transcripts and field notes from couple feedback sessions. We also examined the preliminary utility of MAPS in improving mental health and social connectedness, using quantitative pre-post-measures., Results: Five couples completed the MAPS program. The most common dementia type was Alzheimer's Disease. Participant attendance was 87% across all sessions. Qualitative findings supported acceptability of the program with four emergent themes: being connected to others with shared experiences; reframing thoughts and feelings about dementia; music as a therapeutic tool; and benefits of MAPS., Conclusion: The high retention rate, qualitative findings and positive program evaluation suggest MAPS may be a promising, feasible and acceptable program for couples affected by young-onset dementia., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To describe the local adaptation of the Pathways to Community Living (PCLI) program in an Older Peoples Mental Health (OPMH) service to guide other services., Method: A retrospective observational study was conducted. Data were obtained from service planning meetings and newly developed documents, Clinical Advisory Committee meetings, and OPMH PCLI database., Results: The PCLI program was adapted for the local OPMH service through development of an assessment template, creating a Memorandum of Understanding with a partner Residential Aged Care Facility (RACF) and establishing processes for collaboration and regular review. Between 2019 and March 2023, 20 mental health consumers were referred to the OPMH PCLI program. Their demographic and clinical characteristics are described., Conclusions: Adaptation of the PCLI program for OPMH consumers required consideration of specific older adult needs to develop a bespoke plan for assessment and partnership with the PCLI-funded RACF. The development phase and ongoing processes for review facilitated engagement of key stakeholders across health and RACF sectors, highlighting issues with consumer engagement. Similar models could be used by other health services to implement the PCLI in their local context., Competing Interests: DisclosureThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The four authors receive a part- or full-time salary for their PCLI roles, remitted by Sydney Local Health District. There are no limitations on their clinical research or reporting.

Objective: Self-harm is closely associated with suicide in older adults and may provide opportunity to intervene to prevent suicide. This study aimed to systematically review recent evidence for three components of aftercare for older adults: (1) referral pathways, (2) assessment tools and safety planning approaches and (3) engagement and intervention strategies., Methods: Databases PubMed, Medline, PsychINFO, Embase and CINAHL were searched from January 2010 to 10 July 2021 by two reviewers. Empirical studies reporting aftercare interventions for older adults (aged 60+) following self-harm (including with suicidal intent) were included. Full text of articles with abstracts meeting inclusion criteria were obtained and independently reviewed by three authors to determine final studies for review. Two reviewers extracted data and assessed level of evidence (Oxford) and quality ratings (Alberta Heritage Foundation for Medical Research Standard Quality Assessment Criteria for quantitative and Attree and Milton checklist for qualitative studies), working independently., Results: Twenty studies were reviewed (15 quantitative; 5 qualitative). Levels of evidence were low (3, 4), and quality ratings of quantitative studies variable, although qualitative studies rated highly. Most studies of referral pathways were observational and demonstrated marked variation with no clear guidelines or imperatives for community psychiatric follow-up. Of four screening tools evaluated, three were suicide-specific and one screened for depression. An evidence-informed approach to safety planning was described using cases. Strategies for aftercare engagement and intervention included two multifaceted approaches, psychotherapy and qualitative insights from older people who self-harmed, carers and clinicians. The qualitative studies identified targets for improved aftercare engagement, focused on individual context, experiences and needs., Conclusion: Dedicated older-adult aftercare interventions with a multifaceted, assertive follow-up approach accompanied by systemic change show promise but require further evaluation. Research is needed to explore the utility of needs assessment compared to screening and evaluate efficacy of safety planning and psychotherapeutic approaches.

Objectives: This article examines the psychological effects of falls for older adults through the lens of identity and suggests these may be integrated in the assessment and management of older patients within acute care and rehabilitation settings post-fall. An illustrative vignette is described to demonstrate this approach., Conclusion: Falls in older adults are complex phenomena which can lead to an identity threat, sometimes manifest as psychological symptoms and poor engagement in post-fall rehabilitation. A psychiatric formulation which incorporates an older person's self-identity and agency may inform interventions to address psychological and behavioural sequelae of falls.

Objective: The Zero Suicide (ZS) framework is increasingly used in Australia, but without published adaptations for older people, and limited access by older people when implemented. The aim of this paper is to inform Towards Zero Suicide (TZS) implementations to benefit older adults by considering the key differences in older adults at risk of suicide according to each clinical component of the ZS framework., Conclusion: TZS aspires to reduce deaths by suicide for people within healthcare by refocusing interventions on suicidality rather than diagnosis alone, emphasising evidence-based practices and cultural change. For TZS to be effective for older people, it is essential to ensure practices are based upon evidence relevant to older people and to ensure ageism is effectively counteracted. Older adults have distinct patterns of help seeking and service use, accompanied by differences in risk factors, presentations, and outcomes of suicidal behaviours. Ageism affects assessment, decision-making and actions to address self-harm and suicide for older people. Immediate and longer-term actions are essential to effectively implement TZS in this population.

Objective: Implementing the Towards Zero Suicide (TZS) approach to suicide prevention in older adults requires evidence-based adaptation. This paper aims to highlight important differences and opportunities in healthcare service use by older adults relevant to implementation., Conclusion: The TZS approach may prevent suicide in older adults, but only if implementation aligns with systemic differences in healthcare utilisation by older people. Of greatest importance in older adults are (1) most mental healthcare is delivered outside of specialist mental health services; (2) physical conditions and disability are major modifiable contributors to suicide that must be addressed within TZS; and (3) older people have very low use of Medicare-funded psychological services. Primary healthcare providers, who may be seeing older people at risk of suicide, are often neither equipped to provide expert assessment and care planning for often complex needs, nor may see this as their role. However, they are essential in providing pathways to care, which may prevent suicide. Leaders must recognise TZS for older people will usually involve multiple transitions. This requires engagement of key services with clear roles, targeted training, rapid access to specialist older persons mental health support and development of a new TZS element: the navigator.

Objectives: The aims were to develop and operationalise a method of identifying patients at increased risk of adverse outcomes due to clinical and systems complexity within consultation-liaison psychiatry (CLP), and to formalise escalation processes for enhanced input with targeted clinical and organisational support., Methods: The literature pertaining to methods for identifying and responding to complexity in general hospital settings was reviewed. An Escalation Tool operationalising the identification of complexity and response pathways was devised and tested. Feedback on the face validity and utility guided refinement., Results: Two established tools that assess complexity, INTERMED and the Patient-Centred Accreditation method (PCAM) and a novel 'episode complexity' screening method, were identified and informed the development of a tool for identifying and responding to complexity, which was then piloted. The tool was deemed useful, notwithstanding variability in scoring., Conclusions: The Escalation Tool combined elements of existing measures to identify complexity in general hospital inpatients and guide pathways for action. It was well received and considered feasible for implementation, with local adaptation according to available resources.

Objective:: The primary aim was to comprehensively describe the characteristics of a cohort of older people taking clozapine., Method:: Participants aged ⩾ 60 had a geriatric assessment including full medical, medication and social history. Standardized screening tools for cognition, function, comorbidity and antipsychotic side effects were administered and descriptive statistics utilized., Results:: Thirteen patients were eligible to participate and 10 were assessed. The mean age was 69 years. The mean clozapine dose was 309 mg/day and mean duration of use was 10 years. All participants had executive dysfunction, and half had cognitive impairment. The mean number of co-morbid conditions was five. Seven people met the criteria for polypharmacy. Eight people experienced moderate-severe antipsychotic-related side-effects. The majority demonstrated impaired physical functioning., Conclusions:: This cohort of older people taking clozapine experienced considerable morbidity, functional and cognitive impairment. We suggest routine screening of cognition and function in clozapine patients aged ⩾ 60 years. Those screening positive should be considered for further assessment by Older Person's Mental Health Services and/or a Geriatric Medicine service.

Objectives: The assessment and management of a patient who refuses medical treatment requires clinical skill, and consideration of the relevant law and the patient's decision-making capacity. Psychiatrists are often asked to advise in these situations. We aimed to develop an algorithm describing the relevant legal pathways to assist clinicians, especially psychiatrists, working in New South Wales (NSW), Australia., Methods: We reviewed the academic literature on treatment refusal, relevant legislation, judicial rulings and NSW Health policy directives and guidelines. We consulted with clinicians and representatives of relevant tribunals., Results: We developed an algorithm for managing patients who refuse medical treatment in NSW. The algorithm emphases the evaluation of decision-making capacity and tracks separate pathways depending upon a person's status under the Mental Health Act 2007 (NSW)., Conclusions: The algorithm provides a clear decision tree for clinicians responding to a patient refusing medical treatment in NSW.

Objectives: Consultation-liaison psychiatry (CLP) services sit between mental health and the general hospital, and risk being poorly understood by both systems. The aim of this study was to develop an operational manual for a CLP service, which defined functions and governance., Methods: The CLP literature was reviewed with a focus on descriptions of CLP roles, organisational processes, quality measures and service development. The CLP team held service planning meetings and met with members of the mental health and hospital executives. Site visits and collaboration with other CLP services occurred in defining the roles of the CLP service and organisational governance., Results: A CLP operational document was developed, including a description of the service, its functions, staff roles and governance. Procedural information such as the CLP timetable, referral process, triage and assessment, documentation, activity recording, quality assurance and relevant policies were outlined., Conclusions: The development of a dedicated operational manual for CLP clarified the roles, functions and governance of CLP within the general hospital and mental health systems. The development process facilitated the engagement of key clinicians and administrators of these systems, the determination of quality improvement targets and greater transparency and accountability.

Objectives: The objective of this study was to describe functioning and clinical activities of the St George Acute Care Team and how it compares to the typical crisis resolution model of care., Methods: Descriptive data including demographics, sources of referral, type of clinical intervention, length of stay, diagnoses and outcomes were collected from records of all patients who were discharged from the team during a 10 week period., Results: There were 677 referrals. The team's functions consisted of post-discharge follow-up (31%), triage and intake (30%), case management support (23%) and acute community based assessment and treatment (16%). The average length of stay was 5 days. The majority of patients were diagnosed with a mood (23%) or a psychotic (25%) disorder. Points of contrast to other reported crisis resolution teams include shorter length of stay, relatively less focus on direct clinical assessment and more telephone follow-up and triage., Conclusion: St George Acute Care Team provides a variety of clinical activities. The focus has shifted away from the original model of crisis resolution care to meet local and governmental requirements., (© The Royal Australian and New Zealand College of Psychiatrists 2016.)

Objectives: To detail a diagnostic dilemma of intentional hand amputation in a man with a history of substance misuse and associated psychosis, depression and traumatic brain injury and to highlight issues in joint psychiatric and surgical management of such a complex patient in a general hospital setting., Conclusions: Deliberate limb self-amputation is a rare event with the majority of reported cases occurring during an episode of psychosis. This case illustrates the diagnostic utility of the literature supporting that a person who has self-inflicted amputation of a limb should be treated as psychotic until proven otherwise. The presence of a traumatic brain injury, with associated cognitive and psychosocial sequelae, affected diagnosis and management. Early and ongoing involvement of consultation-liaison psychiatry collaborating with a multidisciplinary general hospital team may improve mental and physical health outcomes for such patients., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

Objective: The aim of this paper is to inform mental health professionals about Activity-based funding (ABF) and the implications for data collection and clinical practice, in particular for consultation-liaison (CL) psychiatry., Conclusions: Activity-based funding may provide an opportunity for mental health services to be more equitably resourced, but much needs to be done to demonstrate that the funding model works in mental health. It is important to ensure that data collected is meaningful and accurate and reflects the diverse roles of mental health clinicians, including in CL. Inpatient and community services should be integrated in the model, as well as safeguards against potential abuse. Clinicians, in partnership with initiatives such as the Australian Mental Health Outcomes and Classification Network, are best placed to guide the development of an ABF system for mental health which appropriately recognises the complexity and variability between patients in different settings., (© The Royal Australian and New Zealand College of Psychiatrists 2014.)

Objectives: Perinatal depression and anxiety are prevalent in migrant women. The main aims of this literature review were to understand the psychosocial determinants of depression and anxiety in migrant women antenatally and to explore common clinical presentations. In addition, we aimed to identify barriers and facilitating factors for help-seeking and treatment, in order to identify directions for service development and improvement., Methods: A review of the literature was performed using electronic databases., Results: Depression and anxiety are over represented in migrant women in the perinatal period. Somatic symptoms are common presentations for emotional distress. An identified difficulty is a perceived lack of support, often as a result of cultural dislocation and social isolation. Significant barriers to help-seeking include the perception that limited assistance is available and reluctance to share personal information with an unknown clinician. Preferred therapeutic approaches include the use of clinical consultants from the same or similar culture, as well as practical and emotional support rather than medical management of symptoms., Conclusion: Clinicians should be aware of psychosocial issues in this vulnerable population. Group programmes with a focus on education about mental and physical health, available supports, and socialisation are effective in engaging and assisting pregnant migrant women.

Objectives: Most postgraduate training for clinicians in Australia and New Zealand regarding mental health legislation focuses on the relevant Mental Health Acts (MHAs) rather than the broader principles of mental health law. Key concepts include treatment in the least restrictive environment, voluntary access to mental health services, treatability, reciprocity and due process. Lack of awareness of these principles may result in a more risk-averse interpretation of MHAs, which is inconsistent with the spirit of mental health law and the promotion of human rights. The aim of this paper is to present some fundamental principles of mental health law, which are essential to proper clinical application of MHAs, and to demonstrate why they should form part of the curriculum for psychiatry training and continuing professional development for psychiatrists., Conclusions: A sound understanding of the principles of mental health law is essential for all clinicians who may be enacting aspects of MHAs. This provides the necessary platform to safeguard human rights and optimise the care of people with a mental illness.

Objectives: The purpose of this paper is to discuss the experience of psychiatry training in the decade 2000-2010. This period was a time of consolidating previous advances made during the decade of the brain, and one in which world events shaped the focus of policy and clinical care. Terrorist acts and war, and their consequences (people seeking refuge and asylum) contributed to a climate of fear which flowed on to psychiatric practice. Training at this time appeared preoccupied with risk assessment. We became more aware of the complexity of physical health problems in people with mental illness and were taught to prevent and manage them in our patients. During this decade, the internet and mobile technology shaped the way we communicate. For psychiatry, it delivered new ways to enhance mental health literacy, and access to information and on-line therapy and support., Conclusions: Local and world events in the 2000s influenced psychiatric practice and consumer involvement. A focus on risk may have led to more conservative management but also to recognition of the profession's responsibility for the physical health of their patients. The new decade promises even more use of internet technology, a new education program and opportunities for trainees.

Objectives: The aim of this study was to develop and pilot a workshop for basic trainees in psychiatry to address perceived gaps in the specialist training program and to foster a culture of mentorship., Methods: A literature review and consultations with clinicians and managers determined interest in the workshop, preferences for content, and feasibility. Six psychiatrists met on several occasions to plan the workshop. Supervisors were surveyed prior to the workshop to ascertain their perceptions of their trainees' knowledge of particular topics and the content of supervision. Registrar self-evaluations and knowledge were assessed before and after the workshop., Results: Twenty-four registrars attended the first session of the workshop and 22 the second. Following the workshop, self-ratings of knowledge and confidence of trainees in topics including risk assessment and duty of care were significantly better. Registrars rated the program highly for collegiate interactions, format, originality and usefulness. Supervisors identified weaknesses in trainee knowledge corresponding to workshop topics., Conclusions: Trainee self-evaluations of key aspects of clinical psychiatry improved significantly after the workshop. The development process described here for implementing a service-based initiative in psychiatry trainee education tailored to local needs may be transferable to other services.

Objectives: The aim of this paper is to describe the experience of an advanced trainee establishing a new psychiatry service, and to demonstrate how such an activity is a viable option for advanced training and helps develop consultancy skills. A detailed description of this process is provided, with a particular focus on consultation, training issues, service evaluation and the challenges encountered., Conclusions: Involvement in establishing a new psychiatric service provides an advanced training experience which may prepare the trainee for consultancy by developing core skills such as communication, administration, leadership, teaching and experience in quality assurance.

Objective: The aim of this paper is to report the experiences of the author during her Advanced Training Fellowship year in Indigenous mental health and consultation-liaison psychiatry through the Royal Australian and New Zealand College of Psychiatry. The description will include a discussion of how such a Fellowship may complement the key learning objectives of advanced training in psychiatry., Conclusions: A Fellowship in Indigenous mental health can offer a variety of experiences for the psychiatry trainee, including clinical work, research and teaching. The planning and collaboration with Aboriginal health organizations, key clinicians and Ethics committees provides a unique opportunity to learn invaluable communication and consultancy skills.

Objective: The aim of the present study was to describe the referral patterns, assessment and suggested management of Aboriginal and Torres Strait Islander peoples referred to an inner-city general hospital psychiatry service. The overarching goal was quality improvement., Method: Participants were identified from the consultation-liaison psychiatry database of all referrals to the service from the general hospital and Emergency Department. All people over 18 identifying as Aboriginal and/or Torres Strait Islander seen during the period 1 July 2004-30 June 2007 were included. Information regarding referral and liaison patterns, suggested psychiatric management, disposition and follow up were gathered retrospectively from the medical records, with a particular focus on cultural references., Results: There were 162 referrals to the consultation-liaison psychiatry team of people identifying as Aboriginal and/or Torres Strait Islander. The rate of referral to consultation-liaison psychiatry was 3%. The Emergency Department had the highest rate of referral followed by Obstetrics and Gynaecology. The most common reason for referral was assessment of risk. The patient's Aboriginal ethnicity was mentioned in 52.5% of consultation-liaison assessments. An Aboriginal health worker was consulted in 48.1% of cases. The most common management approach involved pharmacotherapy. The consultation-liaison service instigated legal interventions in 25% of cases. Forty-five patients were referred for psychiatric admission following their assessment. Mental health follow up was arranged in 43.8% of cases., Conclusions: The range of mental health problems referred and types of diagnoses made in Aboriginal and Torres Strait Islander peoples reflect what has been previously reported, particularly in relation to comorbidity. Aboriginal ethnicity was variably identified and Aboriginal health workers, general practitioners and families were not routinely involved in consultation-liaison psychiatry assessments, highlighting an opportunity to improve communication and the quality of patient care.