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BACKGROUND Virtual reality (VR) and augmented reality (AR) are emerging treatment modalities in psychiatry, which are capable of producing clinical outcomes broadly comparable to those achieved with standard psychotherapies. OBJECTIVE Because the side effect profile associated with the clinical use of VR and AR remains largely unknown, we systematically reviewed available evidence of their adverse effects. METHODS A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework across 3 mental health databases (PubMed, PsycINFO, and Embase) to identify VR and AR interventions targeting mental health diagnoses. RESULTS Of 73 studies meeting the inclusion criteria, 7 reported worsening clinical symptoms or an increased fall risk. Another 21 studies reported “no adverse effects” but failed to identify obvious adverse effects, mainly cybersickness, documented in their results. More concerningly, 45 of the 73 studies made no mention of adverse effects whatsoever. CONCLUSIONS An appropriate screening tool would help ensure that VR adverse effects are correctly identified and reported.

Background Several countries have reported increased demand for eating disorder services during the COVID-19 pandemic, particularly for adolescents. Within New Zealand, anecdotal and media reports suggest similar changes but are limited in scope and detail. We assessed eating disorder service demand in the Waikato district in relation to the COVID-19 pandemic. Methods We retrospectively analysed records of eating disorder admissions and referrals for both children ( Results 106 medical admissions met inclusion criteria (n = 37 in 2019; 69 in 2020). Admissions for eating disorders increased markedly following nationwide lockdown in March 2020 (RR = 1.7, p = 0.01), largely driven by increases in adult admissions (RR 2.0, p = 0.005). The proportion of ‘new patient’ admissions showed comparable increases for both children (RR = 2.0, p = 0.02) and adults (RR = 2.3, p = 0.03). Following lockdown, outpatient referrals increased in acuity (RR = 1.8, p = 0.047) and volume (RR = 1.6, p = 0.076) for children but not for adults. Conclusions Our study confirms a pandemic-related increase in demand for eating disorder services in the Waikato region of New Zealand, consistent with findings reported overseas. We observed contrasting increases in admissions for adults and outpatient referrals for children, exacerbating resource constraints for already stretched services and compromising provision of timely care. Plain English summary The COVID-19 pandemic has been linked to increased numbers and worsening severity of eating disorders in several settings. In New Zealand, similar trends have been noted anecdotally. We assessed clinical records to calculate rates of eating disorder-related hospital admissions and outpatient referrals during 2019 and 2020. We found significant increases in hospital admissions related to COVID-19, particularly for adults, and greater proportions of both children and adults having a first-ever eating disorder-related admission. In outpatient services, young people were referred more frequently during the pandemic and were more physically unwell when referred. These results indicate increased demand for eating disorder services as a result of the pandemic and complement findings reported overseas.

Objective Sodium valproate’s teratogenicity has prompted increasing restrictions to its use. Our initial audit 2 years prior demonstrated continuing hazardous prescription to women of childbearing age in a New Zealand psychiatric inpatient unit, consistent with nationwide dispensing data. Method Following a service-wide educational intervention and application of “black box” warnings, we conducted a follow-up audit of valproate prescription in the same inpatient unit by reviewing records of women admitted over a 10-month period (March 2020–January 2021). Results were compared with local and international guidelines, and against data from our initial audit. Results Two hundred and sixty-one women of childbearing age were admitted over the sampling period, 26 of whom (10%) were prescribed valproate on discharge. Over three quarters (77%) of these patients had diagnoses other than bipolar affective disorder, valproates only approved psychiatric indication in New Zealand. Following intervention, significant improvements were observed in several key indicators of prescribing quality: pregnancy testing, documentation of contraception status, and discussion of teratogenic risk. Conclusions Following intervention, re-audit demonstrated reduced prescription of valproate and improved management of its teratogenic risk in women of childbearing age receiving inpatient psychiatric care. These results demonstrate the value of a systematic approach to improve prescribing practice.

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Background Access to child and adolescent mental health services by ethnic minorities has been poorly studied. Despite rapid growth of the immigrant Korean population, evidence indicates that few Korean families utilise these services in New Zealand. Those that do tend to present late and with significant morbidity. We sought to understand barriers to service access from Korean parents’ perspectives. Method Seven focus groups were undertaken with 31 Korean parents of children aged 18 and under. The focus groups were semi-structured, held in the Korean language and utilised two case scenarios of common childhood/adolescent mental illnesses around which a set of broad, open-ended questions were posed. All conversations were audiorecorded, transcribed and translated into English. Thematic analysis was conducted using NVivo software. Results Both attitudinal and structural barriers were identified. Attitudinal barriers included attribution of mental illness to external stressors or parenting problems, social stigma, denial or normalization of children’s behaviour, fear of family disempowerment, and mistrust of public mental health services. Structural barriers included parents’ lack of information regarding available services, logistical difficulties in access, communication difficulties, concerns over the quality of translators, and cultural competence of service providers. Conclusion Significant barriers prevent Korean immigrant families from accessing child and adolescent mental health services in New Zealand. Measures to improve access, for example by countering stigma, are urgently required.

As Feinmann points out, the effect of the covid-19 pandemic on disordered eating is striking and seems to be international.1 Reports from North America and Europe accord with our observations in New Zealand of distinct increases in both adult and paediatric patients requiring treatment.2 Identifying relevant mechanisms is crucial to guide the effective management of these disabling and potentially lethal disorders. Feinmann’s conference report includes the suggestion that “enforced social avoidance” during lockdowns might occur …

Continuing a decades old narrative in The BMJ , Abbasi emphasises the serious risks posed by doctors’ undisclosed competing interests and usefully extends the principle to scientists, policy makers, and politicians.1 To this list one might add corporate funded “think tanks” and lobbyists advocating policies that affect public health.2 While acknowledging the potential relevance of “less tangible” (non-financial) interests, for the purposes of a UK-wide register of doctors’ interests, Abbasi seems content to focus on the …

Background Regular ingestion of sub-hallucinogenic doses of psychedelics, referred to as “microdosing”, has gained increasing popularity and attention in the press and in online forums, with reported benefits across multiple cognitive and emotional domains. Rigorously controlled studies to date, however, have been limited in scope and have failed to produce results comparable to those reported in the grey literature. Methods Eighty healthy male participants will receive 14 doses of placebo or 10 μg lysergic acid diethylamide orally every 3rd day over a 6-week treatment protocol. A battery of personality, creativity, mood, cognition, and EEG plasticity measures, as well as resting-state fMRI imaging, will be administered at baseline and at the end of the protocol. Creativity, mood, and plasticity measures will additionally be assessed in the acute phase of the first dose. Daily functioning will be monitored with questionnaires and a wearable sleep and activity tracker. Discussion This study will rigorously examine the claims presented in the microdosing grey literature by pairing a comparable dosing protocol with objective measures. Potential therapeutic implications include future clinical trials to investigate microdosed psychedelics as a standalone treatment or as an augmentation of psychotherapy in the treatment of depression, addiction, eating disorders, obsessive-compulsive disorders, and palliative care. Trial registration ACTRN12621000436875. Registered on 19 February 2021

To provide an overview of the New Zealand End of Life Choice Act in comparison with other countries, arguments for and against euthanasia, and consideration of relevant legal and practical issues.Structured descriptive summary of criteria for medical euthanasia in various jurisdictions currently allowing the practice, compared with New Zealand legislation. Narrative review of arguments for and against euthanasia with reference to existing medical literature and legal cases.A strong case for medical assistance in dying, based on autonomy and quality of life arguments, is countered by a long history of medical and legal tradition protecting life.This highly contentious issue is coming before the New Zealand public as a referendum in October 2020. The results will have profound implications for medical practice as well as reflecting societal shifts in attitudes toward death and dying.

Objective: Sodium valproate’s teratogenicity has prompted increasing restriction in its use. It is still widely prescribed to women of childbearing age in New Zealand. To examine this problem, we audited the prescribing pattern of sodium valproate in a psychiatric inpatient unit in New Zealand. Method: We reviewed the clinical records of women admitted over a 2-year period (2016–2018). Results were analysed and compared with local and international guidelines. Results: Five hundred and thirty-four women of child-bearing age were admitted over the sampling period, 96 of whom (18%) were prescribed valproate on discharge. Half of these patients had diagnoses other than bipolar affective disorder, valproate’s only approved psychiatric indication in New Zealand. Pregnancy testing and contraception status were documented in a minority (29 and 10 cases, respectively). Teratogenic risk discussion was documented in only 11 cases. Conclusions: Prescription of valproate to women of childbearing age in our sample currently falls well short of best practice. Urgent action at both clinician and organisational levels is required to address this risk.

Objective: To explore trainee perception of what facilitates or delays completion of the RANZCP Scholarly Project (SP). Method: Of 182 currently registered New Zealand trainees, 33 (18%) completed an online questionnaire and three open-ended questions. Results: Most trainees agreed or strongly agreed that having protected time for research (87.5%) and access to an appropriate supervisor (87.9%) would facilitate the completion of their SP. Other college requirements were identified by most trainees (87.9%) as a factor delaying completion. Conclusions: Identifying and protecting research time and ensuring adequate supervision appear essential to improve the uptake and completion of this training requirement.

Background Clozapine is the most effective drug for treatment-resistant schizophrenia, but its use is limited by toxicity. Because ethnicity has been reported to affect clozapine metabolism, we compared its steady state pharmacokinetics in New Zealand Maori and European patients. Methods Clozapine and norclozapine steady state bioavailability was assessed over 24 h under fasting and fed conditions in 12 Maori and 16 European patients treated for chronic psychotic illnesses with stable once-daily clozapine doses. Plasma clozapine and norclozapine concentrations were assessed using liquid chromatography with tandem mass spectrometry; pharmacokinetic parameters were calculated using standard non-compartmental methods, and compared using unpaired t-tests. Findings Mean pharmacokinetic parameters (AUC, Cmax and Cmin) for clozapine and norclozapine were virtually identical in Maori and European subjects, under both fed and fasted conditions. Discussion Clozapine bioavailability does not vary between Maori and European patients, and thus does not need to be considered in prescribing decisions. Additional studies are needed to identify if there are differences between Maori and European populations for drugs metabolized by other enzyme pathways., Highlights • Metabolism of clozapine, our most effective antipsychotic drug, was compared in New Zealand's two main ethnic groups. • Clozapine pharmacokinetic parameters were similar in Maori and European patients. • Accordingly, clozapine dosing does not need to take Maori or European ethnicity into account. Clozapine is an essential medicine for treatment-resistant schizophrenia, but its use is limited by significant side-effects. We were interested to see if Maori and European patients in New Zealand differed in terms of clozapine pharmacokinetics, as this could influence both clinical response and side-effects. We found essentially no difference in clozapine pharmacokinetics between these groups, meaning that dosing decisions can be made based on clinical factors without regard to ethnicity.

ObjectivePsychiatric comorbidities are common in physical illness and significantly affect health outcomes. Attitudes of general hospital doctors toward psychiatry are important as they influence referral patterns and quality of care. Little is known about these attitudes and their cultural correlates. The aim of this study was to identify attitudes toward psychiatry among general hospital specialists in relation to culture of the practice setting and other clinician factors (gender, age, seniority and specialty).MethodsA cross-sectional, descriptive study was carried out in seven countries (New Zealand, China, Sri Lanka, Russia, Israel, Brazil, the Netherlands). Data were collected from senior medical staff of various disciplines using an updated version of Mayou and Smith’s (1986) self-administered questionnaire.ResultsA total of 889 hospital doctors participated. While favourable attitudes toward both psychiatric consultation and management were endorsed by a majority, significant differences were also observed between countries. Subgroup differences were mostly confined to gender, acuity of practice setting and specialty. For example, female doctors in Russia (χ2=7.7, p=0.0056), China (χ2=9.2, p=0.0025) and the Netherlands (χ2=5.7, p=0.0174) endorsed more positive attitudes compared with their male counterparts, but this gender effect was not replicated in the total sample. Chronic care specialists were overall more inclined to manage patients’ emotional problems compared with those working in acute care (χ2=70.8, p (adjusted)ConclusionsThis study adds to evidence for the association of medical attitudes with individual clinician factors and demonstrates that the influence of these factors varies by country. Understanding these issues may help to overcome barriers and improve quality of care provided to general hospital patients.

Newman’s article, a linked patient commentary, and the tranche of rapid responses show how “long covid” has reignited debate about the causes and management of chronic fatigue syndrome.1 Rather than moving beyond the controversy, most of the ensuing arguments have fallen back into familiar grooves deepened by confirmation bias and dualistic thinking.123 On a more positive note, the intense media attention on and public interest in long covid present a golden opportunity to reshape and extend discussions about …

There is growing international concern about the risks posed by direct-to-consumer advertising (DTCA) of prescription pharmaceuticals, including via the internet. Recent trade agreements negotiated by the United States, however, incorporate provisions that may constrain national regulation of DTCA. Some provisions explicitly mention DTCA; others enable foreign investors to seek compensation if new regulations are seen to harm their investments. These provisions may thus prevent countries from restricting DTCA or put them at risk of expensive legal action from companies seeking damages due to restrictions on advertising. While the most recent example, the Trans-Pacific Partnership Agreement (TPP), collapsed following US withdrawal in January 2017, early indications of the Trump Administration's trade policy agenda signal an even more aggressive approach on the part of the United States in negotiating advantages for American businesses. Furthermore, the eleven remaining TPP countries may decide to proceed with the agreement in the absence of the United States, with most of the original text (including the provisions relevant to DTCA) intact.

Objectives: Sexual-minority youth exhibit increased rates of psychiatric morbidity, subject to various social factors. We examine the impact of ethnicity and culture on these phenomena, with particular reference to Asian youth living in Western societies. Conclusions: Youth from minority ethnic groups who do not identify with their native gender and/or who are not exclusively heterosexual are known as ‘double minorities’. Available evidence suggests that such individuals are at particularly increased risk of depression and suicide, but that this may be mitigated by social support. More research is needed to understand the challenges faced by ‘double minorities’, notably their perception of and ability to access available clinical and social supports.

The government of New Zealand is currently considering a new Therapeutic Products Regulatory Scheme that includes how direct-to-consumer advertising (DTCA) of prescription drugs should be regulated. This article reviews three different types of possible regulation of DTCA: government regulation, industry self-regulation and a mixture of the two. Recent studies demonstrate that DTC ads in the US continue to be misleading and contain minimal if any educational value, despite governmental regulatory efforts by the Food and Drug Administration. Other regulatory models are equally unsuccessful at controlling DTCA. Available evidence suggests that DTC ads are commonly misinterpreted as trusted public health messages and are more likely to affect vulnerable subgroups of New Zealanders. Taken together with the international evidence that regulation has consistently failed to prevent the inappropriate promotion of prescription medicines, these findings suggest that DTCA is more likely to cause harm than benefit and should be banned.

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Psychosocial and psychiatric problems are common in patients admitted to general hospitals, and can negatively influence course of somatic diseases. Hence, early identification and adequate management is important. The aim of this study is to investigate attitudes towards psychosocial and psychiatric problems by non-psychiatrist consultants in an academic hospital. Data were collected by anonymous, self- administered questionnaires which were provided to all consultants during morning reports and by email. Of 431 eligible participants, 187(43%) completed the questionnaire: 64% during morning reports, and 36% by email. Almost all consultants report generally positive attitudes towards mental health problems. However, we identified several obstacles towards management. First, there was a discrepancy between positive attitude and the willingness to take on management responsibility. Reported reasons for this discrepancy were time constraints and lack of skills. We also found that consultants feel little responsibility for the management of depression and chronic drinking. Physicians have generally more positive attitudes than surgeons. Finally, all consultants are less likely to refer patients with dementia and treatment non-compliance to psychiatry, for reasons of perceived ineffectiveness and fear of stigmatizing patients. We conclude targeted education on the management of these problems for hospital consultants is still warranted.

Objectives: Schizophrenia typically has a fluctuating course; rehospitalisation is common. We studied associations between discharge variables and subsequent two-year rehospitalisation rates. Method: Using a New Zealand national database, we obtained rehospitalisation rates and bed days for 451 patients with schizophrenia discharged from three inpatient facilities between July 2009 and December 2011. Results: Nearly half (44%) of the cohort were rehospitalised within two years. Patients over 50 were less likely [hazard ratio (HR) = 0.58, 95% confidence interval (CI) = 0.35–0.97, p = 0.04] to be rehospitalised. Patients whose index admission included compulsory treatment appeared more likely (HR = 1.3, 95% CI = 0.98–1.71, p = 0.06) to be rehospitalised and spent longer rehospitalised ( p = 0.05). Those whose index admission was three weeks or longer were less likely (HR = 0.53, 95% CI = 0.39–0.72, p = 0.001) to be rehospitalised. Antipsychotic types, routes and dosages were not significantly associated with rehospitalisation rate, except for those prescribed clozapine (HR = 0.61, 95% CI = 0.41–0.89, p = 0.01). Conclusions: Rehospitalisation rates were higher for patients under the age of 50 and those with shorter index admissions; the latter finding requires further study. Other than the beneficial effect of clozapine, the type and route of prescribed antipsychotics did not significantly affect rehospitalisation rates.

Psychogenic nonepileptic seizures (PNESs) are closely linked with psychological distress, but their etiology is not well-understood. We reviewed psychiatric comorbidity in PNESs and epileptic seizures (ESs) with an aim to assist understanding, diagnosis, and management of PNESs.A search of Web of Science, MEDLINE (PubMed), PsycINFO, and Scopus identified 32 relevant studies on the prevalence of psychiatric comorbidity in PNESs. We used meta-analysis to compare psychiatric comorbidity between PNESs and ESs.Samples with PNESs had high rates of psychiatric comorbidity overall (53-100%), notably including posttraumatic stress disorder (PTSD), depression, and personality and anxiety disorders. Compared with ESs, samples with PNESs had more psychiatric comorbidity overall (RR: 1.30, 95% CI: 1.14-1.48, p0.0001) with significantly elevated risks found for PTSD, personality disorder, and anxiety but not depression.Psychiatric disorders are more common in PNESs than ESs. Because of methodological limitations of available studies, causality cannot be established; prospective longitudinal designs are required.

Wiersma and colleagues argue convincingly that non-financial interests in medicine can and should be managed.1 Unfortunately, Rodwin’s contrary argument gets diverted by a useful, but not wholly relevant, legalistic description of interests (mainly pecuniary) that can properly constitute “conflicts of interest.”1 The …

Objective: The place of monoamine oxidase inhibitors (MAOIs) in psychiatry is reviewed, and the question posed as to whether they are now justifiably disregarded by prescribers. Method: Multiple databases (PubMed, Medline, Embase, Cochrane) were interrogated to provide an overview regarding the use, efficacy and toxicity of MAOIs. Data regarding funded use of these agents in New Zealand were obtained from PHARMAC. Results: Evidence supports the use of MAOIs in major depressive disorder, certain anxiety disorders and, to lesser extent, bipolar depression. Older non-selective agents, such as phenelzine and tranylcypromine, have distinctive efficacy in ‘atypical’ and treatment-resistant depression, but at the cost of serious tolerability problems. Their relegation and perception by clinicians as ‘last resort’ medications – if considered at all – has occurred in the context of various concerns, notably dietary restrictions, potential adverse drug interactions and the usual requirement for divided doses. Conclusions: Sufficient evidence supports consideration of MAOIs in treatment-refractory and atypical depressive disorders, and in social anxiety disorder. Psychiatrists in training need to gain experience in using these agents.

Inadequate competing interest declarations present interpretive challenges for editors, reviewers, and readers. We systematically studied a common euphemism, ‘unpaid consultant,’ to determine its occurrence in declarations and its association with vested interests, authors, and journals. We used Google Scholar, a search engine that routinely includes disclosures, to identify 1164 occurrences and 787 unique biomedical journal publications between 1994 and 2014 that included one or more authors declaring themselves as an “unpaid consultant.” Changes over time were reckoned with absolute and relative yearly rates, the latter normalized by overall biomedical publication volumes. We further analyzed declarations according to author, consultancy recipient, and journal. We demonstrate increases in the use of “unpaid consultant” since 2004 and show that such uninformative declarations are overwhelmingly (801/865, 92.6%) associated with for-profit companies and other vested interests, most notably in the pharmaceutical, device, and biotech industries. Disclosing ‘unpaid’ relationships with for-profit companies typically signals but does not explain competing interests. Our findings challenge editors to respond to the increasing use of language that may conceal rather than illuminate conflicts of interest.

Background Psychiatric comorbidities are common among patients treated for physical disorders. Attitudes of non-psychiatric doctors toward psychological/psychiatric problems have significant implications for care provision in the general hospital setting. Our objective was to investigate non-psychiatric doctors’ attitudes in China. Method An anonymous online questionnaire pertaining to relevant attitudes was distributed to Chinese hospital-based non-psychiatric doctors using a mobile App. Results A total of 306 non-psychiatric doctors in China voluntarily completed the questionnaire. All but two (99.3%) respondents agreed with the importance of psychological factors underlying physical illness and 85.6% agreed they had a high degree of responsibility for management of patients’ emotional problems. Most respondents endorsed routine assessment of patients’ psychological factors and were willing to consider psychiatric referrals for patients in need; despite 52.0% believing that mental health care by general hospital doctors was impractical. Almost all respondents welcomed more contact with psychiatric services and indicated a need for more time and professional help to manage psychological issues. Respondents’ demographic characteristics and vocational status had some influence on attitudes; female doctors were more likely and surgeons less likely to consider psychological assessment and emotional care for patients with physical illness. More doctors working in hospitals with established consultation-liaison psychiatric services did not feel responsible for their patients’ emotional care (17.7% vs. 6.6%, P = 0.012). Conclusions Our pilot survey demonstrates a potential generally positive attitude toward management of patients’ psychological problems and an urgent need for more time and specialist support for non-psychiatric doctors in China.

Purpose – Police in England and Wales are empowered, under Section 136 of the Mental Health Act 1983 (s136), to detain individuals thought to be a danger to themselves or to others. Use of this authority is widespread, but varies across districts and attracts controversy because of inconsistent application and the fact that it requires police to make judgements about mental health. The purpose of this paper is to examine police attitudes to and criteria for using s136. Design/methodology/approach – The authors conducted focus groups with 30 officers in urban and rural areas of three different regions across England and Wales. Group interviews were audio-recorded, transcribed, and analysed using open and axial coding. Findings – Use of s136 authority has major implications for police work; liaison with mental health services is seen as desirable but often ineffective due to resource constraints and the latter's lack of availability. The decision to invoke s136 depends on social context and other particulars of individual cases. Research limitations/implications – Although the findings have limitations with respect to generalisability across the whole of the UK, there are patterns of responses which have major implications for policy recommendations. Practical implications – Police decisions to apply s136 reflect an implicit values-based classification of and response to emotionally disturbed behaviour, in light of available institutional and social supports. Social implications – Tasked primarily with protecting the public and keeping the peace, police “diagnoses” of risk often contrast with that of mental health professionals. Originality/value – A highly original piece of research which has attracted further funding from BA/Leverhulme.

As Coombes says, right wing think tanks are beholden to their funders and repay their patronage with “free market” advocacy.1 That such advocacy is often at odds with public health is unsurprising, given its usual opposition to environmental protection and …

Nutt describes some of the interesting history of cannabis as medicine and notes the wide variety of maladies for which it is claimed to be useful.1 His enthusiasm for medical cannabis extends to a call for its efficacy and adverse effects to be assessed …

A 2011 publication in World Psychiatry thoughtfully, but somewhat pessimistically, addressed the question of how schizophrenia might be prevented.1 A review of causal evidence2 a decade later offers little further hope. We hypothesise that an emergent increase in syndromal schizophrenia in New Zealand, particularly in Maori (descendants of the indigenous Polynesian population), may present opportunities for prevention. The concept and epidemiology of schizophrenia have generally recognised it as a syndrome, rather than a disease or specific illness. Many theories of aetiology or pathogenesis have been enthusiastically propounded, often to fall by the wayside as unconfirmed or as only minor contributors to pathogenesis. Variable genetic predisposition with multiple possible environmental triggers has been the main fallback position.3 In recent years two groups of researchers have attempted to quantify the relative epidemiology of schizophrenia in New Zealand Maori (15% of the population) and non-Maori.4 5 Using quite different research designs, the researchers both demonstrate significantly increased prevalence and incidence of schizophrenia in Maori compared with the remainder of the New Zealand population. The reported two to threefold increased incidence far exceeds a plausible …