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Intentional faking and/or exaggeration of disability increase unnecessary burden and costs for society, and they could be difficult to detect. This study aimed to explore which and how eye-based me...

Objective: To document the sociodemographic and clinical variables associated with discharge under compulsory treatment orders in patients with schizophrenia or related disorders. Method: Information on various sociodemographic and clinical variables were extracted from the clinical files of 349 patients discharged from an adult (age 18–65) inpatient psychiatric unit with diagnoses of schizophrenia or related disorders. Univariate and multiple logistic regression analyses with legal compulsion (compulsory versus voluntary) as outcomes were applied. Results: Two hundred of the 349 discharged patients were placed under compulsory treatment orders. In the univariate logistic regression analysis, unemployment, diagnosis of schizophrenia, forensic history, dosage of antipsychotics, prescription and frequency of injectable antipsychotics, polypharmacy and a hospital stay of more than 28 days were associated with compulsory status. Being married or in partnership and living with partner was associated with voluntary status. Multiple regression models respectively confirmed most of these relationships observed in the univariate analyses. Conclusion: Clarification of the apparent drivers for compulsory treatment may help thoughtful reductions in the use of compulsion.

Objective The effectiveness of compulsory treatment orders (CTO) in psychiatric practice is an area in need of evidence. There are no recent New Zealand publications on outcomes for patients under CTOs. This study examined the association between CTOs and subsequent rehospitalisation for patients with schizophrenia or related disorders. Method Two year outcome data for 326 consecutive patients discharged in 2013 and 2014 was obtained from the Programme for the Integration of Mental Health Data database. Regression analyses were performed with rehospitalisation as the main outcome. Results For the 54% of patients discharged under CTOs, rehospitalisation was 2–4 times more likely for the CTO group than for voluntary patients. Patients under CTOs also spent longer in hospital post index admission (IA). However, patients placed under CTOs during IA stayed longer than those under CTOs prior to IA. Ethnicity did not contribute significantly to any of the findings. Conclusion This study did not show that patients under CTOs were associated with subsequent reduced resource use. The subgroup analysis suggested that studies with a longer follow-up period may provide better insight into the utility of CTOs.

Background Involuntary admission or treatment for the management of mental illness is a relatively common practice worldwide. Enabling legislation exists in most developed and high-income countries. A few of these countries have attempted to align their legislation with the United Nations Convention on the Rights of Persons with Disabilities. This review examined legislation and associated issues from four diverse South Asian countries (Bangladesh, India, Pakistan and Sri Lanka) that all have a British colonial past and initially adopted the Lunacy Act of 1845. Method A questionnaire based on two previous studies and the World Health Organization checklist for mental health legislation was developed requesting information on the criteria and process for involuntary detention of patients with mental illness for assessment and treatment. The questionnaire was completed by psychiatrists (key informants) from each of the four countries. The questionnaire also sought participants’ comments or concerns regarding the legislation or related issues. Results The results showed that relevant legislation has evolved differently in each of the four countries. Each country has faced challenges when reforming or implementing their mental health laws. Barriers included legal safeguards, human rights protections, funding, resources, absence of a robust wider health system, political support and sub-optimal mental health literacy. Conclusion Clinicians in these countries face dilemmas that are less frequently encountered by their counterparts in relatively more advantaged countries. These dilemmas require attention when implementing and reforming mental health legislation in South Asia.

This study aimed to understand the demographic, clinical and criminological characteristics of Chinese homicide offenders with schizophrenia from a gender-based perspective. Information on all homicide offenders with schizophrenia who received forensic psychiatric assessment between 2010 and 2016 in Hunan Province, China, was systematically retrieved (n = 669). Gender differences in the above characteristics were analyzed, and independent correlates of homicide were explored. The male to female ratio of homicide offenders was about 4:1. Proportionally more males were single, unemployed and younger when committing their first crime than was apparent in females. Male perpetrators were more often influenced by delusions. Females were more likely to target their close family members. For males, living in rural areas and having a family history of mental disorder were positively associated with homicide, while having a criminal history and being unemployed were negatively associated. For females, younger age was positively, while being unmarried and unemployment were negatively associated with homicide. Our results indicate significant gender differences among Chinese homicide offenders with schizophrenia in demographic, clinical and criminological characteristics and in independent correlates of homicide. Further research in this field, especially aims at determining risk factors for crime in this population, should take the gender differences into account.

Background: In western countries, imprisoned females are at high risk for suicide, but the risk in Chinese imprisoned females has not been well established. The aim of this study was to clarify the suicide risk and its correlates among imprisoned females in China. Methods: In this cross-sectional study, subjects were recruited from the Female Prison of Hunan province, China. A standardized questionnaire was used to collect socio-demographic and criminological data. The Suicidality module of the Mini International Neuropsychiatric Interview (MINI) 5.0 and 12-item General Health Questionnaire (GHQ-12) were used to assess suicide risk and mental health problems, respectively. Ordinal logistic regressions were used to identify independent factors associated with increased suicide risk. Results: A total of 2,709 imprisoned females completed the survey questionnaire. Twenty percent were rated as presenting suicide risk. Mental health problems [odds ratio (OR) = 1.21, 95% confidence interval (CI) = 1.00-1.47], self-reported help-seeking for mental health problems (OR = 1.69, 95% CI = 1.11-2.56), violent offending (OR = 1.69, 95% CI = 1.37-2.09), history of drug use (OR = 1.46, 95% CI = 1.15-1.84), family history of mental disorders (OR = 1.57, 95% CI = 1.10-2.23), marital status (OR = 1.29, 95% CI = 1.05-1.58), and low educational level (OR = 1.36, 95% CI = 1.11-1.67) were independently associated with increased suicide risk. Conclusion: One fifth of the imprisoned females are at risk for suicide. This study highlights the importance of assessing mental health status for suicide prevention among female prisoners.

BackgroundRecently, publications have hypothesised that the demonstrated increase in the incidence of schizophrenia in New Zealand is a side effect of the increased strength of available cannabis derivatives over the last 25+ years and the much more recent increase in the population’s use of methamphetamine.AimTo compare the rates of later schizophrenia between age-matched mental health service users with initial diagnoses as alcohol abusers or illicit drug users.MethodFrom the PRIMHD comprehensive national database, all users of the mental health services over a 5-year period who received an ICD-10 presenting diagnosis of alcohol or substance use/abuse were identified. For each person identified, the database was examined for the following 3 years to determine the numbers later diagnosed with schizophrenia.ResultsFor the initial alcohol problem people in their twenties, 1.7% were diagnosed as suffering from schizophrenia in the subsequent 3 years. For the initial drug problem people, the rate was 10.9%. Within that drug-using population, the indigenous Maori developed schizophrenia at a higher rate than did the remainder of the population.ConclusionThese findings in New Zealand require further research into their generalisability, context and explanation.

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.

The acceptability of Child and Adolescent Mental Health Services (CAMHS) to indigenous rangatahi (12–19-year-olds) requires investigation. Evaluation tools able to take account of the more holistic approach to the attainment of mental health that characterises Māori, the indigenous population of Aotearoa (New Zealand) with specificity to the rangatahi population are critical to this examination. The study aims were to: (1) develop an instrument and establish its psychometric properties; and (2) use the measure to establish rangatahi views on desirable CAMHS characteristics. A kaupapa Māori (Māori-driven) research paradigm, based on the traditional Pōwhiri process of engagement and participation, particularly the components of karanga, mihimihi, whaikōrero and koha guided this quantitative research approach. These components are essential to positive contact and commitment to the study processes by researchers and participants. A self-administered survey, Te Tomo mai, was developed by modifying a North American questionnaire, the Youth Services Survey for Youth. The intent of the tool was to record rangatahi experiences and views on service acceptability. The Te Tomo mai survey incorporates questions designed to examine CAMHS delivery in the light of the Whare Tapa Whā, a Māori comprehensive model of health with a focus on culturally responsive services. This survey was completed by a cohort of 69 Māori rangatahi who were referred to six CAMHS District Health Boards in Aotearoa. The Te Tomo mai instrument factor structure, specifically the cultural factor, had similarity to the North American questionnaire from which it had been derived. This work confirms the concept that Māori desire therapeutic methods consistent with the Whare Tapa Whā, such as the importance of culture and spirituality. It further identified issues relevant to Māori rangatahi acceptability with CAMHS such as access, satisfaction and appropriateness. The participants were generally positive about the services they received from the CAMHS, which shows good acceptability of CAMHS for Māori. The Te Tomo mai instrument can prove useful if applied in Aotearoa or other similar cultural settings. It is a means of determining the cultural acceptability which will contribute to improving CAMHS delivery to rangatahi from indigenous populations.

Background : An examination (audit) of the files of patients who had received any mental health services in the year prior to an alleged offence may inform our understanding of the relationship between mental health and crime. More helpfully, it may provide information to facilitate a reduction in the rate of such tragic events Method : The records of all patients assessed by the Midland Regional Forensic Psychiatric service in the 26 months from January 2010 were screened. The 222 who received a diagnosis of a non-organic psychosis and who were recorded as having offended within one year of a previous psychiatric service attendance formed the cohort. The data extracted from their clinical files, relating primarily to that pre-offence psychiatric contact, included legal, clinical and contextual information. Results : Analysis examined the characteristics of this forensic population and most particularly, of their pre-offending service contact. This identified clinical practice and delivery issues which could reduce the rate of conversion of psychiatric patients to “forensic” status. Conclusions : The results inform issues of effectiveness of adult service delivery with particular consideration of the intensity of clinical contact, antipsychotic drug choice and adherence and the use of assertive treatment.

Despite the efforts of the World Health Organization to internationally standardize strategies for mental-health care delivery, the rules and regulations for involuntary admission and treatment of patients with mental disorder still differ markedly across countries. This review was undertaken to describe the regulations and mental-health laws from diverse countries and districts of Europe (UK, Austria, Denmark, France, Germany, Italy, Ireland, and Norway), the Americas (Canada, USA, and Brazil), Australasia (Australia and New Zealand), and Asia (Japan and China). We outline the criteria and procedures for involuntary admission to psychiatric hospitals and to community services, illustrate the key features of laws related to these issues, and discuss their implications for contemporary psychiatric practice. This review may help to standardize the introduction of legislation that allows involuntary admission and treatment of patients with mental disorders in the mainland of China, and contribute to improved mental-health care. In this review, involuntary admission or treatment does not include the placement of mentally-ill offenders, or any other aspect of forensic psychiatry.

Australian & New Zealand Journal of Psychiatry, 49(1) Across the developed world, recruitment into all areas of academic medicine has declined, not least psychiatry. For Australia and New Zealand, this will have a serious impact on undergraduate teaching, on postgraduate training and on our continuing contribution to research. In the UK, the Academy of Medical Sciences became sufficiently concerned about the situation in academic psychiatry to deploy a high-level working group to find ways of strengthening it. In America, the National Institute of Mental Health concluded that a decline in the psychiatrist-researcher workforce was ‘harming public needs’ (Institute of Medicine, 2005). It subsequently appointed a National Psychiatry Training Council to seek ways to improve the situation. In Australia and New Zealand, recruitment into academic psychiatry is in the same precarious state, although paradoxically this is occurring at a time when the knowledge base is undergoing unprecedented expansion. We believe that the specialty suffers from an unfavourable image among young graduates who see it as Why academic psychiatry is endangered

Objectives: To compare by ethnicity the rates of apparent new referrals and admissions to mental health services for selected major diagnostic groupings. Method: Using a Ministry of Health database covering all referrals and admissions to New Zealand’s Mental Health services in 2014 and who had not been patients in the preceding six years, population adjusted rates of presentation were calculated and compared across the two major New Zealand ethnic groupings. Results: Population corrected rates of apparently new cases of schizophrenia are more than twice as common in Māori as in non-Māori. Major depression is also significantly more common in Māori. That same trend was not evident for bipolar patients. Conclusions: These ethnically associated apparent differences in the rates of schizophrenia and depression need both confirmation and explanation.

Background Health and justice have to communicate whenever the question of legal responsibility is raised with respect to a person accused of a serious crime. Both recommendations and practices on expert report design and content vary widely. Methods This paper briefly reviews the characteristics of 27 reports accepted as persuasive in contested New Zealand cases. Results and conclusions Relative brevity, presenting the opinions within a court friendly structure, and emphasising the information available around the time of the events, as opposed to information clinically or legally reconstructed, all appear to be important.

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 …

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in-reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial ("disability") are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic services.

Prompted by four questions, forensic mental health clinicians from Russia, China, Japan, Hong Kong, Australia and New Zealand provided information on both the legislative basis and current practice concerning the relationship between legal insanity, intoxication and drug induced psychosis in their six Pacific Rim Countries which account for nearly 20% of the world's population. Details of the survey for each contributing nation are provided. While there are significant variations in practice that have been shaped by regional legal, clinical and cultural influences there is considerable similarity in the legislation underpinning how these issues are considered. Consequently there remain similar challenges for each nation. In none of the legislative bases was the issue of drug induced psychosis specifically addressed. The authors conclude that evolving pharmaco-neuropsychiatric knowledge, societal values and patterns of substance misuse require nations to consider developments in scientific and clinical knowledge to support their interpretations of the relationship between altered mental states as a result of substance use and the legal construct of insanity.

Objectives: Antipsychotics are the cornerstone of schizophrenia management. There is substantial literature on their efficacy and optimal use. Doubts remain, however, regarding the translation of this knowledge into day-to-day practice. This study aimed to investigate antipsychotic prescribing in three New Zealand regions and its relationship to clinical guidelines and patient characteristics. Methods: We studied 451 patients discharged from inpatient units with a diagnosis of schizophrenia or a related disorder (International Classification of Disease, version 10) between July 2009 and December 2011. Available information included patient demography, legal status, prescribed medications, duration of index admission and prescriber’s country of postgraduate training and years of postgraduate experience. Results: There was a high rate (33.7%) of multiple antipsychotic prescription, and lower than expected clozapine use (20%); Maori were prescribed clozapine more frequently than non-Maori (24% vs. 13%, respectively). Compulsory treatment was associated with more use of injectable medication and increased length of stay in hospital. Clinician characteristics did not significantly influence prescribing. Conclusions: Observed prescribing practice aligned with existing guidelines except for antipsychotic polypharmacy and clozapine under-utilisation.

This article offers a review of the literature illustrating factors that can contribute to responsive Child and Adolescent Mental Health Services (CAMHS) for Māori (indigenous population of Aotearoa/New Zealand) rangatahi [12–19-year-old youths]. The development of a relevant CAMHS rangatahi tool to capture rangatahi views is also discussed. Literature searches using the keywords ‘Māori rangatahi’, ‘Māori health’, ‘mental health’, ‘mental health services’, ‘adolescent health’, ‘child health’ and ‘youth services’ were undertaken using the Medline and Index New Zealand databases as well as Google Scholar. The search was restricted to journals, books, and reports published in English from 1990 to 2012. High unmet CAMHS need for ethnic minorities and indigenous populations has prompted investigations relevant to improving mental health service delivery. Cultural interventions and service user views have provided some guidance. Two tool developments in the international literature (the Youth Services Survey – Families and, nationally, the Te Tomokanga – Caregivers Perspectives) capture a number of these issues. However, there is still an absence of a CAMHS tool in Aotearoa that seeks the specific views of rangatahi. In conclusion, CAMHS research is important for improving practice and CAMHS efficacy. Development of a CAMHS tool that allows specific rangatahi feedback is relevant to service provision in Aotearoa and globally.

Outcome measures are critical to the development of quality mental health services and for their continuous improvement activities. For many cultures, credible and robust outcome measures are not available. This project aimed to continue the development of an outcome measure suitable for use by Māori (the Polynesian indigenous population of Aotearoa [New Zealand]). The tool was developed within the framework of a holistic Māori model of health and tested for its utility in the settings of small Māori Mental Health Service providers. Of the two versions tested, qualitative and quantitative evaluation established a clear endorsement of one version for which some psychometrically credible evidence was obtained. A software package to incorporate the routine collection of such outcome measurement information into a national data base providing online feedback to service providers is also briefly described.

Service users and those who support them have an expectation that a health diagnosis will offer insight into the cause of their symptoms, and will come with a prognosis that will determine treatment options. However, psychiatric diagnostic systems do not usually provide links to aetiology or prognosis, both of which can be highly individualised. As a result, there is a gap between mental health service users’ expectations and what can be realistically provided by diagnosis alone. However, when paired with a thorough and reflective formulation, diagnosis is placed in a context that leads ineluctably to a comprehensive management or recovery plan. This dynamic combination results in a collaborative plan that is better placed to meet both the needs and the expectations of those we serve.

Objective: The phenomenology of patients with schizophrenia is similar world-wide, regardless of culture. However, the prognosis is variable both internationally and within national groups of patients. Furthermore, despite advances in pharmacological treatment, a significant proportion of patients with schizophrenia continue to show residual symptoms and disabilities due to poor response to antipsychotic medication. This study retrospectively assessed differences in outcome by gender, ethnicity and age among a group of treatment-resistant patients with schizophrenia. Method: Patients in the catchment (350 000 people) of a single New Zealand public mental health provider (Waikato) formed the study group. Information concerning demographic profiles, Health of the Nation Outcome Scales (HoNOS) ratings and details of Clozapine usage were extracted from clinical records and the data base. Results: Gender, ethnicity and age did not emerge as significantly associated with any of the outcome variables except for the 30–40 year olds having more improvement on overactivity/aggression ratings than younger or older patients. Conclusions: Despite these negative results in the New Zealand context, there remain many unanswered questions about the higher rate of service use by Maori. Replication of this study on a larger cohort of patients may be indicated before discarding the idea of potential links between ethnicity, treatment choice and outcomes.

Introduction: This study aimed to document experiences and views of practicing mental health nurses on the official psychiatric diagnostic systems and their current usage. Methods: A questionnaire and research design were established by a nursing reference group and resulted in a survey sent to 600 nurses of whom 150 responded. Respondents represented a wide range of clinical practice situations, age, years of experience and both genders. Results: Only 20% of respondents routinely used the World Health Organization (WHO) system of International Classification of Diseases (ICD) 10. The American Diagnostic and Statistical Manual (DSM)-IV was a more popular diagnostic system. Discussion: This study highlights the importance of the classificatory system to treatment planning and to intra-team communication. However, nurses indicated a number of reservations about its utility and appropriateness for their daily work and specified areas they consider for improvement in the development of next versions of the international classificatory systems.

Introduction: Mental health clinicians routinely assess risk in three domains: suicide, violence and self neglect. While the published work on the assessment of these risks has increased, concerns are often expressed that assessment alone does not lead to management of the identified risk. Not all axes of multiaxial classificatory systems are used by clinicians to the same extent, despite their proven usefulness. It is possible that a dedicated axis for risk management as a part of a multiaxial classificatory system could align risk assessment with management and increase utility of multiaxial classificatory systems. Methods: Based on our earlier work we developed a comprehensive risk management axis (RMA), which was then further refined by conducting a pilot study and then used to collect data retrospectively from the case notes of 100 patients consecutively discharged from a general psychiatric ward. Results: Common association between risk factors and three risk domains were as follows. Violence: active symptoms of major mental illness, employment problems, and major mental illness; Suicide: history of abuse, clinically significant depressive symptoms, and alcohol and drug use; Self neglect: neglect of home, personal safety, noncompliance with treatment, male gender, and low income. We also investigated whether the presence of a particular risk factor acted as a barrier or prompt for clinicians to address management factors in the RMA. Discussion: It is possible to assess risk across the three domains and to derive management plans by using the proposed RMA. Minimal clinical background is necessary for collecting data retrospectively. It should be possible to apply this axis prospectively.

Background: Previous surveys have addressed the use and perceived utility of diagnostic systems but not psychiatrists' preferences and expectations about them. This paper attempts to close that gap with data from surveys of psychiatrists in three culturally, socio-economically, and geographically diverse countries. The views of psychiatrists from Brazil, Japan, and New Zealand were sought on global aspects of diagnostic systems and their preferred classificatory systems. Methods: Although the same questionnaire was used in all three countries, the sampling techniques and procedures varied across them. In Brazil and New Zealand, a postal survey was carried out, whereas in Japan a Web-based approach was adopted. The total number of responses obtained was 529 (New Zealand, n = 245; Brazil, n = 160, and Japan, n = 124). Results: Different views on the use of International Classification of Diseases (10th edition) and Diagnostic and Statistical Manual of Mental Disorders (4th edition, revised text) axes were f...

Background & material: In the last five years a number of studies have been conducted in specialist psychiatric and primary care populations in New Zealand which have allowed comparisons in terms of clinical phenomena and therapeutic experiences between Mâori (the indigenous people of New Zealand) and non-Mâori. These studies were reviewed in terms of the methodology used, their major findings and their implications. Discussion: In specialist psychiatric services Mâori were more likely to present with hallucinations and/or aggression and less likely to present with depression and/or episodes of self-harm. They were overly represented in those with schizophrenia. Mâori were more likely to be involved in acts of aggression and to be secluded, and an equivalent episode of care for Mâori appeared to be significantly more costly than for non Mâori. Other studies, conducted in prison and community-based samples, suggested that Mâori were less likely to access care and, when given a diagnosis of depression, less likely to be prescribed anti-depressant medication. The rates of depression were significantly higher in Mâori (women) and Mâori were also overly represented in those with anxiety and substance misuse disorders. These differences remained even after the sample was standardised for socio-economic status. Further exploration of the genesis and implications of these findings, derived from a strong and relatively well-defined indigenous people, may usefully inform the more general issues of culture and its significance for diagnosis, classification and service use. Conclusions: While the methodologies used and the actual results gained differed across studies, there do seem to be differences in phenomenological profiles at presentation, in the diagnostic patterns, the cost of care, and the therapeutic experiences between Mâori and non-Mâori New Zealanders. These differences may reflect actual differences between certain ethnic groups, which then explain the differences in the experiences of those users, or they may reflect inadequacies on the parts of non-Mâori clinicians, their diagnostic tools and the services in which they operate, in catering for Mâori patients.

Objectives: The aim of this study was to assess the extent to which people with mental illness in a New Zealand setting encounter stigma and discrimination and to examine their satisfaction with quality of life. Method: Patients under the care of a range of community mental health services were invited to participate in a survey. Fifty-three females and 47 males completed questionnaires concerning stigma, discrimination and quality of life. Demographic and diagnostic characteristics were also recorded. Results: The majority of participants reported experiencing stigma and discrimination in a variety of contexts. In association with this, they had experienced dissatisfaction with their quality of life in a number of areas. Conclusions: The experience of stigma and dissatisfaction with quality of life among people with mental illness is common. This has implications for clinical assessment and management.

When considering psychiatric evidence courts often take great comfort in the use of labels from official psychiatric classificatory systems, despite the medico-legal criteria usually being worded in non-diagnostic terms and despite it becoming increasingly difficult to defend the use of a purely categorical diagnostic framework. Referenced support for the view that a rethink of the classificatory systems in psychiatry is necessary and is happening, is summarised. The argument is made that the comfort the courts take from the present DSM-IV and ICD categories is illusory.

Objective: To reflect on the surge of interest in ‘outcomes’ in mental health services. Conclusions: Reliable assessments underpin the ability to measure change in clinically relevant health status, and no single measure can represent all relevant variables. The measure of change should be regarded as only one part of a larger and dynamic process. Consumer management and service quality improvement activities may be better enhanced by placing emphasis on assessing those domains, which will inform the development of potential clinical management plans, in a quantitative fashion. Where indicated, repeated assessment will provide information which will inform individual patient care, and by grouping data, service planning and continuous improvement activities.

Objective: To examine the performance of two widely used outcome measures in public adult mental health services. Method: As part of a larger study, clinical staff in eight New Zealand District Health Board areas collected consumer outcomes data for a period of 6 months. Among other measures, the Health of the Nation Outcome Scales (HoNOS) and Life Skills Profile (LSP-16) were completed at the start and end of episodes of care, as well as at 90-day reviews. Results: The performance of these twomeasures was examined in relation to compliance with the data collection protocol, item completion rates, certain psychometric properties, the relationship between them and the relationship of each instrument to the age, sex, principal psychiatric diagnosis and legal status of the consumer. Compliance with the HoNOS was superior to the LSP-16, but the reverse was true for completion. The two instruments were strongly correlated, but not enough to suggest that one may substitute for the other. A five-subscale structure for the HoNOS was supported. Certain HoNOS subscales were associated with age, but the total score was not, and differences between the sexes were small. Some large diagnostic differences were observed on both instruments. All LSP-16 summary scores and all HoNOS summary scores apart from Depression were higher (worse) in involuntary episodes. Only one LSP-16 item, relating to work potential, was related to age and men generally scored higher (worse) than women. Conclusion: From a technical perspective, the HoNOS and LSP-16 appear suitable for routine collection. New Zealand has adopted the HoNOS for routine use but not the LSP-16 because of local concerns about its appropriateness and acceptability. The clinician-rated measures reported here need to be complemented by both consumer-rated and family/carer measures.

The stigma of mental illness affects psychiatry as a medical profession and psychiatrists. The present study aimed to compare the extent and correlation patterns of perceived stigma in psychiatrists and general practitioners. An international multicenter survey was conducted in psychiatrists and general practitioners from twelve countries. Responses were received from N = 1,893 psychiatrists and N = 1,238 general practitioners. Aspects of stigma assessed in the questionnaire included perceived stigma, self-stigma (stereotype agreement), attitudes toward the other profession, and experiences of discrimination. Psychiatrists reported significantly higher perceived stigma and discrimination experiences than general practitioners. Separate multiple regression analyses showed different predictor patterns of perceived stigma in the two groups. Hence, in the psychiatrists group, perceived stigma correlated best with discrimination experiences and self-stigma, while in the general practitioners group it correlated best with self-stigma. About 17 % of the psychiatrists perceive stigma as a serious problem, with a higher rate in younger respondents. Against this background, psychiatry as a medical profession should set a high priority on improving the training of young graduates. Despite the number of existing antistigma interventions targeting mental health professionals and medical students, further measures to improve the image of psychiatry and psychiatrists are warranted, in particular improving the training of young graduates with respect to raising awareness of own stigmatizing attitudes and to develop a better profession-related self-assertiveness.

Comprehensive clinical assessment and patient management plans have been enhanced by the development of multiaxial classificatory systems. Assessment of risk is an essential clinical task for which the conclusions are not currently reflected in the multiaxial diagnostic schemata. Developments in the understanding of risk and its management make possible consideration of its place in multiaxial systems. The structure and principles of a potentially workable axis, summarizing current knowledge of risk in the domains of suicide, self-neglect and violence to others, are described. Clinicians are more likely to use this axis than the multiple, emerging, risk assessment guidelines. Incorporating risk management would be a practical addition to presently available axes and be very widely clinically applicable.

Objective: The aim of this study was to make a case for freeing psychiatry from the limits of categorical diagnosis. Conclusions: From Pinel through to Kraepelin, Bleuler, DSM-IV and ICD-10, clinical and research activities in psychiatry have all depended upon categorical classification. Recent decades have seen increasing argument in favour of dimensional measurement, description and prediction, in part because invalidities in categorical classification are becoming impossible to deny. Some suggestions for developing useful dimensional approaches are made.

Aims and MethodThe study aimed to identify the correlates of aggressive behaviour in an adult acute psychiatric ward. Over a period of 9 months, all incidents of verbal and physical aggressive behaviour exhibited by in-patients were routinely assessed using the Overt Aggression Scale.ResultsOf the 535 patients admitted during the study period, 80 (15%) were involved in a total of 124 aggressive incidents. Of these 80, 44 (55%) had a history of previous violence and 54 (68%) had a history of substance misuse. The majority of events occurred early in the hospital stay and in most cases aggression was against staff. There were significant differences between aggressive and non-aggressive patients in terms of gender and ethnicity, with the lowest rate occurring in European females.Clinical ImplicationsThese results reinforce clinical impressions, and empirical evidence, and allow risk assessment to be performed with greater confidence. The relevance of ethnicity (or more likely culture) highlights the difficulties of a ‘one size fits all’ approach to risk assessment.

The key areas of development in this study were the criteria for the use of the Hua Oranga, an Indigenous mental health outcome measurement tool for use with Māori, the Indigenous people of Aotearoa (New Zealand). The application of the Hua Oranga was expected to improve the care and treatment of tangata whaiora (consumers) in partnership with whānau (family) and clinicians. The Outcomes Recording Analysis (ORA) database (www.ORAdatabase.co.nz), which receives the Hua Oranga data and generates the Hua Oranga reports was essential to this improvement. This development contributes to the skill and expertise of clinicians in interpreting Māori health information that benefit Māori.

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in-reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial ("disability") are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic services.