Care plans in community mental health: an audit focusing on people with recent hospital admissions

The final publication is available at Springer via: http://dx.doi.org/10.1007/s11414-016-9504-0Care planning is a key requirement for recovery-focused mental health care. Audit tools are available so that services can assess their alignment with accepted care planning standards but few benchmarks are available, especially for health services outside the United Kingdom. To assess implementation of recommended care planning in an Australian mental health setting for people recently hospitalised, a sample of service user records was audited against care plan requirements. Of 164 eligible records, 113 (69%) showed a care plan. Of the 113 care plans, 40 (35%) contained a risk assessment and 1 (1%) a crisis management plan. Thirty five (31%) contained some social needs assessment, 1 (1%) contained a physical health assessment, and 53 (47%) identified a primary healthcare physician. This audit indicated a large gap between recommendations and actual practice. Similar audits in other health services are required. Action is needed to integrate care planning into behavioural health practice

Clozapine withdrawal catatonia, psychosis and associated neuroleptic malignant syndrome

© 2017 Elsevier. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/ This author accepted manuscript is made available following 12 month embargo from date of publication (August 2017) in accordance with the publisher's archiving policy

Divided we fall: clinicians and academic psychiatrists need to stand together

Copyright © 2017 The Royal Australian and New Zealand College of Psychiatrists. Reprinted by permission of SAGE PublicationsObjective: Psychiatry faces urgent problems requiring united action. These problems affect academic psychiatrists in the universities, and clinicians in publicly funded mental health services. Academic units are isolated and endangered, finding it difficult to recruit. They could benefit from closer relationships with public mental health services, in terms of recruitment, shared teaching and clinical research. However, mental health services are preoccupied with their own problems, particularly in relation to acute clinical demand. How can we stand together to improve academic units and clinical psychiatry? Conclusions: Clinicians and academic psychiatrists can stand together on important matters, but it takes initiatives from local leaders to overcome the structural barriers between health services and the universities. An example is given of united action by clinicians and academic psychiatrists to address a crisis within a state mental health system. First, psychiatrists undertook independent health services research that compared the state system with those in other Australian and international jurisdictions. The comparative data was used to generate solutions, which were presented at every level from ministerial offices through to service managers. Finally, psychiatrists took up joint academic and clinical leadership roles in the university and the mental health system. This united research-led approach turned around the crisis in the state mental health syste

Australian private practice metropolitan telepsychiatry during the COVID-19 pandemic: analysis of Quarter-2, 2020 usage of new MBS-telehealth item psychiatrist services

Objective: The Australian Commonwealth Government introduced new psychiatrist Medicare-Benefits-Schedule (MBS)-telehealth items in the first wave of the COVID-19 pandemic to assist with previously office-based psychiatric practice. We investigate private psychiatrists’ uptake of (1) video- and telephone-telehealth consultations for Quarter-2 (April–June) of 2020 and (2) total telehealth and face-to-face consultations in Quarter-2, 2020 in comparison to Quarter-2, 2019 for Australia. Methods: MBS item service data were extracted for COVID-19-psychiatrist-video- and telephone-telehealth item numbers and compared with a baseline of the Quarter-2, 2019 (April–June 2019) of face-to-face consultations for the whole of Australia. Results: Combined telehealth and face-to-face psychiatry consultations rose during the first wave of the pandemic in Quarter-2, 2020 by 14% compared to Quarter-2, 2019 and telehealth was approximately half of this total. Face-toface consultations in 2020 comprised only 56% of the comparative Quarter-2, 2019 consultations. Most telehealth provision was by telephone for short consultations of ⩽15–30 min. Video consultations comprised 38% of the total telehealth provision (for new patient assessments and longer consultations). Conclusions: There has been a flexible, rapid response to patient demand by private psychiatrists using the new COVID-19-MBS-telehealth items for Quarter-2, 2020, and in the context of decreased face-to-face consultations, ongoing telehealth is essential

Conversion Parkinson’s Disease with Levodopa Abuse and Psychosis

This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/ This author accepted manuscript is made available following 12 month embargo from date of publication (Sept 2017) in accordance with the publisher’s archiving policyConversion disorder (CD) now recognised as functional neurological symptom disorder (DSMV) presents with physical symptoms that are not well explained by organic aetiology. We describe a unique case of Conversion Parkinson’s Disease (PD)

Electroconvulsive therapy and type 1 Chiari malformation

Crown Copyright © 2018 Published by Elsevier B.V. All rights reserved. This manuscript version is made available under the CC-BY-NC-ND 4.0 license:http://creativecommons.org/licenses/by-nc-nd/4.0/ This author accepted manuscript is made available following 12 month embargo from date of publication (March 2018) in accordance with the publisher’s archiving policyType 1 Chiari Malformation (T1CM) refers to a congenital herniation of the cerebellar tonsils though the foramen magnum of ≥5 mm (Pickard et al., 2012). Total prevalence in normal adults is almost 1%, yet only 0.01–0.04% of the population are symptomatic (Tubbs, 2013). The ectopic tonsils may cause obstruction of cerebrospinal fluid (CSF) flow through the subarachnoid space at the craniocervial junction (Pickard et al., 2012). Patients may be asymptomatic, or display varied symptoms due to brainstem compression, cerebellar displacement, traction on cranial nerves or interference with CSF flow. Transiently elevated intracranial pressure (ICP) due to trapped cerebrospinal fluid causes the most common symptom, headaches, in 81% of patients (Fischbein et al., 2015). 10% of patients have associated hydrocephalus (Tubbs, 2013), and an unknown percentage have idiopathic intracranial hypertension

Neuropsychiatric aspects of frontal lobe meningioma

© 2017 Elsevier B.V. This manuscript version is made available under the CC-BY-NC-ND 4.0 license: http://creativecommons.org/licenses/by-nc-nd/4.0/Brain tumours are known to typically present with neurological signs. Rarely, psychiatric symptoms can be the only manifestation of a brain tumour (Madhusoodanan et al., 2015). Though it is not uncommon for patients to present with psychiatric symptoms as the first clinical manifestation of a brain tumour, they are often non-specific and do not assist in localising the lesion. With the limited available research, it is found that neuropsychiatric disturbances are more frequently associated with frontal and temporolimbic lesions (Filley and Kleinschmidt-DeMasters, 1995). We present a case of a woman with frontal lobe meningioma who presented with a neuropsychiatric syndrome. Ms S is a 50 years old woman with chronic schizophrenia that was stable for several years on a combination of 4 mg of Risperidone and 50 mg of Quetiapine. In early April, she presented with abrupt onset of fever, tremors, generalised weakness, lethargy, confusion, vomiting and loose bowels. On examination, she was noted to have a body temperature of 37.8 °C with borderline tachycardia, bradykinesia, cogwheel rigidity and increased deep tendon reflexes. She did not have diaphoresis or autonomic instability. Laboratory tests showed elevated Creatine Kinase (CK) of 1800 U/L and neutrophilia. With clinical suspicion for NMS, her antipsychotic medications were ceased leading to a decrease in her CK to 60. She was discharged after being commenced on Olanzapine 2.5 mg daily, with positive effect for her psychotic symptoms. Nine days following discharge Ms S presented again with some symptoms of NMS such as worsening tremors, two episodes of fever, rigidity, bradykinesia and was disoriented to time. Her CK and white cell count, however, were within normal levels. She also had catatonic features such as increasingly withdrawn behaviour, mutism and negativism. On hospital presentation, she was afebrile and septic screen was negative, and she was admitted to the psychiatric unit for further investigation. Whilst assessment by the emergency physician suggested that the etiology of her symptoms were related to psychotropic drugs, the psychiatrist opined that it was more likely to be delirium and also considered a differential diagnosis of organic catatonia. CT head was done following the recommendation of the psychiatrist and it showed left frontal lobe meningioma with 12 cm midline shift with surrounding oedema. Ms S then was referred to the neurosurgery department and underwent surgical resection of the meningioma, which was successful. Ms S was a patient with a stable psychiatric illness, who presented with overlapping features of NMS and catatonia but no overt psychotic symptoms. Her neuropsychiatric symptoms were likely to be the pressure effect of a left frontal meningioma. The nature of her presentation made the process of diagnosis challenging, especially with the initial absence of neuroimaging, which resulted in a delay in diagnosis and appropriate treatment. Frontal lobe tumours have higher chances of producing mental status and personality changes with left sided lesions being more associated with inhibition of motor activity, impairment in motor and initiative aspect of speech, diminished generalization ability and general inertia of mental processes as seen in Ms S (Belyi, 1987). Given the absence of frank neurological symptoms to help localise the lesion, a high degree of clinical suspicion is usually required for early diagnosis. In patients suffering from schizophrenia, these symptoms can be explained by the illness itself and the side effects of the medications, thereby increasing the chances of missing the organic pathology due to diagnostic overshadowing of the primary psychiatric illness. Neuroimaging should be considered in patients with atypical psychiatric symptoms, new-onset psychosis, recurrence of previously well-controlled psychiatric symptoms, and if they become refractory to psychiatric treatment (Madhusoodanan et al., 2015). Clinical suspicion must be raised when these symptoms are vague, rare, non-specific, with no clear cause or trigger and are associated with several causative etiologies. Despite the many studies that have been done to correlate clinical presentation to the location of brain lesions, symptoms are still extremely unreliable diagnostic tools, and neuroimaging should be done when there is high suspicion index for organic pathology

Telephone-based low intensity therapy after crisis presentations to the emergency department is associated with improved outcomes

Author version made available in accordance with the publisher's policy.Introduction In Australia there is an overwhelming need to provide effective treatment to patients presenting to the Emergency Department (ED) in mental health crisis. We adapted Improving Access to Psychological Therapies service model (IAPT) from the National Health Service (NHS) method for the large scale delivery of psychological therapies throughout the United Kingdom to an Australian ED setting. This telephone-based low intensity therapy was provided to people presenting in crisis to the EDs with combinations of anxiety, depression, substance use, and suicidal thinking. Methods This uncontrolled study utilised session-by-session, before-and-after measures of anxiety and depression via Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder-7 (GAD-7). Results Of 347 eligible post-crisis ED referred patients, 291 (83.9%) engaged with the IAPT team. Most patients (65%) had attended the ED previously on an average of 3.9 (SD = 6.0) occasions. Two hundred and forty one patients received an average of 4.1 (SD =2.3) contacts of low-intensity psychological therapies including 1.2 (SD = 1.7) community outreach visits between 20th Oct 2011 and 31st Dec 2012. Treated patients reported clinically significant improvements in anxiety, depression and suicidal ideation. Uncontrolled effect sizes were moderate for anxiety (0.6) and depression (0.6). Discussion The Australian ED IAPT program demonstrated that the UK IAPT program could be adapted for emergency mental health patients and be associated with similar clinical benefits as the original program. Funding The Flinders Medical Centre IAPT program received Emergency Department project funding from the Australian Commonwealth Government through the Council of Australian Governments (COAG) and the South Australian Government initiative, Every Patient Every Service (EPES)

Neutropenia Associated with Quetiapine, Olanzapine, and Aripiprazole

Matthew Lander and Tarun Bastiampilla