Psychotherapy in Australia : clinical psychology and its approach to depression

In Australia, clinical psychology training is dominated by cognitive and behavioral treatments (CBTs), although there is exposure to other theoretical orientations. Since 2001, over 20% of general medical practitioners (GPs) have received training in CBT, and psychiatry training increasingly incorporates CBT elements. Psychotherapy by medical practitioners is financially supported by universal health care funding with supplementation by patients and their private health insurance. Federally funded health benefits for up to 12 psychology consultations per year are provided on referral from GPs and psychiatrists, and initial take up has been very strong. Mrs. A would be a typical patient for such a referral. However, she would not fulfil criteria for priority access from state-funded mental health services. Mrs. A would probably consult a GP and receive antidepressants, although she may also access a range of other community support programs. Access to and acceptance of psychotherapy would be greater in urban areas, and if she were of Anglo-Saxon and non- indigenous origin.

Cannabis use and misuse prevalence among people with psychosis

Background: Increasing attention has been given by researchers to cannabis use in individuals with psychosis. As psychoses are relatively low-prevalence disorders, research has been mostly been restricted to small-scale studies of treatment samples.The reported prevalence estimates obtained from these studies vary widely. Aims: To provide prevalence estimates based on larger samples and to examine sources of variability in prevalence estimates across studies. Method: Data from 53 studies of treatment samples and 5 epidemiological studies were analysed. Results: Based on treatment sample data, prevalence estimates were calculated for current use (23.0%), current misuse (11.3%),12-month use (29.2%),12-month misuse (18.8%), lifetime use (42.1%) and lifetime misuse (22.5%). Epidemiological studies consistently reported higher cannabis use and misuse prevalence in people with psychosis. Conclusions: The factor most consistently associated with increased odds of cannabis prevalence was specificity of diagnosis. Factors such as consumption patterns and study design merit further consideration.

Burden of care and general health in families of patients with schizophrenia

Background: De-institutionalization of psychiatric patients has led to a greater emphasis on family management in the community, and family members are often overwhelmed by the demands that caring for a patient with schizophrenia involves. Most studies of family burden in schizophrenia have taken place in developed countries. The current study examined family burden and its correlates in a regional area of a medium income country in South America. Method: Sixty-five relatives of patients with schizophrenia who were attending a public mental health out-patient service in the province of Arica, Chile, were assessed on Spanish versions of the Zarit Caregiver Burden Scale and SF-36 Health Survey (SF-36). Results: Average levels of burden were very high, particularly for mothers, carers with less education, carers of younger patients and carers of patients with more hospitalisations in the previous 3 years. Kinship and number of recent hospitalisations retained unique predictive variance in a multiple regression. Burden was the strongest predictor of SF-36 subscales, and the prediction from burden remained significant after entry of other potential predictors. Conclusions: In common with families in developed countries, family members of schizophrenia patients in regional Chile reported high levels of burden and related functional and health impact. The study highlighted the support needs of carers in contexts with high rates of poverty and limited health and community resources.

Innovative approaches to intervention for problem drinking

Purpose of review: To critique the recent literature on telephone, correspondence-based, and computerized interventions for alcohol problems, which enhance or substitute for practitioner-delivered treatments. Recent findings: There is an unmet need for screening, assessment and intervention for alcohol problems, in part because of the difficulty in accessing such treatment within the current health care system. Research on the efficacy of correspondence or electronic (for example Internet-based) interventions is beginning to emerge. In the period 2003–2004 we identified nine acceptability or feasibility studies of these approaches and seven efficacy trials covering a wide range of settings. These modes of intervention are acceptable to patients and the public, and with careful planning, can be implemented in a variety of settings. Treatment trials demonstrate the efficacy of these interventions in reducing hazardous drinking by university students, in delaying initiation of heavy drinking in children and adolescents, and, intriguingly, in addressing insomnia among recovering alcoholics. Summary: There is strong support among potential users for alcohol interventions that employ telephone assistance, written correspondence, and the Internet. These new technologies offer the prospect of increasing the reach of interventions for problem drinking and being cost- effective alternatives or supplements to face-to-face health service delivery.

A brief motivational intervention for substance misuse in recent-onset psychosis

Substance misuse is common in early psychosis, and impacts negatively on outcomes. Little is known about effective interventions for this population. We report a pilot study of brief intervention for substance misuse in early psychosis (Start Over and Survive: SOS), comparing it with Standard Care (SC). Twenty-five in-patients aged 18-35 years with early psychosis and current misuse of non-opioid drugs were allocated randomly to conditions. Substance use and related problems were assessed at baseline, 6 weeks and 3, 6 and 12 months. Final assessments were blind to condition. All 13 SOS participants who proceeded to motivational interviewing reported less substance use at 6 months, compared with 58% (7/12) in SC alone. Effects were well maintained to 12 months. However, more SOS participants lived with a relative or partner, and this also was associated with better outcomes. Engagement remained challenging: 39% (16/41) declined participation and 38% (5/13) in SOS only received rapport building. Further research will increase sample size, and address both engagement and potential confounds.

Demographic and clinical correlates of comorbid substance use disorders in psychosis : multivariate analyses from an epidemiological sample

Background: While there has been substantial research examining the correlates of comorbid substance abuse in psychotic disorders, it has been difficult to tease apart the relative importance of individual variables. Multivariate analyses are required, in which the relative contributions of risk factors to specific forms of substance misuse are examined, while taking into account the effects of other important correlates. Methods: This study used multivariate correlates of several forms of comorbid substance misuse in a large epidemiological sample of 852 Australians with DSMIII- R-diagnosed psychoses. Results: Multiple substance use was common and equally prevalent in nonaffective and affective psychoses. The most consistent correlate across the substance use disorders was male sex. Younger age groups were more likely to report the use of illegal drugs, while alcohol misuse was not associated with age. Side effects secondary to medication were associated with the misuse of cannabis and multiple substances, but not alcohol. Lower educational attainment was associated with cannabis misuse but not other forms of substance abuse. Conclusion: The profile of substance misuse in psychosis shows clinical and demographic gradients that can inform treatment and preventive research.

The future of cognitive and behavioral therapies in the prevention and early management of psychosis : opportunities and risks

Behavioral and cognitive interventions for people with psychosis have a long and distinguished history, although the evidence for their application to young people remains limited. We anticipate that the next decades will show substantial research into psychological intervention for this population. Important targets will include the management of environmental stressors, reduction of substance misuse, and promotion of early treatment. Psychological management of positive symptoms, depression, and suicidal behavior will continue to be critical objectives. Important secondary prevention goals will be the retention of cognitive functioning, vocational options, social skills, and social network support, including appropriate family support. We expect primary prevention to include both universal programs and interventions for adolescents at particularly high risk. Technical innovations will include increasing use of Internet-based intervention and behavior cueing devices. Pressures for intervention brevity will continue, as will problems with the systematic delivery of effective procedures.

Effects of visuospatial tasks on desensitization to emotive memories

Objectives. Intrusive memories of extreme trauma can disrupt a stepwise approach to imaginal exposure. Concurrent tasks that load the visuospatial sketchpad (VSSP) of working memory reduce the vividness of recalled images. This study tested whether relief of distress from competing VSSP tasks during imaginal exposure is at the cost of impaired desensitization . Design. This study examined repeated exposure to emotive memories using 18 unselected undergraduates and a within-subjects design with three exposure conditions (Eye Movement, Visual Noise, Exposure Alone) in random, counterbalanced order. Method. At baseline, participants recalled positive and negative experiences, and rated the vividness and emotiveness of each image. A different positive and negative recollection was then used for each condition. Vividness and emotiveness were rated after each of eight exposure trials. At a post-exposure session 1 week later, participants rated each image without any concurrent task. Results. Consistent with previous research, vividness and distress during imaging were lower during Eye Movements than in Exposure Alone, with passive visual interference giving intermediate results. A reduction in emotional responses from Baseline to Post was of similar size for the three conditions. Conclusion. Visuospatial tasks may offer a temporary response aid for imaginal exposure without affecting desensitization.

Contrasting views and experiences of health professionals on the management of comorbid substance misuse and mental disorders

Objectives: To determine opinions and experiences of health professionals concerning the management of people with comorbid substance misuse and mental health disorders. Method: We conducted a survey of staff from mental health services and alcohol and drug services across Queensland. Survey items on problems and potential solutions had been generated by focus groups. Results: We analysed responses from 112 staff of alcohol and drug services and 380 mental health staff, representing a return of 79% and 42% respectively of the distributed surveys. One or more issues presented a substantial clinical management problem for 98% of respondents. Needs for increased facilities or services for dual disorder clients figured prominently. These included accommodation or respite care, work and rehabilitation programs, and support groups and resource materials for families. Needs for adolescent dual diagnosis services and after-hours alcohol and drug consultations were also reported. Each of these issues raised substantial problems for over 70% of staff. Another set of problems involved coordination of client care across mental health and alcohol and drug services, including disputes over duty of care. Difficulties with intersectoral liaison were more pronounced for alcohol and drug staff than for mental health. A majority of survey respondents identified 13 solutions as practical. These included routine screening for dual diagnosis at intake, and a range of proposals for closer intersectoral communication such as exchanging client information, developing shared treatment plans, conducting joint case conferences and offering consultation facilities. Conclusions: A wide range of problems for the management of comorbid disorders were identified. While solution of some problems will require resource allocation, many may be addressed by closer liaison between existing services.

The family attitude scale : reliability and validity of a new scale for measuring the emotional climate of families

Research on outcomes from psychiatric disorders has highlighted the importance of expressed emotion (EE), but its cost-effective measurement remains a challenge. This article describes development of the Family Attitude Scale (FAS), a 30-item instrument that can be completed by any informant. Its psychometric characteristics are reported in parents of undergraduate students and in 70 families with a schizophrenic member. The total FAS had high internal consistency in all samples, and reports of angry behaviour in FAS items showed acceptable inter-rater agreement. The FAS was associated with the reported anger, anger expression and anxiety of respondents. Substantial associations between the parents' FAS and the anger and anger expression of students was also observed. Parents of schizophrenic patients had higher FAS scores than parents of students, and the FAS was higher if disorder duration was longer or patient functioning was poorer. Hostility, high criticism and low warmth on the Camberwell Family Interview (CFI) were associated with a more negative FAS. The highest FAS in the family was a good predictor of a highly critical environment on the CFI. The FAS is a reliable and valid indicator of relationship stress and expressed anger that has wide applicability.

Towards a cognitive-behavioural intervention for adult grief reactions

Published accounts of behavioural interventions for grief have relied on exposure and habituation to grief cues as the primary strategy. Such an approach is excessively narrow, since it does not adequately confront the challenges that are posed by a bereavement. Many people cope with a bereavement by themselves, and for those, intervention may well be counterproductive. A cognitive-behavioural intervention, following models for depression/anxiety, can assist vulnerable individuals obtain a more rapid or complete adjustment. The proposed approach differs from dynamic treatments by placing less emphasis on defensive behavior, insight, and interpretation and more emphasis on training of coping skills.

Adjuvant use of nutritional and herbal medicines with antidepressants, mood stabilizers and benzodiazepines

Adjuvant use of nutritional and herbal medicines has potential to increase the efficacy of synthetic pharmaceuticals, and perhaps also decrease their side-effects by allowing lower doses to be prescribed. We evaluated current evidence for adjuvant use of nutritional and herbal medicines with antidepressants, mood stabilizers and benzodiazepines; and explored novel future areas of research. The paper also critiques current evidence for co-administration of St. John’s wort with synthetic antidepressants. We performed a systematic search of MEDLINE, CINAHL, PsycINFO, The Cochrane database, China National Knowledge Infrastructure and the Chinese Science Citation Database. Search results were supplemented by a review of reference lists and a forward search using the Web of Science. Where possible we calculated effect sizes. Encouraging evidence exists for the use of omega-3 fatty acids, SAMe, folic acid and l-tryptophan adjuvantly with antidepressants to enhance response and improve efficacy. Various nutrients also have emerging evidence as effective adjuncts with antipsychotics and mood stabilizers. While some evidence supports nutritional adjuvancy with various psychopharmacotherapies, adjuvant use of herbal therapies has not been sufficiently studied to warrant standard clinical application. This remains a promising area of research via robust, safety-conscious studies.

Collaborative recovery: An integrative model for working with individuals that experience chronic or recurring mental illness.

Objectives: Recovery is an emerging movement in mental health. Evidence for recovery-based approaches is not well developed and approaches to implement recovery-oriented services are not well articulated. The collaborative recovery model (CRM) is presented as a model that assists clinicians to use evidence-based skills with consumers, in a manner consistent with the recovery movement. A current 5 year multisite Australian study to evaluate the effectiveness of CRM is briefly described. Conclusion: The collaborative recovery model puts into practice several aspects of policy regarding recovery-oriented services, using evidence-based practices to assist individuals who have chronic or recurring mental disorders (CRMD). It is argued that this model provides an integrative framework combining (i) evidence-based practice; (ii) manageable and modularized competencies relevant to case management and psychosocial rehabilitation contexts; and (iii) recognition of the subjective experiences of consumers.

Event-related potential (ERP) correlates of impaired visuospatial memory in schizophrenia

Previous studies have reported that patients with schizophrenia demonstrate impaired performance during working memory (WM) tasks. The current study aimed to determine whether WM impairments in schizophrenia are accompanied by reduced slow wave (SW) activity during on-line maintenance of mnemonic information. Event-related potentials were obtained from patients with schizophrenia and well controls as they performed a visuospatial delayed response task. On 50% of trials, a distractor stimulus was introduced during the delay. Compared with controls, patients with schizophrenia produced less SW memory negativity, particularly over the right hemisphere, together with reduced frontal enhancement of SW memory negativity in response to distraction. The results indicate that patients with schizophrenia generate less maintenance phase neuronal activity during WM performance, especially under conditions of distraction.

Working memory correlates of three symptom clusters in schizophrenia

Examined whether discrete working memory deficits underlie positive, negative and disorganised symptoms of schizophrenia. 52 outpatients (mean age 37.5 yrs) with schizophrenia were studied using items drawn from the Positive and Negative Syndrome Scale (PANSS). Linear regression and correlational analyses were conducted to examine whether symptom dimension scores were related to performance on several tests of working memory function. Severity of negative symptoms correlated with reduced production of words during a verbal fluency task, impaired ability to hold letter and number sequences on-line and manipulate them simultaneously, reduced performance during a dual task, and compromised visuospatial working memory under distraction-free conditions. Severity of disorganisation symptoms correlated with impaired visuospatial working memory under conditions of distraction, failure of inhibition during a verbal fluency task, perseverative responding on a test of set-shifting ability, and impaired ability to judge the veracity of simple declarative statements. The present study provides evidence that the positive, negative and disorganised symptom dimensions of the PANSS constitute independent clusters, associated with unique patterns of working memory impairment.