Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

Background: The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge. Method: A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process. Treatment recommendations: This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no special Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.

Telemedicine and developing countries - successful implementation will require a shared approach

Telemedicine is often proposed as a solution to certain health-care problems in the developing world. There seems to be little published experience on which to make judgements. A literature search revealed 39 articles, of which only two related to any kind of direct clinical work; most of them were review articles or editorials. The majority of the work reported was educational in nature, and there has been little clinical experience. It seems probable that telemedicine can help with the education of health-care workers and patients; it seems likely that it could bring major benefits to the organization of health-care. Without proper trials, it will be impossible to determine the place of health-care in the developing world. Trials are the only way in which rational decisions can ultimately be reached regarding whether scarce resources should be devoted to telemedicine in developing countries, or whether they should be employed in more conventional health-care measures whose outcomes are known to be cost-effective.

Management motivation for using financial derivatives in Australia

This study takes a direct approach to determine management motivation for the use of financial derivatives. We survey a sample of Australian firms on attitudes to derivative use and financial risk management. Management views are sought on the importance of a series of theoretical reasons for using derivatives. Generally, we find that managers are focused on the broad reduction of risk and volatility of cash flows and earnings in using derivatives. Specific issues such as reducing bankruptcy costs, debt levels and taxation are not considered as important. A further interesting result from this research is that even though firms may use derivatives they may not necessarily hedge all of their annual exposures across different financial risks. This helps explain the inconsistency of results in many empirical studies on the determinants of derivative use.

Financial and economic performance of long-rotation hardwood plantation investments in Queensland, Australia

In Queensland, Australia, there is presently a high level of interest in long-rotation hardwood plantation investments for sawlog production, despite the consensus in Australian literature that such investments are not financially viable. Continuing genetics, silviculture and processing research, and increasing awareness about the ecosystem services generated by plantations, are anticipated to make future plantings profitable and socio-economically desirable in many parts of Queensland. Financial and economic models of hardwood plantations in Queensland are developed to test this hypothesis. The economic model accounts for carbon sequestration, salinity amelioration and other ecosystem service values of hardwood plantations. A carbon model estimates the value of carbon sequestered, while salinity and other ecosystem service values are estimated by the benefit transfer method. Where high growth rates (20-25 m(3) ha(-1) year(-1)) are achievable, long-rotation hardwood plantations are profitable in Queensland Hardwood Regions 1, 3 and 7 when rural land values are less than $2300/ha. Under optimistic assumptions, hardwood plantations growing at a rate of 15 in 3 ha-1 year 1 are financially viable in Hardwood Regions 2, 4 and 8, provided land values are less than $1600/ha. The major implication of the economic analysis is that long-rotation hardwood plantation forestry is socio-economically justified in most Hardwood Regions, even though financial returns from timber production may be negative. (c) 2003 Elsevier B.V. All rights reserved.

Intelligent decision support for family financial planning

In today’s financial markets characterized by constantly changing tax laws and increasingly complex transactions, the demand for family financial planning (FFP) services is rising dramatically. However, the current trend to develop advisory systems that focus mainly on the financial or investment side fails to consider the whole picture of FFP. Separating financial or investment advice from legal and accounting advice may result in conflicting advice or important omissions that could lead to users suffering financial loss. In this paper, we propose a conceptual model for FFP decision-making process, followed by a novel architecture to support an aggregated FFP decision process by utilizing intelligentagents and Web-services technology. A prototype system for supporting FFP decision is presented to demonstrate the advances of the proposed Web-service multi-agentsbased system architecture and business value.