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.

Developing New Tourism Services: Dinosaurs a New Drive Tourism Resource for Remote Areas

This paper examines issues encountered when developing new tourism services generally, and specific aspects relating to the development of remote area dinosaur fossil fields for tourism. It studies two sites, one in the USA and one in Australia. Access to both sites is by minor roads, and both sites are characterised by long drives separating the sites from small communities that offer limited infrastructure and few other attractions for visitors. In both areas, however, tourism is seen as one of the few possible ways to sustain existing communities in the face of declining primary-industry-based employment. In general, tourists visiting these areas are on touring holidays of two weeks’ duration or more where the attraction is the general attributes of the region as well as to a lesser extent their interest in dinosaur fossils. These provide a potential resource for remote-region economic development through commodification as a new tourism attraction. Development of dinosaur fossil finds as a tourism resource is conceptualised here as new service development. Developing new tourism services, especially in remote regions, is challenging and has not been well examined in the tourism literature. The new service development process used in this case study first examines the characteristics of the existing tourists travelling through the region. The characteristics of a number of potential market segments currently interested in dinosaur fossils were then examined and contrasted with the existing market. This is conceptualised on a specialist-generalist spectrum of interest in fossils. A study of the tourist service features associated with dinosaur fossil tourism in remote regions of the USA was conducted, leading to the identification of a number of possible incremental development opportunities. The paper then takes a strategic approach to examining potential new tourism service development related to dinosaur fossils in remote regions of Queensland, Australia. In particular, it describes use of information about existing services in similar regions as the basis for ideas about development as well as comparison between existing and potential markets.

Mentoring for population health in general practice divisions

This paper describes the implementation and evaluation of a three-way model of service development mentoring. This population health mentoring program was funded by the Commonwealth Department of Health and Ageing to enable staff from eight Divisions of General Practice in South Australia to gain a sound understanding of population health concepts relevant to their workplace. The distinguishing features of service development mentoring were that the learning was grounded within an individual's work setting and experience; there was an identified population health problem or issue confronting the Division of General Practice; and there was an expectation of enhanced organisational performance. A formal evaluation found a consensus among all learners that mentoring was a positive and worthwhile experience, where they had achieved what they had set out to do. Mentors found the model of learning agreeable and effective. Division executive officers recognised enhanced skills among their "learner" colleagues, and commented positively on the benefits to their organisations through the development of well researched and relevant projects, with the potential to improve the efficiency of their population health activities.

Advanced Asia's health systems in comparison

There is growing interest in comparing patterns of social and health service development in advanced Asian economies. Most publications concentrate broadly on a range of core social services such as education, housing, social security and health care. In terms of those solely focused on health, most discuss arrangements in specific countries and territories. Some take a comparative approach, but are focused on presentation and discussion of expenditure, resourcing and service utilization data. This article extends the comparative analysis of advanced Asian health systems, considering the cases of Japan, South Korea, Taiwan, Hong Kong and Singapore. The article provides basic background information, and delves into common concerns among the world's health systems today including primary care organization, rationing and cost containment, service quality, and system integration. Conclusions include that problems exist in 'classifying' the five diverse systems; that the systems face common pressures; and that there are considerable opportunities to enhance primary care, service quality and system integration. (c) 2006 Elsevier Ireland Ltd. All rights reserved.

Curriculum development for professional ethics in Australian human service university programmes

Australian academics and practitioners in the human services are particularly susceptible to social, political and economic influences in respect of their relevance, viability and operations. In fact, it can be argued that the impact of these influences has placed human service practitioners and academics in a perpetual state of vulnerability. Australian universities have been challenged to make their programmes more relevant and viable to the community at large, and practitioners face increasing workloads with limited resources based on restricted fiscal allocation, and the changing relationship between government and service providers. Drawing on interview data from twenty-one (n = 21) practitioners, this article highlights their identified problems regarding the notion of professionalism in the human services with a particular focus on ethical dilemmas in human service practice. Gleaning these details will be a basis for recommending necessary professionalethics curricula content in human services programmes offered in Australian universities. Moreover, while the research data is Australian based, the authors contend that the universal theories and principles underpinning human service practice justify the significance and value of the data as an important source for international consideration in curriculum development of human service academic programmes.

Development of a web-service-agents-based family wealth management system

The roiling financial markets, constantly changing tax law and increasing complexity of planning transaction increase the demand of aggregated family wealth management (FWM) services. However, current trend of developing such advisory systems is mainly focusing on financial or investment side. In addition, these existing systems lack of flexibility and are hard to be integrated with other organizational information systems, such as CRM systems. In this paper, a novel architecture of Web-service-agents-based FWM systems has been proposed. Multiple intelligent agents are wrapped as Web services and can communicate with each other via Web service protocols. On the one hand, these agents can collaborate with each other and provide comprehensive FWM advices. On the other hand, each service can work independently to achieve its own tasks. A prototype system for supporting financial advice is also presented to demonstrate the advances of the proposed Webservice- agents-based FWM system architecture.