A call for multi-agency collaboration in the Pacific Island countries' mental health - The World Federation for Mental Health viewpoint.

OBJECTIVE: To introduce the World Federation for Mental Health (WFMH) viewpoint on the Pacific Island countries' mental health capacity building. CONCLUSION: Multi-agency collaboration guided by a nuanced understanding of the local context can enable a public health model of mental health service delivery in the Pacific Island countries.

Ethical challenges in contemporary psychiatry: an overview and an appraisal of possible strategies and research needs.

Psychiatry shares most ethical issues with other branches of medicine, but also faces special challenges. The Code of Ethics of the World Psychiatric Association offers guidance, but many mental health care professionals are unaware of it and the principles it supports. Furthermore, following codes of ethics is not always sufficient to address ethical dilemmas arising from possible clashes among their principles, and from continuing changes in knowledge, culture, attitudes, and socio-economic context. In this paper, we identify topics that pose difficult ethical challenges in contemporary psychiatry; that may have a significant impact on clinical practice, education and research activities; and that may require revision of the profession's codes of ethics. These include: the relationships between human rights and mental health care, research and training; human rights and mental health legislation; digital psychiatry; early intervention in psychiatry; end-of-life decisions by people with mental health conditions; conflicts of interests in clinical practice, training and research; and the role of people with lived experience and family/informal supporters in shaping the agenda of mental health care, policy, research and training. For each topic, we highlight the ethical concerns, suggest strategies to address them, call attention to the risks that these strategies entail, and highlight the gaps to be narrowed by further research. We conclude that, in order to effectively address current ethical challenges in psychiatry, we need to rethink policies, services, training, attitudes, research methods and codes of ethics, with the concurrent input of a range of stakeholders, open minded discussions, new models of care, and an adequate organizational capacity to roll-out the implementation across routine clinical care contexts, training and research.

'Evaluation of testamentary capacity: A systematic review'.

OBJECTIVE: To systematically review the literature on methods for the standardized and objective assessment of Testamentary Capacity (TC), to identify the best evidence-based and clinically pragmatic method to assess TC. Doubts concerning TC can have far-reaching legal and financial implications. METHOD: A systematic search of the literature was conducted, using PRISMA guidelines, to identify studies which describe methods or tools for the assessment of TC. RESULTS: The Testamentary Definition Scale (TDS); the Testamentary Capacity Assessment Tool (TCAT); and the Testamentary Capacity Instrument (TCI) all have good psychometric properties, but TDS only partially assesses TC, and the TCI is designed for research rather than day-to-day clinical practice. CONCLUSION: The TCAT could usefully supplement the clinical assessment of TC, coupled with a standardized examination of cognition. There is room to develop an all-encompassing TC assessment tool. Currently, the clinical judgement of a medical professional, taking account of the medical, legal, ethical issues informing a capacity or competency decision, remains the gold standard for assessing TC.

Bringing together the World Health Organization's QualityRights initiative and the World Psychiatric Association's programme on implementing alternatives to coercion in mental healthcare: a common goal for action.

BACKGROUND: Stakeholders worldwide increasingly acknowledge the need to address coercive practices in mental healthcare. Options have been described and evaluated in several countries, as noted recently in major policy documents from the World Health Organization (WHO) and World Psychiatric Association (WPA). The WHO's QualityRights initiative promotes human rights and quality of care for persons with mental health conditions and psychosocial disabilities. A position statement from the WPA calls for implementation of alternatives to coercion in mental healthcare. AIMS: We describe the engagement of both the WHO and WPA in this work. We discuss their mutual aim to support countries in improving human rights and quality of care, as well as the differences between these two organisations in their stated goals related to coercion in mental healthcare: the WHO's approach to eliminate coercion and the WPA's goal to implement alternatives to coercion. METHOD: We outline and critically analyse the common ground between the two organisations, which endorse a similar range of rights-based approaches to promoting non-coercive practices in service provision, including early intervention in prevention and care and other policy and practice changes. RESULTS: Advocacy and action based on an agreed need to find practical solutions and advances in this area have the power to build consensus and unify key actors. CONCLUSIONS: We conclude that persons with lived experience, families, mental health professionals and policy makers are now coming together in several parts of the world to work toward the common goals of improving quality, promoting human rights and addressing coercion in mental health services.

OPCAT: How an international treaty regarding torture is relevant to the Australian mental health system.

The United Nations Subcommittee on the Prevention of Torture visits signatory nations to the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). Its role is to monitor and support signatory nations in implementing and complying with the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (CAT). In October 2022, the United Nations Subcommittee on the Prevention of Torture visited Australia but was barred from visiting mental health wards in Queensland and all detention facilities in New South Wales leading to the termination of its visit. This breach of Australia's obligations under the OPCAT presents a significant setback for the rights of people with mental illness and other involuntarily detained populations. This piece sets out to demonstrate the relevance of OPCAT to the mental health system in Australia. Individuals who are detained for compulsory treatment in locked facilities such as acute psychiatric inpatient wards and forensic mental health facilities are deprived of their liberty, often out of public view. Thus, it highlights the ethical and professional obligations of all mental health professionals, especially psychiatrists, to safeguard the human rights of individuals being detained in mental health facilities as enshrined in Australia's international legal obligations under the OPCAT. Adhering to these obligations diminishes the risk of future human rights violations of people with mental illness.

The socio-demographics and clinical profile of patients referred to the GP liaison psychiatry service within a metropolitan Aboriginal medical service.

OBJECTIVE: This study aimed to describe the social demographics and clinical profile of patients referred to the psychiatry service within the local Queensland metropolitan Aboriginal Medical Service (AMS). METHOD: This was a retrospective cohort study of patients referred to the psychiatry service provided at three clinics of a metropolitan AMS, over an 18-month period. Medical records were accessed to determine demographic and diagnostic information. RESULTS: Diagnostically, 53% of patients had mood/anxiety disorders, 10% psychosis, 23% substance use and 14% with other diagnoses. There was approximately 50% non-attendance rate with no statistical difference between gender and age groups. The highest proportion of non-attenders within age groups was males 45-54 years old. The patients needed to travel an average of 20 km to attend the AMS. CONCLUSION: The high non-attendance rates, and proportionately more males within the age group 45-54 years who were more likely to not attend their mental health appointments, suggested a target area for outreach services which have been implemented in the AMS. Some of the recommended solutions included confirming attendance the day prior and supporting with transport. This study highlighted the large distance that Aboriginal and Torres Strait Islander people must travel to access culturally appropriate service.

Assessing the priority of human rights and mental health: the PHRAME approach.

BACKGROUND: Protecting all human rights of people with mental health conditions is globally important. However, to facilitate practical implementation of rights, it is often necessary to decide which of these rights should be given priority, especially when they conflict with each other. AIMS: The aim of the Priorities of Human Rights and Mental Health (PHRAME) project is to develop a replicable approach to establish a proposed set of high-priority human rights of people with mental health conditions, to facilitate practical decision-making and implementation of such rights. METHOD: A two-stage Delphi-style study with stakeholders was conducted to generate a list of key rights of people with mental health conditions, and rank priorities among these rights in terms of feasibility, urgency and overall importance. RESULTS: The stakeholders in this study consistently ranked three rights as top priorities: (a) the right to freedom from torture, cruel inhuman treatment and punishment; (b) the right to health and access to services/treatment; and (c) the right to protection and safety in emergency situations. CONCLUSIONS: Insights from PHRAME can support decision-making about the priority to be given to human rights, to guide practical action. This approach can also be used to assess how human rights are prioritised in different settings and by different stakeholders. This study identifies the clear need for a central voice for people with lived experience in research and implementation of decisions about the priority of human rights, ensuring that action respects the opinion of people whose rights are directly affected.

Does menopause elevate the risk for developing depression and anxiety? Results from a systematic review.

OBJECTIVE: To determine whether menopause elevates the risk for developing diagnostic depression and anxiety. Menopause-associated vasomotor symptoms such as insomnia and hot flushes are well recognized, but no systematic review of the psychological consequences of menopause has been undertaken. Menopause can be a time of social change for women, confounding any correlation. METHODS: Using PRISMA methodology, we conducted a systematic review of all published (in English) original data examining a relationship between menopause and depression and anxiety. We ranked the quality of all included studies using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. RESULTS: Twenty-two selected studies were summarized and compared, being eight cross-sectional surveys; one retrospective cohort, and 13 prospective cohort studies. Depression and anxiety are common during menopause and the post-menopause, with vasomotor symptoms and a prior history of major depression elevating risk of menopausal associated depression. Psychosocial factors also may increase risk of depression during menopause. CONCLUSIONS: Menopause increases vulnerability to depression and anxiety, perhaps via estrogen fluctuations affecting serotonin and GABA. Underlying neuroticism and contemporaneous adverse life events are also risk factors for menopausal decompensation with depression.

Renewal of academic psychiatry without addressing gender equity will render it Jurassic rather than endangered.

While two editorials have raised concerns about the decline in Australian academic psychiatry, for a genuine rejuvenation to ever occur, we will need to re-examine how women can be better included in this important endeavour. While attainment of fellowship has reached gender parity, academic psychiatry has disappointingly lagged, with 80% of its senior leadership roles across Australia and New Zealand still held by men, with a similar situation in the United Kingdom and the United States as well as many other countries. Encouraging women into academic psychiatry is not only critical to progress as a profession but also will help address the current blindness to sex differences in biological psychiatry, as well the social impact of restrictive gender norms and the effects of gender-based violence on mental health. This potentially creates opportunities for significant gains and insights into mental disorders. However, addressing the barriers for women in academia requires tackling the entrenched disparities across salaries, grant funding, publications, teaching responsibilities, keynote invitations and academic promotions alongside the gender-based microaggressions, harassment and tokenism reported by many of our female academics. Many women must grapple with not just a 'second shift' but a 'third shift', making the burden of an academic career unreasonable and burnout more likely. Addressing this is no easy task. The varied research in academic medicine reveals no quick fixes, although promoting gender equity brings significant potential benefits. Areas such as academic psychiatry need to recognise our community's growing discomfort with workplaces that choose to maintain status quo. Gender equity must be a critical part of any quest to revive this important area of practice for our profession.

The impact of the COVID-19 pandemic on the mental health and wellbeing of refugees and asylum seekers-A Narrative Review of the Literature.

OBJECTIVE: To identify the factors affecting refugees and asylum seekers mental health and wellbeing during the COVID-19 pandemic. METHODS: A narrative review of available international research literature from January 2020 to June 2021 was conducted to identify these factors. RESULTS: Seven factors were identified: pre-existing physical health vulnerabilities, pre-existing mental health vulnerabilities, environmental, social, cultural-specific, economic and legal/welfare challenges. CONCLUSION: Multiple interacting bio-psycho-socio-economic-cultural-ecological factors lead to greater impact of COVID-19 pandemic on refugee and asylum seekers wellbeing than the general population.

Translating research into action: The design and development of an Indigenous specific suicide intervention skills training program (I-ASIST).

Note: We respectfully refer to Aboriginal and Torres Strait Islander people as Indigenous in this study. OBJECTIVE: To design and develop an Indigenous specific suicide intervention skills program that focuses on education and intervention training as an effective suicide prevention strategy. METHOD: Using a co-designed wrap-around framework, we developed a program in collaboration with >90 communities, stakeholders and service providers across Australia to understand knowledge, awareness and sense of connectedness between at-risk groups and health services or support groups. RESULTS: The I-ASIST training provides participants with the necessary skills and knowledge to apply a suicide intervention model. The framework behind the intervention model provides caregivers the awareness to recognise when someone may be at risk of suicide. It then gives them the skills to connect with a person at risk of suicide and to understand and clarify that risk, steps to keep that person safe for a specific period and then provide them with the resources or links required for further help. The program enables the development of knowledge through interactive strategies through cultural recognition and empowerment of participants. Based on a social-enterprise model, I-ASIST has been translated into a certified program supported by LivingWorks Australia. CONCLUSION: Based on a strengths-based and self-determination model of co-design, this grass roots innovative framework creates suicide safer communities.

Transparency and accountability are needed to clarify large differences in the use of forensic orders across Australia.

OBJECTIVE: Although wide variation in the use of community treatment orders mandating treatment for patients with mental illness is well known, there is much less information on the use of forensic orders mandating treatment for patients diverted from justice systems. We therefore examined the use of forensic mental health orders in Australia using routinely available data. METHOD: We completed a retrospective review of publicly reported data about forensic orders and health or criminal justice outcomes across Australia's jurisdictions. Data on the initiation and prevalence of forensic orders were extracted from annual reports by health and justice system entities with governance of forensic mental health patients. Linear mixed models were used to test for differences between jurisdictions in the number and rate of increase of forensic orders per capita open at the end of each calendar year, and the patterns of forensic order use and reporting were analysed for lessons regarding a minimum data set about the number of forensic orders, rates of re-offending, and vulnerable cohorts including Indigenous and female patients. RESULTS: While larger states generally provided useful information about the health engagement of people on forensic orders, no states routinely reported recidivism data or fully addressed vulnerable cohorts, although Victoria provided some information about Indigenous patients and Victoria and Tasmania about female patients. There were significant differences between jurisdictions on both the number of forensic orders in place in 2003, and in the rate of increase in forensic orders between 2003 and 2020. Consistent with the relative number of forensic orders extant in 2003, Queensland showed a large and NSW a moderate rate of increase in the number of people on forensic orders per capita compared with Victoria and WA. CONCLUSIONS: A standard set of minimum reported data is needed to monitor and interpret the causes and consequences of large variations in forensic systems across jurisdictions, with the greatest potential benefits for Indigenous and female patients.

Improving the mental health of Australians: A renewed call for primary care psychiatry.

OBJECTIVE: To describe different ways to improve liaison between psychiatrists and general practitioners in Australia. CONCLUSION: Strengthening the links between psychiatry and GPs in primary care is an effective approach to improve the mental health of Australians.

Mental health review board under the Mental Health Care Act (2017), India: A critique and learning from review boards of other nations.

The Mental Healthcare Act, 2017 (MHCA) of India is a landmark and welcome step towards centering persons with mental illness (PwMI) and recognizing their rights concerning their treatment and care decisions and ensuring the availability of mental healthcare services. As mentioned in its preamble, the Act is a step towards aligning India's laws or mental health (MH) policy with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), which India ratified in 2007. Amidst several positives, the implementation of the Act has been marred by certain practical issues which are partly attributed to the inherent conceptual limitations. Countries across the globe, both High Income- and Low-and Middle-Income Countries, have enacted legislation to ensure that the rights of treatment and care of PwMI are respected, protected, and fulfilled. They have also provisioned quasi-judicial bodies (Mental Health Review Boards MHRBs/tribunals) for ensuring these rights. However, their structure and function vary. This paper compares the constitution and functioning of review boards across different countries and intends to provide future directions for the effective implementation and functioning of the MHRB under India's MHCA. This review found that effective implementation of the MHRB under MHCA is compromised by an ambitious, six-membered, constitution of the MHRB, lack of clarity about the realistic combination of the quorum to adjudicate decisions, inadequate human and financial resources, and an overstretched area of functioning. Although MHRB has been envisaged as a quasi-judicial authority to ensure the rights of PwMI, it needs to be made more pragmatic. The size and composition of the MHRB currently envisaged is likely to be a barrier in the establishment of the MHRB as well as its functioning. A smaller composition (3-5 membered) involving one psychiatrist, one judicial/legal member, and at least one PwMI or member from civil society having lived experience of working with PwMI or caregiver, could be a more pragmatic approach. The passing of this law also necessitates increasing the overall health budget, especially the mental health budget with funds earmarked specifically for the implementation of the law, which necessarily includes setting up the MHRB. An evaluation of the implementation of the MHRB, including its determinants, would be a useful step in this direction.

Indian psychiatrists in the Australian workforce - From brain drain to brain exchange.

Worldwide doctors have been migrating from low- and middle-income countries to high-income countries for decades. This contributes to dearth of doctors, especially psychiatrists, in low- and middle-income countries - often referred to as 'brain drain'. Australia has a fair share of psychiatrists of Indian origin in its workforce. This article endeavours to re-formulate the migration phenomenon as 'brain exchange' through the experiential insight of the authors along with published literature and discusses the contribution of substantial number of psychiatrists of Indian origin to the Australian society. Furthermore, the article highlights the potential for the Royal Australian and New Zealand College of Psychiatrists to be a leader in this area by facilitating globally responsible practice by giving back to countries from which psychiatrists originate. The key observations and recommendations are transferrable to other similar countries and equally to other medical specialities.

Opening the doors: Critically examining the locked wards policy for public mental health inpatient units in Queensland Australia.

The Queensland Government issued a policy directive to lock all acute adult public mental health inpatient wards in 2013. Despite criticism from professional bodies and advocacy for an alternative, the policy has been retained to this day. A blanket directive to treat all psychiatric inpatients in a locked environment without individualised consideration of safety is inconsistent with least restrictive recovery-oriented care. It is against the principles of the United Nations Convention on the Rights of Persons with Disabilities, to which Australia is a signatory. It is also contrary to the main objects of the Mental Health Act 2016 (Qld). Queensland Health has reported a reduction in 'absences without permission' from psychiatric inpatient wards after the introduction of the locked wards policy; however, no in-depth analysis of the consequences of this policy has been conducted. It has been argued that patients returning late or not returning from approved leave is a more common event than patients 'escaping' from mental health wards, yet all may be counted as 'absent without permission' events. A review of the international literature found little evidence of reduced absconding from locked wards. Disadvantages for inpatients of locked wards include lowered self-esteem and autonomy, and a sense of exclusion, confinement and stigma. Locked wards are also associated with lower satisfaction with services and higher rates of medication refusal. On the contrary, there is significant international evidence that models of care like Safewards and having open door policies can improve the environment on inpatient units and may lead to less need for containment and restrictive practices. We recommend a review of the locked wards policy in light of human rights principles and international evidence.