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.

Beware bandwagons! The bandwagon phenomenon in medicine, psychiatry and management.

OBJECTIVES: We examined the literature on bandwagons, fashions and fads in the fields of medicine, psychiatry and health management. CONCLUSIONS: The bandwagon effect appears to operate across medicine, psychiatry and health management, often to the detriment of patients and health organisations. The authors provide advice on recognising and managing this phenomenon.

What's to be done when 'foul whisp rings are abroad'? Gossip and rumour in health organisations.

OBJECTIVES: This article explores the relevance of gossip and rumour to health organisations and presents what limited empirical research is available specific to the management of gossip and rumour in health organisations. CONCLUSION: The concept of a sentinel function for gossip and rumour in health organisations is proposed as a topic worthy of further research.

Use of personal electronic devices by psychiatric inpatients: benefits, risks and attitudes of patients and staff.

OBJECTIVES: The study aimed to evaluate the attitudes of patients and staff in relation to the potential benefits and risks of allowing psychiatric inpatients controlled access to personal electronic devices (PEDs), and to document a snapshot audit of practice within the mental health inpatient units of New South Wales, Australia. METHODS: Psychiatric inpatients and staff at Royal North Shore Hospital's Mental Health inpatient units were surveyed, and an audit of the policies of the psychiatric inpatients of New South Wales was undertaken. RESULTS: Access to PEDs is denied in 85% of New South Wales psychiatric inpatient units. While patients and staff appear to concur on the risks of access to PEDs and the need for risk assessment and rules, compared to patients, staff appear to underestimate the importance of PEDs to maintaining social connection and recovery. CONCLUSIONS: This study may assist in the formulation of local policy and procedure to allow a more recovery-oriented approach to the question of whether patients should have access to their PEDs while in hospital.

Pharmacological management of acute severe behavioural disturbance: a survey of current protocols.

OBJECTIVES: The investigators reviewed protocols for the pharmacological management of acute severe behavioural disturbance (ASBD) used in Australasian psychiatric settings. Relevant literature was also examined, with a focus on Australian research. METHODS: All Fellows of the RANZCP were emailed on two occasions in 2014 requesting a copy of the guidelines for pharmacological management of the ASBD patient used in their workplace. A literature search was also undertaken. RESULTS: Thirty-six pharmacological management protocols for the ASBD patient were received. Twenty-six of these referred to patients aged 18-65 years and were selected for analysis. A number of recent publications provided new evidence in relation to the safe and effective management of patients with ASBD. CONCLUSIONS: ASBD is a heterogeneous, transnosological set of presentations requiring careful assessment and rational clinical decision making. Treatment protocols arising from an evolving evidence base provide safe and effective pathways for the majority of patients. However, sound clinical knowledge and a careful assessment of each presentation is required to enable the clinician to tailor treatment individually.

A substantial peer-worker workforce in a psychiatric service will improve patient outcomes - the case against.

OBJECTIVES: The aim of this work was to examine, via narrative review, the evidence supporting the drive for more peer workers to gauge the likely impact on patient outcomes. CONCLUSIONS: Despite considerable research into the effectiveness of peer workers in clinical psychiatry, there is insufficient evidence to support the proposition that a substantial peer workforce would improve the outcomes of people living with mental illness.

How shortcomings in the mental health system affect the use of involuntary community treatment orders.

Objective The aim of the present study was to examine stakeholder perspectives on how the operation of the mental health system affects the use of involuntary community treatment orders (CTOs). Methods A qualitative study was performed, consisting of semi-structured interviews about CTO experiences with 38 purposively selected participants in New South Wales (NSW), Australia. Participants included mental health consumers (n=5), carers (n=6), clinicians (n=15) and members of the Mental Health Review Tribunal of NSW (n=12). Data were analysed using established qualitative methodologies. Results Analysis of participant accounts about CTOs and their role within the mental health system identified two key themes, namely that: (1) CTOs are used to increase access to services; and (2) CTOs cannot remedy non-existent or inadequate services. Conclusion The findings of the present study indicate that deficiencies in health service structures and resourcing are a significant factor in CTO use. This raises questions about policy accountability for mental health services (both voluntary and involuntary), as well as about the usefulness of CTOs, justifications for CTO use and the legal criteria regulating CTO implementation. What is known about this topic? Following the deinstitutionalisation of psychiatric services over recent decades, community settings are increasingly the focus for the delivery of mental health services to people living with severe and persistent mental illnesses. The rates of use of involuntary treatment in Australian community settings (under CTOs) vary between state and territory jurisdictions and are high by world standards; however, the reasons for variation in rates of CTO use are not well understood. What does this paper add? This paper provides an empirical basis for a link between the politics of mental health and the uptake and usefulness of CTOs. What are the implications for practitioners? This paper makes explicit the real-world demands on the mental health system and how service deficiencies are a significant determinant in the use of CTOs. Practitioners and policy makers need to be candid about system limitations and how they factor in clinical and legal justifications for using involuntary treatment. The results of the present study provide data to support advocacy to improve policy accountability and resourcing of community mental health services.

Time to invest in developing community mental health services.

OBJECTIVES: To report on the evaluation of publicly funded community mental health services in two New South Wales health districts. METHODS: Qualitative and quantitative data from 28 publicly funded adult community mental health teams in two NSW health districts were gathered using structured interviews, benchmarking surveys, focus groups and online questionnaires. RESULTS: The community mental health services studied lacked a coherent strategic and recovery oriented framework or model of care for service delivery. There was evidence of poor role definition at the team level, resulting in duplication and inefficiency. There were inadequate staffing levels for stated objectives, a lack of training and continuing education in evidence based intervention, poor consumer and family participation in service design, and no development and monitoring of meaningful outcome measures. CONCLUSIONS: This review and benchmarking study highlights the need for mental health policy implementation to be further supported with: development of a service delivery framework outlining essential components of a specialist community mental health system; operational guidance to enable effective team specialisation in accordance with research; investment in practitioner training to support the development of evidence based practice; and processes to ensure effective consumer and carer participation in developing recovery oriented services.

Quis custodiet ipsos custodes? An audit of records of involuntary detention.

OBJECTIVES: To determine the appropriateness and utility of the certificates issued under the New South Wales Mental Health Act (MHA) and compliance with the requirements of the MHA. The analysis also compares MHA documentation by different groups of health professionals and police. METHODS: The MHA certificates associated with 100 consecutive involuntary Emergency Department presentations were audited. RESULTS: Considerable variability exists between professional groups in the level of detail, appropriateness, clinical utility and compliance of MHA certificates. Over 10% of Schedule 1s failed to meet the requirements of the MHA, potentially invalidating the involuntary detention of these patients. Information provided by police was typically superior in informing initial risk assessment and emergency management. CONCLUSIONS: A number of patients are presently being detained under incomplete MHA certificates. Educational initiatives that aim to improve awareness of the MHA's requirements, and the potential uses of the information contained in MHA certificates, could encourage professionals to complete these certificates in a more appropriate and clinically useful manner.

The Board evaluation: method, findings and recommendations.

OBJECTIVES: To describe the background, method, findings and recommendations of the Royal Australian and New Zealand College of Psychiatrists Board evaluation. CONCLUSIONS: An evaluation of the Board in the first half of its initial term indicates that the Board and the new governance processes are developing well. There appears to be a healthy group dynamic and effective working relationships with the Chief Executive Officer and management. A number of priority areas emerged for the Board's attention. The nature and low level of response from the wider membership indicate a low level of engagement in governance matters. It also seems that there are low levels of 'governance literacy' and that a different approach, perhaps facilitated focus groups, may be a more effective method for eliciting effective feedback on Board performance from the membership.

Involuntary psychiatric treatment in the community: general practitioners and the implementation of community treatment orders.

BACKGROUND: There are no data about general practitioners' (GPs') involvement in involuntary psychiatric community treatment orders (CTOs). We examined stakeholder perspectives on the GP's role in this area. METHODS: Semi-structured interviews were conducted around CTO experiences with 38 participants: patients, carers, clinicians and Mental Health Review Tribunal members. Data were analysed using established qualitative methodologies. RESULTS: Sixteen participants specifically spoke about GPs. The analysis identified four themes in their accounts: GPs as 'instruments' of CTOs; GPs as primary caregivers within a CTO; GPs as 'outsiders'; and practical challenges for GPs. Within these themes, participants identified the value of GPs in the provision of care for people living with severe and persistent mental illness, the challenges of coercive processes and the dangers of GPs being isolated from them. DISCUSSION: GPs play an important role in the implementation of CTOs. Failure to better integrate GPs in the care of people on CTOs appears to be a significant shortcoming of its implementation.

The Sydney Mental Health Client Mortality Audit: what does it tell us and what are we to do?

OBJECTIVES: To examine the characteristics of those mental health clients of an Australian metropolitan health service who died during a 6 year period, 2005 - 2010. METHODS: The medical records, and where available, coronial post-mortem examinations were audited for 109 people with schizophrenia who died while they were clients of the mental health service. RESULTS: The mean age of death for men was 45 years and for women, 47 years, compared to the general population's male and female life expectancy of 79 and 84 years, respectively. About one-half of the deaths were due to suicide (n = 55), followed by natural causes (n = 42; 39%), undetermined causes (n = 7), and accidents or acts of violence (n = 5). Smoking rates, diagnosed diabetes and hypertension were higher in the group that died from natural causes. Morbid obesity (body mass index (BMI) > 35 kg/m(2)) rates were higher in the group that died of natural causes (38%), compared with the suicide group (5%). CONCLUSIONS: While suicide accounts for the majority of those dying prematurely in this study cohort, it appears that for those who survive the risk of suicide in the earlier period of a chronic psychotic illness, there is yet another threat to life expectancy: death from preventable cardiorespiratory disorders, due to a poor lifestyle and social deprivation.

The lived experience of involuntary community treatment: a qualitative study of mental health consumers and carers.

OBJECTIVE: To describe the lived experiences of people subject to community treatment orders (CTOs) and their carers. METHOD: We recruited 11 participants (five mental health consumers and six carers) through consumer and carer networks in NSW, Australia, to take part in interviews about their experiences. We analysed the interview data set using established qualitative methodologies. RESULTS: The lived experiences were characterised by 'access' concerns, 'isolation', 'loss and trauma', 'resistance and resignation' and 'vulnerability and distress'. The extent and impact of these experiences related to the severity of mental illness, the support available for people with mental illnesses and their carers, the social compromises associated with living with mental illness, and the challenges of managing the relationships necessitated by these processes. CONCLUSIONS: The lived experience of CTOs is complex: it is one of distress and profound ambivalence. The distress is an intrinsic aspect of the experience of severe mental illness, but it also emerges from communication gaps, difficulty obtaining optimal care and accessing mental health services. The ambivalence arises from an acknowledgement that while CTOs are coercive and constrain autonomy, they may also be beneficial. These findings can inform improvements to the implementation of CTOs and the consequent experiences.

Reflective accounts of psychiatry in Australasia, 1963-2000.

OBJECTIVE: To provide reflective accounts of psychiatry through the first four decades of the existence of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). CONCLUSIONS: The period from the 1960s to the end of the millennium saw significant changes in both the craft of psychiatry and the social and cultural context in which specialist training in psychiatry occurred.

Reply to Obegi, J.H. Distinguishing Prevention from Treatment in Suicide Prevention. Comment on "Turner et al. The Paradox of Suicide Prevention. Int. J. Environ. Res. Public Health 2022, 19, 14983".

One of the aims of our paper "The Paradox of Suicide Prevention" is to promote greater discourse on suicide prevention, with a particular focus on the mental health models used for the identification of, and interventions with, individuals who come into contact with tertiary mental health services [...].

Identification of prognostic biomarkers for antibiotic associated nephrotoxicity in cystic fibrosis.

BACKGROUND: Our objective was to discover novel urinary biomarkers of antibiotic-associated nephrotoxicity using an ex-vivo human microphysiological system (MPS) and to translate these findings to a prospectively enrolled cystic fibrosis (CF) population receiving aminoglycosides and/or polymyxin E (colistin) for a pulmonary exacerbation. METHODS: We populated the MPS with primary human kidney proximal tubule epithelial cells (PTECs) from three donors and modeled nephrotoxin injury through exposure to 50 µg/mL polymyxin E for 72 h. We analyzed gene transcriptional responses by RNAseq and tested MPS effluents. We translated candidate biomarkers to a CF cohort via analysis of urine collected prior to, during and two weeks after antibiotics and patients were followed for a median of 3 years after antibiotic use. RESULTS: Polymyxin E treatment resulted in a statistically significant increase in the pro-apoptotic Fas gene relative to control in RNAseq of MPS: fold-change = 1.63, FDR q-value = 7.29 × 10-5. Effluent analysis demonstrated an acute rise of soluble Fas (sFas) concentrations that correlated with cellular injury. In 16 patients with CF, urinary sFas concentrations were significantly elevated during antibiotic treatment, regardless of development of AKI. Over a median of three years of follow up, we identified seven cases of incident chronic kidney disease (CKD). Urinary sFas concentrations during antibiotic treatment were significantly associated with subsequent development of incident CKD (unadjusted relative risk = 2.02 per doubling of urinary sFas, 95 % CI = 1.40, 2.90, p < 0.001). CONCLUSIONS: Using an ex-vivo MPS, we identified a novel biomarker of proximal tubule epithelial cell injury, sFas, and translated these findings to a clinical cohort of patients with CF.

The emperor's edicts stop at the village gate.

OBJECTIVE: To present an overview of policy implementation, and develop principles for effective policy development and implementation. METHOD: An overview of literature on policy implementation, and analysis of lessons from some recent experiences in Australian and New Zealand mental health services. CONCLUSIONS: Effective development and deployment of policy is much more complex than the commonly held, simplistic compliance model. There are principles that can guide effective policy development and implementation. Future areas of study include the policy implementation systems and change management processes in the health service setting.

An Acute Recovery Unit: the first 18 months.

OBJECTIVES: To describe a new type of acute inpatient unit, the Acute Recovery Unit, at the Concord Centre for Mental Health, Sydney and to report patient characteristics and outcome data for the first 18 months of operation. METHODS: The mission, values, principles of care and operation of the Acute Recovery Unit are presented, including the lessons from a review of the first 18 months of operation. The specialist assessment procedure, academic detailing and range of specialist interventions are described. RESULTS: Clinical outcome measures including the Health of the Nation Outcome Scale, Multidimensional Incomplete Recovery - Clinical Global Index and community tenure time post-discharge are presented. CONCLUSIONS: The Acute Recovery Unit is an important component of the range of services required at a regional level to respond to those who will develop treatment refractory mental illness.