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.

Models of care for gender dysphoria in young persons: How Psychiatry lost and is finding its voice.

Globally, models of care for young persons with gender dysphoria differ across jurisdictions. Historically, developed countries have utilised the medical approach. More recently, broader models that place a greater emphasis on psychological interventions are emerging. This piece utilizes the Australian experience to compare models of care for gender dysphoria. Reflecting on the relative passivity of Psychiatry to date, historical reasons for this silence are explored. As relative experts in relationship dynamics and key bearers of the history of sexual health diagnoses, it is proposed that Psychiatrists have both the requisite skills and responsibility to share reflective lessons with other medical specialties in this space. Only by doing so may they provide appropriate care and treatment for young persons suffering mental distress due to gender incongruence.

New injectable antiretroviral therapy for HIV facilitates novel treatment pathways for persons without capacity to consent to medical treatment.

OBJECTIVE: The development of new injectable antiretroviral therapy facilitates treatment for Human immunodeficiency virus (HIV) positive individuals who lack capacity to consent, posing a safety risk to both themselves and the wider community. We consider pathways to enforce treatment and propose an algorithm to determine the most appropriate legal instrument for application. CONCLUSION: Legislative safeguards in mental health and guardianship legislation provide oversight and protection for those who suffer from illness and require coercive treatment. These frameworks have utility in the treatment of HIV patients who lack capacity to consent to treatment.

On the receiving end: have patient perceptions of the side-effects of cancer chemotherapy changed since the twentieth century?

BACKGROUND: Studies in 1983 and 1993 identified and ranked symptoms experienced by cancer patients receiving chemotherapy. We repeated the studies to obtain updated information on patient perceptions of chemotherapy-associated symptoms. PATIENTS AND METHODS: A cross-sectional interview and patient-reported outcome questionnaires were administered to out-patients receiving chemotherapy. Patients selected from 124 cards to identify and rank the severity of physical and non-physical symptoms they had experienced and attributed to chemotherapy (primary endpoint). The patient's medical oncologist and primary chemotherapy nurse were invited to rank the five symptoms they believed the patient would rank as their most severe. We analysed the association of symptoms and their severity with patient demographics, chemotherapy regimen, and patient-reported outcomes. Results were compared to the earlier studies. RESULTS: Overall, 302 patients completed the interview: median age 58 years (range 17-85); 56% female; main tumour types colorectal 81 (27%), breast 67 (22%), lung 49 (16%); 45% treated with curative intent. Most common symptoms (reported by >50%) were: alopecia, general weakness, effects on family/partner, loss of taste, nausea, fatigue, difficulty sleeping, effects on work/home duties, and having to put life on hold. The most severe symptoms (ranked by >15% in top five) were: concern about effects on family/partner, nausea, fear of the future, fatigue, not knowing what will happen, putting my life on hold, and general weakness. Perceptions of doctors and nurses of patients' symptom severity closely matched patients' rankings. CONCLUSIONS: Compared to earlier studies, there was an increase in non-physical concerns such as effects on family and future, and a decrease in physical symptoms, particularly vomiting, but nausea, fatigue and general weakness remained bothersome. HIGHLIGHTS: • Symptoms related to chemotherapy have changed over time, likely due to less toxic regimens and improvements in supportive care. • Effects on family/partner, fear of the future, not knowing what will happen, and "life on hold" were major issues for patients. • Vomiting has decreased but nausea, fatigue and general weakness remain common symptoms for chemotherapy patients.

Use of a quality improvement strategy to introduce co-design of the mental health discharge plan in rural and remote New South Wales.

PROBLEM: Patients have not traditionally partnered in the design of their discharge plans, with discharge summaries at times not completed. In rural settings, discharge planning communicates care to a complex geographic area with fragmented resources. Patients may also be socially disadvantaged, with relatives and friends sometimes excluded. DESIGN: Situational analysis and liaison with key partners occurred in the months prior to the core project. Opportunities for improvement were noted. An audit of all discharges in May 2020 was planned to assess rates of discharge completion, co-design and inclusion of next of kin. Qualitative feedback was also noted from staff. SETTING: Dubbo inpatient mental health units (Gundaymarra and Barraminya). KEY MEASURES FOR IMPROVEMENT: Rates of discharge summary completion, co-design of discharge plan, engagement of next of kin. Qualitative measures included reflections of clinical staff involved. STRATEGY FOR CHANGE: Junior doctors were key in facilitating each patient to co-design their discharge plan and collaborate with all biological and psychosocial treatments and providers in a forum for open discussion. The inclusion of nominated next of kin was core. EFFECTS OF CHANGE: Discharge summary completion rates were high; co-design of discharge plans occurred frequently; and next of kin were involved with few exceptions. The adoption of the person as expert in modifying their plan became a norm. Medical staff wanted this care frame for each person. LESSONS LEARNT: Engaging patients and their next of kin directly in their discharge planning improves care opportunities in a rural setting, as well as understanding for all parties. This approach also prioritises the process of discharge completion.

Should we be Royal?

OBJECTIVE: Our college name The Royal Australian and New Zealand College of Psychiatrists (RANZCP) and Crest (Coat of Arms) are echoes of our colonial past, which create a barrier to an inclusive 21st-century Australasian psychiatry. Two hundred and fifty years after European settlement, this article reviews the colonial legacy, the evolution of the college and the process by which the prefix 'Royal' came to be attached. This is now an anachronism that symbolically undermines our mission to create a fully inclusive psychiatry for all Australians and New Zealanders, from indigenous people across the spectrum of cultures drawn from recent migrations within our complex multicultural society. CONCLUSION: As psychiatrists, it is time to modernise and reinvent the college name and Crest. We will be a healthier and more inclusive community of practice without the 'Royal' prefix, and with a new symbol for our college that embodies our values and vision.

Preventing prejudice by preserving the spirit of mental health legislation during the COVID-19 national emergency.

OBJECTIVE: The COVID-19 national emergency activates legislative powers that allow a proportional infringement upon individual liberties. We canvas the complex legal landscape governing mental health consumers in this climate, highlight ethical considerations in application of the law and offer a simple algorithm to navigate this space. CONCLUSION: In times of emergency, it is crucial that we uphold the safeguards embodied within mental health legislation to prevent prejudicial treatment of mental health consumers.

Considering context: lessons from global mental health.

OBJECTIVE: The development of international mental health has been characterised by the globalisation of Western psychiatric nosology that is arguably ill-suited to developing countries. This piece highlights the limitations of our current classification systems and explores how we may seek to overcome these limitations by considering the context in which symptoms present. CONCLUSION: In developing a global model of psychiatric illnesses, it is important to emphasise contextual value judgements. Doing so welcomes integration of traditional models of care and encourages partnership across nations.

The importance of self-awareness: musings of a medical student.

OBJECTIVE: Self-awareness is essential for combating burnout, promoting self-care, and wellbeing in health professionals. This article examines modern day roadblocks to developing this skill in medical practice and highlights some simple solutions for consideration. CONCLUSION: The capacity for self-awareness is essential to the modern-day physician seeking a long and fulfilling career. Mindfulness meditation and reflective writing are two simple, proven methods that can be easily implemented into medical training.

Transgender ward allocation in single-sex mental health wards: contemporary considerations.

OBJECTIVES:: Allocation of transgender patients to single-sex mental health wards in Australasia can be a complex and challenging decision in the absence of adequate awareness, education and policy that prioritize consumer safety and preference. It is a point of care that can go wrong for a transgender person. We examine relevant literature, law and existing principles of care and offer an approach. CONCLUSION:: Transgender individuals experience an excess health burden and have difficulties that are poorly understood by many health practitioners. This is partly the result of both informational and institutional biases. Relevant legal frameworks, while supportive, are still to be translated into policy. We suggest a framework that canvasses the needs of various stakeholders and considers them equally in the decision-making process.

Psychiatric advance directives in Australian mental-health legislation.

OBJECTIVE: Following the recent widespread reform of mental-health legislation in Australia, psychiatric advance directives (PADs) have now been incorporated in four jurisdictions. We contextualise the potential role for PADs within the Australian legal framework and note their varying introduction across jurisdictions, with a focus on progressive legislation in the Australian Capital Territory (ACT). CONCLUSION: The formal recognition of PADs effectively shifts the trajectory of mental-health law towards a stronger recognition of consumer autonomy, albeit to varying degrees across jurisdictions. The most inspiring of these changes may be seen in the ACT Act, where an innovative framing of PAD provisions creates a safe space for clinicians and patients to engage, build therapeutic alliances and develop appropriate frameworks for further change.