Practical psychiatry: On therapeutic equipoise - Principles of a balanced approach to psychiatric treatments.

OBJECTIVE: There are many burgeoning treatments, and a large range of therapeutic options for 21st century psychiatry. This paper briefly comments upon considerations for balancing treatment to suit the patient, their illness, and their milieu. CONCLUSIONS: Therapeutic equipoise, for psychiatric care, is an aspiration rather than a position easily achieved. In day-to-day clinical practice, there will be unexpected demands and barriers that cannot always be accommodated or surmounted. Psychiatrists can work collaboratively with patients, carers, and colleagues in conceptualising and care-planning to avoid extremes of therapeutic hubris and despair, and to adapt evidence-based care more effectively so that it is suited to the patient and their circumstances.

Unpeeling the onion: Digital triage and monitoring of general practice, private psychiatry, and psychology.

OBJECTIVE: The Australian federal government is considering a 'digital front door' to mental healthcare. The Brain and Mind Centre at the University of Sydney has published a discussion paper advocating that the government should adopt a comprehensive model of digital triage and monitoring (DTM) based on a government-funded initiative Project Synergy ($30 million). We critically examine the final report on Project Synergy, which is now available under a Freedom of Information request. CONCLUSION: The DTM model is disruptive. Non-government organisations would replace general practitioners as care coordinators. Patients, private psychiatrists, and psychologists would be subjected to additional layers of administration, assessment, and digital compliance, which may decrease efficiency, and lengthen the duration of untreated illness. Only one patient was deemed eligible for DTM, however, during the 8-month regional trial of Project Synergy (recruitment rate = 1/500,000 across the region). Instead of an unproven DTM model, the proposed 'digital front door' to Australian mental healthcare should emphasise technology-enabled shared care (general practitioners and mental health professionals) for the treatment of moderate-to-severe illness.

A level playing field? Evaluation of the virtual Objective Structured Clinical Examination in Psychiatry and Addiction Medicine: A mixed methods study.

OBJECTIVE: The Objective Structured Clinical Examination (OSCE) has been used for clinical assessment of a broad range of medical student competencies in Psychiatry and Addiction Medicine. However, there has been little research into online assessments. We investigated the virtual OSCE (v-OSCE) from the user perspective to better understand its acceptability, usefulness, benefits, challenges and potential improvements. METHODS: At the conclusion of the v-OSCE, all participants (medical students, examiners and simulated patients) were invited to participate in a brief online survey, based on the Technology and Acceptance Model. Freeform qualitative feedback was also obtained to explore participants' experiences and attitudes. RESULTS: Participants reported the v-OSCE was acceptable, efficient, convenient and easy to use. It was perceived as useful for demonstrating students' interviewing skills and interacting with the simulated patient. Benefits included greater convenience, reduced stress and travel time. Challenges were similar to those experienced in 'real world' telepsychiatry, primarily related to assessment of non-verbal cues and emotional prosody. CONCLUSIONS: Our findings inform recommendations for improving online examinations. These include increased preparation, practice and professionalism, to better simulate the in-person experience. Study credibility was strengthened by the triangulation of qualitative, quantitative and psychometric data.

Mostly harmless? Clinical practice guidelines need further consideration of psychotherapy adverse effects.

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines on mood disorders recommend psychotherapy as foundational care for patients with acute depression with minimal discussion of any potential adverse effects. Randomised controlled trial evidence on psychotherapy adverse effects is limited. This is problematic because clinicians must balance the benefits of treatment against the harms, and clinical decisions become skewed without data on adverse effects. We suggest that clinical practice guidelines should be more guarded about recommending psychotherapy and add consensus statements on adverse effects for informed consent and clinical decision-making.

The 2024-2025 Commonwealth Budget for Mental Health: Funding unproven initiatives and stings in the tail.

We discuss the ramifications of the Commonwealth of Australia Budget allocations for mental healthcare for 2024-2025. There is funding for population-based mental health initiatives for milder anxiety and depression but no direct funding of services for the most severe and disabling forms of mental illness, other than pre-existing state/territory disbursements from the Commonwealth for state-based health services. There are substantial concerns that the Commonwealth funding has potentially been misallocated to ineffective interventions that are unlikely to reduce the population prevalence of mild anxiety and depression in Australia. Funds may have been better allocated to provide effective care for those with the most severe and disabling illnesses including schizophrenia, bipolar disorder and severe depression.

The travails of women with severe mental illness and pregnancy.

Women with severe mental illness and pregnancy suffer substantial travails in accessing care for mental and perinatal health. Women with psychotic illnesses such as schizophrenia face higher risks of pregnancy and postnatal complications. Similarly, lack of access to holistic psychiatric care presents particular perils for these women and their children. Tailored care for these mothers-to-be and their babies is needed to prevent and ameliorate health complications, mental and physical. This will require targeted funding of services that connect women with and provide continuity of care.

Reflection on the RANZCP position on the adverse effects of psychotherapy.

OBJECTIVE: In this perspective, we investigate how the Royal Australian and New Zealand College of Psychiatrists' (RANZCP) position statement on psychotherapy takes the potential for adverse effects into account. CONCLUSIONS: Psychotherapy has two critical outcomes - efficacy and adverse effects. Evidence-based psychotherapy is significantly more effective than care-as-usual for about one in 10 psychotherapy patients. However, a similar proportion also reports adverse effects. Despite this, the RANZCP position statement on psychotherapy focuses on efficacy with minimal discussion of the adverse effects. This is an oversight because psychiatrists have legal and ethical obligations to consider the adverse effects as well as the benefits of any treatment. We therefore reflect on the RANZCP's six recommendations in light of the adverse effects of psychotherapy.

Practical psychiatry: Taking gaming seriously - a primer for psychiatrists on gamers and gaming culture.

OBJECTIVE: Up to three billion, of the eight billion people in the world, play videogames. Gaming is a significant global sociocultural influence. This primer will aid psychiatrists in understanding sociocultural milieux of gamers, who include patients and their communities. METHOD: A rapid narrative review. RESULTS: Benefits include expression of personality, identity and culture through social aspects of gaming. Improved physical health, neurocognition, self-efficacy and quality of life are associated with gaming in those with certain mental health disorders including schizophrenia. Harms may include in-game discrimination, disordered gaming, as well as encouragement of online gambling. There is no longitudinal association between violent games and youth aggression. CONCLUSIONS: Psychiatrists should enquire about gaming as part of the sociocultural milieux of patients' lives, and the perceived mental health benefits and harms of gaming.

Australian specialised mental healthcare labour shortages: Potential interventions for consideration and further research.

OBJECTIVE: Specialised mental healthcare delivery is highly labour intensive, and the COVID-19 pandemic has exacerbated workforce shortfalls. We explore the information on the mental healthcare labour supply in Australia from a health policy viewpoint. Our purpose is to stimulate discussion, further research and development of interventions. CONCLUSIONS: The mental healthcare labour market has a number of features that make it prone to shortages and other distortions. These include: the labour-intensive nature of healthcare work;, long-training periods; that traditional policy levers like pay are only partially effective; as well as other challenges in retaining and recruiting mental health nurses and psychiatrists, especially in public mental health services. Further research is needed to develop and evaluate effective interventions.

Bullying within specialist medical training in Australia: Analysis of the medical training survey, 2020-2023.

OBJECTIVE: Bullying is common in medical specialist training in Australia. To understand bullying rates across medical specialist training programs, we analyse the recent Medical Training Survey, administered by the Medical Board of Australia to all registered medical practitioners. METHODS: Medical Training Survey data were extracted and averaged from 2020 to 2023. RESULTS: Many speciality trainees reported personally experiencing or witnessing bullying. This was lowest in general practice (13% personally experienced and 15% witnessed) and highest in obstetrics and gynaecology (27% and 41%). The highest rate of bullying by supervisors was in surgery: 60% of surgical trainees stated that when they were bullied it was by their supervisor. Within psychiatry, 22% of trainees had personally experienced bullying and 32% of trainees had witnessed bullying. When they were bullied, the perpetrator was less commonly a supervisor (40%). In all specialities, there was a very low percentage of bullying which was reported, and was identified as having a satisfactory outcome: the most satisfactory outcomes (13%) were in general practice. CONCLUSION: Current rates of bullying for medical specialist trainees, the reluctance to report, as well as the lack of satisfactory outcomes, is of grave concern for Australian healthcare. This requires urgent attention at a systems level.

Psychosocial workplace safety in mental health services - Commentary and considerations to improve safety.

OBJECTIVES: Psychosocially unsafe workplaces are related to burnout, especially amongst trainees and psychiatrists. Burgeoning research on psychosocial workplace safety indicates the importance of organisational governance to reduce adverse professional, and consequently patient, outcomes in healthcare by balancing job demands and resources. We provide a brief commentary on the relevance of the concept of the Psychosocial Safety Climate model for mental health services and healthcare workers, and considerations for action. CONCLUSIONS: Based on the Extended Job Demand-Resource model, the Psychosocial Safety Climate model has been developed and validated in community and healthcare environments. Psychosocial safety is also an Australian workplace safety requirement. An important direction to improve working conditions, reduce adverse outcomes, and improve recruitment and retention of healthcare workers, may be to adopt and formalise psychosocial workplace safety as a key performance indicator of equal importance to productivity for mental healthcare services.

Behind the curtain of Australasian Psychiatry: The practice of a medical journal and a call for reviewers.

The process of medical scientific journal publishing merits further explanation for authors and readers. Prospective authors need to understand the scope of the journal and the article types that are published. We give an overview of the editorial process, including selection of reviewers, peer review and decisions regarding revision, acceptance and rejection of papers for Australasian Psychiatry. We encourage authors and readers to submit papers, and volunteer as peer reviewers, working together with the journal editorial team.

Psychiatric electronic health records in the era of data breaches - What are the ramifications for patients, psychiatrists and healthcare systems?

OBJECTIVE: To update psychiatrists and trainees on the realised risks of electronic health record data breaches. METHODS: This is a selective narrative review and commentary regarding electronic health record data breaches. RESULTS: Recent events such as the Medibank and Australian Clinical Labs data breaches demonstrate the realised risks for electronic health records. If stolen identity data is publicly released, patients and doctors may be subject to blackmail, fraud, identity theft and targeted scams. Medical diagnoses of psychiatric illness and substance use disorder may be released in blackmail attempts. CONCLUSIONS: Psychiatrists, trainees and their patients need to understand the inevitability of electronic health record data breaches. This understanding should inform a minimised collection of personal information in the health record to avoid exposure of confidential information and identity theft. Governmental regulation of electronic health record privacy and security is needed.

Healthcare provider data breaches - framework for crisis communication and support of patients and healthcare workers in mental healthcare.

Increasing numbers of healthcare data breaches highlight the need for structured organisational responses to protect patients, trainees and psychiatrists against identity theft and blackmail. Evidence-based guidance that is informed by the COVID-19 pandemic response includes: timely and reliable information tailored to users' safety, encouragement to take protective action, and access to practical and psychological support. For healthcare organisations which have suffered a data breach, insurance essentially improves access to funded cyber security responses, risk communication and public relations. Patients, trainees and psychiatrists need specific advice on protective measures. Healthcare data security legislative reform is urgently needed.

Comparing the trends of MBS telepsychiatry and consultant physician telehealth services from 2017 to 2022: A retrospective study.

OBJECTIVE: The Medicare Benefit Schedule (MBS) telehealth items were expanded in March 2020 during the COVID-19 pandemic. We measured the use of MBS telepsychiatry items compared to consultant physician telehealth items within the context of these item changes, to understand differences in telepsychiatry and physician telehealth utilisation. METHODS: Monthly counts of face-to-face and telehealth (videoconferencing and telephone) MBS items for psychiatrists and physicians from January 2017 to December 2022 were compiled from Services Australia MBS Item Reports. Usage levels were compared before and after telehealth item expansion. Usage trends for MBS telepsychiatry and physician telehealth items were compared in time-series plots. RESULTS: Telehealth item expansion resulted in a greater rise of telepsychiatry services from 3.8% beforehand to 43.8% of total services subsequently, compared with physician telehealth services (from 0.6% to 20.0%). More physician telehealth services were by telephone compared with telepsychiatry services. Time-series of both telehealth services displayed similar patterns until mid-2022, when physician telehealth services declined as telephone items were restricted. Telepsychiatry services consistently comprised a greater proportion of total services than physician telehealth services. CONCLUSIONS: MBS psychiatrist services showed a more substantial and persistent shift to telehealth than physician services, suggesting a greater preference and use of telepsychiatry.

Deprescribing antidepressants for depression - what is the evidence for and against?

OBJECTIVE: Recent guidelines suggest that the overall quantity and duration of antidepressant prescriptions should be reduced. In this paper, we comment on the evidence both for and against this view. METHODS: We critically review the arguments proposed by proponents of antidepressant deprescribing in the context of the evidence-base for the treatment of depression. RESULTS: Proponents of deprescribing do not address the substantive issues of whether inappropriate prescribing has been demonstrated, and when prescribing is needed. Their arguments for deprescribing are rebutted in this context. CONCLUSIONS: Whether or not to deprescribe antidepressant medication needs to take into consideration the risk-benefit profile of the decision, the responsibility for which needs to be shared and based on the context of the patient's depression, their preferences, experiences and perspectives.

Comparison of the out-of-pocket costs of Medicare-funded telepsychiatry and face-to-face consultations: A descriptive study.

OBJECTIVE: Telepsychiatry items in the Australian Medicare Benefits Schedule (MBS) were expanded following the COVID-19 pandemic. However, their out-of-pocket costs have not been examined. We describe and compare patient out-of-pocket payments for face-to-face and telepsychiatry (videoconferencing and telephone) MBS items for outpatient psychiatric services to understand the differential out-of-pocket cost burden for patients across these modalities. METHODS: out-of-pocket cost information was obtained from the Medical Costs Finder website, which extracted data from Services Australia's Medicare claims data in 2021-2022. Cost information for corresponding face-to-face, video, and telephone MBS items for outpatient psychiatric services was compared, including (1) Median specialist fees; (2) Median out-of-pocket payments; (3) Medicare reimbursement amounts; and (4) Proportions of patients subject to out-of-pocket fees. RESULTS: Medicare reimbursements are identical for all comparable face-to-face and telepsychiatry items. Specialist fees for comparable items varied across face-to-face to telehealth options, with resulting differences in out-of-pocket costs. For video items, higher proportions of patients were not bulk-billed, with greater out-of-pocket costs than face-to-face items. However, the opposite was true for telephone items compared with face-to-face items. CONCLUSIONS: Initial cost analyses of MBS telepsychiatry items indicate that telephone consultations incur the lowest out-of-pocket costs, followed by face-to-face and video consultations.

Indigenous suicide rates in the United States, Australia and New Zealand between 2006 and 2019.

OBJECTIVE: Indigenous suicide prevention is an important focus for national health policies. Indigenous suicide rates in formerly colonial English-speaking countries such as the United States, Australia and New Zealand are considerably higher than the general population, particularly in young males. Given the similarities in their sociocultural history, a time series analysis was conducted to assess recent sex and age trends of suicide in the Indigenous and general populations in the United States, Australia and New Zealand. METHODS: Using the number of deaths by intentional self-harm and estimated resident population, suicide incidence rates were calculated for the years 2006-2019 and stratified by Indigenous status, year, time period, sex and age group (above 15 years). Incidence rates were plotted. Using the Poisson regression model, calculated suicide incidence rate ratios were used to make comparisons for sex and age. RESULTS: Across all countries studied, Indigenous suicide rates have increased over time, with Indigenous males having higher suicide rates than Indigenous females. However, the increase in Indigenous female suicides was greater than that for Indigenous males in Australia and New Zealand. Indigenous males aged 15-44 years have the highest suicide rates across all countries. CONCLUSION: Indigenous suicide rates have remained consistently high in the United States, Australia and New Zealand, with Indigenous males aged 15-44 years showing the highest rate. However, suicide rates for Indigenous females in Australia and New Zealand are increasing more rapidly than males. Given this, it is critical that further research is dedicated to understanding and addressing the issues driving this problem, particularly in youth.

Practical psychiatry: Providing temporary psychiatric cover.

OBJECTIVE: Psychiatric cover for healthcare staffing shortfalls is increasingly common post-pandemic. We aim to provide comprehensive practical advice on providing temporary inpatient or outpatient cover as a psychiatrist, based on the authors' clinical experience and the existing research literature. CONCLUSIONS: There is limited peer-reviewed advice available on providing safe and effective temporary psychiatric consultant cover for patient care. We suggest a framework for reviewing the potential hazards and benefits of a temporary post, and planning for the role, guided by consideration of the following: caring for patients, supporting staff, working with peers, and understanding local healthcare systems and the local regulatory environment. Application of this reflective framework is informed by the psychiatrist's assessment of the temporary role, and consideration of the local service conditions.

Remaining on course, online: Reflections and recommendations on more effective psychiatrist participation in online chat forums in the context of social media dynamics.

OBJECTIVE: To provide a synthesis of psychiatrist experience, online resources, and peer-reviewed literature to document benefits and challenges, and thus derive recommendations on participating in professional psychiatrist online chat forums. CONCLUSIONS: Psychiatrists should carefully consider and curate their participation in online chat forums. Convivial discourse, including shared interests, knowledge, and skills are benefits. However, social media dynamics influence online roles and behaviour. There is a performative aspect to chat forums and social media, through depiction of a participant's persona, which can be understood through social avatar theory. Even on well-moderated chat forums, there remain the risks of subtle forms of negative social media roles and behaviour (e.g. cyberbullying, online abuse, and trolling). Furthermore, there are potential risks to professional identity and reputation from posting material as well as others commenting upon psychiatrists' posts. A single unprofessional post can have a devastating impact on reputation. There are also opportunity costs from the time, attentional and emotional costs of following a forum, which can also lead to harms from anxiety and depression due to excessive social media use. We provide practical recommendations on e-professionalism for more effective participation online.