"What you're born with, you die with." Half a Lifetime of Psychiatric Care for a Traumatized Young Woman With Cystic Fibrosis.

This case report describes 19 years of psychiatric care of a young female survivor of childhood sexual and physical abuse and neglect who also had the misfortune of having a life-compromising and life-limiting physical disease, cystic fibrosis. It summarizes ~ 100 therapeutic contacts from age 21 to age 40 and spans her journey through lung transplantation to the end of her life. The nature of cystic fibrosis and its treatment is reviewed and there is a discussion of the therapeutic process. The case is enriched by emails from the young woman describing her struggles to maintain personal integrity as her lung function declined. The case is presented with the young woman's consent.

Fathers attending the birth of their baby: Views, intentions and needs.

BACKGROUND: There is limited information about fathers' views, intentions and needs leading up to childbirth. AIMS: This study explores the factors influencing fathers' intention to attend the birth, and the needs and supports required leading up to childbirth. METHODS: Cross-sectional survey of 203 prospective fathers attending antenatal appointments at an outer metropolitan public teaching hospital in Brisbane, Australia. RESULTS: A total of 201/203 (99.0%) participants intended to attend the birth. The reported reasons included: responsibility (99.5%), protectiveness (99.0%), love for their partner (99.0%), the right thing to do (98.0%), desire to see the birth (98.0%), the perception that partners should attend (97.4%), duty (96.4%) and partner preference (91.4%). Some felt pressured by their partner (12.8%), society (10.8%), cultural expectations (9.6%) and family (9.1%), and 10.6% perceived adverse consequences for not attending. Most participants (94.6%) felt well supported, experienced good communication (72.4%), had the opportunity to ask questions (69.8%) and received an explanation of events (66.3%). They were less often supported by antenatal visits (46.7%) and by a plan for future visits (32.2%). Ten per cent of all fathers and 13.8% of experienced fathers requested better mental health support, and 9.0% prefer better clinician communication. CONCLUSIONS: Most fathers intend to attend childbirth for personal and moral reasons; however, a small proportion feel pressured. Most fathers feel well supported, although potential improvements include planning for future visits, provision of information, mental health support, clinician communication, increased involvement in their partner's care, the opportunity to ask questions and more frequent clinic visits.

"Echoes of a dark past" is a history of maternal childhood maltreatment a perinatal risk factor for pregnancy and postpartum trauma experiences? A longitudinal study.

BACKGROUND: Although associations between maternal exposure to adverse childhood experiences (ACEs) and perinatal anxiety and depression are established, there is a paucity of information about the associations between ACEs and perinatal trauma and perinatal post-traumatic stress outcomes. For the purposes of this article, perinatal trauma is defined as a very frightening or distressing event that may result in psychological harm. The event must have been related to conception, pregnancy, birth, and up to 12 months postpartum. METHODS: Women recruited at an antenatal appointment (n = 262) were invited to complete online surveys at two-time points; mid-pregnancy and eight weeks after the estimated date of delivery. The ACE Q 10-item self-reporting tool and a perinatal trauma screen related to the current and/or a previous perinatal period were completed. If the perinatal trauma screen was positive at either time point in the study, women were invited to complete a questionnaire examining symptoms of perinatal post-traumatic stress disorder and, if consenting, a clinical interview where the Post-traumatic Symptoms Scale was administered. RESULTS: Sixty women (22.9%) reported four or more ACEs. These women were almost four times more likely to endorse perinatal trauma, when compared with those who either did not report ACEs (OR = 3.6, CI 95% 1.74 - 7.36, p < 0.001) or had less than four ACEs (OR = 3.9, CI 95% 2.037.55, p < 0.001). A 6-sevenfold increase in perinatal trauma was seen amongst women who reported having at least one ACE related to abuse (OR = 6.23, CI 95% 3.32-11.63, p < 0.001) or neglect (OR = 6.94, CI 95% 2.95-16.33, p < 0.001). The severity of perinatal-PTSD symptoms for those with perinatal trauma in pregnancy was significantly higher in those women exposed to at least one ACE related to abuse. CONCLUSIONS: Awareness of maternal exposure to childhood adversity/maltreatment is critical to providing trauma-informed approaches in the perinatal setting. Our study suggests that routine screening for ACEs in pregnancy adds clinical value. This adds to previous research confirming the relationship between ACEs and mental health complexities and suggests that ACEs influence perinatal mental health outcomes.

"Fighting for the Last Gasp"-Severe Borderline Personality Disorder and Posttraumatic Stress Disorder, Chronic Deliberate Ingestion of Foreign Bodies, and Palliative Struggles in Intensive Care.

Repeated deliberate ingestion of foreign bodies can have tragic long-term consequences. We report the case of a young woman with borderline personality disorder and chronic posttraumatic stress disorder, whose chronic repeated ingestion of razor blades and batteries eventually resulted in severe medical complications. We focus on the involvement of the consultation-liaison psychiatry team as part of her multidisciplinary care, predominantly in the intensive care environment. Her care posed extensive challenges due to the retraumatizing effects of the intensive care environment and the measures required to provide life-sustaining care when the young woman was emotionally dysregulated. Strategies used to address team dynamics and "compassion fatigue" are discussed, including some pertinent relevant literature that was used as educational material for staff to develop a better understanding of the confronting and apparently self-defeating antitherapeutic behavior she frequently displayed. The consultation-liaison psychiatry team has a significant role to play in such situations, carefully balancing patient advocacy roles while simultaneously supporting staff who may be vicariously traumatized by the substantial emotional challenges of providing care in these circumstances.

Cadence discovery: study protocol for a dose-finding and mechanism of action clinical trial of sodium benzoate in people with treatment-refractory schizophrenia.

BACKGROUND: Schizophrenia is a persistent psychotic disorder often accompanied by severe disability and premature mortality. New pharmacological treatments are urgently needed. Sodium benzoate, a common food preservative holds potential to be an effective, accessible treatment for schizophrenia, though the optimal dosing and mechanism of action of the compound requires further investigation. METHODS: Individuals with persistent treatment-refractory schizophrenia (n=52) will be recruited. Patients will be randomised in a 1:1:1:1 ratio to receive treatment of one of three active doses (1000, 2000 or 4000 mg daily) of sodium benzoate or placebo for 6 weeks duration. The primary outcome measurement is change in the Positive and Negative Syndrome Scale (PANSS) total score. Secondary outcome measurements are PANSS subscales, Global Assessment of Function (GAF), Clinical Global Impression (CGI) and Patient Global Impression (PGI-I). Change in concentrations of peripheral amino acids (D-alanine, L-alanine, D-serine, L-serine, glycine and glutamate), plasma sodium benzoate, plasma catalase, 3-nitrotyrosine, malondialdehyde and high-sensitivity C-reactive protein (hs-CRP) will be determined as tertiary measures. DISCUSSION: This trial seeks to build upon previous research indicating potential efficacy of sodium benzoate for reduction of symptoms in individuals with treatment-refractory schizophrenia. The trial aims to improve the understanding of the mechanism of action of the compound. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000327886 . Registered on 23 March 2021.

Dangers in the dark: Calling for a safer practice of transvaginal ultrasonography.

BACKGROUND: The intimate examination is an important component of the assessment of a patient presenting with obstetric or gynaecological concerns. Ultrasound practitioners, like any other medical practitioner, are in a unique and privileged position. During the examination, the sonographers engage in a very close and personal interaction with an individual whom they have likely never met. They are also most likely unfamiliar with their social situation, cultural background, previous experiences with the healthcare profession and more importantly, any history of sexual trauma. It is an extremely sensitive area of practice which places a great deal of responsibility on the clinician to ensure that they not only protect their patient from psychological distress, but also themselves, from the threat of litigation arising from such distress. AIMS: This paper highlights the current governance requirements for sonographers and makes suggestions to support them in safeguarding their patients and themselves from allegations of unprofessional conduct, until such a regulatory body exists. MATERIALS AND METHODS: A wide-ranging review of the literature exploring the perceptions of female patients regarding intimate sonographic examination was performed using standard search engines. Additionally, grey literature was searched for policy statements and government regulatory documents for guidance on the topic. RESULTS: Although much research has been undertaken in this field across diverse cultures and knowledge in this area is ever increasing; however, the guidelines for sonographers appear to be site specific and variable. At present, there is no overarching governance for sonographers, as there is with practitioners registered with the Australian Health Practitioner Regulation Agency. DISCUSSION: While there are practice standards for the purposes of Medicare set out by the Diagnostic Imaging Accreditation Scheme, there is no regulatory professional standard that sonographers are held accountable to. This is problematic and has the potential for inadvertent boundary transgression by the practitioner, as there is also no existing framework for management of such incidents in an equitable manner. CONCLUSION: The intimate examination is generally well tolerated; however, there is a subset of the population who are vulnerable to psychological distress arising from the examination. The sonographer must be astute to signs of distress and act in accordance with the intimate examination guidelines set out by AHPRA, for the dual purpose of protecting their patients against harm and also themselves from the threat of litigation.

"Little more than a gut feeling?"-considerations when prescribing psychotropic medications to patients undergoing bariatric surgery.

OBJECTIVE: Bariatric surgical procedures are being commonly performed increasingly, and many surgical candidates are concomitantly taking psychotropic medication. This paper aims to elucidate issues when prescribing psychiatric medication in this setting of substantial anatomical and physiological change. METHOD: A hand search of the literature to assess the current understanding of effects of various bariatric procedures on the bioavailability of psychotropic medication. RESULTS: Predominantly malabsorptive bariatric procedures may reduce bioavailability of some but not all commonly used psychiatric medications. There is minimal information about the effects of the most commonly performed surgery, vertical sleeve gastrectomy. Lithium prescription and monitoring requires caution. CONCLUSIONS: There is limited guidance for prescription for psychotropic medication in the bariatric surgery patient group, and vigilance for unexpected adverse effects or altered efficacy is warranted.

Effect of Sodium Benzoate vs Placebo Among Individuals With Early Psychosis: A Randomized Clinical Trial.

Importance: There is evidence that sodium benzoate (BZ) may be an effective adjunctive treatment for schizophrenia. The clinical efficacy of BZ has been investigated in chronic schizophrenia; however, the efficacy of this agent has not been studied in individuals with early psychosis. Objective: To examine the clinical efficacy of the adjunctive use of BZ for symptoms in people with early psychosis. Design, Setting, and Participants: Using a placebo-controlled double-masked parallel-group design, this randomized clinical trial was conducted from August 2015 to July 2018. Participants aged between 15 and 45 years experiencing early psychosis were enrolled from 5 major clinical sites in Queensland, Australia. Data analysis was conducted from October 2018 to February 2020. Interventions: Participants were randomized 1:1 (50 participants in each group) to receive 500 mg of sodium benzoate twice daily or placebo for 12 weeks. Main Outcomes and Measures: The primary efficacy outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 12 weeks. The key secondary efficacy measures were (1) the Clinical Global Impression score, (2) the Hamilton Depression Rating Scale for depression, (3) functioning as assessed by the clinician-rated Global Assessment of Function, and (4) the Assessment of Quality of Life Scale. The PANSS subscale scores and impact on selected amino acid concentrations were also assessed. Results: The study comprised 100 participants with a mean (SD) age of 21.4 (4.1) years, of whom 73 (73%) were male individuals. The mean (SD) baseline PANSS score was 75.3 (15.4). We found no improvement in total PANSS score in the BZ group compared with the placebo group. The end result of least-squares mean difference (SE) for total PANSS was -1.2 (2.4) (P = .63). There were no differences in any subscales of the PANSS, any secondary measures, nor any amino acid concentrations. The dose of BZ was well tolerated without any clinically significant treatment-emergent adverse event differences between BZ and placebo groups. Conclusions and Relevance: In this randomized clinical trial, there was no evidence that adjunctive use of 500 mg of BZ twice daily is an effective treatment for individuals with early psychosis. Trial Registration: anzctr.org.au Identifier: ACTRN12615000187549.

Engagement with perinatal mental health services: a cross-sectional questionnaire survey.

BACKGROUND: Perinatal depression and/or anxiety disorders are undertreated pregnancy complications. This is partly due to low rates of engagement by women. This study aimed to identify barriers and facilitators to women accessing perinatal mental health services in an outer metropolitan hospital in Queensland, Australia. METHODS: Data was collected from pregnant women through a cross-sectional survey. Women rated the extent certain factors influenced their engagement. Respondents were separated into three groups: women who were not offered a referral to perinatal mental health services, women who were offered a referral but did not engage, and women who engaged. RESULTS: A total of 218 women participated. A response rate of 71% was achieved. 38.1% of participants did not believe themselves knowledgeable about mental illness in the perinatal period, and 14.7% did not recall being asked about their mental health during their pregnancy. Of those participants who recalled being asked about their mental health, 37.1% were offered a referral. Of these, just over a third (36.2%) accepted, and out of this group, 40% attended an appointment. Regardless of referral and engagement status, the factors identified as influencing participant engagement were time restraints, lack of childcare support, and encouragement by family and health care professionals. Stigma was not identified as a barrier. CONCLUSIONS: Perinatal mental health service engagement could be improved by health services: ensuring universal screening and actively engaging women in the process: assisting with childcare; improving appointment immediacy and accessibility; and educating health care professionals about their influence on women's engagement.

Protocol update and statistical analysis plan for CADENCE-BZ: a randomized clinical trial to assess the efficacy of sodium benzoate as an adjunctive treatment in early psychosis.

BACKGROUND: CADENCE-BZ is a multi-centre, parallel-group, double-blind randomized controlled trial designed to examine the clinical efficacy and safety of an accessible food preservative, sodium benzoate, as an add-on treatment for patients with early psychosis. The original study protocol was published in 2017. Here, we describe the updated protocol along with the Statistical Analysis Plan (SAP) for the CADENCE-BZ trial prior to study completion. METHODS AND MATERIALS: Two important changes were made to the original protocol: (1) improvements to our statistical analysis plan permitted a reduction in sample size; and (2) a revision in the secondary outcomes with the intent of reducing redundancy and excluding those measures that were not appropriate as outcomes. CONCLUSIONS: We provide the updated SAP prior to the completion of the study with the intent of increasing the transparency of the data analyses for CADENCE-BZ. The final participants are currently completing the study and the results will be published in the near future. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12615000187549 ). Registered on 26th February 2015.

"Too much too soon, let me out of here!" Psychiatric and obstetric implications of a child's pregnancy.

OBJECTIVE: Psychiatrists may become involved in circumstances where a child is seeking termination of pregnancy. Potential roles include capacity advice and advocacy, but ethical and legal uncertainties abound. This paper uses illustrative cases, in an Australian jurisdiction, to exemplify the issues. CONCLUSION: Termination of pregnancy at the youthful extreme raises unique challenges for all involved.

'Conceivably Neglected' - Are prescribers sufficiently aware of the risks of prescribing sodium valproate to women with mental illness?

OBJECTIVES: To describe prescription of sodium valproate (SV) for bipolar mood disorder to potentially child-bearing women within one public mental health service and describe risks of fetal exposure, and safe prescribing practices among psychiatrists. METHODS: A 24-month retrospective chart review with descriptive analysis; narrative review of literature and guidelines. RESULTS: Review of 383 charts demonstrated prescription of valproate to 20% of 98 women aged 15-45, with little evidence of advice regarding risk and contraception. Robust evidence of teratogenic and neurodevelopmental risk underpins increased regulation, and recommendations that valproate not be prescribed to this cohort. CONCLUSIONS: The significant risks associated with SV oblige all prescribers to proactively access authoritative guidelines such as those published by the Centre of Perinatal Excellence.

Perceptions of pregnant women regarding antidepressant and anxiolytic medication use during pregnancy.

OBJECTIVE: The objective of this study was to explore attitudes and decision-making by pregnant women regarding antidepressant and anxiolytic use during pregnancy. METHOD: An observational study at an outer metropolitan hospital in Brisbane, Queensland. Pregnant women presenting for their first antenatal clinic visit were invited to complete a questionnaire. Participants were asked about current or previous antidepressant/anxiolytic use, influences on drug decision-making and the adequacy of information received. Perceptions were measured on a 7-point Likert scale. RESULTS: A total of 503 pregnant women were surveyed. The background prevalence of anxiety and depression was 30.0% (151), with 9.3% (47) respondents using antidepressant or anxiolytic medications during the current pregnancy. Of these 47 women, 68% ceased these medications during or while trying to become pregnant, most commonly due to potential side effects to the baby (16), health professional advice (8) and symptomatology that was under control (7). While the effect was modest, decision-making was most strongly influenced by general practitioners, family and the internet. CONCLUSIONS: Most women cease antidepressant/anxiolytic medication before and during pregnancy for reasons other than stability of condition. This study reveals an unmet need for accessible reliable information to guide pregnant women and their care providers.

'Not quite out of the woods': potential for misdiagnosis of delayed neurologic syndrome of carbon monoxide poisoning as relapse of mental illness.

OBJECTIVE: The aim of this paper is to provide an overview of the delayed neurologic syndrome of carbon monoxide poisoning and its clinical importance in psychiatric settings. METHOD: A brief review of carbon monoxide poisoning is presented with a focus on the delayed neurologic syndrome and a case of deliberate self- poisoning is described. RESULTS: As in the case described, the delayed manifestations of carbon monoxide poisoning can resemble a relapse of psychiatric illness. CONCLUSIONS: In cases of carbon monoxide poisoning it is important to consider the delayed neurologic syndrome as misdiagnosis could lead to inappropriate treatment and worsened outcome.

The efficacy of sodium benzoate as an adjunctive treatment in early psychosis - CADENCE-BZ: study protocol for a randomized controlled trial.

BACKGROUND: Psychotic disorders affect up to 3% of the population and are often chronic and disabling. Innovation in the pharmacological treatment of psychosis has remained stagnant in recent decades. In order to improve outcomes for those with psychotic disorders, we present a protocol for the trial of a common food preservative, sodium benzoate, as an adjunctive treatment in early psychosis. METHODS: Persons experiencing early psychosis (n = 160) will be recruited through hospitals and community mental health services in Queensland, Australia. Patients will be randomized to receive either 12-week treatment with 1000 mg (500 mg twice daily (BD)) sodium benzoate or placebo. Patients will undergo fortnightly outcome assessments, in addition to weekly ongoing capacity to consent, drug compliance and safety assessments. The primary outcome measure is the Positive and Negative Syndrome Scale (PANSS) total score. Secondary outcomes are Global Assessment of Function (GAF), Assessment of Quality of Life Scale (AQOL), the Activity and Participation Questionnaire (APQ6), International Physical Activity Questionnaires (IPAQ), Simple Physical Activity Questionnaire (SIMPAQ), Physical Activity Questionnaire, Clinical Global Impression (CGI), Hamilton Depression rating Scale-17 items (HDRS), Opiate Treatment Index (OTI) and the Patients' Global Impression of Improvement (PGI-I). As a tertiary objective, changes from baseline to endpoint in to serum markers related to D-alanine, L-alanine, D-serine, L-serine, glycine and glutamate will be investigated. DISCUSSION: Consumers and clinicians are keen to help develop better treatments for those with psychosis. This study, part of the wider Cadence clinical trials platform will examine if a safe and accessible food preservative can help optimize outcomes in those with psychosis. TRIAL REGISTRATION: Australian New Zealand Clinical Trials registry (ANZCTR), ACTRN12615000187549 . Registered on 26 February 2015.

'Mastication rage': a review of misophonia - an under-recognised symptom of psychiatric relevance?

OBJECTIVE: To explore the condition of misophonia, its definition, possible neurological correlates, its associated morbidity, its possible psychiatric relevance and potential treatment. METHOD: Provision of an illustrative case vignette and a review of the limited literature. RESULTS: Misophonia is a symptom associated with obsessive-compulsive disorder and anxiety disorders and may be a syndrome in itself associated with significant distress and avoidance. Treatments are not well validated. CONCLUSION: Misophonia may be an under-recognised condition of psychiatric relevance.