Development and Preliminary Evaluation of a Rapid Screening Tool for Detecting Borderline Personality Disorder in People Aged over 60 Years.

OBJECTIVES: Screening and diagnostic instruments for Borderline Personality Disorder (BPD) are not validated in people aged over 60. We report a pilot study examining the sensitivity and specificity of a de-novo screening instrument in older adults. METHODS: The BPD-OA screening tool incorporates DSM 5 and literature describing the expression of BPD in older adults. This study was conducted using a case control design. The Diagnostic Interview for Borderlines-Revised (DIB-R) and the McLean Screening Instrument for BPD (MSI-BPD) were used as comparators. Comprehensive assessment by psychiatric teams determined participants to be (i) BPD-positive (n = 22) or (ii) BPD-negative (gender matched; n = 21). RESULTS: The BPD-OA was the most sensitive instrument for discriminating older adult BPD from non-BPD participants (sensitivity = 0.82). No significant relationship was found between the BPD-OA score and age in BPD-diagnosed participants (r = -0.181, n = 21, p = .432). Participant age explained 3.2% of the variance in BPD-OA scores. Of the 21 BPD-negative participants, eight false positives experienced prominent mood disorders (specificity = 0.62). CONCLUSIONS: The BPD-OA screening tool is clearly superior to instruments validated for use in younger people. Further refinement and evaluation will enhance its sensitivity and specificity. CLINICAL IMPLICATIONS: Detection of BPD in older adult care settings will improve outcomes for patients, families, and staff through better understanding and appropriate management and treatment strategies.

An evaluation of the practice of electroconvulsive therapy (ECT) in a Victorian health service before and after the Mental Health Act 2014.

OBJECTIVE: The aim of the project was to identify changes in the practice of electroconvulsive therapy (ECT) in a metropolitan mental health service before and after the Mental Health Act 2014 (2014 Act) in Victoria. METHOD: Retrospective clinical file audit of ECT administration across all three sites at Eastern Health (EH) two years before and two years after introduction of the 2014 Act. RESULTS: There was a statistically significant decrease in the number of compulsory ECT treatments and in the number of patients who had compulsory ECT across the three hospitals at EH in the two years following the 2014 Act compared to the two years prior to the 2014 Act. There was no significant difference in the number of voluntary ECT treatments and in the number of patients who had voluntary ECT. CONCLUSION: The review showed that there has been a significant decrease in the number of compulsory ECT treatments and in the number of patients who had compulsory ECT after the introduction of the 2014 Act. Potential reasons for the changes are discussed.

Family Presence During Electroconvulsive Therapy.

BACKGROUND: The practice of electroconvulsive therapy (ECT) is often hampered by stigma and myths prevailing among patients and families. Family attendance at ECT has not been systematically studied. METHODS: From January 2017 to May 2018, 69 consecutive patients were approached for family attendance at ECT. The inclusion criteria for entry to the ECT suite were consent from families and patients, age older than 18 years, and 1 family member at a time. After watching ECT, family members completed a multiple-choice questionnaire regarding their experience. RESULTS: Twenty-one family members watched ECT. A majority viewed the idea of attendance at ECT as reassuring, and a few indicated that it was anxiety provoking. Five participants (24%) felt distressed while watching the procedure, whereas 16 family members rated their experience as comfortable or rewarding (76%). In terms of the outcome, a clear majority have responded that watching the procedure alleviated their fears of ECT or provided transformative knowledge, whereas others felt no change in their attitude toward ECT (71% vs 29%). Most of the participants recommended watching ECT to other family members, whereas a minority was uncertain about their opinion (62% vs 38%). There were no adverse effects, premature exit from the ECT suite, interferences with treatment, or litigations. CONCLUSIONS: A clear majority of families viewed their attendance at ECT as a beneficial experience. Family presence during ECT may have the potential to promulgate its practice by reducing stigma and misconceptions.

Psychotherapeutic skills training for nurses on an acute aged mental health unit: A mixed-method design.

This study examines the need for, and outcomes of, a psychotherapeutic skills training programme, within an acute psychogeriatric unit. Nursing staff were surveyed to explore their training needs in psychotherapeutic skills with inpatients diagnosed with depressive, anxiety, or neurocognitive disorders. Staff were then invited to participate in a focus group (n = 6) to identify content of such training, possible barriers, and an implementation strategy. Next, to ascertain the feasibility and acceptability of such training, materials and schedules were developed and piloted with a small group of nurses (n = 8), before being administered to nurses across the unit (n = 23). Impacts of training on the confidence and competence of nurses to use such skills were investigated. Of nurses surveyed (n = 20), 80% wanted to use psychotherapeutic skills in routine practice, but only 35% had received training in such skills in the last 5 years. Focus group results identified that nurses wanted training in skills related to engaging patients, responding to resistance from patients, problem solving, reminiscence, relaxation, and cognitive behaviour therapy. Nurses who underwent the pilot training reported increases in confidence and competence in using such skills. These findings were replicated in the unit-wide training programme and were found to be durable across a 3-month follow-up period. This study highlighted the training needs of nurses working in an inpatient psychogeriatric setting, approaches to implementing new skills, and benefits of training for nurses' levels of confidence and competence in using psychotherapeutic skills.

Missed diagnosis: The emerging crisis of borderline personality disorder in older people.

OBJECTIVE: Clinical experience suggests a growing prevalence of borderline personality disorder in aged residential care and psychiatric facilities with attendant difficulties in their management. This paper reviews the literature concerning the prevalence, phenomenology and diagnosis of borderline personality disorder in old age. The aim is to elucidate the phenomenological differences in old age and thus improve identification of the disorder. METHODS: A systematic search was conducted using MEDLINE, PubMed, EMBASE and PsycINFO databases, employing the search terms including 'personality disorder', 'borderline personality disorder', 'aged care', 'gerontology', 'geriatric psychiatry' and 'life span'. The search included articles in English involving participants 65+ years. Long-term prospective studies of borderline personality disorder, long-term follow-up studies and studies involving older adults from 50+ years were also examined. RESULTS: There is a paucity of literature on borderline personality disorder in the elderly. No diagnostic or rating instruments have been developed for borderline personality disorder in the elderly. The phenomenology of borderline personality disorder in the aged population differs in several respects from that seen in younger adults, causing some of the difficulties in reaching a diagnosis. Escalations of symptoms and maladaptive behaviours usually occur when the diagnosis of borderline personality disorder is either not made or delayed. Improved identification of borderline personality disorder in older patients, together with staff education concerning the phenomenology, aetiology and management of these patients, is urgently needed. CONCLUSION: Diagnostic instruments for borderline personality disorder in the elderly need to be developed. In the interim, suggestions are offered concerning patient symptoms and behaviours that could trigger psychiatric assessment and advice concerning management. A screening tool is proposed to assist in the timely diagnosis of borderline personality disorder in older people. Timely identification of these patients is needed so that they can receive the skilled help, understanding and treatment needed to alleviate suffering in the twilight of their lives.

Retrospective comparison of effectiveness of right unilateral ultra-brief pulse with brief pulse ECT in older adults (over 65) with depression.

BACKGROUND: To compare response, remission and switch (to other pulse width and/or electrode placement) rates and number of treatments between groups receiving right unilateral ultra-brief (RUL-UB), Bitemporal brief (BT), Bifrontal Brief (BF) and Right unilateral brief (RUL-B). METHOD: Data was collected from case notes in three centers. There were 133 in total, grouped as RUL-UB (50), BT (43), BF (23), RUL-B (17). Two of the three centers had a preferred electrode placement and pulse width. RESULTS: Apart from age, the groups did not differ significantly on sex distribution, proportion of bipolar depression and psychotic symptoms. 56% of patients in RUL-UB switched compared to 12.5% in RUL-B, 4.9% in BT and none in BF (p value < 0.0001). When we considered patients who switched as treatment failures, remission rates were significantly different (p value < 0.0001) 40% in RUL-UB, 81.3% in RUL-B, 73.9% in BF and 78.0% in BT. Mean number of treatments in each group was significantly different (p value < 0.0001); 12.02 in RUL-UB, 10.2 in RUL-B, 7 in BF and 7.5 in BT. Post-hoc analysis indicated that RUL-UB differed significantly from BT and BF. Final response and remission rates including patients who switched were 98% and 82% in RUL-UB, 100% and 93.8% in RUL-B, 100% and 73.9% in BF and 97.7% and 83.7% in BT. CONCLUSION: Majority commencing RUL-UB switched and received 4-5 more treatments compared to bilateral placements. RUL-UB ECT appears less effective and might not be appropriate as first line for all older adults as some patients at higher anaesthetic risk would benefit from having reduced number of treatments.

Experience from mental health clinics held during medical service camps in Fiji.

OBJECTIVE: We aim to describe the experience and findings of mental health clinics held during medical service camps in the rural settings of Fiji. METHOD: Descriptive data collated at the end of the medical camps across 2011-2014 are used to highlight the main findings. RESULTS: The exposure to mental health assessments and brief interventions at these camps was a validating experience for both individuals and medical students attending the clinics. The most common presentations can be categorised under symptoms of depression, anxiety and relationship problems. CONCLUSIONS: The accessibility of mental health support services is a challenge in Fiji. Medical service camps can form an important pathway in promoting mental health awareness, especially amongst the rural communities of Fiji, and a useful platform for medical students to acquire some clinical exposure.

Is electroconvulsive therapy use among young-old and old-old adults comparable? A 10-year population-level analysis of service provision.

OBJECTIVES: Existing research on electroconvulsive therapy (ECT) in older adults has largely examined its efficacy and safety in treating depression, but there are few population-level studies of its use in this patient group. Our objective was to provide a comprehensive 10-year picture of ECT use among adults aged 65 years and older in the State of Victoria, Australia. We focused especially on comparing patterns of ECT use between young-old and old-old individuals, to better inform practicing physicians, policy makers, and researchers about ECT practices in this diverse range of patients. METHODS: We analyzed statewide ECT service provision data from 1998 to 2007 provided by the Office of the Chief Psychiatrist of Victoria. RESULTS: Age-adjustment of crude data revealed that old-old adults had the highest rate of ECT use overall (especially women) as well as the highest utilization rates for depression and public sector treatment. Although the highest rate of exclusively involuntary treatment under the Mental Health Act was also observed among old-old adults, most of the old-old patients were treated on an exclusively voluntary basis. The number of ECT treatments administered to young-old and old-old patients did not differ. CONCLUSIONS: The higher ECT utilization rates we previously reported in older adults as a whole were further accentuated in old-old individuals. Old-old adults may have medical comorbidities and personal care needs that have implications for ECT technique and service delivery. Our findings underscore the need for greater inclusion of old-old patients in future ECT research to increase its clinical applicability.

Has electroconvulsive therapy use remained stable over time? A decade of electroconvulsive therapy service provision in Victoria, Australia.

OBJECTIVE: Despite the long history of electroconvulsive therapy (ECT) as a psychiatric treatment modality in Australia, existing literature regarding ECT use and practices in Australia is limited. In this unique study, we report ECT provision in Victoria to adults aged 25 years and over from 1998 to 2007, based on complete data from all public and private treatment settings within the State; compare our results to previous literature in the field; and offer possible explanations for these findings as a basis for future research. METHOD: Analysis of statutory ECT service provision data collected by the Office of the Chief Psychiatrist of Victoria. RESULTS: ECT use declined overall from 2001 onward, followed by a small increase in use in 2007. Eighty per cent of patients received ECT for depression and 14% for psychosis. Sixty-two per cent of ECT recipients were women. Although patients aged 65 years and over were small in number, age adjustment of data was indicative of a higher utilisation rate in this group. With increasing age, the percentage of ECT recipients treated for depression increased, whereas the percentage treated for psychosis decreased. Sixty per cent of patients were treated in the public sector. Public-private sector ECT use did not differ greatly for depression, but more patients were treated in the public sector for psychosis. The majority of patients with depression received treatment voluntarily, but the converse was true for patients with psychosis. Unilateral electrode placement predominated. CONCLUSIONS: While utilisation rates gradually declined over the decade studied, patients continued receiving ECT in significant numbers, suggesting its role in treating severe mental illness is far from superceded. The present, population-level research cannot explain the causative factors underlying the patterns observed, but raises interesting questions for further investigation. Ongoing collection of statutory ECT data in a manner making it amenable to research applications is recommended.

Reducing restraint and seclusion in an acute aged person's mental health unit.

OBJECTIVE: This paper describes how a significant reduction in restraint and seclusion rates was achieved in an acute aged person's mental health unit. METHOD: We analysed seclusion and restraint data in 2009. This was supplemented with a random audit of patient files and qualitative data obtained from a survey of nursing staff. We also obtained management views on changes in management practice. RESULTS: Four major factors were found to reduce rates of restraints and seclusion. These included: (i) leadership and support from management in nursing practices, (ii) increased multidisciplinary team input, (iii) renovations to the inpatient setting, and (iv) changes in treatment-related factors such as collection of behaviour management history and improving documentation in patient files. CONCLUSION: Experiences such as this provide insights and practical strategies that can be applied in other aged inpatient units to reduce or eliminate rates of seclusion and restraints.

Intervention for depression among palliative care patients and their families: A study protocol for evaluation of a training program for professional care staff.

BACKGROUND: Clinical depression is highly prevalent yet under-detected and under-treated in palliative care settings and is associated with a number of adverse medical and psychological outcomes for patients and their family members. This article presents a study protocol to evaluate a training intervention for non-physician palliative care staff to improve the recognition of depression and provide support for depressed patients and their family members. Details of the hypotheses and expected outcomes, study design, training program development and evaluation measures are described. METHODS AND DESIGN: A randomised controlled trial will be implemented across two palliative care services to evaluate the "Training program for professional carers to recognise and manage depression in palliative care settings". Pre-, post- and three-month follow-up data will be collected to assess: the impact of the training on the knowledge, attitudes, self-efficacy and perceived barriers of palliative care staff when working with depression; referral rates for depression; and changes to staff practices. Quantitative and qualitative methods, in the form of self-report questionnaires and interviews with staff and family members, will be used to evaluate the effectiveness of the intervention. DISCUSSION: This study will determine the effectiveness of an intervention that aims to respond to the urgent need for innovative programs to target depression in the palliative care setting. The expected outcome of this study is the validation of an evidence-based training program to improve staff recognition and appropriate referrals for depression, as well as improve psychosocial support for depressed patients and their family members. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000183088.

An intensive community team in aged persons mental health.

OBJECTIVE: The aim of this paper was to describe an intensive community team (ICT) in aged persons' mental health. The rationale for setting up the team, the principles, service activity and findings from the evaluation of the service are discussed. CONCLUSIONS: The program was found to provide substantial support and benefit for patients. ICT does not replace the need for acute inpatient beds but it does provide an opportunity for some patients, who otherwise would have been admitted, to be managed in their homes. It also has the potential of reducing the length of stay for a number of patients.

An evaluation of the beyondblue Depression Training Program for aged care workers.

BACKGROUND: The prevalence of depression among older people receiving care is high, yet the rate of treatment of this disorder is low. One way to improve the pathway to care is to train care staff to recognize the symptoms of depression and raise their confidence in responding to them. In this study we evaluated the efficacy of the beyondblue Depression Training Program to achieve this aim. METHODS: Staff (N = 148) from low level care facilities and community care facilities in metropolitan Melbourne completed the beyondblue Depression Training Program, while staff in other facilities (N = 96) acted as controls. Pre-program, post-program and follow-up questionnaire data were collected and referrals for depression by staff were recorded. RESULTS: Training improved carers' knowledge about depression, their self-efficacy in responding to signs of depression and their attitudes towards working with depressed aged care recipients. In addition, training increased the number of referrals for depression made by carers. CONCLUSION: Training aged care staff in depression can improve the pathways to care for depressed care recipients, and has the potential to improve the quality of life of older people.

Vanuatu: happiest nation on earth, mental health and the Church.

OBJECTIVE: The aim of this paper was to gain an understanding of the mental health needs and services in Vanuatu, and examine the importance of the Church in the lives of the local people and the part that the Church can play in mental health service delivery. METHOD: The author visited Vanuatu to gain an understanding of the mental health needs and services in Vanuatu. This was followed by interaction with a number of churches to find out the views of church leaders about mental illness and their interest to learn about mental illness. A questionnaire was completed by 80 individuals who were also involved in some training. RESULTS: There was a widely held view that mental illness was due to a weak faith, sin or demon possession. However, there is a desire and an interest among churches to have a better understanding about mental illness. CONCLUSION: Churches in Vanuatu can and need to be mobilized to make mental health service delivery successful in the country.

Psychiatric admission in dementia care-Cultural and social factors may determine outcome.

BACKGROUND: There is a rising tide of the elderly in developed and developing nations and this would mean that there would be a similar increase in the prevalence of dementia. Data from China and India, which are the most populous nations, suggest this trend and that it will be a major social and health problem. The demented elderly will cause a rapid increase in the contribution to the global burden of disease and disability over the next 20 years unless a miracle cure for dementia is found soon. None of the nations are going to be able to keep pace with the medical needs of the elderly, especially the needs of the elderly suffering from dementia. The finite resources we have need to be managed very carefully. OBJECTIVE: This paper argues that the psychiatric needs of the elderly dementia sufferers can be met without admission to acute inpatient psychiatric units. Apart from a tiny minority, most of the problems can be managed in the community unless they have co-morbid medical problems that need admission to a general medical hospital. The paper argues that most admissions into acute inpatient psychiatric units are mainly for social rather than for psychiatric reasons. Admission might meet the needs of the carer but it is debatable as to whether the needs of dementia sufferers are best met by hospitalisation. On the contrary, we may be doing more harm than good by our interventions. Two examples are given of dementia care in a developed nation and a developing nation. We may be able to learn aspects of dementia care from developing countries.

Knowledge of late-life depression: an empirical investigation of aged care staff.

OBJECTIVES: This study examined knowledge of late-life depression among staff working in residential and community aged care settings, as well as their previous training in caring for older people with depression. METHOD: A sample of 320 aged care staff (mean age = 42 years) completed a survey questionnaire. Participants included direct care staff, registered nurses and Care Managers from nursing and residential homes and community aged care services. RESULTS: Less than half of the participating aged care staff had received any training in depression, with particularly low rates in residential care. Although aware of the importance of engaging with depressed care recipients and demonstrating moderate knowledge of the symptoms of depression, a substantial proportion of staff members saw depression as a natural consequence of bereavement, aging or relocation to aged care. CONCLUSION: Experience in aged care appears to be insufficient for staff to develop high levels of knowledge of depression. Specific training in depression is recommended for staff working in aged care settings in order to improve the detection and management of late-life depression, particularly among direct carers, who demonstrated least knowledge of this common disorder.

Barriers to care for depressed older people: perceptions of aged care among medical professionals.

The current study evaluated barriers to detection of depression among older people. Focus groups were conducted with 21 professional carers, 4 nurses, 10 general practitioners, and 7 aged care managers. The results demonstrated that care for older people is primarily focused on physical care. Further, staff resources, a lack of continuity of care, multiple co-morbidities, reluctance by older people to discuss depression, negative attitudes among carers, as well as a lack of skills all contributed to a failure to detect and treat depression. The implications of these findings for training programs for professional carers are discussed.

Depression training program for caregivers of elderly care recipients: implementation and qualitative evaluation.

The prevalence of untreated depression is high among older adults who receive care in residential facilities or in their own omes and is associated with reduced quality of life and other medical conditions, Research has suggested a number of rea-p sons for the low detection and treatment rates for this problem, including lack of knowledge and efficacy among those who provide direct care and poor communication between these caregivers and senior staff, and between senior staff and genera practitioners. In this study, we report on the implementation of a training program for care staff that aims to address these issues. Focus groups with participants who completed the training indicated a high level of satisfaction with the program and reported improvements in knowledge, self-efficacy, and communication within services. It is recommended that the program be more systematically evaluated in relation to its longer term effects on care provider practices and the well-being of depressed elderly care recipients.

Professional carers' knowledge and response to depression among their aged-care clients: the care recipients' perspective.

Depression is an under-diagnosed disorder among the elderly, even in those who are in receipt of aged-care services. One factor associated with this under diagnosis has been identified as a reluctance amongst the elderly to discuss their mood and emotions with their medical practitioners. The current study focused on why depression is not recognised and acted on by those providing residential or home-based care to older people. We interviewed 15 elderly people residing in high-level or low-level aged-care facilities, and three elderly people who were receiving personal care in their homes. All participants had been identified by their care agencies as depressed. Participants reported their perceptions of their personal carers' knowledge and practices in managing the residents' depression. Although the participants described their carers in positive terms, they were critical of their knowledge and skills in recognising depression, and indicated that the communication between personal carers and care recipients about depressive symptomatology was seriously flawed. Training for personal carers in these areas, and efforts to change organisational culture are recommended.

Effectiveness of a training program for carers to recognize depression among older people.

OBJECTIVE: Depression is a mental disorder that is frequently not detected among older people. The current study was designed to evaluate the effectiveness of a training program to assist carers to better recognize depression among older people in both community and residential care settings. METHODS: In total, 52 professional carers (26 in community care, 26 in residential care) across a range of occupations completed a four session (for personal care attendants) or six session (for registered nurses or managers) training program. The program provided training for staff to identify and respond appropriately to signs of depression. In addition, nurses and managers were trained on the use of screening tools and referral processes. Outcomes were evaluated at post-test, and 6-month follow-up. RESULTS: The results demonstrated that for all groups training was effective in increasing carers' knowledge of depression and self-efficacy in detecting depression, as well as reducing the barriers to care at both post-test and 6-month follow-up. CONCLUSIONS: The training program evaluated in the current study was effective in increasing the level of skills necessary for care staff to better detect depression among older people in both community and residential care settings. Further research is needed to determine if these improved skills are sustained over time, and if they actually improve the level of recognition of depression among older people.