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General medicine

Mental health Guideline summary 5 February 2018 Free

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders: bipolar disorder summary

Introduction: In December 2015, the Royal Australian and New Zealand College of Psychiatrists published a comprehensive set of mood disorder clinical practice guidelines for psychiatrists, psychologists and mental health professionals. This guideline summary, directed broadly at primary care physicians, is an abridged version that focuses on bipolar disorder. It is intended as an aid to the management of this complex disorder for primary care physicians working in collaboration with psychiatrists to implement successful long term management. Main recommendations: The guidelines address the main phases of bipolar disorder with a particular emphasis on long term management, and provide specific clinical recommendations. Mania: All physicians should be able to detect its early signs so that treatment can be initiated promptly. At the outset, taper and cease medications with mood-elevating properties and institute measures to reduce stimulation, and transfer the patient to specialist care. Bipolar depression: Treatment is complicated and may require trialling treatment combinations. Monotherapy with mood-stabilising agents or second generation antipsychotics has demonstrated efficacy but using combinations of these agents along with antidepressants is sometimes necessary to achieve remission. Commencing adjunctive structured psychosocial treatments in this phase is benign and likely effective. Long term management: Physicians should adjust treatment to prevent the recurrence of manic and/or depressive symptoms and optimise functional recovery. Closely monitor the efficacy of pharmacological and psychological treatments, adverse effects and compliance. Changes in management as a result of the guidelines: The guidelines position bipolar disorder as part of a spectrum of mood disorders and provide a longitudinal perspective for assessment and treatment. They provide new management algorithms for the maintenance phase of treatment that underscore the importance of ongoing monitoring to achieve prophylaxis. As a first line treatment, lithium remains the most effective medication for the prevention of relapse and potential suicide, but requires nuanced management from both general practitioners and specialists. The guidelines provide clarity and simplicity for the long term management of bipolar disorder, incorporating the use of new medications and therapies alongside established treatments.

Gin S Malhi · Tim Outhred · Grace Morris · Philip M Boyce · Richard Bryant · Paul B Fitzgerald · Malcolm J Hopwood · Bill Lyndon · Roger Mulder · Greg Murray · Richard J Porter · Ajeet B Singh · Kristina Fritz

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General medicine Research 15 January 2018 Free

Diagnosing COPD and supporting smoking cessation in general practice: evidence–practice gaps

Objectives: To review the accuracy of diagnoses of chronic obstructive pulmonary disease (COPD) in primary care in Australia, and to describe smokers’ experiences with and preferences for smoking cessation. Design, setting and participants: Patients were invited to participate if they were at least 40 years old and had visited participating general practice clinics in Melbourne at least twice during the previous 12 months, reported being current or ex-smokers with a smoking history of at least 10 pack-years, or were being managed for COPD. Interviews based on a structured questionnaire and case finding (FEV1/FEV6 measurement) were followed, when appropriate, by spirometry testing and assessment of health-related quality of life, dyspnoea and symptoms. Results: 1050 patients attended baseline interviews (February 2015 – April 2017) at 41 practices. Of 245 participants managed for COPD, 130 (53.1%) met the spirometry-based definition (post-bronchodilator FEV1/FVC < 0.7) or had a clinical correlation; in 37% of cases COPD was not confirmed, and no definitive result was obtained for 9.8% of patients. Case finding and subsequent spirometry testing identified 142 new COPD cases (17.6% of participants without prior diagnosis; 95% CI, 15.1–20.5%). 690 participants (65.7%) were current smokers, of whom 360 had attempted quitting during the previous 12 months; 286 (81.0% of those attempting to quit) reported difficulties during previous quit attempts. Nicotine replacement therapy (205, 57.4%) and varenicline (110, 30.8%) were the most frequently employed pharmacological treatments; side effects were common. Hypnotherapy was the most popular non-pharmacological option (62 smokers, 17%); e-cigarettes were tried by 38 (11%). 187 current smokers (27.6%) would consider using e-cigarettes in future attempts to quit. Conclusions: COPD was both misdiagnosed and missed. Case finding and effective use of spirometry testing could improve diagnosis. Side effects of smoking cessation medications and difficulties during attempts to quit smoking are common. Health professionals should emphasise evidence-based treatments, and closely monitor quitting difficulties and side effects of cessation aids. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12614001155684.

Jenifer Liang · Michael J Abramson · Nicholas A Zwar · Grant M Russell · Anne E Holland · Billie Bonevski · Ajay Mahal · Kirsten Phillips · Paula Eustace · Eldho Paul · Sally Wilson · Johnson George

17 00664
Health services administration Supplement 20 November 2017 Open Access

Targeting mental health care attributes by diagnosis and clinical stage: the views of youth mental health clinicians

Promoting routine, consistent collection of clinical stage data may enhance appropriate targeting of mental health care delivery

Matthew P Hamilton · Sarah E Hetrick · Cathrine Mihalopoulos · David Baker · Vivienne Browne · Andrew M Chanen · Kerryn Pennell · Rosemary Purcell · Heather Stavely · Patrick D McGorry

General medicine Guideline summary 20 November 2017 Free

COPD-X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update

Chronic obstructive pulmonary disease (COPD) is characterised by persistent respiratory symptoms and chronic airflow limitation, and is associated with exacerbations and comorbidities

Ian A Yang · Juliet L Brown · Johnson George · Sue Jenkins · Christine F McDonald · Vanessa M McDonald · Kirsten Phillips · Brian J Smith · Nicholas A Zwar · Eli Dabscheck

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Endocrinology Letters 20 November 2017 Free

Cortisone injections for tennis elbow should be an “avoid”, rather than a recommended procedure

To the Editor: We are strong supporters of Choosing Wisely, which promotes appropriate use of medical procedures and evidence-based medicine. We bring to your attention an example of a recommendation published in the 2017 edition of the Australian Therapeutic Guidelines for rheumatology,1 which is contrary to level 1 evidence (ie, multiple randomised control trials) and the Choosing Wisely ethos. The guidelines suggest that local corticosteroid injections may be considered for lateral epicondylitis (tennis elbow) and repeated if needed. The recommendation uses the less than prudent justification: “local corticosteroid injection can provide pain relief for 6–12 weeks”.1 There are now at least five high quality randomised control trials of corticosteroid injection for tennis elbow with 6 or more months follow-up, and collectively they show harm of corticosteroid compared with placebo injection or conservative treatment for time periods greater than 3 months. We reference three of these trials,2-4 and others show consistent results. There are no high quality published trials showing benefit of corticosteroid over placebo injection at time periods greater than 3 months, and one review, in fact, showed an association of poorer long term outcome with repeated injections.5 It is not reasonable, nor should it be good clinical practice, to justify a possible medium term harm by reference to a much shorter term benefit. Based on current evidence, corticosteroid injection for tennis elbow should become a Choosing Wisely “avoid” procedure. Practice guidelines such as the Australian Therapeutic Guidelines for rheumatology ought to more carefully consider level 1 evidence to avoid supporting a prevailing traditional treatment option that is not evidence-based. In treatments with potential benefits and harms that have been tested by randomised control trials, recommendations should only support those treatments with a high quality trial evidence of benefits outweighing harms.

John W Orchard · Bill Vicenzino

Tennis Elbow
Social determinants of health Letters 18 September 2017 Free

Family violence: an illustrated guide to the terminology

To the Editor:Recent reports from the World Health Organization1 and from Australian agencies2,3 emphasise the urgency of improving health service response to family violence. Understanding the victim and survivor experience and perpetrator patterns is essential to improving health practitioners’ capacities for recognising and responding appropriately to family violence.1,3 Although there is an increasing awareness of the severity of health consequences of family violence,1,4 there is little standardisation of terminology within the national and international literature. The Royal Australian College of General Practitioners recognises physical, emotional, economic, social, sexual, psychological, verbal and spiritual abuse as forms of family violence.4 Family violence includes any violence or abuse that occurs within a family,4 including between partners, parents, children, siblings, uncles or aunts, cousins, grandparents and in-laws. Complexities arise because of the pervasive nature of violence when trying to differentiate the types of violence and individual victims. For example, studies show that 50% of children who experienced physical abuse and 40% of children who experienced sexual abuse have a mother who experienced intimate partner violence.5 “Domestic violence” emphasises the place of the violence, whereas “family violence” emphasises the relationships between the victim and the perpetrator. “Intimate partner violence” refers to the “behaviour within an intimate relationship” of current or former partners (including same-sex relationships) causing “physical, emotional, sexual, economic and social harm to those in the relationship”.4 Family violence (Box) encompasses domestic violence, intimate partner violence and sibling violence. Cases of child neglect, child abuse, child sexual abuse, sexual assault and rape may occur in the context of family violence; however, these forms of violence may also occur outside the context of the family, such as institutional abuse or stranger violence. Likewise, older people abuse, which can include sexual abuse and rape, may occur in the context of family violence and also in institutional contexts, in the context of service provision or between people who have no familial or institutional relationships. An increased understanding of the terminology used in the research literature enhances the capacity for delivering high quality care to women, children and men experiencing the health impacts of family violence. Box – Terminology for family violence Figure by Debbi Long and Serena Lee.

Debbi Long · Serena Lee · Jan Y Coles

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