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Mental health

Mental health Letters 2 July 2018 Free

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

To the Editor:Based on the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders,1 Malhi and colleagues have produced guideline summaries for major depression2 and bipolar disorder.3 The major depression summary is likely to be used as a stand-alone guideline by primary care physicians treating depression.2 Bipolar disorder often presents as recurrent depression.1,3 It is therefore worrying that the major depression summary omits discussion of bipolar disorder. Identifying bipolar disorder is important because the treatment is different from that required for other types of depression.2,3 The bipolar disorder summary looks to the early detection of mania, as bipolar depression cannot be reliably distinguished from major depression.3 However, there are clues to a bipolar diagnosis during the preceding depressions. Bipolar disorder might be suspected in a pervasive depressive episode which does not make sense psychologically.4,5 A family history may also be suggestive.1 Bipolar disorder should be fully integrated into the management of major depression. After diagnosing major depression, ask routinely: “Could this be an episode of bipolar disorder?”. While the question cannot be answered definitively, it most definitely warrants the asking. Suspecting bipolar disorder can provide the patient and family with some explanation and can involve them in decisions about treatment. Suspecting bipolar disorder earlier could lead to a better outcome. It may allow earlier bipolar treatment and avoid exacerbating the condition with antidepressant or psychotherapy monotherapy. At least, we could warn patients of the risk of inducing mania or cycling with antidepressants.1,3 Omitting bipolar disorder from the guidelines for major depression means that such a warning may not be considered. The major depression summary2 recommends lithium, atypical antipsychotics and electroconvulsive therapy for treatment-resistant depression. Some psychiatrists believe that these are only effective in treating melancholic depression. For the more common treatment-resistant non-melancholic depression, stronger psychotherapies such as dialectical behaviour therapy and acceptance and commitment therapy may be more efficacious than stronger biological therapies. A final thought:Depression’s a broad diagnosis and mostly a kind of neurosis. But try to enable the bipolar label and really improve the prognosis.

Norman Zimmerman

Environmental health Research 14 May 2018 Free

Psychological distress in remote mining and construction workers in Australia

Objectives: To assess the prevalence and correlates of psychological distress in a sample of remote mining and construction workers in Australia. Design, setting: A cross-sectional, anonymous Wellbeing and Lifestyle Survey at ten mining sites in South Australia and Western Australia, administered at meetings held during 2013–2015. Participants: 1124 employees at remote construction, and open cut and underground mining sites completed the survey. Main outcome measures: General psychological distress (Kessler Psychological Distress Scale, K10) and self-reported overall mental health status; work, lifestyle and family factors correlated with level of psychological distress. Results: The final sample comprised 1124 workers; 93.5% were men, 63% were aged 25–44 years. 311 respondents (28%) had K10 scores indicating high/very high psychological distress, compared with 10.8% for Australia overall. The most frequently reported stressors were missing special events (86%), relationship problems with partners (68%), financial stress (62%), shift rosters (62%), and social isolation (60%). High psychological distress was significantly more likely in workers aged 25–34 years (v ≥ 55 years: odds ratio [OR], 3.2; P = 0.001) and workers on a 2 weeks on/1 week off roster (v 4 weeks on/1 week off: OR, 2.4; P < 0.001). Workers who were very or extremely stressed by their assigned tasks or job (OR, 6.2; P = 0.004), their current relationship (OR, 8.2; P < 0.001), or their financial situation (OR, 6.0; P < 0.001) were significantly more likely to have high/very high K10 scores than those not stressed by these factors. Workers who reported stress related to stigmatisation of mental health problems were at the greatest risk of high/very high psychological distress (v not stressed: OR, 23.5; P < 0.001). Conclusions: Psychological distress is significantly more prevalent in the remote mining and construction workforce than in the overall Australian population. The factors that contribute to mental ill health in these workers need to be addressed, and the stigma associated with mental health problems reduced.

Jennifer Bowers · Johnny Lo · Peta Miller · Daveena Mawren · Brooklyn Jones

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Mental health Letters 5 March 2018 Free

Why medically unexplained symptoms and health anxiety don’t need to make your heart sink

To the Editor: We read the article by Newby and Andrews1 with great interest and wholeheartedly agree with both the prevalence of health anxiety and the effectiveness of cognitive behaviour therapy. We would add that, firstly, the scope of this problem is not confined to the primary care practitioner, and secondly, cognitive behaviour therapy can also be used to treat psychosomatic symptoms not just health anxiety.2 A proportion of medically unexplained symptoms are psychosomatic or functional in origin.3 Functional symptoms are those experienced by patients due to a problem in the nervous system or other organs not functioning appropriately, in the absence of structural abnormalities or pathological changes. Studies estimate that 15% of patients seen in a standard neurology practice are diagnosed with a functional disorder.4,5 These symptoms and syndromes are also common in other specialties; for example, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, idiopathic chronic cough, idiopathic chronic pelvic pain and globus pharyngeus, to name a few.6 The successful management of functional neurological disorders requires careful assessment of the patient’s history, presentation and investigation findings, followed by an honest clear discussion of the diagnosis and treatment options.7,8 A good explanation of the symptoms to a patient with a functional disorder — while reassuring them of the validity of their symptoms — is vital to ensure successful treatment.7,8 Metaphorical descriptions are often used in the neurological explanation of functional disorders (eg, “the hardware is fine, but there is a software problem”).7 We find that emphasising to the patient that functional symptoms are common and often reversible and that self-help is a key part of getting better also assist in empowering the patient. We direct the reader to well written articles about components of a good explanation.5-8 Finally, we often educate the patient about basic cognitive behaviour therapy concepts, including challenging negative thoughts, distraction techniques and mindfulness, as strategies to deal with or terminate the symptoms. Once this is done, patients are often more receptive to psychology or psychiatry referrals for further work. Our experience with educating and empowering patients with these strategies is that they often lead to successful treatments and grateful patients.

Benjamin Nham · Anna Williard

Letter to the Editor1
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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