The things I’m excited about:

1. Getting a good grasp on brain chemistry and the action of substances of abuse (as well as psychiatric medication).

2. Working in a real lab – with all sorts of instruments and beakers and weird contraptions invented by the people in this centre. And maybe getting to use a mass spectrometer! (What can I say…Abby Sciuto is my geek girl hero.)

3. Being able to wear casual clothes and runners (very different to my job, which has clinical contact!). Shallow, I know, but I like being comfortable.

Exciting! But, at the same time, major changes are afoot in the future of my training/profession, changes that I don’t know a whole lot about yet, but that make me wary. On one hand, there is a (wholly justifiable) push to better regulate the profession, and to require a higher level of qualifications, in line with other countries. On the other, the federal government has recently and dramatically cut the number of sessions available to patients under Medicare (from 18 to 10), which doesn’t comply with evidence-based treatment for a lot of psychological disorders/severity (a good summary here). So on the one hand, lengthier and more stringent training is required, and on the other, you are somewhat thwarted once you finish the training. More changes may be coming up too. Anyway, all I can do is take it one step at a time and hope for the best.

I recently attended some talks on mental health in refugees, people from CALD¹ backgrounds, and Indigenous people. Really interesting and important stuff. How appropriate is it to assess someone with these backgrounds using established “mainstream” tools? How do mental illness symptoms manifest themselves differently in different cultures? What are some of the signs to look out for in terms of trauma, torture, domestic violence? And what are the risk factors for developing a mental illness in these populations? These are some of the points raised in the talks, and things I’ve been thinking about lately.

It all comes under the umbrella of culturally-competent practice, which in a nutshell, is not imposing assumptions, and being open to information that may conflict with your beliefs/stereotypes/established norms, etc to be able to treat people from cultural backgrounds different to your own. The main point I took away regarding culturally-competent practice is that it’s not necessarily “how much” you know, but how open you are to receiving information. I would add to this the need to be aware of your own context, and of biases and beliefs that influence you – no one is a blank slate and I think the only way to deal with this is to be mindful of your own position and what you’re bringing to the table.

Here are some points I picked up:

1. Being an immigrant does not inherently boost the risk of developing a mental illness. Pre- and post-migration factors play a big part. Pre-migration factors may be political turmoil in the country of origin, trauma/torture/persecution of yourself or family, having to leave family behind. Post-migration factors include not having a good support network, not being able to find employment, language and cultural barriers to receiving appropriate care, and discrimination.

2. In many cultures, it is perfectly appropriate to have experiences that would normally put you in the “severe, possibly psychotic mental illness” category quite squarely – such as hearing voices. This is quite usual for many Indigenous people, who may hear family members and friends who’ve passed away talking to them.

3. It’s important to look at methods of healing traditionally endorsed by the client’s/patient’s culture. Normally healthcare in Australia stays away (or tries to) from anything to do with spirituality or religion,
but in some cases it would be appropriate to ask a spiritual leader for a prayer, or wearing a holy talisman, having a house blessed, etc.

4. Advocacy is important, especially for people who’ve left family behind – producing supporting documentation to help reunite the family, for example, or that shows that certain types of work are not appropriate, or to help secure disability services as needed.

5. Respect for boundaries is very important, for example choosing age- and gender- appropriate health providers for people from cultures that emphasise a separation of values between such groups.

6. Body language may not always be read correctly. For example, avoiding eye contact may be a way of showing respect. Also, short “yes/no” answers may be a way of avoiding real issues in an attempt to make an assessment/interview/session come to an end quickly, so these are to be avoided. Open-ended questions and plenty of time for answers are best (although it’s frustrating that the health system in general really doesn’t encourage spending a lot of time with each individual).

7. This is really basic but also really important: explaining every procedure, therapy, medication, etc in a way that can be easily understood and making the treatment process collaborative, rather than something being ordered “from above” by an authority figure (which, let’s face it, would make many of the people in the above groups quite uneasy, frightened or non-compliant, and with really good reason – or, on the flipside, some people may comply too easily and not ask enough questions, without fully understanding a procedure). It’s best to have an interpreter or a cultural consultant present, rather than family members (although interpreters can be hard to find with languages that are not common community languages).

These are the things that come to mind – I may add more if I remember other points later.

And some links:

NSW Multicultural Health Communication Service

Health information and resources in languages other than English – by language or by topic

NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS)

The Australian Indigenous Psychologists Association (AIPA)

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1. CALD = culturally and linguistically diverse

The issue of suicide is very personal to me. Like many of us, I’ve lost a loved one to suicide. Looking back on it, I realise there were little to no resources for him to access at the time, and that his issues were not understood, or were ignored. His death has left a trail of destruction in the lives of those who were close to him.

For WSPD this year I wanted to post some information about suicide and where to get help.

National Crisis Services
Emergency: 000
Lifeline (telephone crisis counselling): 13 11 14
Suicide Callback Service: 1300 659 467

Please see the bottom of this post for state-specific resources and for national information lines.

Risk factors for suicide in Australian youth
Being male, living rurally, being Indigenous, non-heterosexual, having a mood disorder, a history of suicide attempts, substance abuse, stressful or traumatic life events, family problems, family history of suicide, easy access to means of suicide, social disengagement, unemployment.

Suicide Myths
1. Talking about suicide will cause suicide. False: Talking openly about suicide can save a life. Sometimes people don’t want to die, but don’t feel they have a choice.

2. People who threaten to commit suicide won’t do it. False: Threatening to commit suicide is not just attention-seeking. It needs to be taken seriously as a cry for help.

3. After an unsuccessful attempt, the danger has passed. False: The danger period is not over. The person needs to be monitored for at least 90 days.

4. Suicide is an impulsive act. False: Not always – sometimes it’s planned for a long time and/or in detail.

5. “Truly” suicidal people have already made up their mind to die. False: some people don’t want to continue living in their current situation but don’t necessarily want to die. Suicide may be seen as the lesser of two evils.

6. A suicide attempt is not serious and the person is just “seeking attention”. False: Take every suicide attempt seriously.

7. If a previously depressed person suddenly seems happy, relieved or upbeat it means that they feel better. False: sometimes the person may seem “happy” or “content” because they’ve made the decision to take their own life as an option to get out of current pain and suffering. Watch for any sudden swings in mood. Also watch for the person giving away personal belongings and putting affairs in order.

8. Suicide is a cowardly act. False: It’s often a desperate act for people who are overwhelmed by their circumstances, who are sometimes not thinking clearly, and who need help.

National Information Services
Beyondblue Info Line: 1300 224 636
MensLine Australia: 1300 789 978
Australian Psychological Society Referral Line: 1800 333 497
SANE Australia: 1800 187 263
Relationships Australia: 1300 364 277
Carers Australia: 1800 242 636

ACT
Crisis Assessment and Treatment Team: 1800 629 354
Gay and Lesbian Telephone Help, Referral and Outreach Bureau (THROB): (02) 6247 2726

NSW
Suicide Prevention and Support: 1300 133 911
Salvation Army Prevention & Crisis Line: 02 9331 2000 (Metro) and 1300 363 622 (Rural)
Gay and Lesbian Counselling Service of NSW: 1800 184 527 or (02) 8594 9596

NT
Mental Health on Call Team: Top End (08) 8999 4988
Mental Health on Call Team: Central Australia (08) 8951 7777
Gay & Bisexual Mens Line Telephone Service: 1800 181 888

QLD
Salvo Crisis Counselling Service: Metro (07) 3831 9016 & Rural 1300 363 622
Gay and Lesbian Welfare Association: 1 800 184 527 or (07) 3017 1717

SA
Mental Health Assessment and Crisis Intervention Service: 13 14 65
Gay and Lesbian Counselling Service of SA: 1 800 182 233 or (08) 8334 1623

TAS
Mental Health Services Helpline: 1800 332 388
Working It Out: http://www.workingitout.org.au/contact.html

VIC
Mental Health Advice Line: 1300 280 737
SuicideLine: 1300 651 251
Gay and Lesbian Switchboard: 1 800 184 527 or (03) 9827 8544

WA
Mental Health Emergency Response Line (Metro): 1300 555 788
Rural Link (Rural): 1800 552 002
Gay and Lesbian Community Services of Western Australia: 1 800 184 527 or (08) 9420 7201
Samaritans Crisis Line: 1800 198 313

The new job I’m quite excited about; it will have a high interaction component with a clinical population, as part of a large treatment trial. I’m also planning to study a related subject next semester, and hopefully the synergy will make the (large) workload more manageable. I’m looking forward to learning more about this particular population.

Here are some of the things I’ve been thinking and reading about lately:

* SSRIs vs placebo in different severities of depression (yes, via “that JAMA article”)
* the relationship between pharma companies and how healthcare is conceptualised, delivered, and researched (Big Pharma, Bad Medicine, an article by Marcia Angell, the ex-editor-in-chief of the New England Journal of Medicine)
* the hyperreality of the consumerism-constructed world (via The Last Psychiatrist)
* Gordon, the robot(/chimera) with a biological brain made up of rat neurons (not exactly “news” – two years old, but still fascinating).

Regular blogging will resume once I finish writing the report I’m working on (about self-esteem/body image).

I like the collapse into “substance use disorders” of “substance dependence”/”abuse” – for example, Alcohol-Use Disorder, as opposed to Alcohol Abuse and Alcohol Dependence (click on the “DSM-IV” tab for details).

There will also be new suicide risk scales, adult and adolescent, chronic and acute. I’d be interested to look at the details, but can’t find these on the website at the moment.

The new edition is generating a lot of discussion, which is A Good Thing. The significant levels of unrest in the mental health field are because the DSM is seen to at least partly control the psychiatric diagnosis process, which in turn regulates treatment (pharma and non-pharma), as well as insurance pay-outs and allowances for psych care items.

The APA is framing the new edition as nothing short of revolutionary and at the same time, as usual, it runs an extremely tight ship regarding input and output. There have been calls for greater transparency into the process of creating the DSM-V, including from Dr. Allen Frances, the head of the APA taskforce that produced the last edition of the DSM.

Some of the problems that Dr. Frances has with DSM-V production process and taskforce are:

1. The very idea of a “paradigm shift” in the new edition. Psychiatric diagnosis is still descriptive, pretty much. Even as we have seen great advances in neuroscience, molecular biology, and brain imaging since the release of the last DSM edition, causality has not been proved to a level where biological tests can be a part of the DSM, and the findings of neuroscientific research are not yet suitable for clinical practice, and won’t be for quite a while.

2. The creation of new instruments, which is slow and resource-intensive, was not necessary.

3. Indirect involvement of pharma companies. To promote drug sales, pharma companies may sponsor selective “education” campaigns focusing on the diagnostic changes that increase the rate of diagnosis for disorders that will lead to the increased writing of prescriptions.

4. The inclusion of many new categories to capture subthreshold versions of disorders (for example, “pre-psychotic”, for those considered at risk for developing psychotic disorders). The intended purpose is to reduce the occurrence of false negatives (missed cases), hence boosting early detection and preventive treatment. However, this could also have the negative consequence of increasing false positives and, in Dr. Frances’s words, the “wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments.” (Eeek!)

5. Ditto for a new series of behavioural addictions (to sex, the internet, etc.) which may cause a medicalisation of behavioural problems.

6. A failure to specify the level of empirical support needed to approve any changes to the information contained in the previous edition.

7. A lack of openness to constructive criticism.

These are all very important concerns and I’d like to see the APA address them – especially no. 4, 5 and 6. Regarding no. 7, the APA is inviting feedback and opinions on the draft, and the fact that the release date is more than 3 years from now could mean that they will have the time to consider suggestions and criticism received.

My own thinking on the DSM is that it’s not perfect, and it should not be a “bible” for psychiatry and psychology. No psych*ist I know only uses the DSM for diagnosis. It’s a tool to be used by qualified and experienced clinicians in conjunction with a thorough interview and history-taking. However, indirect influences such as selective education could play a part in even the most thorough diagnostic process.

Also, many instruments are based on DSM criteria, so while the DSM itself may not be specifically used for diagnosis or for research, it has a wide reach.

I see disorders as cultural constructs. By this I don’t mean to imply that they are “made up”, or that their effects are not extremely serious, but that a certain grouping of symptoms into a coherent disorder is arrived at in a culturally-grounded way. I don’t think there will ever be conclusive scientific proof that shows that a certain cluster of symptoms should always be grouped together to form a certain disorder (not that scientific research is not culturally-grounded and -driven itself). This can be seen in the significant changes that DSM disorders have gone through from one edition of the DSM to the next. Then, even symptoms can vary culturally. For example, in certain Middle Eastern populations mood disorders present more somatic symptoms than in Western populations. And then you have culture-bound syndromes as well.

I think it’s important to keep disorders (and symptoms) -as-constructs in mind when looking at DSM debates; however, since the biomedical model of illness, including mental illness, requires the clinician to draw a line – what does and doesn’t require treatment, what requires one particular treatment or another, a particular intervention, a particular dosage, what is and isn’t relevant in a court of law, what is and isn’t worthy of compensation, awareness of disorders as cultural constructs may not be very useful in a practical clinical way.

However – I think one of the biggest steps forward that the DSM has made over time, which gives heed to the idea of subjectivity of classification and diagnosis, is the fact that many disorders in the DSM have as one of their inclusion/exclusion criteria the degree of impairment (physical, psychological, social) that the symptoms are causing the individual. In other words, even considering the subclinical categories which will be introduced in DSM-V, one of the determining factors for treatment will still be the answer to the question: “how affected by these symptoms is your life?”. After all, unpleasant or painful symptoms that affect quality of life don’t need to be part of some greater and well-defined disorder, nor do they need to be universal in manifestation, to be taken seriously and treated in other branches of healthcare, so I don’t see why they should be disregarded in mental health. Of course, it’s also of utmost importance to heed Dr. Frances’s warnings of overmedication and overpathologisation.

Overall, I’m both excited and anxious about DSM-V and I will be taking the time to go through the information on DSM5.org tomorrow.

Charcot and his pupils, who included Freud and Babinski as well as Tourette, were among the last of their profession with a combined vision of body and soul, ‘It’ and ‘I’, neurology and psychiatry. By the turn of the century, a split had occurred, into a soulless neurology and a bodiless psychology…

Oliver Sacks, renown New York neurologist and author of The Man Who Mistook His Wife for a Hat, attempts to reconcile this split, both in his practice and through his writing. And this is the very reason I find his work so compelling – without losing sight of the chemical imbalances and neural damage underlying the disorders described in his writing, he treats his patients holistically – as a system of flesh, bones, electricity and chemistry, beliefs, values and fears, family and community members, loved ones, history, symbols and wonder.

In one of the chapters of The Man Who Mistook His Wife for a Hat, Sacks describes how he spent 3 months analysing all the implications – psychological, social, economical – of treatment with haloperidol (a dopamine antagonist) for a patient with Tourette’s syndrome, “Witty Ticcy Ray”. He did this in weekly sessions with Ray and in the end they came up with an unconventional but satisfactory solution that was best for Ray (controlling Tourette’s during the week with medication, and letting it run its course on weekends). I find this so inspiring – this process of working with each individual patient, recognising the unique ways in which a disorder might affect them, and tailoring treatment to suit them, rather than making them fit a rigid and generic treatment regimen.

I also find fascinating the way in which disorders can become more or less accommodated or integrated within an individual’s personality and life – especially with chronic disorders. They become part of the person, altering who they are – which is why, in cases like Ray’s, simply “taking the disorder away” was impossible and disastrous for Ray’s sense of self, which was partly based on Tourette’s.

Sacks never loses a sense of wonder in what he encounters; disorders don’t only cause deficits, but can also cause excesses (of energy, mood, movement, reflexes, thought) and can be productive in a Foucauldian sense, contributing to identity (subjectivity) production. However, Sacks also always preserves empathy for his patients – they never become mere “subjects” or “curios”.

Sometimes I feel this is a lost art (at least in the Western biomedical model) – treating the disorder (symptoms and underlying causes), but also treating the patient – as a complete person enmeshed in a larger network, where both the internal and external workings rely on delicate and complex sets of balances. Homeostasis needs to be maintained, or restored, both inside and outside the body. Sacks seems to have an intuitive understanding of this, and I think anyone who works in any sort of healthcare profession (especially mental health!) would get a lot out of his writing.

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Sacks, O. (1986). The Man Who Mistook His Wife for a Hat. London: Picador

2. Get funding and obtain a large sample size (N = 1.47 million).

3. Break down the sample size into the following, seemingly random, categories based on country of origin:

A. Sweden
B. Finland
C. Western countries (Norway, Denmark, Iceland, Germany, Great Britain, USA, Canada, Australia, Other Western)
D. Eastern and Southern Europe (Poland, Hungary, Other Eastern Europe, Yugoslavia, Greece, Italy, Other Southern Europe)
E. Non-European (Middle East: Turkey, Iran, Iraq, Other Middle East; Asia: Far East, South Asia; Latin America: Chile, Other Latin America; Africa)

4. Claim that your break-down of the population into these groups is due to the diversity of ethnic backgrounds of immigrants in Sweden, which left you no other option but to create categories based on “similarities in lifestyle and living conditions.”

(4b. Because surely the lifestyle and living conditions of immigrants from Finland is hugely different to that of immigrants from Norway, as opposed to immigrants from Japan, Chile, Iran and The Country of Africa, which are practically like part of the same big happy colourful nation.)

5. Congratulations, you’ve arrived at your destination: FAIL.

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Hjern, A., Wicks, S., & Dalman, C. (2004). Social adversity contributes to high morbidity in psychoses in immigrants – A national cohort study in two generations of Swedish residents. Psychological Medicine, 34(6), 1025-1033.

Few universities don’t routinely use the interview selection process. These universities consider the possibility of excluding a candidate who will prove to be quite solid despite poor interview performance, or on the contrary, the admission of a flaky but great-interviewing candidate significant.

The rest of the universities, as I recently and unofficially found out, use the clinical interview to weed out psychopathology (i.e. to exclude on basis of mental health status), in addition to exploring suitability of candidates to the programs they offer. Some universities also require disclosure of mental health status before admission to clinical courses.

This makes me quite uneasy. Yes, on the one hand, clinical programs are demanding and it would be unfortunate if any mental health issues were exacerbated by the stress, or if the prospective clinical students were potentially “difficult to deal with”, and since clinical programs have a strong practicum focus, the health and safety of the patients that come in contact with the clinical students needs to be considered (quality of treatment plus liability).

However – this seems strangely hypocritical for a field that not only treats psychiatric illness, but advocates for the rights of people with mental health issues. It is discrimination on the basis of disability, to some extent, depending on the disorder. It also removes a lot of agency from the prospective students. If you have a mental health condition and want to undergo clinical training, chances are you’ve weighed the pros and cons and are pretty aware of the stressful conditions and type of work you’ll have to do. You already have pretty good undergraduate results (which shows you’re capable of focus and achievement), otherwise you wouldn’t be going for clinical postgraduate qualifications in the first place. And if you have a really hard time at some point in the postgraduate degree, it would be no different to a student with no prior mental health issues experiencing a prolonged bout of physical illness caused by an accident, for example, or an adjustment type disorder caused by sudden but normal life changes. And chances are, if you have a mental disorder, you have a more intuitive and more advanced understanding of mental health, and a greater interest in investigating treatment, as this is not just a professional, but also a personal issue for you.

Mental health professionals advocate for improved quality of life and improved working conditions for their clients. For example, flexible working hours and conditions. Because even if a company’s code of ethics states that it is anti-discrimination on paper, this needs to translate into actions – actual policies and work conditions. And I don’t see why universities should be exempt from this.

So is the requirement for self-disclosure or the clinical interview process ethical? I don’t know. I don’t know how much weight the risk of patient interaction carries, and how much is sheer inconvenience avoidance on behalf of the university. I should also note that the interview is not semi-/structured, and it doesn’t include any actual assessment instruments (so you could just avoid certain topics, or not disclose – except that, if you do go through a tough time later on caused by a mental health issue, this non-disclosure could in theory be used against you).