Patients' appraisal of psychiatric trainee interview skills.

OBJECTIVE: The aim of this pilot project was to explore the extent to which judgments made by psychiatrist examiners accord with those of patients in postgraduate clinical examinations, so as to inform further consideration of the role of patients in such assessments. METHOD: Senior psychiatrist examiners (N=8) and patients (N=30) rated 16 aspects of trainee psychiatrist interviewing style and performance during 30 observed clinical interviews (OCIs) conducted in the format of official examinations. RESULTS: Significant differences were apparent in the judgments of examiners and patients regarding 7 of 16 rated aspects of trainee performance. Differences were evident largely in domains in which patients could be expected to be "expert," reflecting their subjective experience of the interviewer. By contrast, there was little difference in the judgments of patients and examiners on the more technical criteria. CONCLUSION: These preliminary findings provide some challenge to the assumption that psychiatrists are the best judges of the "technical" skills and knowledge required by the profession. They support previous findings, with simulated patients, of the discrepancy between patient and examiner judgments of the more subjective elements of the examination. Psychiatric patients could contribute to clinical examinations as co-examiners, rather than merely constituting the substrate for the examination.

Which family--what therapy: Maori culture, families and family therapy in New Zealand.

New Zealand is a relatively young and small country which has seen steady migration for nearly seven centuries. Despite a long history of rivalry and hostility between Maori and European values, the country has also seen some significant synergism between the two cultures. For the last three decades Asians have also migrated at a significant pace. The country faces the challenge of delivering quality mental health services to such cultures which are bifurcated in being socio-centric (Maori, Pacific Islanders and Asian total 32% combined) or ego-centric (European total 68%). Significant progress has been made in including families of the mentally ill in their treatment and care planning. Legislative requirements have been introduced for the family to be consulted in the treatment of those who are being compelled to receive psychiatric care under the Mental Health Act. Models of family therapy developed through innovation meeting the unique local needs or adaptation of existing models from overseas are being used. An overview of such family therapy modalities is presented.

Courts' misplaced confidence in psychiatric diagnoses.

In considering psychiatric evidence, criminal justice systems make considerable use of labels from official psychiatric classificatory systems. There are legislated requirements for psychological and/or behavioural phenomena to be addressed in legal tests, however medico-legal use of the current categorical diagnostic frameworks which are increasingly complex is difficult to justify. The lack of validity in large domains of the present classificatory systems is now more openly acknowledged, prompting a critical rethink. Illustrative examples include post-traumatic stress disorder, various personality disorders, and dissociative identity disorder. It follows that the Courts' faith in the present categorical classifications (e.g., DSMIV and ICD10) is misplaced and may be ultimately unhelpful to the administration of justice.

Psychiatric diagnoses in legal systems: an issue of validity.

When considering psychiatric evidence, justice systems from many countries are frequently presented with diagnostic labels from official psychiatric classificatory systems. A lack of validity in much of these classificatory systems is receiving increasing attention. Illustrative examples include post-traumatic stress disorder, various personality disorders and dissociative identity disorder. The courts and review bodies from many jurisdictions place tremendous faith in the present categorical classifications (e.g., DSMIV and ICD10). This paper questions whether the reliance on these classifications systems is appropriate in legal proceedings.

Externalising and emotional categories, diagnostic groups and clinical profiles.

BACKGROUND: It has been proposed that gains would be made in the validity of the psychiatric classification system if many of the present 'neurotic' or personality disorders were subsumed into two over-arching groups, externalising and emotional disorders. If diagnostic sub-categories from the first digit coding structures within ICD-10 do, in fact, share clinical phenomenology that align with the major externalising/emotional distinction, this further supports the proposal and contributes to face validity. The aim of the study was to examine the distribution of particular psychopathology within and between two proposed over-arching groupings - externalising and emotional disorders - in a clinical sample. METHOD: The distributions of HoNOS derived information in relation to the proposed clusters of emotional disorders and extrinsic disorders are examined. RESULTS: Statistically significant differences in profiles between the emotional and the externalising groupings are consistent with the proposed classification development. The HoNOS (Health of Nation Outcome Scale) measures of self harm, depression, aggression, occupational/leisure problems and drug and alcohol consumption are the five most significant discriminators between the two groups. DISCUSSION: The details of the profile differences within the two over arching groups suggest that further examination is required. Useful work could include examination in credibly large and unselected patient populations of the factor structure demonstrated in non patient samples. Prospective comprehensive trials of the contributions the proposed classification could make to clinical decision making would also help illuminate this area.

Tangata whaiora/consumers perspectives on current psychiatric classification systems.

BACKGROUND: A number of studies have been undertaken with the aim of considering the utility of mental health classification systems from the perspective of a variety of stakeholders. There is a lack of research on how useful consumers/tangata whaiora think these are in assisting them in their recovery. METHODS: Seventy service users were involved in seven focus groups in order to consider this question. RESULTS AND DISCUSSION: While for clinicians diagnosing someone might be a discrete event and easily forgotten as a moment in a busy schedule, most people in this study remembered the occasion and aftermath very clearly. The overall consensus was that whether being 'diagnosed' was helpful or not, in large part, depended on how the process happened and what resulted from being 'labeled' in the person's life. CONCLUSION: Overall, people thought that in terms of their recovery, the classification systems were tools and their utility depended on how they were used. They suggested that whatever tool was used it needed to help them make sense of their distress and provide them with a variety of supports, not just medication, to assist them to live lives that were meaningful to them.

Classification in psychiatry: Does it deliver in schizophrenia and depression?

BACKGROUND: In the context of ongoing work to develop the next iteration of psychiatric classification systems, we briefly review the performance of current systems against their own stated objectives, for two major diagnostic groupings. DISCUSSION: In the major groupings of schizophrenia and depression, experience over the last 50 years has highlighted particular inadequacies in the utility and validity of available classifications. SUMMARY: Advances in psychiatric knowledge and practice notwithstanding, present classification systems would be enhanced by the incorporation of dimensional components. Minor tinkering with current systems will reflect only a missed opportunity. Improving classification will facilitate quality improvement of mental health systems.