New laws that prohibit conversion therapy pose no material risk to evidence-based and clinically appropriate practice.

OBJECTIVE: To examine the extent to which the Sexuality and Gender Identity Conversion Practices Act 2020 (ACT) and Change or Suppression (Conversion) Practices Prohibition Act 2021 (Vic) might pose a risk to evidence-based and clinically appropriate practice. METHOD: Using a recent publication by Parkinson and Morris as a starting point, the provisions of the new legislation are carefully examined. RESULTS: The ACT and Victorian laws do not imperil psychiatrists undertaking evidence-based and clinically appropriate practice. CONCLUSIONS: While it may be wise for psychiatrists to abandon this area of practice if they hold strong personal beliefs that the failure to identify with one's natal gender is morally wrong, nothing in the new laws should deter psychiatrists from providing people with gender dysphoria with evidence-based and clinically appropriate care.

Simulation-based medical education can be used to improve the mental health competency of emergency physicians.

OBJECTIVE: We explored the feasibility of developing, running and evaluating a simulation-based medical education (SBME) workshop to improve the knowledge, skills and attitudes of emergency department (ED) doctors when called on to assess patients in psychiatric crisis. METHOD: We designed a four-hour workshop incorporating SBME and a blend of pre-reading, short didactic elements and multiple-choice questions (MCQs). Emergency department nurses (operating as SBME faculty) used prepared scripts to portray patients presenting in psychiatric crisis. They were interviewed in front of, and by, ED doctors. We collected structured course evaluations, Debriefing Assessment for Simulation in Healthcare (DASH) scores, and pre- and post-course MCQs. RESULTS: The pilot workshop was delivered to 12 ED registrars using only existing resources of the Psychiatry and Emergency Departments. Participants highly valued both 'level of appropriateness' (Likert rating µ = 4.8/5.0) and 'overall usefulness' (µ = 4.7/5.0) of the programme. They reported an improved understanding of the mental state and of relevant legal issues and rated the debriefings highly (participant DASH rating: n = 193; score µ = 6.3/7.0). Median MCQ scores improved non-significantly pre- and post-course (7.5/12 vs 10/12, p = 0.261). CONCLUSION: An SBME workshop with these aims could be delivered and evaluated using the existing resources of the Psychiatry and Emergency Departments.

The frequency of references to decision-making capacity in reports to the NSW Mental Health Review Tribunal did not change after legislative reforms that promoted them.

OBJECTIVE: To assess the impact of a 2015 reform to the Mental Health Act 2007 (NSW) (MHA) that was interpreted as requiring a reference to decision-making capacity (DMC) in reports to the NSW Mental Health Review Tribunal (MHRT). METHOD: A sample of reports to the MHRT were audited for references to the MHA's treatment criteria and DMC in periods before and after the reforms, and the frequency of references between the two periods was compared. RESULTS: The frequency of references to DMC did not change significantly after the reforms. (However, references to the 'least restriction' criterion increased markedly between the two periods). CONCLUSION: Despite legislative reforms and a supporting education campaign promoting the importance of consideration of DMC, references to DMC did not increase after the reforms.

SMS SOS: a randomized controlled trial to reduce self-harm and suicide attempts using SMS text messaging.

BACKGROUND: Hospital-treated deliberate self-harm (DSH) is common, costly and has high repetition rates. Since brief contact interventions (BCIs) may reduce the risk of DSH repetition, we aim to evaluate whether a SMS (Short Message Service) text message Intervention plus Treatment As Usual (TAU) compared to TAU alone will reduce hospital DSH re-presentation rates in Western Sydney public hospitals in Australia. METHODS/DESIGN: Our study is a 24-month randomized controlled trial (RCT). Adult patients who present with DSH to hospital emergency, psychiatric, and mental health triage and assessment departments will be randomly assigned to an Intervention condition plus TAU receiving nine SMS text messages at 1, 2, 3, 4, 5, 6, 8, 10 and 12-months post-discharge. Each message will contain telephone numbers for two mental health crises support tele-services. Primary outcomes will be the difference in the number of DSH re-presentations, and the time to first re-presentation, within 12-months of discharge. DISCUSSION: This study protocol describes the design and implementation of an RCT using SMS text messages, which aim to reduce hospital re-presentation rates for DSH. Positive study findings would support the translation of an SMS-aftercare protocol into mental health services at minimal expense. TRIAL REGISTRATION AND ETHICS APPROVAL: This trial has been registered with the Australian and New Zealand Clinical Trials Registry (Trial registration: ACTRN12617000607370 . Registered 28 April 2017) and has been approved by two Local Health Districts (LHDs). Western Sydney LHD Human Research Ethics Committee approved the study for Westmead Hospital and Blacktown Hospital (Protocol: HREC/16/WMEAD/336). Nepean Blue Mountains LHD Research Governance Office approved the study for Nepean Hospital (SSA/16/Nepean/170).

How Should Physicians Use Their Authority to Name a Stigmatizing Diagnosis and Respond to a Patient's Experience?

Patients with delusional infestation are unlikely to agree to take the mainstay of treatment-antipsychotic medication. While stressing the general importance of truth telling in medicine, we suggest that, in some cases of delusional infestation, patients' lack of decision-making capacity will-provided a series of criteria are met-justify briefly withholding their diagnosis. We acknowledge this action as a kind of deception with ethical pitfalls and discuss those related to prescribing antipsychotic medication without frank disclosure. We recommend full disclosure of a delusional infestation diagnosis when the patient is recovered, despite this action's potential to exacerbate stigma.

The correlates of physical activity among adult Métis.

OBJECTIVES: Métis, with a population of close to 390,000 people, are a culturally distinct and constitutionally recognized Aboriginal group in Canada that suffers from poorer overall health than non-Aboriginal Canadians. One important predictor of good health is physical activity. Guided by frameworks based on social and Aboriginal-specific determinants, we investigated the correlates of leisure-time physical activity (LTPA) and active transportation (walking) among adult Métis, with a particular focus on how culturally specific variables were associated with these two types of activity. We also examined how demographic, geographic, socioeconomic and health-related factors were associated with physical activity. DESIGN: We used data from Statistics Canada's 2006 Aboriginal Peoples Survey and Métis Supplement to analyze the correlates of physical activity among Métis aged 20-64, using a series of logistic regression models. RESULTS: Having attended a Métis cultural event in the past year was positively associated with LTPA, as was a high level of spirituality. Similarly, those who had attended a cultural event in the last year were more likely to report a high level of active transportation. Speaking an Aboriginal language and being a member of a Métis organization were not independently associated with the two types of physical activity. Self-perceived health, being male and household income were other correlates positively associated with LTPA, whereas age, body mass index and smoking were negatively associated with this type of activity. Active transportation was positively associated with self-perceived health and being female, while negatively associated with age and body mass index. CONCLUSIONS: The results of this study suggest that interventions aimed at increasing physical activity among adult Métis might be more successful if they are connected to cultural activities and spirituality. This research also suggests that demographic, socioeconomic and health-related factors are important considerations when designing initiatives to increase physical activity among adult Métis.

A substantial peer-worker workforce in a psychiatric service will improve patient outcomes - the case against.

OBJECTIVES: The aim of this work was to examine, via narrative review, the evidence supporting the drive for more peer workers to gauge the likely impact on patient outcomes. CONCLUSIONS: Despite considerable research into the effectiveness of peer workers in clinical psychiatry, there is insufficient evidence to support the proposition that a substantial peer workforce would improve the outcomes of people living with mental illness.

How shortcomings in the mental health system affect the use of involuntary community treatment orders.

Objective The aim of the present study was to examine stakeholder perspectives on how the operation of the mental health system affects the use of involuntary community treatment orders (CTOs). Methods A qualitative study was performed, consisting of semi-structured interviews about CTO experiences with 38 purposively selected participants in New South Wales (NSW), Australia. Participants included mental health consumers (n=5), carers (n=6), clinicians (n=15) and members of the Mental Health Review Tribunal of NSW (n=12). Data were analysed using established qualitative methodologies. Results Analysis of participant accounts about CTOs and their role within the mental health system identified two key themes, namely that: (1) CTOs are used to increase access to services; and (2) CTOs cannot remedy non-existent or inadequate services. Conclusion The findings of the present study indicate that deficiencies in health service structures and resourcing are a significant factor in CTO use. This raises questions about policy accountability for mental health services (both voluntary and involuntary), as well as about the usefulness of CTOs, justifications for CTO use and the legal criteria regulating CTO implementation. What is known about this topic? Following the deinstitutionalisation of psychiatric services over recent decades, community settings are increasingly the focus for the delivery of mental health services to people living with severe and persistent mental illnesses. The rates of use of involuntary treatment in Australian community settings (under CTOs) vary between state and territory jurisdictions and are high by world standards; however, the reasons for variation in rates of CTO use are not well understood. What does this paper add? This paper provides an empirical basis for a link between the politics of mental health and the uptake and usefulness of CTOs. What are the implications for practitioners? This paper makes explicit the real-world demands on the mental health system and how service deficiencies are a significant determinant in the use of CTOs. Practitioners and policy makers need to be candid about system limitations and how they factor in clinical and legal justifications for using involuntary treatment. The results of the present study provide data to support advocacy to improve policy accountability and resourcing of community mental health services.

Factors associated with heavy drinking among off-reserve First Nations and Métis youth and adults: Evidence from the 2012 Canadian Aboriginal Peoples Survey.

Objective . Aboriginal people in Canada are at higher risk to heavy alcohol consumption than are other Canadians. The objective of this study was to examine a set of culturally specific correlates of heavy drinking among First Nations and Métis youth and adults. Methods . Demographic, geographic, socioeconomic and health-related variables were also considered. Data were used from Statistics Canada's 2012 Aboriginal Peoples Survey to predict heavy drinking among 14,410 First Nations and Métis 15years of age and older. Separate sets of binary sequential logistic regression models were estimated for youth and adults. Results . Among youth, those who had hunted, fished or trapped within the last year were more likely to be heavy drinkers. In addition, current smokers and those who most frequently participated in sports were at higher odds of heavy alcohol consumption. Among adults, respondents who had hunted, fished or trapped within the last year were more likely to drink heavily. On the other hand, those who had made traditional arts or crafts within the last year were less likely to drink heavily. Conclusions . Men, younger adults, smokers, those who were unmarried, those who had higher household incomes, and those who had higher ratings of self-perceived health were more likely to be heavy drinkers. Efforts aimed at reducing the prevalence of heavy drinking among this population may benefit from considering culturally specific factors, in addition to demographic variables and co-occurring health-risk behaviors.

A cross-sectional examination of the correlates of current smoking among off-reserve First Nations and Métis adults: Evidence from the 2012 Aboriginal Peoples Survey.

INTRODUCTION: The purpose of this study was to examine the correlates of current smoking among off-reserve First Nations and Métis adults, two Aboriginal Canadian groups that are at higher risk to smoke and more likely to suffer from chronic health conditions relative to their non-Aboriginal counterparts. A particular focus was on culturally specific factors and their associations with current smoking. METHODS: We used data from Statistics Canada's, 2012 Aboriginal Peoples Survey to investigate the correlates of smoking among 12,720 First Nations and Métis adults. Sequential binary logistic regression models were estimated to examine associations between smoking and culturally specific, demographic, geographic, socioeconomic and health-related variables. RESULTS: Overall, 39.4% were current smokers. Multivariate results found that those who had hunted, fished or trapped within the last year were more likely to be smokers. In addition, respondents who were exposed to an Aboriginal language at home or outside the home were more likely to be smokers. Current smoking was significantly associated with being aged 35 to 49 years, living in a small population center, low income, low education, unemployment, being unmarried, low ratings of self-perceived health, heavy drinking and low body mass index. Respondents aged 65 years and older and those living in British Columbia were less likely to smoke. DISCUSSION: The results of this study suggest that it may be useful to consider cultural characteristics, particularly language in efforts to reduce the prevalence of manufactured tobacco use among First Nations and Métis adults. Interventions should also consider demographic, geographic and socioeconomic variables, in addition to co-occurring health-risk behaviors.

The correlates of current smoking among adult Métis: Evidence from the Aboriginal Peoples Survey and Métis Supplement.

OBJECTIVE: To examine the correlates of current smoking among Métis aged 18 years and older, with a particular focus on culturally-specific factors. Cultural factors included spirituality, knowledge of an Aboriginal language, membership in a Métis organization and attendance at Métis cultural events. Demographic, geographic, socio-economic and health-related variables were also considered. METHODS: Data from 6,610 adult Métis aged 18 years and older who responded to the 2006 Aboriginal Peoples Survey and Métis supplement were used to examine the correlates of current smoking using sequential binary logistic regression modelling. RESULTS: Overall, 39.9% of adult Métis respondents in the sample were current smokers. Adult Métis who reported a high level of spirituality were less likely to be current smokers. Those who spoke an Aboriginal language, or lived in a house where an Aboriginal language was spoken, were more likely to be current smokers. Being a member of a Métis organization and attending cultural events were not independently associated with current smoking. Métis with higher household income, greater education, higher self-perceived health, and greater physical activity participation were less likely to be current smokers, whereas those who reported heavy alcohol consumption were more likely to be current smokers. CONCLUSIONS: The results of this study suggest that interventions aimed at reducing smoking among adult Métis might be more successful if they include some connection to spirituality. It is also evident that co-occurring risk behaviours, in addition to demographic and socio-economic factors, are important considerations when developing interventions to reduce smoking among this population.

Suicide risk categorisation of psychiatric inpatients: what it might mean and why it is of no use.

OBJECTIVE: Existing suicide risk assessment policies and guidelines do not specify whether the risk to be assessed is absolute, relative to other patients or relative to the same patient at an earlier time. METHODS: We utilised the results of a recent study of inpatient suicide to explore the implications of each of the above types of risk. RESULTS: No interpretation of the current requirements for suicide risk categorisation of psychiatric inpatients can lead to information that might usefully guide clinical decision-making. CONCLUSIONS: Policies and guidelines requiring suicide risk categorisation of inpatients should be withdrawn. The College should delete the mandatory entrustable professional activity requiring risk assessment.

Potentially incapable patients objecting to treatment: doctors' powers and duties.

Generally, a patient may only be assessed and treated with his or her consent. It is difficult to interpret the law regarding doctors' powers and duties to assess and treat in cases where a patient refuses to accept medical advice but it is unclear whether the patient has decision-making capacity (DMC) or whether they are mentally ill. An examination of legal principles in this area suggests that there is a limited justification for doctors to detain a person for the purpose of assessment if they have good reason to suspect the person may either lack DMC or be mentally ill and if failure to detain the person is likely to lead to serious harm. This limited justification to detain would only apply for as long as the uncertainty about DMC or mental illness prevailed. Doctors have a duty to provide appropriate advice to patients who want to leave their care in circumstances where medical assessment or treatment may be required. Whether there is also a duty to detain someone in this situation is less clear, but we provide guidance to health care practitioners faced with this situation.