Burnout and job satisfaction in New Zealand psychiatrists: a national study

OBJECTIVES: To estimate the prevalence of burnout and the level of job satisfaction among New Zealand psychiatrists, and to ascertain relationships between socio-demographic variables, job satisfaction and burnout in the target population. METHOD: In phase one of the study a postal survey was mailed out to every practising psychiatrist on record as well as all doctors working in psychiatry without specialist qualifications (MOSS). Three questionnaires were used: a socio-demographic questionnaire, the Maslach Burnout Inventory (MBI) and a Job Diagnostic Survey (JSS). Regression analysis was performed on returned data sets using socio-demographic characteristics as explanatory variables and score components of the MBI and JDS as the outcome measures. RESULTS: The results showed that the prevalence of burnout in New Zealand psychiatrists is cause for concern. Two-thirds of all psychiatrists described moderate to severely high levels of emotional exhaustion, with a similar proportion describing low levels of personal accomplishment. Depersonalisation did not appear to be a major problem in the population. Job satisfaction remained relatively high despite the high prevalence of burnout, although there was a relationship between burnout and job satisfaction scores. CONCLUSIONS: This study has demonstrated a high prevalence of burnout and factors associated with it among New Zealand psychiatrists. Further research is needed to ascertain why job satisfaction remains high in the presence of burnout, and factors predisposing to, or protective of, burnout.     

Prevalence of psychiatric disorders in New Zealand prisons: a national study

OBJECTIVE: The paper describes the methodologies and results obtained on a large cohort of prison inmates in New Zealand who were screened for psychiatric disorder. METHOD: All women and remanded male inmates in New Zealand prisons, and a randomly selected cohort of 18% of sentenced male inmates were interviewed. Interviewers used the Composite International Diagnostic Interview - Automated to establish DSM-IV diagnoses, and the Personality Disorders Questionnaire to identify personality disorder. All prisons in New Zealand were visited. RESULTS: The results indicate markedly elevated prevalence rates for major mental disorder in the prison population when compared with community samples. This is especially the case for substance misuse, psychotic disorders, major depression, bipolar disorder, obsessive- compulsive disorder and posttraumatic stress disorder. Of particular concern is not only the increased prevalence rates for schizophrenia and related disorders but also the high level of comorbidity with substance misuse disorders demonstrated by this group. While 80.8% of inmates diagnosed with bipolar disorder were receiving psychiatric treatment in the prison, only 46.4% of depressed inmates and 37% of those suffering from psychosis were receiving treatment. Maori inmates were grossly overrepresented in the remand, female and male sentenced inmate population compared with the general population. CONCLUSIONS: A significant increase in provision of mental health services is required to cope with the high number of mentally ill inmates. The level of need demonstrated by this study requires a level of service provision that is quite beyond the capacity of current forensic psychiatry services, Department of Corrections Psychological Services or the prison nursing and medical officers. The elevated rates of common mental disorders argues for the use of improved psychiatric screening instruments, improved assessment and treatment capacities in the prison and an increased number of forensic psychiatric inpatient facilities to care for those psychotic inmates who are too unwell to be treated in the prison.     

Perpetrators of homicide with schizophrenia: a national clinical survey in England and Wales

OBJECTIVE: Few studies have described rates of schizophrenia in a national sample of homicide perpetrators. This study aimed to describe this group's social and clinical characteristics, mental state features, offense details, and outcome in court. METHOD: Analyses used a national clinical survey that collected data on people convicted of homicide in England and Wales (1996-1999). Data were collected for those with schizophrenia or other delusional disorders from psychiatric reports and questionnaires. RESULTS: Of the 1,594 people convicted of homicide, 85 (5 percent) had schizophrenia. Of the 57 people with schizophrenia for whom data were available, 32 (56 percent) had been ill for less than 12 months, and in the month before the offense, 32 (56 percent) had shown a change in the quality, intensity, or conviction of or emotional response to their delusional beliefs. Twenty-four (28 percent) had no previous contact with psychiatric services. CONCLUSIONS: Regular assessment of delusions may help to detect an increased risk of violence, including homicide. More intensive care should be available for patients with a history of schizophrenia and previous violence.     

How mental health clinicians view community treatment orders: a national New Zealand survey

OBJECTIVE: To determine New Zealand mental health clinicians' views about community treatment orders, indications for their use, their benefits, problems and impact on patients and therapeutic relationships. METHOD: A national survey of New Zealand psychiatrists and a regional survey of non-psychiatric community mental health professionals for comparison. RESULTS: The great majority of NZ psychiatrists prefer to work with community treatment orders as an option. They consider they are used properly in most cases, can enhance patients' priority for care, provide a structure for treatment, support continuing contact and produce a period of stability for patients during which other therapeutic changes can occur. They consider these orders can harm therapeutic relationships, especially in the short term, but when used appropriately their overall benefits outweigh their coercive impact. The other mental health professionals surveyed have similar views. A minority of clinicians do not support their use. CONCLUSIONS: The precise impact of community treatment orders on patients' quality of life remains an open question. Until that matter is more clearly resolved, New Zealand law should continue to authorise compulsory outpatient care, provided it is carefully targeted and adequate community services are available.     

Late‐life homicide‐suicide: a national case series in New Zealand

Homicide‐suicide is a rare event, but it has a significant impact on the family and community of the perpetrator and victim(s). The phenomenon of late‐life homicide‐suicide has not been previously studied in New Zealand, and there is only limited data in the international literature. The aim of this study is to systematically review coroners' records of late‐life homicide‐suicides in New Zealand. After ethics approval was granted, the Coronial Services of New Zealand was approached to provide records of all closed cases with a suicide verdict (age 65+) over a five‐year period (July 2007–December 2012). Of the 225 suicides, 4 cases of homicide‐suicide were identified (an estimated incidence of 0.12 per 100 000 per persons year). All four perpetrators were men; three had been farmers. Their ages ranged from 65 to 82. One case occurred in the context of an underlying psychiatric illness (psychotic depression in bipolar disorder). Firearms were used in three cases. Two cases were categorized as spousal/consortial subtype, one case as filicide‐suicide, and one case as siblicide‐suicide. The prospect of major social upheaval in the form of losing their homes was present in all four cases. The findings of this case series were consistent with the limited existing literature on homicide‐suicide. Age‐related biopsychosocial issues were highlighted in this case series of late‐life homicide‐suicide. Additionally, evaluating firearm licences in high‐risk groups may represent a prevention strategy.     

Prison mental health in-reach teams in Aotearoa New Zealand: A national survey

The STAIR in-reach model of care for prisoners with serious mental illness focuses on screening, triage, assessment, interventions and reintegration by using the principles of assertive community treatment. An evidence base exists for the efficacy for its use in Aotearoa New Zealand. However, little is known about its adoption throughout the country. This national survey of managers of in-reach teams to all prisons (N = 19) aimed to determine the pattern of in-reach service delivery. It compared STAIR in-reach teams with other teams regarding service structure, staffing, interventions, reintegration strategies and training needs. This study signals gains made by adopting the STAIR model (multi-disciplinary team service delivery, ‘through the wire’ support and use of technologies to assist discharge planning) and potential areas of improvement (further use of psychosocial interventions and training needs). To assist national adoption of STAIR, a review is required to consider the cultural responsivity, gender-responsivity and recovery-orientated characteristics of the model.Key words: assessment, in-reach, intervention, prison, reintegration, screening, triage     

Mentally disordered offenders: Clinical,political and legal developments in the United States

Australians with only passing knowledge of what transpires on the other side of the Pacific are probably aware that law in the United States is neither a stagnant nor a very stable enterprise. Where it intersects with the business of psychiatry, the law's in‐flux character is especially pronounced. The last decade or so has seen as much change as any, as the law has sought to keep pace with advances in medical theory and technology and with psychiatric reconceptualizations that have affected both the diagnosis and treatment of mental disorders. “Keeping pace” means not just the incorporation of what is new, but sometimes also its rejection (not to mention its exploitation or distortion for partisan legal gain or to accommodate the winds of political change). A review of the more significant legal changes shows the various ways whereby the law has sought to accommodate new developments in psychiatric medicine.     

Relationship between clinical and radiological diagnostic criteria for Alzheimer's disease and the extent of neuropathology as reflected by 'stages': a prospective study

The distribution of pathology related to Alzheimer's disease (AD) is not uniform throughout the brain. Sites which have a predilection for the development of Alzheimer-type pathology are the limbic regions and neocortical association areas. The changes in these areas of the brain develop gradually, following a well-determined sequence that allows a pathological staging of the disease process. According to the staging hypothesis, the first pathological alterations develop in the transentorhinal and entorhinal regions. The neurofibrillary pathology then spreads into the hippocampus, but not until the final stages does it affect the neocortex. In this study we analyse the relationship between the pathological stages of AD, according ot the staging hypothesis, and the clinical diagnosis in a prospectively assessed patient group. Prediction of any given pathological stage from the clinical diagnosis was found to be poor. This may be partly due to the fact that additional pathologies can alter the clinical picture and severity of dementia in patients who are only in the initial stages of AD. Nevertheless, the NINCDS-ADRDA clinical criteria had a high sensitivity for detection of AD-related pathology: the 'probable AD' category included 22/38 (57.9%) of those in the late isocortical stage, while the 'possible AD' category included 19/23 (82.6%) of those in the limbic stage. Using proposed neuro-imaging protocols for improved identification of patients with AD-related pathology, we largely identified subjects in whom the extent of pathology had spread to the neocortex.     

Fitness to Stand Trial in New Zealand: Different Factors Associated with Fitness to Stand Trial Between Mentally Disordered and Intellectually Disabled Defendants in the New Zealand Criminal Justice System

Individuals on trial for an offence are expected to contribute to their own defence via liaison with their defence team and be able to participate meaningfully in the court process. Defendants who are unable to do so are deemed unfit to stand trial. The factors associated with fitness to stand trial within the New Zealand criminal justice system have not been closely examined. This study compared sociodemographic, offence-related, clinical and court-related factors associated with fitness to stand trial for 200 mentally disordered and intellectually disabled (ID) defendants assessed for the New Zealand Courts. The study found generic sociodemographic, offence-related and clinical factors were not significantly associated with fitness to stand trial. By contrast, court-related factors such as previous assessment of fitness to stand trial and previous finding of unfitness, and clinical factors such as previous diagnosis of ID and low cognitive functioning were significantly associated with unfitness to stand trial. Court liaison nurses' concerns about the defendant's ability to communicate and comprehend appeared to be reliable indicators of unfitness, suggesting that this may be a useful initial screen of eligibility before more formal assessment of competency and intelligence.     

Family perspective on community treatment orders: a New Zealand study

BACKGROUND: People with serious mental disorders typically live with family members. Despite increasing interest in compulsory community treatment for such patients, the experience and views of their family members have been little studied. MATERIAL: Qualitative interviews with 27 family members, whose relatives have been subject to compulsory community treatment. DISCUSSION AND CONCLUSIONS: Family members are generally in favour of the use of compulsory community treatment orders. They perceive a positive influence on their relative, on themselves, on family relationships, and on relations with the clinical team. Family members are aware of the ethical and other dilemmas that attend the use of compulsory community care.     

Report of a national survey of older people with lifelong intellectual handicap in New Zealand

ABSTRACT. This paper reports on a national project to investigate the numbers, health status and service needs of people with mental retardation born before 1940. A prevalence of 1–43 per thousand was established nationally, with wide regional variation. Intensive local case finding produced 19% of the study group, not otherwise known to service agencies. In 1990, 42% of the population resided in institutions, 7% with family, 13% in rest homes, and 38% in community-based residential facilities. Of 1063 cases identified, 13% were people with Down's syndrome, 25% were identified as having a psychiatric diagnosis and 17% as having epilepsy, but 23% had no major disability. About 32% had visual problems, 40% had weight problems and 75% received regular medication. Seventy-five per cent have at least occasional contact with their families. The service system is in the process of change as a result of shifts in public policy, responsibility and funding. Personal interview data, reported elsewhere, demonstrated the desire and ability of the people concerned to be included in these decisions. Major needs identified were therapeutic services, medical care, community and recreational services, and support for families. Research areas recommended as priorities are consensus classification and definition of the population, identification of patterns of ageing among different subgroups, and studies of public policy.     

Affective disorder and homicide: a case of familial filicide theoretical and clinical considerations

This paper discusses a case of maternal homicide which occurred in the course of a major affective disorder. The relationship between mental illness and criminality is reviewed with a particular emphasis on affective disorder in relation to filicide. A number of significant issues are dealt with including consequences of failure to elicit positive family history of affective disorder, suicide and filicide. Indeed, a history of familial double filicide raises the question of possible hereditary influences. The significance of hypochondriacal symptomatology in the course of the illness and the role of steroids in precipitating or aggravating a psychotic depression also need to be explored. It primarily addresses the importance of prevention and recognition of risk factors associated with child murder committed by depressed parents.     

Coexisting psychiatric disorders in a New Zealand outpatient alcohol and other drug clinical population

OBJECTIVE: To describe the extent of psychiatric disorder and mental health service utilization in a representative outpatient alcohol and other drug (AOD) treatment sample in New Zealand. METHOD: A total of 105 patients were randomly recruited from two outpatient AOD treatment services in New Zealand and completed a diagnostic interview within the first 2 months of treatment. Axis I psychiatric diagnoses were made using the computerized Composite International Diagnostic Interview (CIDI-Auto), and were supplemented by the South Oaks Gambling Scale (SOGS) and the conduct disorder and antisocial personality disorder section of the Diagnostic Interview for Genetic Studies (DIGS). RESULTS: Seventy-four per cent of the sample had a current non-substance or gambling axis I disorder, with a lifetime rate of 90%. The most commonly diagnosed of these coexisting psychiatric disorders were major depressive episode (34%), social phobia (31%) and posttraumatic stress disorder (31%). Past contact with mental health services was common, while contact at the time of baseline assessment was uncommon. CONCLUSIONS: Coexisting psychiatric disorder was the rule and not the exception in this sample. AOD patients are clearly part of the larger population of mental health patients. AOD services need to be capable of comprehensive assessment and treatment planning, which includes coexisting psychiatric disorders, and should work toward better integration with other mental health services.