ACPARIAN Issue6 Jul2013

CP A A
THE AUSTRALIAN CLINICAL PSYCHOLOGY ASSOCIATION
Acparian
The ocial e-journal of the Australian Clinical Psychology Association
ISSUE 6: JUNE 2013
ACPARIAN Issue 6 JUN 2013
Psychosis Issue
In this issue Cognitive de cits Delusional misidenti cation syndrome Methamphetamine and psychosis Early interventions and functional recovery CBTp Pharmacotherapy Schizophrenia treatment review Ethics committees demysti ed
EDITORIAL
Kaye Horley, PhD Editor appraising the quality of evidence of treatments, including psychological treatments. From the perspective of a patient ambassador, Richard discusses some of the feelings and fears that have accompanied him in his life with schizophrenia. He is an example of how this condition need not hinder ones aspirations in life. Significant for our readers, he provides poignant advice, derived from his own experience, for a clinical psychologist who works with anyone with schizophrenia. This issue concludes with Maria McKenzie's overview of the purpose of, and issues addressed by, human research ethics committees.
he 2010 national survey of Australians1 aged between 18 and 64 years estimated the prevalence of meeting criteria for a psychotic illness (under mental health services) at 3.1 cases per 1,000 population. The most common disorder was schizophrenia (47%), followed by bipolar, mania (17.5%), schizo-affective disorder (17.5%), severe depression without psychosis (8.7%), delusional and other non-organic psychoses (5%), depressive psychosis (4.4%), and other psychotic disorders (1.4%). The prevalence of psychotic disorders was higher in males than females (3.7 and 2.4 cases, respectively, per 1,000), with the highest rate occurring in 25-34 year old males (5.2 cases per 1,000), and the lowest in 18-24 year old females (1.6 cases per 1,000). Schizophrenia accounted for the majority of psychotic illness in males (56.3%) but for only a third in females (33.2%). Two thirds (64.8%) of people with a psychotic illness experienced their first episode before the age of 25 years. Impaired cognitive functioning is a crucial feature of the psychotic disorders. A comprehensive overview of specific deficits and their trajectory is provided by Aleksandra Kralj and Philip McGuire. Cognitive deficits as a predictor of functioning and novel interventions to facilitate cognitive functioning, such as cognitive remediation, are described. More florid manifestations of dysfunctional cognitive processing in psychosis are those emanating from delusional beliefs. One of the more interesting types is delusional misidentification syndrome. Some of the complexities involved in attempting to conceptualise this syndrome, along with possible aetiologies, are explored by Max Coltheart. The recreational use of methamphetamine is of concern because of its potency and likely psychotic effect in long-term heavy users. Rebecca McKetin writes of the diagnostic problems in differentiating methamphetamine and schizophrenia spectrum psychoses, their differing symptom severity, and the importance of clinical management. Early interventions for first episode psychosis are important in influencing prognosis and minimising risk. Emphasising functional recovery in young people, Ein Killackey discusses the rationale of early intervention at this critical stage of development and the need for development of interventions. A further emphasis upon first episode psychosis is provided by Craig Macneil, Sarah Bendall, and Mario Alvarez-Jimenez in their examination of the key components of cognitive behaviour therapy for psychosis. An overview of the pharmacological management of psychosis is provided by Cherrie Galletly and practical guidelines are given for clinical practice. Indications for the use of psychotic medications, side effects, and precautions are presented. The efficacy of treatments for schizophrenia is difficult to determine. With the use of their Schizophrenia Library, Vaughan Carr, Sandra Matheson, and Alana Shepherd conducted a systematic review of meta-analyses, critically
___ 1 Morgan, V. A., Waterreus, A., Jablensky, A., Mackinnon, A., McGrath, J. J., Carr, V., Saw, S. (2011). People living with psychotic illness 2010. Canberra, Australia: Department of Health and Ageing.
CONTENTS
1 2 4 8 11 14 18 24 26 28 30 Editorial From the President Cognition in psychosis Delusional misidentification syndrome Methamphetamine and psychosis Functional recovery in first episode psychosis Cognitive behavioural interventions for first episode psychosis: A rationale and overview Pharmacotherapy for psychosis The quality and strength of evidence for various treatments in schizophrenia A patient ambassadors perspective: Having schizophrenia Demystifying human research ethics committees
ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013
We were also invited to make a submission to the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in response to their Draft Guidelines for Communication between Psychiatrists, General Practitioners, and Psychologists developed by the RANZCP Private Practitioners Network Special Interest Group prior to this being sent to GPs for their feedback. Regular meetings are held with the RANZCP Executive to share concerns that affect both psychiatry and clinical psychology and to consider issues related to mental health. Further submissions are being prepared for various bodies on a range of issues. We have written numerous letters to Ministers and the Opposition, providing them with information and analyses of psychology training and the contribution qualified clinical psychologists can make to the mental health workforce. Of most concern has been a campaign for specialist recognition for qualified clinical psychologists in order to give informed choice, and greater protection, to the public. This is of specific and imminent importance for our Western Australian colleagues who, along with the public of that state, have enjoyed the benefits of clear standards, and the recognition and value of extensive training in clinical psychology via specialist recognition, which they are soon to lose. ACPA actively and successfully supported the Motor Traffic Authority in NSW in setting clinical neuropsychology endorsement by the PsyBA as a requirement to undertake clinical neuropsychology assessments. This was strongly opposed by the APS who offered to establish a team to review applications from unqualified clinical neuropsychologists to determine their competency to undertake these assessments. This is to mention but a very few of our national activities. For a more extensive, but by no means complete, review of activities, members can log in at acpa.org.au and see a wider range of letters and submissions. Internally, ACPA is supported by a strong, cohesive, and active Board that works tirelessly behind the scenes in a supportive manner to advance the cause of qualified clinical psychologists nationally. The Board is further supported by strong committees providing CPD, the student prize, the mentoring program for new members of the profession, the scientific reliability of ACPA activities and events, and the soon to be reconstituted Ethics Committee. ACPA has entered a period of strength, stability, and growth that is a pleasure to see come to fruition. In some ways we have struggled to manage our success. As our membership has grown, so have the administrative requirements. The organisation has rapidly developed beyond our capacity to cope via the old paper system of applications and renewals. With the advent of the new website in March 2013 and the employment of an administrator, we did expect this to become more manageable, and it certainly has; renewals are readily processed, applications create new member profiles, changes of membership category are readily responded to, and everything is easily available to the administration team.
FROM THE PRESIDENT

Judy Hyde, PhD ACPA President My Fellow Acparians, ACPA is growing and flourishing! We are stepping onto the world stage. As President of ACPA I have been invited to attend the 5th International Congress on Licensure, Certification, and Credentialing in Psychology in Stockholm in July. The small group of approximately 80 invitees from all continents represents the elite of psychology organisations internationally. The group is meeting with the aim of achieving "a global agreement on identifying the benchmark competencies that define professional psychology". This invitation was issued as our organisation had come to attention at the 3rd International Congress on Licensure, Certification, and Credentialing in Psychology, held here in Sydney in July 2010, which was very early in our development. Nationally, our work this year has been ongoing. Submissions have been made to the Australian Psychology Accreditation Council (APAC) in response to the proposed lowering of standards for clinical psychology training, and the poor international benchmarking of the standards of training for generalist psychologists, proposed in the Accreditation Standards for Programs of Study in Psychology. ACPA has also submitted draft guidelines for competencies for clinical psychologists to APAC and has contributed to the review of APAC itself, raising awareness of the lack of independence of this body from the Australian Psychological Society (APS). APAC now has six months to become independent or be replaced as the accrediting body for psychology. Submissions have also been made to the Psychology Board of Australia (PsyBA) on the National Examination for registration of generalist psychologists, and we are about to submit on the 5 + 1 generalist training that meets no international standards, maintaining Australia as having the most poorly trained workforce of psychologists in the developed world.
However, if we expected website processing to make for a less hectic administrative pace, we were very much mistaken! In the last three months there has been a 20% increase in membership as we become better known nationally, and appreciated for our achievements, by eligible qualified clinical psychologists desperate to have their much valued training acknowledged and appreciated nationally. One problem that has emerged with the new website is that the members listed on the old Find a Clinical Psychologist Directory needed to re-create their profiles. A very large number of members are still to do so, and I again encourage you to log in to Your Account and complete this process. In conjunction with the Board, I would like to thank each member of ACPA for your ongoing support, warmth, and
encouragement, and for the very valuable contributions you make. A strong membership provides the lifeblood of our organisation and fuels the passion for the recognition and value of qualifications in clinical psychology for working in mental health. The 2013 ACPA conference is to be held in Brisbane on Sunday 14 July, immediately following the International Society for Psychotherapy Research conference on 10-13 July. The ACPA conference will showcase the work of Nancy McWilliams with a full day workshop on working with the self-defeating personality. Both conferences will offer much of clinical interest to ACPA members and I look forward to seeing you there.
COGNITION IN PSYCHOSIS
Aleksandra Kralj, BSc(Hons), MSc Philip McGuire, MD, PhD, FRCPsych, FMedSci Aleksandra Kralj studied initially human psychology and subsequently psychiatric research at the Institute of Psychiatry, where she is now employed as a Research Worker. Aleksandra is pursuing her interest in schizophrenia by assisting on a number of trials within the Department of Psychosis Studies. Philip McGuire studied physiology and medicine at the University of Edinburgh, and then was a research fellow in neuroanatomy at Yale University. He trained in psychiatry at the Maudsley hospital in London. Philip is currently Professor and Head of the Department of Psychosis Studies at the Institute of Psychiatry. He is also Academic Lead and Joint Leader of the Psychosis Clinical Academic Group, which integrates the departments research on psychosis with the clinical services for psychosis in the South London and Maudsley NHS trust in London. He is Director of two clinical services within the Psychosis Clinical Academic Group OASIS (Outreach and Support in South London) and the Voices Clinic. Please address all correspondence to: Aleksandra Kralj Department of Psychosis Studies Institute of Psychiatry De Crespigny Park, Denmark Hill London SE5 8AF, UK Email: aleskandra.kralj@kcl.ac.uk
Moore, Nayak, & Patel, 2007) and in patients who are antipsychotic nave (Andersen et al., in press). Impairments in cognitive functions are present before the onset of psychosis, become more prominent in the first years of illness, and then level out to follow a stable course in its chronic stages (Meesters et al., 2013). In schizophrenia, neuropsychological impairments have traditionally been regarded as unrelated to the severity of psychotic symptoms (Addington, Addington, & Maticka-Tyndale, 1991). For example, a meta-analysis of 187 studies found that working memory and phonological, visuo-spatial, and executive functions are impaired in schizophrenia, with effect sizes of 0.51 to 1.29, 0.55 to 1.41, and 0.73 to 0.92, respectively, and these deficits were independent of symptom severity (Forbes, Carrick, McIntosh, & Lawrie, 2009). Saleem et al. (2013) observed deficits in the attention domain, showing that patients with psychosis display slowing reaction times and have problems in sustaining attention over time. However, alterations in other cognitive processes, such as self-monitoring (McGuire et al., 1995) and the processing of salience (Kapur, 2003), may underlie specific symptoms, such as hallucinations and delusions. Psychotic disorders are classically associated with deficits in verbal and spatial memory, verbal fluency, attention, working memory, and planning (Meesters et al., 2013), and impairments in executive functions have been referred to as a core deficit in schizophrenia (Joyce, Hutton, Mutsatsa, & Barnes, 2005). These deficits may contribute to the social and functional disability associated with psychotic disorders. For example, an impairment in spatial memory has been found to be a significant predictor of planning impairments (Badcock, Dragovic, Waters, & Jablensky, 2005), which negatively affects a patients daily routines and, therefore, quality of life (Saleem et al., 2013). The notion that cognitive deficits underlie functional disability in psychosis has stimulated interest in new interventions that may improve these impairments, particularly as existing treatments for psychosis have no significant impact on cognitive function (Goldberg et al., 2007). The treatment of cognitive impairments in psychosis is discussed further at the end of the article. Cognitive deficits are found to precede the illness Fuller et al. (2002) obtained school records for 70 patients with schizophrenia, and found that their scores at age 16 and 17 were significantly lower than those of both their peers and state norms. Cognitive function has also been examined in young adults who are at ultra high risk of developing psychosis; these individuals usually present to clinical services with attenuated psychotic symptoms in the context of declining social and vocational function (Fusar-Poli et al., 2012). Seidman et al. (2010) found that ultra high risk subjects were significantly impaired in neuropsychological functioning, in particular coding and verbal memory. Furthermore, these cognitive impairments were more severe in the subgroup who later developed psychosis than in those who did not. A recent meta-analysis found strong evidence for consistent cognitive deficits amongst ultra high risk subjects, with impairments in overall intelligence, attention, executive function, verbal fluency, and working memory, relative to controls. Furthermore, later transition to psychosis
mpaired cognitive functioning is a primary feature of psychotic disorders, and was recognised as such by Kraepelin and Bleuler (Bozikas, Kosmidis, Kioperlidou, & Karavatos, 2004). Cognitive impairments are evident at all stages of psychotic disorders: in the first episode (Mohamed, Paulsen, OLeary, Ardnt, & Andreasen, 1999) and chronic phases (Pietrzak et al., 2009), and even before the onset of illness (Fusar-Poli et al., 2012). Cognitive impairments are not simply secondary to effects of psychosis or its treatment, as they are evident in patients who are in remission (Krishnadas,
was associated with more marked impairments in verbal fluency, visual and verbal memory, and working memory (Fusar-Poli et al., 2012). How do cognitive deficits in psychosis affect real-world functioning? Cognition in schizophrenia is a predictor of real-world functioning and ability to perform everyday living and occupational skills (Green, Kern, Braff, & Mintz, 2000). A review of studies of neurocognitive deficits and functional outcome in schizophrenia found that vigilance, working memory, verbal memory, and executive functioning were associated with functional outcomes, such as community functioning, social skills, and skill acquisition (Green et al., 2000). Whilst these cognitive deficits can be concluded to affect functional outcomes in the broad sense, they can also have a great impact in terms of patients ability to live independently and monitor their physical health (George et al., 2000; Keefe & Harvey, 2012) and occupational satisfaction (Dickerson et al., 2007). Independence Cognitive deficits associated with psychosis can impair a patients ability to perform everyday living skills, such as cooking and maintaining personal hygiene, and are, therefore, strongly related to patients ability to live independently (Keefe & Harvey, 2012). Green et al. (2000) found that a deficit in executive functions is a significant predictor of daily living and independent functioning as executive functions involve core cognitive processes, including planning, problem solving, and adapting to ones environment (Reed, Harrow, Herbener, & Martin, 2002). They are required for many every day activities, such as cooking and travelling. Furthermore, deficits in vigilance and attention may result in difficulties following social conversations and basic instructions or in watching television (Keefe & Harvey, 2012), which would lead to struggles when trying to lead a normal day-to-day life. However, it is verbal memory which has been seen to be one of the most consistent predictors of community functioning and independent living (Revhein et al., 2006), with verbal memory predicting the level of community functioning with an independent variance of 45% (Fujii & Wylie, 2003). These studies provide evidence for the difficulty people with psychosis may have when attempting to live independently, and highlight the need for treatments in these areas. Employment Deficits in psychomotor speed, attention, information processing, memory, and, in particular, executive functions are associated with poor functional outcomes in patients with psychosis, especially in relation to their vocational quality of life (Kluwe-Schiavon, Sanvicente-Viera, Kristensen, & Grassi-Oliviera, 2013). Dickerson et al. (2007) found that the impairment of immediate verbal memory in patients with psychosis was the strongest predictor of whether participants were in employment. Immediate verbal memory is fundamental to the ability to perform everyday activities in the workplace, and deficits in this area, as seen in patients
with psychosis, may hinder ability to strive vocationally (Toulopoulou & Murray, 2004). An important caveat to the above is that other features of psychosis may also contribute to functional disability in psychosis. One of the most important is the effect of negative psychotic symptoms, including a loss of motivation, psychomotor slowing, and poverty of speech. Effects on clinical engagement and treatment adherence Keefe and Harvey (2012) suggested that deficits in executive function, such as planning, directly affect a patients ability to seek help when needed. George et al. (2000) also found that impairments in memory and attention exhibited in patients with psychosis are directly correlated with their inability to reduce damaging behaviour, such as smoking. Jeste et al. (2003) found that the common deficit in memory shown in people with a diagnosis of schizophrenia was a significant predictor of medication adherence. This is clinically a very important finding as poor medication adherence is associated with worsening of symptoms, worse health outcomes, and subsequent relapse (Jarboe & Schwartz, 1999). Can clinical intervention improve cognitive deficits? The mainstay of treatment for psychotic disorders is antipsychotic medication. However, while there have been reports that some of these drugs could improve cognitive function in psychosis, there is little evidence for a marked effect (Goldberg et al., 2007). Similarly, there is no evidence that cognitive behaviour therapy (CBT) has any effect on cognitive impairments in schizophrenia (Bowie, McGurk, Mausbach, Patterson, & Harvey, 2012). Nevertheless, the concept that cognitive dysfunction contributes to functional disability in psychosis has driven a search for new treatments for cognitive impairments. Cognitive remediation Cognitive remediation (CR) is a behavioural trainingbased intervention intended to improve cognitive processing, such as memory, attention, and executive function, with the aim of these effects becoming generalisable and durable (Anaya et al., 2012). Wykes and Spaulding (2011) state that CR training protocols use four main techniques to aid cognition, but these techniques must be supplemented by practice in carrying out tasks to help improve the automatisation of the processes. These protocols are: errorless learning, where participants are taught to conduct cognitive tasks with a reduced opportunity for making errors by having the therapist assist greatly in the beginning of the task and slowly withdraw their help as the patient becomes more skilled and confident; self-monitoring, which allows patients to develop techniques of rehearsal of task instructions and for completion, usually in the form of reminds and hints; scaffolding, where a patient is assigned a task designed at their level of competence which requires some effort on their part, a protocol that ensures that all task components and skills have been learned and that the patient practises the task in varied complexities to aid engagement; and, finally
chunking, an alternative learning support that allows processing of smaller sub-goals that can be rehearsed and monitored (Wykes & Spaulding, 2011). Penads et al. (2006) found that CR produced an improvement in neurocognitive function compared to CBT in patients with schizophrenia, whereas CBT was more effective at reducing levels of anxiety and depression. In contrast, Gharaeipour and Scott (2012) reported that patients with schizophrenia who received CR showed a reduction in psychotic symptoms as well as an improvement in cognitive function. In a meta-analysis of 40 studies, Wykes, Huddy, Cellard, McGurk, and Czobor (2011) found a small to moderate effect of CR on cognitive outcomes when measured post-treatment and at follow-up. The effect size for CR has been found to be smaller in patients with more severe symptoms (Wykes et al., 2011). An important practical consideration for CR is its logistical feasibility. Some forms of CR are relatively demanding in terms of both staff and patient time, with daily training sessions. CR that can be delivered via an interactive computer programme, especially when this involves a game, may be more practicable. Only a few studies have assessed whether improvements in task performance are maintained in the long term. Wykes et al. (2003) reported that beneficial effects on memory were still evident after six months, but that there were no significant differences in cognitive flexibility, planning, social functioning, or self-esteem. Fiszdon, Bryson, Wexler, and Bell (2004) tested performance on two memory tasks and found that while the improvements in digit span were sustained at six months, word sequenced recall showed no beneficial effects at follow-up. A further issue is whether improvements in task performance are associated with significant changes in real world functioning. Bowie et al. (2012) found relatively little evidence that improvements in cognition following CR transferred to everyday life. However, translation to everyday functioning may be enhanced if CR is used alongside other approaches, such as work therapy (McGurk, Mueser, Feldman, Wolfe, & Pascaris, 2007) or intensive social cognitive training (Eack et al., 2009). A number of new pharmacological treatments, designed to improve cognitive function in psychosis, are also undergoing evaluation. These include drugs that act on the cholinergic and the glutamatergic neurotransmitter systems. The effectiveness of these new interventions is not yet known. The use of cholinergic drugs to improve cognitive function in psychosis in interesting, as these act on nicotinic receptors, and the prevalence of cigarette smoking in patients with psychosis is very high (60-70% of some samples). One potential factor in the high rates of smoking in psychosis is that patients use the nicotine in cigarettes to alleviate cognitive impairments. Conclusion Impairments in cognitive function are a core feature of psychotic disorders, and are present before and throughout the course of illness. They are an important factor in the functional disability associated with psychosis, and deficits in certain processes may also underlie specific psychotic symptoms. Existing treatments for psychosis have little
impact on these deficits, but a number of novel cognitive and pharmacological interventions are under investigation.
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DELUSIONAL MISIDENTIFICATION SYNDROME

Max Coltheart, PhD, DSc, HonDLItt Max Coltheart is Emeritus Professor of Cognitive Science at Macquarie University, Honorary Professor of Psychology at the University of Queensland, and formerly Director of the Macquarie Centre for Cognitive Science. He is a Fellow of the Australian Academy of Science, the Academy of the Social Sciences in Australia, and the British Academy. Please address all correspondence to: Emeritus Professor Max Coltheart Centre for Cognition and its Disorders Department of Cognitive Science Macquarie University Sydney NSW 2109 Australia Email: max.coltheart@mq.edu.au
schizophrenia, other cases were associated instead with stroke, epilepsy, or dementia. To elaborate still further upon point (b), consider the mirrored-self misidentification delusion. This is the belief that when you are looking at your reflection in a mirror, the person you are seeing is not you, but a stranger who looks like you (Breen, Caine, Coltheart, Hendy, & Roberts, 2000; Connors & Coltheart, 2011). This is yet another kind of delusional misidentification since the person being misidentified is yourself, rather than someone known to you (such as your spouse; as in Capgras delusion) or someone unknown to you (as in Fregoli delusion). All three of the kinds of delusional misidentification that I have described exhibit features considered characteristic of delusional conditions. For example, all are highly resistant to the presentation of counter-evidence, and for all three the response to counter-evidence is not to doubt the truth of the delusional belief, but instead to rationalise. When the wife of a man with Capgras delusion is pointed out to him and he is asked What makes you think this woman is not your wife?, a typical response would be to claim that this woman differs in some slight physical way from his wife he might say that this womans eyes are closer together than his wifes. When a man with mirrored-self misidentification is asked If that man isnt you, why is he always wearing the same clothes as you?, the response might be the non sequitur Hes not changing his clothes. Delusional aetiologies misidentification has many different
ncorrect identification of other people is a symptom seen in some people suffering from psychosis, and this is usually referred to as delusional misidentification syndrome. For example, Silva and Leong (1992) reviewed 31 cases of people, diagnosed with schizophrenia, who exhibited the delusional misidentification syndrome known as Capgras delusion. In Capgras delusion, the deluded person believes that someone who is an intimate of theirs often that persons spouse has been replaced by some stranger who looks like that spouse; that is, the spouse is misidentified as some unknown person. Two key points need to be appreciated here, though, if we are to understand properly the nature of delusional misidentification. These points are: (a) Capgras delusion is not confined to people diagnosed with schizophrenia. Coltheart, Langdon, and McKay (2007) noted that, in addition to schizophrenia, there are 13 other aetiologies which have been reported in cases of Capgras delusion, including head injury, stroke, AIDS, and viral encephalitis; Capgras delusion is only one amongst a number of different kinds of misidentification syndrome.
To understand delusional misidentification from a clinical and a scientific point of view, considerations of aetiology are unhelpful because this condition occurs with many different aetiologies, even if the most commonly associated aetiology is schizophrenia. Nor is it helpful to use the term delusional misidentification syndrome since, as I have shown, there are various different kinds of delusional misidentification conditions; it is not reasonable to lump these together and treat them as a single condition. What might be a more helpful approach to understanding delusional misidentification, from both a clinical and a scientific perspective, is as follows. For the term delusional misidentification to be applicable at all, the deluded person must be identifying person X as person Y, where X and Y are different persons. So for any case of delusional misidentification, we can ask: In this case, who is person X, and who is person Y? For Capgras delusion, the answer here is: X is someone known to the deluded person (and emotionally close to that person; e.g., a spouse), and Y is a stranger. For the mirrored-self misidentification delusion, the answer here is: X is the deluded person himself or herself (reflected in a mirror), and Y is a stranger. For Fregoli delusion, the answer here is: X is someone unknown to the deluded person (i.e., a stranger), and Y is someone known to the deluded person.
(b)
To elaborate upon point (b), consider Fregoli delusion. This is the belief that one or more people known to the deluded person continually follow the deluded person about, but are unidentifiable because these followers are continually changing their appearance (e.g., by disguise or by plastic surgery). Here, unknown people (strangers seen by the deluded person) are misidentified as people the deluded person knows; this is quite different from, and might even be considered the opposite of, Capgras delusion. Mojtabai (1994), reviewing 34 cases of Fregoli delusion, noted that while the most common accompanying aetiology was
In these three scenarios, either X is known to the deluded person whilst Y is not, or else it is the other way around. That prompts the question: Are there any cases of delusional misidentification where both X and Y are known to the deluded person? There are. Breen, Caine, and Coltheart (2002) reported the case of a man who, after emerging from coma following a severe head injury, exhibited the belief that his wife was not his wife but a different woman who had been also known to him, this woman being a former business partner of his. The two-factor theory of delusional belief What causes delusional belief? Here one might be asking a question about the brain (What forms of brain damage give rise to delusional conditions?) or about cognition (In what ways have the normal processes of belief generation, evaluation, and adoption been impaired in delusional people?). No answer to the first of these questions is currently available. The two-factor theory of delusional belief (Coltheart, 2007; Coltheart, Langdon, & McKay, 2011; Langdon & Coltheart, 2000) proposes an answer to the second question. According to this theory, we will understand any kind of delusional belief if we can discover the answer to two questions. The first question is: What prompted the delusional idea in the first place? The second is: Given that this idea is so bizarre and that there is good evidence against it, why was it adopted as a belief rather than being rejected? People with Capgras delusion do not show the normal autonomic response to familiar faces; they respond autonomically to seeing a familiar face no more than to seeing an unfamiliar face (Ellis, Young, Quale, & De Pauw, 1997). The absence of this response to a spouses face might initially prompt the idea that this is not the spouse, but someone unfamiliar. That idea ought to be rejected; it is not, because of a second cognitive impairment, an impairment of a belief evaluation system located in the right frontal lobe (where there is documented damage in cases of Capgras delusion). People with mirrored-self misidentification delusion have either impaired face processing (so that the face they see in the mirror no longer looks like theirs) or mirror agnosia (loss of the ability to understand how mirrors work, so that mirrors are treated as if they are windows, and hence anyone seen in a mirror is in a different part of space than ones self and so must be a different person). These are the factors that initially prompt the idea that the person in the mirror is a stranger. That idea ought to be rejected; it is not, because of a second cognitive impairment, an impairment of a belief evaluation system located in the right frontal lobe (where there is documented damage in cases of mirrored-self misidentification delusion).
Suppose that in Fregoli delusion the face recognition system is abnormally responsive, so that even the faces of strangers produce strong autonomic responses. That might initially prompt the idea that people who are strangers are actually known to the affected person. Since these strangers dont look like any known people and deny that they are known to the affected person, this idea too should be rejected. The two-factor theory, therefore, requires that it should be possible to demonstrate cases of Fregoli delusion in the right frontal lobe; this is a project for future research on this delusion since no work of this kind has yet been done with Fregoli patients. Conclusions It is true that delusional misidentification is a symptom seen in some people suffering from psychosis, but it is important to appreciate that every different form of delusional misidentification can occur in various other conditions as well, rather than occurring only in association with psychosis. So whatever the patterns of cognitive impairments are that are responsible for each form of delusional misidentification, each particular pattern can emerge as a consequence of many different aetiologies
References Breen, N., Caine, D., & Coltheart, M. (2002). The role of affect and reasoning in a patient with a delusion of misidentification. Cognitive Neuropsychiatry, 7, 113138. Breen, N., Caine, D., Coltheart, M., Hendy, J., & Roberts, C. (2000). Delusional misidentification. Mind & Language, 15, 74-110. Reprinted in M. Coltheart, & M. Davies (Eds.), Pathologies of Belief. Oxford: Blackwells. Coltheart, M. (2007). The 33rd Bartlett Lecture: Cognitive neuropsychiatry and delusional belief. Quarterly Journal of Experimental Psychology, 60, 1041-1062. Coltheart, M., Langdon, R., & McKay, R. T. (2011). Delusional belief. Annual Review of Psychology, 62, 271-298. Connors, M., & Coltheart, M. (2011). On the behaviour of senile dementia patients vis--vis the mirror: Ajuriaguerra, Strejilevitch and Tissot (1963). Neuropsychologia, 49,1679-1692. Ellis, H. D., Young, A. W., Quayle, A. H., & de Pauw, K. W. (1997). Reduced autonomic responses to faces in Capgras delusion. Proceedings of the Royal Society, Series B (Biological Sciences), 264, 1085-1092. Langdon, R., & Coltheart, M. (2000). The cognitive neuropsychology of delusions. Mind & Language, 15, 184-218. Mojtabai, R. (1994). Fregoli syndrome. Australian and New Zealand Journal of Psychiatry, 28, 458-462. Silva, J. A., & Leong, G. B. (1992). The Capgras delusion in paranoid schizophrenia. Psychopathology, 25, 147153.
can persist for longer, or there may be residual symptoms. However, if symptoms consistently recur in the absence of drug use, they are more likely to reflect schizophrenia or another primary psychotic disorder. Symptoms are most likely to occur in heavy long-term users of the drug, the majority of whom will experience psychotic symptoms at some point in their drug-using career, with around one-quarter of regular users reporting symptoms within the past year (McKetin, McLaren, Lubman, & Hides, 2006). Methamphetamine psychosis is thought to be caused primarily by the large efflux of dopamine in the brain that occurs during methamphetamine intoxication and possibly also by alterations in the regulation of dopamine activity that can occur with chronic use of the drug (Angrist, Sathananthan, Wilk, & Gershon, 1974; Iyo et al., 1993; Sekine et al., 2001). Genetic factors and other comorbidities also affect vulnerability to the condition (Chen et al., 2003; Chen et al., 2005). Box 1. Adapted from DSM-V Diagnostic Criteria for Substance-Induced Psychotic Disorder (American Psychiatric Association, 2013)
METHAMPHETAMINE AND PSYCHOSIS

Rebecca McKetin, BSc(Psychol), PhD Rebecca McKetin is a Fellow at the Australian National Universitys Centre for Research on Ageing, Health and Wellbeing. Her research interests include the relationship between substance use and mental health, drug-induced psychosis, and depression. Much of her research has focused on methamphetamine, for which she has received a NSW/ACT Young Tall Poppy Science Award. Please address all correspondence to: Dr Rebecca McKetin Centre for Research on Ageing, Health and Wellbeing The Australian National University Canberra ACT 0200 Australia Email: rebecca.mcketin@anu.edu.au
1.
2.
3.
4.
Prominent symptoms: Hallucinations and /or Delusions. Evidence (history, clinical, laboratory): The symptoms are closely associated with substance intoxication (e.g., during, after, withdrawal or exposure) and The substance must be capable of being the causative agent of the symptoms The effect must be distinct from any nonsubstance-induced psychotic disorder in consideration of such factors as onset, time period, course and atypical features. The symptoms cause clinically significant distress in major areas of functioning.
Characteristics of methamphetamine psychosis
ethamphetamine is arguably the most potent psychotogenic drug available on the illicit drug market. Australia has one of the highest rates of use in the world (McKetin, Baker, Lee, & Kay-Lambkin, 2012), with an estimated 97,000 Australians meeting criteria for a stimulant use disorder (including methamphetamine, cocaine, and other amphetamine-type drugs) (Sara, Burgess, Malhi, & Whiteford, 2011). Psychosis induced by methamphetamine is characterised by hallucinations and/or delusions (see Box 1). Delusions are typically paranoid in nature, and hallucinations are most often auditory or visual, but can occur in other senses (e.g., olfactory hallucinations). Symptoms of thought disorder (tangential thought, derailment, neologisms) and negative symptoms (e.g., blunted affect) can occur but are less common (Angrist, Lee, & Gershon, 1974; Connell, 1958; Harris & Batki, 2000). The symptoms of methamphetamine psychosis are transient, typically lasting hours to days. In some cases they
Diagnosis A diagnosis of methamphetamine psychosis can be made using the Structured Clinical Interview for DSM Disorders (SCID), and arguably other structured instruments, but the attribution of symptoms to methamphetamine use rather than a primary psychotic disorder, such as schizophrenia, is somewhat subjective and problematic (Mathias, Lubman, & Hides, 2008). The Psychiatric Research Interview for Substance and Mental Disorders (PRISM) has gone to greater lengths than other psychiatric interviews to differentiate substanceinduced from primary psychotic disorders, but its use requires substantial training (http://www.columbia. edu/~dsh2/prism/). A careful assessment of the onset of psychotic symptoms in the patients life, and the temporal relationship between
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the use of methamphetamine and these symptoms, is needed to understand the extent to which psychotic symptoms are related to methamphetamine use. A family history of schizophrenia, or other psychotic disorders, highlights the possibility that the person may have a primary psychotic disorder or that they may go on to develop such a disorder. Diagnostic instruments tend to miss the majority of psychotic symptoms that are produced by methamphetamine, because these symptoms are often too brief or too mild to meet diagnostic criteria for a psychotic episode. For this reason, measures that capture the severity of psychotic symptoms can have greater utility in clinical practice. Two such measures are the Brief Psychiatric Rating Scale (Lukoff, Nuechterlein, & Ventura, 1986) and the Positive and Negative Symptom Scale (see the PANSS institute for details: http://www.panss.org/ home/index.php?option=com_content&task=view&id=23&It emid=66). Both scales involve a semi-structured interview to identify the nature and severity of psychotic symptoms and they also assess other symptom domains (e.g., depression, anxiety). Management The treatment of methamphetamine psychosis in psychiatric emergencies usually involves the administration of benzodiazepines and/or antipsychotic agents to sedate the patient and alleviate psychotic symptoms (for an example, see Dore and Sweeting, 2006). Benzodiazepines are often sufficient because of the time-limited nature of symptoms. There have been a handful of trials that have assessed the relative benefits of different medication regimes, but there is no clear forerunner (Shoptaw, Kao, & Ling, 2009). One of the complications of methamphetamine psychosis is that it can be accompanied by agitation and, in some cases, unpredictable violent behaviour (Bunting, Fulde, & Forster, 2007). Chemical restraint can be required to manage the patient. Presentations that involve police referral can be complicated by injuries sustained during police handling and restraint (McKetin, Kelly, & McLaren, 2005). Applying guidelines for the management of behavioural disturbances (Allen, Currier, Carpenter, Ross, & Docherty, 2005) can help reduce the risk of harm to both the patient and health professionals. The majority of methamphetamine users who experience psychotic symptoms will not attend hospital because their symptoms are transient and not sufficiently severe to warrant emergency psychiatric care. While milder, these psychotic symptoms can still have a detrimental impact on the persons interpersonal relationships and employment, and cause them distress. Psychological therapies and psychosocial support can play an important role in managing the impact of these milder symptoms, and can alleviate the potential adverse impact that these symptoms, and more severe psychotic episodes, can have on a persons well-being (Smith, Nathan, Juniper, Kingsep, & Lim, 2003).
The need for follow-up care Unfortunately, patients who present with methamphetamine psychosis often receive little follow-up care to address their drug use, leading to a revolving door phenomenon, with discharged patients experiencing recurrent episodes of psychosis because they return to drug use. Methamphetamine can also precipitate and exacerbate symptoms of psychosis in people with primary psychotic disorders (Curran, Byrappa, & McBride, 2004), increasing readmission rates among these patients. In both scenarios, providing patients with referral to drug treatment would help reduce the incidence of methamphetamine psychosis. Psychotic symptoms abate in most users when they stop taking the drug (McKetin, Lubman, Baker, Dawe, & Ali, 2013). Methamphetamine use can be effectively treated by the intensive application of psychological interventions, such as cognitive behavioural therapy and contingency management (Colfax et al., 2010). Educating methamphetamine users about the relationship between methamphetamine use and psychosis can also reduce their risk of psychosis. Methamphetamine users who are familiar with the early signs of psychosis (i.e., sub-clinical symptoms such as illusions, fleeting auditory hallucinations, and feeling paranoid) can reduce their drug use to avoid the development of more severe psychotic symptoms. More detail on the types of sub-clinical symptoms that methamphetamine users experience and related selfhelp information can be found in the On Thin Ice brochure (http://ndarc.med. unsw.edu.au/resource/ice). Prognosis Little is known about the prognosis for people who experience methamphetamine psychosis. However, there is growing speculation that methamphetamine psychosis may sensitise people to psychosis, increasing their risk of experiencing recurrent episodes of substance-induced psychosis or of developing a more enduring psychotic disorder, such as schizophrenia (Sato, 1992). A recent study conducted in Finland found that 30% of people initially diagnosed with a stimulant-induced psychosis (such as methamphetamine psychosis) would go on to be diagnosed with schizophrenia within the next eight years; most of these people were re-diagnosed within three years (Niemi-Pynttari et al., 2013). While these data do not indicate whether the schizophrenia was triggered by stimulant use, or whether stimulant use was merely incidental to the development of the psychotic disorder (Schuckit, 2006), they provide important prognostic information for people who have been diagnosed with methamphetamine psychosis. These data also highlight the importance of monitoring patients within the first few years of their initial diagnosis so that prompt intervention can be provided should the patient show signs of transitioning to a primary psychotic disorder. In the meantime, offering patients effective treatment for methamphetamine use is likely to reduce their risk of experiencing recurrent psychotic episodes.
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References Allen, M., Currier, G., Carpenter, D., Ross, R., & Docherty, J. (2005). The expert consensus guideline series. Treatment of behavioral emergencies 2005. Journal of Psychiatric Practice, Suppl 1, 5-108. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA. Angrist, B., Lee, H. K., & Gershon, S. (1974). The antagonism of amphetamine-induced symptomatology by a neuroleptic. American Journal of Psychiatry, 131(7), 817-819. Angrist, B., Sathananthan, G., Wilk, S., & Gershon, S. (1974). Amphetamine psychosis: Behavioral and biochemical aspects. Journal of Psychiatric Research, 11, 13-23. Bunting, P. J., Fulde, G. W., & Forster, S. L. (2007). Comparison of crystalline methamphetamine (ice) users and other patients with toxicology-related problems presenting to a hospital emergency department. Medical Journal of Australia, 187, 564-566. Chen, C.-K., Lin, S.-K., Sham, P. C., Ball, D., Loh, E.-W., & Murray, R. M. (2005). Morbid risk for psychiatric disorder among the relatives of methamphetamine users with and without psychosis. American Journal of Medical Genetics, Part B, Neuropsychiatric Genetics: the Official Publication of the International Society of Psychiatric Genetics. 136B(1), 87-91. Chen, C.-K., Lin, S.-K., Sham, P. C., Ball, D., Loh, E.-W., Hsiao, C.C., . . . Murray, R. M. (2003). Pre-morbid characteristics and co-morbidity of methamphetamine users with and without psychosis. Psychological Medicine, 33(8), 1407-1414. Colfax, G., Santos, G.-M., Chu, P., Vittinghoff, E., Pluddemann, A., Kumar, S., & Hart, C. (2010). Amphetamine-group substances and HIV. The Lancet, 376(9739), 458-474. Connell, P. H. (1958). Amphetamine psychosis. (Maudsley Monograph No. 5). London: Oxford University Press. Curran, C., Byrappa, N., & McBride, A. (2004). Stimulant psychosis: Systematic review. British Journal of Psychiatry, 185, 196-204. Dore, G., & Sweeting, M. (2006). Drug-induced psychosis associated with crystalline methamphetamine. Australasian Psychiatry, 14(1), 86-89. Harris, D., & Batki, S. L. (2000). Stimulant psychosis: Symptom profile and acute clinical course. American Journal on Addictions, 9(1), 28-37. Iyo, M., Nishio, M., Itoh, T., Fukuda, H., Suzuki, K., Yamasaki, T., . . . Tateno, Y. (1993). Dopamine D2 and serotonin S2 receptors in susceptibility to methamphetamine psychosis detected by positron emission tomography. Psychiatry Research, 50(4), 217-231. Lukoff, D., Nuechterlein, K. H., & Ventura, J. (1986). Manual for the expanded Brief Psychiatric Rating Scale. Schizophrenia Bulletin, 12, 594-602. Mathias, S., Lubman, D. I., & Hides, L. (2008). Substanceinduced psychosis: A diagnostic conundrum. Journal of Clinical Psychiatry, 69(3), 358-367. McKetin, R., Baker, A., Lee, N., & Kay-Lambkin, F. (2012). Patterns of use and current drivers of patterns of use. In S. Allsop & N. Lee (Eds.), Amphetamine Type Stimulants (pp. 5-20). Melbourne, Australia: IP Communications.
McKetin, R., Lubman, D. I., Baker, A. L., Dawe, S., & Ali, R. (2013). Psychotic symptoms are dose-related in chronic methamphetamine users: Evidence from a prospective longitudinal study. JAMA Psychiatry. Advance online publication. McKetin, R., McLaren, J., & Kelly, E. (2005). The Sydney methamphetamine market: Patterns of supply, use, personal harms and social consequences (Monograph Series No. 13). National Drug Law Enforcement Research Fund. McKetin, R., McLaren, J., Lubman, D. I., & Hides, L. (2006). The prevalence of psychotic symptoms among methamphetamine users. Addiction, 101(10), 14731478. Niemi-Pynttari, J., Sund, R., Putkonen, H., Vorma, H., Wahlbeck, K., & Pirkola, S. (2013). Substance-induced psychosis converting into schizophrenia: A registerbase study of 18,478 Finnish inpatient cases. Journal of Clinical Psychiatry, 74(1), e94. Sara, G., Burgess, P., Malhi, G., & Whiteford, H. (2011). Stimulant use and stimulant disorders in Australia: Findings from the National Survey of Mental Health and Wellbeing. Medical Journal of Australia, 195, 607610. Sato, M. (1992). A lasting vulnerability to psychosis in patients with previous methamphetamine psychosis. Annals of the New York Academy of Sciences, 654, 160-170. Schuckit, M. A. (2006). Comorbidity between substance use disorders and psychiatric conditions. Addiction, 101 Suppl 1, 76-88. Sekine, Y., Iyo, M., Ouchi, Y., Matsunaga, T., Tsukada, H., Okada, H., . . . Mori, N. (2001). Methamphetaminerelated psychiatric symptoms and reduced brain dopamine transporters studied with PET. American Journal of Psychiatry, 158(8), 1206-1214. Shoptaw, S. J., Kao, U., & Ling, W. W. (2009). Treatment for amphetamine psychosis. Cochrane Database of Systematic Reviews, 2009(1). doi:10.1002/14651858.CD003026.pub3 Smith, L., Nathan, P., Juniper, U., Kingsep, P., & Lim, L. L. (2003). Cognitive behavioural therapy for psychotic symptoms: A therapists manual. Perth, Australia: Centre for Clinical Interventions.
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ameliorating symptoms, particularly when applied early in the course of illness, functional recovery is not seen to automatically follow symptomatic improvement (Rinaldi et al., 2010). Over time, functional impairment left untreated has the potential to be a greater cause of disability than the initial psychotic illness. It is, therefore, important that interventions are provided to the young person with psychosis so that in addition to achieving a symptomatic recovery, he or she also achieves a functional recovery. By functional recovery we mean such things as a return to school or work, having a place to live, and addressing physical health needs. In considering this definition of functional recovery, it is worth revisiting the World Health Organisations (2011) definition of mental health. Mental health is not just the absence of mental disorder. It is defined as a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. Functional recovery, as well as being congruent with the World Health Organisations definition of mental health, is also closely aligned to the stated aims of people with psychotic illness who rate positive functional outcomes as being more important than symptomatic remission (Morgan et al., 2011). While this was found to be the case in schizophrenia, it has recently been found to be equally so in young people treated for their first psychotic episode in both the USA (Ramsay et al., 2011) and India (Iyer, Mangala, Anitha, Thara, & Malla, 2011). Ramsay and colleagues found that the top five life goals of young people with first episode psychosis (FEP) were (in descending order): employment, education, relationships, housing, and general health. Recovery from the current episode was rated ninth. Iyer et al. (2011) in India found an almost identical list (work, interpersonal, school, symptom relief, living situation). What areas of functioning are impacted in FEP? A number of domains are impacted in first episode psychosis (FEP). One of the key reasons that these domains are impacted is that the onset of psychosis tends to occur in late adolescence and early adulthood, which is a key developmental phase. Disruption to this development leads to the functional impairment seen in FEP. Key tasks of this phase of life include finishing education and transitioning to employment, establishing independent living, establishing romantic relationships, developing independent economic and social participation, and taking responsibility for ones physical health. The impact of psychosis for people with psychotic illness is seen in examining the functional outcomes across these domains. Only 22% are employed, with only 32% completing high school (Waghorn et al., 2012). Nearly 13% have experienced homelessness in the previous 12 months (Harvey, Killackey, Groves, & Herrman, 2012). People with psychotic illnesses are less likely to be in relationships (Morgan et al., 2011) than the general population. As a consequence of their unemployment, they are less likely to be financially independent, and this constricts the degree to
FUNCTIONAL RECOVERY IN FIRST EPISODE PSYCHOSIS

Ein Killackey, DPsych(Clin) Ein Killackey is an NHMRC Fellow and the Director of Psychosocial Research at Orygen Youth Health Research Centre and The Centre for Youth Mental Health at The University of Melbourne. He completed his Doctorate in Clinical Psychology at Deakin University in 2000. He has worked as a clinical psychologist in adolescent and adult public mental health settings and in private practice. His research is primarily in the area of functional recovery for young people with mental illness. Please address all correspondence to: Associate Professor Ein Killackey Orygen Youth Health Research Centre 35 Poplar Road Parkville Victoria 3052 Email: eoin@unimelb.edu.au
Introduction
he onset of a psychotic illness represents a crisis in the life of a young person. In addition to the frequently frightening symptoms of hallucinations and delusions, there are often traumatic experiences in the course of accessing and receiving care. Despite much development, and contrary to guideline recommendations, in many public systems of care treatment is still largely based on medication, and often does not include a significant input of psychosocial treatment (Killackey, et al., 2008). This lack of psychosocial treatment compounds the effects of the illness because psychotic illnesses not only cause symptomatic distress, but they also significantly impair functioning in a number of domains. While there is increasing evidence that pharmacological and other interventions that target the symptoms are doing an increasingly good job of
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which individuals are able to participate socially (Killackey, Jackson, Gleeson, Hickie, & McGorry, 2006). Finally, people with psychotic illness are more obese, smoke more, and die earlier than the rest of the population (Thornicroft, 2011). Plainly, paying attention only to the symptomatic element of illness is not sufficient. There is an urgent need for both the development of interventions targeting functional recovery, and, more importantly, the implementation of those interventions found to work. Rationale for early intervention The rationale for early intervention is that by intervening as early as possible in the course of illness, not only is the extent of symptoms limited, but, more importantly, the development of disability is curtailed (McGorry et al., 2010). The rationale is further justified because it is known that the first five years after onset, the so-called critical period (Birchwood & Fiorillo, 2000), is the time when disability reaches its greatest level. Being able to reduce development of disability in this phase is likely to lead to lower long-term disability. More recent research shows that a focus on functional recovery is at least equally important as a focus on symptomatic recovery. lvarez-Jiminz et al. (2012) found that functional rather than symptomatic recovery at 14 months post-first-admission was predictive of full recovery (symptomatic and functional) at 7.5 years in a sample of 209 people with FEP. Therefore the question arises, what interventions are known to be of use in addressing functional recovery in FEP? Interventions This article will consider interventions in two domains vocational recovery and physical health and the evidence associated with them. In other domains there is still a need to develop interventions and associated evidence. Vocational recovery. There have been a number of approaches to vocational recovery in mental illness. Broadly these break into two approaches. The first is pre-placement training. That is, a person is trained in working, or in a job task, with the idea that they will then be able to go and compete in the open labour market. This sort of approach to employment is characterised by an approximate 20% (Crowther, Marshall, Bond, & Huxley, 2001) success in obtaining competitive employment. The second approach is called supported employment and consists of people being aided to find a job in the open labour market and then provided with support to keep it (Killackey et al., 2006). The most defined form of supported employment is individual placement and support (IPS), which has eight principles (Dartmouth IPS Supported Employment Center, 2012): 1. Every person with severe mental illness who wants to work is eligible for IPS supported employment. 2. Employment services are integrated with mental health treatment services. 3. Competitive employment is the goal. 4. Personalised benefits counselling is provided. 5. The job search starts soon after a person expresses interest in working.
6.
7. 8.
Employment specialists systematically develop relationships with employers based upon their clients work preferences. Job supports are continuous. Client preferences are honoured.
IPS has been very successful in populations with chronic schizophrenia. It has only more recently been adapted to FEP. Because of the age range of people with FEP, IPS in this group includes not only employment outcomes but also educational outcomes. Two RCTs of IPS in FEP have shown that approximately 85% of people with FEP can return to school or work using this intervention (Killackey, Jackson, & McGorry, 2008; Nuechterlein et al., 2008). Physical health. People with psychotic illnesses have a much shorter lifespan than the general population, and for the majority the cause is preventable disease brought about through obesity and tobacco smoking (De Hert et al., 2011). While 24% of Australians experience obesity, 42% of Australians with psychosis are obese (Morgan et al., 2011). Seventeen percent of the Australian population smoke cigarettes compared to 66% of Australians with psychotic illness (Morgan et al., 2011). The rationale for early intervention is particularly strong in this area, as smokers who quit before age 30 have nearly the same long term health risks as non-smokers, and the onset of weight gain is known to happen early in the course of illness. Weight gain and obesity: There have been a number of approaches to prevention of weight gain and managing obesity. However, there has been only one RCT which looked at this issue specifically in first episode psychosis. AlvarezJimenez and colleagues (2006) found that a 3-month individually tailored behavioural lifestyle intervention focused on diet and exercise could prevent weight gain in those with first episode psychosis. Unfortunately, despite the initial positive results, the benefit was not maintained at 12 months follow-up, indicating the need for either ongoing or booster sessions (Alvarez-Jimnez et al., 2010). Smoking: Currently there is little to no evidence to suggest interventions to address smoking by people with first episode psychosis. Conventional advice extrapolates from the general population and suggests either a nicotine replacement therapy such as patches, a nicotine antagonist such as bupropion, or cognitive behaviour therapy. There have been no studies examining the efficacy of these approaches in young people with first episode psychosis. There is some suggestion that bupropion may be contraindicated for people who are taking anti-psychotics. Conclusions Functioning in any domain affects functioning in other domains. For example, it is harder to get a job if one is homeless, and homelessness is also associated with poorer physical health. The functional recovery of people with psychotic illness is increasingly being seen as requiring the same attention, and having the same importance, as their symptomatic recovery. Unfortunately, knowledge about and evidence for interventions in this domain is less developed than in the symptomatic domain; however, this is slowly
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beginning to change. There is now a strong evidence base for vocational recovery for this group. The crucial need to develop interventions for physical health has been acknowledged, and interventions are being developed and trialled that focus on improving physical health in this population. In other areas, such as homelessness, there is still a need to ascertain the scale of the problem and begin to design interventions to effectively address it. Finally, interventions developed in the future need to address needs in several functional domains simultaneously.
References lvarez-Jimnez, M., Gleeson, J. F., Henry, L. P., Harrigan, S. M., Harris, M. G., Killackey, E., McGorry, P. D. (2012). Road to full recovery: Longitudinal relationship between symptomatic remission and psychosocial recovery in first-episode psychosis over 7.5 years. Psychological medicine, 42(3), 595-606. Alvarez-Jimnez, M., Gonzlez-Blanch, C., Vzquez-Barquero, J. L., Prez-Iglesias, R., Martnez-Garca, O., PrezPardal, T., Crespo-Facorro B. (2006). Attenuation of antipsychotic-induced weight gain with early behavioral intervention in drug-naive first-episode psychosis patients: A randomized controlled trial. Journal of Clinical Psychiatry, 67(8), 1253-1260. Alvarez-Jimnez, M., Martnez-Garca, O., Prez-Iglesias, R., Ramrez, M. L., Vzquez-Barquero, J. L., & CrespoFacorro, B. (2010). Prevention of antipsychoticinduced weight gain with early behavioural intervention in first-episode psychosis: 2-year results of a randomized controlled trial. Schizophrenia Research, 116(1), 16-19. Birchwood, M., & Fiorillo, A. (2000). The critical period for early intervention. Psychiatric Rehabilitation Skills, 4(2), 182198. Crowther, R. E., Marshall, M., Bond, G. R., & Huxley, P. (2001). Vocational rehabilitation for people with severe mental illness (Review). Cochrane Database of Systematic Reviews, 2001(2), 1-55. Dartmouth IPS Supported Employment Center. (2012, January 17). Core Principles of IPS Supported Employment. Retrieved from http://www.dartmouth.edu/~ips/page29/page31/pa ge31.html De Hert, M., Correll, C., Bobes, J., Cetkovich-Bakmas, M., Cohen, D., Asai, I., Leucht, S. (2011). Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry, 10(1), 52-77. Harvey, C., Killackey, E., Groves, A., & Herrman, H. (2012). A place to live: Housing needs for people with psychotic disorders identified in the second Australian national survey of psychosis. Australian and New Zealand Journal of Psychiatry, 46(9), 840-850.
Iyer, S. N., Mangala, R., Anitha, J., Thara, R., & Malla, A. K. (2011). An examination of patient-identified goals for treatment in a first-episode programme in Chennai, India. Early Intervention in Psychiatry, 5(4), 360-365. Killackey, E., Jackson, H. J., & McGorry, P. D. (2008). Vocational intervention in first-episode psychosis: A randomised controlled trial of individual placement and support versus treatment as usual. British Journal of Psychiatry, 193, 114-120. Killackey, E., Jorm, A. F., Alvarez-Jiminez, M., McCann, T., Hides, L., & Couineau, A.-L. (2008). Do we do what we know works, and if not, why not? Australian and New Zealand Journal of Psychiatry, 42(6), 439-444. Killackey, E. J., Jackson, H. J., Gleeson, J., Hickie, I. B., & MCGorry, P. D. (2006). Exciting career opportunity beckons! Early intervention and vocational rehabilitation in first episode psychosis: Employing cautious optimism. Australian and New Zealand Journal of Psychiatry, 40, 951-962. McGorry, P., Dodd, S., Purcell, R., Yung, A., Thompson, A., Goldstone, S., Killackey, E. (Eds.). (2010). Australian clinical guidelines for early psychosis (2nd ed.). Melbourne, Australia: Orygen Youth Health Research Centre. Morgan, V. A., Waterreus, A., Jablensky, A., Mackinnon, A., McGrath, J. J., Carr, V., Saw, S. (2011). People living with psychotic illness 2010. Canberra, Australia: Department of Health and Ageing. Nuechterlein, K. H., Subotnik, K. L., Turner, L. R., Ventura, J., Becker, D. R., & Drake, R. E. (2008). Individual placement and support for individuals with recentonset schizophrenia: Integrating supported education and supported employment. Psychiatric Rehabilitation Journal, 31(4), 340-349. Ramsay, C. E., Broussard, B., Goulding, S. M., Cristofaro, S., Hall, D., Kaslow, N. J., Compton, M. T. (2011). Life and treatment goals of individuals hospitalized for firstepisode nonaffective psychosis. Psychiatry research, 189(3), 344-348. Rinaldi, M., Killackey, E., Smith, J., Shepherd, G., Singh, S. P., & Craig, T. (2010). First episode psychosis and employment: A review. International Review of Psychiatry, 22(2), 148-162. Thornicroft, G. (2011). Physical health disparities and mental illness: The scandal of premature mortality. The British journal of psychiatry, 199, 441-442. Waghorn, G., Saha, S., Harvey, C., Morgan, V. A., Waterreus, A., Bush, R., McGrath, J. J. (2012). Earning and learning in those with psychotic disorders: The second Australian national survey of psychosis. Australian and New Zealand Journal of Psychiatry, 46(8), 774-785. World Health Organisation. (2011). Mental health: A state of well-being. Retrieved from http://www.who.int/features/factfiles/mental_health/ en/index.html
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THE AUSTRALIAN CLINICAL PSYCHOLOGY ASSOCIATION
C A AP
www.acpa.org.au
4th Annual National Conference: Presenting a lecture and clinical workshop by
2013
Dr Nancy McWilliams Self-Defeating Patterns and Their Clinical Implications

Queensland University of Technology (QUT), Brisbane: Sunday, 14 July 2013
COGNITIVE BEHAVIOURAL INTERVENTIONS FOR FIRST EPISODE PSYCHOSIS: A RATIONALE AND OVERVIEW
Craig A Macneil, BA(Hons), DClinPsy, MBPsS Sarah Bendall, PhD, PGDipClinPsych Mario Alvarez-Jimenez, PhD, DClinPsy, MA(ResearchMeth) Craig Macneil is a Senior Clinical Psychologist at the Early Psychosis Prevention & Intervention Centre, Orygen Youth Health, Melbourne Sarah Bendall is Senior Research Fellow and Clinical Psychologist at Orygen Youth Health Research Centre and Centre for Youth Mental Health, University of Melbourne Mario Alvarez-Jimenez is CR Roper Fellow and a Senior Research Fellow at Orygen Youth Health Research Centre and Centre for Youth Mental Health, University of Melbourne Please address all correspondence to: craig.macneil@mh.org.au
research has found that around 10% of the population have experienced at least one vivid hallucinatory experience (Tien, 1991), and Freeman and colleagues (2005) reported that around 15% - 30% of people in the general population make paranoid attributions. Freeman and colleagues (2008) demonstrated that over 40% of participants in the general population reported paranoid thoughts in a simulated public transport experiment, and concluded that Our study is the clearest demonstration yet that paranoid thinking is not confined to people with severe mental illness (p. 262). Freeman (cited in Nauert, 2008) went further, stating, Worries about other people are so common that they seem to be an essential if unwelcome part of what it means to be human. Interestingly, groups such as the Hearing Voices Network have emphasised the importance of the meaning associated with hallucinations, with Bentall (2003) noting of one of the first psychotic patients he saw professionally, it was obvious that his voices were not merely the random product of a damaged nervous system (p. 348). Furthermore, psychotic disorders often seem underpinned by normal thinking errors such as an increased likelihood of jumping to conclusions (Dudley & Over, 2003), searching for confirmatory biases (Freeman, Garety, Kuipers, Fowler, & Bebbington, 2002), and difficulties identifying whether perceptions come from the self or others (Anselmetti et al., 2007; Favrod, Vianin, Pomini, & Mast, 2006). It is also becoming increasingly clear that in the same way that adverse experiences in childhood can contribute to depression and anxiety, these experiences increase the risk for psychosis (Cutajar et al., 2010; Spataro, Mullen, Burgess, Wells, & Moss, 2004). Insecure attachment histories, including those evidenced in children of unwanted pregnancies (Rankin, Bentall, Hill, & Kinderman, 2005), and conflict at home impacts on the onset and course of psychosis (Vaughn & Leff, 1976). A recent meta-analysis of the role of childhood adversity on the risk of developing psychosis found that the odds of developing psychosis were significantly increased as a result of sexual abuse (odds ratio = 2.38), physical abuse (odds ratio = 2.95), emotional abuse (odds ratio = 3.40), bullying (odds ratio = 2.39), and neglect (odds ratio = 2.90), but not parental death (Varese et al., 2012). A review of 46 studies found that between 28% and 73% of people with psychosis have experienced trauma such as sexual, physical, or emotional abuse in childhood (Bendall, Jackson, Hulbert, & McGorry, 2008). There are two leading proposed mechanisms for this. The first is that adversity can lead to development of schemas involving social humiliation and subordination, which may drive voices and paranoia (Garety, Bebbington, Fowler, Freeman, & Kuipers, 2007). The second is that childhood adversity can lead to post-traumatic stress disorder, the symptoms of which can manifest as psychotic symptoms (Morrison, Frame, & Larkin, 2003). For example, hallucinations have been theorised as post-traumatic intrusions attributed to an external source (Bentall, 2000, 2003). Interventions designed specially to help people with childhood trauma and psychosis have been called for (Bendall, Alvarez-Jimenez, Nelson, & McGorry, 2013) and are beginning to attract research (van den Berg & van der Gaag, 2012).
Introduction Two of the central tenets of clinical psychology formulation and intervention are that presenting symptoms are often on a continuum with normal experiences, and that they can be contextualised within a persons current and past experiences. While psychotic symptoms such as hallucinations and delusions can initially appear ununderstandable and be confronting for clinicians, in this overview we will suggest that the approach of seeking to understand and contextualise these symptoms is similar to work we currently undertake with higher prevalence disorders. We will then describe the evidence base for cognitive behavioural therapy (CBT) for psychosis, its key components, their application in first episode psychosis, and directions for future research.
hile we find it easy to conceptualise depression and anxiety on a continuum with universal experiences of sadness and worry, positive symptoms of psychosis such as hallucinations and delusions appear more difficult to understand in this way. However, there has been increasing evidence in recent years that delusions and perceptual disturbances - as opposed to the traditional view of being clear, first rank symptoms of psychosis - in fact lie on a continuum. Epidemiological
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The conceptualisation that symptoms of psychosis are understandable within the context of the individuals past experiences has underpinned the many different cognitive behavioural therapies for psychotic symptoms. While there was an explosion in research into cognitive behavioural therapy for psychosis (CBTp) in the 1990s, it is worth noting that Aaron Beck published a case study as early as 1952 of a successful psychological intervention with a man experiencing a chronic psychotic disorder (cited in Morrison, 2002). Data now show that CBTp can: improve insight and medication adherence (Rathod, Kingdon, Smith, & Turkington, 2005), reduce symptoms in the acute phase (Rathod & Turkington, 2005), reduce symptoms in people with persisting symptoms (Kuipers et al., 1997; Sensky et al., 2000), reduce transition to psychosis (Morrison et al., 2004), improve cognitive deficits (Wykes et al., 2003), improve social skills (Lecomte et al., 2008), improve overall functioning (Wykes, Steel, Everitt, & Tarrier, 2008), reduce relapse rates and rehospitalisation (Gumley et al., 2003), and improve negative symptoms (Turkington et al., 2008). In a metaanalysis, Villeneuve, Potvin, Lesage, and Nicole (2010) reported a dropout rate of only 13% for CBTp. Interestingly, CBT has also been found to help reduce burden in carers of people with first episode psychosis (FEP) (Gleeson et al., 2010). As a result of this overwhelming evidence, a number of international guidelines advocate the use of CBT in treatment for psychosis. For example, the Royal Australian and New Zealand College of Psychiatrists (2005) guidelines on psychotic disorders states that Comprehensive psychosocial interventions should be routinely available to all patients and their families... (p. 2), with similar recommendations being made by the American Psychiatric Association (Lehman et al., 2004) and the United Kingdoms National Collaborating Centre for Mental Health (2009). While attracting considerable discussion, a delphi study by Morrison and Barratt (2010) proposed the following core components of CBTp. Engagement, which should be collaborative and normalising. The importance of the therapeutic relationship appears particularly important when working with young people with FEP (Bendall, Killackey, Marois, & Jackson, 2005; Hermann-Doig, Maude, & Edwards, 2003). People with FEP, by definition, have not had time or interventions to encourage the development of clear explanatory models. Encouragingly, evidence suggests that positive therapeutic alliances can be formed regardless of psychotic symptom severity or duration (Evans-Jones, Peters, & Barker, 2009). Ways to promote engagement may include focussing on the individuals strengths and interests, being particularly aware of non-verbal cues, matching language to that of the client, and giving clear psychoeducation about the nature of therapy (Bendall et al., 2005). Structure, which should include goal and agenda setting. CBT manuals for FEP have also emphasised the importance of structure of and transparency about the therapy process (Bendall et al., 2005). Young people with FEP often have little knowledge of the rules of therapy; many are not help-seeking and may have little
experience of talking one-on-one with an adult who is not a family member or an authority figure. Clearly describing the structure of therapy, following through with this, and giving the client as much autonomy within the therapy process as possible are considered key in FEP treatment. Formulation, which has been described as ... the cornerstone of Cognitive Therapy for psychosis (Chadwick, Williams, & McKenzie, 2003, p. 671). Formulation is central to CBT treatment in FEP because it is likely to be the first time the client has an opportunity to make sense of and contextualise his or her experiences. Morrison and Barratt (2010) emphasised that this should include strengths and be a shared exercise. However, it appears important that formulation is completed sensitively. Chadwick and colleagues (2003) and Morburg-Pain, Chadwick, and Abba (2008) reported that around half their participants described CBTp formulation as a negative experience. While this is not necessarily a reason to exclude formulation, it perhaps highlights the need for it to be done carefully and thought given by the clinician around how much it should be shared. Assessment, which should be idiosyncratic and identify the roles of cognitions, behaviours, and emotions in symptomatology. In FEP treatment, comprehensive assessment of hallucinations and delusions allows the clinician to gain a thorough understanding of the content of these and undertake accurate formulation. Key questions can include: what symptoms occur? (e.g., hallucinations, delusions); what is the content of the experience? (what the voices say; the gender, age, and accent of the voice; the beliefs of the delusion); and when does the experience occur? (times of day; associations with particular events). Further questions can relate to: duration of experience (hours or minutes); frequency of experience; intensity of experience; extent to which the experience feels real to the person; distress caused by experience (how much and in what form this is expressed); conviction regarding the experience (level of belief, usually expressed as a percentage from 0 (no belief) to 100 (complete belief), and the degree to which this fluctuates); and coping strategies the client has utilised (Bendall et al., 2005). Homework, which is described as an ongoing part of therapy, and as a bridge between therapy and the real world (Morrison & Barratt, 2010, p. 140) Inclusion of change strategies with exploration of alternative explanations for the persons experiences and behavioural experiments to test these alternatives. Regarding working with voices, Leudar and Thomas (2000) advise that Attempts to intervene psychologically without attending to the persons social reality are likely to be unsuccessful (p. 128). Finally, Morrison and Barratt (2010) suggest that it is important that therapists are able to perceive delusions as understandable and that psychotic-like experiences are common and can happen to anyone.
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A number of psychological interventions have been developed specifically for the challenges and opportunities of first episode psychosis, including Cognitively Oriented Psychotherapy for first Episode Psychosis (COPE) (Henry, Edwards, Jackson, Hulbert, & McGorry, 2002), Systematic Treatment of Persistent Psychosis (STOPP) (Hermann-Doig et al., 2003) and the ACE project (Jackson et al., 2008). These interventions emphasise the importance of establishing a strong therapeutic relationship and of attempting to minimise disruption to the young persons developmental trajectory. COPE focuses on adaptation to psychosis, the meaning a person ascribes to their diagnosis, and assisting the young person find meaning from their experiences. STOPP emphasises assisting those who may be at risk of experiencing persisting symptoms, and facilitates recovery through a phase-specific intervention. Specifically, this includes careful psychoeducation, identifying and strengthening coping strategies, and encouraging social reintegration. ACE includes COPE adaptation interventions and also specific CBTp interventions to treat hallucinations and delusions (Bendall et al., 2005). While undertaking psychological interventions without medication remains controversial, some evidence is emerging that it can be effective (Morrison et al., 2012). Francey et al. (2010) reviewed the evidence-base for psychological interventions in psychosis, the staging model (in which less harmful interventions are used in the earlier phases of a disorder), and potential for medication side effects. They concluded, These risks indicate the necessity for a cautious and individualised risk-benefit analysis when prescribing antipsychotics (p. 3). This was echoed more recently in a review paper by Morrison et al. (2012). They referred to papers indicating that antipsychotic medication may not have been as effective as was initially believed (i.e., that the number needed to treat is six), and that only 17-22% of people experience benefit which could be attributed to medication rather than placebo or natural recovery (Leucht, Arbter, Engel, Kissling, & Davis, 2009; Leucht et al., 2006). There is also some indication that these figures may be somewhat optimistic, with the meta-analysis by Leucht et al. (2009) suggesting that papers which did not show an effect are unlikely to be published. Furthermore, Morrison and colleagues (2012) also drew sharp attention to cardiovascular difficulties, increased mortality, and evidence that antipsychotic medication can result in secondary negative psychotic symptoms in healthy volunteers. Interestingly, however, Lieberman and colleagues (2005), in the CATIE Project, found that 74% of people with a diagnosis of schizophrenia cease medication within 18 months. Similarly, 60% of FEP patients report no, or inadequate, adherence within the first 12 months of treatment (Coldham, Addington, & Addington, 2002), perhaps making the debate on medication efficacy in FEP somewhat redundant. There are a number of emerging areas in this field that will attract future research. Specifically, further study of the role and effectiveness of CBT for psychosis in the absence of antipsychotic medication appears important. In addition, there are some early signs that third wave CBT treatments offer promise. For example, competitive memory training and detached mindfulness have been shown to reduce the emotional impact of persistent auditory hallucinations (van
der Gaag, van Oosterhout, Daalman, Sommer, & Korrelboom, 2012), and positive-psychology informed CBT for psychosis (i.e., strengths-based interventions) have shown promise in improving social functioning in schizophrenia (Hall & Tarrier, 2003). It also appears important that we continue to research the big questions of what works (i.e., effective elements of CBT for psychosis, and, in particular, for which phase), for whom (i.e., individual characteristics that predict CBT responsiveness), and how (i.e., clearer understanding of the mechanisms of action). In conclusion, we appear to have come a long way from the beliefs that psychotic phenomena are simply ununderstandable and due solely to chemical imbalances in the brain, and that psychological interventions are simply a wellmeaning add-on to medication. The staging model and current discussion regarding whether antipsychotic medication should be used for all patients, particularly early in the course of psychosis, appear to have significant implications (McGorry et al., 2007). The rationale and evidence-base for CBTp is overwhelming and widely acknowledged as an essential part of treatment for psychotic disorders. With a greater emphasis on patient choice of treatments and evidence that psychological interventions may be at their most effective early in the course of the disorder, it appears essential that we continue to develop our understanding of psychotic processes and effective treatments for this population.
Further reading Chadwick, P., Birchwood, M., & Trower, P. (1996). Cognitive therapy for delusions, voices and paranoia. Chichester, England: Wiley. Freeman, D., & Garety, P. (2006). Helping patients with paranoid and suspicious thoughts: A cognitivebehavioural approach. Advances in Psychiatric Treatment, 12, 404-415. Larkin, W., & Morrison, A. P. (2006). Trauma and psychosis: New directions for theory and therapy. London, England: Routledge.
References Anselmetti, S., Cavallaro, R., Bechi, M., Angelone, S. M., Ermoli, E., Cocchi F., & Smeraldi, E. (2007). Psychopathological and neuropsychological correlates of source monitoring impairment in schizophrenia. Psychiatry Research, 150(1), 51-59. Bendall, S., Alvarez-Jimenez, M., Nelson, B., & McGorry, P. (2013). Childhood trauma and psychosis: New perspectives on aetiology and treatment. Early Intervention in Psychiatry, 7, 1-4. Bendall, S., Jackson, H. J., Hulbert, C. A., & McGorry, P. D. (2008). Childhood trauma and psychotic disorders: A systematic, critical review of the evidence. Schizophrenia Bulletin, 34, 568-578. Bendall, S., Killackey, E., Marois, M.-J., & Jackson, H. J. (2005). ACE manual: Active cognitive therapy for early psychosis. Melbourne, Australia: ORYGEN Research Centre.
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Bentall, R. (2003). Madness explained. London, England: Allen Lane. Bentall, R. P. (2000). Hallucinatory experiences. In E. Cardena, & S. J. Lynn (Eds.). Varieties of anomalous experience: Examining the scientific evidence (pp. 85-120). Washington, DC: American Psychological Association. Chadwick, P., Williams, C., & Mackenzie, J. (2003). Impact of case formulation in cognitive behaviour therapy for psychosis. Behaviour Research and Therapy, 41, 671680. Coldham, E. L., Addington, J., & Addington, D. (2002). Medication adherence of individuals with a first episode of psychosis. Acta Psychiatrica Scandinavica, 106(4), 286-290. Cutajar, M. C., Mullen, P. E., Ogloff, J. R. P., Thomas, S. D., Wells, D. L., & Spataro, J. (2010). Schizophrenia and other psychotic disorders in a cohort of sexually abused children. Archives of General Psychiatry, 67(11), 11141119. Dudley, R. E. J., & Over, D. E. (2003). People with delusions jump to conclusions. Clinical Psychology and Psychotherapy, 10, 263-274. Evans-Jones, C., Peters, E., & Barker, C. (2009). The therapeutic relationship in CBT for psychosis: Client, therapist and therapy factors. Behavioural and Cognitive Psychotherapy, 37, 527-540. Favrod, J., Vianin, P., Pomini, V., & Mast F. W. (2006). A first step toward cognitive remediation of voices: A case study. Cognitive Behaviour Therapy, 35(3), 159-163. Francey, S. M., Nelson, B., Thompson, A., Parker, A. G., Kerr, M., Macneil, C., . . . McGorry., P. D. (2010). Who needs antipsychotic medication in the earliest stages of psychosis? A reconsideration of benefits, risks, neurobiology and ethics in the era of early intervention. Schizophrenia Research, 119, 1-10. Freeman, D., Dunn, G., Garety, P. A., Bebbington, P., Slater, M., Kuipers, E., . . . Ray, K. (2005). The psychology of persecutory ideation I: A questionnaire study. Journal of Nervous and Mental Disease, 193, 302-308. Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., & Bebbington, P. E. (2002). A cognitive model of persecutory delusions. British Journal of Clinical Psychology, 41, 331-347. Freeman, D., Pugh, K., Antley, A., Slater, M., Bebbington, P., Gittins, M., . . . Garety, P. (2008). Virtual reality study of paranoid thinking in the general population. British Journal of Psychiatry, 192, 258-263. Garety, P. A., Bebbington, P., Fowler, D., Freeman, D., & Kuipers, E. (2007). Implications for neurobiological research of cognitive models of psychosis: A theoretical paper. Psychological Medicine, 37(10), 1377-1391. Gleeson, J. F., Cotton, S. M., Alvarez-Jimenez, M., Wade, D., Crisp, K., Newman, B., . . . McGorry, P. D. (2010). Family outcomes from a randomized control trial of relapse prevention therapy in first-episode psychosis. Journal of Clinical Psychiatry, 71(4), 475-483. Gumley, A. I., OGrady, M., McNay, L., Reilly, J., Power, K., & Norrie, J. (2003). Early intervention for relapse in schizophrenia: Results of a 12-month randomised controlled trial of cognitive behavioural therapy. Psychological Medicine, 33(3), 419-431.
Hall, P. L., & Tarrier, N. (2003). The cognitive-behavioural treatment of low self-esteem in psychotic patients: A pilot study. Behaviour Research and Therapy, 41(3), 317-332. Henry, L., Edwards, J., Jackson, H., Hulbert, C., & McGorry, P. (2002). Cognitively oriented psychotherapy for first episode psychosis (COPE): A practitioners manual. Melbourne, Australia: EPPIC. Hermann-Doig, T., Maude, D., & Edwards, J. (2003). Systematic Treatment of Persistent Psychosis. London, England: Martin Dunitz. Jackson, H. J., McGorry, P. D., Killackey, E., Bendall, S., Allott, K., Dudgeon, P., . . . Harrigan, S. (2008). The ACE project: A randomised controlled trial of CBT versus befriending for first episode psychosis: Acute phase and one-year follow-up results. Psychological Medicine, 38, 725-735. Kuipers, E., Garety, P., Fowler, D., Dunn, G., Bebbington, P., Freeman, D., & Hadley, C. (1997). London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. I. Effects of the treatment phase. British Journal of Psychiatry, 171, 319-327. Lecomte, T., Leclerc, C., Corbire, M., Wykes, T., Wallace, C. J., & Spidel, A. (2008). Group cognitive behavior therapy or social skills training for individuals with a recent onset of psychosis? Results of a randomized controlled trial. Journal of Nervous and Mental Disease, 196(12), 866-875. Lehman, A. F., Lieberman, J. A., Dixon, L. B., McGlashan, T. H., Miller, A. L., Perkins, D. O., & Kreyenbuhl, J. (2004). Practice guideline for the treatment of patients with schizophrenia (2nd ed.). Retrieved from http://psychiatryonline.org/pdfaccess.ashx?ResourceI D=243185&PDFSource=6 Leucht, S., Arbter, D., Engel, R. R., Kissling, W., & Davis, J. M. (2009). How effective are second generation antipsychotic drugs? A meta-analysis of placebocontrolled trials. Molecular Psychiatry, 14, 429-447. Leucht, S., Kane, J. M., Etschel, E., Kissling, W., Hamann, J., & Engel, R. R. (2006). Linking the PANSS, BPRS, and CGI: Clinical implications. Neuropsychopharmacology, 31, 2318-2325. Leudar, I., & Thomas, P. (2000). Voices of Reason, Voices of Reality. London, England: Routledge. Lieberman, J. A., Stroup, T. S., McEvoy, J. P., Swartz, M. S., Rosenheck, R. A., Perkins, D. O., . . . Hsiao, J. K. (2005). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New England Journal of Medicine, 353, 1209-1223. McGorry, P. D., Purcell, R., Hickie, I. B., Yung, A. R., Pantelis, C., & Jackson, H. J. (2007). Clinical staging: A heuristic model for psychiatry and youth mental health. Medical Journal of Australia, 187(7), 40. Morberg Pain, C., Chadwick, P., & Abba, N. (2008). Clients experience of case formulation in cognitive behaviour therapy for psychosis. British Journal of Clinical Psychology, 47, 127-138. Morrison, A., French, P., Walford, L., Lewis, S., Kilcommons, A., Green, J., . . . Bentall, R. (2004). Cognitive therapy for the prevention of psychosis in people with ultra high risk. British Journal of Psychiatry, 185, 291-297. Morrison, A. P., & Barratt, S. (2010). What are the components of CBT for psychosis? A delphi study. Schizophrenia Bulletin, 36(1), 136-142.
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Morrison, A. P., Frame, L., & Larkin, W. (2003). Relationships between trauma and psychosis: A review and integration. British Journal of Clinical Psychology, 42, 331-353. Morrison, A. P., Turkington, D., Wardle, M., Spencer, H., Barratt, S., Brabban, A., . . . Turkington, D. (2012). A preliminary exploration of predictors of outcome and cognitive mechanisms of change in cognitive behaviour therapy for psychosis in people not taking antipsychotic medication. Behaviour Research and Therapy, 50, 163-167. National Collaborating Centre for Mental Health. (2009). Schizophrenia: Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. London, England: National Institute for Health and Clinical Excellence (NICE). Nauert, R. (2008). Paranoid thoughts are relatively common. Retrieved from http://psychcentral. com/news/2008/04/01/paranoid-thoughts-arerelatively-common/2104.html Rankin, P., Bentall, R., Hill, J., & Kinderman, P. (2005). Perceived relationships with parents and paranoid delusions. Psychopathology, 38(1), 16-25. Rathod, S., Kingdon, D., Smith, P., & Turkington, D. (2005). Insight into schizophrenia: The effects of cognitive behavioral therapy on the components of insight and association with sociodemographics: Data on a previously published randomised controlled trial. Schizophrenia Research, 74 (2), 211-219. Rathod, S., & Turkington, D. (2005). Cognitive-behaviour therapy for schizophrenia: A review. Current Opinion in Psychiatry, 18(2), 159-163. Royal Australian and New Zealand College of Psychiatrists. (2005). Clinical practice guidelines for the treatment of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry, 39, 1-30. Sensky, R., Turkington, D., Kingdon, D., Scott, J. L., Scott, J., Siddle, R., Barnes, T. R. (2000). A randomised controlled trial of cognitive-behavioural therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry, 57, 165172. Spataro, J., Mullen, P. E., Burgess, P. M., Wells, D. L., & Moss, S. A. (2004). Impact of child sexual abuse on mental health: Prospective study in males and females. British Journal of Psychiatry, 184, 416-421.
Tien, A. Y. (1991) Distributions of hallucinations in the population. Social Psychiatry and Psychiatric Epidemiology, 26, 287-292. Turkington, D., Sensky, T., Scott, J. L., Barnes, T. R. E., Nur, U., Siddle, R., . . . Kingdon, D. (2008). A randomized controlled trial of cognitive-behavior therapy for persistent symptoms in schizophrenia: A five-year follow-up. Schizophrenia Research, 98(1-3), 1-7. van den Berg., D. P. G., & van der Gaag., M. (2012). Treating trauma in psychosis with EMDR: A pilot study. Journal of Behavior Therapy and Experimental Psychiatry, 43(1), 664-671. van der Gaag, M., van Oosterhout, B., Daalman, K., Sommer, I. E., & Korrelboom, K. (2012). Initial evaluation of the effects of competitive memory training (COMET) on depression in schizophrenia-spectrum patients with persistent auditory verbal hallucinations: A randomized controlled trial. British Journal of Clinical Psychology, 51(2), 158-171. Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., . . . Bentall, R. (2012). Childhood adversities increase the risk of psychosis: A metaanalysis of patient-control, prospective- and crosssectional cohort studies. Schizophrenia Bulletin, 38(4), 661-671. Vaughn, C. E., & Leff, J. P. (1976). The influence of family and social factors on the course of psychiatric illness. British Journal of Psychiatry, 129, 125-137. Villeneuve, K., Potvin, S., Lesage, A., & Nicole, L. (2010). Metaanalysis of rates of drop-out from psychosocial treatment among persons with schizophrenia spectrum disorder. Schizophrenia Research, 121, 266270. Wykes, T., Reeder, C., Williams, C., Corner, J., Rice, C., & Everitt, B. (2003). Are the effects of cognitive remediation therapy (CRT) durable? Results from an exploratory trial in schizophrenia. Schizophrenia Research, 61, 163174. Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy for schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34(3), 523-537.
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psychotic illness remain on medication, and working with them to encourage good medication adherence is essential. The effective use of antipsychotic drugs depends on selecting the best drug for the individual person, informed by knowledge of the side effects and benefits of each drug. Apart from clozapine, described in more detail below, all the antipsychotic drugs are equally effective, although individuals may find one drug works better for them than another. It is important that if someone is not doing well on an antipsychotic drug, either due to lack of efficacy or side effects, that dose adjustments or other antipsychotic medication options are explored. If the person is stable, though not functioning well, there may be a reluctance to change medications and risk relapse, but careful switching between medications is generally possible and often very beneficial.
PHARMACOTHERAPY FOR PSYCHOSIS

Cherrie Galletly MBChB, DPM, FRANZCP, PhD Cherrie Galletly, professor of psychiatry at the University of Adelaide, has a clinical and research interest in the psychoses. Her recent projects include the Second Australian Survey of Psychosis (2010) and an ARC funded study into co-morbidity. She is an Associate Editor of the Australian and New Zealand Journal of Psychiatry, and a member of the Editorial Advisory Committee for Australian Prescriber and the Executive of the Australasian Society of Psychiatric Research. She has more than 90 peer reviewed publications. She is currently chairing the working group revising the RANZCP Clinical Practice Guidelines for Schizophrenia and Related Disorders. Please address all correspondence to: Professor Cherrie Galletly University of Adelaide Suite 13 33 Park Terrace Gilberton SA 5081
There are more than a dozen different antipsychotic drugs. In the literature they tend to be divided into old (conventional, first generation) and new (novel, second generation) drugs, but recent research suggests that the differences between these classes of drugs may not be as great as previously thought. All of these drugs block dopamine in the limbic system, and this action is thought to be responsible for their therapeutic effect. The most common side effects are: weight gain, leading to metabolic syndrome. People with severe mental illnesses such as schizophrenia die, on average, 12-25 years earlier than expected. Whilst suicide is a factor, most of these deaths are due to cardiovascular causes. The risk of weight gain varies greatly, with clozapine, olanzapine, and seroquel often being associated with substantial weight gain, whilst aripiprazole and ziprasidone are weight-neutral. A recent Australian survey found that 76% of men and 91% of women with psychosis, aged 18-64 years, had abdominal obesity. The obesity and increased cardiovascular risk began very early in the course of illness. sedation. The drugs associated with weight gain tend also to be associated with sedation. This can help reduce anxiety and assist sleep, but daytime sedation can be a problem. The sedating effects are helpful during acute exacerbations, when people may be admitted to hospital, but if they do gain weight or complain of sedation after discharge, then switching to a weightneutral, non-sedating drug should be considered. side effects associated with prolactin elevation. Some of the antipsychotic drugs, such as risperidone, block dopamine in the hypothalamus, resulting in prolactin elevation. This can cause loss of periods in women along with sexual dysfunction in men and women. drug-induced parkinsonism and other movement disorders. These effects are due to dopamine blockade in the substantia nigra. Some of the antipsychotic drugs can cause stiffness and tremor. The blank facial expression and lack of movement associated with druginduced parkinsonism is sometimes mistaken for depression. Conversely, people may develop akathisia, a feeling of intense inner restlessness, leading to pacing and agitation. This can be thought to indicate anxiety,
ntipsychotic medications are most commonly used to treat psychotic disorders disorders characterised, at least some of the time, by hallucinations and/or delusions. These disorders include schizophrenia, severe bipolar disorder, psychotic depression, and druginduced psychoses, as well as psychoses related to brain injury. Antipsychotic drugs have also been shown to be effective mood stabilisers, so are used sometimes as an alternative to lithium and other mood stabilisers in bipolar disorder. Antipsychotic drugs are the mainstay of the treatment of schizophrenia, and cessation of maintenance medication is the most common reason for relapse. In schizophrenia, delays in starting treatment and prolonged periods without medication are associated with a worse outcome. It is generally very important that people with an established
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leading to the addition of other drugs or a dose increase, which makes the problem worse. Dystonia is a druginduced muscle contraction, most commonly affecting the eye muscles (leading to uncontrollable rolling up of the eyes). These side effects are generally treated by switching to a different antipsychotic drug, or occasionally by adding anti-parkinsonian drugs. tardive dyskinesia. This is a long-term side effect of antipsychotic drugs, beginning with involuntary chewing or sucking movements of the mouth, then extending to the face and limbs. This is a serious disorder and, as it is often dose related, it is important to keep doses as low as possible. cardiac rhythm abnormalities. Antipsychotic drugs may be associated with an increase in sudden death, especially in the elderly, most likely due to cardiac problems (QT prolongation on the ECG).
Other indications Some of the antipsychotic drugs are effective for nonpsychotic depression. They are usually prescribed as a second or third line treatment, often added to an antidepressant. Some are also approved for use in delirium and dementia. In addition, these drugs are sometimes used for behavioural disorders associated with intellectual disabilities and autism. There is considerable debate about whether antipsychotic drugs should be used in young people at ultra-high risk of psychosis, but the evidence favours using other measures (such as CBT and fish oil) and only starting antipsychotics if the person develops significant hallucinations and/or delusions. Off-label use Off-label refers to use outside the indications approved by the TGA. There is concern that antipsychotic drugs are increasingly being used to treat non-specific symptoms of general distress, along with anxiety and insomnia. The side effects of these drugs can be very significant, and there is a risk of developing tardive dyskinesia (which may persist even after the drug is stopped), so a risk-benefit analysis generally does not support using them in these circumstances. Managing physical health in people with psychosis Besides the high rates of obesity, Australians with psychotic disorders have very high rates of smoking and substance abuse. They often have undiagnosed diabetes, hypertension, and high cholesterol. They tend to be very physically inactive. Despite all these problems, some of which can be related to medication, they tend to receive poor general medical care. Clinicians can assist by ensuring that these lifestyle factors are recognised and addressed, and that people with psychosis receive the usual monitoring and preventive measures available to other Australians.
Antipsychotic drugs are usually taken orally. Ziprasidone must be taken with food, and asenapine has to be taken under the tongue, with no food or drink for the next 10 minutes. Depot drugs Some antipsychotic drugs are also available as depot formulations most commonly risperidone and paliperidone. The drug is suspended in oil and is injected into the muscle where it releases slowly, so it can be given as a single injection every 2-4 weeks. People with very limited insight who do not wish to take medication, but have a severe illness which places themselves or others at serious risk, can be subject to Guardianship Board orders requiring them to receive depot injections. These orders are reviewed every 612 months. Sometimes people have improved with regular, effective treatment and the orders are no longer needed. Clozapine Clozapine is used for treatment resistant psychosis, and is effective in up to 70% of people when all other treatments have failed. Clozapine reduces suicidality and aggression. Unfortunately, it is associated with weight gain and sedation, although some people do become more active and manage to control their weight. Clozapine can cause a rare blood disorder, so regular blood monitoring is needed. It can also cause cardiac problems so cardiac screening is also required. Despite these problems, the death rate on clozapine is low due to the reduction in suicide risk.
Further reading Morgan, V. A., Waterreus, A., Jablensky, A., Mackinnon, A., McGrath, J. J., Carr, V., Saw, S. (2012). People living with psychotic illness in 2010: The second Australian national survey of psychosis. Australian and New Zealand Journal of Psychiatry, 46, 735-752.
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contradictory findings. However, highly powered, large, and impeccably designed RCTs are difficult to achieve in schizophrenia treatment research, and one must learn to settle for less than perfection in deciding with sufficient confidence whether a real treatment effect exists and, if so, how big it is. Critical appraisal of low-bias meta-analyses based on multiple RCTs of acceptable standard can closely approximate the truth about treatment effects. In the Schizophrenia Library, we adopted the methodology of systematic reviews to describe and quality assess what is known about the efficacy of various treatments for schizophrenia (Schizophrenia Research Institute, 2010). We included reviews that were published in full text in English from the year 2000; we excluded treatment guidelines, overviews, and non-systematic reviews. Reviews were identified by searches of MEDLINE, EMBASE, CINAHL, Current Contents, PsychINFO, and the Cochrane Library. To date, 663 treatment reviews have been included in the Library. In evaluating the quality of evidence for treatments of schizophrenia, RCTs were taken as the gold standard and systematic reviews with meta-analyses of RCTs have been critically evaluated in the following way. The reporting transparency of all systematic reviews was assessed using the PRISMA statement checklist (Moher, Liberati, Tetzlaff, & Altman, 2009). Systematic reviews with a high risk of reporting bias were excluded; these were reviews that addressed fewer than 33% of items on the checklist. The evidence contained within the remaining reviews was then assessed using a strategy adapted from the GRADE Working Group (2004). Using this method, RCT evidence, which would generally be considered high quality, could be downgraded to moderate or low quality in the presence of statistical heterogeneity among study results, imprecise confidence intervals around the pooled effect sizes, and/or indirectness of comparisons or interventions. While most treatment reviews include only RCTs, some include observational studies, which would generally be regarded as lower quality, but could be upgraded for consistency or precision in the results if effect sizes or study samples were large, or if there was a dose-response relationship. The strength of the evidence resulting from the meta-analyses was quantified on the basis of the magnitude of the effect size. Standardised mean differences, risk ratios, or odds ratios were categorised as large, medium, or small effects using a strategy adapted from the GRADE Working Group (2004) approach. Further information on the methodology used in compiling the Library is detailed elsewhere (Matheson, Shepherd, Draganic, & Carr, 2011). The evidence was then grouped into two classes: high quality and medium quality, and within each class the evidence was sub-grouped into large and medium effect sizes. Treatments with only low quality evidence are not included here, and outcomes with only small effect sizes are very unlikely to be clinically significant and are also not reported here, although they may be of theoretical interest to specialists in the area. High quality evidence with large effect sizes was found for combining pharmaceutical and psychosocial treatment
THE QUALITY AND STRENGTH OF EVIDENCE FOR VARIOUS TREATMENTS IN SCHIZOPHRENIA

Vaughan Carr, MD, FRANZCP Sandra Matheson, BSc(Hons), MPH Alana Shepherd, BSc(Hons) Vaughan Carr is a professor in the School of Psychiatry, University of New South Wales, and CEO and Scientific Director of the Schizophrenia Research Institute. He holds a clinical appointment as a senior consultant psychiatrist at St Vincents Hospital, Darlinghurst. Sandra Matheson and Alana Shepherd compiled the on-line Schizophrenia Library, conducted their own meta-analyses in selected areas, and are PhD candidates. Please address all correspondence to: Professor Vaughan Carr UNSW Research Unit for Schizophrenia Epidemiology OBrien Building, Level 4 St. Vincents Hospital 394-404 Victoria St Darlinghurst NSW 2010 Email: v.carr@unsw.edu.au
ertainty about the efficacy of treatments for schizophrenia which treatments work for which aspects of schizophrenia cannot be achieved as long as undue reliance is placed on studies that are biased through failure to adhere to transparent guidelines for conducting randomised controlled trials (RCTs) (Moher, Schulz, & Altman, 2001). The results of research flawed by such things as biased participant selection, inadequate randomisation, small sample size, and poorly defined endpoints are likely to fail the test of independent replication, or be undermined by the emergence of
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programs in reducing symptoms and relapse rates, and for social skills training in improving social interactions. There was no other high quality evidence with large effect sizes. High quality evidence with medium effect sizes was found for antipsychotic medication compared to placebo, and several other biomedical interventions under certain conditions. The latter included repeated transcranial magnetic stimulation for auditory hallucinations or negative symptoms (depending on frequency of the magnetic stimulation and the anatomical site at which it was administered); oestrogen therapy in improving positive and negative symptoms in women; antidepressant medications in reducing negative symptoms; and Ginkgo biloba for reducing positive symptoms. A number of psychosocial treatments were supported by high quality reviews with evidence falling within the medium effect range. These included cognitive behavioural therapy (CBT) for reducing global symptoms; psycho-education for reducing relapse rates and improving treatment adherence; cognitive remediation for improving a range of cognitive functions; integrated neurocognitive and social cognitive interventions for improving cognition and global functioning; and supported employment programs using an individual placement and support model for improving levels of competitive employment. There was no moderate quality evidence with large effect sizes reported, but several treatments contained medium effect sizes. These included non-steroidal anti-inflammatory drugs for all symptoms, but especially positive symptoms, and clozapine for treatment resistant schizophrenia. In addition to these bio-medical treatments were crisis interventions for reducing readmissions to hospital and reducing family disruption; music therapy for improving global state; social skills training for improving general psychopathology and reducing relapse rates; and family interventions for improving functioning and reducing relapse rates. Overall, this approach in grading evidence for treatments of schizophrenia highlights some intriguing findings and enables some interesting comparisons. First, high quality evidence with large effect size was found for combined psychosocial and pharmaceutical treatment in controlling classical indicators of the illness reducing clinical symptoms and relapse rates. This evidence highlights the therapeutic augmentation achieved by combining medication and psychosocial treatments compared to the medium effect sizes found when antipsychotics alone are compared to placebo. Evidence of similarly high quality and large effect size was found for social skills training in improving social skills, which is a very robust effect. A common complaint of people with psychotic disorders is loneliness or social isolation (Morgan et al., 2012), presumably attributable, at least in part, to deficits in social cognition. Encouraging psychological treatments that focus on enhancing capacities for accurate detection and interpretation of, and responding to, social cues is likely to be useful in helping to overcome this poignant and often hidden dimension of schizophrenia.
Strikingly, there was both high and moderate quality evidence for medium effect sizes in relation to a comparatively large number of other psychosocial interventions in improving various symptomatic and functional outcomes. This indicates a remarkable degree of responsiveness of schizophrenia to a variety of psychological treatments and related interventions. There is, then, robust evidence for the important role of several psychological treatments in schizophrenia, indicating how critical it is that mental health services provide access to these treatments in addition to the usual case management approaches. There is also clear evidence for the efficacy of a number of biomedical and related interventions for various symptoms and areas of functioning, but it is not likely that all people with schizophrenia would have ready access to the full suite of such treatments in most public mental health services. Naturally, all of the foregoing may change as new evidence comes to light, new studies are completed, and new reviews are undertaken. Some findings may be strengthened while others may be refuted and have to be cast aside. While some of the results may provoke a degree of scepticism, we are confident that all reviews passed the tests applied in assessing quality and strength of evidence. Moreover, we would argue that there are lower levels of bias inherent in taking this approach to identifying what treatments work for schizophrenia than would be found in the domains of expert opinion, scholarly articles and textbooks, clinical anecdote, and Google queries for schizophrenia treatment that yield 31,800,000 results in 0.13 seconds.
References GRADE Working Group. (2004). Grading quality of evidence and strength of recommendations. BMJ, 328, 14901497. Matheson, S. L., Shepherd, A. M., Draganic, D., & Carr, V. J. (2011). A new web-based Schizophrenia Library Evidence compiled and graded systematically. Schizophrenia Research, 126, 300-302. Moher, D., Liberati, A., Tetzlaff, J., Altman, G., for the PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. BMJ, 339, 332-336. Moher, D., Schulz, K. F., & Altman, D., for the CONSORT Group. (2001). The CONSORT Statement: Revised recommendations for improving the quality of reports of parallel-group randomized trials. Journal of the American Medical Association, 285, 1987-1991. Morgan, V. A., Waterreus, A., Jablensky, A., Mackinnon, A., McGrath, J. J., Carr ,V., Saw, S. (2012). People living with psychotic illness in 2010. The second Australian national survey of psychosis. Australian and New Zealand Journal of Psychiatry, 46, 735-752. Schizophrenia Research Institute. (2010). Worlds first Schizophrenia Library in development. Retrieved from www.schizophreniaresearch. org.au/library/home.php
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A PATIENT AMBASSADORS PERSPECTIVE: HAVING 1 SCHIZOPHRENIA

Richard
I am 32. I have schizophrenia. I have had the illness since I was 23. The night I discovered I had the illness was the worst of my life. I had just seen a GP who had prescribed Risperidone but asked me not to look up online what the drug was used for. Of course we did just the opposite. Risperidone is used in the treatment of schizophrenia. I cried and cried.
unbidden and recur in a way that would make me very uncomfortable. I would often have thoughts manifest themselves, almost voices, that spoke to my greatest fears about myself Youre mad. Youre losing your mind. You are a deviant. I think this is an important point to understand the voices and thoughts that harry many people with schizophrenia can come from deep within their own fears and neuroses. I was once told of a man, a dedicated Catholic, who experienced a voice calling him the anti-Christ. Can you imagine how that affects ones self-esteem? Ones selfconfidence? I also had a peculiar experience of detachment. Detachment from myself, but also detachment from the world around me. It was like being smothered, as if I was sensing the world through a blanket. If I can use a cinematographic simile, I would refer to the scene in the film Trainspotting where Renton has a heroin overdose, and looks out at the world as if down a long corridor. Another symptom was what is sometimes called delusions of reference. These delusions are beliefs that something in the environment has a special meaning just for you; almost as if it is talking to you. Objects that seemed to have some connection to schizophrenia, to suffering, to mental illness, would take on a special feeling for me. I used to describe it as a flash. For example, I might see a cartoon where a character has birds flying round their head. For some reason, these birds symbolised that which is unhinged, and would have a special significance for me. If I could use another cinematographic reference and this is a film I would recommend you all see John Nash in A Beautiful Mind would look over sheets of newspapers and messages would flash out at him. There are also symptoms that some people in the schizophreniform spectrum experience that I did not really experience. Although I imagined voices, I dont think I had full-blown auditory hallucinations. And whilst my mental state was certainly unbalanced, I never believed in any of the delusions I was experiencing. I was a lucky one. I am now in a state of productivity and social engagement. It took me quite a while, and experimenting with a number of medications, before I settled down with Clopine (clozapine). Clopine is a strong a-typical antipsychotic that has a small attendant risk of low white blood cell count. Sure, the medication makes me sleep 12 to 14 hours a day, but I am lucky enough working in the Sydney University system to shape work around my needs. If you were to ask me what lessons a mental health worker should apply when approaching a person with psychosis, I would say this: Neither overstimulate nor understimulate that person. Understand that this person may be experiencing delusions and hallucinations that appear to be completely real to them you wont be able to talk them out of it, and that they must understand how frightening their personal experience may be. And, finally, no matter how mentally unstable or isolated a person may be, they still need understanding and love, especially in the long process of recreating their lives after treatment.
have come a long way since then. I completed my Law degree with 1st class Honours in 2005, finishing the degree whilst on exchange at New York University. I completed a Masters in Journalism at the University of Technology, Sydney, in 2008. I am now writing a PhD about schizophrenia. I am writing about the impact diagnosis, treatment, and hospitalisation can have on the personality of people diagnosed with schizophrenia. I am, of course, dealing with issues I have experienced personally and, I hope, I am writing about topics that are important not only to me, but to other sufferers too. I am recruiting subjects from the Australian Schizophrenia Research Bank. I expect to find that schizophrenia poses a real biographical disruption to peoples lives, and that they must both re-construct themselves their desires and hopes and dreams and be careful to whom they disclose their illness. Schizophrenia affects about one in one hundred people. That makes around 200,000 people in Australia, 60 million people world-wide. The illness generally manifests from late teens to early twenties. The illness can have serious impact upon cognition, affect, behaviour, and empathy. Of course, the illness also impacts upon the loved ones of a sick person. The economic and social consequences are likewise dire. I would like to give you some idea about what schizophrenia feels like. It is true that the Diagnostic Statistical Manual lists a variety of symptoms and forms of schizophrenia. Symptoms can include delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, affective flattening, and lack of volition. It also describes a continuum, or spectrum, of psychotic disorders, from schizophrenia, to schizoaffective disorder, to psychotic depression, to mood disorder with psychotic features. As such, I cannot speak for the experience of all people, but I can speak from what happened to me. Perhaps the dominant emotion I felt was fear. Fear that I was losing my mind. Thoughts would seem to enter my mind
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A final thought We have medications for schizophrenia, but no cure. A cure will emerge one day. We just have to wait till then, and support the amazing research that is going on. In the meantime we must make the world as comfortable as possible for those who suffer this dreadful disease.
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Richard is a patient ambassador at the Schizophrenia Research Institute. He is available to talk to individuals or groups about schizophrenia, and can be contacted via the Schizophrenia Research Institute at http://www.schizophrenia research.org.au/index.php
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DEMYSTIFYING HUMAN RESEARCH ETHICS COMMITTEES

Maria McKenzie, BBSc(Hons) Maria has a psychology background, has had considerable experience in medical research managing major psychological/psychiatric research studies, and has 15 peerreviewed publications. The focus of her work has been in the areas of grief, bereavement, family therapy, palliative care, the psychosocial impact of physical illnesses, such as cancer and heart disease, and adolescent mental health. She is currently completing a PhD at the University of Melbourne which explores the young adult outcomes of adolescent depression and anxiety. Maria has been a member of the Alfred Human Research Ethics Committee since 2003 and chair of the low risk process since 2008. Please address all correspondence to: maria.mckenzie66@gmail.com
community. Currently, the HREC on which I serve has twentyfive members, including a secretary, while administrative ethics staff also regularly attend meetings. What is the role of HRECs and why do we need them? Human research is research conducted with or about people, or their personal data or tissue. In the main part, there is little risk associated with human research and most is conducted safely and ethically. However, some research brings with it significant risks and there is the potential for things to go wrong. Rarely, particularly in days gone by, research has even involved intentional harm to humans. From a psychological perspective, who can forget the notorious Milgram series of experiments of the early 1960s, on obedience to authority figures, conducted by Yale University psychologist, Stanley Milgram? These studies explored the willingness of participants to obey an authority figure who instructed them to perform acts that conflicted with their personal conscience, such as believing they were administering electric shocks to others (Perry, 2012). Likewise, the Stanford 'prison' experiment, conducted by psychology professor Phillip Zimbardo in 1971, studied the psychological effects of becoming a 'prisoner' or 'prison guard' (Zimbardo, 2007)? Horrifically, both groups became so involved in their roles that the experiment had to be terminated. Male students were selected to take on randomly assigned roles of prisoners and guards in a mock prison at Stanford University. Guards subjected some prisoners to psychological torture, which the latter passively accepted and, at the request of the guards, harassed other prisoners who attempted to prevent it. As 'superintendent', Zimbardo permitted the abuse to continue. Although extreme, these examples of unethical research highlight the potential for research participation to go wrong and underscore the importance of protecting research participants. What do ethics committees do? While they may vary slightly in terms of number of members and in how they do things (i.e., their processes), all HRECs review and monitor the ethical and scientific aspects of research and, in the case of hospitals, medical activities involving participants from their respective institutions. It is a requirement of the NHMRC that all medical or scientific research involving humans be approved by a properly constituted ethics committee. All research involving humans should conform to the National Statement on Ethical Conduct in Human Research (NHMRC, 2007b) and the Australian Code for the Responsible Conduct of Research (2007a). How do we as a Committee decide whether research will be conducted ethically? Put simply, we assess each project on the values and principles of ethical conduct respect for human beings (recognising the value of human autonomy and protecting/empowering those with diminished or no autonomy such as those suffering from mental illness), research merit and integrity (of the proposed research and of the researchers), justice (a regard for the equality of human beings in terms of the fair distribution of the benefits and burdens of research and the fair treatment of participants), and beneficence (an assessment of the risks of harm and the potential benefits of research to participants
mong some in the research community, there is an impression that Human Research Ethics Committees (HRECs) are made up of pedantic "fuss-pots", "busybodies", and "party-poopers" delighting in holding up million dollar research projects because of, for instance, a missing comma on page 22 of the application! Even worse is the view that HRECs may be like secret societies, shrouded in mystery, populated by hooded, chanting figures, attending cloak and dagger meetings in basements behind locked doors! Is this the reality or, as is usually the case, is the truth far removed from this scenario and more common-place, yet still fascinating and just as exciting? Let us open the (perfectly ordinary) door and enter the world of an HREC. What does such a committee involve? What does it do? What is it like being an HREC member? What is a human research ethics committee? Australian HRECs are constituted and operate according to the guidelines of the National Health and Medical Research Council (NHMRC, 2011) and the National Statement on Ethical Conduct in Human Research (NHMRC, 2007b). An HREC meets regularly, generally once per month to review research applications and to address any ethical matters needing attention. The minimum membership of an HREC is eight and, if possible, there should be equal numbers of males and females. At least one third of the members should be from outside the institution. Minimum membership comprises a chairperson; at least two laypeople, one male and one female, not associated with the institution, and not currently engaged in medical, scientific, legal, or academic work; at least one member with knowledge of, and current experience in, the professional care, counselling, or treatment of people; at least two members with knowledge of, and current experience in, the areas of research regularly considered by the Committee; at least one lawyer; and at least one person who performs a pastoral care role in the
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and a sensitivity to the welfare and interests of research participants). Participant consent is also a fundamental issue considered by HRECs whether or not it will be obtained by researchers and, if so, how, by whom, and in what form. Of crucial importance to HRECs is also respecting and maintaining participant privacy and confidentiality in respect of their data and, where applicable, tissue samples. As a committee, we assess, consider, and discuss the ethical issues inherent in databanks; clinical registries; interventions and therapies, including clinical and non-clinical trials; innovations; devices; human tissue samples; genetic research; and specific participant groups, such as pregnant women, children, and young people, people in dependent or unequal relationships, people with a cognitive impairment or a mental illness, and people who may be involved in illegal activities. Our role is to facilitate research, not create obstacles for researchers, while protecting participants from physical and psychological harm, as well as guarding their privacy and the confidentiality of their data and any tissue samples. Ethics committees are transparent in their role and processes. They review new research projects and monitor approved research. Research projects are reviewed according to their level of risk there are different processes for research carrying a high level of risk for participants, such as drug or intervention studies, which require greater scientific scrutiny, and those with a lower level of risk, such as health or psychological projects. Each month administrative ethics staff assign new projects for review to members, with whom they regularly liaise. In doing so, they take account of member expertise and project risk level. Members also review low risk projects and project amendments requested by researchers. Low risk research is defined by the National Statement on Ethical Conduct in Human Research (2007b) as research where "the only foreseeable risk is one of discomfort" (p. 18). HRECs also discuss general ethical issues such as those arising from new medical and scientific technologies, NHMRC public consultations on various issues, new guidelines, printed information, such as brochures, to be given to patients, and ethical issues relating to wider community attitudes. Most HRECs have monthly meetings that are facilitated by a chairperson, structured, agenda-driven, and minuted, and can run for a few hours. Members provide comments and feedback about new research applications, issues arising from approved projects that have come to the meeting, and new processes; the committee as a whole (if there is a quorum) then decides on the most appropriate action to be taken. Researchers themselves sometimes attend the meeting, at the request of the committee, to clarify details of their research, provide further information, or answer queries. Also attending meetings from time to time are observers, either internal or external to the institution, who are required to maintain the confidentiality of HREC business. Ethics committees are very ably assisted by administrative ethics staff who work extremely hard and perform a multitude of
functions. These include, but are by no means limited to, liaising with researchers to receive applications, answering queries and providing advice, dealing with any complaints from research participants, and providing an educational role to their institution regarding human research ethics. What is my role on an HREC? I have been a member with knowledge of relevant research areas since 2003. In addition, I have been chair of the low risk process since 2008. I am also the only psychologist on the committee. Every month, because of my psychological background and expertise, I am assigned and review two or three mostly psychological or psychiatric research projects, and, in addition, several project amendments. Examples of the types of projects I review include: those involving elderly patients with multiple comorbidities in the community; projects screening for depression and/or anxiety in outpatient populations; projects involving people with schizophrenia and their first degree relatives; autism studies; neuropsychological and cognitive studies involving different populations such as schizophrenic, elderly, stroke, or trauma participants; transcranial magnetic stimulation studies involving people with schizophrenia and healthy controls; sexual health projects; and psychoeducational trials. There may be a (mis)perception in the community that people with a cognitive impairment or mental illness are unable to participate in research. They are entitled to do so, as long as they are able to provide informed consent and to participate in the research. Their capacity to consent to and participate in research may vary for reasons such as the nature of the condition; their medication or treatment; their level of discomfort or distress; the complexity of the research; and fluctuations in their condition. It is important, therefore, that researchers monitor these participants' ability to provide consent and to participate. Even when capable of giving consent and participating, people with a mental illness or cognitive impairment may be particularly vulnerable to discomfort or distress and ethics committees need to be reassured that ways of minimising the effects of this susceptibility are clearly described in the research application. HRECs will also be interested in how researchers will determine the capacity of these participants to consent to the research. I read and assess ethics applications and all relevant attachments such as questionnaires, advertisements, flyers, researcher curricula vitae, participant information and consent forms, and forward my comments and queries to the researchers via the ethics staff. When responses are received from the researchers, I review these and decide whether more information is required, or the responses are satisfactory and the project or amendment request can be approved, or whether there are sufficient issues of concern to recommend that the project be discussed at the monthly HREC meeting. HREC meeting attendance is a core part of committee membership and involves reading agenda items beforehand, and being prepared to speak about reviewed projects and to summarise any outstanding issues or concerns. Occasionally, I also act as spokesperson during researcher interviews, which involves providing a synopsis of
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the research project to the committee and then leading the discussion once the researchers join the meeting, both at monthly HREC meetings and at specially convened out of session meetings. The latter meetings occur from time to time with a few HREC members to discuss specific issues or projects, or to meet with researchers. My role with low risk projects has involved acting as chair of a subcommittee, comprising a small group of HREC members, which met fortnightly to discuss and review the ethical issues in low risk applications, to liaise with researchers, and to decide on the best action to take. HRECs deal with low risk projects differently and processes can and do change over time. I have helped to refine our low risk process and have contributed to its development, including preparing low risk guidelines and application forms for researchers. Occasionally, I am called upon as chair to provide a 'second opinion' or to adjudicate decide if projects really are low risk or if they should be full submissions and whether any further information is needed from the researchers and/or what further action should be taken. Mentoring new HREC members in the low risk process is also an enjoyable part of my role. What is it like being on an ethics committee? I have found it to be a great experience very rewarding and one of the best things I have done! Prior to joining the committee, I had little understanding of ethics or HRECs, but my interest was immediately piqued and I have subsequently developed a real interest and learnt a great deal over the years. I am fortunate to be a member of an excellent, wellrespected, and supportive committee with hardworking, dedicated, and passionate members and ethics staff and an approachable, inclusive, very experienced, and knowledgeable chairperson, who values members' opinions and facilitates and encourages open discussion. HREC membership is rewarding, but it is also a real commitment and can involve much preparation, work, and time (all ethics committees have seen a substantial increase in ethics applications over time). However, it is a great forum for the exchange of ideas and different perspectives, and a wonderful opportunity to contribute to, and make a difference in, peoples' experience of research participation. Despite our different roles and backgrounds, as members of an HREC we share a common interest in healthcare, medical research, community issues, the welfare of individuals, and human rights. We probably share particular traits as well it is important to be able to reason, to question, to be logical, analytical, tactful, and diplomatic, to have a sense of fairness, and to be able to voice an opinion while listening to and respecting others' point of view. Also important is the ability to be open to change, and to fresh views and perspectives, in order to avoid staleness.
What are the challenges of being on an ethics committee? Like most areas in life, often there is no clear 'right' or 'wrong' and things are rarely 'black' or 'white'. It can be difficult to live with 'grey' areas and make the most appropriate decision. Consequently, some decisions take longer than others. Time can be a limiting factor - with a full agenda and many projects to discuss, there is not always ample time in meetings to consider wider ethical issues. It can be challenging in my role as low risk chairperson to adjudicate and provide a second opinion is a project really low risk and, if not, how should it be processed? I still grapple with issues such as: researchers' legal obligations; in what instances the use of participant data is secondary use of data, which does not require consent; under what conditions is a waiver of the need to provide information to, and to seek consent from, participants appropriate; whether older adolescents are 'mature minors'; and in projects involving clinical registries, whether 'opt-off' consent is really consent. Research where participants are unable to provide consent for themselves and require the use of a 'person responsible' can be fraught with ethical issues. It can also be frustrating for HREC members and ethics staff when researchers submit incomplete or rushed applications and, in rare instances, when researchers seem uncooperative. Despite occasional challenges, it is satisfying to contribute to setting high standards for the ethical conduct of research, to keep participants' research experience positive, and to be part of a supportive, not gatekeeping, process where the needs of both researchers and participants are met and a win/win situation can be, and is, achieved.
References NHMRC (2007a). Australian Code for the Responsible Conduct of Research. Retrieved from http://www.nhmrc.gov.au/publications/synopses/ r39syn.htm NHMRC (2007b). National Statement on Ethical Conduct in Human Research. Retrieved from http://www.nhmrc.gov.au/publications/ synopses/ e72syn.htm NHMRC (2011). Human research ethics committees. Retrieved from http://www.nhmrc.gov.au/ healthethics/human-research-ethics-committees-hrecs Perry, G. (2012). The Shock Machine: The untold story of the notorious Milgram psychology experiments. Melbourne, Australia: Scribe. Zimbardo, P. G. (2007). The Lucifer effect: Understanding how good people turn evil. New York, NY: Random House.
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L o o k f o r t h e A C P AMe mb e r l o g o
D o e s y o u r p s y c h o l o g i s t h a v e a c c r e d i t e d q u a l i c a t i o n s i n c l i n i c a l p s y c h o l o g y ?
C l i n i c a l p s y c h o l o g i s t s a r e s p e c i a l i s t s i n t h e a s s e s s me n t a n d e v i d e n c e b a s e d t r e a t me n t o f a w i d e r a n g e o f me n t a l h e a l t h p r o b l e ms , i n c l u d i n g :
A d d i c t i o n s A t t e n t i o n D ec i t a n d H y p e r a c t i v i t y D i s o r d e r s A u t i s t i c S p e c t r u mD i s o r d e r s B i p o l a r D i s o r d e r D e p r e s s i o n &Mo o d D i c u l t i e s D r u g &A l c o h o l A b u s e E a t i n g D i s o r d e r s E mo t i o n a l &B e h a v i o u r a l P r o b l e ms i n C h i l d r e n F e a r s , P h o b i a s , A n x i e t y &P a n i c A t t a c k s G r i e f , L o s s &B e r e a v e me n t O b s e s s i o n s &C o mp u l s i v e B e h a v i o u r P a i n a n d S o ma t i c S y mp t o ms P e r s o n a l i t y D i s o r d e r s P o s t t r a u ma t i c S t r e s s D i s o r d e r P s y c h o t i c I l l n e s s e s R e c o v e r y f r o mC h i l d h o o d T r a u ma S c h i z o p h r e n i a S e p a r a t i o n A n x i e t y S o c i a l A n x i e t y S l e e p D i s o r d e r s A s k t h e p s y c h o l o g i s t p r o v i d i n g y o u r me n t a l h e a l t h t r e a t me n t w h a t a c c r e d i t e d p o s t g r a d u a t e q u a l ic a t i o n s t h e y h a v e i n c l i n i c a l p s y c h o l o g y . T on d a c l i n i c a l p s y c h o l o g i s t w h o i s a me mb e r o f t h e A u s t r a l i a n C l i n i c a l P s y c h o l o g y A s s o c i a t i o n g o t o : w w w . a c p a . o r g . a u a n d s e a r c h :
T h e A u s t r a l i a n C l i n i c a l P s y c h o l o g y A s s o c i a t i o n ( A C P A ) r e p r e s e n t s o n l y c l i n i c a l p s y c h o l o g i s t s w h o h a v e o b t a i n e d t h e a c c r e d i t e d q u a l i c a t i o n s s e t d o w n b y t h e P s y c h o l o g y B o a r d o f A u s t r a l i a f o r r e c o g n i t i o n a s a c l i n i c a l p s y c h o l o g i s t .
T h e s e a r e : A n a c c r e d i t e d Ma s t e r s ( t w o y e a r ) o r D o c t o r a l ( t h r e e y e a r ) d e g r e e i n c l i n i c a l p s y c h o l o g y ; a n d Ap o s t d e g r e e p e r i o d o f s u p e r v i s i o n t o b r i n g t h e t o t a l o f p o s t g r a d u a t e t r a i n i n g t o f o u r y e a r s . I n c h o o s i n g a n A C P AMe mb e r y o u a r e e n s u r i n g t h a t y o u r c l i n i c a l p s y c h o l o g i s t h a s c o mp l e t e d t h i s e s t a b l i s h e d s t a n d a r d o f t r a i n i n g . A c c r e d i t e d Ma s t e r s a n d D o c t o r a l l e v e l t r a i n i n g i n c l i n i c a l p s y c h o l o g y : P r o v i d e s t h e h i g h e s t l e v e l s o f t r a i n i n g c u r r e n t l y o e r e d w i t h i n t h e p s y c h o l o g y p r o f e s s i o n i n A u s t r a l i a F a c i l i t a t e s t h e d e v e l o p me n t o f h i g h l e v e l , s p e c i a l i s e d s k i l l s i n me n t a l h e a l t h a s s e s s me n t , d i a g n o s i s , a n d e v i d e n c e b a s e d t r e a t me n t p l a n n i n g a n d i mp l e me n t a t i o n N o t a l l p s y c h o l o g i s t s w h o a r e p e r mi t t e d t o u s e t h e t e r m c l i n i c a l p s y c h o l o g i s t i n A u s t r a l i a h a v e c o mp l e t e d t h i s l e v e l o f t r a i n i n g . I n d e e d , s o me h a v e n o t c o mp l e t e d a n y p o s t g r a d u a t e q u a l i c a t i o n s i n c l i n i c a l p s y c h o l o g y . I n t e r n a t i o n a l s t a n d a r d s r e q u i r e p o s t g r a d u a t e q u a l i c a t i o n s i n c l i n i c a l p s y c h o l o g y f o r a l l c l i n i c a l p s y c h o l o g i s t s .
T h e A u s t r a l i a n C l i n i c a l P s y c h o l o g y A s s o c i a t i o n ( A C P A ) P OB o x 1 2 4 2 B R O A D W A Y , N S W , 2 5 8 1
w w w . a c p a . o r g . a u
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ACPARIAN is the official publication of the Australian Clinical Psychology Association and is published three times a year. Aim ACPARIAN provides for the dissemination of knowledge on topics of interest informative to clinical psychologists. Its focus is on the latest clinical theory and research relevant to clinical practice including assessment and intervention, training, and professional issues. Content Submissions to ACPARIAN may include: Letters to the Editor General articles, viewpoints, opinions, and comments Articles of particular ethical and/or legal interest to the profession Research reviews Theoretical perspectives Technology updates Students news and viewpoints Book reviews General information and announcements From time to time, ACPARIAN will focus on topics or issues of interest and call for submissions accordingly. The ACPA Editorial Board welcomes contributions and suggestions for topics from the membership. Contributions Submissions should be made electronically, in a Word document, to the Editor, Kaye Horley: kaye@practicalpsychology.com.au Please observe the following word limits: Letters to the Editor: 200 words Client perspectives, research articles, student matters, and ethics and legal matters: 750 to 1000 words Feature articles: 1000 - 1500 words. References should be in APA style. Please ensure that submissions are made by the stated deadline. Late submissions may not be accepted. Authors can expect the Editorial Board to review and change content for clarity and style. The Editorial Board will endeavour to make any significant revisions in consultation with the author. The Editor reserves the right to include or reject written works at any point in the publication process. The views expressed by authors in ACPARIAN do not necessarily reflect those of the ACPA Editorial Board. Editorial Board Editor Kaye Horley, PhD Associate Editors Giles Burch, PhD Tamera Clancy, MA(Psych) Fiona Jamieson, MPsych(Clin) Dixie Statham, DPsych(Clin) Copy Editor John Moulds, PhD Design Ben Callegari, MPsych(Clin)
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Child & Family Therapy

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THE AUSTRALIAN CLINICAL PSYCHOLOGY ASSOCIATION

ISSUE 6: JUNE 2013

ACPARIAN Issue 6 JUN 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

FROM THE PRESIDENT

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

DELUSIONAL MISIDENTIFICATION SYNDROME

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

METHAMPHETAMINE AND PSYCHOSIS

Characteristics of methamphetamine psychosis

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

FUNCTIONAL RECOVERY IN FIRST EPISODE PSYCHOSIS

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

THE AUSTRALIAN CLINICAL PSYCHOLOGY ASSOCIATION

4th Annual National Conference: Presenting a lecture and clinical workshop by

Dr Nancy McWilliams Self-Defeating Patterns and Their Clinical Implications

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

PHARMACOTHERAPY FOR PSYCHOSIS

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ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

THE QUALITY AND STRENGTH OF EVIDENCE FOR VARIOUS TREATMENTS IN SCHIZOPHRENIA

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ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

A PATIENT AMBASSADORS PERSPECTIVE: HAVING 1 SCHIZOPHRENIA

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ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

DEMYSTIFYING HUMAN RESEARCH ETHICS COMMITTEES

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ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

Editorial Policy and Guidelines

Child & Family Therapy

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

2013 Advertising Rate Card

Australian Clinical Psychology Association

ACPARIAN: ISSUE 6: May 2013 Australian Clinical Psychology Association 2013

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