Psychiatry - Theses

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    Adjunctive Natural Low Dose Docosahexanoic Acid (DHA) Omega-3 in Residual Symptoms in Depressed Patients
    Piperoglou, Michael Vasilios ( 2021)
    The stated goal of psychiatric treatment is the remission of all presenting symptoms and a return of the patient to full pre-morbid functional status. Increasingly, the presence of residual symptoms of disorder have been linked to an early relapse of the underlying psychiatric syndrome. While pharmacological treatments of moderate to severe psychiatric disorders are the main therapeutic approach, remission is achieved in around 30% of patients with the first treatment. Adjunctive treatment regimens based on medications, so-called ‘nutraceuticals’ or psychotherapy, have been investigated for their ability to alleviate these persistent residual symptoms. Among adjunctive treatments omega-3 polyunsaturated fatty acids (PUFAs) have been investigated for their effects on symptoms of depression and anxiety. While many questions remain, one PUFA, docosahexaenoic acid (DHA), has shown promise as an adjunct to the treatment for the presenting complaints in Major Depressive Disorder but has not been investigated for residual symptoms. This exploratory study utilised a double-blind, placebo-controlled, cross-over methodology to investigate the efficacy of DHA in patients with residual symptoms of depression and anxiety meeting DSM-V criteria for a Major Depressive Disorder. Depression and anxiety symptoms were assessed at the end of 12-weeks of either placebo or DHA (and then the crossed-over situation) with clinician and patient rated scales and compared using a repeated measures analysis of variance. Neither the last observation carried forward nor the observed cases sets of data showed any statistically significant changes in depression or anxiety symptoms during treatment with placebo or DHA. Changes in patient rated scales, assessed using the same statistical methodology, were concordant with the findings from the clinician rated scales. It is concluded that DHA, in the doses used in this study, does not offer significant clinical benefits to patients with persistent residual mood symptoms. Several factors specific to the patient population studied are discussed which may explain the apparent lack of clinical effect. Further studies are suggested which could overcome some of the barriers to efficacy encountered in this trial.
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    A comparison of homocysteine levels in first episode psychosis patients and age matched controls
    Stephens, Timothy Charles Bondfield ( 2007)
    Elevated serum homocysteine concentrations are neurotoxic and are strongly implicated as a risk factor for neuropsychiatric disease (Fabender, Mielke, Bertsch, & Hennerici, 1999; Kim & Pae, 1996; Kruman et al., 2000; Reutens & Sachdev, 2002). This study compares homocysteine levels in early stages psychosis patients and healthy controls. Data from 48 healthy controls were compared with 50 previously diagnosed psychosis patients, 15-25 years, and with a gender ratio males: females 7:3. Patients were outpatients or inpatients at ORYGEN Youth Health, with a diagnosis of first episode of psychosis defined as daily psychotic symptoms lasting longer than a week that could not be explained by other means such as “drug-induced” or “organic”. All subjects were interviewed to collect information relating to family psychotic history. A possible history of psychotic disease in control subjects was tested using the SCID Psych Screening Module, drug use recorded using Alcohol Use Disorders Identification Test (AUDIT) (for alcohol use), The Modified Fagerström Tolerance Questionnaire (mFTQ) (for smoking), Opiate Treatment Index (OTI) (for opiate-type drugs). Dietary and medication histories were also taken. Blood tests were performed to determine serum homocysteine, serum folate, red blood cell folate and serum vitamin B12 levels. An independent sample t test to compare homocysteine levels in patients and controls was performed. Serum homocysteine levels were significantly higher for patients (M = 12.9, S.D. = 3.6) than controls (M = 11.1, S.D. = 2.7) (t(96) = 2.7, p = 0.007, two-tailed). After General Linear Model (GLM) analysis it was found that group (patients or controls), and not serum folate, vitamin B12 and the T allele of MTHFR C677 polymorphism had significant effect on homocysteine levels. Thus a number of factors that may increase homocysteine levels were ruled out. Although it was not possible to obtain a complete data set for some factors (alcohol, smoking and caffeine consumption) (a weakness of the study), strengths included consecutive recruitment, minimisation of selection bias, good matching for age and gender between patients and controls, and the consideration of (serum) folate and (serum) vitamin B12 as potential confounding variables. A number of other studies have found significantly increased homocysteine levels in young patients compared with controls, particularly males. Most related studies favoured the homocysteine-psychosis link. The probability of symptomatic recovery is very high (80-90%) after treatment for first episode psychosis (Robinson et al., 1999) and delayed treatment, but prolonged duration of treatment is associated with poorer response in treatment and worse outcome (Malla & Norman, 2002). This justifies studying homocysteine levels and cognitive function in that first period of psychosis. This research offers evidence for the importance of serum homocysteine levels as showing involvement in the etiology of psychosis. Lowering homocysteine may have a beneficial effect on symptoms and cognitive dysfunction in psychotic illness. Two randomised controlled trials have demonstrated benefit in psychotic illness of giving folate and consequently reducing homocysteine.(Godfrey & Toone, 1990; Levine et al., 2006b). Benefits of taking folate were found in both trials for both cognition and psychotic symptoms. By reducing homocysteine levels early in the illness, some of the excess cardiovascular mortality may be prevented. Secondary prevention of CVD does not appear to influence outcome (Hermann, Herrmann, & Obeid, 2007), so the right time to intervene and reduce risk would appear to be early in the course of psychosis. Additionally, by lowering homocysteine cognitive functioning and psychotic symptoms may be improved (Levine et al., 2006b).
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    What are the special characteristics of families who provide long term care for children of parents with mental illness?
    Cowling, Vicki ( 2003)
    This project investigated characteristics relating to family functioning and attitudes to mental illness, and caregiving, which distinguish families choosing to care for children of parents with mental illness (CPMI) from families who choose not to but do care for other children (NCPMI), and from families not involved in the adoptive care system (COMM). Welfare agencies seeking long term home based care for children of parents with mental illness (among other groups of children) report that potential caregivers are concerned about the child’s genetic risk, and the requirement that they facilitate access visits with the birth parent. Consequently it is more difficult to recruit caregivers to care for children of parents with mental illness. Previous studies found that families who adopt children with special needs had family systems that were flexible and able to adapt to changing needs, and in which family members felt close to one another. It was not known if the functioning of families who care for children of parents with mental illness would differ from other family groups. Nor was it known if these families would differ in motivation to be caregivers and attitudes to mental illness from other family groups. Forty four families completed a questionnaire providing background information, and a family functioning questionnaire which included the FACES II measure (Family Adaptability and Cohesion Evaluation Scale) and questions assessing level of altruism, and tendency to respond in a socially desirable manner. Data from the FACES II measure was used to classify families according to the Circumplex Model of Marital and Family Systems. Q-methodology was used to assess participants’ attitudes to eight issues related to the research question: mental illness, children of parents with mental illness, parents having a mental illness, family environment, motivation to be caregivers, ongoing contact between child in care and parent, approval of others when deciding to be a caregiver, and flexibility in deciding to accept a certain child for placement. The Q-method required participants to rate 42 statements (a Q-set), concerning these issues, according to a fixed distribution, from statements with which they strongly agreed to statements with which they strongly disagreed. Participants could also give open-ended responses to questions addressing the same issues in a semi-structured interview. The CPMI group were found to have a lower level of income and education than the other two groups, and were more likely to be full time caregivers. Both caregiver groups were unlikely to have children of their own. The profiles of the three groups on the cohesion and flexibility sub-scales of FACES II were similar. The classification of the family groups on the Circumplex model showed that the CPMI group were located in the balanced and mid-range levels of the model more so than the other two groups. Responses to the Q-sort and interview questions suggested that the CPMI families were more understanding of mental illness, and of the needs of the children and capacity of their parents. It is suggested that future studies increase the number of participants, and investigate in more detail the factors which motivate families who provide long term care for children of parents with mental illness.
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    The history of Yarra Bend Lunatic Asylum, Melbourne
    BONWICK, RICHARD ( 1996-11)
    The thesis is in three major sections, plus a brief conclusion. The first section provides essentail background by describing the care of the mentally ill in England and New South Wales (including the Port Phillip district) in the period prior to the establishment of Yarra Bend Lunatic Asylum in 1848. The second section is a chronological history of Yarra Bend, particularly focusing on the period from its inception in 1848 until the Royal Commission of 1884; with some extension to describe the other psychiatric services within Victoria during the same period.The third section discusses at length a number of key issues identified within the chronological history.
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    The effects of catecholamine depletion and acute psychosocial stress on neurocognition
    Letic, Tony Robert ( 2012)
    Extensive research has clearly established that neurocognition is negatively impacted by various stressors. While the extant research has focused on the effects of cortisol on declarative memory, little attention has been given to the role of the catecholamines in the deterioration of neurocognitive performance following psychosocial stress. Forty healthy male (n = 21) and female (n = 19) volunteers aged between 18-47 years who had been screened for eligibility participated in the study. Heart rate, blood pressure and salivary cortisol were measured at baseline, pre-stress, post stress (immediate) and after one hour of rest (post stress recovery). Neurocognitive assessment included immediate and delayed verbal recall, spatial learning and strategy, attention and working memory (spatial and non-spatial) at the same four phases. Participants randomly received an L-tyrosine and L-phenylalanine depleted (DEP) or a nutritionally balanced (BAL) amino acid drink in a randomised, double blind, placebo-controlled parallel group design 5 hrs before exposure to the Trier Social Stress Test (TSST). The ratio of L-tyrosine and L-phenylalanine to the sum of other large neutral amino acids (ΣLNAAs) in plasma were both significantly reduced by -80% at the post-ingestion period (5 h) compared to baseline. Exposure to the TSST for both ATPD and balanced-treated participants resulted in the robust stimulation of the sympathomedullary (SAM) and hypothalamic-pituitary adrenocortical (HPA) axes. This was demonstrated by significant increases in heart rate and blood pressure immediately after stress exposure compared to baseline in both ATPD and balanced conditions. Salivary cortisol levels significantly increased immediately after the completion of the TSST compared to pre-stress levels. There were a limited number of effects of the TSST combined with ATPD on measures of neuropsychological performance. These outcomes suggest that neurocognition is not severely impacted by acute social stress under conditions of catecholamine depletion.
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    Culture and stigma towards mental illness: a comparison of general and psychiatric nurses of Chinese and Anglo-Australian backgrounds
    Ku, Tan Kan ( 2007)
    A sample of 208 nurses (a response rate of 63%) participated in a study by responding to a questionnaire comprising of 170 items which examined nurses’ attitudes towards mental illness, and the association between contact, cultural values, general and practice stigma. General stigma refers to attitudes towards the mentally ill while practice stigma is informed from differential clinical practice approaches towards the care of two case vignettes describing a patient with mental illness and one with diabetes. Subjects were recruited using the snowballing technique and comprised of nurses (83 Anglo Psychiatric, 41 Anglo General, 49 Chinese Psychiatric and 35 Chinese General) currently practising in Victoria. Age ranged from 21 to 65 years. Principal components analyses were conducted on items to develop subscales related to individualism and collectivism, contact types, general and practice stigma. Analyses of variance and covariance were conducted to examine differences between nurse type and ethnicity and respectively, to account for possible differences in background, contact and in the case of practice stigma, general stigma. The key findings revealed differences according to nurse type and ethnicity in several of the subscales. Psychiatric nurses endorsed a higher level of contact than general nurses with mentally ill people on the variables ‘Contact Through Work Situation’, ‘Patient Help Nurses’ and ‘External Socialisation with Patient’, but not on the variable ‘Relative With Mental Illness’. By virtue of more contact, psychiatric nurses also endorsed less general stigma than general nurses, assessed by results from analysing social distancing, but not by negative stereotyping of people with mental illness. With respect to practice stigma, while care and satisfaction did not differ according to patient type and nurse type, psychiatric nurses expressed less authoritarianism and negativity than general nurses towards the mental illness case than general nurses while lesser differences between nurse types were evident for the diabetes case. Chinese nurses when compared with Anglo-Australian nurses, endorsed more highly collectivist values measured by the variables ‘Ingroup Interdependence’ and ‘Ingroup Role Concern’ but there was no difference in individualist values. This may reflect acculturation towards Western values but also retention of Chinese values, interpreted in the light of other results on cultural affiliation, as a bicultural position. Chinese nurses endorsed more highly general stigma towards the mentally ill than Anglo nurses when statistically controlling for differences in background demographics and contact factors. Nursing satisfaction did not differ in ethnicity and patient type. Chinese nurses endorsed more highly care and authoritarianism in their clinical practice approaches than Anglo-Australian nurses, although there was no significant interaction effect between ethnicity and patient type on care and authoritarianism. Chinese nurses endorsed more highly negativity than Anglo-Australian nurses for the mental illness case than the diabetes case, an effect later shown to be mediated by differences in general stigma between the two ethnic groups. Within the Chinese sample, higher contact was associated with lower differential negativity for the mental illness than the diabetes case. Several path analyses suggested Chinese values influenced differential negativity, mediated by general stigma and prior diversified contact with people having a mental illness. It may be concluded from these results that practice stigma is related to cultural values but the relationship is mediated by general stigma and contact. What aspect of the Chinese values specifically correlates with general stigma remains a question for further research, but several possibilities are discussed.