Panacea Vol 47 Issue 1 (July 2013)

panacea the official magazine of the australian medical students’ association

the mental health issue

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panacea volume 47 issue 1

contents 6 editorial

7 words from the president ben veness

articles

8 understanding mental health seshika ratwatte 10 mental state university ben veness 13 down the rabbit hole beatrice dowsett 15 stepping up harry jennens 17 the cannula david mathew 19 a hidden reality alexandra brown 24 a problem to be solved benjamin lewis 27 three shots and out emily webb-smith

reflections

9 it’s a personal thing anonymous 11 a learning experience matt mcalpine 16 wish you were here inu shahira 20 depresh confesh nicole kalish 21 a bandaid ain’t enough diana ethell 25 the drugs do work anonymous 34 an open letter amelia zaunders

academic

12 stigma in mental health prasadi adikari 18 mental illness in indian women erin burge 26 perceptions of dementia natalie chilko 30 diagnosing catatonia priscilla wee 32 early treatment in anorexia jessica cutting

reviews

35 pocketbody ben finlay

36 think differently! ASC 2013 claire mcallister 37 the house of god toby vinycomb

publications officer arghya gupta subeditors john farey divya raghavan cover flickr: FromSandToGlass advertising + sponsorship georgia carroll miranda norquay all images in this publication have been used under the offer of a creative commons licence and/or fair use policies panacea is the biannual publication of the australian medical students’ association (amsa) australian medical students’ association 42 macquarie st barton ACT 2600 postal address po box 6099 kingston ACT 2604 phone 02 6140 5446 fax 02 6270 5499 website www.amsa.org.au twitter @youramsa for any editorial or publications enquiries please contact the publications officer publications@amsa.org.au 2nd edition: published 9 July 2013

medsoc reports 42 adelaide 38 australian national 38 bond 39 deakin 39 griffith 41 james cook 41 monash 42 melbourne 44 newcastle 44 new england 45 notre dame sydney 45 notre dame fremantle 48 sydney 48 western australia 49 western sydney contributors

prasadi adikari, alexandra brown, erin burge, natalie chilko, jessica cutting, beatrice dowsett, diana ethell, ben finlay, harry jennens, nicole kalish, benjamin lewis, david mathew, claire mcallister, matt mcalpine, seshika ratwatte, inu shahira, ben veness, toby vinycomb, emily webb-smith, priscilla wee, amelia zaunders, two anonymous

medsoc reports

thomas carin, grace cowderoy, greg evans, john farey, colin giorcelli, lauren godde, sam harkin, felicity mcivor, alyssa parsons, aditi raut, andrew robinson, justin winters, ghassan zammar, kylie zhong, dean zinghini thank you to all the representatives and the members of the executive who helped with the production of this edition of panacea particular thanks are due to treasurer alexander murphy for his photographs

medsoc reports

all articles included in this publication are done on good faith, they do not represent the views of amsa, and all enquiries should be directed at individual authors

6

HIGHS AND LOWS We go through our lives experiencing ecsatic periods of joy and success, intertwined with episodes of debilitating stress and sadness.

For many of us in medicine, we can probably go through these feelings within the period of a day. We may have the elation of doing a few successful cannulations in the morning, then dealing with the stress and awkwardness of being present in a family meeting with an ICU patient in the afternoon. We may go home from our day in the hospital, only to find our fridge has broken down, the street has lost its power, or someone in our extended family has died. All these events happened to me within a week, and I’m just one person.

What we are pursuing is a life full of stress; whether ours, our patients’, our colleagues’, or society’s in general. It’s a choice we made, perhaps to aspire to the benefits which will hopefully come with it. Every time we get to the other side though, there will be autumn leaves littered among the green. Most of the time, we can deal with these stresses. We may get angry, sad, and frustrated, but in the end, we accept our fate, or we fight.

Sometimes, however, we can’t.

Everyone experiences that breaking point. Some struggle with it everyday, without any intention of it being that way.

Given our demographics and our circles, chances are you or I will experience some sort of mental illness during our lifetime, or have people in our immediate family and friends who do. While maybe one of our colleagues

australian medical students’ association

may find a cure for diseases such as depression and schizophrenia, what we can all do is increase understanding. By talking about our experiences, by reading more about the aetiology of these conditions, by sharing what we have learned; we can help society find an answer, or at the very least, a path to one.

Putting together this Mental Health issue of Panacea has been fun, exciting, inspiring, but to be brutally honest, it has been shocking and depressing too. There are articles about different aspects of mental health, there are personal reflections of medical students in our cohorts bravely telling us their stories - and I thank them and am proud of them for doing so, and there are academic essays and research reports which have opened my eyes.

Together, with others, I hope these open your eyes too.

Ask how your friends are going. Talk to them about their 6.30am plastics ward round and laugh about it, even if they’re hallucinating from insomnia. Let them know you’re there when they do. Because if this issue has made me realise something, it’s that there is definitely someone in every common room who could contribute a story to this issue. If it’s you, then know that you can do something about it, because you can. Talk to someone, a friend, a counsellor, contact a help centre. It will let others know that when they need it, they can too.

Arghya Gupta AMSA Publications Officer

7

WORDS FROM THE PRESIDENT Just before lunch one recent Sunday, I walked with a friend I hadn’t seen in a couple of years. We spent a while talking about his semester on exchange in Switzerland and subsequent travels through Europe, and then moved on to discussing why he’s applying to medical school for 2014. I chuckled when his face lit up while talking of his post-GAMSAT hospital admission, for appendicitis. He spoke eagerly of how interesting his three days in the ward had been, and of all the questions he had been able to ask his doctors.

We moved on to discussing my experience of medical school, and I remarked how lucky I thought we were to be learning such interesting material and gaining an expedited, vicarious life experience through the patients and families we meet. The exposure we get is startling, which I mean mostly as a good thing.

It can, however, also be confronting. For most of us, we eventually find at least one of the patients we meet has a story that hits close to home. I remember being particularly distracted in first-year by a patient my examination skills group met while practicing something or other. Mysteriously, this very acquiescent young man had trouble speaking, and something called a PEG tube sticking through his abdomen. It transpired that he had taken a deliberate drug overdose and then suffered damage to his vocal cords during a botched intubation attempt. In addition to not being able to speak properly, he could now neither eat nor drink, and a return of function was purely hypothetical. He would soon be discharged and yet despite maybe never again being able to share a drink or a meal with his friends, we hoped he would not attempt suicide again. His face has faded in my memory, but as I write this I still empathise and wonder how he is doing now.

There are students for whom this experience might have hit even closer to home. The dearth of epidemiological data specific to the Australian university context is a deficiency AMSA would like to see addressed, but a recent survey of 30,000 students in Canada, reported in The Globe and Mail, revealed that 9.5 per cent had seriously considered taking their own lives in the past year, while 1.3 per cent said they had attempted suicide1. An Australian study of University of Adelaide students conducted across various faculties in 2010 found that 44 per cent of medical students were classified as psychologically distressed (Kessler Measure of Psychological Distress score greater than or equal to 22)2. This was similar to the rate (48 per cent) the authors found for all students surveyed, which was noted to be 4.4 times that

of age-matched peers. Is there something in the water? If correct and generalisable, these numbers are startling.

In line with AMSA’s stated priority to advocate for an improvement in mental health services for all university students, we have themed this first issue of Panacea for 2013 around the topic of mental health. We are very grateful for all of the contributions we have received, particularly from those students who were brave enough to share their personal experiences. Reducing the stigma around mental illness is a crucial step towards improved access to care and enhanced quality of life, and our responsibility to facilitate this started yesterday. It’s heartening to read in some of these stories of the wonderful support provided to colleagues in need. I hope we all take heed of their example and pay careful attention to the wellbeing of ourselves and others. It is, of course, in patients’ best interests that doctors be healthy, too.

In addition to passing a Student Mental Health and Wellbeing Policy earlier this year, AMSA has set up two small project teams to aid the National Executive in addressing this important and still somewhat neglected issue. One, led by Ben Middleton from Flinders University, is benchmarking the preventative and interventional services and initiatives provided by universities across Australia. Ben’s team is starting with a pilot in New South Wales and will report by the end of the year. The other, led

by Tasha Wahid from Deakin University, is helping to plan our student mental health advocacy strategy more broadly. Student mental health features prominently in our Federal Election strategy and we are seeking to address both the vice-chancellors and chancellors via Universities Australia. Your help would be welcomed (please email me at president@amsa.org.au).

Thank you very much to Arghya Gupta from the University of Sydney for editing this issue. Arghya has compiled a very impressive collection of articles by authors across Australia, and I commend them to you. If reading this inspires you to seek support for yourself or a friend, you may benefit from reading AMSA’s Keeping Your Grass Greener Guide, exploring the many other services available (see page 48), or in an urgent situation, calling Lifeline on 13 11 14 or an ambulance on 000.

Thank you for reading Panacea. On behalf of AMSA, best wishes,

Benjamin Veness AMSA President

1. Miller, A. Postsecondary students dealing with multiple mental-health issues [internet]. The Globe and Mail. 2013 Jun 17.

2. Leahy, C., Peterson, R.F., Wilson, I.G., et al. Distress levels and self-reported treatment rates for medicine, law, psychology and mechanical engineering tertiary students: cross-sectional study. Australian and New Zealand Journal of Psychiatry, 2010;44:608–615.

panacea / 1. 2013

8 UNDERSTANDING MENTAL HEALTH seshikaratwatte newcastle

Not long ago I got a phone call, from someone I am very close to, who was in absolute hysterics. They called because they were so worked up and so distressed that they no longer believed that people loved them. The phrases; “worst day of my life”, “you don’t know how bad I’m feeling”, and “I’m so scared of the future,” were all cried to me. They say you can tell you love someone when you can share in the full strength of their happiness and feel the full strength of their pain. Let me tell you, a glimpse of this person’s pain was enough to break something inside of me. I can’t bear to think what it is to constantly live with such self doubt, to live with such little self worth. This tiny window into the thoughts of someone who had depression and anxiety scared me.

I believe that mental health issues, in particular depression and anxiety, are not something you can truly understand unless you have had some sort of direct experience with it: either personally or watching someone close to you struggle with it. It can be incredibly frustrating as a bystander to watch someone struggle to overcome it. There have been numerous times that I have wanted shake a different thought pattern into people, to scream ‘just take control of your actions; make yourself not feel bad’. But depression does not work like that. It is not something you can shake

off in two weeks like a virus, or remove in a few hours like an appendix; treatment is a long process and it’s a disease which rears its head time and time again.

Mental health issues affect our communities to a devastating effect, and the burden is particularly high amongst young people. In the 15-24 year age group, mental health issues account for 55% of the total burden of disease. Mental health conditions in anyone can be debilitating, but in this age group it is particularly significant because it marks a point where we are making significant decisions in our lives. It’s when you finish school, go to university or TAFE, or get job, start a family; you’re trying to form lasting relationships.

Even the most pragmatic people in society should be able to appreciate the financial burden of mental disease. In 2009, mental illness in the 12-25 age group cost Australia $10.6b, with 71% of this due to the costs of lost productivity from people not being able to work or contribute to their full potential.

Bottom line: these are significant issues which need to be addressed.

It is important to be aware that mental health within our own cohort and colleagues is significant. We’re studying a highly demanding course; stress is high, pressure is high, the majority of us are Type-A personalities and high achievers,

australian medical students’ association

we are confronted with other people’s personal issues and circumstances in the hospital or on placement and this means there are times when we all struggle to cope. For many of us this represents a bad day or week, or a stressful exam period. None the less it is important to look out for each other, and especially watch for when these feelings don’t go away.

As medical students and future health practitioners we have a lot of responsibilities to society and each other as peers. I believe that helping to address mental health issues is one such responsibility. Whether it be through providing a support network for our friends and colleagues, or spending that extra bit of time with patients who are struggling to cope and pointing them in the right direction to get help, or advocating to the government with bigger organisations about the importance of these issues, we all have a role to play.

I write this article not to get you down, or say the world is a horrible place, nor to preach at you, but rather to share my small story (albeit in a fairly superficial way) in the hopes that it gets these issues a bit more out in the open in our community and to encourage you to consider how in little ways you can do your bit.

9

IT’S A PERSONAL THING anonymous melbourne

Depression and anxiety sneak up on you. In the beginning, I thought that I was just lazy. Maybe I was; but the day I was halfway to the station and then had to return to my bed should have served as a warning. Instead, I felt I was letting myself down and that I needed to suck it up.

up. I sometimes believe that everyone knows more than me. But, as I deal with intermittent return of horrid feelings, I have to be forgiving of myself. I’m not going to top the class or know all the answers all the time. What I do know is that I want to be here, and I am entitled to, despite the issues I have with my mental health.

I can’t speak for anyone else who has experienced an episode of depression and/or anxiety, but the hardest part for me was feeling like I didn’t want to be that way, but it was all I could do.

Looking back I can’t feasibly understand feeling and acting like I did - it feels like a different person was occupying my mind. It was like having two consciousnesses present - the wild selfhating miserable beast, and the scared mouse, both sharing the same house.

My experience makes my life harder - but I would never change it, it enriches my life and helps me see things through a different lens. I’ve been forced to reflect on myself time and time again, and this helps me relate to others better. Having dealt with mental illness I feel better equipped to talk to those that I’ll come across as a doctor.

Someone once told me, “Your health has to come first. If you’re not healthy yourself, you can never truly love or support your friends and families as well as you’d want to.” I think this is not only applicable in caring for your friends, but also in living out your vocation - if you are not healthy your work will be diminished.

I entered this medical degree knowing that I carried a burden - and I wonder how many people are experiencing the same feelings as I am. I’ve missed lectures, and feel completely overwhelmed by the thought of catching

Mental illness is a personal experience, in the exact same way that how you experience life is personal. It is never your place to make a judgment on how someone should feel, or their underlying motivations. What is important is to listen to what is right in front of you at the time. The skill of just being able to listen and to not try and fix it is a gift that can only be learned.

Therapy of any kind is not trying to tell you what to think, but helping you to develop/improve/build a framework of how to think. At any point a person who is didactic in their treatment of how you feel is never going to make a difference.

But by understanding why someone might think that way and suggesting other ways of looking at it, a receptive patient can learn ways of managing and living

within the world we maintain. I am so happy to have been given the chance to better understand my brain and its inner workings, and to be continually developing a framework of thinking.

What we need is a change in perspective - an understanding that seeking help is not weak and can be cost effective. The benefits of mental health therapy are worth every penny (and every missed overseas trip) and we need society to acknowledge that the outcomes of good mental health are multiple - for the individual, family, friends and society. People are inherently fallible to any illness, and being able to forgive actions that they were not in control of and allow them to heal needs to be a priority in the future.

I like to think I’m worth more than any diagnosis, and that amidst all this knowledge we are consuming we continue to put people first, including our peers. Your friendliness in the passageway goes a long way to making me feel better about myself.

As students learning to become part of one of the greatest professions, we need to not just learn how to treat mental illness, but to epitomise what it is to accept mental illness - to see the person and not the disease.

panacea / 1. 2013

10 MENTAL STATE UNIVERSITY benveness sydney / amsapresident

Six years ago, almost to the day, 33 students and staff died at Virginia Polytechnic Institute and State University (“Virginia Tech”). One of these was Seung-Hui Cho, a Korean-born student whose family immigrated to the United States during his childhood.

Mr Cho had a well-established history of mental illness, and was known to the University’s multi-disciplinary “Care Team”, campus police, the state Department of Mental Health, a psychiatric hospital in nearby Radford, and the university’s counselling centre.

For several years, his behaviour in class and in his residence had been observed by numerous teachers and peers as markedly unusual and threatening.

On the 16th of April 2007, Mr Cho shot and killed 32 people, wounded 17 more, then committed suicide.

In hindsight, the shootings and suicide could be considered an expectable consequence of long-term, untreated mental illness and disaffection. The fact that appropriate and coordinated care was never offered nor enforced upon Mr Cho represents a tragic systemic failure on the part of both the university and the government health service. It would seem that none of the people who knew the most about Mr Cho’s behaviour knew how to help him, and that communication between them was limited.

Such disconnection was noted broadly at Virginia Tech, and is unfortunately not uncommon at many universities.

One of the recommendations of the government review into the incident was that “universities should recognise their responsibility to a young, vulnerable, population … and promote the sharing of information internally, and with parents, when significant circumstances pertaining to health and

safety arise”. Furthermore, the review called for universities to have systems that link troubled students to appropriate medical and counselling services, either on or off campus.

The events at Virginia Tech were an extreme example of the consequences of ignoring a student’s mental health; students with mental health problems usually pose no threat to others. More commonly, the worst that happens is that individuals commit suicide, as happened with an international student at my university last year, and with an intern who died just a few weeks into their new job early this year.

The Australian Medical Students’ Association (AMSA) spent a great deal of its first Council meeting for 2013 discussing the topic of student mental health, and passed a Student Mental Health and Wellbeing Policy that is available on the AMSA website.

It seeks to bring attention to this issue and forms the bedrock for AMSA’s future policy initiatives in the area.

Mental health is one of Australia’s nine National Health Priority Areas (predating the addition of diabetes, asthma, arthritis, obesity, and dementia). Australian Institute of Health and Welfare (AIHW) data show more than one quarter (26 per cent) of the 16-24 age group experience a mental health disorder in a 12-month period – the highest incidence of any age group. Anxiety disorders are the most common, followed by substance use disorders and affective disorders. Furthermore, compared with other age groups, youth are less likely to access services for mental health problems.

There is an opportunity being missed. More than 1.2 million students are enrolled at Australia’s 39 universities, and more than 60 per cent of domestic students are aged less than 25 years (by which age roughly 75 per cent of mental disorders have their onset).

australian medical students’ association

Federal Government policy is to broaden access to tertiary education, with the goal that 40 per cent of 25-34 year olds hold a bachelor’s degree or higher by the year 2025. This means that nearly half of all young people will soon be attending university for three, four, five, or more years – making them accessible in a way that is otherwise rare once people leave school.

AMSA would like to see universities and governments take advantage of this window of opportunity, implementing effective prevention and early intervention programmes for students’ mental health.

One of the obvious starting points is regulation, so we’re currently speaking to the Standards Panels that are reviewing the higher education provider standards monitored by the new industry regulator, the Tertiary Education Quality and Standards Agency.

Suggested interventions are broad, and will require collaboration between governments, universities, and students.

This is a tricky issue, but it is also a battle that AMSA believes is worth the fight. The university student group includes some of the best and brightest of Australia’s youth, captive in a potentially supportive environment for a small but significant number of years, and with open minds eager for opportunities for growth and personal development.

AMSA will do all it can to help them succeed.

Editor’s note: An earlier version of this article was previously published on the AMA website.

11 A LEARNING EXPERIENCE mattmcalpine westernsydney

During a shift in the emergency department, a mother carried in her 6 year old daughter with a deep gash in her arm, with blood still seeping through a makeshift tea-towel bandage.

Although she was in pain, the girl was pretty comfortable being assessed and treated. I was asked to hold her still as the ED physician gave the local anaesthetic and stitched the wound shut.

For the next ten minutes I found myself firmly gripping the screaming girl’s wrists while a nurse held her legs; it was all we could do to keep her still.

Her mother was by her side, reassuring her that it would end, that she loved her and that this had to happen for the pain to go away. All the while the girl crying‘mummy, make them stop!’

I still haven’t forgotten the look in her eyes as the sutures pierced the skin.

Pain, confusion, and abandonment written across her face as she looked up at her mother begging for an end.

Of course, the end came and all was well. But in that moment, anything would have been better than the pain of being fixed. Anything.

As medical students and future doctors we have the most amazing opportunity to be welcomed into people’s lives when they are most vulnerable.

Our hands will one day be suturing the wounds of children kicking and screaming and begging us to stop, and although we may choke back tears – we will continue. Why? Because we understand that sometimes in medicine, momentarily enduring pain is necessary to facilitate true recovery and healing.

As a 17 year old in my first year of medicine, life could not have been more perfect. I left home, started the most brilliant course, met some amazing people, enjoyed a fulfilling relationship and loved the adventure of each day.

Seemingly overnight however, everything changed to the point that I found myself violently sobbing under my bed for

hours each night, pushing away the people that cared about me most, and loathing everything about my brave new world. I was at a point where I no longer recognised myself; and I was trapped inside a mind and body I couldn’t control. After months of denial, I finally sought help, and began the painful journey to recovery that I still crawl along.

Mental illness doesn’t discriminate and can arbitrarily devastate everything, leaving you helpless and void of hope. There are no words to describe the absolute desolation that infiltrates each and every day. My story is just one, and I forewarn that my story is an incredibly individual experience. But I hope that in embracing vulnerability and sharing my story, others may find solace in their own.

I discovered the bitter irony of depression; that once you find yourself at the end of the earth where worthlessness and despair wreak havoc – rock bottom can actually be the most comfortable place.

Not comforting, not bearable and certainly not sustainable … but comfortable nonetheless. I slowly began to embrace the suffering and heartache, and amazingly it momentarily relieved the anxiety I felt about the present. The future still scared me, the past still haunted me – but finally the present was bearable. Although my wounds were open and bleeding, I opted for the temporary relief of isolation and alcohol; and kicked and screamed at the thought of acknowledging weakness and accepting help - the sutures I so desperately needed.

Whoever you are, whatever you are going through - please know that recovery and redemption are possible … but not without great cost. Trying to get better is not easy. It is excruciating.

Choosing to exercise, sort out your sleep, eat healthier, see friends when you’d rather be alone - these things aren’t easy. They are excruciating. You will resent every step you take - every meal you force down, every event you attend, every alarm you set. Slowly however, your body will begin to thank you.

Choosing to see your doctor, talking with a psychologist, even to start medication if necessary, isn’t easy.

Acknowledging weakness and putting yourself at the mercy of a pill is humbling; sharing your most guiltridden thoughts with a stranger can be humiliating … but you are dedicating your life to this profession; start by trusting it.

Choosing to reach out to those who care for you isn’t easy. It’s excruciating.

Making yourself vulnerable, risking embarrassment, and rejection, isn’t comfortable. Sharing your story will tear your heart open in all the places you swore to keep safe and protected.

But it’s this catharsis that leads to understanding, support, and safety.

Once you reach out and take that initial step – you are not alone. Hopefully, you will find people around you holding your hand, and cheering you on.

I cannot promise that it will be simple or quick; in fact I promise that it won’t be.

I cannot promise that people will always understand what you’re going through, or how hard the choices you make are.

They usually won’t. I cannot promise there won’t be failures, setbacks, and relapses. Again, I can guarantee them.

I can however promise you this: This is not the end of your story.

Your heart and mind are not beyond redemption.

You are dearly loved, and you do not have to be alone on this road.

Your future is worth fighting for.

Take a deep breath; hold the hands of those who care for you while you endure each excruciating needle and stitch.

Recovery is real, and the sun is already beginning to rise.

Keep your head up, keep your heart strong.

panacea / 1. 2013

12 STIGMA IN MENTAL HEALTH prasadiadikari jamescook

Our approach to mental health has decidedly come a long way since the ‘locking away’ of the mentally unfit. Innovative reforms such as the increased deinstitutionalisation of psychiatric patients, development of family therapy, and the introduction of social support groups have undoubtedly improved outcomes for consumers of mental health1-3.

However, while society is more empathetic towards victims of these crippling diseases, there still remain hidden stigmas associated with mental health3-6. This is evident in the common misconceptions held by society, the media, and by individuals3-6.

‘Them’. Strangely that is the most common word used in reference to people with mental illness. Not ‘us’ or ‘me’ but ‘them’. Ask the common ‘Jo’ off the street and he would probably deny that mental illness could affect him.

In fact this ‘sweeping under the carpet’ approach to mental health is one of the reasons why stigmatisation exists3-6.

Alienating the subject makes it sound as if mental disorders are negative and abnormal. The fiction that mental health is rare is highlighted by recent surveys that show almost 50 per cent of the Australian population have experienced a mental disorder and that 1 in 7 experience depression3-6. Sadly this ignorance that swamps society results in isolation and shunning of individuals with mental disease; labelling them as ‘freaks’ or ‘outcasts’3-6. In order for people to accept mental health, more light has to be shed on the commonality of these diseases.

Despite its prevalence, society still has a poor understanding of those with a

mental illness6-9. Indeed it is not unusual to hear words such as ‘loony’ and ‘crazy’ being carelessly tossed around to describe those suffering from mental disorders6-9.

But are we fully to blame? With characters such as the Joker from The Dark Knight, and portrayal of mental asylums such as that in Shutter Island, it is no wonder that people potentially associate mental health with disrepute and destruction. A recent study on media depiction of mental illness showed that ‘criminality’, ‘dangerousness to others’ and ‘violence’ were the most common topics under which mental health was discussed6-9. More communication needs to be created between those with and without mental disorders in order to bury false representations and unnecessary fear.

While society and media play large part in stereotyping mental health, individuals suffering from mental disorders also play a key role10-13. Interestingly, self-inflicted stigma is not an uncommon phenomenon with some individuals believing that mental disorders are more a ‘personal weakness’ rather than a clinical disease. Shrugging feelings of loneliness and symptoms such as crying as character flaws not in line with images of ‘strength’ and ‘success’ are typical in certain cultures and personalities14,15. Remarkably an association was found between a cartain ‘type S’ personality (those always seeking a positive outcome at all costs) and masked depression14,15. While this is likely due to the sufferer’s own self-critical nature, it may also stem from a lack of knowledge about the biochemistry and genetic basis of mental disorders14,15. For assurance that mental illness is not a ‘personal defect’, but a disease that is out of one’s control it is important that initiatives, such as those led

by BeyondBlue, continue to educate people

australian medical students’ association

about the causes and diagnostic factors of mental health.

Overall while there have been definite advancements in mental health, stigmatisation is still a barrier which needs to be charged at with full force.

The process of ‘de-stigmatisation’ will not happen overnight and requires the re-moulding of certain misconceptions and beliefs prominent in society.

Improving education via introducing mental health discussion into schools and workplaces as well as opening up communication between people with and without mental illness may be steps taken towards acceptance.

REFERENCES 1. Council of Australian Governments (2010), National Action Plan on Mental Health 2006-2011.

2. Australian Bureau of Statistics, 2007-2008 National Survey of Mental Health and Wellbeing: Summary of Results, (4326.0).

3. Senate Community Affairs Committee (2008), Towards recovery: mental health services in Australia.

4. Corrigan P. Mental Health Stigma as Social Attribution: implications for research methods and attitude change. WILEY 2006; 7: 49-67.

5. Hickie I, Davenport T, Luscombe G et al. Australian mental health reform: time for real outcomes. Med J 2005; 182: 401-406.

6. Pinfold V, Thornicroft G, Huxley P et al. Active ingrdients in anti-stigma programmes in mental health. BJ Psych 2005; 17 (2): 123-131.

7. Form A. Mental health literacy: Public knowledge and beliefs about mental health. BJ Psych 2010; 196-401.

8. Lemoine P, Zawieja P, Ohayon M. Associations between morningness/ eveningness and psychotherapy: An epidemiological survey in three in-patient psychiatric clinics. ELSIEVIER 2013; 47: 1-4.

9. Thornicroft G. Shunned: Discrimination against people with mental illness. Oxford J 2006.

10. Papastylianou A. Personality Traits and depression: Research and implications. EJCOP 2013; 2: 1.

11. Paul A. Frewen, M.A., David J.A. Dozois, PhD. Self-Worth Appraisal of Life Events ad Beck’s Congruency Model of Depression Vulnerability.

Journal of Cognitive Psychotherapy: An International Quarterly. 20(2); 2006: 231-240.

12. Suls, J., Fletcher, B. The relative efficacy of avoidant and non-avoidant coping strategies: A meta-analysis Health Psychology 4 247–288 1985.

13. Peter Tyrer, Sarah Mitchard, Caroline Methuen, Maja Ranger, (2003).

Treatment Rejecting and Treatment Seeking Personality Disorders: Type R and Type S. Journal of Personality Disorders: Vol. 17, No. 3, pp. 263-268.

14. Polman R, Borkoles E, Nicholls A. Type D personality, stress and burnout: the influence of avoiding coping and social support. BJ Psych 2010; 15: 581-696.

15. Thompson A, Hunt C, Issakidis C. Why wait? Reasons for delay and promopts to seek help for mental health problems in Australian Clinical Sample. Soc Psychiatric Epidemiol 2004; 38: 810-817.

DOWN THE RABBIT HOLE

13

beatricedowsett wollongong

I have often likened medical school to Alice in Wonderland. It is a wondrous little microcosm with something new around every corner. This vibrant newness can be very stimulating, but, sometimes it can also be very overwhelming. There will always be a fast-paced White Rabbit (the personification of ‘medical knowledge’, perhaps?) who we try and follow as best we can. We may encounter a condescending Queen of Hearts, who teaches us the power of resilience. And, if we’re lucky, we may also encounter a Cheshire Cat who seeks to guide us at times when we need help. Nevertheless, we all know that medical school has the potential to be a stressful place and, alas, sometimes we can become more Mad Hatter than chilled-out Caterpillar.

Medicine is a profession that conjures images of melodramatic TV dramas, heroic saving of lives, crisp white coats and stethoscopes dignifiedly draped across proud shoulders. However, the vision of medical students just before major exams presents quite a different image. We all know what it’s like: puffy eyes, slightly scruffier-than-usual hair, stiff trapezius muscles from hours spent at a desk, the inability to open doors (or maybe that last one is just me?). Usually, this heightened sense of stress dissipates once exams are over and we are no longer inclined to

watching Grey’s Anatomy late at night whilst clutching a pillow and whimpering “One day...one day...” (or is this once again just me?). Jokes aside, the art of trying to balance study, a mildly-functioning personal life, and finances can sometimes become overwhelming. It is important to note that medical students, just like everyone else, are not impervious to burnout.

Impairment in medical practice refers to any physical or mental illness, which is likely to be detrimental to a person’s ability to perform their work effectively and safely. Under the Medical Practice Act, this doctrine also applies to medical students.

If you ever feel that you are not coping, always have someone to talk to; whether this is a mentor, a counsellor, or your own personal GP. My university also recently alerted our attention to the Doctors’ Health Advisory Service, a confidential service that is available twenty-four hours a day. Asking for help will never reflect badly upon your character. In contrast, hiding a problem and letting it impinge upon your professionalism is not ethically sound. Getting help early is not a sign of weakness; it is a sign of courage and strength. As I’m sure you’re all aware, the best doctors know the importance of seeking advice in the face of uncertainty.

So, what about those of us for whom stress doesn’t affect the practice of medicine, but does affect the enjoyment of daily life?

Personally, I have found that yoga is an effective way of calming my mind and sustaining a satisfactory level of fitness.

Whilst I could extol the benefits of yoga until the cows come home, I realise that it is not for everybody. The important thing is to find a hobby that gives you a replenishing break from medicine.

However, always make sure that your hobby is beneficial to your health and not detrimental to it (drugs and alcohol are not a viable solution to stress, and dependence on said substances will lead to further impairment). One thing that works for all students, I believe, is time management. By scheduling in set study and relaxation periods during the week, we are not only giving ourselves concrete study goals to achieve, but, we are also giving ourselves permission to relax which is important.

Finally, sometimes having a glimpse of the bigger picture can help soothe those prickly medical school nerves.

Amidst all the stress and sacrifices of medical school, it’s nice to be reminded how privileged we are to be a part of this miraculous little microcosm, or Wonderland. As future doctors, we can look forward to constant intellectual growth and stimulation. As future doctors, we have the ability to alter people’s lives in a positive way. And in these truths, dear colleagues, there lies great comfort.

panacea / 1. 2013

avant

15

STEPPING UP harryjennens melbourne

“So… why did you choose medicine?”

“Oh, I want to help people.”

Great! There is no better reason.

Maybe not everyone entered their course with this idea clear in their head.

But I sure hope it’s at the top of your list now, or at least high up.

But how exactly are you going to help people? And when?

Will you adjust tablets to control blood pressure? Will you give resuscitation in ED? Will you coax appendices out of minute incisions? Will you counsel patients with major depression?

Perhaps you’ll venture out to disadvantaged communities to ply and share your skills with people who need them most. (If so, more power to you!)

All these things will come at the end of your degree. But how would you like to do something that will help to protect the health and welfare of billions of people around the world for generations to come… right now?

We are in the Critical Decade for our climate. Last year the World Bank reported that current energy practices are likely to lead to a mean global temperature rise of 4˚C by the end of this century, and even more beyond.

Unless we act, the consequences will be nothing short of devastating for our planet and the human race: metres of sea level rise, inundation of coastal cities, displacement and conflict, crop failures, famine, major cyclones, droughts, floods, fires, and increases in heat-related illnesses and the spread

of infectious diseases. Indeed, the World Bank warns that there is “no certainty that adaptation to a 4˚C world is possible”. The Lancet and University College London certainly weren’t kidding in 2009 when they identified climate change as “the biggest global health threat of the 21st century”. And already today in Australia we are seeing warmer days, more severe heatwaves, bushfires and floods.

In short, it’s a big problem. Fortunately, there is a solution. You. I’m not just talking about riding bikes, switching off lights, and eating vegetarian.

All those things help, but focusing on them exclusively keeps the spotlight on us as individuals and away from the institutions that prosper under the status quo. We need to understand the problem individually, but we need to address it collectively. Why do our politicians drag their feet in drafting significant policies to address this emergency? Why does our media give equal or greater coverage to climate change deniers when the proportion of scientists agreeing on it is over 97%?

Simply put, it is because large industries have enormous interests in keeping it that way, and they’re not afraid to exercise their power.

But things are changing. A movement of fossil fuel divestment has sprung up across the United States. Following student and community campaigns, six universities and colleges, 16 city councils and ten religious institutions have pledged to freeze and wind down all their investments in the coal, oil, and gas companies that commercialise our planet’s destruction. The movement is still building and has spread to Australia, where university groups are campaigning and

the Uniting Church Synod of NSW and the ACT has also committed to divest.

Now is our chance to turn around our society’s dangerous environmental trajectory, starting with our own social institutions.

To help make this kind of change, I’ve joined Doctors for the Environment Australia, a national association of medical students and doctors dedicated to addressing the health risks imposed by damage to our environment. At a student level, we have a network of members around most medical schools in Australia running seminars, meetings, film screenings, actions and our annual conference. Visit www.dea.org.au if you’d like to join and get in touch with your state representative. If there isn’t yet a group at your university, there should be, and you can make it happen.

We would love your help – we are all responsible for what happens to our world, and everyone can make a big difference.

We are medical students, and we will be doctors. We are among the academic elite. We are trained to critically evaluate information and make difficult decisions in the face of uncertainty. Most importantly, we have the trust of the public that we will do our best to serve the interests of everyone.

We are ideally placed to lead our world to a healthy future.

Let’s make the most of it.

Harry is the Victorian Student Representative for Doctors for the Environment Australia.

panacea / 1. 2013

16 WISH YOU WERE HERE inushahira newcastle

My name is Inu and I was diagnosed with Type I Bipolar Disorder at the end of last year. I was hospitalised for 3 weeks in a psychiatric ward due to my ‘sickness’. It was there I had my first manic episode. I had a few depression episodes before that. I just want to share a little bit of what I had experienced that touched me during that troubling time.

While I was in an Australian hospital, my parents were in Malaysia. They were very determined to come to Australia, especially my mother. My mum asked my dad to find money so that she could come to Australia to be with her child.

My father’s friends donated enough money for my mum to come, with just a backpack a small suitcase.

She took care of me. She was really patient when I had my mood swings.

My tantrums, my childishness – she put up with it. My father would call me after I had my breakfast everyday. He would listen to me and would try to comfort me when I started demanding ridiculous things such as wanting to talk to [Malaysian Prime Minister] Dato’ Sri Najib or to President Obama. He said he would try his best to adhere to my demands, but later he would call my

mum and say; “Your daughter is asking for ridiculous things. What am I supposed to do?”

And then they would laugh together.

When I went back on a trip to Malaysia, I had to struggle with myself. I felt so bad. I felt that I was a monster for becoming what I had. I hurt people when I mentioned my illness. People were angry with me. People were hurt with my words, with my actions.

People kept on saying that I was ‘sick’ during that time, as if trying to suggest if I was a ‘normal’ person, I would not have done the things I did. When I tried to let out my feelings, people rejected me. They could not take me seriously because I was seeing a psychiatrist. People feared me. They stayed away from me. I was embarrassed because of the messages that I wrote where I tried to express my feelings.

I tried fruitlessly to reverse my actions by deleting all the messages that I wrote to people, my Facebook posts, just because people said my writing was radical. I apologised again and again. I wrote an apology message on my Facebook wall, I wrote apology messages personally to people who I thought were affected by my situation, whether directly or indirectly.

Some replied, some did not. To the ones

australian medical students’ association

who replied, I thank them so much. To the ones who did not, I understand they must have been busy. I regretted my actions, because I thought it was wrong - because people told me that. Because it’s a ‘disease’ where you became stark raving lunatic.

Or so I thought. I was afraid of what people were talking or thinking about me.

I just want to give a shout out to people like me, especially to those with bipolar disorder, people with mental illnesses, people who are different or weird, people who are going through a tough time; you are not alone. To people who have family members with an illness or know someone like this; love them. If you love someone sincerely, don’t be afraid to tell it to them. Show to them what love is because actions speak louder than words. Take the time to listen to their stories. Cherish them.

Try to understand. Be patient. Respect them. Respect their opinions, respect their decisions, even if you don’t agree.

We are born to be different. Try and embrace each other differences.

17 THE CANNULA davidmathew monash

The next procedure: laparoscopic cholecystectomy. Being with the anaesthetists, that was all I needed to know for now.

The patient was ready. A 26 year old lady, clad in a hospital gown. Her trolley was wheeled into the OT. She was otherwise healthy, and could readily move herself to the OT bed.

The nurses got her comfortable and straightened her arm out so we could put in a drip.

I headed for the facemask and chose my gloves - medium. Gloves were important. Too tight and they would make the whole process uncomfortable.

Too loose and they would get in your way.

Then I prepared my equipment.

One pink cannula.

Tourniquet.

Some alcohol swabs.

And some local anaesthetic.

I put all the equipment into a dish next to me. The patient was very confused.

She obviously knew she was here for the operation, but now everything was in a whirl. Nurses were hurrying around.

Surgeons were getting scrubbed. And here, the anaesthetist was holding her hand.

“Just gonna put a little drip in your hand, alright?”

She nodded back. A timid nod; maybe slightly fearful. She didn’t like the pain, didn’t like the needle. I put the tourniquet on, just above her wrist. She had good veins.

“Is it gonna hurt?”

A simple question, but one that

mattered to her.

“It’s just gonna be a tiny prick, like an ant bite. And then the area will go numb and we’ll put in the drip. You’ll just feel a bit of pressure.”

She nodded, contented.

Her veins were all there, like little snakes, bulging and joining up. Like little streams, flowing to a river. I picked one coming out of a Y junction, took the alcohol swab and tore it open.

“Just gonna clean the area, alright? You’ll feel a little cold.”

I took the flimsy piece of swab and cleaned.

Putting in a drip was like inserting a foreign body. The area had to be clean. Another good thing about the alcohol, cleaning made the veins show up better. Some law of physics I never understood.

She looked away, knowing the worst was about to come.

“You’re gonna feel a little sting, alright? And then the worst part of is all gonna be over.”

She whimpered unintelligibly, and looked away, overcome by fear.

I stuck the local exactly where I wanted. A little bulge formed and a tiny drop of blood emerged.

While waiting for the local to work, I jammed a piece of gauze onto it; partly to clear the blood, partly to reduce the lump.

“You’re gonna feel a little pressure now okay.”

This time she didn’t even answer. Her head managed a weak nod, her eyes fixated someplace else. I grasped her palm – to prevent her from making sudden large movements, and also to anchor the vein.

I concentrated on the spot and inserted the cannula. Felt the needle pierce the skin; the resistance. The resistance eased, and I knew I entered the vein.

Saw the flashback. I advanced the cannula further. And as I did I searched for the flow of blood.

It came, and I breathed a sigh of relief. I pushed the cannula as far as it could go.

I undid the tourniquet. I carefully occluded the vein and took out the needle.

The nurse handed me the drip and I connected it. I looked up at the drip as the nurse opened the valve. The drops came, slowly at first, and then steadily.

I breathed a sigh of relief.

“All over now, the hardest part is over,” I said as I motioned for a Tegaderm. The patient looked at her hand, still fearful.

“It’s just a little plastic in there, won’t hurt you.”

She nodded, and a little smile crept across her face. She survived this. It was not even the operation, but you could see her relief.

And then I took the cannula. Flicked open the plastic covering from above, exposing the needle. Looked at the spot where I put the local. The cannula was going to go through the same spot, but this time further, piercing the vein and settling inside. It was all technique.

panacea / 1. 2013

18 MENTAL ILLNESS AS A SUBSEQUENCE OF DOMESTIC VIOLENCE IN INDIA development of an organisation as a solution erinburge monash The prevalence of mental disorders effecting married women in India is being embraced by the global community as studies are released that relate physical and mental marital abuse to mental illness. The causative agents of mental illness suffered include domestic violence, disempowerment and separation from family, as well as age of first child. An organisation focused solely on targeting the needs of Indian women in abusive marriages through educational programs would be an ideal way in which to advance female mental health.

Education and psychiatric support programs catering for the needs of Indian women in abusive marriages, both mental and physical, are necessary to target the high levels of abuse and subsequent mental illnesses suffered by these women. An article released by the Indian Clinical Epidemiological network stated that “a history of being the target of violence puts women at increased risk of depression, suicide attempts, psychosomatic disorders and physical injury… with 4005 [of the 9938 women surveyed] (40%) reported experiencing `any violence’ during their marriage, of whom 2243 (56%) had SRQ scores indicating poor mental health”1 correlating marital abuse with subsequent mental illness.

An aspirational idea to help these women would be the formation of an organisation which aims to deliver support in terms of psychological services for the diagnosis and treatment of mental illness brought about by domestic violence. The aim of this organisation would be to support and treat women during and after periods of domestic abuse through free psychological counselling and community support networks created by the organisation. It should be noted that abuse can come in many forms, including disempowerment,

forced seclusion and insults and therefore supportive services to help with self-esteem and empowerment should also be offered to these women. Many organisations today work to help alleviate the domestic violence inflicted on these women as a solution to solving the issues of mental illness, however until that aim of reducing domestic violence is reached, mental illness in these women experiencing abuse will continue.

The planning involved in this form of organisation takes substantial time and financial aid, compliance from affected women and their families as well as dedication from staff. To create the sense of support which the program aims to extend to these women, psychological programs would need to be scheduled at regular intervals to give women a consistency that they cannot find elsewhere in their lives as well as provide goals and tasks to work towards in terms of ridding themselves of their mental illness. Furthermore, even though domestic violence is relatively widespread throughout India, certain areas of the country have been targeted with having higher levels of marital abuse. An article relating to abuse of Indian women from John Hopkins University stated that “lifetime rates of physical beating or mistreatment for our study sample range from a low of 16% in Maharashtra to a high of 31% in Tamil Nadu”2 emphasising that the initial placement of these educational and support programs should be in areas with the greatest initial need, with future expansive aims. Moreover, planning would initially need to be conducted into how the recruitment of abused women into these programs would be achieved as it has been stated that “49% of [Indian] women felt nothing would improve the situation”3 and therefore refused to seek help for their subsequent mental issues relating to their abuse.

Alleviating mental health issues in India takes not only planning, but action. The global community is becoming more aware

australian medical students’ association

of issues affecting Indian women, however reforms are still in their infancy.

The worldwide community hears of these injustices against women from reports, such as the ‘2012 Dehli Gang Rape Case’, which reached Western media. However, mental illnesses relating to these forms of attacks are more common and damaging than is reported in Western newspapers and TV programs. It’s the global communities’ obligation to work towards alleviating mental illness in Indian women by supporting the work of organisations who deal with this form of mental illness. As more organisations become dedicated to helping the plight of Indian women, more light will be shed on the daily suffering of these women, mentally and physically, which hopefully one day will see a substantial change occur.

The number of organisations and support services for women experiencing mental issues relating to domestic violence is lacking in India and therefore mental illness continues.

Throughout this essay, an organisation has been described whose main aim is in psychologically supporting Indian women with mental illness brought on by domestic violence. Ideally, one day this organisation will become integral to improving outcomes for women who are trapped in cycle of domestic violence and subsequent mental illness.

REFERENCES 1. Frances, R. “Domestic Violence and Its Mental Health Correlates in Indian WomenKumar S, for the IndiaSAFE Steering Committee (India Clin Epidemiology Network, Chennai; Et Al) Br J Psychiatry 187:62–67, 2005§.” Yearbook of Psychiatry and Applied Mental Health 2007 (2007): 111. Print.

2. Koenig, M. A., R. Stephenson, R. Acharya, L. Barrick, S. Ahmed, and M. Hindin. “Domestic Violence and Early Childhood Mortality in Rural India: Evidence from Prospective Data.” International Journal of Epidemiology 39.3 (2010): 825-33. Print.

3. Shrivastava, Prateek S., and Saurabh R. Shrivastava. “A Study of Spousal Domestic Violence in an Urban Slum of Mumbai.” International Journal of Preventative Medicine (2013): 111. Print.

19

A HIDDEN REALITY alexandrabrown australiannationaluniversity

Imagine this; a student in your class, the picture of perfection. Flawless skin, fancy clothes, oozing confidence, an astounding intelligence. The friendliest of students, the social guru, the sports star, the student advocate.

Then imagine getting a phone call from a friend terrified and hysterical. You can barely hear what they are saying. You need to get to their place. You are out for dinner and you are a little confused.

But their final words make you sit up.

“Overdose.”

You arrive at your friend’s house to empty pill packets beside a limber body on the bed. The body is your friend; unresponsive, but a strong pulse and slow breaths. You try to rouse your friend to no avail, the ambulance arrives and you watch them get taken to hospital.

Scenarios such as these do happen.

And with the rising rates of mental illness amongst students, and medical students in particular, it is not as uncommon an event as one may think.

Mental illness isn’t rare. Depression is real. It affects 6-7% of young people

aged 16-24 each year in Australia. Of the mental disorders affecting 16-85 year olds, 14% were anxiety disorders. And to all of you reading this out there, this exact thing, this health problem is affecting our colleagues and is likely to one day affect us along the path of our career unless we take action now.

kind of mental illness, is necessary.

For me it’s exercise, it’s motivating people to get out there and run through their pain and stress. It is not simply about awareness, although that too is important. We have to equip ourselves with ways to recognise and help others who are falling from the grips of sanity.

However it is not only anxiety and depression which wreak havoc through the students across Australia. Substance abuse is becoming an ever-increasing concern. Whether it is alcohol, prescription or ‘recreational’ drugs, we are vulnerable to this abuse; to the overconsumption and the attempt to use these substances to alleviate our worries, our guilt, our stress and our pain.

Medicine is not meant to be a walk in the park. I think there would barely be any medical student who thought it would be. But with this illustrious endeavour we have all made comes what seems to be a debilitating responsibility and workload. For this reason, we, as peers to one another, must guide and assist all who walk the path we do, share in each others experiences, and most importantly, share the times when not everything is all fine and dandy.

The most important fact I have learnt while being at med school, is that you’re never on your own. If you’re beginning to succumb to the pressure and workload that is innate to medicine, then most likely a large proportion of your class are too. If you are feeling overwhelmed like you could never know everything you need to, then others will be feeling it too.

Having strategies in place to cope with situations like the one mentioned, and for any suspected friends experiencing any

And remember, if you notice the signs or if you get that call, don’t judge. Be aware. Be vigilant. Look after your wellbeing. And look after your friends, your family and all your colleagues, because you never know who is slowly killing themselves inside.

panacea / 1. 2013

20 DEPRESH CONFESH nicolekalish sydney

This is the story about what I have come to call “My Second Year Depresh”, how I overcame it and what you can do to help your friends who are feeling it too.

I never ever thought I would get into Sydney Medical School, and so, the euphoria of gaining entry seemed to continue endlessly. Stage 1 was filled with amazing people and an even more incredible atmosphere with MedCamp, MedBall, Convention, Revue, RAW, end of block parties; each event better than the last. It was the best year of my life and I had never been happier. After a wonderful holiday I was excited to return to Sydney and see what Stage 2 had to offer.

Uni was still full of the same gorgeous people and the same wonderful, neverending social calendar; but something was definitely different. This time I wasn’t excited; not at all. The elation of getting into the SMP had worn off and suddenly I wasn’t enthusiastic about anything and just seemed to be going through the motions. As someone who regularly gets told to calm down and be quiet, this new bland demeanour did not feel comfortable, but unfortunately, it was one I just couldn’t shake off. I constantly felt sad for no reason at all. As all you keen beans might have figured out (and also, I gave it away already), these are all signs of depression. I recognised them too, and so in desperation, I called a friend and admitted to her that “I’m

feeling depresh”. I felt so silly explaining to her that after the awe of Stage 1 I had realised that Med school was just my life now, and it wasn’t as exciting as I thought it would be. Thankfully, she listened and did not judge and it was such a relief to share my feelings with someone.

We set a date and agreed that if I had not started to feel better by then, that I would go speak to a doctor. Over the subsequent weeks we spoke regularly and I called her whenever I felt particularly low and slowly the clouds began to fade and I found myself enjoying uni life again. Ultimately the catalyst which pulled me out of my “depresh” occurred one clinical day, when an interaction with a patient reminded me how much I loved the opportunity to be involved in a patient’s wellbeing. It reminded me that my ultimate goal was not just to get into a good med school, but rather to be a good doctor; a goal I had yet to achieve and thus one I could work towards. Since having this epiphany I have often thought back on my second year “depresh” and I would like to share some of the things I have learnt from the experience.

Firstly, just because someone acts fine doesn’t mean they are. Taking a hint from The Bro Code, whenever I felt sad, I stopped being sad and was awesome instead; or at least I pretended to be awesome. I put on a great show of being my usually bubbly, extroverted self and I doubt if anyone cottoned on to how down I really felt. Please ask your friends how they

australian medical students’ association

are, or if they need help, and don’t let their actions dismiss your suspicions.

Secondly, just because you aren’t yet a doctor, doesn’t mean you can’t be “doctorly”. I will forever be grateful to my friends for their help, support and their professionalism. I doubt the help I received under their care could be bettered by any qualified doctor. I hope that when I actually am a doctor, I will be able to provide my patients with as much comfort and support.

I know that this vignette is silly when compared to the tragedies which have befallen many people reading this; as a cohort we have lost brothers, sisters, parents, grandparents and friends. For many it has been a hard, heart-breaking year, and I beg you; please don’t forget that we need to support each other.

Be the person that someone seeks to lean on and gain strength from. Be the friend who shows support throughout any tragedy, no matter how big or small.

Most importantly, if you think you might be in trouble and you need help yourself, please confide in somebody and let them help you; everything is easier with a friend at your side.

Editor’s note: This article was previously published in Sydney University Medical Society’s publication, ‘Innominate’. It was selected for inclusion in Panacea given its relevance and nomination by an AMSA Representative.

21 A BANDAID ISN’T ENOUGH TO FIX IT dianaethell notredamefremantle

The power of words and the English language is a force to be reckoned with. Depression, anxiety, bipolar, schizophrenia – names given to mental illnesses, words associated with stigma and in many cases isolation, words associated with “crazy people”, and, words commonly met with the phrase “it will never happen to me.” It is the power of the language society uses that has contributed to our beliefs about people with a mental illness that has fuelled the fire of stigmatism and segregation, and yet 1 in 5 Australians are expected to experience a mental illness in their lifetime.

Growing up, I did not (and still don’t think I do) fully understand what it meant to have a mental illness. Yes, I understood it was an illness. No, it wasn’t something people did for attention. But I did not truly understand the impact it can have on an individual, a family, or a community. I feel confident to say, even as a teenager I would not intentionally segregate someone with a mental illness, but what I do know is that I did not understand how or why it could affect someone so much. It was not until it has affected me directly that I have begun to understand the ripple effect of mental illness and its complexities.

Mental illness is not like a graze that can have a bandage put on, where a scab will form underneath, heal, maybe

leave a scar – but within a week you have forgotten its existence. No, mental illness is something much more complex than a graze; it involves everyone, and no matter what, it is always there, always being managed, and you never forget when it affects you.

happen to people like me”, and the uttermost wish and want that she would just “snap out of it”. As a consequence, I recognised that I wanted a quick fix, something that would help her instantly so she was not struggling with pain and sadness.

I clearly remember the day my Mum told me that my younger sister (who was in London at the time) was suffering from depression. Even more clearly, I remember the day my sister told me herself that she was suffering from depression and had thought about suicide on several occasions.

I remember choking back tears on the phone. I remember feeling the thousands of kilometres between us and having to hang up very quickly. I felt like the world around me was falling apart. There was nothing I could do, and the scariest thought of all was that I could not fix it.

Obviously, there is no quick fix, she didn’t just “snap out of it”, and while I now know this, it took me a long time to truly understand it. It was through a team of clinical psychologists, my sister’s general practitioner, counsellors, and us as a supportive and loving family, alongside medication over several years, that my sister has learned to live with her depression. She is not cured, but she is a happy person. She has strategies to deal with it when she isn’t, and she lives her life to the fullest.

Forever being the older sister that looked after her younger sister, helped her out, and gave advice, it was the helplessness that truly overwhelmed me. Never did I think that I would be in a position where one of my best friends and family members would experience such depression that they were struggling to get out of bed each day and had no will to live. I remember thinking; how could my sister, the sister that had it all – great friends, good education, a supporting and loving family and the ability to pursue any of her dreams – have depression? It was then I realised I applied a stigma to mental illness, the belief that “it doesn’t

For me, experiencing mental illness through someone I truly love, adore, and respect, has also allowed me to reflect on the stigmas I had about mental illness without even knowing. I believe mental illness is multifaceted, and often it is something that can be overcome and managed with the right help. Ultimately, how people view mental illness can be altered depending on their experiences with it and, for me; mental illness does not consume ones life, it becomes another facet of life we experience each day.

panacea / 1. 2013

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A PROBLEM TO BE SOLVED benjaminlewis monash The consult has reached its 40th minute - almost an eternity in GP land - and I sit quietly nodding in vague sympathy at the generic story of the depressed patient. My mind has long since drifted to thoughts of coffee, muffins, and the episode of Game of Thrones that will be on that night. The GP I am consulting with eventually enters, calmly reassures the patient before ushering her from the room glancing at me somewhat telepathically. It’s a common scene for many GPs dealing in chronic mental health and the patient has already been flagged with the enduring term ‘heartsink’.

Much about the way we view mental health has improved over recent years.

Organisations such as Beyond Blue have improved social awareness of depression and the push for early intervention by visible figures such as Patrick McGorry further brings discussion about mental health into the public arena. What tends to persist in the medical profession however is a sense of fatigue and frustration about the way to manage patients with chronic mental illness.

As students, medical school teaches us to approach patients with a particular paradigm in mind: The ailments of our patients are seen as problems to be solved, and most of us feel a sense of comfort through the understanding of why an illness occurs. Many have criticised the simplicity of such an approach but we would nonetheless be lost without it. Relating a group of

clinical symptoms to a biological aetiology not only provides an obvious practical benefit it allows us to cast a patient in the ‘sick role’. “You’re being too scientific!” I hear you say, “patients are people not just problems to be solved!”

As much as we like to see ourselves as endlessly empathetic we have to admit that we each have our own limit. Even the most kind-hearted medical student will eventually grow tired of the same patient presenting for the 20th time because they “just aren’t enjoying life”. If, on the other hand, a patient presents for the 20th time with high cholesterol we might be annoyed by their choice of lifestyle but we can nevertheless be content that the way forward is clear.

There is a feeling of satisfaction that comes with the objectivity of medicine and the sense that suffering can be grounded in something physical. After all, if an objective medical approach means that fewer people are suffering then doesn’t it make the rest of the argument seem a little pointless?

It’s been said that in order to cure you must first understand, and in no area of medicine does this statement have greater resonance than the area of mental health. I can hear the collective sigh of exasperation when the prospect of understanding neuropsychopathology is mentioned but I’d like to propose that here and now, in 2013, there may be a light at the end of the tunnel. I am spending this year at the Monash Alfred Psychiatry research centre (or MAPrc). Here, a team of dedicated researchers have been proposing a technique called transcranial magnetic stimulation (TMS) to both investigate and

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treat a range of psychiatric illnesses.

The prospect of brain stimulation usually conjures up thoughts of One Flew Over the Cuckoo’s Nest but TMS by contrast is completely non-invasive with only a slight risk of seizure in those with a history of epilepsy, and a small risk of a mild headache poststimulation. The procedure is currently in use at a number of health centres for the treatment of depression and has been shown to be equivalent to pharmacotherapy in terms of its efficacy.

What is perhaps most exciting about technology like TMS is that it seems to herald a very real coalescence between the biological and the psychological.

One can perhaps imagine a time in the not too distant future when techniques such as this allow us to accurately explain the symptoms we see in our patients. A time when we can for example, say to a depressed patient: “Ah, your results suggest you have some dysfunction of your dorsolateral prefrontal cortex, I’m going to refer you for a course of TMS and I’d like to see you again in 3 weeks.”

Perhaps I’m being too fanciful, but I think if history has taught us anything it’s that those who cry ‘impossible’ are often taught a very valuable lesson. I choose to remain a cautious optimist, whilst always hoping for the day when mental illness can become grounded in the same orthodoxy that has allowed us to alleviate the suffering of so many others for so long.

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THE DRUGS DO WORK anonymous griffith Studying medicine is a roller coaster ride. We have all experienced the amazing highs and depressing lows of studying something that you love, and we have all had to come to terms with the sheer enormity of it all. My story in medicine is similar to most; trying to balance my workload while maintaining some semblance of a life outside of medicine. Where it differs, in one small way, is that I have a serious mental health condition that sees me taking medications every night and visiting my psychiatrist every month.

However I’m not writing this to talk about my journey to wellness but rather about what it is like to have a mental health condition and to be studying medicine. I hope that perhaps someone who may be at the beginning of their own mental health journey might see that there is some light at the end of the tunnel. I also hope that my well peers will take something out of this, maybe as future treating doctors, or maybe thinking again about that discussion on advising people with serious mental health conditions against breeding together (yep this really happened to me).

For me, my mental health condition and medicine are intricately entwined.

In fact it was the excitement of starting medicine that precipitated my first manic episode, and then the subsequent decreased-fun major depressive episode. Unfortunately this saw me having to defer from first year as trying to find the right drug in this disease (as I’m sure you have or will learn) is not the easiest task. Having been tried on six different drugs, and with some lovely extra-pyramidal side effects (akithesia is not fun) along the way, it was a long road before finding the one. But hey, we all have to kiss some frogs don’t we?

So what does my mental illness mean for me and studying medicine? Well, not a huge amount really. I just happen to have a mental health condition and be a medical student. It took me a long time to see this but now it is clearer to me. I don’t define myself by my other chronic health condition (asthma), so why should I treat my bipolar any differently? I am on a mood stabiliser that works for me so I am really not that much different from any other student. I may have to be a little bit more careful with my sleep patterns and watching out for triggers but that’s pretty much it. I still go to all the parties! I just make sure that I have my meds stashed in all my bags so that I can take them before bed (short half life = horrible withdrawals). Probably the trickiest thing is dealing with the metabolic side effects. Those delicious treats in PBL are just that little bit harder to resist. I do really crave carbs more than the average person

My journey to health took a good two years; with some hospitalisations, lots and lots of psychiatrist visits, tears (not just mine) and some amazing friends, family and medical school as well.

now due to the drugs, but falling prey would introduce insulin to my regimen.

I have been really lucky in medicine to have some great friends. Some know about my condition and some do not, but they all relate with me for who I am. I really wish I were brave enough to be more open about my bipolar.

Unfortunately, the stigma associated with mental health is still very strong and kicking, even within medicine. I was studying in a PBL room once and hadn’t realised that my medication had fallen out of my bag and onto the floor. A fellow student soon found it. Fortunately for me, they didn’t assume that the medication was mine. Less fortunate was the subsequent discussion on who might be the crazy person in our cohort. This was not my finest moment; I went along with the conversation rather than admitting that the medication was indeed mine. I hope that in the future I will feel comfortable enough to speak honestly in such a circumstance.

I have shared my experiences in the hope that we can promote positive changes in this area. Let’s create a world where people can be open and honest rather than ashamed of what is essentially just a medical condition. I look around me and see some brilliant and passionate people in my course. I strongly feel that together we can play a part in making this a reality.

panacea / 1. 2013

26

FORGETFUL BUT NOT FORGOTTEN nataliechilko deakin

Imagine waking every morning and being slightly confused about your surroundings. It doesn’t seem like your home, but there is something familiar in the setting. Then someone enters your room and tells you it is shower time.

You are confused because you usually don’t have a shower in the morning; you prefer night time. Then this person approaches and starts undressing you. You are startled and become aggressive. Next, you are restrained at the bedside for fear of others’ safety.

You are left feeling isolated, confused and frightened.

We, in the health profession, witness fundamental human struggles in patients on a daily basis. Sickness can leave people feeling scared and vulnerable as they become confronted with their mortality, and physicians are in a unique position to observe this. It is thus essential that we remember the human being in patient care. This is particularly important for those who need us to be their advocates. People with dementia generally lack the cognitive capacity to form new memories, to make decisions and judgements, and to communicate verbally, but their fundamental human needs of engagement, inclusion, and acceptance, remain.

Dementia is a neurological syndrome marked by a gradual decline in memory and other cognitive domains, such as language, reasoning and comprehension. Although this syndrome is increasingly recognised, it is not typically involved in the mental health conversation. The public discussion of dementia usually focuses on memory loss. However a range of behavioural and psychological symptoms accompanies the cognitive deficits. It is these symptoms which combine to create a truly debilitating disease for patients both physically and socially.

The dramatic statistics regarding dementia prevalence highlight the importance for health professionals and the community to be aware of this syndrome and its associated mental health. On average, there is a new case of dementia in Australia every six minutes1. Worldwide, dementia prevalence is expected to triple to 115.4 million cases by 20502. Such increases in prevalence will lead to

significant increases in the cost and burden of disability attributed to this disease, with dementia predicted to require the greatest funding of all health conditions in Australia by 20701. Whilst modern medicine has significantly advanced life expectancy for the developed world, an ageing population brings its own challenges to the health system.

Persons with dementia attempt to navigate a world in which they are confused, frightened, and operating on islands of brain that decline at different rates. The decline in social functioning compounds the physical disability. Anxiety, apathy, depression, and psychosis are psychological symptoms that have been identified in the literature.

Approximately 90% of people with dementia will experience one of these symptoms at least once in their condition3.

Prevalence of each of the symptoms ranges between 56% and 90%3, although the actual presentation varies. Because dementia involves a gradual neurological decline, the behaviour associated with the mental health disorder is influenced by the cognitive state of the person. For example, anxiety, which typically involves rumination on thoughts, may manifest as agitation or aggression in more advanced dementia.

Similarly, depression may manifest as a state of apathy, with increasingly unresponsiveness. Additional depressive behaviours include loss of appetite, anhedonia, insomnia, increased confusion, and lack of energy4.

Persons with dementia have a sad history of being treated as incapable, and as ‘vegetables’ without a social standing4.

This perception has changed in recent decades, and the assumption that people with dementia are unemotional has been challenged. Recent research supports person-centred care approaches in reducing problem behaviours. The hypothesis behind this is that human connection and involvement caters for fundamental human values that reduce the agitation, depression and anxiety that comes with being marginalised4.

Person-centred approaches recognise that behaviours in dementia can be a form of communication, and that the feelings of these people can be intact despite cognitive decline. The Australian CADRES study used a cluster randomized trial design to assess person-centred care, and found a significant reduction in agitation in residential facility clients in this group compared to those receiving usual care5.

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Humour therapy has also been found to reduce agitation in dementia, potentially comparable to the effectiveness of antipsychotic medication6. Humour therapy involves clowns visiting residential aged care facilities and using gestures, noise and props to engage persons with dementia, rather than solely verbal communication6. Many other studies support these positive findings7 8 9.

The results of research into personcentred care remind us that a person exists behind the physical, cognitive, psychological and behavioural symptoms with which they present10.

Kitwood theorized that people have a sense of personhood that is based on the respect, recognition and trust that exists in social relationships10. A sense of personhood is significantly compromised in persons with dementia who are generally ignored because they are assumed to be unable to engage with society4. As a society and as a profession, we need to recognise that a person exists behind the disease. How can we do this? We must incorporate the life story of our patient into the care plan. We need to consider our patients’ socio-economic, historic and cultural context, their individual preferences, likes and dislikes, and then use these to engage with our patients both in therapeutic and care situations. We need to listen to the vulnerable through their unique communication style, and realize that they too can feel withdrawn, depressed and anxious.

We need to remember that a person exists behind the disease that makes them forget.

References 1.Access Economics. 2009, Report for Alzheimer’s Australia.

2. Alzheimer’s Disease International, World Alzheimer Report.

3. Dementia Behaviour Management Advisory Service and Dementia Collaborative Research Centre, Behaviour Management - A Guide to Good Practice. Managing Behavioural and Psychological Symptoms of Dementia (BPSD), 2012.

4. National Institute for Health and Clinical Excellence Social Care Institute for Excellence, Dementia. 2007, NICE-SCIE: London.

5. Chenoweth, L., King, M.T., Jeon, Y.H. et al. Lancet Neurology, 2009. 8(4): p. 317-25.

6. Low, L., Brodaty, H., Goodenough, B. et al. BMJ Open, 2013. 3: p. 1-8.

7. Spector, A., M. Orrell, and J. Goyder, A. Ageing Research Reviews, 2013. 12: p. 354-64.

8. Cohen-Mansfield, J. and J. Mintzer. Alzheimer Disease and Associated Disorders, 2005. 19: p. 37-40.

9. Orsulic-Jeras, S., K.S. Judge, and C.J. Camp. The Gerontologist, 2000. 40: p. 107-111.

10. Kitwood, T. Aging and Mental Health, 1997. 1: p. 13-22.

27 THREE SHOTS AND OUT emilywebb-smith westernaustralia

I like coffee. I like the taste of it, I like the routine of it, I like being able to say “let’s go grab a coffee”. Coffee takes me into its warm embrace at midnight when my ethics essay is only half complete. You could almost say that it is my go-to drug. Coffee loves me. I may even love it. And I suspect you might too.

Caffeine is the most widely used psychoactive drug in the world.

Drinking 2-3 cups of coffee will land you in caffeine intoxication.

And then comes the caffeine withdrawal. Caffeine intoxication, caffeine-induced anxiety disorder, caffeine-induced sleep disorder, and caffeine-related disorder not otherwise specified are listed as a substance-use disorders in the DSM-IV and now caffeine withdrawal join them in the DSM-V. However, it’s not common to ask patients about their caffeine intake. We focus on alcohol and other substances. It’s also not common to reflect on your own caffeine intake. We know we might abuse caffeine at exam time (No Doz, anyone?). Or when we stay out late (Red Bull, you know it). Or on a daily basis (many cups of warm delicious coffee?). Throw in any of the other myriad of caffeinated beverages we guzzle down (ie. tea and cola). It might even get to the point where you can’t sleep and

your doctor doles out the temazepam. Whoops, it’s just my 6 a day habit.

Are we putting enough thought into how this caffeine culture, widely accepted amongst medical students, is affecting our own mental well-being? Excessive caffeine intake has been pretty well linked to anxiety and sleep disturbances. It may increase our performance in some areas, however it ultimately can negatively affect our mental wellbeing. Mental wellbeing is about realising your own potential, being able to cope with normal stressors in our lives, working productively and fruitfully and being able to make a contribution to our community (WHO). That sounds pretty desirable to me. In our profession, it’s very important to have an understanding of our own mental wellbeing. We’ll be better doctors for it. We risk heading down the path of early burn out if we don’t watch it. We know we should watch what we eat and get daily exercise to be physically healthy. Is it about time we watched our intake of other substances as well?

I still love coffee. But I love me too. Maybe I’ll give herbal tea a go.

panacea / 1. 2013

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30

DIAGNOSING CATATONIA priscillawee jamescook

Introduction Catatonia was first described by Karl Kahlbaum (1874) as a motor disturbance that represents a phase in a progressive illness involving depression, mania, confusion, stupor and dementia praecox1-6. Catatonic symptoms include negativism, mutism, posturing, grimacing, mannerisms, staring, waxy flexibility and echophenomena1.

Despite the term “catatonia” being over a century-old, and many attempts to define and classify it, the literature remains unclear regarding pathophysiology and classification of catatonia1-5,7-10. However, studies are unanimous in asserting its possible lethality1-3,8. Considering the poor prognosis of catatonia, it is vital to diagnose it early to commence aggressive treatment rapidly, improving patient outcomes. The difficulty is that catatonia and many other syndromes have similar clinical presentations. Such problems prompt the question, “How does one diagnose catatonia?”

This essay will answer this question via exploration of different catatonia types, differential diagnoses of the clinical presentations and investigations that aid diagnosis, as well as reviewing the current literature. The implications of these findings will be applied to the overall management of catatonia.

Methods A literature search was conducted using the databases Medline, NCBI, SpringerLink and ScienceDirect for fulltext articles including the following terms: “catatonia OR catatonic AND diagnosis” and “catatonia OR catatonic AND differential diagnosis”. These searches were restricted to Human/s, in English, and to be between the dates 1999-Current.

Ten articles were selected for this essay because of their relevance and information. These included 8 systematic reviews (Level 3a), 1 case control study (Level 3b) and 1 Case-

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31 series (Level 4).

The literature search highlighted the scarcity of evidence-based studies on catatonia and its differential diagnoses.

This can be attributed to the rarity of its presentation4,7, difficulty in obtaining ethical approval, and its elusive nature blurring classification and diagnoses.

Therefore, it must be noted that this essay, although supported by thorough systematic reviews by experienced psychiatrists, lacks conclusive evidence due to the nature of the topic.

Classifications of Catatonia Catatonia is classified by DSM-IV-TR as a schizophrenia type, a specifier for mood episodes or due to general medical conditions (GMC). Fink’s literature review demonstrated that catatonia has grown to include syndromes such as delirious mania, neuroleptic malignant syndrome (NMS) and toxic serotonin syndrome (TSS)7.

There are two main presentations of catatonia: (1) Retarded (including immobility, negativism/mutism and posturing); (2) Excited (excessive motor activity, echophenomena, verbigation and delirium)4-7, 9. Patients can cycle between both presentations4.

Another type of catatonia (which is regarded as an insidious progression from other catatonic states) is “lethal catatonia”1,4-6. This type involves autonomic instability including tachycardia, tachypnoea, hypertension, fever and disorganised speech, delusional thoughts and refusal of foods and liquids2,7. Malignant catatonia, NMS and TSS are subsets of this type4,7,9.

As any catatonia can lead to lethal catatonia, early diagnosis is important3.

The Differential Diagnoses of Catatonia Taylor et al. and Bhati’s literature reviews revealed six syndromes similar, but distinguishable to catatonia5,6. They are elective mutism, metabolic-induced stupor, Parkinsonism, malignant hyperthermia, locked-in syndrome and stiff-person’s syndrome. Additionally, Penland et al’s extensive literature review included delirium in their differential diagnoses2,9. The Hem and collegues’ report on two cases with literature review support proposed that coma should be included as a differential.

Investigations and Management of Catatonia To investigate catatonia, a thorough history of the patient should occur,

looking for a history of Parkinson’s, antipsychotics and serotinergic use which may lead to NMS or TSS, and a surgical history for malignant hyperthermia. A psychiatric history, especially affective mood disorders1,10, may highlight catatonia or elective mutism.

One should examine for autonomic instability (NMS and TSS), generalised rigidity (stiff-person’s syndrome, locked-in syndrome and malignant hyperthermia) and cogwheel rigidity (parkinsonism).

The literature also suggests that the following investigations should take place for catatonic presentations: Serology: FBC (infections such as meningitis, encephalitis), CMP (hypocalcaemia)6, BSL (hyper/ hypoglycaemia)5 and eLFTs (metabolic stupor) Imaging: CT head may reveal lesions that cause stuporous states and rule out catatonia. An MRI should be considered to investigate stiff-persons syndrome or stroke5,9.

Others: if meningitis is queried, a lumbar puncture is considered8. Muscle biopsy if malignant hyperthermia considered5.

Management of queried catatonia presentations is unanimous in the literature, especially regarding the diagnosis of catatonia with a primary differential of NMS. Withdrawal of antipsychotics and initiation of benzodiazepines and ECT have been found to be very effective in patient treatment1,2,5,6,8,9. In a cohort study by Fink, two-third’s of patients were relieved of catatonia and NMS by high doses of lorazepam (6-16mg)2. Penland and colleagues, in their literature review, refer to at least one clinical trial revealing the efficacy of benzodiazapines on treatment of catatonia and NMS, but also asserted the use of ECT if a patient is unresponsive to benzodiazapines9. In his literature review, Francis revealed that treatment of parenteral or oral benzodiazapines such as lorazepam had a success rate of 60-80% within hours to days. He also revealed that clinical experience and case studies highlighted the efficacy of ECT when benzodiazapines fail to treat.8 Huang et al in their 2-year cohort study (n=34) concluded that ineffective treatment of catatonia or NMS via benzodiazepines and ECT may be due to the need to treat specific aetiologies of catatonia1. This highlights that part of management should involve specific classification of catatonic presentations in regards to its aetiology (DSM-IV-TR), to aid in treatment. A treatment load of

benzodiazapines has proved harmless, but will also aid in ruling out catatonia or NMS, if these aren’t the cause of the presentation5.

Recommendations for the Future In conclusion, precise diagnosis of catatonia is vital due to its potential lethality and the similarity of its presentation to other fatal diseases.

Catatonia is a syndrome that still lacks evidence-based research and requires further study regarding its aetiology and classification, in order to achieve successful management. Despite this, current literature reveals a way to diagnose and classify catatonia in order to deduce differentials, allowing appropriate investigations and management to be carried out. Efficient, rapid diagnosis of catatonia is crucial as lethal catatonia kills if not appropriately managed.

References

1. Huang TL, Ree SC, Huang YC, Liu HY, Yang YY. Catatonic features: differential diagnosis and treatments at an emergency unit. Psychiatry Clin Neurosci. 1999 Feb;53(1):63-6.

2. Fink M. Catatonia: syndrome or schizophrenia subtype? Recognition and treatment. J Neural Transm.

2001;108(6):637-44.

3. Hem E, Andreassen OA, Robasse JM, Vatnaland T, Opjordsmoen S. Should catatonia be part of the differential diagnosis of coma? Nord J Psychiatry.

2005;59(6):528-30.

4. Fink M. Catatonia: a syndrome appears, disappears, and is rediscovered. Can J Psychiatry. 2009 Jul;54(7):437-45.

5. Taylor MA, Fink M. Catatonia in psychiatric classification: a home of its own. Am J Psychiatry. 2003 Jul;160(7):1233-41.

6. Bhati MT, Datto CJ, O’Reardon JP. Clinical manifestations, diagnosis, and empirical treatments for catatonia. Psychiatry (Edgmont). 2007 Mar;4(3):46-52.

7. Fink M, Taylor MA. The many varieties of catatonia.

Eur Arch Psychiatry Clin Neurosci. 2001;251 Suppl 1:I8-13.

8. Francis A. Catatonia: diagnosis, classification, and treatment. Curr Psychiatry Rep. 2010 Jun;12(3):180-5.

9. Penland HR, Weder N, Tampi RR. The catatonic dilemma expanded. Ann Gen Psychiatry. 2006;5:14.

10. Smith JH, Smith VD, Philbrick KL, Kumar N. Catatonic disorder due to a general medical or psychiatric condition. J Neuropsychiatry Clin Neurosci. 2012 Spring;24(2):198-207.

panacea / 1. 2013

32 INVOLUNTARY TREATMENT ORDERS FOR THE EARLY INTERVENTION OF ANOREXIA NERVOSA jessicacutting jamescook Introduction Anorexia nervosa is a destructive mental illness characterised by extreme measures to lose weight, a strong fear of becoming fat, and amenorrhoea1,2,3.

It has the highest rate of mortality amongst all mental disorders; with a suicide rate 1.5 times that of major depression4,5. Anorexia has a prevalence of up to 1%, is most common in females and generally presents in adolescence or early adulthood. The treatment of anorexia is complex and multifactorial, requires multidisciplinary input, empathy and perseverance, with a highly variable outcome2,4. Studies are suggesting that early intervention may improve the outcome for recovery of anorexic individuals2,3. However, getting those with anorexia nervosa to engage in treatment is difficult due to the poor insight and altered values that are part of the illness1,6,7. This is where the Mental Health Act may intervene.

Under the Australian Mental Health Act 2000 a person with a mental illness can be treated without consent using an involuntary treatment order (ITO). The criteria for an ITO includes: the person has a mental illness; they require immediate treatment; the treatment is available at an authorized mental health service; because of the illness there is imminent risk of harm to self or someone else, or the person is likely to suffer serious mental or physical deterioration; there is no less restrictive way of ensuring appropriate treatment; and the person lacks capacity to consent to treatment or has unreasonably refused treatment for the illness8. This article aims to discuss whether there are grounds to place an individual with anorexia on an ITO early in the course of their illness to prevent serious physical harm and improve longterm psychological outcome.

Rationale for involuntary treatment in eating disorders

australian medical students’ association

33 A topic that has been much studied and debated is the issue of competence and capacity in those with anorexia nervosa. In a study that was published in the journal Philosophy, Psychiatry and Psychology, participants, aged 13 to 21 years, were assessed using the MacCAT-T test of competence, a highly regarded clinical tool in identifying patient competence.

The participant’s scores were analogous with control group scores from a previous study and showed high reasoning and understanding.

Unfortunately due to the sample size this study is not statistically significant, but it is important to note that the issue of competence in anorexia nervosa is highly complex, and even with high insight, judgment may still be impaired. However, even when a patient is deemed competent, the mental health act allows for mental health professionals to treat patients if there is a risk to themselves, as there is in anorexia6. It is widely agreed by both mental health professionals and individuals with anorexia nervosa alike that compulsory treatment is justified to save a patient’s life when their illness has become life threatening1,7.

However, as research has shown that early intervention is superior in delivering a better outcome in remission of anorexic patients, the question remains: should patients with early anorexia be placed under a compulsory treatment order, if they are unwilling to undergo treatment2,4,9?

At all stages of anorexia patients are at risk to themselves, and an ITO may provide an environment in which their physical health can be prevented from deteriorating, while their mental health can be treated and the patient encouraged to move through the stages of change7,9. Early intervention may prevent an individual from developing chronic anorexia nervosa by targeting treatment at a stage of illness that may be easier to treat9.

Studies have shown that short-term outcome is similar between patients treated voluntarily and involuntarily for anorexia nervosa, and in general, compulsory patients respond well to treatment. Unfortunately, there is little data on long-term outcomes in patients treated by an ITO5,7,10. One study has

described an increased long-term morbidity in those treated by coercion, however this may be influenced by the higher degree of severity and chronicity of anorexia nervosa seen in those who are currently placed on involuntary treatment orders10.

Encouraging engagement in treatment Interestingly, an article studying patient attitudes to involuntary treatment found that patient relationships with the treating team, as well as trust and a caring and supportive environment were more important than freedom of choice in their treatment. The patients who did begrudge their perceived loss of rights were those who had a poor relationship with those engaged in their treatment and who felt disempowered and demeaned in their treatment course1. Research has found that if compulsory treatment is used within a trusting relationship, it may be experienced as good care1,9. The goal of early involuntary treatment should be the voluntary continuation of treatment and motivation of the individual to change. This may involve empowering the individual and allowing some freedom of choice regarding treatment methods1,5,9.

A long held view is that an ITO may be detrimental to an individual’s recovery if used inappropriately, such as when a person is not in immediate, life-threatening risk. However, as other studies have shown that the involuntary nature of treatment may not affect outcome, perhaps the altered view that it is the type of treatment and the relationship between the treating team and the patient, that may have the detrimental effect, should be considered. If a patient feels that their feelings and opinions are ignored, they are more likely to resist help, as exhibited by patients in the research6.

outcomes in individuals with anorexia nervosa; which was also commented on in several articles. Early intervention to prevent the progression of the illness may lead to better outcomes for the individual and an ITO may be the means of providing this secondary prevention.

All health professionals need to consider the role of an ITO in the early treatment of anorexia nervosa.

References 1. Tan JO, Stewart A, Fitzpatrick R, Hope T. Attitudes of patients with anorexia nervosa to compulsory treatment and coercion. Int J Law Psychiatry. 2010 Jan-Feb;33(1):13-9.

2. Attia E, Walsh T. Anorexia Nervosa. Am J Psychiatry. 2007 01 December 2007;164:1805-10.

3. Fitzpatrick KK, Lock J. Anorexia nervosa. Clin Evid (Online).

2011;2011.

4. Beumont P, Beumont R, Hay P, Beumont D, Birmingham L, Derham H, et al. Australian and New Zealand Clinical Practice Guidelines for the Treatment of Anorexia Nervosa. Focus. 2005 01 October 2005;3:618-28.

5. Espindola CR, Blay SL. Long term remission of anorexia nervosa: factors involved in the outcome of female patients. PLoS ONE. 2013 February 2013;8(2):e56275.

6. Tan DJ, Hope PT, Stewart DA, Fitzpatrick PR. Competence to make treatment decisions in anorexia nervosa: thinking processes and values. Philos Psychiatr Psychol. 2006 Dec;13(4):267-82.

7. Tan JO, Doll HA, Fitzpatrick R, Stewart A, Hope T. Psychiatrists’ attitudes towards autonomy, best interests and compulsory treatment in anorexia nervosa: a questionnaire survey. Child Adolesc Psychiatry Ment Health. 2008;2(1):40.

8. Mental Health Act 2000. Sect. Involuntary Treatment (2002).

9. Schmidt Holm J, Brixen K, Andries A, Horder K, Klinkby Stoving R. Reflections on involuntary treatment in the prevention of fatal anorexia nervosa: a review of five cases. Int J Eat Disord.

2012 2012;45:93-100.

10. Watson TL, Bowers WA, Andersen AE. Involuntary treatment of eating disorders. Am J Psychiatry. 2000 01 November 2000;157:1806-10.

Conclusion In conclusion, anorexia nervosa is a serious condition with a significant morbidity and mortality. More needs to be done to treat this illness, which has a major impact on the lives of the individual, as well as their families1. More research is needed to better assess the effect compulsory treatment has on long-term outcome in anorexic patients.

However, particular attention needs to be taken to ensure results are not biased by the already poor prognosis of patients currently placed on ITO’s. Limitations in the literature included a lack of controlled trials and very little research on long-term

panacea / 1. 2013

34

AN OPEN LETTER ameliazaunders sydney

Editors note: This reflection has been included in this edition after the release of the initial online version.

For the past half hour, I have been sitting here crying reading some of the articles in this edition of Panacea.

A few of the things mentioned in the anecdotes and articles really hit home, last year being diagnosed with depression and an eating disorder.

Reading these pieces has reinforced for me that most important aspects of any mental health campaign is dispelling the misconceptions of mental health and removing the stigma of having such a disease.

The first point that stood out to me in the magazine is the fact that you can’t “just snap out of it” (“A Bandaid isn’t Enough to Fix It”, Diana Ethell). It’s scary how debilitating mental illness can be. It’s easy to forget that like any other illness, it’s something that begins physiologically. But worse than the helplessness is the frustration that comes with it - you feel as though it is something that you should be able to control, unlike quadriplegia, for instance.

Unfortunately, like paralysis, it consumes you entirely. And yet, before I started going through my own experience, I found myself in a few situations upon which I now look in shame, where others around me suffered from mental illness. I wanted to shake these people who I loved so much and tell them to stop being pathetic. I wanted their ‘normal’ self to come back. I feel disgusted just thinking about my attitude towards the disease based on such little understanding of what they were really going through.

The second assertion that really touched me was the devastation that you cause to those around you as a mentally ill person (“Wish You Were Here”, Inu Shahira) which can only be eased by confronting the illness head-on, despite our fear to do so. My family were so distressed at first by my illness which only encouraged my self-loathing for imposing that pain on them. It wasn’t their fault, but it made me realise how important it is that people reach out as soon as they sense that something’s wrong. The earlier you snip mental illness in the bud, the better for everyone.

However, we are often frightened to confront someone, of becoming involved in the illness in case that someone takes their illness out on us.

Given the stigma of mental illnesses, people often get very defensive when

told they need help. I know that for me my mother and I fought for months as she tried to force me to eat while I absolutely refused (in anorexia, the trickiest part is the lack of desire to actually get better: the first step is making someone realise that that is the only way forward for them). But I now admire my mum so much for her strength to do what she knew was right for me, despite it causing me all that extra pain when I was already so low; it must have hurt her incredibly as a mother. Part of changing the way we deal with mental illness is removing that fear of confrontation, on all sides. Like other ailments, mental illness can be extremely painful, however it only gets worse if left untreated. It’s better to risk the anger knowing that you’ve tried to help than to stand by and watch someone slowly deteriorate.

than go out with their friends suffering clinical depression or are they just a homebody?

The important thing is to really talk to your friends and family and even those you don’t know that well. If I didn’t have my best friend with whom I inadvertently shared a lot throughout my descent, I don’t know how much worse I would have got before I acted on it. One day at work, somebody left an ‘R U OK?’ badge on the desk, making me dash to the bathroom and burst into tears - I longed for someone there to ask me that question; I hadn’t eaten for 24 hours and I felt like I was literally disappearing.

It’s essential to recognise the signs of mental illness early on because due to the stigma of mental illness it’s often very difficult to admit to oneself that one is ill.

Thirdly, I was moved by the admission that it’s easy to convince yourself that you or a loved one are not sick because “it doesn’t happen to people like me” (Diana Ethell). False. Mental illness, whether rooted in nature or nurture, doesn’t only touch women, or the elderly, or homosexuals, or any other social category. It’s a human thing. Your brain malfunctions; that’s what mental illness is. Logically, it can therefore happen to anyone. Furthermore, eating disorders in particular occur mostly among perfectionists who incidentally and deceivingly look like they’re on top of it all when really they’re trying so hard to keep up the appearance that inside they’re not crumbling from the pressure. Like burning out from exams, one burns out from an eating disorder due to the constant trials you put yourself through to attain deliberately unreachable goals in order to be able to punish yourself further. It’s even harder for someone in that situation to admit that they’re not perfect and that they need help.

These are just a few points that the articles highlighted for me – the tendency to underestimate mental illness, the importance of removing the fear behind confrontation and the indiscretion with which is affects the community. However there is so much more to say than can be expressed in one letter. I wish that mental illnesses were more understood; just like every other physically debilitating disease, they deserve respect and a certain amount of comprehension so that we can care for those who suffer from it.

Talking about it relieves so much of the pressure of the illness. For me, anyway, things get so distorted in my head that it’s scary to constantly keep thoughts to myself; saying them aloud allows me to properly analyse them for their true value and challenge irrational and harmful thoughts. This is the most important step to ultimately rewiring your brain to better cope with these thoughts, leading to a more fulfilling life.

THERE IS NO SHAME IN ASKING FOR HELP.

If you know anybody with a mental illness, don’t be afraid to talk to them about it. Some, like me and those authors of personal memoirs in the magazine, are perfectly OK to be open.

Others may need assurance that they’re safe to talk to you before they begin.

It’s integral to the removal of the stigma that we’re not afraid to have these discussions and for that I praise this publication and the work that AMSA is doing to fight mental illness in student populations. I look forward to joining your ranks as a medical student in the near future.

It’s also difficult to self-diagnose or diagnose another when words such as “depression”, “anxiety”, and “stress” have become very broad in meaning and are used in a casual sense more frequently than as terms for clinical symptoms or illnesses. How do we distinguish someone who is stressed by their work load, such as a medical student, from someone who has an anxiety disorder? It’s easy to look at their expressions of this mental state, for example my decision to starve myself compared to someone who doesn’t eat properly for a week but forgets their stress once they’ve finished their assignment.

However, sometimes the symptoms are not so overt. Is someone who prefers to stay at home and watch movies rather

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I thank you for reading this. It means a lot to be able to speak openly about this.

35 POCKET BODY app review benfinlay flinders

PocketBody is a musculoskeletal anatomy application for iPhone and iPad. The app lends itself to the larger screen of the iPad, but is equally functional and easy to use on the iPhone.

The app shows a virtual human body, which you can view in layers from the skeleton down to the skin. You can customise the view to show any combination of bones, ligaments, muscle layers, and skin, as well as allowing users to view blood vessels and nerves. Internal organs are included for completeness, though the anatomical detail is not as complete as it is for the musculoskeletal system. The app also allows you to rotate the body to view from anterior, posterior, left, and right, lateral aspects.

The atlas content is very detailed. Each structure has details listed such as origin, insertion, relations to other structures, and

other clinical pearls that can come in handy. You can also make your own notes in the app. The useful search feature allows you to search for a structure and view it on the screen along with relevant information, making the app a good quick reference.

The graphics are good, and the interface doesn’t take too long to get used to.

The quiz function is perhaps one of the best features of the app, making it an alternative to carrying around all your anatomy flash cards. You can make your own quiz on the fly, based on the anatomy you need to learn. You can also add your own ‘pins’ to the body to mark other structures of interest.

With iPads and iPhones ubiquitous amongst med students, these apps are a handy reference and learning tool, and great value compared to the price of old fashioned alternatives.

panacea / 1. 2013

36 AUSTRALASIAN SCHIZOPHRENIA CONFERENCE 2013 a review clairemcallister griffith

Recently I had the pleasure of attending the Australasian Schizophrenia Conference (ASC). I chose this conference as I believed it would give me an insight into the current research in schizophrenia, particularly in my area of interest; molecular biology.

and supportive mental health system in Australia. The most striking pictures were shown at the end of the speech, and they were of a man that had been kept in a cage for eight years, but after only one year of proper treatment, he was able to live in the community, get married, and have a son.

I first attended a satellite session on Mothers’ Day, quite fittingly on Women’s Mental Health. It was a great insight into the hormonal aspects of mental health, including studies on contraceptive pills, menopause, and Premenstrual Dysphoric Disorder (PMDD).

James Le Bas – “Prestige and Bipolarity: An evolutionary perspective” This talk focused on the evolution of humans and their new reliance on communal problem solving. The result of this reliance was that leadership was now being gained through “prestige competition” such as narrative skills, affective engagement and social goal pursuit. Social withdrawal may have also provided protection through “stealth” processes. He proposed that these two evolutionary models could be translated into the manic and depressive phases of biopolar disorder.

The conference officially began bright and early on the Monday morning with a welcome speech from a hilarious comedian. But after all the laughter, it was time to get into business. I went to a number of different sessions over the two days but I’ll give you a run down of some of my favourites.

Pat McGorry – “Clinical staging and Personalised Medicine in Potentially Serious Mental Disorders”. Pat McGorry works at ORYGEN Youth Health Research Centre and was the Australian of the Year in 2010. He has recently developed a clinical staging model for the early detection of mental illness and believes this early recognition will drastically improve outcomes. He also spoke of the future possibility of using biomarkers to aid in this stratified or personalised medicine.

Cokorda Lesmana – “Healing the living zombies of paradise: A model of a community-based treatment of the physically restrained schizophrenics in Bali”. This was the most inspiring talk of the entire conference, having moved some delegates to tears. The images of mental health patients in Bali being kept in woodstocks will stay with me for a very long time, and it reiterated how lucky we are to have a functional

Rachel Hill – “A ‘two-hit’ rat model of developmental stress shows sex-specific disruptions in spatial memory and anhedonia and alterations in exon-specific BDNF expression in the hippocampus” The “two-hit” model is popular in molecular research and proposes that two or more major disruptions during development can precipitate schizophrenia. This study used rats given two hits; neonatal maternal separation and the administration of corticosterone in adolescence. They found two sex-dependent behavioural phenotypes that correlated with sexspecific and region-specific alterations in neuronal BDNF expression. The male two hit rats had decreased spatial short term memory in a Y-maze, with dorsal hippocampus alterations in BDNF, whilst female two hit rats had anhedonia in a sucrose preference test, with ventral hippocampus BDNF expression changes.

The sucrose preference test was perhaps the most interesting aspect of the speech.

In it, rats can choose between normal water and sugar water. The female rats that had the “two hits” were the only ones that

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didn’t have a preference for the sugar water over normal water, demonstrating characteristics associated with anhedonia.

Jeff Conn – “Allosteric modulators of GPCRs as a novel approach for treatment of Schizophrenia” Selective M1 and M4 mAChR activators have been seen to improve schizophrenia symptoms with less antimuscarinic side effects (thought to be mediated by M2 and M3 receptors). Dr Conn’s lab has been developing PAMs (positive allosteric modulators) of these receptors.

In their animal models, highly selective M1 PAMs appear to improve cognition, whilst highly selective M4 PAMs improve antipsychotic symptoms. They are partnering with drug companies at present to develop drugs that may one day be used in clinical treatment.

James Gold – “Reward processing and negative symptoms in schizophrenia”.

There have been many theories into how the brain produces negative symptoms in schizophrenia. Dr Gold’s tests in humans (healthy, schizophrenics with low negative symptoms and schizophrenics with high negative symptoms) show that they have difficulty representing the prospective value of potentially rewarding actions, rather than finding them not rewarding to begin with. This means that they are unable to calculate cost/benefit – i.e. their brain sees the effort required to obtain the reward as too high.

I had a fantastic time at the conference, not to mention all the other things I did in Melbourne. I recommend anyone interested in psychiatry, psychology or neurology attend it in future years. Big thanks also to GUMS (my medsoc) for helping me attend this conference through their subsidy scheme.

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THE HOUSE OF GOD book review tobyvinycomb monash

You may laugh; you may cry; you may get a little bit turned on, but Samuel Shem’s didactic novel The House of God is really just the ‘what to expect in medicine’ guidebook that should be posted with every medical school offer.

Shem’s novel is set in the mid-1970s when 80-hour work weeks, flings with nurses, and paternalistic doctors were the norm. Dr Roy G. Basch – the novel’s narrator and protagonist – is a bright young internist that has just graduated from the BMS (‘Best Medical School’) and is beginning his treacherous intern year at the House of God Hospital.

Shem’s warning came late for me. I was given the book by my third year ethics tutor who had a fascination with quoting the book’s Laws of the House of God. “Law #3: At a cardiac arrest, the first procedure is to take your own pulse.”

These thirteen laws – all humorous and absurd, yet insightful in their own way – should be added to the Hippocratic Oath. If you feel this is mutiny against the Hippocratic Oath, don’t worry; Hippocrates likely taught some of them to his students in 400BC. “Law #12: If the radiology resident and the medical student both see a lesion on the chest X-ray, there can be no lesion there.”

Following Bach is as bleak as it is inspiring. As internists, Bach and his colleagues are haunted by their medical mistakes, lead into despair by the senior physicians, and pushed to the edge until one of them commits suicide. This

leaves them to deal with the pain of their patients and colleagues dying.

Bach’s mentor is his second year resident that he affectionately calls The Fat Man. The Fat Man, an aspiring gastroenterologist, humours Bach with his special viewing device that he is adamant will make him rich. However, The Fat Man’s secret success has been coining the term GOMER (‘Get Out of My Emergency Room’) – immortalising the term into medical literacy.

“Law #1: GOMERs don’t die.”

The actions of Bach, his colleagues and some of the senior doctors will likely seem farcical to those outside the medical field. Even from within the field, it can feel that Shem is just a cynic: doctors using patients as cash cows, treating them with a cavalier attitude, laughing at the GOMERs idiosyncrasies.

“Law #9: The only good admission is a dead admission.”

For those who read the book and thought, “I’ll never be like that”, are you sure?

Had I been handed this book before I started medical school, I would have agreed. How is it possible that medical staff be so callous and insensitive to treat their patients in this way? However, fast-forward and I have found that clinical years have sublimely taught me that it is easy to be inconsiderate and indifferent when tittering about the quirks of a patient. Everyone does it: senior doctors, nursing staff, and allied health - it’s part of the medical culture to cope with disease, death, and dying.

Readers who enjoy Fifty Shades of Grey will not be let down by The House of God. Shem details the minutiae of Bach’s adulterous encounters with the nurses: “she was dressed in a slinky gold wrap around which left one shoulder bare, two nipples poking. And a partridge in a pear tree.”

The House of God is not without its controversies. Over-treatment of patients is a major theme in the novel.

I doubt Shem is a clairvoyant, but an increasing number of treatment options gives rise to the question ‘are we doing too much’?

“Law #13: The delivery of medical care is to do as much nothing as possible.”

The House of God is as relevant today as it was in the 1970s. Shem – not his real name by the way – provides a unique perspective into hospital hierarchy, doctors’ personalities, the funding of medical practice, and the personal cost of choosing medicine as a profession. Readers are given insight into dealing with the internal and external conflict of working within the medical workforce before they inevitably face it themselves.

Readers have been polarised by the The House of God but I would recommend it to all aspiring medical professionals.

Available for under $20, the novel is a bargain that not only highlights some of the difficulties of working as a junior doctor, but is also a good summer holiday read.

“Law #4: The patient is the one with the disease.”

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ANU MEDICAL STUDENTS’ SOCIETY (ANUMSS) the australian national university samharkin amsarep

2013 is going beautifully for ANUMSS. This year’s Med Revue, Para-Medical Activity, was a rollicking success, raising an exceptional $6500 for the Neonatal Intensive Care Unit at the Canberra Hospital. We’ve also hosted numerous events – The Annual Medical Symposium, featuring a panel of prominent consultants addressing end of life issues; ‘When I Grow Up’ evenings; Global Health guest speaker nights; a Med vs. Law debate; and a ‘No Lights, No Lycra’ wellbeing event just to keep things holistic.

Our four year levels are currently locked in an (unsurprisingly) intense, hard-fought battle for the inaugural Inter-Year Sporting Cup – led at the moment by the enthusiastic and deceptively athletic first years.

The Fiji Village Project team hosted the inaugural ‘Fiji Village Five’ walk, raising money for their cause and representing the ANUMSS proudly in the Canberra community. Our ‘Live Below The Line’-rs also did a sterling job in their fundraising efforts. We soon have the muchanticipated ‘What Happens in Vegas’ themed Winter Formal, a shining light in the notsoanticipated Canberra winter!

Our graduating class of 2013, and MedSoc, at large have been grateful for the advocacy and support provided by AMSA in what is an increasingly ‘interesting’ internship situation!

Finally, it would be remiss not to mention the hype that is building to uncontrollable levels for the record number of Convention attendees; ANUMSS will see you at GC2013!

MEDICAL STUDENTS’ SOCIETY OF BOND UNIVERSITY (MSSBU) bond university andrewrobinson amsarep Coming in from a highly successful semester (with MedBall 2013 and the launch of our new publication Synapse) we kicked our 132 season off with one of our best MedEagles yet. Filled with the fresh faces of our newly initiated first years, MedEagle once again proved to be the gold standard for getting to know your peers in other years, and to catch up with friends after the much-needed holidays.

It’s just days until the AMSA National Convention right here on the Gold Coast, and our Bond team have been hard at work preparing – we’ve had the highest number of registered delegates from Bond ever this year, and thusly it promises to be one for everyone else to remember.

This year has seen us run two separate trivia nights, one for all our Bond meddies, and one for our postgrads specifically, which was a perfect opportunity australian medical students’ association

for our teams to prove that their brains swallow filthy pop-culture just as well as a list of differentials for microangiopathic hemolysis.

We’ve also launched our university’s first ever Surgical Interest Group, working dilligently to plant our roots into Queensland’s florid surgical society. Our launch event garnered unprecedented interest, and we can’t wait to see how far we can take this.

Coming up is our inaugural ‘All Abilities Olympics’ on June 19 - a fun sports day for children of all abilities to come together and enjoy themselves in our safe and very awesome new initiative. We’ve got a great number of events planned for our fine competitors, a day of good fun and competition awaits.

Stay updated on the latest by checking out our publication Synapse, which always brings a great mix of MedSoc updates and your very own submissions.

DEAKIN MEDICAL STUDENTS’ ASSOCIATION (MeDUSA) deakin university gregevans amsarep Our Medcamp and Cocktail Nights had record attendance back in February. Our Victorian MDNM ball went off well in May, with creative costumes all round, as well as some good socialising between Victorian med schools. MeDUSA is also getting into the merchandise game, with our first round sales of keyrings, ID tags, and eye-catching Keepcups being a resounding success.

Rivalry is strong between our 1st and 2nd years. We’ve had a primary school themed sports day, and an AFL clash is planned for later in the year. They are also super keen to commence the battle for blood-drop costume rights come July, whilst 3rd and 4th years have had their share of social nights, resume writing/interview workshops, and careers seminars.

Our MedSchool continues to be receptive to our feedback regarding marking, assessments, and content delivery; and our rural western Victorian GP/

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hospital students have started an academic mentoring and support program to help bridge the sometimes large distances between their various clinic sites.

On the community front, our community minded students participated in a number of charity events, a refugee biographical movie night, and our Deakin Surgical Interest Group (D-SIG) has recently run an organ donation advocacy campaign in conjunction with Diversitat.

Our students have chosen very capable and motivated junior AMSA Reps, and this is my first of many public thanks for their contributions and initiatives they’ve led so far. Let’s hope they continue their good work!

Deakin’s Convention delegation is 60 strong, more than double the numbers of any other of our six illustrious years as a medical school. Our preclinical students have really got on board with the spirit of convention and are keen to GAI and represent with vigour. Training for this year’s boat races with full strength beer is similar to altitude training...right?

GRIFFITH UNIVERSITY MEDICAL SOCIETY (GUMS) griffith university felicitymcivor amsarep

So, What’s Been Happening at Griffith?

Twenty thirteen has become a year of big changes at the Griffith University Medical School, with some of them expected, and others not so much. Firstly, the long-awaited Gold Coast University Hospital is opening this year, as is the shiny new Griffith Health Building just across the road. The Medical School will be moving to the new building during Convention, with pre-clinical students based in this new facility from 15 July and clinical students visiting for their “Clinical Learning through Extended Immersion in Medical Simulation” weeks from then onwards.

A couple of more unexpected changes, however, have also occurred recently, with modification of admissions criteria, now 25:25:50 weighting of GPA, GAMSAT, and Interview respectively; as well as

changes to OSCE-based assessment for clinical students, with stations now eight minutes rather than five.

Finally, Griffith University has announced the implementation of an MD program from 2014, replacing the current MBBS programme. According to the School, this will not lead to any significant change at the curriculum level, which may allow current students to graduate with the MD title. Details are currently scant, with more information expected soon. GUMS has been involved in discussions regarding these changes through representation on various school committees and will continue to take an active interest in these and future issues.

panacea / 1. 2013

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ANUMSS MedRevue

JCUMSA

JCUMSA; Amuthan Annamalai (L)

MUMUS; Monash Medical Orchestra

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JCU MEDICAL STUDENTS’ ASSOCIATION (JCUMSA) james cook university colingiorcelli amsaliaison This year has been a busy year so far for JCUMSA. We kicked off the year with a carnival experience for the sign-on barbeque, which welcomed the 240 first year medical students to Far North Queensland.

A few weeks later this was soon followed by 120 medical students making their way to Prosepine for the annual Medcamp, full of fun and acitivities for the new students to meet older students. The guest speaker night saw Dr Will Millford present to students of all years, followed by a pre-clinical skills night involving cannulation, suturing, and phlebotomy.

These was just a few of the events JCUMSA has organised so far and there are many more to come, including Medball and Clinical Cocktail Parties.

On a sadder not however, earlier this year the medical student community at JCU experienced the loss of our fellow student and friend, Amuthan Annamalai.

He was a young man passionate about medicine, global health and most of all his family and friends.

Andy; we all miss you and may you rest in peace.

MONASH UNIVERSITY MEDICAL UG SOCIETY (MUMUS) monash university gracecowderoy amsarep

MUMUS has been working hard in 2013 to introduce exciting new events and revitalise old favourites. Our most exciting achievement this year is the release of the MUMUS Revision & Study App (MRSA), an incredible question bank for medical students all over the country (available for download free for Apple and Android) created by incredibly talented Monash students.

Monash was proud to produce the two fantastic coordinators of the first Victorian National ‘remier Night. Delegates from Melbourne (FM), Monash, Deakin, rAdelaide, JMP, and Tasmania, ‘layed the great game in style, encouraging the burgeoning Victorian ‘remier scene and encouraging interstate networking, vital to our future careers.

Our magazine and logo have both been revamped.

Our beloved MUMUS man has moved forward into the suave world of incorporated business, while our Medsoc magazine, ‘The Auricle’ has been beautified and relaunched on the web, massively increasing our readership – over 75% of our cohort has read it in either its online or paper forms.

Our intra-soc sporting event, the Caduceus Cup, has taken another step this year with the introduction of faculty mascots and an explosion of events including the Mothers Day Classic, Bowling, Laser Force, Soccer, Netball, Tennis, Track, Dodgeball and golf.

With year levels pitted against each other, this year’s cup is sure to be fiercely contested and incredible fun.

panacea / 1. 2013

42 ADELAIDE MEDICAL STUDENTS’ SOCIETY (AMSS) adelaide university alyssaparsons amsarep

As things in rAdelaide begin to settle down in the lead-up to pre-clinical exams, we have a chance to reflect on the year that has been thus far, and look ahead to what will no doubt be an epic second half of the year.

Some big things to come out of the AMSS include; the introduction of a Health and Wellbeing Officer to our Committee to adequately reflect the importance of this issue among our cohort; the welcoming of a new Dean of Medicine to the mix, Professor Alistair Burt; planning towards the introduction of a parallel MD program to begin in 2014; advocacy relating to recent changes to internships; drafting of new AMSA policy; logistically trying to figure out how to maximise

enjoyment and minimise collateral damage as 270+ Adelaideans prepare to descend on the Gold Coast for what will be an unforgettable and unparalleled Convention experience; and of course observing Convention 2014 take shape under the leadership of the brilliant James Johnston.

Keep an eye on Adelaide. Big things are on the horizon.

UoM MEDICAL STUDENTS’ SOCIETY (UMMSS) the university of melbourne thomascarins amsarep MD Student Conference The MD Student Conference is part of the new curriculum at the University of Melbourne. This weeklong conference allows for multiple year levels of the course to come together and interact in a way that allows for strong student input. The Conference is organised by a group of medical students who are appointed by the Medical Faculty to oversee its running each year. Typically the format of the week allows for different topics to be discussed, such as Mindfulness sessions, debates, andbreakout sessions. Although timetabling issues forced the conference to be split between the yearlevels this year, next year everyone will once again be united into an enormous single conference.

It’s not all about lectures though, with a social program supporting the academic program. The australian medical students’ association

social events this year included an Opening Cocktail Event, a Red Cocktail evening to raise awareness for HIV/AIDS, and an End of Conference Party. The final year MD students will be conducting their ownresearch next year, with many students able to present their research at the Conference.

Furthermore, with all year levels present, the 2014 Conference will see over 1300 students attend, making it even larger than AMSA Convention.

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AMSS at NLDS

UMMSS Red Cocktail

AMSS MedCamp

UMMSS Red Cocktail

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44 UNIVERSITY OF NEWCASTLE MEDICAL SOCIETY (UNMS) the university of newcastle laurengodde amsarep

In 2013, UNMS introduced its first major academic support initiative in the form of MedPALS. These are sessions that utilise the experience of older successful students to guide earlier years and in doing so, support the spiral learning style of Medicine at Newcastle.

Sessions are run in small groups of no more than 20 in a semi-structured & interactive atmosphere at the end of each semester. Dinner is provided, funded by our MedSoc’s Education budget, and they are held on campus in tutorial rooms. Our sessions this semester have had an 85% attendance level from students.

Feedback surveys have delivered overwhelming positive responses as well as improvements to the structure and process of the sessions.

Being a course based entirely on end of semester 100% assessments, with next to no remediation offered if students fail, the lead up to exam time is very stressful. The MedPALS initiative provides academic support for students when they need it most. On a broader scale, this initiative has engaged a wider range of students than any other initiative has!

UNMS is committed to providing educational support to its members and we feel that this has made our society more accessible to students who would not normally engage in our events.

UNE MEDICAL STUDENTS’ ASSOCIATION (UNEMSA) the university of new england wellbeing gym classes, BodyStep, Combat, and kyliezhong amsarep This year, the University of New England Medical Students’ Association has seen its first graduates and alumni cohort. The organisation is now in its fifth year of development, representing more than 300 medical students.

UNEMSA has settled well into the new year, equipping first years and new clinical students with the survival skills necessary to life in Armidale and in Medicine. First semester has been hectic+ ; with great academic and social events for Armedillos to GAI and FSU. Some highlights include First Incision, Surviving Medicine, O Camp with our Novocastrian siblings, Futures in Medicine, MedWeek, the Annual Charity MedBall, and Students vs Hospital Cricket.

UNE students aren’t all play - UNEMSA promotes a balanced lifestyle and continues to support its students with Peer Assisted Study Sessions, OSCE preparations, and advocacy. Committee members represent on various School councils and boards. Fortnightly australian medical students’ association

Balance, are well attended and supplement the many extracurricular activities of UNEMSA members. There is an inter-year blood drive competition (we’re coming Deakin!), our quarterly publications are amazing, and UNE pride is at an all-time high!

UNEMSA continues its amazing tradition of achievements. We are currently placing 1st in the AGH LBL Cup, and have commenced the new soccer and mixed netball seasons - 2013 will be the fourth consecutive year that UNEMSA FC brings home the Premiership!

Special interest groups have continued to pump out exciting top-quality events, including GPSN Trivia Night, UNESS Surgical Skills Day, NERCHA Indigenous Health Night, and ASPIRE Maternal Health Weekend - rounding out an already-packed 2013 calendar!

There is a lot more on the way for Armedillos, with the Committee working hard to prepare for many upcoming events - and the third annual Med Revue “Around the Wards in 80 Hours” is in full development with production and rehearsals well under way, and boy, it is looking good!

MEDICAL ASSOCIATION OF NOTRE DAME SYD (MANDUS) the university of notre dame, sydney johnfarey amsarep Yo ho diablo! I’m writing this MANDUS update in the aftermath of our annual Red Party soiree yesterday evening. The Little Red Riding Hood theme turned out spectacularly, with every student adorned as little Miss Red herself or the Big Bad Wolf. This year, we’re doubling-down on HIV awareness by transforming our annual MedBall event into RedBall with all the funds raised going to Ametur House in Port Moresby, a short-stay hospice for HIV positive people to receive basic care. We’re very proud of this initiative, especially since blood-borne viruses are still shockingly taboo in Papua New Guinea.

Did you know that the average medical curriculum has less than 1.5 hours of formal teaching on prescribing exercise for your patients? If you’re looking for a great wellbeing idea for your Medsoc, we’ve just held a very successful lecture series on the topic of “Exercise is the Best Medicine”. Newcastle legends The Naked

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Runners held an interactive session on the best way to motivate patients, make appropriate referrals to allied health, and topped it all off with an outstanding talk on nutrition and exercise for Aboriginal and Torres Strait Islanders by Nat Heath from the Indigenous Marathon Project. We highly recommend these guys!

On the not to distant horizon the inaugural Medicine XV match between Notre Dame, Sydney and the University of Sydney will be held in early-mid September. We’ve made sure all our former and current representative players will be available, so brace yourselves USyd. The game will be a friendly match followed by a barbeque fundraising for Men’s Sheds, providing peer support for men in need of help arising from mental illness.

Watch out for us on the Gold Coast – we’re bringing our biggest ever Convention contingent. You’ll be all like “Dayum!” when Notre walk past.

John’s big prediction: UNDS NSWMSC Sports Day Champions. You read it here first.

MEDICAL STUDENTS’ ASSOCIATION OF NOTRE DAME (MSAND) the university of notre dame, fremantle ghassanzammar amsarep

By gosh it’s been a hectic start of the year for MSAND. We’ve put on a plethora of popular educational events hosted by our Special Interest Groups. Our social events have run smoothly, minus a missing cutout of a Singapore Airlines waitress that ended up in the bed of a dodgy first year student.

There goes another potential venue off our list.

This year’s jointly run Leadership Development Workshop with WAMSS was a huge hit, reaching a record number of ticket sales. Guest speakers included public health advocate Professor Daube, AMA (WA) President Dr Richard Choong, and W.A Chief Health Officer Professor Turan Weeramanthri.

years ready to destroy the UWA med team in 2013.

All we need to do now is teach the first years (60% from QLD and NSW) a little bit about AFL! More importantly, our convention costume committee (a.k.a the CCC) is busy creating some wild and wonderful outfits, with the sole purpose of showing as much painted flesh as legally permitted in the state of Queensland.

See you on the Gold Coast.

Guy’s football and girl’s touch rugby training has commenced and with a huge turn out from our first panacea / 1. 2013

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UNMS

UNEMSA MedCamp

UNEMSA

MSAND

UNMS

australian medical students’ association

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WAMSS Dragon Boat Racing Day

UWSMS

SUMS Medical Leadership Seminar

WAMSS

UWSMS Blue Week

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48 SYDNEY UNIVERSITY MEDICAL SOCIETY (SUMS) the university of sydney student and how these opportunities can extend to a aditiraut amsajuniorrep SUMS Medical Leadership Seminar 2013 The SUMS Medical Leadership Seminar is one of our most popular academic events of the year and the 2013 edition did not disappoint! With the theme of “Crossing Boundaries: Dynamic Leadership Across Fields” in mind, five incredible doctors challenged, inspired, and revitalised the minds of the medical students attendees.

Dr Joe Duncan, founder of the Bowral Brewing Company, was a crowd favourite and shared the nuances of continuing to follow his passion alongside a medical career. Next, SUMS hero Dr. Monique Atkinson highlighted the many benefits of immersing oneself in the leadership opportunities as a medical

fulfilling career as physician.

This holistic self-development was further underlined

by NSW Shadow Minister for Health Dr Andrew McDonald who shared with us the challenges of acting as both an MP and as a paediatrician. His leadership mantra of “persistence” and “being realistic” resonated with the audience. Dr. Helen Redmond defined herself as the “accidental leader” and has used her role to champion environmental issues.

The final talk by Dr Mohammed Khadra filled the audience with awe. His character and life experience showed us the very essence of what it means to be a person of integrity, whilst maintaining a wicked sense of humour. The seminar left us feeling empowered, with a renewed sense of purpose, equipped to artfully tackle the balancing act that is the life of the modern medical student.

WESTERN AUSTRALIAN MEDICAL STUDENTS’ SOCIETY (WAMSS) the university of western australia justinwinters amsarep What a beginning to the year it has been. The social and sports teams have put together an incredible list of events to welcome us all back from our much loved holidays and electives. The inaugural gladiatorstyle WAMSS Warfare and huge team entry into the mud-crawling Warrior-Dash proved to be instant hits.

These were backed up by an incredible social agenda including O’Camp, a sold-out Allied Health, and the River Cruise.

With student wellbeing high our list of priorities, our dedicated wellbeing team and Students Passionate About Mental Health (SPAMH) have been taking a lead in ensuring everyone has a place to go and a friend to turn to during difficult times. Sometimes it is as simple as remembering to ask R U OK? The Coffee Crawl has been a huge success; we’ve enjoyed Pancake day and the fundraiser Scrubber day, with the weekly Temple of Wellbeing being a friendly reminder of the lighter side of medicine and life in general. australian medical students’ association

WAMSS has proudly encouraged the development of global health initiatives in the university. Our Global Health Group - Interhealth - has taken on board national projects like Crossing Borders for Health (CB4H), forming a partnership with the Fremantle Multicultural Centre to assist newly arrived refugees settling into an unfamiliar environment, as well as continuing with old favourites like Red Party, Greening WAMSS through Code Green, supporting little kiddies through Teddy Bear Hospital and the ZONTA birthing kits workshop.

Finally, our academic and advocacy teams are also charging full steam ahead. Keeping abreast of all things “Moving to MD”, and ensuring our current students aren’t left behind is a full time job. The dedicated work of our team is bringing fruitful results, overseeing changes big and small to the new curriculum, and providing hugely valuable feedback to the Faculty. Yet on top of all this, there is still time to run great events such as the WAMSS-MSAND Leadership Development Workshop, suturing workshops, and peer-to-peer Student Grand Round teaching sessions.

UWS MEDICAL SOCIETY (UWSMS) the university of western sydney

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deanzinghini amsarep It’s great to see this relatively young med school grow year after year. So quickly we have adapted the ways of the medical students’ culture that many of us may occasionally attend non-compulsory seminars just for the free food. More interestingly however, is how often I see even the younger ‘firsties’ omit crucial letters of the alphabet when talking to tutors, lecturers, and most humorously, their unsuspecting doctors. Whilst ‘reparing for a ‘rocedure is a common task to most of our colleagues, some of the consultants still struggle to grasp the aetiology of our unusual speech impediment.

This year has seen launch of our remarkable new website which has greatly assisted in our interaction and communication with our members whilst also promoting our work, events and values nationwide.

Nonetheless, the UWS Meddies power through these communication barriers. We direct our efforts to not only being academically, professionally and clinically proficient, but also to being admirable and worthy medical students from the youthful grounds of Sydney’s west.

UWS Meddies constantly look forward to every AMSA event as a chance to interact with and make great networks with as many students from around Australia... a thought that can keep a smile on any AMSA Rep’s face.

Such events included the wellbeing project, ‘Blue Week,’ which was highly successful. It promoted mental health and well-being to the medical society and the local community with a balance of entertainment, information and (perhaps most importantly) free blue lollies!

Dream PLAN ACT TOGETHER 2013 AMSA Global Health Conference 12–15 September 2013 Wrest Point Hotel & Conference Centre Hobart, Tasmania Registration on now

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If you need support to get you through when you are feeling down, experiencing some stress, there is always something to help you understand, and someone to help you cope.

Talk to a friend Talk to your educational counsellor Talk to your GP Get a referral for a psychologist or psychiatrist Read the AMSA Keeping Your Grass Greener Guide Get in touch with one of these centres Headspace 1800 650 890 www.headspace.org.au www.eheadspace.org.au (online counselling) Beyond Blue 1300 22 4636 www.beyondblue.org.au Reach Out au.reachout.com SANE Australia 1800 18 7263 www.sane.org National Sexual Assault and Domestic Violence Counselling 1800 737 732 For immediate and urgent help, contact the following Suicide Call Back Service 1300 659 467 Lifeline 13 11 14 Emergency Services 000

“Psychiatry terms seem particularly prone to causing distress. One of my experiences involved accompanying a psychiatrist while she interviewed a young woman newly on remand for fatally stabbing her own mother during an altercation. The social history elicited was sorrowful, and her distress and anxiety understandably intense. Another patient who comes to mind was a wheelchair-bound elderly immigrant from Asia with severe Parkinson’s Disease who had recently attempted suicide. A third was a fascinating, but again very sad, case of Cotard’s Syndrome, in which the patient believed that she was dead, as evinced by the ‘maggots’ she could see near her.

Especially for those students who themselves have a mental health difficulty, some of the stories found during psychiatry placements are upsetting.”

- (Anon) Stage 3 Student at Sydney australian medical students’ association

Copyright 2013, All Rights Reserved Australian Medical Students’ Association

panacea the official magazine of the australian medical students’ association the mental health issue volume 47 issue 1 july 2013 edition 2