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OBJECTIVES: To provide guidance for the optimal administration of electroconvulsive therapy, in particular maintaining the high efficacy of electroconvulsive therapy while minimising cognitive side-effects, based on scientific evidence and supplemented by expert clinical consensus. METHODS: Articles and information were sourced from existing guidelines and the published literature. Information was revised and discussed by members of the working group of the Royal Australian and New Zealand College of Psychiatrists' Section for Electroconvulsive Therapy and Neurostimulation, and findings were then formulated into consensus-based recommendations and guidance. The guidelines were subjected to rigorous successive consultation and external review within the Royal Australian and New Zealand College of Psychiatrists, involving the full Section for Electroconvulsive Therapy and Neurostimulation membership, and expert and clinical advisors and professional bodies with an interest in electroconvulsive therapy administration. RESULTS: The Royal Australian and New Zealand College of Psychiatrists' professional practice guidelines for the administration of electroconvulsive therapy provide up-to-date advice regarding the use of electroconvulsive therapy in clinical practice and are informed by evidence and clinical experience. The guidelines are intended for use by psychiatrists and also others with an interest in the administration of electroconvulsive therapy. The guidelines are not intended as a directive about clinical practice or instructions as to what must be done for a given patient, but provide guidance to facilitate best practice to help optimise outcomes for patients. The outcome is guidelines that strive to find the appropriate balance between promoting best evidence-based practice and acknowledging that electroconvulsive therapy is a continually evolving practice. CONCLUSION: The guidelines provide up-to-date advice for psychiatrists to promote optimal standards of electroconvulsive therapy practice.

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BACKGROUND: Pregabalin is a treatment option for patients with persistent neuropathic pain. Its use has been associated with changes in mood and the development of depression and/or suicidal ideation. OBJECTIVE: Case presentations were reviewed of five patients reporting changes in mood, depression and suicidal ideation from the first 50 (approximately) patients commenced on pregabalin at the clinic. DISCUSSION: Although these patients had a history of depression, their mood had been stable before commencing pregabalin. Soon after commencement they reported changes in mood, and development of depression and/or suicidal ideation, which improved with dose reduction or cessation of pregabalin. Ultimately, all five patients ceased pregabalin treatment. Suicidal ideation is a recognised adverse effect of pregabalin. Patients should be warned of and monitored for deterioration in mood.

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BACKGROUND: A recent series of case reports has demonstrated a significant, previously unrecognized drug interaction between serotonin reuptake inhibitors (SRIs) and methylene blue (MB). OBJECTIVE: The authors review the case reports and clinical audits relevant to this interaction and consider the diagnosis of serotonin syndrome in these cases. METHOD: Articles were obtained from a systematic search of MEDLINE and PsychInfo databases, and from the bibliographies of relevant articles. Studies were considered relevant if the patient received MB and developed an acute confusional state, neuropsychiatric complications, or autonomic instability. RESULTS: The review identified nine case reports and two retrospective reviews; 26 patients developed an acute confusional state after MB infusion; 24 of these patients were taking an SRI, and 1 was taking clomipramine. Serotonin syndrome was a possible diagnosis in all 25 of these patients. CONCLUSION: SRIs can interact with MB, causing a serious adverse reaction consistent with serotonin syndrome.

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OBJECTIVE: To ascertain the presence, and describe the pattern and extent, of restrictive care practices in the treatment of mental health inpatients in a rural New Zealand unit. METHODS: Retrospective data was anonymously extracted from patient records at Rotorua Hospital (Rotorua, New Zealand). Data sets were compiled from 300 consecutive patient admissions between January 2000 and December 2001. The demographic and diagnostic characteristics extracted were gender, age, ethnicity (Maori or non-Maori classification only), primary diagnosis, length of hospital stay, seclusion, medication on discharge, dosage of antipsychotic medication if given, referral to psychotherapy, voluntary/involuntary status on admission, and readmission rates. RESULTS: After controlling for other clinical variables, ethnicity was not associated with specific diagnoses, increased use of seclusion, and involuntary status on admission or higher readmission rates. Maori patients were more likely to receive antipsychotic medication and at higher doses than non-Maori. Maori were less likely to be referred to psychotherapy services and had shorter lengths of stay. CONCLUSION: There was no evidence of widespread restrictive care practices against Maori, although the disparities in antipsychotic prescription and psychotherapy referral suggest some restrictive care practices do exist. The use of specialist cultural teams in general mental health services may prevent restrictive care practices.

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PURPOSE: To report a case of autonomic, neurological and neuromuscular instability following methylene blue infusion for parathyroidectomy; to advance the argument for a diagnosis of serotonin syndrome; and to consider this diagnosis in previous, unexplained reports of adverse reactions amongst patients undergoing parathyroidectomy using methylene blue. CLINICAL FEATURES: Methylene blue was administered to a 58-yr-old woman undergoing a parathyroidectomy under general anesthesia. The patient had a background of obsessive compulsive disorder treated with paroxetine. Postoperatively, she demonstrated symptoms and signs of serotonin syndrome; specifically tachycardia, agitation, dystonia and abnormal eye movements. These clinical findings spontaneously resolved themselves over the subsequent 48 hr. CONCLUSION: An interaction between methylene blue and serotonergic agents may give rise to the serotonin syndrome. Consideration should be given to avoiding methylene blue in patients taking serotonergic agents. The diagnosis should be considered in patients with autonomic, neuromuscular or neurological changes and should be managed accordingly.

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OBJECTIVES: The prosecution of psychiatric inpatients for violent acts remains controversial but is increasingly considered as a management option for a minority of patients. Most of the literature so far has been based in North America. This study in a rural New Zealand psychiatric unit was undertaken to explore the rates, reasons and outcomes of referring psychiatric inpatients to the police for possible prosecution of violent acts committed while in hospital. METHODS: Data were extracted retrospectively from the log of ward incident forms of the inpatient unit for the 24 months between July 2002 and June 2004 inclusive. Any incident fitting an operationalized definition of physical or verbal aggression was included in this study. The type, time, location and persons involved in each incident were recorded. Case files of all patients were used to extract information on diagnosis, treatment and further details of the incident. The details and outcome of each incident was individually verified with the local police department. RESULTS: Data were available for 31 incidents. There were three cases of assault by three patients that resulted in police involvement, and one patient was convicted. Brief histories and descriptions of the incidents are provided. CONCLUSIONS: Despite an increasing awareness that prosecution of patients for violent acts is an option for psychiatric staff, such referrals to the police and subsequent convictions remain rare. In the absence of clear national policies, individual hospitals must be proactive in formulating flexible policies to address such incidents on a case by case basis.

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OBJECTIVE: To explore possible contributing or mitigating factors for burnout in New Zealand psychiatrists as well as future research directions in this area. METHOD: A selective review of the literature pertaining to burnout and reports regarding New Zealand's medical workforce. RESULTS: Possible factors contributing to burnout in New Zealand psychiatrists include rapid changes in the country's health system, the challenge of recruiting and retaining psychiatrists, poor distribution of staff and funds and difficulties in psychiatric training. Potential protective factors against burnout include lifestyle factors, long experience in psychiatry, proposed long lengths of career in New Zealand and potentially positive changes in the health system. Research challenges include subject recruitment, the lack of exploration of personal protective factors and completing longitudinal studies. CONCLUSIONS: Given the current state of knowledge, it would be difficult to accurately know whether New Zealand psychiatrists were burnt out or satisfied with their work. Carefully designed studies would help to clarify this issue.

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