Australia has a universal health insurance scheme covering part costs for private mental health care and which supports the public system. The Medical Benefits Schedule (MBS) schedule provides a recommended fee for each service, the amount the Australian Government thinks the service should cost. Many patients still pay a gap fee for the service. Similarly a system for medications, the Pharmaceutical Benefits Scheme (PBS) subsidises the cost of medicines for most medical conditions. As new evidence emerges in the treatment of psychiatric conditions, it is important that the MBS and PBS are updated so patients receive subsidised best practice treatment.

To provide an overview of RANZCP efforts to expand treatment availability through evidence and advocacy to government.

The RANZCP made submissions to the independent Medical Services Advisory Committee (MSAC) requesting an MBS listing for repetitive transcranial magnetic stimulation (rTMS) for treatment of antidepressant medication-resistant major depressive disorder. Submissions were made to the independent Pharmaceutical Benefits Advisory Committee (PBAC) to request ability to prescribe quetiapine in 25mg ranges for maintenance therapy.

Following RANZCP submissions, the MSAC supported public funding for initial treatment with rTMS for adults with major depression who have tried antidepressant medicine or psychological therapy and remain unwell. The PBAC has recommended changes allowing prescription of 25mg quetiapine tablets for maintenance therapy for acute mania, bipolar 1 disorder and in the treatment of schizophrenia following RANZCP submission.

The RANZCP has achieved access to treatments to provide optimal symptom relief for people living with mental illness.

Establishing a valid communication is not only a basic clinical need to be met but also a relevant ethical commitment.

On the basis of the relevant literature, ethical issues arising from specific, important situations in clinical practice were identified.

The main ethical problems regarding communication about the disorder, both in general and in relation to prodromal stages, were described and discussed together with those regarding communication about voluntary and involuntary treatments, “dual roles” enacted in clinical practice, genetic counseling, and end-of-life conditions; on the basis of what emerged, ethically driven indications and suggestions were provided.

Several situations put the psychiatrist in front of relevant dilemmas and doubts which are no easy to face with; an ethically driven approach based upon the principle of the best interest of patients may support clinicians in their decisions.

Few studies have looked at subjective memory impairment from electroconvulsive therapy (ECT) after treatment completion. We aimed to systematically review all available evidence for subjective post-treatment effects.

We included 16 studies in this review. There was considerable between-study heterogeneity in clinical population, ECT modality and assessment scales used. The most common assessment scale (eight studies) was the Squire Subjective Memory Questionnaire. The majority of studies reported an improvement in subjective memory after ECT, which correlated with improved depression scores. Subjective complaints were fewer in studies that used ultra-brief pulse ECT. Longer pulse widths were associated with more subjective complaints, as was female gender and younger age of treatment in the largest study.

There is considerable heterogeneity between studies, limiting meaningful conclusions. Ultra-brief pulse ECT appears to result in fewer subjective complaints.

None.

To determine the treatment and outcomes of a cohort of adults with the Fontan circulation diagnosed with intracardiac thrombus.

Formation of thrombus is common after the Fontan operation, albeit little has been published on the treatment and outcomes of these patients once they have developed an intracardiac thrombus.

We identified all patients who had been converted to the Fontan circulation from the cardiology database at the Toronto Congenital Cardiac Centre for Adults, Toronto, and The Royal Brompton Hospital, London, studying the period from 1981 to 2003. We then reviewed the relevant echocardiograms and medical records.

Intracardiac thrombus was identified in 28 of 235 patients with the Fontan circulation, the patients having an average age of 27 plus or minus 9 years. Of the patients, 21 were initially medically treated, 19 with heparin or warfarin, and 2 with thrombolysis, whereas 7 patients underwent immediate surgical removal of the clot. Overall mortality was 18%, with residual clots seen in 39% of surviving patients at 1 year of follow up. At presentation, the haemodynamic stability of each patient with intracardiac thrombus dictated initial strategies for management, with 17% of those with stable presentations undergoing immediate surgical treatment, as opposed to 75% of those with unstable presentations (p-value equals 0.04), as well as correlating with ultimate clinical outcome. The rate of death was 8% in haemodynamically stable patients, versus 75% in haemodynamically unstable patients (p value equals 0.01).

Formation of intracardiac thrombus is not rare in adults with the Fontan circulation, and carries a significant risk of death, especially in clinically unstable patients. Emphasis on prevention of formation of the clot is warranted.