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Background: The pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) might be curtailed by vaccination. We assessed the safety, reactogenicity, and immunogenicity of a viral vectored coronavirus vaccine that expresses the spike protein of SARS-CoV-2. Methods: We did a phase 1/2, single-blind, randomised controlled trial in five trial sites in the UK of a chimpanzee adenovirus-vectored vaccine (ChAdOx1 nCoV-19) expressing the SARS-CoV-2 spike protein compared with a meningococcal conjugate vaccine (MenACWY) as control. Healthy adults aged 18–55 years with no history of laboratory confirmed SARS-CoV-2 infection or of COVID-19-like symptoms were randomly assigned (1:1) to receive ChAdOx1 nCoV-19 at a dose of 5 × 10 10 viral particles or MenACWY as a single intramuscular injection. A protocol amendment in two of the five sites allowed prophylactic paracetamol to be administered before vaccination. Ten participants assigned to a non-randomised, unblinded ChAdOx1 nCoV-19 prime-boost group received a two-dose schedule, with the booster vaccine administered 28 days after the first dose. Humoral responses at baseline and following vaccination were assessed using a standardised total IgG ELISA against trimeric SARS-CoV-2 spike protein, a muliplexed immunoassay, three live SARS-CoV-2 neutralisation assays (a 50% plaque reduction neutralisation assay [PRNT 50]; a microneutralisation assay [MNA 50, MNA 80, and MNA 90]; and Marburg VN), and a pseudovirus neutralisation assay. Cellular responses were assessed using an ex-vivo interferon-γ enzyme-linked immunospot assay. The co-primary outcomes are to assess efficacy, as measured by cases of symptomatic virologically confirmed COVID-19, and safety, as measured by the occurrence of serious adverse events. Analyses were done by group allocation in participants who received the vaccine. Safety was assessed over 28 days after vaccination. Here, we report the preliminary findings on safety, reactogenicity, and cellular and humoral immune responses. The study is ongoing, and was registered at ISRCTN, 15281137, and ClinicalTrials.gov, NCT04324606. Findings: Between April 23 and May 21, 2020, 1077 participants were enrolled and assigned to receive either ChAdOx1 nCoV-19 (n=543) or MenACWY (n=534), ten of whom were enrolled in the non-randomised ChAdOx1 nCoV-19 prime-boost group. Local and systemic reactions were more common in the ChAdOx1 nCoV-19 group and many were reduced by use of prophylactic paracetamol, including pain, feeling feverish, chills, muscle ache, headache, and malaise (all p80 and in 35 (100%) participants when measured in PRNT 50. After a booster dose, all participants had neutralising activity (nine of nine in MNA 80 at day 42 and ten of ten in Marburg VN on day 56). Neutralising antibody responses correlated strongly with antibody levels measured by ELISA (R 2=0·67 by Marburg VN; p

Aims: to review the key features of an effective lecture and to rate a series of medical school lectures to inform a broader initiative in staff development in effective lecturingBackground: Lectures are the primary method of delivering information to an audience in tertiary education and remain a key part of medical school educationMethod: Literature review confirmed fourteen elements thought to contribute to the quality of a lecture. A lecture series was then rated using these criteria Results: The three highest rated criteria were explaining and summarising key concepts, presenting material at an appropriate level to the audience, and the use of clear audio-visual aids and voice. The three lowest rated aspects of our lecture program were stating goals of the talk, monitoring audience understanding and responding appropriately, and providing a conclusion to the talk.Conclusions: These findings will provide direction to staff development to further improve the quality of lectures provided to students.Â

Summary Background: Rural longitudinal placements are now a key part of clinical medical education, and are part of workforce strategies to enhance the rural medical workforce. Learning trajectories (a map to guide student learning) have been recommended as a means of maximising student learning on placements, and have the potential to assist long-term rural students and supervisors in adapting to a longitudinal clerkship. Context: This study focuses on year-3 medical students in rural longitudinal clinical placements at an Australian graduate-entry medical school. Innovation: This article reports the outcomes of working with current rural supervisors and students to develop a learning trajectory across the rural stream year, for implementation in future years. Implications: Students and supervisors identified incremental learning goals in keeping with Dreyfus’s model of progressive skill development. Students offered tips to future students to adjust to variations in learning experiences across rural sites. Some supervisors were reluctant to have a learning trajectory, fearing it would be seen as proscriptive and reduce student ambition for varied rich experiences. Future research will focus on the impact of the rural learning trajectory.

OBJECTIVE: Recent efforts to redress the deficit of rural medical practitioners have considered the problem of recruitment and retention of rural doctors as one of influencing individuals' career choices. Exposure to rural medical environments during basic medical training is one long-standing example of an initiative aimed in this direction and there is some evidence that it is effective. This study sought to determine whether or not various domains of personality are related to medical students' attitude to practising as rural doctors after graduation. DESIGN: The sample comprised 914 students commencing medical studies in Australian universities. They were recruited as part of the Medical Schools Outcomes Database project and indicated intended location of future medical practice. SETTING: Seven Australian basic medical training programs. MAIN OUTCOME MEASURES: All students completed the NEO five-factor index (NEO-FFI) and Adjective Checklist (ACL) personality instruments. RESULTS: A preference for a rural practice location was associated with a combination of six domains of personality. The probability of rural preference was greater with higher scores on openness to experience, agreeableness and self-confidence but lower with higher scores on extraversion, autonomy and intraception. Taken together these six domains of personality provide useful although imperfect discrimination between students with a rural versus urban location preference. After controlling for student age the associations with extraversion and agreeableness failed to reach statistical significance. CONCLUSIONS: While personality does not fully explain medical students' attitude towards practicing as a rural doctor, the data suggest it is an important factor and that some individuals may be better suited to a rural medical career than others. Considering personality along with other characteristics of the individual might allow targeted 'marketing' of rural practice.

Objective To quantify utilisation of allied health care services by diabetics in rural NSW and explore reasons for any underutilisation. Design Self-administered mail survey of 268 patients with diagnosed diabetes identified from practice registers. Setting Two rural general practices. Participants One hundred seventeen respondents with diabetes. Main outcome measure Annual frequency of visits to allied health practitioners. Results In the last year, 40.2% of patients had seen a diabetes educator (DE), 21.4% a dietitian and 47% a podiatrist. However, 25–40% of patients had never used each of the services. Reasons for nonutilisation were non-referral (35.9–68.0%) and lack of perceived need (40.6–59.0%). One third of patients who had not seen a DE in the last year thought their ‘general practitioner (GP) provides a similar service’. However, mean annual GP visits (5.6) were significantly lower than urban and rural comparisons. Patients with formal management plans were, in the last year, twice as likely to have seen a DE and podiatrist, and reported two extra visits to their GP compared to those without. Conclusions Rates of allied health service utilisation were not significantly lower than urban rates; however, there is room for increased uptake of multidisciplinary services. Patients who do not access these services may expect their GP to fulfil multiple roles within a limited number of visits and may not understand the role of other practitioners. Where allied health services are available locally, utilisation may be improved by increasing use of management plans and fostering awareness of the role of allied health practitioners in diabetes management.

Objective This study explores the associations between psychological distress in junior doctors and their work environment and how they cope with work stressors. Methods A cross-sectional survey designed by Health Education and Training Institute was delivered in 2014 to over 1900 junior doctors across 15 hospital networks through Australian Capital Territory and New South Wales. Psychological distress was evaluated using the Kessler Psychological Distress Scale-10 (K10). Numerous variables were assessed for associations with psychological distress to identify the strongest relationships and the coping strategies used. Potential associations between work demands, coping strategies and psychological distress were explored. Results 540 responses were analysed. 414 (81%) thought their workload was reasonable, 376 (75%) were enjoying their current job and 446 (82.6%) were content with their work life. However, 85 (15.7%) reported that they would not study medicine if given their time again, and 146 (27%) reported workplace bullying. The mean K10 score was 17.2 (σ=6.3) and the prevalence of elevated psychological distress was between 63% and 80% higher than the general community. Variables most strongly associated with distress were: being discontented with workload, lack of enjoyment from current job, taking time off work and having experienced workplace bullying. There was a preference to use social activities as a method of coping but at higher levels of psychological distress there is a greater proportion who took time off work. Conclusions Psychologically distressed junior doctors need recognition, support and treatment. Future interventions should focus on improving work environment, job satisfaction, provision of supports, use of healthy coping strategies and improving work-related relationships. This could potentially reduce levels of psychological distress in junior doctors, optimise delivery of healthcare to patients and maximise workforce potential.

Attitudes and beliefs concerning the nature and treatment of bulimia nervosa (BN) were compared among young adult women at low risk of an eating disorder (n = 332), at high risk (n = 83), or already showing symptoms (n = 94). Participants completed a self-report questionnaire that included a measure of eating disorder symptoms. A vignette of a fictional person suffering from BN was presented, followed by a series of questions addressing the nature and treatment of the problem described. High-risk and symptomatic participants were more likely than low-risk participants to report that they would not approach anyone for advice or help, were they to have BN or a similar problem, because they would not want anyone to know. Symptomatic participants were more likely to believe that someone with BN would be discriminated against, more likely to consider bulimic behaviors to be acceptable, and more likely to view BN as being common among women in the community, than low-risk participants, participants in the high-risk group being intermediate on each of these questions. The findings suggest that the attitudes and beliefs of individuals with eating disorder symptoms differ systematically from those of individuals at high risk, but who do not yet have symptoms, and from those at low risk. They also indicate specific attitudes and beliefs that may need to be addressed in prevention and early intervention programs. The potential benefits of assessing individuals' attitudes and beliefs concerning the nature and treatment of eating-disordered behaviour and tailoring program content accordingly may be worthy of investigation.

Introduction: Medical student concern that the submission of named examination scripts to examiners could cause bias initiated a study on the effect of identified and de‐identified scripts on assessment outcome. Methods: Data were collected from a convenience examination sample of Year 1 (n = 88 students; n = 29 questions) and Year 2 scripts (n = 75 students; n = 27 questions). Scripts were randomised for presentation to examiners with or without identification for all of a given student's work. Assessment outcomes, by year and marking condition, were a non‐normal distribution. Results: Non‐parametric analysis determined that there were no systematic differences in assessment outcome under the two marking conditions (MW < 0.05). Conclusion: We continue for a range of pedagogical reasons to present identified papers to examiners. Importantly, this study also demonstrates a research‐led approach to resolving student queries.

In this study conducted with 80 first‐year students in a graduate medical course at the Australian National University, Canberra, students’ critical thinking skills were assessed using the Watson‐Glaser Critical Thinking Appraisal (Forms A and B) in a test‐retest design. Results suggested that overall subjects retained consistent patterns of ability in critical thinking over the year. Subjects aged 30 years and over were more likely to perform better on the tests than subjects aged under 30. However, there was a significantly lower group mean on Form B than on Form A. Subjects with an above‐mean score on Form A, or subjects aged 30 years and over, were more likely to be associated with a reduced score on Form B than were subjects with a below‐mean score on Form A, or aged less than 30 years. In motivational terms, it is suggested that subjects who had more highly developed critical thinking skills, and older subjects, conducted a more realistic effort/reward analysis before the administration of Form B, a...

This study is a randomised controlled trial comparing outcomes from an 8-week Interpersonal Psychotherapy group (IPT-G) for postnatal depression with 'treatment as usual' (TAU), conducted in a routine community setting in the Australian Capital Territory (ACT). Eligible women were recruited and randomly assigned to either IPT-G or TAU conditions. This study compared outcomes on such variables as depressive symptoms, marital adjustment, social support and mother-infant bond at baseline, mid-treatment, end-of-treatment and 3 months follow-up. Participants were also independently assessed using the Hamilton Depression Rating Scale (HAM-D). 50 women completed baseline assessments and were included in the analysis. Comparisons of treatment conditions showed that by end of treatment both the TAU and IPT-G groups significantly improved in terms of mean depression scores, however, the IPT-G women improved significantly more and had continued improvements at 3 months post therapy. Furthermore, women who received IPT-G displayed significant improvement in terms of marital functioning and perceptions of the mother-infant relationship compared to TAU participants. These findings highlight the potential benefits of an interpersonally based treatment, which not only improves outcomes for the mother but also potentially for the couple and the infant when compared to usual care.

Aim: We hypothesize that a reason for the infrequent uptake of treatments by people with eating disorders is poor knowledge about treatments and outcomes for eating disorders (ED-Mental Health Literacy; ED-MHL). Our aim was to test putative health benefits of a brief ED-MHL intervention. Methods: In a community-based two-phase survey, 122 young women (mean age 28.5 SD 6.3 years) with ED symptoms meeting DSM-IV criteria for clinical severity were randomized to receive either a brief ED-MHL intervention (comprising information about efficacious treatments, reputable self-help books and where to go for further information and/or services) or information about local mental health services only. All were given feedback on their scores on measures of ED symptoms and quality of life. ED-MHL, ED symptoms and health-related quality of life were assessed prior to the intervention and at 6- and 12-month follow-up. Results: One hundred and two participants (84%) completed follow-up at 12 months. Symptomatic improvement and changes in specific aspects of ED-MHL, namely, less pessimism about how difficult EDs are to treat and improved recognition and knowledge, as well as increased help seeking, were observed in both groups. Differences between groups were uncommon but compared with control participants, those in the intervention group had improved health-related quality of life. Conclusions: A brief community-based intervention aimed to improve knowledge and beliefs about EDs and their treatments may be a valuable first step in improving health-related outcomes for people with ED, but more research is needed.

Aim: To assess cognitive function prospectively in women with early breast cancer before, during and after the administration of adjuvant chemotherapy. Methods: Between May 2000 and November 2001, 35 assessable patients were entered into the study. Thirty-one received oral cyclophosphamide, methotrexate and 5-fluorouracil (CMF) and four received epirubicin and cyclophosphamide followed by CMF ((cyclophosphamide, methotrexate and 5-fluorouracil)). Testing consisted of the completion of a battery of neuropsychological and psychological inventories and was performed prior to chemotherapy and repeated after 3 (n = 31) and 6 months (n = 30) of chemotherapy and also 6 months after the completion of chemotherapy (n = 27). Results: Prior to chemotherapy a proportion of the patients already exhibited some evidence of impairment of cognitive function. However, on completion of chemotherapy, the neuropsychological scores for short-term verbal memory and verbal learning were significantly lower than prior to, or 6 months after chemotherapy. In all other domains, cognitive function either remained constant or even appeared to improve. Symptom scales showed that fatigue, nausea and vomiting, constipation and diarrhea were worst half way through the chemotherapy. Quality of life scales indicated that functioning was best after completion of chemotherapy. Conclusion: Patients with early breast cancer may have impaired cognitive function before chemotherapy. Although transient deteriorations in verbal memory and verbal learning were observed on completion of chemotherapy, overall, cognitive function did not decline. It is likely that practice effects influenced our findings.

Objective: To examine levels of eating disorder behaviours and cognitions of young women with obesity in the Australian Capital Territory, Australia and assess the impact upon psychological status. Design: General population cross-sectional survey. Subjects: A total of 4891 young women from the community aged 18–42 years, of which 630 were in the obese weight range. Measurements: Body mass index (BMI), eating disorder psychopathology (eating disorder examination questionnaire), and psychological distress (K-10). Results: Women with obesity had significantly higher levels of dietary restraint, eating concern, weight concern, shape concern, binge eating, misuse of diuretics, use of diet pills and fasting compared to other women in the community. These eating disorder cognitions and behaviours were associated with increased levels of psychological distress. In women with obesity, eating concern, weight concern, shape concern, dietary restraint and decreased age predicted psychological distress in a multivariate model. Among other women in the community, behaviours such as laxative misuse, 'hard' exercise and subjective bulimic episodes also contributed to the model predicting psychological distress. Conclusion: As disordered eating psychopathology is high in young obese women and negatively impacts upon psychological status, obesity prevention and treatment should consider eating disorder psychopathology and mental health outcomes.

Background and objectives The effects of questionnaire length and mode of delivery on response rates were examined in an epidemiological study of eating-disordered behavior. Methods Short (8 pages) and long (14 pages) questionnaires were posted or hand-delivered to a community sample of 802 women. Nonrespondents who received the first questionnaire by hand delivery received a reminder letter and replacement questionnaire by post; those who received the initial questionnaire by post were further randomized to receive the first reminder by hand delivery or by post, in short or long form. A second reminder letter and questionnaire (in short or long form) were posted to all remaining nonrespondents. Results The overall response rate was 52.9%. This is a conservative estimate of true response, because in a substantial proportion of cases (12.2%) individuals were no longer resident at the listed address. There was a significant effect of mode of delivery on response, favoring hand delivery, at both the initial mailout and first reminder. There was no effect of questionnaire length on response to the initial mailout, although overall response was significantly higher for the longer form. It was estimated that an overall response of 58.0% would have been achieved had first reminders been hand-delivered to all nonrespondents who received the initial mailout by post. Conclusions Delivery of questionnaires by hand may be an effective way to increase response rates in epidemiological research, but little is to be gained by reducing questionnaire length.

Objective: Although the efficacy of a number of psychotherapeutic interventions has been well established in tightly controlled, randomized trials, there remains a paucity of literature examining the effectiveness of these interventions in community practice settings. In light of this, the Australian Capital Territory Mental Health Services (Canberra, ACT) set out to investigate the effectiveness of an empirically supported psychotherapeutic intervention, interpersonal psychotherapy (IPT). The present study describes a pilot evaluation of the training programme for health professionals and the IPT treatment programme. Methods: Forty community mental health professionals participated in intensive IPT training. Clinicians who completed a course of supervision were asked to apply the treatment with non-psychotic acutely depressed patients. Measures of patients’ health outcomes were taken before and after treatment using a standardized outcome measure. Results: A total of 17 out of 21 patients who were selected completed a course of 12–16 weeks of IPT. The majority of the patients had a depression originating in the post-partum period. A comparison of pre- and post-treatment scores of treatment completers revealed a significant decrease in mean depression scores. Clinicians who completed a course of training and supervision found that they were able to confidently apply IPT in a clinical setting. Conclusions: Although there were a number of barriers and obstacles to the introduction of an evidenced-based treatment, the results are promising and demonstrate that IPT can be readily taught to experienced mental health professionals. Further study is required to determine the feasibility of IPT in other non-academic settings using larger sample sizes and homogenous groups of patients.

Objective: To examine trends in the use of oral conventional, depot and atypical antipsychotic medications in Australian States and Territories between 1995 and 2001. Methods: For each 6 month interval between July 1995 and December 2001, prescription data obtained were converted into a measure of drug utilization expressed as the number of defined daily doses per thousand population per day (DDDs/1000/day). Data concerning the major specialty of the prescriber were available for the period 1996–2000. Results: In each State and Territory, use of atypical antipsychotic medications increased markedly while use of oral conventional and depot medications declined. Between July 2001 and December 2001, the proportion of total prescriptions for antipsychotic medications accounted for by prescriptions for atypical medications varied from 63.1% in South Australia to 76.1% in the Australian Capital Territory (ACT). Relative use of atypical medications was higher in the ACT than in other regions, while relative use of depot medications was higher in the Northern Territory than in other regions. During the year 2000, the proportion of prescriptions for oral conventional and depot medications written by general practitioners (GPs) exceeded 75% in all regions other than the ACT. Between 1996 and 2000, the proportion of prescriptions for atypical medications written by GPs increased markedly in all regions but remained lower than for oral conventional and depot medications. Conclusions: Atypical antipsychotic medications have replaced conventional medications as the first-line pharmacological treatment for psychotic disorders in all regions of Australia. Continued expansion of programmes designed to foster collaboration between GPs and mental health services will be essential in achieving optimal prescribing of antipsychotic medications.

Objective: The aim of this review was to examine the level of evidence supporting the assumed link between a positive therapeutic alliance among patients and case managers and effective outcome for patients with a mental illness who are managed in community mental health services. Method: MedLine, PsychINFO and Social Sciences Index search of articles from 1986 to 2001 returned 84 articles and two texts. Inclusion criteria were the use of validated measures and relevance to psychiatry and community case management. Results: A definite correlation exists in the psychotherapy literature between the therapeutic relationship and improved outcomes, with its potential as a prognostic indicator acknowledged. Attempts to apply the concept to patients outside the field of psychotherapy have been slow, although expansion of the concept to other forms of change-inducing therapy was a current trend. Issues of definition, quantification and measurement of the relationship caused rigorous debate in the literature. Case management research demonstrating the importance of the therapeutic relationship and ‘goodness-of-fit’ between patients and case managers was sparse with no published Australian studies. Conclusions: The level of evidence supporting the link between the therapeutic alliance of patients with mental illness and improved outcomes although sparse is encouraging. It indicates the potential of the alliance as a predictor of outcome for patients engaged in case management services in community mental health. Research to determine the role and effectiveness of the alliance in the patient/case manager dyad is needed to define this potential. Effectiveness of clinical practice in the case management field could be enhanced if research findings confirmed the genesis and value of the alliance in case management. Focus on relationship strategies as a clinical tool gives the clinician and service provider a potential vehicle for promoting partnerships with the seriously mentally ill person in managing their illness and optimizing their strengths in the community.

The focus of the present study was to examine the extent of noncompliance in psychiatric aftercare in an integrated hospital and community mental health service. Characteristics of those patients who were noncompliant were explored in order to facilitate the prediction of treatment noncompliance at the point of discharge from hospital. A consecutive cohort of patients discharged from an acute psychiatric general hospital unit into an integrated community mental health service provided data regarding demography, disease state, attitude to treatment and actual treatment availed in aftercare. At six months follow-up 36% of the initial cohort of 128 patients had met the study criteria of noncompliance in psychiatric aftercare. A number of demographic and clinical criteria distinguished this group including the engagement in skilled employment and the presence of an anxiety rather than psychotic disorder. Noncompliant patients were less symptomatic with more disturbed behavior than those patients remaining in treatment. Noncompliant patients were significantly more likely to have a case manager of lesser experience, to have committed serious crimes and to have predicted their default from treatment at the time of discharge. Noncompliance in psychiatric aftercare persists (despite the availability of integrated hospital and community mental health services) raising the question of the goodness of fit between patient need and service provision.

The purpose of this study was twofold: to examine the patient characteristics at discharge from an acute psychiatric unit that were associated with an increased likelihood of rehospitalization within the following six months, and to examine the relationship between rehospitalization and the nature of psychiatric aftercare in a well-integrated hospital and community based psychiatric service. The study reviewed the extent of psychiatric rehospitalization following the closure of large numbers of institutional psychiatric beds. At six months after discharge 38% of the patients had been readmitted to an institution, most commonly a hospital. Despite the provision of an integrated hospital and community health service with excellent welfare support, dissatisfaction with finances independently exerted an influence on the risk of readmission. Implications for future research and treatment planning are discussed focussing on the complex integration of health and welfare services.

Background: In order to elucidate the individual and community health burden of body dissatisfaction (BD), we examined impairment in quality of life associated with BD in a large, general population sample of women. Methods: Self-report measures of BD, health-related quality of life (SF-12 Physical and Mental Component Summary scales) and subjective quality of life (WHOQOL-BREF Psychological Functioning and Social Relationships subscales) were completed by 5,255 Australian women aged 18 to 42 years. Results: Most participants (86.9%) reported some level of dissatisfaction with their weight or shape and more than one third (39.4%) reported moderate to marked dissatisfaction. Higher levels of BD were associated with poorer quality of life for all items of both quality of life measures, the degree of impairment being proportional to the degree of BD. Associations were strongest for items tapping mental health and psychosocial functioning, although greater BD was associated with substantially increased risk of impairment in certain aspects of physical health even when controlling for body weight. Post-hoc analysis indicated that the observed associations between BD and quality of life impairment were not accounted for by an association between BD and eating disorder symptoms. Conclusions: In women, BD is associated with marked impairment in aspects of quality of life relating to mental health and psycho-social functioning and at least some aspects of physical health, independent of its association with body weight and eating disorder symptoms. Greater attention may need to be given to BD as a public health problem. The fact that BD is “normative” should not be taken to infer that it is benign.

Background: Effective feedback is instrumental to effective learning. Current feedback models tend to be educator driven rather than learner-centred, with the focus on how the supervisor should give feedback rather than on the role of the learner in requesting and responding to feedback. Context: An alternative approach emphasising the theoretical principles of student-centred and self-regulated learning is offered, drawing upon the literature and also upon the experience of the authors. Innovation: The proposed feedback model places the student in the centre of the feedback process, and stresses that the attainment of student learning outcomes is influenced by the students themselves. This model emphasises the attributes of the student, particularly responsiveness, receptiveness and reflection, whilst acknowledging the important role that the context and attributes of the supervisor have in influencing the quality of feedback. Implications: Educational institutions should consider strategies to encourage and enable students to maximise the many feedback opportunities available to them. As a minimum, educators should remind students about their central role in the feedback process, and support them to develop confidence in meeting this role. In addition, supervisors may need support to develop the skills to shift the balance of responsibility and support students in precipitating feedback moments. Research is also required to validate the proposed model and to determine how to support students to adopt self-regulatory learning, with feedback as a central platform.

Objective The study sought to identify the types of housing preferred by people with psychiatric disabilities seeking accommodations through a community mental health service in Sydney, Australia. Methods Housing options available in the mental health service's catchment area were identified, and the extent of demands on residents' behavior that was associated with each option was assessed using an established measure. Clients examined descriptions of each housing option and rank-ordered the options based on their preferences. Clients' current levels of functioning and symptoms were also assessed. Results Clients most preferred environments that ensured living alone in settings of low behavioral demand. Living in one's own home was the most preferred option, followed by living in government-subsidized housing, For-profit boarding houses were preferred over psychiatric group homes, and homelessness, long-term hospitalization, and crisis accommodations were least preferred. Shelter, privacy, food, and safety were highly valued housing attributes. Demographic characteristics, level of functioning, and severity of psychiatric symptoms did not predict accommodation preferences. Conclusion Consumers' resistance to psychiatric group housing with high levels of behavioral demand is unrelated to consumer characteristics and should be considered in planning suitable accommodations for persons with psychiatric disabilities.

One hundred oncology patients from a major teaching hospital and their treating health staff were studied in the second phase of research examining attitudes towards cardiopulmonary resuscitation (CPR). A descriptive approach was used incorporating semistructured interviews of patients and established questionnaire measures, examining knowledge of and attitude towards disease and treatment, psychological functioning, and current and projected attitude toward resuscitation. Health staff also participated in a semistructured interview. This phase of the project focused particularly on a direct comparison of patient and staff assessments. In current circumstances, 10% of patients refused resuscitation. This was associated with disease of good prognosis. In a future hypothetical deteriorated scenario presented to patients, 39% declined resuscitation. This was associated with a past history of suicidal behavior. In current circumstances, health staff designated 14% of patients “Do-Not-Resuscitate” (DNR)—this was associated with a number of variables considered to predict poor outcome in resuscitation. In the future scenario, staff designaied 54% of patients DNR—this was associated again with poor resuscitation outcome variables, but also independently, with a past psychiatric history. Comparison of patient and health staff preferences for resuscitation showed moderate yet significant concordance in current circumstances but not in the future scenario. The findings indicate firstly the feasibility of discussing resuscitation preferences with seriously ill patients and secondly an urgent need to improve patient and staff discussions regarding resuscitation, as staff and patients' attitudes to resuscitation differ.

One hundred patients with cancer were interviewed regarding their attitude to a range of final life events in both their current real and hypothetical future circumstances. Patients who anticipated a future possible role for the more passive options of wishing death to come early or ceasing all treatment, were more hopeless and had a reduced quality of life. Patients however who anticipated a role for the more active options of suicide and/or euthanasia were less fatalistic and did not report a reduced quality of life. The desire for suicide was particularly positively related to younger age, a personal psychiatric past history, and a number of treatment-related variables reflecting increased patient autonomy.

Summary Background: With the increasing emphasis on ambulatory health care, clinical educators need to ensure that students are sufficiently prepared to maximise learning opportunities during placements in ambulatory settings. Context: This study focuses on third-year medical students entering urban or rural clinical placements at an Australian graduate entry medical school. Innovation: All rural and a subset of urban students received intensive training in taking Papanicolaou (Pap) smears prior to starting the clinical placement. Training involved gynaecological teaching associates, active practice and real-time feedback. Evaluation included workshop feedback, reflection on effectiveness during the placement, and comparison of trained and untrained students’ recorded clinical experience of taking Pap smears. Implications: Students given pre-placement training praised their learning experience, and on average took more Pap smears during their placement than did their untrained peers. The difference, however, did not reach statistical significance. The pre-placement teaching workshop on a difficult skill was popular and worthy of further study regarding other challenging clinical skills.

Rural health workforce issues are a priority area for the Australian Government and substantial funding has been provided for rural education programs to address health workforce disparities across Australia's rural and remote communities. The Australian Government established a Rural Health Strategy in 2001 and as a result there are now 14 rural clinical schools in Australia. The 2008 Urbis Report highlighted the lack of research on rural programs and workforce outcomes, essential to ensuring that educational efforts, resources and funding are being concentrated appropriately. This study examined the Australian National University (ANU) Medical School's 4 year rural program to identify the impact of elective and compulsory program components on student intentions to practice in a rural and remote location post-graduation. The study also explores factors that affect student decisions to apply for year-long rural placements. METHODS; ANU Medical School's graduating cohort of 2008 fourth year medical students completed an anonymous and voluntary online survey questionnaire. Survey sections included student demographics, compulsory and elective components of the ANU rural program, and an overall evaluation of the ANU rural curriculum. The survey contained a mixture of forced-answer questions and open-ended commentary. Quantitative data were analyzed for descriptive and frequency statistics using EpiInfo V3.5.1 (a href='http://wwwn.cdc.gov/epiinfo/' target='_blank'http://wwwn.cdc.gov/epiinfo/). Qualitative data were reviewed and consistent themes among responses extracted.In total, 40 students from a cohort of 88 (45%) responded, with 26 respondents (65%) indicating that at medical school commencement they considered working in a rural or remote area. At the end of their medical education, 33 respondents (82%) indicated their intention to spend some time in their careers working in a rural or remote area. Students from non-rural backgrounds had greater positive change in their intentions to practice rurally as a direct effect of ANU rural programs when compared with students from rural backgrounds. More than 70% of students believed the amount of rural focus in the curriculum was correct, 75% believed that they will be better medical practitioners because of the program, and 85% found the curriculum was delivered effectively. Students who undertook elective rural programs such as a year-long rural placement were more likely to have future rural career intentions when compared with students undertaking compulsory rural components. Compulsory components, however, had a strong influence on students applying for elective programs. Regarding application for the year-long rural placement, students reported clinical exposure was the most encouraging factor, and time away from family and friends, and lack of spousal and family support were the most discouraging factors.Rural programs at the ANU, and medical school exposure to rural health experiences is important in influencing students' perceptions of a career in rural and remote health. This study provides evidence that both compulsory and elective components contribute to a successful holistic rural program which nurtures the rural interest of all students. Overall, students at the ANU medical school were satisfied with the rural curriculum. The results confirm that there is difficulty in recruiting students with family commitments into year-long rural placement programs, despite incentives. Those students who select long-term rural study for reasons other than an interest in a career in rural health end the program with positive rural intentions.

One hundred oncology and hematology cancer patients from a major teaching hospital and their treating doctors were studied regarding their attitudes toward cardiopulmonary resuscitation (CPR). A descriptive approach was used, incorporating semistructured interviews of patients and medical staff and established questionnaire measures, examining knowledge of and attitudes toward disease and treatment, and projected attitude toward CPR and current psychological functioning. One-third of the patient sample anticipated a time when they would not consent to cardiopulmonary resuscitation. This was significantly associated with good disease prognosis. Patients with a psychiatric past history were also overrespresented. It appears that patient attitude to treatment withdrawal and refusal of CPR is related to disease progression and likely to change over time. This supports a dynamic and evolving model of advance directives rather than any fixed decree. Medical staff reported that they planned to provide half the sample with intensive medical treatment (including Intensive Care support in the event of their cardiac arrest), and 32% were designated for ward-based resuscitation only. Eighteen percent would not be resuscitated. These patients were older, had more treatment side effects, and a poorer quality of life. Those patients with either a psychiatric past history or higher ratings of depressive affect were also overincluded in the doctors' "Do-Not-Resuscitate" (DNR) group. These results suggest that there are other qualitative factors (e.g., current psychological functioning and past psychiatric history) that contribute to DNR decisions beyond the usual disease-based criteria seen in formal DNR protocols.

One hundred oncology patients from a major teaching hospital were asked about their attitudes to a number of final life events including active withdrawal from treatment, the refusal of cardiopulmonary resuscitation, suicide and euthanasia. A descriptive approach was used incorporating semi-structured interviews and established questionnaire measures. One third of the patient sample anticipated some role for taking active steps to end their own lives. This was not restricted to those currently psychologically disturbed nor to any particular demographic subgroup. Patients with more severe illness or poor prognosis did not express interest in suicide and euthanasia. A positive past psychiatric history increased the potential for seeing suicide as an option. The results have significant implications for the establishment of patient care protocols in final life events.

Purpose. This study considered how a peer review process could work in an Australian public hospital setting. Method. Up to 229 medical personnel completed an online performance assessment of 52 Junior Medical Officers (JMOs) during the last quarter of 2008. Results. Results indicated that the registrar was the most suitable person to assess interns, although other professionals, including interns themselves, were identified as capable of playing a role in a more holistic appraisal system. Significant sex differences were also found, which may be worthy of further study. Also, the affirmative rather than the formative aspect of the assessment results suggested that the criteria and questions posed in peer review be re-examined. Conclusion. A peer review process was able to be readily implemented in a large institution, and respondents were positive towards peer review generally as a valuable tool in the development of junior medical staff. What is known about the topic? The literature generally concurs that peer review is a useful tool in professional development and can provide a rounded view from diverse sources about a peer’s professional performance. It has been implemented in at least one Canadian medical facility as a mandatory process. What does this paper add? Our study identifies who is considered the most suitable peer(s) to assess interns, various substantive issues about peer review and about the process itself, and raises questions about the voluntary v. mandatory nature of peer review. It is the first study to trial peer review amongst interns in an Australian hospital. What are the implications for practitioners? That peer review is a suitable tool in professional development and generally supported in our study, suggesting that it could be implemented into Australian healthcare practice. However, education about the nature and value of peer review would be required amongst healthcare professionals, and the use of peer review could imply greater managerial engagement in medical practice. Peer review is a more effective assessment tool than that currently employed in many Australian hospitals.

We compared the health burden of eating-disordered behavior with that of overweight in a community-based sample of women aged 18-42 years residing in the Australian Capital Territory region of Australia. Participants (n = 4643) completed self-report measures of eating disorder psychopathology, health-related quality of life and health service utilization. Body mass index (BMI) was derived from self-reported height and weight.Overweight was associated with marked impairment in physical health functioning and comparatively little impairment in psychosocial functioning, whereas eating-disordered behavior was associated with marked impairment in psychosocial functioning and comparatively little impairment in physical health functioning. Further, (1) impairment in psychosocial functioning associated with eating-disordered behavior was greater than impairment in physical health functioning associated with overweight, and (2) impairment in physical health functioning associated with eating-disordered behavior was greater than impairment in psychosocial functioning associated with overweight. Overweight and eating-disordered behavior were associated with similarly elevated rates of primary care consultations during the past 6 months and of lifetime treatment from a health professional for an eating or weight problem.In young adult women, the health burden of eating-disordered behavior may be more substantial than previously recognized. Better information concerning the spectrum of disordered eating that exists at the population level needs to be made available. Eating-disordered behavior warrants greater attention when considering the public health burden of obesity and in developing programs to reduce this burden.

Background: Prior use of health services was examined in a community sample of women with bulimic-type eating disorders. Method: Participants (n = 159) completed a structured interview for the assessment of eating disorder psychopathology as well as questions concerning treatment-seeking and type of treatment received. Results: Whereas a minority (40.3%) of participants had received treatment for an eating problem, most had received treatment for a general mental health problem (74.2%) and/or weight loss (72.8%), and all had used one or more self-help treatments. Where treatment was received for an eating or general mental health problem, this was from a primary care practitioner in the vast majority of cases. Only half of those participants who reported marked impairment associated with an eating problem had ever received treatment for such a problem and less than one in five had received such treatment from a mental health professional. Conclusion: Women with bulimic-type eating disorders rarely receive treatment for an eating problem, but frequently receive treatment for a general mental health problem and/or for weight loss. The findings underscore the importance of programs designed to improve the detection and management of eating disorders in primary care. © 2007 by Wiley Periodicals, Inc. Int J Eat Disord 2007

The correlates of self-induced vomiting and laxative misuse were examined in a large community sample of young adult women (N = 5255). Scores on measures of eating disorder psychopathology, general psychological distress, functional impairment, as well as the use of health services for an eating or weight problem were compared among participants who reported regular self-induced vomiting, but not laxative misuse (N = 59), and those who reported regular misuse of laxatives, but not vomiting (N = 39). Individuals who misused laxatives were older, perceived poorer physical health, and were less likely to have sought treatment specifically for a problem with eating than those who engaged in self-induced vomiting. In all other respects, the groups were similar. However, individuals who regularly engaged in both forms of purging (N = 8) had particularly high levels of eating disorder and comorbid psychopathology. The perception among women of normal weight that only syndromes involving the use of self-induced vomiting constitute an eating disorder may need to be addressed in prevention programs. The combination of self-induced vomiting and laxative misuse may indicate a particularly severe psychiatric disturbance.

In 2002, Epstein and Hundert undertook a review of all medical literature that studied the reliability and validity of measures of the clinical or professional competence of clinicians, medical students and residents to consider current assessment formats for doctors and trainees. They noted that current means of assessment test core knowledge and skills reliably, with the most commonly used assessment methods identified as: multi-choice examinations to evaluate factual knowledge and abstract problem solving, standardised patient assessments of physical examination and technical and communication skills. However, Epstein and Hundert also observed that assessment formats under-emphasise some important domains, including professionalism.

Background Rates of trauma and Posttraumatic Stress Disorder (PTSD) were examined in order to compare the profile in clients of an Australian Public Mental Health Service with that reported in the international literature for clients with major mental illness and to explore the effect of this on client health outcomes. Potential factors contributing to increased levels of trauma/PTSD in this group of clients and the issue of causality between PTSD and subsequent mental illness was also explored. Methods A convenience sample of 29 clients was screened for trauma and PTSD using the Posttraumatic Stress Diagnostic Scale™ (PDS) and selected outcome measures. Paired and independent samples t-test and ANOVA were applied to the data. Results High levels of undocumented trauma and PTSD were found. Twenty clients, (74%) reported exposure to multiple traumatic events; 33.3% (9) met DSM IV diagnostic criteria for PTSD. Significant difference was found for PTSD symptomatology, severity and impairment and for client and clinician-rated scores of Quality of Life (QOL) outcomes in the PTSD group. No effect for PTSD symptomatology on the Working Alliance (WA) was found. Factors that may influence higher rates of PTSD in this group were identified and included issues associated with the population studied, the predominance of assaultive violence found, and vulnerability and risks factors associated with re-traumatisation within the social and treating environments. Conclusion A similar trauma and PTSD profile to that reported in the international literature, including greater levels of trauma and PTSD and a poorer QOL, was found in this small sample of clients. It is postulated that the increased levels of trauma/PTSD as reported for persons with major mental illness, including those found in the current study, are primarily related to the characteristics of the population that access public mainstream psychiatric services and that these factors have specific implications for service delivery, and raise issues of efficiency and effectiveness of resource use in achieving successful outcomes in public mental health services for clients with co-morbid PTSD. Further research with a more rigorous design is needed to test these preliminary findings within Australian Community Mental Health Services.

Objective: to examine disability associated with community cases of the more commonly occurring eating disorders and with particular eating disorder behaviours. Method: self-report questionnaires, which included measures of eating disorder symptoms and impairment in everyday functioning, were completed by 495 female residents of the Australian Capital Territory region aged between 18 and 45 years. A structured interview for the assessment of eating disorders was completed by a subgroup (n=208) of participants. Discriminant function analysis was used to identify cases of eating disorders in the total sample (n=495) based on the characteristics of individuals interviewed. Impairment in functioning, as measured by the Medical Outcomes Study Short Form, was compared among eating disorder cases and non-cases, among subgroups of participants engaging in particular eating disorder behaviours, and among community cases of anxiety and affective disorders identified from the Australian National Survey of Mental Health and Well-Being. Results: community cases of eating disorders (n=31; 6.3%) were associated with substantial impairment in functioning, comparable with that of community cases of anxiety and affective disorders. Among eating disorder behaviours, the use of extreme weight-control behaviours, in particular self-induced vomiting, was associated with the highest levels of impairment, although the occurrence of regular episodes of overeating was also associated with considerable impairment. Conclusions: the burden on the community of the more commonly occurring eating disorders may be substantial. Improving women's recognition of the adverse effects of eating disordered-behaviour on functioning, as well as their knowledge of effective treatments, will be important in reducing this burden.

Objective To examine the beliefs of women concerning the helpfulness of various possible interventions for bulimia nervosa. Method Face-to-face interviews were conducted with a community sample of 208 women aged 18–45 years. Respondents were presented with a vignette describing a fictional person meeting diagnostic criteria for bulimia nervosa and were asked to indicate whether various persons, treatments, medications, and self-help activities would be helpful, harmful, or neither helpful nor harmful for the person described. Results Respondents indicated that seeing a general practitioner (GP), counselor, or dietitian was more likely to be helpful than seeing either a psychologist or a psychiatrist. GPs were perceived as the individuals likely to be most helpful for the problem described, and most likely to be approached first, whereas counseling was regarded as the most helpful treatment. Self-help interventions, including the use of vitamins and minerals, were also highly regarded, while a minority of participants believed that anti-depressant medication would be helpful. Conclusions Information concerning treatments that are effective for eating disorders should be included in prevention programs. Collaborations between mental health specialists and primary health providers are vital to ensure the optimal treatment of eating-disordered behavior. © 2004 by Wiley Periodicals, Inc. Int J Eat Disord 36: 62–68, 2004.

The involvement of women with mental health problems in cancer screening was examined in order to explore service delivery options among this particular group. Structured interviews were used to identify the utilization of cancer screening and barriers experienced in accessing such screening among this group. The sample of women reported similar utilization rates of cancer screening as the general female population of the same Australian state. However, they identified a number of barriers to effective access to cancer screening. In response to the interview finding that consumers valued screening services from a well-known provider in a familiar environment, a series of women's health clinics were offered within a mental health service. This experience is described and was used to try to better understand barriers to cancer screening experienced by women with mental health problems. The women's health clinics were most efficiently offered in conjunction with hospital-based psychiatric services.

Objective: A model of intermittent psychiatric service provision to rural and remote New South Wales communities by metropolitan psychiatrists and mental health professionals has been evaluated. The services provided included peer support to lone mental health and generic health workers, direct psychiatric care to clients in their own environment and skills development education sessions to general health staff and other professionals affiliated with health care (e.g. police and ambulance officers). Method: There were 10 visits of teams made up of a psychiatrist and another mental health professional to six rural and remote locations. Outcomes of the services delivered were examined including clinical services and teaching skills training sessions. Indirect outcome measures included changes to Pharmaceutical Benefits Scheme prescription patterns in areas serviced and data regarding transfer of clients for psychiatric care in regional centres. Difficulties in evaluation are discussed. Results: The feasibility of intermittent service provision was demonstrated. Education packages were well received and a positive change in workers' attitudes toward mental health practice was found. Conclusion: Intermittent psychiatric services in remote settings add value to health care delivery particularly when dovetailed with skills-based education sessions.

Objective. To compare the uptake of peer review among interns in mandatory and voluntary peer-review programs. Population. All first and second year graduates (n = 105) in two Australian hospitals. Main outcome measures. Completion of peer review, and reported responses by doctors to peer review. Results. Eight of sixty interns undertaking the mandated program completed all steps. In the voluntary program, none of 45 interns did so. Resistance to peer review occurred at all stages of the trial, from the initial briefing sessions to the provision of peer-review reports. Discussion. Hospital internship is a critical period for the development of professional identity among doctors. We hypothesise that resistance to peer review among novice doctors reflects a complex tension between the processes underpinning the development of a group professional identity in hospital, and a managerial drive for personal reflection and accountability. Peer review may be found threatening by interns because it appears to run counter to collegiality or ‘team culture’. In this study, resistance to peer review represented a low-cost strategy in which the interns’ will could be asserted against management. Conclusion. To enhance uptake, peer review should be structured as key to clinical development, and modelled as a professional behaviour by higher-status colleagues. What is known about this topic? In non-clinical settings, peer review can lead to improvements in performance. Studies in the US and Canada have demonstrated that junior doctors in hospital have low rates of uptake of peer review. What does this paper add? In Australia, junior doctors had low rates of engagement with both mandatory and voluntary peer review. Peer review may be resisted because it threatens to undermine the collegiate atmosphere among hospital peers. What are the implications for practice? Peer review should be modelled as professional behaviour by higher-status colleagues, especially registrars and consultants, and presented as central to improvement in clinical skills.

Background The aim of this study was to research the feasibility of training mental health consumers as tutors for 4th year medical students in psychiatry. Methods A partnership between a consumer network and an academic unit in Psychological Medicine was formed to jointly develop a training package for consumer tutors and a curriculum in interviewing skills for medical students. Student attitudes to mental health consumers were measured pre and post the program. All tutorial evaluation data was analysed using univariate statistics. Both tutors and students evaluated the teaching program using a 4 point rating scale. The mean scores for teaching and content for both students and tutors were compared using an independent samples t-test. Results Consumer tutors were successfully trained and accredited as tutors and able to sustain delivery of tutorials over a 4 year period. The study found that whilst the medical students started with positive attitudes towards consumers prior to the program, there was a general trend towards improved attitude across all measures. Other outcomes for tutors and students (both positive and negative) are described. Conclusions Consumer tutors along with professional tutors have a place in the education of medical students, are an untapped resource and deliver largely positive outcomes for students and themselves. Further possible developments are described.

Background This study was designed to assess the motivations of senior medical clinicians to teach medical students. This understanding could improve the recruitment and retention of important clinical teachers. Methods The study group was 101 senior medical clinicians registered on a teaching list for a medical school teaching hospital (The Canberra Hospital, ACT, Australia). Their motivations to teach medical students were assessed applying Q methodology. Results Of the 75 participants, 18 (24%) were female and 57 (76%) were male. The age distribution was as follows: 30–40 years = 16 participants (21.3%), 41–55 years = 46 participants (61.3%) and >55 years = 13 participants (17.3%). Most participants (n = 48, 64%) were staff specialists and 27 (36%) were visiting medical officers. Half of the participants were internists (n = 39, 52%), 12 (16%) were surgeons, and 24 (32%) were other sub-specialists. Of the 26 senior clinicians that did not participate, two were women; 15 were visiting medical officers and 11 were staff specialists; 16 were internists, 9 were surgeons and there was one other sub-specialist. The majority of these non-participating clinicians fell in the 41–55 year age group. The participating clinicians were moderately homogenous in their responses. Factor analysis produced 4 factors: one summarising positive motivations for teaching and three capturing impediments for teaching. The main factors influencing motivation to teach medical students were intrinsic issues such as altruism, intellectual satisfaction, personal skills and truth seeking. The reasons for not teaching included no strong involvement in course design, a heavy clinical load or feeling it was a waste of time. Conclusion This study provides some insights into factors that may be utilised in the design of teaching programs that meet teacher motivations and ultimately enhance the effectiveness of the medical teaching workforce.

To help predict aggressive and violent behaviors, the frequency and types of these behaviors in acute psychiatric inpatient settings were examined, and potential interactions between staffing and patient mix and rates of the behaviors were explored.Data on violent incidents were gathered prospectively in three adult acute psychiatric units in a general hospital and two units in a primary psychiatric hospital in Sydney, Australia. Staff recorded violent and aggressive incidents, which were ranked on an 8-level scale. They also completed weekly reports of staffing levels and patient mix. Poisson regression analysis was used to calculate relative rates, 95 percent confidence intervals, and p values.A total of 1,289 violent incidents were recorded over a seven-month period. Based on the scale, 58 percent of the incidents were serious. Seventy-eight percent were directed toward nursing staff. Complex relationships between staffing, patient mix, and violence were found. Relative risk increased with more nursing staff (of either sex), more nonnursing staff on planned leave, more patients known to instigate violence, a greater number of disoriented patients, more patients detained compulsorily, and more use of seclusion. The relative risk decreased with more young staff (under 30 years old), more nursing staff with unplanned absenteeism, more admissions, and more patients with substance abuse or physical illness. In total these factors accounted for 62 percent of the variance in violence.Violent incidents in psychiatric settings are a frequent and serious problem. Incidents appear to be underreported, and the seriousness of an incident does not guarantee it will be reported.

Background We sought to evaluate the hypothesis that mental health impairment in underweight women, where this occurs, is due to an association between low body weight and elevated levels of body dissatisfaction and/or eating-disordered behaviour. Methods Subgroups of underweight and normal-weight women recruited from a large, general population sample were compared on measures of body dissatisfaction, eating-disordered behaviour and mental health. Results Underweight women had significantly greater impairment in mental health than normal-weight women, even after controlling for between-group differences in demographic characteristics and physical health. However, there was no evidence that higher levels of body dissatisfaction or eating-disordered behaviour accounted for this difference. Rather, underweight women had significantly lower levels of body dissatisfaction and eating-disordered behaviour than normal-weight women. Conclusions The findings suggest that mental health impairment in underweight women, where this occurs, is unlikely to be due to higher levels of body dissatisfaction or eating-disordered behaviour. Rather, lower levels of body dissatisfaction and eating-disordered behaviour among underweight women may counterbalance, to some extent, impairment due to other factors.

Violent incidents in inpatient psychiatric settings were examined among a group of repeatedly violent patients to better understand the clinical and occupational health significance of repeated violence.Data on violent incidents were collected prospectively over seven months in five psychiatric units in Sydney, Australia. Recidivist patients--those responsible for more than 20 incidents of violence or aggression--and nonrecidivist violent patients were compared in terms of the nature of the incidents, warning signs, and staff responses to violence.Of the 174 patients involved in violent incidents, 20 (12 percent) were recidivists. These patients accounted for 69 percent of the 752 violent incidents identified. Recidivists were significantly older than nonrecidivist patients. Compared with nonrecidivists, the men recidivists were more likely to have an organic brain syndrome, and the women recidivists were more likely to have a personality disorder. When a recidivist patient was violent, staff members' response was significantly less likely to include institutional mechanisms for dealing with violence, such as contacting occupational health and safety officers, completing injury notification forms, and notifying police. Violence occurred among recidivists despite their giving more warning signs than nonrecidivists, suggesting that recidivists' threats were not taken seriously by staff, perhaps reflecting demoralization in the face of repeated violence.Even though this study focused only on serious incidents and defined recidivism narrowly, it found that recidivism of violence and aggression among psychiatric patients was a serious problem. The relative lack of response by staff members to the violent acts of recidivist patients is of concern.