1. Clinical Psychologists and Psychiatrists
How They Work Together to Produce Better Outcomes
Simone Pica
Chief Psychologist –The Melbourne Clinic

2. Areas to be Covered:
Clinical Psychologists and Psychiatrists - Health Providers
The Melbourne Clinic- The Treatment Setting
Onset of Mental Disorders and types
How we work together- Treatment Specialisations, Assessment,Treatment Planning, Provision of Treatment and Ongoing Challenges

3. Clinical Psychologists
Psychologists are specialists in human behaviour, development and functioning. They have expertise in conducting research and applying research findings in order to reduce distress, address behaviour and psychological problems, and to promote good mental health.
Today, most psychologists tend to specialise in one or more areas. To date the APS has 9 colleges including; Clinical Neuropsychology; Clinical Psychology. Couselling Psychology, Educational Psychologists and Forensic Psychologists

4. Of these specialties, Clinical Psychologists are trained to work with people with mental disorders
IN brief, Clinical Psychologists are specialists in the assessment, diagnosis and treatment of psychological problems and mental illness.
They work with children, adolescents, adults and the elderly in a range of agencies including public and private hospitals, private practice and general medical services

5. Skills and Competencies of Clinical Psychologists
1. Psychological assessment and diagnosis
Clinical psychologists have specialist training in the assessment and diagnosis of major mental illnesses and psychological problems. Clinical psychologists are qualified to provide expert opinion in clinical, compensation, educational and legal jurisdictions.

6. Clinical Psychologists cont.
2. Treatment
Clinical psychologists are trained in the delivery of a range of (non-drug) techniques, strategies and therapies with demonstrated effectiveness in treating mental health disorders. They are specialists in applying psychological theory and scientific research to solve complex clinical problems requiring individually tailored interventions.
3. Research, teaching and evaluation

7. Psychiatrists
Psychiatrists are specialist medical doctors who diagnose and treat mental disorders.
Qualifying as a psychiatrist involves first obtaining a medical degree and then undertaking a minimum of 5 years’ postgraduate specialisation in psychiatry.

8. The nature of their training means that psychiatrists have a strong grounding in both biological and psychological frameworks for understanding mental disorders. They are trained both to recognise and treat the effects of emotional disturbances on the body as a whole, as well as the effects of physical conditions on the mind

9. Differences between Clinical Psychologists and Psychiatrists
A Psychiatrist is required to complete a medical degree prior to specialising in mental disorders including biological conditions (psychiatrists are physicians)
A Psychiatrist can prescribe medication; a Clinical Psychologist cannot.
Clinical Psychologists have specialist training in non-medical interventions (psychological) and work closely with Psychiatrists
Psychiatrists should be able to provide biological, psychological and social treatments

10. The Melbourne Clinic – The Treatment Setting
The Melbourne Clinic (TMC) is a purpose built psychiatric hospital established in the 1970’s and was initially privately owned by a group of psychiatrists. Since 1985 it has been managed by Healthscope Limited
TMC is the largest and longest established private psychiatric hospital in Australia. It has 106 beds, well over 100 accredited psychiatrists and employs a multi-disciplinary team including psychiatrists, nurses, psychologists, social workers, occupational therapists and dieticians

11. Inpatient Programs - TMC
TMC provides a comprehensive range of inpatient and day programs as well as an outreach program
The Inpatient Programs include:
General Psychiatry (Living Well Program group interventions)
Intensive Psychiatric Care
Older Person’s Psychiatry Unit
Professorial Unit
Anxiety and Depression Program
Obsessive Compulsive Disorder Program
Eating Disorders Program
Substance Withdrawal Program

12. Day Programs - TMC The Day Programs Include: Life strategies program
Sills-based Psychosocial Program
Anxiety Day Treatment Program
Depression Management Program
Managing Bipolar Disorder Program
Mindfulness Based Cognitive Therapy
Dialectical Behaviour Therapy Program
Eating Disorders Program
Outreach Program -The outreach program provide assessment, support, rehabilitation and treatment in their own home and local community

13. Onset of Mental Disorders
One in 5 Australians will suffer from a mental disorder at some point in their lives. 
A mental disorder is a health problem that significantly affects how a person thinks, behaves and interacts with other people and functions in their daily life.
Mental disorders are diagnosed according to standardised criteria. One of the major wordwide classificatory systems is the Diagnostic and Statistical Manual of Mental Disorders (DSM

14. What causes Mental Disorders?
Mental illness results from complex interactions between the mind, body and environment.
Factors which can contribute to mental disorders are:
Biological factors
Including genetics, neurochemistry, diseases of the brain, physical illness drugs affecting the brain (use of alcohol, drugs and other substances ),
Psychological factors
Including cognitive styles such as constant negative thoughts about the self and the world, personality styles including avoidance, low self esteem and confidence, poor coping styles and poor problem solving approaches

15. What Causes Mental Disorders cont.
Social factors
Including life events, long-term and acute stress in all areas of one’s life (e.g. personal. family, work, relationships, financial), trauma, violence
Work stress is categorized under social factors. Apart from major physical injuries and exposure to or involvement in a traumatic event, patients often report work stress as the significant contributing factor which was an ongoing event which wasn’t addressed nor resolved.
Common examples include harassment, bullying, little or no supervision or training, work overload, poor communication/support or difficulties with managers/supervisors.

16. Types of Mental Disorders
Mental disorders are of different types and degrees of severity. Some of the major types of mental disorders include:
Depression
Bipolar Disorder
Anxiety Disorders
Schizophrenia
Drug and Alcohol Disorders

17. Mood Disorders Depression
The term depression is used to describe feelings of sadness and grief, which many people experience at some stage.
Reactive Depression - depression in response to a distressing event, such as bereavement, relationship breakdown or loss of a job. The feelings are more severe or persistent than normal unhappiness and symptoms often include anxiety, sleep problems and changes in eating habits.

18. Mood Disorders cont.
Endogenous or Major Depression - more severe than in reactive depression and there may or may not be a triggering event.
Symptoms include sleep disturbance, appetite or weight changes, sadness or irritability, loss of interest in work or hobbies, loss of sexual interest, fatigue, poor concentration, difficulty making decisions, guilt and poor self-esteem or suicidal thoughts. Symptoms are persistent and severe and may leave the person unable to function or care for themselves.

19. Mood Disorders cont.
Bipolar Mood Disorder (previously called Manic Depression) - extremes in mood, with periods of depressed mood alternating with periods of mania. The manic phase may involve extreme happiness, overactivity, rapid speech, reduced need for sleep, a lack of inhibition, irritability with those who question them, and grandiose plans and beliefs

20. Anxiety Disorders
Anxiety refers to the physical, mental and behavioural changes we feel in response to a threat.
These changes are sometimes referred to as the 'fight or flight' response, because they prepare us to respond to danger.
Some anxiety is inevitable in today's society and in many situations it is an appropriate and reasonable response. Anxiety disorders are different from 'everyday' anxiety in being more intense and persistent, to a degree which interferes with a person's life.

21. Anxiety Disorders cont.
• Panic attack - a sudden feeling of panic associated with physical symptoms like: shortness of breath, dizziness, chest pain, an urge to flee, difficulty gathering thoughts, fear of dying or losing control
Some anxiety disorders include panic disorder, agoraphobia, phobias

22. Anxiety Disorders cont.
Obsessive-Compulsive Disorder - a person experiences obsessions (persistent, unwanted thoughts) and compulsions (being driven to perform a ritual or behaviour) and causes disruption to their everyday life.
• Generalised Anxiety Disorder - excessive general worry and anxiety and is very difficult for the person to control.
• Post-traumatic Stress Disorder (PTSD) - recurrent feelings of terror, frightening dreams or relived memories which result from a previous traumatic event memories or flashbacks may be triggered by a particular event and are intrusive, interfering with everyday life.

23. Schizophrenia
Schizophrenia is characterised by unusual or bizarre thoughts and emotions that others consider inappropriate. Schizophrenia is not a 'split personality‘. The term refers to changes in the person's mental and social functioning, when their thoughts and perceptions become disordered.
Symptoms of schizophrenia include hallucinations, delusions and problems with feelings, behaviour, motivation and speech. People may have disorganised thoughts and difficulty concentrating. A collection of such symptoms is sometimes termed psychosis, and can occur in other disorders as well, for example in severe depressive illnesses

24. Substance Use Disorders
People with substance use disorders have generally taken one or more drugs of abuse over an extended period, and are showing various behavioural, physical and psychological symptoms.
People may develop substance use disorders for a number of reasons, such as anxiety or depressive disorders, a family history of substance abuse, being prone to the effects of stress and tension, or experiencing psychosocial problems (e.g. work stress, family problems, and relationship breakdown). Addiction may have both physiological and psychological components

25. Overview of Psychological and Medical Treatments
Psychological Treatments
Psychotherapy is a useful treatment for may mental disorders including depression and anxiety disorders
There are many types of psychotherapies including Cognitive Behavioural Therapy (CBT) which is an evidence based treatment that has been evaluated and proven to be effective.
Historically, this treatment was viewed as two separate therapies which today are used in combination to treat mental disorders

26. Psychological Treatments cont.
Cognitive Therapy- the aim of cognitive therapy is to help individuals realise that they can influence their emotions by identifying and changing their thoughts and beliefs.
when people are depressed, for example, they often think very negative thoughts about themselves, their lives and the future. This in turn further worsens their mood.
Cognitive Therapy focuses on discovering and challenging unhelpful assumptions and beliefs and developing balanced thoughts, more realistic, rational ones

27. Psychological Treatments cont.
Behaviour Therapy focuses often maladaptive behaviours that occur during an episode of mental disorder.
Behaviour therapy aims to identify and change aspects of behaviour that may perpetuate or worsen a person’s mental disorder.
Some behavioural strategies include skills training, goal setting, activity scheduling and structured problem solving
These 2 therapies, more commonly known as CBT, have been found to be effective either on their own for certain disorders or in combination with psychiatric medications

28. Psychiatric Medications
Psychiatrists are experts in prescribing and monitoring psychiatric medications.
Medications are the cornerstone of treatment for most mental disorders. Medications will alleviate or ease symptoms for most people. The ongoing use of medications will assist in stabilising symptoms and preventing relapse.
Medications have both desired effects (e.g. reducing symptoms) and undesired effects commonly called side effects (e.g. drowsiness).
The aim is to find medications that are tolerable and have the least number of side effects as well as effectively reducing symptoms. Adherence to medications is much more likely when it is clear that the benefits of taking the medication outweigh the costs.

29. Psychiatric Medications cont.
A feature of most psychiatric medications is that they may only begin to have a beneficial effect over several weeks. It is useful for the psychiatrist to provide information about
• The name of the medication, what it is supposed to do, and when it should begin to take effect;
• How it is taken and for how long this might be necessary;
• Any food, drinks, other medicines the person should avoid while taking this medication;
• Possible side effects and what should be done if they occur;
• Sources of information about this medication (e.g. pamphlets).

30. Medications for Depression
These are used for treating symptoms of depression, such as persistent sadness, hopelessness, poor appetite, insomnia, lack of energy, difficulty in concentrating and diminished interest in usually pleasurable activities.
Selective serotonin reuptake inhibitors are most commonly prescribed because of their safety and tolerability.
Selective serotonin re-uptake inhibitors (SSRIs)
Generic name Common brand names
citalopram Cipramil, Celapram, Talam, Talohexal
escitalopram Lexapro
fluoxetine Genrix, Fluohexal, Lovan,
Prozac, Zactin
Fluvoxamine Faverin, Luvox, Movox
paroxetine Aropax, Oxetine, Paxetine
sertraline Xydep, Zoloft

31. Mood Stabilisers Medications for mood disorder
Mood stabilizers are medicines that reduce the symptoms of acute manic and depressive episodes. They also prevent the recurrence of mania and depression in bipolar disorder
when taken regularly over an extended period of time.
Generic name Common brand names
carbamazepine Tegretol, Teril
lithium carbonate Lithicarb, Quilonum SR
sodium valproate Epilim, Valpro

32. Medications for Anxiety Disorders-anxiolytic medications
They are also useful in helping to manage agitation. Some are used to help people to sleep.
Antidepressant medications, particularly the SSRIs, are used to treat a range of anxiety disorders without the tolerance and dependence problems associated with benzodiazepines (Valium and drugs like it).
Benzodiazepine medications
Generic name Common brand names
Alprazolam Kalma, Xanax Alprax
Diazepam Atenex, Ducene, Valium
lorazepam Ativan
oxazepam Alepam, Murelax, Serapax

33. Antipsychotic Medications
Medications for psychosis
Antipsychotic medications are used for treating schizophrenia,
schizophreniform psychosis, schizoaffective disorder, substance induced psychosis and other conditions where psychotic symptoms
(ie. hearing voices, hallucinations disorganised thinking or
delusional ideas) are present.

34. Antipsychotic medications cont.
Atypical antipsychotic medications
Generic name Common brand names
Amisulpride Solian
Aripiprazole Abilify
clozapine Clozaril,Clopine
olanzapine Zyprexa

35. Working Together –The Assessment and Management of Mental Disorders
1.To engage the patient in the treatment process from the initial stage, beginning with the initial interview. Failure to do so often results in an incomplete assessment which will then limit how management should proceed
2.To conduct a thorough psychiatric, psychological, social and medical assessment (including a suicide assessment)
3. Decide where the patient should be treated, in hospital or the community and give a thorough explanation to the patient if they need to be hospitalised

36. 4.To provide education and support for the individual and family
5.To treat the mental disorder, e.g. depression and associated depressive features with psychiatric medication and CBT
6.To address and improve overall behavioural functioning and always aim to treat the person for return to their employment
7.To monitor the person’s condition and work toward preventing relapse or recurrence of their mental disorder

37. 2. The Assessment What are the sign and symptoms of the illness?
What is the risk of self-harm, or harm to others?
How disabling is the illness?
The individual’s general level coping and functioning
Is their any evidence of a previous or ongoing mental disorder?
Whether there is any family history of mental disorders

38. The Assessment cont.
Whether there were any triggers to the disorder, and if there were, what was their meaning to the individual
If there were triggers, did they entirely cause the mental disorder, or did they trigger or worsen the person’s exisiting condition
The nature of family or friendship supports
Their personality style
Their drug and alcohol history
Whether there are any relevant medical problems
What is their understanding/explanation of their current condition?

39. Clinical Psychologists’ Assessments
A well know test which is used worldwide is the MMPI
The MMPI is composed of 567 true/false items. Personality inventories like the MMPI are intended to discover what the individual is like as a person. A number of areas are assessed by the MMPI to answer such questions as: "Who is this person and what would they typically feel, think and behave? What psychological problems and disorders are relevant to this person right now?“ “What is the prognosis likely to be and what difficulties will they experience in their recovery”

40. Psychiatrists’ Assessments
Psychiatrists must perform a medical assessment in addition to the psychiatric interview. Various test and investigations are used to determine if there is a medical problem causing/contributing to the mental disorder
Some tests include relevant special investigations bloods, ECG, CT or MRI scans

41. 3. Where should the person be treated?
Most people prefer not to go to hospital and the majority of the time people can be treated in the community.
In some instances hospitalisation will be both necessary and beneficial. Especially if the person cannot guarantee their safety of if they are seriously unwell and are unable to care for themselves without assistance.
People may also be admitted to hospital for specialised medical and psychological treatments.

42. 4. Psychoeducation and Support for the Family
The main goal of education is to facilitate understanding about the disorder and its management:
A mental disorder is an illness, not a sign of weakness. Recovery is the rule, not the exception.
Treatment is effective and there are many treatment options available.
The goal of treatment is to get well and minimise relapse.

43. 4.Psychoeducation and Support for the Family cont.
Treatment options (i.e., psychotherapy, medication) and relevant information about each alternative (e.g., side effects, duration, costs).
Recognising and acting upon early warning signs
Managing ongoing stressful problems that directly impact on recovery

44. 5. Medical and Psychological treatments in combination
The essential features of the management of most mental disorders involve physical treatments and/or psychotherapy. Physical treatments involve the administration of psychiatric medication. Psychotherapy includes CBT.
The choice of psychiatric medication is based on a number of factors but is best made in consultation with specialist psychiatric opinion.

45. Cognitive Therapy
Individuals who are depressed or anxiously show a style of thinking that focuses on negative views of the world, themselves as individuals, of their experiences, and of their future. They come to think of themselves as worthless and of the world as being a bad or unfair place, without hope of their lives improving in the future.
Some classic irrational beliefs which depressed or anxious people believe include: I will never get better, If I were a better/smarter person this would never had happened to me, I won’t be able to cope when I return to work, People don’t won’t to be with me because I am crazy, nothing can help me, If I did things perfectly then everything would be OK
The aim of cognitive therapy is to help individuals identify, challenge or test their belief and correct their distorted and negatively-biased thoughts with a more reasonable and realistic thought.

46. 6. Improving Behavioural Functioning
In addition to tackling the symptoms of mental disorders, the challenge to a full recovery often relies on the person being able to pick up and carry on at the level they did before becoming unwell.
Mental disorders lead to a decline in functioning where the person may not be able to look after themselves as well as they did before, stop them form returning to work, a general slowing in their performance of activities and avoidance of family and friends.
It is vital to monitor and tackle these problems from the beginning which can get worse over time and the individual struggles enormously to overcome.
Behavioral strategies are vitally important in addressing these problems by addressing what problems the individual is experiencing and planning how to tackle them.

47. 6. Improving Behavioural Functioning cont.
Patients will often show signs of getting worse when faced with ongoing stressors such making claims for their work injuries which is a painful and protracted process.
Ongoing therapy and skills training (e.g. dealing with difficult situations, maintaining good physical health, exercise, learning how to communicate and assert oneself more effectively, overcoming inactivity, planning activities in advance, engaging in pleasant events with other people) are all important strategies.
Monitoring the use of poor coping strategies is also important such as the use of drugs and alcohol, not taking medications regularly, missing appointments
Improving the individual’s ability to function is important to avoid demoralization and the person giving up

48. 7. Preventing Relapse
Ongoing treatment involves the identification of conditions where the person may relapse or have a set back. In general the following need to be monitored and addressed by the patient’s Clinical Psychologist and Psychiatrist
The first step is to identify high risk situations. These situations may include :relationship break-ups, moving house, illness, or financial and status losses e.g.loss of a job, loss of a role

49. 7. Preventing Relapse cont.
It is vital to help the person plan how they can respond most effectively in these situations. One aim of planning is to encourage individuals to realise that they can cope with these situations if they do indeed occur
As with many mental disorders it is likely that some individuals will be able to identify changes in their thoughts, feelings, or behaviours which may signify that they are becoming unwell again. By being aware of early warning signs and acting immediately on these signs it may be possible for the individual to decrease the potential severity and duration of the episode.
Ongoing adherence to medication and psychological treatment is likely to minimise relapse