Major self-mutilation (MSM) is a rare but catastrophic complication of severe mental illness. Most people who inflict MSM have a psychotic disorder, usually a schizophrenia spectrum psychosis. It is not known when in the course of psychotic illness, MSM is most likely to occur. In this study, the proportion of patients in first episode of psychosis (FEP) was assessed using the results of a systematic review of published case reports. Histories of patients who had removed an eye or a testicle, severed their penis, or amputated a portion of a limb and were diagnosed with a schizophrenia spectrum psychosis were included. A psychotic illness was documented in 143 of 189 cases (75.6%) of MSM, of whom 119 of 143 (83.2%) were diagnosed with a schizophrenia spectrum psychosis. The treatment status of a schizophrenia spectrum psychosis could be ascertained in 101 of the case reports, of which 54 were in the FEP (53.5%, 95% confidence interval 43.7%-63.2%). Patients who inflict MSM in FEP exhibited similar symptoms to those who inflict MSM later in their illness. Acute psychosis, in particular first-episode schizophrenia, appears to be the major cause of MSM. Although MSM is extremely uncommon, earlier treatment of psychotic illness may reduce the incidence of MSM.

The Coffs Harbour AIDS Information Network was set up to co-ordinate care planning and support service delivery for HIV/AIDS patients. This paper describes a collaborative model of care that brought together private general practitioners, a community nurse and a sexual health counsellor. Time involved in delivering services was monitored for each of the health professional groups during a 6 month period. Twenty-three patients were involved in our study. Doctors averaged 23 min per consultation over 57 occasions of service. Travel or telephone contact took up 17% of the time spent on these patients. Corresponding figures for the nurse and counsellor were an average of 67 min over 144 services and 71 min over 16 services. They spent 16% and 27% of their time travelling or on the phone, respectively. HIV/AIDS care is time consuming for health professionals but comprehensive care can be given in rural areas with adequate support and integration.

The study highlights the importance of identification of FEP, particularly in the 10-18-year age group, where cognitive problems are likely to adversely affect schooling as well as be detrimental to social relationships. Service provision for FEP youth in rural areas requires innovation and coordination of limited resources, including better provision of training and ongoing clinical supervision.

Objective: To discuss the challenges and rewards of training in psychiatry while living and working in a rural area. The authors draw on their experiences as registrars on the mid-north coast of New South Wales, Australia. Conclusions:Rural psychiatrists and mental health workers meet with various challenges and rewards while practising and living in places of relative isolation; these have been described by practitioners in Australia, New Zealand and the USA. Psychiatry trainees often share these experiences but can also feel the impact of the disadvantages shared by most rural communities, particularly the lack of mental health services and maldistribution of mental health professionals. There are also unique difficulties and rewards to do with the process of training.