Breast screening participation and degree of spread of invasive breast cancer at diagnosis in mental health service users: A population linkage study.

BACKGROUND: Women living with mental health conditions may not have shared in improvements in breast cancer screening and care. No studies have directly examined the link between reduced screening participation and breast cancer spread in women using mental health (MH) services. METHODS: Population-wide linkage of a population cancer register, BreastScreen register, and mental health service data set in women aged 50 to 74 years in New South Wales, Australia, from 2008 to 2017. Incident invasive breast cancers were identified. Predictors of degree of spread (local, regional, metastatic) at diagnosis were examined using partial proportional odds regression, adjusting for age, socioeconomic status, rurality, and patterns of screening participation. RESULTS: A total of 29 966 incident cancers were identified and included 686 (2.4%) in women with MH service before cancer diagnoses. More than half of MH service users had regional or metastatic spread at diagnosis (adjusted odds ratio, 1.63; 95% CI, 1.41-1.89). MH service users had lower screening participation; however, advanced cancer was more common even when adjusting for screening status (adjusted odds ratio, 1.53; 95% CI, 1.32-1.77). Advanced cancer was more common in women with severe or persistent MH conditions. CONCLUSIONS: Low screening participation rates explain only small part of the risk of more advanced breast cancer in women who use MH services. More study is needed to understand possible mechanisms contributing to more advanced breast cancer in women living with MH conditions. Health systems need strategies to ensure that women living with MH conditions enjoy population gains in breast cancer outcomes.

Suicidal ideation, suicide plans and suicide attempts among Australian adults: Findings from the 2020-2022 National Study of Mental Health and Wellbeing.

OBJECTIVE: This study aimed to describe the epidemiology of suicidal ideation, suicide plans and suicide attempts, examine services received for suicide attempts, and explore the relationship between suicide attempts and self-harm without suicidal intent. METHODS: We used survey data from the 2020-2022 National Study of Mental Health and Wellbeing, which involved a nationally representative sample of Australian adults aged 16-85 (n = 15,893). Comparisons were made with the 2007 National Study of Mental Health and Wellbeing (n = 8841). RESULTS: In 2020-2022, the proportions of adults who had experienced suicidal ideation, suicide plans and suicide attempts during their lifetime were 16.6%, 7.5% and 4.9%, respectively. The proportions who had experienced these in the past 12 months were 3.3%, 1.1% and 0.3%. The odds of experiencing suicidal ideation and making a suicide plan were significantly higher in 2020-2022 than in 2007. Groups at heightened risk of suicidal ideation, suicide plans and/or suicide attempts in the previous 12 months were males, young people, people who were gay, lesbian, or bisexual or used some other term to describe their sexual identity, people outside the labour force, people from disadvantaged areas and people with mental disorders. Two-fifths of those who attempted suicide during the previous 12 months did not use health services following their attempt, and two-thirds also self-harmed without suicidal intent. CONCLUSION: The implications of these findings for the forthcoming National Suicide Prevention Strategy are discussed. Suicidal thoughts and behaviours confer risk for suicide and are significant problems in their own right. Their prevention requires a strong whole-of-government response.

Persons with mental disorders and suicidality in crisis or high-risk situations involving police negotiation: a systematic review.

Police negotiators respond to crisis and high-risk situations including mental health crises, but little is known about the nature, frequency and characteristics of these events. This systematic review examined literature about mental disorder and suicidality prevalence in negotiation events from peer-reviewed articles published within the last 20 years. Of 1455 articles identified, 11 met study inclusion criteria. Most contributed only indirect evidence using data on fatal police encounters, case reviews and analysis of communication techniques. Reliable prevalence estimates were not found, though findings suggest suicidality was a precipitating factor in more than half of events and was present during most events. Mental disorder (primarily substance use, mood and psychotic disorders) was also identified as a significant factor prior to and during events. Few articles described frequency or characteristics of these critical events. Further research is needed to inform frontline responses, resourcing and support pathways for police providing this crucial service.

Vaccine-preventable hospitalisations in adult mental health service users: a population study.

BACKGROUND: Vaccine-preventable conditions cause preventable illness and may increase mortality in people living with mental illness. We examined how risks of hospitalisation for a wide range of vaccine-preventable conditions varied by age and sex among mental health (MH) service users. METHODS: Linked population data from New South Wales (NSW), Australia were used to identify vaccine-preventable hospitalisations (VPH) for 19 conditions from 2015 to 2020. Adult MH service users (n = 418 915) were compared to other NSW residents using incidence rates standardised for age, sex and socioeconomic status. Secondary analyses examined admissions for COVID-19 to September 2021. RESULTS: We identified 94 180 VPH of which 41% were influenza, 33% hepatitis B and 10% herpes zoster. MH service users had more VPH admissions [adjusted incidence rate ratio (aIRR) 3.2, 95% CI 3.1-3.3]. Relative risks were highest for hepatitis (aIRR 4.4, 95% CI 4.3-4.6), but elevated for all conditions including COVID-19 (aIRR 2.0, 95% CI 1.9-2.2). MH service users had a mean age of 9 years younger than other NSW residents at first VPH admission, with the largest age gap for vaccine-preventable pneumonias (11-13 years younger). The highest relative risk of VPH was among MH service users aged 45-65. CONCLUSIONS: MH service users have increased risk of hospitalisation for many vaccine-preventable conditions. This may be due to reduced vaccination rates, more severe illness requiring hospitalisation, greater exposure to infectious conditions or other factors. People living with mental illness should be prioritised in vaccination strategies.

Age-specific differences in cervical cancer screening rates in women using mental health services in New South Wales, Australia.

OBJECTIVE: Women living with mental health conditions have lower cervical cancer screening rates and higher mortality. More evidence is needed to target health system improvement efforts. We describe overall and age-specific cervical cancer screening rates in mental health service users in New South Wales. METHODS: Cervical cancer screening registers were linked to New South Wales hospital and community mental health service data. Two-year cervical screening rates were calculated for New South Wales mental health service users aged 20-69 years (n = 114,022) and other New South Wales women (n = 2,110,127). Rate ratios were compared for strata of age, socio-economic disadvantage and rural location, and overall rates compared after direct standardisation. RESULTS: Only 40.3% of mental health service users participated in screening, compared with 54.3% of other New South Wales women (incidence rate ratio = 0.74, 95% confidence interval = [0.74, 0.75]). Differences in age, social disadvantage or rural location did not explain screening gaps. Screening rates were highest in mental health service users aged <35 years (incidence rate ratios between 0.90 and 0.95), but only 15% of mental health service users aged >65 years participated in screening (incidence rate ratio = 0.27, 95% confidence interval = [0.24, 0.29]). CONCLUSION: Women who use mental health services are less likely to participate in cervical cancer screening. Rates diverged from population rates in service users aged ⩾35 years and were very low for women aged >65 years. Intervention is needed to bridge these gaps. New screening approaches such as self-testing may assist.

Early impacts of the 'National Suicide Prevention Trial' on trends in suicide and hospital admissions for self-harm in Australia.

OBJECTIVES: The National Suicide Prevention Trial was announced by the Australian Government in 2016 and aimed to prevent suicidal behaviour in 12 trial sites (representing a population of ~8 million). This study investigated the early population-level impact of the National Suicide Prevention Trial activity on rates of suicide and hospital admissions for self-harm in comparison to control areas. METHODS: Relative and absolute differences in monthly rates of suicide and hospital admissions for self-harm were compared in the period after the National Suicide Prevention Trial implementation (July 2017-November 2020) to the period prior to implementation (January 2010-June 2017) in (1) 'National Suicide Prevention Trial areas' and (2) 'Control areas', using a difference-in-difference method in a series of negative binomial models. Analyses also investigated whether associations for suicide and self-harm rates differed by key socio-demographic factors, namely sex, age group, area socio-economic status and urban-rural residence. RESULTS: There were no substantial differences between 'National Suicide Prevention Trial areas' and 'Control areas' in rates of suicide (2% relative decrease, relative risk = 0.98, 95% confidence interval = [0.91, 1.06]) or self-harm (1% relative decrease, relative risk = 0.99, 95% confidence interval = [0.96, 1.02]), adjusting for sex, age group and socio-economic status. Stronger relative decreases in self-harm only were evident for those aged 50-64 years, high socio-economic status areas, metropolitan and remote geographic areas. CONCLUSION: There was limited evidence that the National Suicide Prevention Trial resulted in reductions in suicide or hospital admissions for self-harm during the first 4 years of implementation. Continued monitoring of trends with timely data is imperative over the next 2-3 years to ascertain whether there are any subsequent impacts of National Suicide Prevention Trial activities.

Breast cancer screening participation in women using mental health services in NSW, Australia: a population study.

PURPOSE: Population screening programs have contributed to reduced breast cancer mortality, but disadvantaged or vulnerable groups may not have shared these improvements. In North American and European studies, women living with mental health conditions have reduced breast screening rates. There are no current Australasian data to support health system planning and improvement strategies. METHODS: The New South Wales (NSW) BreastScreen program offers free screening to NSW women aged 50-74. We compared 2-year breast screening rates for mental health service users (n = 33,951) and other NSW women (n = 1,051,495) in this target age range, after standardisation for age, socioeconomic status and region of residence. Mental health service contacts were identified through linkage to hospital and community mental health data. RESULTS: Only 30.3% of mental health service users participated in breast screening, compared with 52.7% of other NSW women (crude incidence rate ratio 0.57, 95% CI 0.56-0.59). Standardisation for age, socioeconomic disadvantage or rural residence did not alter this screening gap. Around 7000 fewer women received screening than would be expected from comparable population rates. Screening gaps were largest in women over 60 and in socioeconomically advantaged areas. Women with severe or persistent mental illness had slightly higher screening rates than other mental health service users. CONCLUSIONS: Low breast cancer screening participation rates for NSW mental health service users suggest significant risk of later detection, possibly leading to more extensive treatment and premature mortality. Focussed strategies are needed to support greater breast screening participation for NSW women who use mental health services.

Incidence of sight-threatening diabetic retinopathy in an established urban screening programme: An 11-year cohort study.

AIMS: Systematic annual screening to detect sight-threatening diabetic retinopathy (STDR) is established in the United Kingdom. We designed an observational cohort study to provide up-to-date data for policy makers and clinical researchers on incidence of key screening endpoints in people with diabetes attending one screening programme running for over 30 years. METHODS: All people with diabetes aged ≥12 years registered with general practices in the Liverpool health district were offered inclusion. Data sources comprised: primary care (demographics, systemic risk factors), Liverpool Diabetes Eye Screening Programme (retinopathy grading), Hospital Eye Services (slit lamp biomicroscopy assessment of screen positives). RESULTS: 133,366 screening episodes occurred in 28,384 people over 11 years. Overall incidences were: screen positive 6.7% (95% CI 6.5-6.8), screen positive for retinopathy 3.1% (3.0-3.1), unassessable images 2.6% (2.5-2.7), other significant eye diseases 1.0% (1.0-1.1). 1.6% (1.6-1.7) had sight-threatening retinopathy confirmed by slit lamp biomicroscopy. The annual incidence of screen positive and screen positive for retinopathy showed consistent declines from 8.8%-10.6% and 4.4%-4.6% in 2007/09 to 4.4%-6.8% and 2.3%-2.9% in 2013/17, respectively. Rates of STDR (true positive) were consistently below 2% after 2008/09. Screen positive rates were higher in first time attenders (9.9% [9.4-10.2] vs. 6.1% [6.0-6.2]) in part due to ungradeable images (4.1% vs. 2.3%) and other eye disease (2.4% vs. 0.8%). 4.5% (3.9-5.2) of previous non-attenders had sight-threatening retinopathy. Compared with people with type 2 diabetes, those with type 1 disease demonstrated higher rates of screen positive (11.9% vs. 6.0%) and STDR (6.4% vs. 1.2%). Overall prevalence of any retinopathy was 27.2% (27.0-27.4). CONCLUSIONS: In an established screening programme with a stable population screen, positive rates show a consistent fall over time to a low level. Of those who are screen positive, fewer than 50% are screen positive for diabetic retinopathy. Most are due to sight threatening maculopathy. The annual incidence of STDR is under 2% suggesting future work on redefining screen positive and supporting extended intervals for people at low risk. Higher rates of screen positive and STDR are seen in first time attenders. Those who have never attended for screening should be specifically targeted.

Barriers to mental health care for Australian children and adolescents in 1998 and 2013-2014.

OBJECTIVE: To assess changes in barriers to mental health care for children and adolescents over 16 years. METHODS: We used data from two nationally representative surveys of Australian children and adolescents (4-17 years old), conducted in 1998 (N = 4509) and 2013-2014 (N = 6310). Barriers to care were assessed among parents who had reported a perceived partially met or unmet need for their child in the past 6 months in 1998, and the past 12 months in 2013-2014; barriers were similarly assessed among adolescents in relation to themselves. We addressed measurement inconsistencies between surveys by harmonising barriers to accommodate differences in wording and performing sensitivity analyses among those with a 1-month disorder to equalise the timeframes in which barriers were assessed. To assess change, we examined whether the rank order of the three most commonly endorsed barriers changed and whether the 95% confidence intervals (CI) around their estimates overlapped. RESULTS: Similar proportions of parents reported a partially met or unmet need in 1998 (12.9%, 95% CI = [11.7, 14.0]) as in 2013-2014 (14.3%, 95% CI = [13.2, 15.3]), but the ratio of unmet to partially met need decreased from 3:1 in 1998 to 1:1 in 2013-2014. Top three parent-endorsed barriers ('self-reliance', 'unsure where to get help', and 'cost') were the same at both time points; 'self-reliance' decreased from 65.9% (95% CI = [61.1%, 70.7%]) to 34.9% (95% CI = [31.5%, 38.3%]). Top two adolescent-endorsed barriers ('self-reliance' and 'concerned what others might think') were the same at both time points, the third differed, but none of them decreased. CONCLUSION: Perceived unmet need for mental health care for children and adolescents may have decreased between 1998 and 2013-2014, but the gap in receiving sufficient care may have increased. Despite investments in community awareness and treatment during this period, key barriers seemed largely unchanged. For parents, the decrease in self-reliance may reflect a positive shift in beliefs about the potential benefits of treatment.

Disordered eating among Australian adolescents: Prevalence, functioning, and help received.

OBJECTIVE: To estimate the prevalence of disordered eating (DE) among Australian adolescents and examine associations with clinical mental health problems, problems with functioning, and help received. METHOD: We analyzed data from the Young Minds Matter survey (n = 2,298, 13-17 years). We derived an index of DE severity with four levels: (1) no DE; (2) subclinical DE; (3) suspected eating disorder; and (4) lifetime eating disorder diagnosis. RESULTS: In 2013-2014, 31.6% (95%CI 35.5-39.9) of Australian adolescents experienced DE, comprising 25.7% (95%CI 23.9-37.6) with subclinical DE, 11.0% (95%CI 9.7-12.6) with a suspected eating disorder, and 0.9% (95%CI 0.6-1.3) with a lifetime eating disorder diagnosis. DE was more common among girls (41.4%, 95%CI 37.9-44.4) than boys (34.0%, 95%CI 31.1-37.0; p = .002). Adolescents with DE, compared to those without, were more likely to experience clinical mental health problems and problems with functioning. Most adolescents with DE reported help-seeking in the past year, commonly self-help; around 40% used school-based, primary care or specialist services (i.e., formal services). In multivariate analyses, the use of more specialized and intensive services was associated with more severe DE, greater problems with functioning, female gender, and 12-month mental disorder or subthreshold mental disorder symptoms. DISCUSSION: The implementation of mental health promotion and prevention efforts for DE, and screening for DE in school and primary care settings, may facilitate detection and appropriate help-seeking among adolescents with DE.

Community treatment orders increase community care and delay readmission while in force: Results from a large population-based study.

OBJECTIVE: There is debate about the effectiveness of community treatment orders in the management of people with a severe mental illness. While some case-control studies suggest community treatment orders reduce hospital readmissions, three randomised controlled trials find no effects. These randomised controlled trials measure outcomes over a longer period than the community treatment order duration and assess the combined effectiveness of community treatment orders both during and after the intervention. This study examines the effectiveness of community treatment orders in a large population-based sample, restricting observation to the period under a community treatment order. METHODS: All persons ( n = 5548) receiving a community treatment order in New South Wales, Australia, over the period 2004-2009 were identified. Controls were matched using a propensity score based on demographic, clinical and prior care variables. A baseline period equal to each case's duration of treatment was constructed. Treatment effects were compared using zero-inflated negative binomial regression, adjusting for demographics, clinical characteristics and pre-community treatment order care. RESULTS: Compared to matched controls, people on community treatment orders were less likely to be readmitted (odds ratio = 0.90, 95% confidence interval = [0.84, 0.97]) and had a significantly longer time to their first readmission (incidence rate ratio = 1.47, 95% confidence interval = [1.36, 1.58]), fewer hospital admissions (incidence rate ratio = 0.90, 95% confidence interval = [0.84, 0.96]) and more days of community care (incidence rate ratio = 1.55, 95% confidence interval = [1.51, 1.59]). Increased community care and delayed first admission were found for all durations of community treatment order care. Reduced odds of readmission were limited to people with 6 months or less of community treatment order care, and reduced number of admissions and days in hospital to people with prolonged (>24 months) community treatment order care. CONCLUSION: In this large population-based study, community treatment orders increase community care and delay rehospitalisation while they are in operation. Some negative findings in this field may reflect the use of observation periods longer than the period of active intervention.

The development and validation of the Brief Experience of Caregiving Inventory (BECI).

BACKGROUND: The social network supporting an individual with psychosis may be adversely affected by the experience of caregiving. The Experience of Caregiving Inventory (ECI) is 66 item self-report measure of the impact of caregiving for carers of people diagnosed with psychotic disorders. This study aimed to create a brief version of the ECI, and evaluate its reliability and validity (n = 626). METHODS: The validation process was conducted through a Multidimensional Item Response Theory (MIRT) approach, using a graded response model and a complementary network approach. RESULTS: This resulted in a 19 item, four factor inventory with a good model fit, displaying good reliability and validity. CONCLUSION: The BECI is a valid measure. The simplicity, ease of application and robust psychometric properties further enhances its acceptability and usefulness as a brief measure in clinical research and trials, as well as in routine practice providing reliable and valid data on experience of caregiving in families of an individual with psychosis.

A systematic review of clinician-rated instruments to assess adults' levels of functioning in specialised public sector mental health services.

BACKGROUND: Functioning is one of the key domains emphasised in the routine assessment of outcomes that has been occurring in specialised public sector mental health services across Australia since 2002, via the National Outcomes and Casemix Collection. For adult consumers (aged 18-64), the 16-item Life Skills Profile (LSP-16) has been the instrument of choice to measure functioning. However, review of the National Outcomes and Casemix Collection protocol has highlighted some limitations to the current approach to measuring functioning. A systematic review was conducted to identify, against a set of pre-determined criteria, the most suitable existing clinician-rated instruments for the routine measurement of functioning for adult consumers. METHOD: We used two existing reviews of functioning measures as our starting point and conducted a search of MEDLINE and PsycINFO to identify articles relating to additional clinician-rated instruments. We evaluated identified instruments using a hierarchical, criterion-based approach. The criteria were as follows: (1) is brief (<50 items) and simple to score, (2) is not made redundant by more recent instruments, (3) relevant version has been scientifically scrutinised, (4) considers functioning in a contemporary way and (5) demonstrates sound psychometric properties. RESULTS: We identified 20 relevant instruments, 5 of which met our criteria: the LSP-16, the Health of the Nation Outcome Scales, the Illness Management and Recovery Scale-Clinician Version, the Multnomah Community Ability Scale and the Personal and Social Performance Scale. CONCLUSION: Further work is required to determine which, if any, of these instruments satisfy further criteria relating to their appropriateness for assessing functioning within relevant service contexts, acceptability to clinicians and consumers, and feasibility in routine practice. This should involve seeking stakeholders' opinions (e.g. about the specific domains of functioning covered by each instrument and the language used in individual items) and testing completion rates in busy service settings.

Key performance indicators for Australian mental health court liaison services.

OBJECTIVES: The aim of this paper is to describe the development and technical specifications of a framework and national key performance indicators (KPIs) for Australian mental health Court Liaison Services (CLSs) by the National Mental Health Court Liaison Performance Working Group (Working Group). METHODS: Representatives from each Australian State and Territory were invited to form a Working Group. Through a series of national workshops and meetings, a framework and set of performance indicators were developed using a review of literature and expert opinion. RESULTS: A total of six KPIs for CLSs have been identified and a set of technical specifications have been formed. CONCLUSIONS: This paper describes the process and outcomes of a national collaboration to develop a framework and KPIs. The measures have been developed to support future benchmarking activities and to assist services to identify best practice in this area of mental health service delivery.

Mental Health and Criminal Charges: Variation in Diversion Pathways in Australia.

Mental health and criminal justice legislation must provide the appropriate mechanisms for ensuring the assessment and care of mentally ill individuals. It must also balance the right to justice of these individuals with the rights of the community. In Australia, each jurisdiction has its own legislative provisions related to mental health, criminal legislation and sentencing, with variation in the mental health diversion options that are available. This article uses a national survey of court liaison services and mental health courts in Australia and a review of the relevant legislative frameworks to compare jurisdictional approaches to mental health diversion. Despite calls from the National Mental Health Commission for consistency, the Australian approach to the provision of mental health services to people in the criminal justice system is heterogeneous and piecemeal. Variation in the diversion pathways available to individuals with mental illness exists across Australia. The presence of problem-solving courts in some, but not all, jurisdictions results in differences in access to legal and treatment options.

First Prospective Cohort Study of Diabetic Retinopathy from Sub-Saharan Africa: High Incidence and Progression of Retinopathy and Relationship to Human Immunodeficiency Virus Infection.

PURPOSE: To describe the prevalence, incidence, and progression of retinopathy and to report associations with demographic, clinical, and biochemical variables in people with diabetes in Southern Malawi. DESIGN: Prospective cohort study. PARTICIPANTS: Subjects were systematically sampled from 2 primary care diabetes clinics. METHODS: We performed the first prospective cohort study of diabetic retinopathy from Sub-Saharan Africa over 24 months. Visual acuity, glycemic control, blood pressure, human immunodeficiency virus (HIV) status, urine albumin-to-creatinine ratio, hemoglobin, and lipids were assessed. Retinopathy was graded at an accredited reading center using modified Wisconsin grading of 4-field mydriatic photographs. MAIN OUTCOME MEASURES: Incidence of sight-threatening retinopathy and progression of retinopathy by 2 steps on the Liverpool Diabetic Eye Study Scale. RESULTS: A total of 357 subjects were recruited to the 24-month cohort study. At baseline, 13.4% of subjects were HIV positive and 15.1% were anemic. The 2-year incidence of sight-threatening diabetic retinopathy (STDR) for subjects with level 10 (no retinopathy), level 20 (background), and level 30 (preproliferative) retinopathy at baseline was 2.7% (95% confidence interval [CI], 0.1-5.3), 27.3% (95% CI, 16.4-38.2), and 25.0% (95% CI, 0-67.4), respectively. In a multivariate logistic analysis, 2-step progression of diabetic retinopathy was associated with glycosylated hemoglobin (odds ratio [OR], 1.27; 95% CI, 1.12-1.45), baseline grade of retinopathy (OR, 1.39; 95% CI, 1.02-1.91), and HIV infection (OR, 0.16; 95% CI, 0.03-0.78). At 2 years, 17 subjects (5.8%) lost ≥15 letters. CONCLUSIONS: Incidence of STDR was approximately 3 times that reported in recent European studies. The negative association of HIV infection with retinopathy progression is a new finding.

Frequency and quality of mental health treatment for affective and anxiety disorders among Australian adults.

OBJECTIVES: To describe the frequency, type and quality of mental health treatment among Australian adults with past-year affective and/or anxiety disorders. DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of data for 8831 adults aged 16-85 years interviewed for the 2007 National Survey of Mental Health and Wellbeing, of whom 17% (n = 1517) met International Classification of Diseases, 10th revision (ICD-10) criteria for a past-year affective and/or anxiety disorder. MAIN OUTCOME MEASURES: Three levels of mental health treatment received in the past year: (1) any consultation with a health professional for mental health; (2) any evidence-based intervention (antidepressant medication, mood stabiliser medication, cognitive behaviour therapy and/or psychotherapy); and (3) minimally adequate treatment (a "dose" of an evidence-based intervention above a minimum threshold, consistent with treatment guidelines). RESULTS: Of participants with past-year affective and/or anxiety disorders, 39% sought professional help for mental health, 26% received an evidence-based treatment, and 16% received minimally adequate treatment. After controlling for clinical factors including type and severity of disorder, the odds of all levels of treatment were lower among younger adults (16-29 years) compared with middle-aged adults, and the odds of receiving an evidence-based treatment or minimally adequate treatment were lower among people who consulted a general practitioner only compared with a mental health professional. CONCLUSIONS: Closing the gap in treatment quality requires strategies to increase the use of evidence-based interventions, and to ensure these are delivered in sufficient doses. Research to elucidate why some patients are at increased risk of inadequate treatment, and the aspects of treatment that contribute to inadequate care, is indicated.

Stimulant use disorders in people with psychosis: a meta-analysis of rate and factors affecting variation.

OBJECTIVE: Stimulant abuse and dependence often complicate the care of people with psychotic disorders. This study systematically reviews the prevalence estimates reported for stimulant abuse and dependence in people with psychotic disorders, and examines personal, clinical, regional and methodological factors which explain variation in these rates. METHODS: PsychINFO, EMBASE and MEDLINE (1946-2013) were searched systematically for studies reporting on stimulant drug use disorders in representative samples of people with psychotic disorders. Random effects models estimated the pooled rate of a stimulant use disorder, defined to include stimulant abuse and stimulant dependence. Study characteristics associated with heterogeneity in rates of stimulant use disorder were examined by subgroup analyses for categorical variables, by meta-regression for continuous independent variables and by multiple meta-regression. RESULTS: Sixty-four studies provided 68 estimates of lifetime or recent stimulant use disorders in 22,500 people with psychosis. The pooled rate of stimulant use disorder was 8.9% (95% CI 7.4%, 10.5%). Higher rates of stimulant use disorders were reported in studies of affective psychosis, studies from inpatient settings, studies from the USA and Australia, and studies with higher rates of cannabis disorder; in multiple meta-regression analysis these factors explained 68% of between-study variance. Rates of stimulant use disorder were stable over time, and unrelated to age, sex, stage of psychosis, type of stimulant drug or study methodology factors. CONCLUSIONS: Reported rates of stimulant use disorder in people with psychosis are much higher than in the general population but vary widely and are associated with regional, service setting and clinical differences between studies. It is likely that stimulants contribute to the overall burden of psychosis, and that social and environmental factors combine with drug and illness-related factors to influence stimulant use in psychosis.

Routine outcome measurement in Australia.

Australia has been implementing routine outcome measurement in its specialized public sector mental health services for over a decade. It uses a range of clinician-rated and consumer-rated measures that are administered at set times during episodes of inpatient, ambulatory and community residential episodes of care. Routine outcome measurement is now embedded in service delivery, and data are made available in a variety of ways to different audiences. These data are used by policy-makers and planners to inform decisions about system-wide reforms, by service managers to monitor quality and effectiveness, and by clinicians to guide clinical decision-making and to promote dialogue with consumers. Consumers, carers and the general community can use these data to ensure that services are accountable for the care they deliver. This paper describes the status quo in Australia with respect to routine outcome measurement, discusses the factors that led to its successful implementation, and considers the steps that are necessary for its continued development.

Cannabis and stimulant disorders and readmission 2 years after first-episode psychosis.

BACKGROUND: Few studies have examined the impact of stimulant use on outcome in early psychosis. Ceasing substance use may lead to positive outcomes in psychosis. AIMS: To examine whether baseline cannabis or stimulant disorders and ongoing drug use predict readmission within 2 years of a first psychosis admission. METHOD: Predictors of readmission were examined with Cox regression in 7269 people aged 15-29 years with a first psychosis admission. RESULTS: Baseline cannabis and stimulant disorders did not predict readmission. A stimulant disorder diagnosis prior to index psychosis admission predicted readmission, but a prior cannabis disorder diagnosis did not. Ongoing problem drug use predicted readmission. The lowest rate of readmission occurred in people whose baseline drug problems were discontinued. CONCLUSIONS: Prior admissions with stimulant disorder may be a negative prognostic sign in first-episode psychosis. Drug use diagnoses at baseline may be a good prognostic sign if they are identified and controlled.