Can improvement in delivery of smoking cessation care be sustained in psychiatry inpatient settings through a system change intervention? An analysis of statewide administrative health data.

OBJECTIVE: This study evaluated maintenance of improved delivery of smoking cessation assistance in adult acute psychiatry inpatient units 3 years post statewide implementation of a system change intervention through analysis of a statewide administrative health dataset. METHOD: Rates of documenting smoking status and providing a brief smoking cessation intervention (the Smoking Cessation Clinical Pathway) in all eligible Queensland public adult acute psychiatry inpatient units (N = 57) during the implementation phase (October 2015-September 2017) of a system change intervention were compared to the maintenance phase (October 2017-October 2020) using interrupted time series analysis. RESULTS: Across implementation and maintenance phases, the percentage of discharges from psychiatry inpatient units that had a smoking status recorded remained high with the statewide average exceeding 90% (implementation phase 93.2%, 95% confidence interval = [92.4, 93.9]; and maintenance phase 94.6%, 95% confidence interval = [94.0, 95.2]). The percentage of discharges statewide with a completed Pathway stabilised during the maintenance phase (change in slope -3.7%, 95% confidence interval = [-5.2, -2.3]; change in level 0.4%, 95% confidence interval = [-7.0, 7.9]). CONCLUSION: An evidence-based smoking cessation intervention implemented with a system change intervention resulted in sustained improvement in addressing smoking in adult inpatient psychiatry units up to 3 years post implementation.

Electroconvulsive therapy, personal protective equipment and aerosol generating procedures: a review to guide practice during Coronavirus Disease 2019 (COVID-19) pandemic.

OBJECTIVE: To review the literature on the definition of aerosol-generating procedures (AGPs), identify high-risk AGPs, guidelines to use personal protective equipment (PPE) and review evidence to see if electroconvulsive therapy (ECT) is a high-risk AGP requiring the use of PPE. METHODS: Existing guidelines and research data were reviewed to answer the questions. RESULTS: There is consensus about the type of anaesthesia used during ECT, what constitutes AGPs and what PPE should be used. It was not clear if ECT was an AGP, but we argue that it is one based on evidence. CONCLUSION: We conclude that ECT is an AGP and that it requires the appropriate use of PPE after taking in to account local supply and demand.

Queensland smoking care in adult acute mental health inpatient units: Supporting practice change.

OBJECTIVE: To review a clinical practice improvement approach to statewide implementation of smoking care in adult acute mental health inpatient units across public mental health services in Queensland. METHOD: Queensland public mental health services, with adult acute inpatient units, joined a statewide collaborative to work together to increase the routine screening of smoking and delivery of a Smoking Cessation Clinical Pathway brief intervention to identified smokers. RESULTS: Over a 2-year period, statewide improvements were demonstrated in the recording of smoking status (88-97%) and in the provision of a brief smoking cessation intervention to smokers (38-73%). In addition, all individual mental health services increased the delivery of a brief intervention to identified smokers and the recording of smoking status either improved or remained at high levels. CONCLUSION: Smoking remains an ongoing challenge for mental health services and one of the most important physical health issues for people living with a mental illness. The ability to implement statewide smoking care in public mental health services is an important step in shifting poor health outcomes. The clinical practice change approach adopted in Queensland has demonstrated encouraging outcomes in improving the delivery of smoking care that has been sustained over a 2-year period.

Revisiting the role of electroconvulsive therapy in schizophrenia: Where are we now?

OBJECTIVE: The purpose of this opinion article is to review the recent evidence base in relation to the role of electroconvulsive therapy (ECT) in the management of patients with schizophrenia. Specifically, we explore the efficacy and safety of ECT. Furthermore, consideration is given to the profile of patients who benefit most from ECT, the role of maintenance ECT and what happens when ECT is not given. CONCLUSION: Our brief review of the evidence suggests that clinical practice in developing countries has not kept up with the growing literature supporting ECT use in schizophrenia. As such, we advocate that ECT should not be a treatment of last resort. Rather, it should be considered more readily as an add-on therapy when there has been a poor response to antipsychotic medications or concerns exist about side effects. Further research is needed into the efficacy of maintenance ECT.

Evidence of a Causal Relationship Between Smoking Tobacco and Schizophrenia Spectrum Disorders.

There has been emerging evidence of an association between tobacco smoking and schizophrenia spectrum disorders (SSD). Two meta-analyses have reported that people who smoke tobacco have an ~2-fold increased risk of incident schizophrenia or psychosis, even after adjusting for confounding factors. This study aimed to critically appraise the research which has examined the association between tobacco smoking and SSD against the Bradford Hill criteria for causality, to determine the strength of the evidence for a causal relationship. Eight longitudinal studies (seven cohort studies and one case control study) were identified which examined tobacco smoking as an exposure and psychosis as an outcome. All seven cohort studies were assessed as being of high quality using the Newcastle-Ottawa Scale. Six of the eight studies found a statistically significant positive association between tobacco smoking and onset of SSD. These studies reported a consistent association with a moderate to large effect size and a dose response relationship. The studies adjusted for multiple potential confounders including age, sex, socioeconomic status, shared genetic risk, prodromal symptoms, and comorbid cannabis and other substance use. The studies did not adjust for exposure to childhood trauma or prenatal tobacco. There was substantial though inconclusive evidence supporting a causal relationship between tobacco smoking and increased risk of SSD. If a causal relationship does exist, nicotine is most likely responsible for this association. This raises serious public health concerns about the increasing use of e-cigarettes and other products, particularly by adolescents whose nicotine use may increase their risk of SSD. Research is urgently needed to examine the association between e-cigarette use and incident psychosis, particularly in adolescents and young adults.

Mental health services planning for G20 summit in Brisbane and assessment of impact.

OBJECTIVE: The objective of this study was to inform planning for similar events, our aim was to describe planning undertaken by Brisbane Mental Health Services for the 2014 G20 Summit and the impact of the Summit on service use. METHODS: We analysed routinely collected service data comparing presentations and discharges for the same time period in two consecutive years. RESULTS: While presentations to mental health services increased from the previous year across a five-month period (including the month of G20), the week of the G20 Summit showed little change. CONCLUSIONS: Our findings will be useful to other services that prepare for major events, such as G20. Our experience shows that, with detailed planning and extra resources, the G20 Summit passed without any major mental health incidents or major increase for mental health presentations.

Psychiatrists' follow-up of identified metabolic risk: a mixed-method analysis of outcomes and influences on practice.

Aims and method To describe and explain psychiatrists' responses to metabolic abnormalities identified during screening. We carried out an audit of clinical records to assess rates of monitoring and follow-up practice. Semi-structured interviews with 36 psychiatrists followed by descriptive and thematic analyses were conducted. Results Metabolic abnormalities were identified in 76% of eligible patients screened. Follow-up, recorded for 59%, was variable but more likely with four or more abnormalities. Psychiatrists endorse guidelines but ambivalence about responsibility, professional norms, resource constraints and skills deficits as well as patient factors influences practice. Therapeutic optimism and desire to be a 'good doctor' supported comprehensive follow-up. Clinical implications Psychiatrists are willing to attend to physical healthcare, and obstacles to recommended practice are surmountable. Psychiatrists seek consensus among stakeholders about responsibilities and a systemic approach addressing the social determinants of health inequities. Understanding patients' expectations is critical to promoting best practice.

A collaborative approach to improve the assessment of physical health in adult consumers with schizophrenia in Queensland mental health services.

OBJECTIVE: The objective of this study was to apply a quality improvement collaborative to increase the number of physical health assessments conducted with consumers diagnosed with schizophrenia in adult community mental health services across Queensland. METHOD: Sixteen adult mental health service organisations voluntarily took part in the statewide collaborative initiative to increase the number of physical health assessments completed on persons with a diagnosis of schizophrenia spectrum disorders managed through the community mental health service. RESULTS: Improvement in the physical health assessment clinical indicator was demonstrated across the state over a 3-year period with an increase in the number of physical health assessments recorded from 12% to 58%. CONCLUSIONS: Significant improvements were made over a 3-year period by all mental health services involved in the collaborative, supporting the application of a quality improvement methodology to drive change across mental health services.

Way Forward: an Indigenous approach to well-being.

OBJECTIVE: Aboriginal and Torres Strait Islander individuals are overrepresented in mental health services in the state of Queensland (QLD), Australia; indicating greater prevalence and less preventative management of mental illness. This paper describes a project to enhance the model of care to improve mental health, alcohol and other drug outcomes for Aboriginal and Torres Strait Islander Community members in two metropolitan Hospital and Health Services, in Brisbane, Australia. METHODS: Individual and focus group consultations were conducted with stakeholders, to determine key themes. RESULTS: The consultative phase of the project revealed three priority areas for action: governance and supervision arrangements for the workforce in the area of Indigenous mental health, alcohol and other drugs; the cultural capability of non-Indigenous clinicians; and consumer access to services. CONCLUSIONS: The Way Forward project is a broad workforce redesign approach to address these three key areas. This approach is designed to acknowledge the strengths among the Indigenous Aboriginal and Torres Strait Islander workforce and to utilise their specialised cultural knowledge. This strategy will also include working in relationships with key Community-controlled health and other organisations. The approach will be reviewed and evaluated.

A model for managing the mentally ill fixated person at major events.

OBJECTIVE: The main risk of serious harm at major public figure gatherings comes not from terrorists or criminal activity but from fixated persons, many of whom have a serious mental illness. This paper reviews a collaborative mental health-police diversionary model for assessing and managing mentally ill individuals who attend major events because of their fixation on a dignitary or some idiosyncratic cause. METHOD: We examine the role of a multidisciplinary fixated threat assessment service during the pre-operational, operational and post-operational phases of major events in Queensland in 2014, including the G20 World Leaders' Summit. The benefits and challenges of this unique approach are reviewed. RESULTS: The royal visit and G20 Finance Ministers' Meeting presented opportunities for the Queensland Fixated Threat Assessment Centre to develop and refine its approach to assessing and managing the threat posed by fixated persons at such events. Based on this experience, we also developed a typology to assist in the assessment of mentally ill people who present at public figure gatherings. In the week prior to the G20 Summit, six fixated people required hospitalisation for acute psychosis. A further 18 cases were identified during the event, one of whom was an involuntary patient whose leave from hospital was revoked as a consequence of his concerning behaviour at one of the G20 venues. There were no other admissions to hospital during the event, but in the remaining cases, where indicated, follow-up was arranged through the treating mental health service or general practitioner. There were no disruptive incidents involving fixated individuals during the G20. CONCLUSION: This novel diversionary model for assessing and intervening with concerning, fixated persons at major events proved effective in mitigating the risk posed by these individuals. It also highlighted the need for police, security and mental health services to consider the fixated in major event planning, for the safety of the event, the public and vulnerable mentally ill, fixated persons.

Monitoring and management of metabolic abnormalities: mixed-method evaluation of a successful intervention.

OBJECTIVE: To describe the process and impact of a service-level intervention on metabolic monitoring and follow-up of patients of a mental health service who were prescribed clozapine, and describe the metabolic health of these patients. METHODS: The intervention - Let's Get Physical - involved designating two months annually as 'physical health months', during which revised service protocol required metabolic monitoring for all eligible patients. Mixed methods were used to assess rates of monitoring at baseline, during the two physical health months, and follow-up and factors influencing practice. Data was analysed using a descriptive statistics and framework approach. RESULTS: Monitoring was completed for around two thirds of eligible patients during each physical health month, representing a statistically significant increase (approximately fourfold) from baseline. Perceptions regarding scope of practice and perceived competency managing metabolic abnormalities were key determinants of clinicians' practice. Low rates and inconsistency of follow-up were observed. CONCLUSION: Let's Get Physical is cost effective in enhancing adherence to monitoring guidelines. The use of clinical algorithms supporting timely response to abnormalities should be considered. Ongoing education, role clarity and dedicated resources are required if psychiatrists are to contribute meaningfully to improving the physical health of people with mental illness.

Clinical Practice Improvement Payments: incentives for delivery of quality care.

OBJECTIVE: In 2008, Queensland Health mental health services participated in a quality incentive payment scheme referred to as the Clinical Practice Improvement Payment. Services across the state engaged in local improvement projects with the collective aim of improving the number of consumers, diagnosed with schizophrenia, followed up within seven days post discharge. This paper describes the application of this approach over two and a half years. METHOD: Sixteen mental health services across Queensland participated and were provided with the opportunity to receive incentive payments during the period between January 2009 and June 2011. Data collection was conducted using information available on existing Queensland Health databases. Services were provided with regular updates on their progress through a secure intranet site, state-wide forums and individual service presentations, enabling them to compare their individual service data with peer and state data. RESULTS: State-wide results showed steady and continual improvement in the indicator over the reporting period. CONCLUSIONS: The results suggest that the implementation of incentive payments for routine clinical work in mental health can assist with state-wide service improvement. The impact of target setting and supporting activities remains unclear and improvements appeared to be robust to administrative challenges and unexpected external events.

Long acting risperidone in Australian patients with chronic schizophrenia: 24-month data from the e-STAR database.

BACKGROUND: This observational study was designed to collect treatment outcomes data in patients using the electronic Schizophrenia Treatment Adherence Registry (e-STAR). METHODS: Patients with schizophrenia or schizoaffective disorder in Australia who were prescribed risperidone long-acting injection (RLAI) between 2003 and 2007 were assessed 12-months retrospectively, at baseline and 24-months prospectively at 3-monthly intervals. The intent-to-treat population, defined as all patients who received at least one dose of RLAI at baseline, was used for the efficacy and safety analyses. RESULTS: At total of 784 patients (74% with schizophrenia, 69.8% male) with a mean age of 37.1 ± 12.5 years and 10.6 ± 9.5 years since diagnosis were included in this Australian cohort. A significant improvement in mean Clinical Global Impression - severity score was observed at 24-months (4.52 ± 1.04 at baseline, 3.56 ± 1.10 at 24-months). Most of this improvement was seen by 3-months and was also reflected in mean Global Assessment of Functioning score, which improved significantly at 24-months (42.9 ± 14.5 at baseline, 59 ± 15.4 at 24-months). For patients still receiving RLAI at 24-months there was an increase from a mean baseline RLAI dose of 26.4 ± 5 mg to 43.4 ± 15.7 mg. Sixty-six percent of patients discontinued RLAI before the 24-month period--this decreased to 46% once patients lost to follow-up were excluded. CONCLUSION: Over the 24-month period, initiation of RLAI was associated with improved patient functioning and illness severity in patients with schizophrenia or schizoaffective disorder. Improved outcomes were observed early and sustained throughout the study. TRIAL REGISTRATION: Clinical Trials Registration Number, NCT00283517.

A new clinical protocol for the pharmacological management of acute behavioural disturbance.

OBJECTIVE: Psychiatry is awash with pharmacological acute behavioural disturbance protocols which list oral or intramuscular benzodiazepines and antipsychotics with numerous options. This results in frequent over-sedation and occasional profound sedation and death. This paper describes the development of a simplified sedation protocol for the pharmacological management of acute behavioural disturbance. METHOD: Following the wider availability of intramuscular lorazepam in 2008, Metro North Mental Health developed a protocol utilizing only two products - oral or intramuscular lorazepam or olanzapine - which was subsequently developed into a statewide protocol. RESULTS: The advantage of utilizing only two sedating medications is that it greatly reduces the risk of profound sedation and theoretically reduces the risk of other complications including deaths. Clinical staff who have utilized the protocol report a reduction in over-sedation of inpatients. CONCLUSION: A simplified protocol makes the pharmacological management of acute behaviour disturbance safer for both patients and staff.

To be or not to be a clinical director?

OBJECTIVE: This article is designed to raise the interest of psychiatrists in the position of clinical director. CONCLUSIONS: The clinical director can improve the recovery of large numbers of mental health consumers by influencing the direction of local mental health policy, planning and funding. The effective clinical director will be an experienced psychiatrist with clinical credibility, who is present and available, leads by example, is flexible, energetic, delegates, can "manage up" and has probably undergone management training.

The Eating Disorders Outreach Service: enabling clinicians statewide to treat eating disorders.

OBJECTIVE: The aim of this paper is to describe the Eating Disorders Outreach Service (EDOS), which supports clinicians in the treatment and management of eating disorder patients across Queensland. EDOS's mandate is to facilitate intake to the specialist inpatient and outpatient services at the Royal Brisbane and Women's Hospital (RBWH) and to provide eating disorders education and consultation liaison to clinicians statewide. METHOD: EDOS provides services in four key areas: intake facilitation, service development, education and training, and consultation liaison. Each area is described in detail. RESULTS: EDOS has grown since its inception to currently comprise a full-time team manager and a number of specialist clinician positions in psychiatry, nursing, dietetics, social work and psychology. The Service has become an integral part of the RBWH Adult Eating Disorders Service, providing statewide assessment and treatment recommendations, consultation liaison services and specialist intervention programs. CONCLUSIONS: EDOS has been successful in facilitating patient access to local general medical and psychiatric facilities. EDOS also plays a significant leadership role in the development of effective statewide networking forums for clinicians and key stakeholders, in inservice delivery and in the provision of evidence-based educational opportunities, each of which has contributed to improved access to services for eating disorder patients.

The Queensland Mental Health Clinical Collaborative and the management of schizophrenia.

OBJECTIVE: This paper describes the development of a collaborative group of mental health clinicians who have come together to improve practice in adult acute mental health settings for the inpatient management of schizophrenia. METHOD: Sixteen acute adult mental health inpatient services across Queensland worked together to develop clinical indicators related to the inpatient treatment of schizophrenia. Data collection was conducted by using information available on existing databases and through statewide chart audits using scannable form technology. Through a secure intranet site, and statewide forums, clinicians were able to access information on clinical indicators enabling them to compare their site data to peer and state data. RESULTS: Available data from 15 of the 16 sites provided information on clinical indicators including average length of stay, 28-day readmission rates, antipsychotic prescribing, medication dose and the use of multiple antipsychotic medications at discharge. CONCLUSIONS: The formation of the Mental Health Clinical Collaborative has brought together clinicians across the State to develop clinical indicators and openly discuss ideas to inform and improve clinical practice. This process has been effective in improving the quality of routinely collected information across the State and in engaging clinicians in using health information to drive clinical practice.

Comparing cognitive behavior therapy, problem solving therapy, and treatment as usual in a high risk population.

Cognitive behavior therapy (CBT), problem-solving therapy (PST), or treatment as usual (TAU) were compared in the management of suicide attempters. Participants completed the Beck Hopelessness Scale, Beck Scale for Suicidal Ideation, Social Problem-Solving Inventory, and Client Satisfaction Questionnaire at pre- and posttreatment. Both CBT and PST indicated significant improvements over time within the majority of measured variables; when compared to TAU, both groups showed significant differences on satisfaction. When PST was compared to TAU, results indicated significant differences on suicidal ideation, indicating overall efficacy of brief therapies with suicide attempters.