Can lithium be used in the setting of clozapine commencement in patients with COVID-19 associated neutropenia: A case report.

COVID-19 infection may increase the likelihood of neutropenia in patients already on clozapine. In clozapine treated patients experiencing COVID-19 associated neutropenia, adjunct therapy with lithium can be considered.

Comparison of the out-of-pocket costs of Medicare-funded telepsychiatry and face-to-face consultations: A descriptive study.

OBJECTIVE: Telepsychiatry items in the Australian Medicare Benefits Schedule (MBS) were expanded following the COVID-19 pandemic. However, their out-of-pocket costs have not been examined. We describe and compare patient out-of-pocket payments for face-to-face and telepsychiatry (videoconferencing and telephone) MBS items for outpatient psychiatric services to understand the differential out-of-pocket cost burden for patients across these modalities. METHODS: out-of-pocket cost information was obtained from the Medical Costs Finder website, which extracted data from Services Australia's Medicare claims data in 2021-2022. Cost information for corresponding face-to-face, video, and telephone MBS items for outpatient psychiatric services was compared, including (1) Median specialist fees; (2) Median out-of-pocket payments; (3) Medicare reimbursement amounts; and (4) Proportions of patients subject to out-of-pocket fees. RESULTS: Medicare reimbursements are identical for all comparable face-to-face and telepsychiatry items. Specialist fees for comparable items varied across face-to-face to telehealth options, with resulting differences in out-of-pocket costs. For video items, higher proportions of patients were not bulk-billed, with greater out-of-pocket costs than face-to-face items. However, the opposite was true for telephone items compared with face-to-face items. CONCLUSIONS: Initial cost analyses of MBS telepsychiatry items indicate that telephone consultations incur the lowest out-of-pocket costs, followed by face-to-face and video consultations.

Seasonal Surge for Mental Health Demand in Emergency Departments.

Objective: To analyze emergency department (ED) mental health presentations over a 7-year period to estimate the timing and magnitude of the seasonal effect across Australia.Methods: We analyzed data collected by the Australian Institute of Health and Welfare (AIHW) from 2014-2015 to 2020-2021, which included all public hospital ED presentations in Australia that received a mental health diagnosis per the Australian Modification of ICD-10. The data were divided into 4 sequential quarters (Q1 = July-September, Q2 = October-December, Q3 = January-March, Q4 = April-June) and analyzed by sex and age (youth: 18-24 years, adult: 25-64 years, and older adult: > 65 years). Regression analysis was used to assess seasonal variation.Results: On average, mental health ED presentations were 9% higher in October-December than April-June, which had the lowest rates of mental health ED presentations for males and females. The peak continued into January-March, most prominently for females. Seasonality was evident in the 18-24 and 25-64 age groups. There were increased ED psychiatry presentations in October-December of 14.4% (males) and 9% (females) in the group aged 18-24, as well as increases of 10.3% (males) and 10.1% (females) in those aged 25-64. In January-March, there was an increase in presentations for females of 7% (aged 18-24) and 10.3% (aged 25-64). For adults aged > 65, there were increased presentations in July-September compared to April-June of 4.9% (males) and 3.9% (females).Conclusions: We found strong, statistically significant peaks in mental health ED presentations in spring and summer. Mental health services need to plan for significantly higher ED mental health demand during these seasons. Further research is required to estimate the size of the mental health seasonal effect in acute hospital settings.Prim Care Companion CNS Disord 2024;26(1):23m03629. Author affiliations are listed at the end of this article.

The changing psychiatry workforce in Australia: Still lacking in rural and remote regions.

INTRODUCTION: There is a long standing and worsening shortage of psychiatrists in Australia particularly in rural areas. The majority of psychiatrists work in major cities. OBJECTIVE: To identify recent trends in the Australian rural psychiatrist workforce compared with the metropolitan workforce. DESIGN: We descriptively analysed population-level data from the National Health Workforce Data Set (NHWDS), the Australian Institute of Health and Welfare (AIHW) and the Australian Bureau of Statistics (ABS). A descriptive analysis of the numbers (count) and gender of psychiatrists from 1995 to 2022 working in Australia was conducted. For the period 2013 to 2022, we analysed for rurality, gender, years' experience, hours worked, Medicare-subsidised services provided and proportions of Specialist International Medical Graduates (SIMG) by sex, with a focus on the rural workforce. For international comparison, psychiatrist numbers were obtained for other OECD countries. The number of psychiatrists working in Australia, as per NHWDS and AIHW, was quantified. We analysed trends in demographics, hours worked and rurality of psychiatrists working in Australia in a serial cross-sectional design. FINDINGS: Most psychiatrists are maldistributed to major cities, while outer regional and remote areas have few resident psychiatrists. Outer regional New South Wales (NSW) and South Australia (SA) have the lowest numbers of psychiatrists per capita. The full-time equivalent (FTE) of psychiatrists per 100 000 has increased from 12.6 in 2000 to 15.2 in 2022. However, the average hours worked by psychiatrists has declined. In total, available psychiatrist hours worked per 100 000 population has increased by 6.1% since the beginning of the millennium. DISCUSSION: Rural areas in NSW and SA have the greatest shortage of psychiatrists. Specialist International Medical Graduates and females (43% of the overall workforce) are the predominant workforce in rural areas. Although Medicare-subsidised services per 1000 people have increased in rural areas, they remain lower than for those living in major cities. CONCLUSION: There remains an acute shortage of psychiatrists in many regional and remote areas of Australia, with an increasing proportion of SIMGs and females working in these areas, in the context of future increased demand.

Medicare Benefits Schedule (MBS) Review Advisory Committee post-implementation review of MBS telehealth items: abolition of initial telehealth consultations for non-general practitioner specialists.

In 2022, the Australian Federal Minister for Health and Aged Care commissioned the Medicare Benefits Schedule (MBS) Review Advisory Committee (MRAC) to conduct a post-implementation review of MBS telehealth services, including settings of video and telephone consultations. The MRAC has made a series of administrative recommendations for telehealth practice that appear at cross-purposes to the evidence-base on medical consultations and that would limit patient access to medical specialist assessment in Australia. These recommendations particularly underestimate the role of telehealth in rural and remote Australia and did not take into account high patient satisfaction with telehealth assessment and treatment during the ongoing coronavirus disease 2019 (COVID-19) pandemic. They also appear to contradict the Medical Board of Australia's guidance on telehealth. On this basis, the recommendations for telehealth principles and abolition of reimbursement for telehealth for all initial non-general practitioner medical specialist consultations should be withdrawn.

Recurrent Mental Health Presentations to Public Hospital Services: A Focus on Borderline Personality Disorder.

Objective: To investigate associations between patients with borderline personality disorder (BPD)-related symptoms and their hospital presentations as well as the effect of inpatient length of stay (LOS) on time to hospital re-presentation.Methods: A retrospective cohort design was used to investigate mental health emergency department (ED) visits and inpatient admissions. The cohort comprised 13,320 men and 12,290 women with a follow-up period between January 1, 2014, and December 31, 2019.Results: Across all presentations in the study period, approximately 4% of mental health patients were discharged from ED or inpatient admission with primary diagnosis of BPD. Both male and female patients with BPD were at higher risk of hospital re-presentation when compared to patients with any other type of mental disorder (P < .01). Patients with BPD who had LOS > 14 days in their first inpatient admission were, on average, more likely to experience a repeat ED or inpatient presentation 58 days sooner than patients who had LOS < 2 days (P = .036).Conclusions: Findings suggest the need for (a) more accurate recording of BPD and related presentations, (b) more in-depth investigations of BPD care pathways, and (c) identifications of subpopulations who may benefit from a specific inpatient length of stay.Prim Care Companion CNS Disord 2024;26(1):23m03559. Author affiliations are listed at the end of this article.

Psychiatric electronic health records in the era of data breaches - What are the ramifications for patients, psychiatrists and healthcare systems?

OBJECTIVE: To update psychiatrists and trainees on the realised risks of electronic health record data breaches. METHODS: This is a selective narrative review and commentary regarding electronic health record data breaches. RESULTS: Recent events such as the Medibank and Australian Clinical Labs data breaches demonstrate the realised risks for electronic health records. If stolen identity data is publicly released, patients and doctors may be subject to blackmail, fraud, identity theft and targeted scams. Medical diagnoses of psychiatric illness and substance use disorder may be released in blackmail attempts. CONCLUSIONS: Psychiatrists, trainees and their patients need to understand the inevitability of electronic health record data breaches. This understanding should inform a minimised collection of personal information in the health record to avoid exposure of confidential information and identity theft. Governmental regulation of electronic health record privacy and security is needed.

Practical psychiatry: On therapeutic equipoise - Principles of a balanced approach to psychiatric treatments.

OBJECTIVE: There are many burgeoning treatments, and a large range of therapeutic options for 21st century psychiatry. This paper briefly comments upon considerations for balancing treatment to suit the patient, their illness, and their milieu. CONCLUSIONS: Therapeutic equipoise, for psychiatric care, is an aspiration rather than a position easily achieved. In day-to-day clinical practice, there will be unexpected demands and barriers that cannot always be accommodated or surmounted. Psychiatrists can work collaboratively with patients, carers, and colleagues in conceptualising and care-planning to avoid extremes of therapeutic hubris and despair, and to adapt evidence-based care more effectively so that it is suited to the patient and their circumstances.

Practical psychiatry: Taking gaming seriously - a primer for psychiatrists on gamers and gaming culture.

OBJECTIVE: Up to three billion, of the eight billion people in the world, play videogames. Gaming is a significant global sociocultural influence. This primer will aid psychiatrists in understanding sociocultural milieux of gamers, who include patients and their communities. METHOD: A rapid narrative review. RESULTS: Benefits include expression of personality, identity and culture through social aspects of gaming. Improved physical health, neurocognition, self-efficacy and quality of life are associated with gaming in those with certain mental health disorders including schizophrenia. Harms may include in-game discrimination, disordered gaming, as well as encouragement of online gambling. There is no longitudinal association between violent games and youth aggression. CONCLUSIONS: Psychiatrists should enquire about gaming as part of the sociocultural milieux of patients' lives, and the perceived mental health benefits and harms of gaming.

Mitigating the consequences of electronic health record data breaches for patients and healthcare workers.

Electronic health records (EHRs) have been widely adopted in Australian public sector healthcare and will remain an ongoing, essential data system. However, recent substantial data breaches from hacked business data systems in Australian enterprises, as well as international healthcare providers, mean that EHR data breaches are increasingly likely in Australia. Risks include medical identity theft and extortion attempts based on threats to release sensitive patient information. Hacking is now a foreseeable additional risk of medical treatment. Risk mitigation for the consequences of data breaches needs to be considered, as well as support for patients (and families) and healthcare workers. This includes identity theft protection services, cybersecurity insurance, and psychological support.

Seven decades of antipsychotic drugs: Why is the life of Australians with schizophrenia still so suboptimal?

The advent of dopamine (D2) receptor-blocking medications over 70 years ago, ushered in a new era of biological treatment for schizophrenia. However, we argue that little subsequent progress has been made in translating this into fulfilled and fulfilling lives for people with schizophrenia. This Viewpoint asks why this is the case, and suggests ways forward for capitalising on extant and emerging new treatments for psychotic disorders, to the betterment of the lives of people living with schizophrenia.

Unpeeling the onion: Digital triage and monitoring of general practice, private psychiatry, and psychology.

OBJECTIVE: The Australian federal government is considering a 'digital front door' to mental healthcare. The Brain and Mind Centre at the University of Sydney has published a discussion paper advocating that the government should adopt a comprehensive model of digital triage and monitoring (DTM) based on a government-funded initiative Project Synergy ($30 million). We critically examine the final report on Project Synergy, which is now available under a Freedom of Information request. CONCLUSION: The DTM model is disruptive. Non-government organisations would replace general practitioners as care coordinators. Patients, private psychiatrists, and psychologists would be subjected to additional layers of administration, assessment, and digital compliance, which may decrease efficiency, and lengthen the duration of untreated illness. Only one patient was deemed eligible for DTM, however, during the 8-month regional trial of Project Synergy (recruitment rate = 1/500,000 across the region). Instead of an unproven DTM model, the proposed 'digital front door' to Australian mental healthcare should emphasise technology-enabled shared care (general practitioners and mental health professionals) for the treatment of moderate-to-severe illness.

Impact of community mental health services on the adult psychiatric admission through the emergency unit: a 20-year population-based study.

Background: There is a lack of real-life population-based study examining the effect of community mental health services on psychiatric emergency admission. In Hong Kong, Integrated Community Center for Mental Wellness (ICCMW) and telecare service were introduced in 2009 and 2012, respectively. We examined the real-life impact of these services on psychiatric emergency admissions over 20 years. Methods: Number of psychiatric emergency admissions between 2001 and 2020 was retrieved from the Hong Kong Clinical Data Analysis & Reporting System. We used an interrupted time series analysis to examine monthly psychiatric admission trend before and after service implementation, considering socioeconomic and environmental covariates. Findings: A total of 108,492 psychiatric emergency admissions (47.8% males; 64.9% aged 18-44 years) were identified from the study period, of which 56,858, 12,506, 12,295, 11,791, and 15,051 were that for schizophrenia-spectrum disorders, bipolar affective disorders, unipolar mood disorders, neuroses, and substance use disorders. ICCMW introduction has an immediate effect on psychiatric emergency admission (adjusted estimate per 100,000: -10.576; 95% CI, -16.635 to -4.518, p < 0.001), particularly among adults aged 18-44 years (-8.543; 95% CI, -13.209 to -3.877, p < 0.001), females (-5.843; 95% CI, -9.647 to -2.039, p = 0.003), and with neuroses (-3.373; 95% CI, -5.187 to -1.560, p < 0.001), without a significant long-term effect. Unemployment, seasonality, and infectious disease outbreak were significant covariates. Interpretation: ICCMW reduced psychiatric emergency admission, but no further reduction following full implementation. Community mental health services should be dynamically tailored for different populations and socioeconomic variations over time. Funding: None.

Systematic Review of Psychiatric Observation Units and Their Impact on Emergency Department Boarding.

Objective: To investigate the effectiveness of acute short-stay hospital admissions in psychiatric observation units for improving the flow of patients with mental health presentations through the emergency department (ED).Data Sources: CINAHL, MEDLINE, OVID, PsycINFO, PubMed, Web of Science, and Google Scholar were systematically searched for English-language studies from 1990 onward. Descriptors used to describe psychiatric observation units were identified, and in databases with MESH term availability, the terms "mental disorder" and "emergency services, psychiatric" were also utilized to further enhance the search.Study Selection: A total of 6,571 studies were screened. The PICOS framework was used to determine the inclusion and exclusion criteria, and the process of study selection followed PRISMA guidelines. Articles were included if the unit studied had a length of stay (LOS) < 72 hours and if patients suffered from a mental health condition and were treated as hospital inpatients.Data Extraction: Reviewers performed data extraction and quality assessment of the included studies following the review protocol.Results: A total of 14 psychiatric observation unit studies were included in the review: 5 in North America and 9 in Australia. Most of these units were in large urban general hospitals. There appears to be some improvement in ED LOS for patients with mainly crisis mental health presentations. Seven of the 14 studies specifically discussed ED LOS, and 6 of these studies showed mild to moderate improvement in ED LOS, ranging from 17 minutes to > 11 hours.Conclusions: Psychiatric observation units were mainly located in North American and Australian settings. These units may reduce ED LOS based on limited, poor-quality evidence. Further research is required to determine whether psychiatric observation units have ongoing effects on ED LOS and alleviate access block.Prim Care Companion CNS Disord 2023;25(6):22r03468. Author affiliations are listed at the end of this article.

The unfulfilled promises of electronic health records.

We provide a brief update on the current evidence on electronic health records' benefits, risks, and potential harms through a rapid narrative review. Many of the promised benefits of electronic health records have not yet been realised. Electronic health records are often not user-friendly. To enhance their potential, electronic health record platforms should be continuously evaluated and enhanced by carefully considering feedback from all stakeholders.

Deterioration of mild anxiety and depression with Better Access treatment: implications for scaling up psychotherapy worldwide.

The Australian Medicare Better Access initiative in mental health reached one in every 10 Australians in 2021 (more than 2.6 million people) with interventions targeted at mild-to-moderate anxiety and depression, provided by general practitioners, allied health professionals, and/or psychiatrists, at a cost of AUD1.2 billion. However, the overall mental health of the Australian population has not improved since the introduction of Better Access. The benefits of population-scale mental health interventions (medications and psychotherapies) might have been overestimated for milder conditions, and the iatrogenic potential underestimated. A recent evaluation of Better Access found that mild anxiety and depressive symptoms were threefold more likely to worsen (32%) rather than improve (10%). Better Access might be targeted more cost-effectively towards severe and complex conditions, for which treatment appears to have superior risk-benefit ratios. These findings have implications for similar initiatives worldwide, such as those proposed by the World Health Organization.