Co-designing restrictive practice elimination: A systems thinking approach with mental health service users and practitioners in rural/regional Australia.

Elimination of restrictive practices (physical/mechanical restraint and seclusion) from adult acute mental health care services has been demanded internationally for many decades. This study aimed to: (1) Identify priority issues in the elimination of and use of alternative approaches to restrictive practices (seclusion and physical/mechanical restraint) in rural/regional acute adult mental healthcare services, as told by mental healthcare service users and practitioners, (2) identify the community-based, system-level feedback loops that enhance or reduce the use of restrictive practices and viable alternatives and, (3) identify potential action areas to improve system structures to increase regional mental healthcare services' ability to eliminate restrictive practices and use alternative approaches. Group model building (GMB) workshops were held with a small group (n = 9) of mental healthcare practitioners and service users with lived experience of restrictive practice use. This participatory approach enables exploration and visual mapping of local structures causing behaviour patterns of practitioner and service user concern over time - in this case, the barriers, and enablers to alternative approaches to restrictive practices in adult acute mental healthcare services within the Geelong-Barwon region. This is the first study that specifically applies GMB in the discussion of the elimination of restrictive practices in mental health in the non-metropolitan regional/rural context. Participants identified four key priorities in relation to eliminating restrictive practices: (1) self-advocacy, (2) continuity of care, (3) early intervention, and (4) safety for all. The study findings were distilled into a novel preliminary set of mental healthcare practitioner and service user action ideas.

Person-centred growth-oriented language and care: Fundamental to successful mental health reform.

OBJECTIVE: Person-centred growth-oriented language and care are considered vital for achieving favourable outcomes in mental health care. Personal testimonies detailed in the Final Report of the Royal Commission into Victoria's Mental Health System (RCVMHS) illustrate the need for a more compassionate and hope filled system, and demonstrate the opportunity to achieve this through embedding best practice person-centred growth-oriented language. A current gap exists in understanding the process and language involved in individuals growing to mental health. Recovery has long been the paradigm for people in the mental health system 'returning to baseline', a stark contrast to our lived experience. We experienced a new beginning post decline, daily personal growth and healing, aiming for constant improvement as we work towards mental health, a status that many may not have even experienced before becoming unwell. CONCLUSIONS: Person-centred growth-oriented care includes healing, supportive relationships with the 'caregivers' ideally being transformation specialists; knowing and understanding the process of daily personal growth. While the system is metamorphosing, it is highly recommended to embed person-centred growth-oriented language and care to aid in the transformation of individuals in the service.

Mental health triage tools: A narrative review.

Mental Health Triage (MHT) tools may be defined as any clinician administered scale that specifies psychiatric signs or symptoms, proposes a corresponding service response, and determines priority categories based on the level of perceived acuity. Multiple MHT tools are used across different jurisdictions and care settings. This article summarizes the literature on MHT tools, describes the available tools and the supportive evidence, evaluates the impact and clinical applications, and compares their strengths and weaknesses. This review utilized a systematic review process to identify articles examining MHT tools. Several benefits of using MHT tools are described; however, in general, the supportive evidence for their use is lacking. A modified Australasian Triage Scale has the strongest evidence base for use in emergency settings; however, further data are needed to establish improved outcomes. There is limited evidence for the use of MHT tools in ambulatory or primary care settings. No evidence was found supporting any one tool as effective in guiding service responses across the entire clinical spectrum. Future research could focus on developing and evaluating MHT tools that service all levels of illness presentation. Additionally, more robust studies are required to support the use of MHT tools in emergency settings. Finally, there is an impetus for the development and evaluation of MHT tools in ambulatory, community, and primary care settings.

A first-hand experience of co-design in mental health service design: Opportunities, challenges, and lessons.

In an era of mental health service reform, co-design is emerging as a leading framework to guide the design and implementation of new services. Co-design uses the expertise of clinicians, those with lived experiences of services (both consumers and carers) and provocateurs (curious questioners) to understand a 'problem' and develop innovative strategies to address it. It relies on the creation of a safe environment where power imbalances are acknowledged and mitigated, and decisions are made collaboratively. Understanding how to do this effectively within the mental health sphere, where experiences of uneven power distribution and trauma are common, can feel overwhelming. Building a shared understanding of the opportunities and limitations within co-design is also important to establish its place within broader mental health reform. This paper uses an experiential approach to reflect on a co-design process, offering an opportunity to learn from a specific example. Factors that enhanced co-design included formal, remunerated roles, the allocation of time to establish and maintain an intimate, trusting team culture, and the capacity for all team members to be vulnerable. Equally important, strategies needed to be employed to mitigate the challenges inherent within the process, including the impact of power differences, a push to make fast-paced decisions, and a sense of cynicism remaining from previous projects or experiences. When these factors are attended to, the process of co-design can be dynamic, innovative, and transformational for the people participating in it, the project and the mental health sector.

Hospital-in-the-Home as a Model for Mental Health Care Delivery: A Narrative Review.

Objective: Hospital-in-the-home (HITH) is a service model widely adopted in medical specialties to help alleviate pressure on the availability of inpatient beds and allow patients to receive acute care in familiar surroundings. To date, such models are not widely utilized in mental health care. The authors review existing HITH-type mental health services, focusing on the domains of design, implementation, and outcomes.Methods: An electronic database search was conducted of MEDLINE, PsycINFO, CINAHL, Embase, Scopus, Web of Science, and Google Scholar. Fifty-six studies were eligible for inclusion in this review. Because of heterogeneous methods and outcome reporting in the available research, a narrative approach was used to highlight key themes in the literature.Results: Mental health HITH services exist under a wide range of names with differing theoretical origins and governance structures. Common characteristics and functions are summarized. The authors found moderate evidence for a reduced number and length of hospital admissions as a result of mental health HITH programs. HITH is likely to be cost-effective because of these effects. Limited evidence exists for clinical measures, consumer satisfaction, and effects on caregivers and staff.Conclusions: Mental health HITH services are an effective alternative to inpatient admission for certain consumers. The authors propose a definition of HITH as any service intended to provide inpatient-comparable mental health care in the home instead of the hospital. Standardized studies are needed for systematic analysis of key HITH outcomes.

Long-term outcomes of patients admitted to an intensive care unit with intentional self-harm.

Self-harm is one of the most common reasons for admission to an intensive care unit (ICU). While most patients with self-harm survive the ICU admission, little is known about their outcomes after hospital discharge. We conducted a retrospective cohort study of patients in the Barwon region in Victoria admitted to the ICU with self-harm (between 1998 and 2018) who survived to hospital discharge. The primary objective was to determine mortality after hospital discharge, and secondarily estimate relative survival, years of potential life lost, cause of death and factors associated with death. Over the 20-year study period, there were 710 patients in the cohort. The median patient age was 37 years (interquartile range (IQR) 26-48 years). A total of 406 (57%) were female, and 527 (74%) had a prior psychiatric diagnosis. The incidence of ICU admission increased over time (incidence rate ratio 1.05; 95% confidence interval (CI) 1.03-1.06 per annum). There were 105 (15%) patients who died after hospital discharge. Relative survival decreased each year after discharge, with the greatest decrement during the first 12 months. At ten years, relative survival was 0.85 (95% CI 0.81-0.88). The median years of potential life lost was 35 (IQR 22-45). Cause of death was self-harm in 27%, possible self-harm in 32% and medical disease in 41%. The only factors associated with mortality were male sex, older age and re-admission to ICU with self-harm. Further population studies are required to confirm these findings, and to understand what interventions may improve long-term survival in this relatively young group of critically ill patients.

Occupational violence and staff safety in general practice.

BACKGROUND: The recent death of a Victorian surgeon who was assaulted by a member of the public when leaving work has re-highlighted the risk and potential cost of violence experienced by healthcare workers. OBJECTIVE: The aim of this article is to outline the risk of occupational violence experienced by doctors, and general practitioners in particular, and to discuss practical measures that can be taken to manage this risk. DISCUSSION: The majority of doctors have experienced aggression or violence in their workplaces in the past 12 months. Risks for violence include elements of workplace design, policy and procedures, and client factors. A series of practical tools designed to assist the assessment and management of risk of occupational violence are discussed.

Thyroid function testing in an inpatient mental health unit.

OBJECTIVE: Thyroid function tests are a common screening investigation for patients admitted to a psychiatric inpatient unit. METHOD: This study aimed to retrospectively assess the clinical utility of routine thyroid function testing performed on newly admitted psychiatric patients over a 4-year period in Victoria, Australia via chart review of all abnormal results identified. RESULTS: Our retrospective audit revealed only two cases where identification of thyroid dysfunction informed patient management. In each case, the patient had a known history of thyroid disease. In this audit period, 893 patients required screening to yield one clinically relevant abnormal result, costing AU$24,975.57. CONCLUSION: Such low clinical utility does not support routine admission thyroid function tests for psychiatric inpatients. We conclude that thyroid function tests should only be performed where the history and clinical signs suggest a likely contribution of thyroid dysfunction to the psychiatric presentation.

The impact of maternal smoking during pregnancy on depressive and anxiety behaviors in children: the Norwegian Mother and Child Cohort Study.

BACKGROUND: Maternal smoking during pregnancy (MSDP) is associated with multiple adverse childhood outcomes including externalizing behaviors. However, the association between MSDP and internalizing (anxiety and depressive) behaviors in offspring has received less investigation. We aimed to assess the association between MSDP and childhood internalizing (anxiety and depressive) behaviors in a very large, well-characterized cohort study. METHODS: We assessed the association between MSDP and internalizing behaviors in offspring utilizing information drawn from 90,040 mother-child pairs enrolled in the Norwegian Mother and Child Cohort Study. Mothers reported smoking information, including status and frequency of smoking, twice during pregnancy. Mothers also reported their child's internalizing behaviors at 18 months, 36 months, and 5 years. Associations between MSDP and childhood internalizing behaviors, including dose-response and timing of smoking in pregnancy, were assessed at each time point. RESULTS: MSDP was associated with increased internalizing behaviors when offspring were aged 18 months (B = 0.11, P <0.001) and 36 months (B = 0.06, P <0.01), adjusting for numerous potential confounders. Higher rates of smoking (e.g., >20 cigarettes per day) were associated with higher levels of internalizing behaviors. Maternal smoking during early pregnancy appeared to be the critical period for exposure. CONCLUSIONS: We found evidence supporting a potential role for MSDP in increasing internalizing (anxiety and depressive) behaviors in offspring. We also found evidence supportive of a possible causal relationship, including dose-dependency and support for a predominant role of early pregnancy exposure. Further investigation utilizing genetically informed designs are warranted to assess this association.

Pop, heavy metal and the blues: secondary analysis of persistent organic pollutants (POP), heavy metals and depressive symptoms in the NHANES National Epidemiological Survey.

OBJECTIVES: Persistent environmental pollutants, including heavy metals and persistent organic pollutants (POPs), have a ubiquitous presence. Many of these pollutants affect neurobiological processes, either accidentally or by design. The aim of this study was to explore the associations between assayed measures of POPs and heavy metals and depressive symptoms. We hypothesised that higher levels of pollutants and metals would be associated with depressive symptoms. SETTING: National Health and Nutrition Examination Survey (NHANES). PARTICIPANTS: A total of 15 140 eligible people were included across the three examined waves of NHANES. PRIMARY AND SECONDARY OUTCOME MEASURES: Depressive symptoms were assessed using the nine-item version of the Patient Health Questionnaire (PHQ-9), using a cut-off point of 9/10 as likely depression cases. Organic pollutants and heavy metals, including cadmium, lead and mercury, as well as polyfluorinated compounds (PFCs), pesticides, phenols and phthalates, were measured in blood or urine. RESULTS: Higher cadmium was positively associated with depression (adjusted Prevalence Ratios (PR)=1.48, 95% CI 1.16 to 1.90). Higher levels of mercury were negatively associated with depression (adjusted PR=0.62, 95% CI 0.50 to 0.78), and mercury was associated with increased fish consumption (n=5500, r=0.366, p<0.001). In addition, several PFCs (perfluorooctanoic acid, perfluorohexane sulfonic acid, perfluorodecanoic acid and perfluorononanoic acid) were negatively associated with the prevalence of depression. CONCLUSIONS: Cadmium was associated with an increased likelihood of depression. Contrary to hypotheses, many of persistent environmental pollutants were not associated or negatively associated with depression. While the inverse association between mercury and depressive symptoms may be explained by a protective role for fish consumption, the negative associations with other pollutants remains unclear. This exploratory study suggests the need for further investigation of the role of various agents and classes of agents in the pathophysiology of depression.

Oxidative & nitrosative stress in depression: why so much stress?

Many studies support a crucial role for oxidative & nitrosative stress (O&NS) in the pathophysiology of unipolar and bipolar depression. These disorders are characterized inter alia by lowered antioxidant defenses, including: lower levels of zinc, coenzyme Q10, vitamin E and glutathione; increased lipid peroxidation; damage to proteins, DNA and mitochondria; secondary autoimmune responses directed against redox modified nitrosylated proteins and oxidative specific epitopes. This review examines and details a model through which a complex series of environmental factors and biological pathways contribute to increased redox signaling and consequently increased O&NS in mood disorders. This multi-step process highlights the potential for future interventions that encompass a diverse range of environmental and molecular targets in the treatment of depression.

Neuroprogression in schizophrenia: Pathways underpinning clinical staging and therapeutic corollaries.

OBJECTIVE: Whilst dopaminergic dysfunction remains a necessary component involved in the pathogenesis of schizophrenia, our current pharmacological armoury of dopamine antagonists does little to control the negative symptoms of schizophrenia. This suggests other pathological processes must be implicated. This paper aims to elaborate on such theories. METHODS: Data for this review were sourced from the electronic database PUBMED, and was not limited by language or date of publication. RESULTS: It has been suggested that multiple 'hits' may be required to unveil the clinical syndrome in susceptible individuals. Such hits potentially first occur in utero, leading to neuronal disruption, epigenetic changes and the establishment of an abnormal inflammatory response. The development of schizophrenia may therefore potentially be viewed as a neuroprogressive response to these early stressors, driven on by changes in tryptophan catabolite (TRYCAT) metabolism, reactive oxygen species handling and N-methyl d-aspartate (NMDA) circuitry. Given the potential for such progression over time, it is prudent to explore the new treatment strategies which may be implemented before such changes become established. CONCLUSIONS: Outside of the dopaminergic model, the potential pathogenesis of schizophrenia has yet to be fully elucidated, but common themes include neuropil shrinkage, the development of abnormal neuronal circuitry, and a chronic inflammatory state which further disrupts neuronal function. Whilst some early non-dopaminergic treatments show promise, none have yet to be fully studied in appropriately structured randomized controlled trials and they remain little more than potential attractive targets.

Portfolio careers for medical graduates: implications for postgraduate training and workforce planning.

Portfolio careers in medicine can be defined as significant involvement in one or more portfolios of activity beyond a practitioner's primary clinical role, either concurrently or in sequence. Portfolio occupations may include medical education, research, administration, legal medicine, the arts, engineering, business and consulting, leadership, politics and entrepreneurship. Despite significant interest among junior doctors, portfolios are poorly integrated with prevocational and speciality training programs in Australia. The present paper seeks to explore this issue. More formal systems for portfolio careers in Australia have the potential to increase job satisfaction, flexibility and retention, as well as diversify trainee skill sets. Although there are numerous benefits from involvement in portfolio careers, there are also risks to the trainee, employing health service and workforce modelling. Formalising pathways to portfolio careers relies on assessing stakeholder interest, enhancing flexibility in training programs, developing support programs, mentorship and coaching schemes and improving support structures in health services.

Stage managing bipolar disorder.

OBJECTIVES: Clinical staging is widespread in medicine - it informs prognosis, clinical course, and treatment, and assists individualized care. Staging places an individual on a probabilistic continuum of increasing potential disease severity, ranging from clinically at-risk or latency stage through first threshold episode of illness or recurrence, and, finally, to late or end-stage disease. The aim of the present paper was to examine and update the evidence regarding staging in bipolar disorder, and how this might inform targeted and individualized intervention approaches. METHODS: We provide a narrative review of the relevant information. RESULTS: In bipolar disorder, the validity of staging is informed by a range of findings that accompany illness progression, including neuroimaging data suggesting incremental volume loss, cognitive changes, and a declining likelihood of response to pharmacological and psychosocial treatments. Staging informs the adoption of a number of approaches, including the active promotion of both indicated prevention for at-risk individuals and early intervention strategies for newly diagnosed individuals, and the tailored implementation of treatments according to the stage of illness. CONCLUSIONS: The nature of bipolar disorder implies the presence of an active process of neuroprogression that is considered to be at least partly mediated by inflammation, oxidative stress, apoptosis, and changes in neurogenesis. It further supports the concept of neuroprotection, in that a diversity of agents have putative effects against these molecular targets. Clinically, staging suggests that the at-risk state or first episode is a period that requires particularly active and broad-based treatment, consistent with the hope that the temporal trajectory of the illness can be altered. Prompt treatment may be potentially neuroprotective and attenuate the neurostructural and neurocognitive changes that emerge with chronicity. Staging highlights the need for interventions at a service delivery level and implementing treatments at the earliest stage of illness possible.

Socio-demographic, lifestyle and psychological predictors of benzodiazepine and z-hypnotic use patterns.

AIMS: Risk and demographic factors for benzodiazepine and z-hypnotic use are incompletely understood. The aim of the paper was therefore to investigate socio-demographic, lifestyle and psychological factors predicting onset and differential pattern of prescribed benzodiazepine and z-hypnotic use in a Norwegian population sample. METHODS: This retrospective cohort study obtained socio-demographic, psychological and lifestyle variables from the Nord-Trøndelag Health Study. Information about benzodiazepine prescriptions from the Norwegian prescription database were linked to epidemiological questionnaire data. Benzodiazepine use was classified into single-period, intermittent and chronic use, and high dose use was defined as being prescribed a yearly average above 180 daily defined doses. RESULTS: Older age, sleep difficulties and smoking were positively associated with all patterns of benzodiazepine use. Male gender was related to a reduced risk of all patterns of use, whereas educational achievement was negatively associated with single-period use. Alcohol consumption, anxiety and tension were positively related to intermittent and chronic use, while exercise was negatively related to chronic use. Smoking, sleep difficulties and old age were positively associated with prescriptions of high benzodiazepine doses, while exercise was associated with lower doses. CONCLUSIONS: Patterns of prescribed benzodiazepine use are linked to demographic, lifestyle and clinical variables. Non-pharmacological treatment for sleep difficulties and smoking cessation may reduce the risk of chronic benzodiazepine use.