The NSW Emergency Psychiatry Network.

Emergency Psychiatry is evolving. In an environment that lacks a clear evidence base, and where a constellation of factors is driving up Emergency Department presentation rates and lengths of stay, several stakeholders are working towards and clamouring for change. With the goal of collaborating with such parties, we believe Emergency Psychiatrists should position themselves to establish and advocate for best-practice change in culture, research, clinical care and training, and funding in the provision of mental health crisis care. To this end, we have formed the NSW Emergency Psychiatry Network, a group of Emergency Psychiatrists with a broad experience in a range of settings, from tertiary metropolitan emergency facilities with access to subspecialty psychiatric services, to rural and remote emergency settings with sporadic in-reach from local mental health services and telehealth. We unanimously recognise the need to upskill both Emergency Department and Mental Health clinicians in crisis care, and the need for committed, evidence-based Mental Health resourcing within Emergency Departments.

Improving metabolic stability and removing aldehyde oxidase liability in a 5-azaquinazoline series of IRAK4 inhibitors.

In this article, we report our efforts towards improving in vitro human clearance in a series of 5-azaquinazolines through a series of C4 truncations and C2 expansions. Extensive DMPK studies enabled us to tackle high Aldehyde Oxidase (AO) metabolism and unexpected discrepancies in human hepatocyte and liver microsomal intrinsic clearance. Our efforts culminated with the discovery of 5-azaquinazoline 35, which also displayed exquisite selectivity for IRAK4, and showed synergistic in vitro activity against MyD88/CD79 double mutant ABC-DLBCL in combination with the covalent BTK inhibitor acalabrutinib.

Human rights implications of introducing a new mental health act - principles, challenges and opportunities.

OBJECTIVE: The United Nations Convention on the Rights of Persons with Disabilities (CRPD), 2006 has influenced the evolution of mental health legislation to protect and promote human rights of individuals with mental illness. This review introduces how the human rights agenda can be systematised into mental health services. Exploration is made of how some principles of CRPD have been incorporated into Queensland's Mental Health Act 2016. CONCLUSION: Although progress has been made in some areas, e.g. heavier reliance on capacity assessment and new supported decision-making mechanisms, MHA 2016 has continued to focus on involuntary treatment. A Human Rights Act 2019 has been passed by the Queensland parliament, which may fill in the gap by strengthening positive rights.

Service availability and capacity in rural mental health in Australia: Analysing gaps using an Integrated Mental Health Atlas.

OBJECTIVE: Access to services and workforce shortages are major challenges in rural areas worldwide. In order to improve access to mental health care, it is imperative to understand what services are available, what their capacity is and where existing funds might be spent to increase availability and accessibility. The aim of this study is to investigate mental health service provision in a selection of rural and remote areas across Australia by analysing service availability, placement capacity and diversity. METHOD: This research studies the health regions of Western New South Wales and Country Western Australia and their nine health areas. Service provision was analysed using the DESDE-LTC system for long-term care service description and classification that allows international comparison. Rates per 100,000 inhabitants were calculated to compare the care availability and placement capacity for children and adolescents, adults and older adults. RESULTS: The lowest diversity was found in northern Western Australia. Overall, Western New South Wales had a higher availability of non-acute outpatient services for adults, but hardly any acute outpatient services. In Country Western Australia, substantially fewer non-acute outpatient services were found, while acute services were much more common. Acute inpatient care services were more common in Western New South Wales, while sub-acute inpatient services and non-acute day care services were only found in Western New South Wales. CONCLUSION: The number and span of services in the two regions showed discrepancies both within and between regions, raising issues on the equity of access to mental health care in Australia. The standard description of the local pattern of rural mental health care and its comparison across jurisdictions is critical for evidence-informed policy planning and resource allocation.

Community pharmacists' experiences and people at risk of suicide in Canada and Australia: a thematic analysis.

PURPOSE: To explore Canadian and Australian community pharmacists' practice experiences in caring for people at risk of suicide. METHODS: We conducted a thematic analysis of 176 responses to an open-ended extension question in an online survey. RESULTS: Four themes were identified and include referrals and triage, accessibility for confiding, emotional toll, and stigma. Subthemes included gatekeeping the medication supply, sole disclosure, planning for end of life, concerns of support people, assessing the validity of suicidality, gaps in the system, not directly asking, ill-equipped, resources in the pharmacy, relying on others to continue care, and attention seeking. CONCLUSIONS: Community pharmacists are caring for patients at risk of suicide frequently, and often with patients seeking the help of pharmacists directly. Pharmacists engage in activities and actions that would be considered outside of the traditional dispensing roles and provide support and intervention to people at risk of suicide through collaboration and other mechanisms. Further research to determine appropriate education and training and postvention supports is required.

How shortcomings in the mental health system affect the use of involuntary community treatment orders.

Objective The aim of the present study was to examine stakeholder perspectives on how the operation of the mental health system affects the use of involuntary community treatment orders (CTOs). Methods A qualitative study was performed, consisting of semi-structured interviews about CTO experiences with 38 purposively selected participants in New South Wales (NSW), Australia. Participants included mental health consumers (n=5), carers (n=6), clinicians (n=15) and members of the Mental Health Review Tribunal of NSW (n=12). Data were analysed using established qualitative methodologies. Results Analysis of participant accounts about CTOs and their role within the mental health system identified two key themes, namely that: (1) CTOs are used to increase access to services; and (2) CTOs cannot remedy non-existent or inadequate services. Conclusion The findings of the present study indicate that deficiencies in health service structures and resourcing are a significant factor in CTO use. This raises questions about policy accountability for mental health services (both voluntary and involuntary), as well as about the usefulness of CTOs, justifications for CTO use and the legal criteria regulating CTO implementation. What is known about this topic? Following the deinstitutionalisation of psychiatric services over recent decades, community settings are increasingly the focus for the delivery of mental health services to people living with severe and persistent mental illnesses. The rates of use of involuntary treatment in Australian community settings (under CTOs) vary between state and territory jurisdictions and are high by world standards; however, the reasons for variation in rates of CTO use are not well understood. What does this paper add? This paper provides an empirical basis for a link between the politics of mental health and the uptake and usefulness of CTOs. What are the implications for practitioners? This paper makes explicit the real-world demands on the mental health system and how service deficiencies are a significant determinant in the use of CTOs. Practitioners and policy makers need to be candid about system limitations and how they factor in clinical and legal justifications for using involuntary treatment. The results of the present study provide data to support advocacy to improve policy accountability and resourcing of community mental health services.

The Port Arthur massacre and the National Firearms Agreement: 20 years on, what are the lessons?

The 20th anniversary of the National Firearms Agreement (NFA) offers lessons for mental health and public health. Along with similar international legislation, the NFA exemplifies how firearms regulation can prevent firearm mortality and injuries. The gun lobby claims that mental illness underpins gun violence and should be a key site for intervention. A modest but significant link exists between mental disorders and community violence. However, the vast majority of mentally ill individuals are not violent. Despite media portrayals of their dangerousness, they are more likely to be victims of violence and of suicide. Most violent individuals do not have mental illness, and most mass murderers do not have identifiable severe mental illness. Many have maladaptive personality configurations. Gun availability and gun ownership, not severe mental illness, determines most gun homicides. Following recent gun massacres in the United States, there have been calls for better resourcing of mental health services to help identify and respond to those at risk and to regulate firearms access. Screening mentally ill populations for violence risk is misguided. However, clinicians can play a key role in working with legal authorities to monitor and assist regulation of firearm access, especially among high risk populations. Clinician involvement must be complemented by wider gun control measures. The gun lobby's turning the firearms availability debate into a question about whether people with mental illness histories should access such weapons is a calculated appeal to prejudice.

Using accountability for mental health to drive reform.

Greatly enhanced accountability can drive mental health reform. As extant approaches are ineffective, we propose a new approach. Australia spends around $7.6 billion on mental health services annually, but is anybody getting better? Effective accountability for mental health can reduce variation in care and increase effective service provision. Despite 20 years of rhetoric, Australia's approach to accountability in mental health is overly focused on fulfilling governmental reporting requirements rather than using data to drive reform. The existing system is both fragmented and outcome blind. Australia has failed to develop useful local and regional approaches to benchmarking in mental health. New approaches must address this gap and better reflect the experience of care felt by consumers and carers, as well as by service providers. There are important social priorities in mental health that must be assessed. We provide a brief overview of the existing system and propose a new, modest but achievable set of indicators by which to monitor the progress of national mental health reform. These indicators should form part of a new, system-wide process of continuous quality improvement in mental health care and suicide prevention.

Involuntary psychiatric treatment in the community: general practitioners and the implementation of community treatment orders.

BACKGROUND: There are no data about general practitioners' (GPs') involvement in involuntary psychiatric community treatment orders (CTOs). We examined stakeholder perspectives on the GP's role in this area. METHODS: Semi-structured interviews were conducted around CTO experiences with 38 participants: patients, carers, clinicians and Mental Health Review Tribunal members. Data were analysed using established qualitative methodologies. RESULTS: Sixteen participants specifically spoke about GPs. The analysis identified four themes in their accounts: GPs as 'instruments' of CTOs; GPs as primary caregivers within a CTO; GPs as 'outsiders'; and practical challenges for GPs. Within these themes, participants identified the value of GPs in the provision of care for people living with severe and persistent mental illness, the challenges of coercive processes and the dangers of GPs being isolated from them. DISCUSSION: GPs play an important role in the implementation of CTOs. Failure to better integrate GPs in the care of people on CTOs appears to be a significant shortcoming of its implementation.

The lived experience of involuntary community treatment: a qualitative study of mental health consumers and carers.

OBJECTIVE: To describe the lived experiences of people subject to community treatment orders (CTOs) and their carers. METHOD: We recruited 11 participants (five mental health consumers and six carers) through consumer and carer networks in NSW, Australia, to take part in interviews about their experiences. We analysed the interview data set using established qualitative methodologies. RESULTS: The lived experiences were characterised by 'access' concerns, 'isolation', 'loss and trauma', 'resistance and resignation' and 'vulnerability and distress'. The extent and impact of these experiences related to the severity of mental illness, the support available for people with mental illnesses and their carers, the social compromises associated with living with mental illness, and the challenges of managing the relationships necessitated by these processes. CONCLUSIONS: The lived experience of CTOs is complex: it is one of distress and profound ambivalence. The distress is an intrinsic aspect of the experience of severe mental illness, but it also emerges from communication gaps, difficulty obtaining optimal care and accessing mental health services. The ambivalence arises from an acknowledgement that while CTOs are coercive and constrain autonomy, they may also be beneficial. These findings can inform improvements to the implementation of CTOs and the consequent experiences.

Mental health reform in Australia - unfinished business.

Australia was one of the first countries to develop a national mental health strategy. This article reviews the progress of reform, outlining some strengths, weaknesses and prospective challenges.

Patterns of mental healthcare provision in rural areas: A demonstration study in Australia and Europe.

Introduction: Mental healthcare systems are primarily designed to urban populations. However, the specific characteristics of rural areas require specific strategies, resource allocation, and indicators which fit their local conditions. This planning process requires comparison with other rural areas. This demonstration study aimed to describe and compare specialized rural adult mental health services in Australia, Norway, and Spain; and to demonstrate the readiness of the healthcare ecosystem approach and the DESDE-LTC mapping tool (Description and Evaluation of Services and Directories of Long Term Care) for comparing rural care between countries and across areas. Methods: The study described and classified the services using the DESDE-LTC. The analyses included context analysis, care availability, placement capacity, balance of care, and diversity of care. Additionally, readiness (Technology Readiness Levels - TRL) and impact analyses (Adoption Impact Ladder - AIL) were also assessed by two independent raters. Results: The findings demonstrated the usability of the healthcare ecosystem approach and the DESDE-LTC to map and identify differences and similarities in the pattern of care of highly divergent rural areas. Day care had a greater weight in the European pattern of care, while it was replaced by social outpatient care in Australian areas. In contrast, care coordination was more common in Australia, pointing to a more fragmented system that requires navigation services. The share between hospital and community residential care showed no differences between the two regions, but there were differences between catchment areas. The healthcare ecosystem approach showed a TRL 8 (the tool has been demonstrated in a real-world environment and it is ready for release and general use) and an AIL of 5 (the target public agencies provided resources for its completion). Two experts evaluated the readiness of the use of DESDE-LTC in their respective regional studies. All of them were classified using the TRL. Discussion: In conclusion, this study strongly supports gathering data on the provision of care in rural areas using standardized methods to inform rural service planning. It provides information on context and service availability, capacity and balance of care that may improve, directly or through subsequent analyses, the management and planning of services in rural areas.

The Next-Generation Oral Selective Estrogen Receptor Degrader Camizestrant (AZD9833) Suppresses ER+ Breast Cancer Growth and Overcomes Endocrine and CDK4/6 Inhibitor Resistance.

Oral selective estrogen receptor degraders (SERD) could become the backbone of endocrine therapy (ET) for estrogen receptor-positive (ER+) breast cancer, as they achieve greater inhibition of ER-driven cancers than current ETs and overcome key resistance mechanisms. In this study, we evaluated the preclinical pharmacology and efficacy of the next-generation oral SERD camizestrant (AZD9833) and assessed ER-co-targeting strategies by combining camizestrant with CDK4/6 inhibitors (CDK4/6i) and PI3K/AKT/mTOR-targeted therapy in models of progression on CDK4/6i and/or ET. Camizestrant demonstrated robust and selective ER degradation, modulated ER-regulated gene expression, and induced complete ER antagonism and significant antiproliferation activity in ESR1 wild-type (ESR1wt) and mutant (ESR1m) breast cancer cell lines and patient-derived xenograft (PDX) models. Camizestrant also delivered strong antitumor activity in fulvestrant-resistant ESR1wt and ESR1m PDX models. Evaluation of camizestrant in combination with CDK4/6i (palbociclib or abemaciclib) in CDK4/6-naive and -resistant models, as well as in combination with PI3Kαi (alpelisib), mTORi (everolimus), or AKTi (capivasertib), indicated that camizestrant was active with CDK4/6i or PI3K/AKT/mTORi and that antitumor activity was further increased by the triple combination. The response was observed independently of PI3K pathway mutation status. Overall, camizestrant shows strong and broad antitumor activity in ER+ breast cancer as a monotherapy and when combined with CDK4/6i and PI3K/AKT/mTORi. SIGNIFICANCE: Camizestrant, a next-generation oral SERD, shows promise in preclinical models of ER+ breast cancer alone and in combination with CDK4/6 and PI3K/AKT/mTOR inhibitors to address endocrine resistance, a current barrier to treatment.

Can mental health commissions really drive reform? Towards better resourcing, services, accountability and stakeholder engagement.

OBJECTIVE: In this second and final part of this series about mental health commissions, we consider the extent to which it is possible to find hard evidence that these new structures really can drive mental health reform. Four key domains of improvement are established for the purposes of this review: do commissions lead to better resources, better services, better accountability and better stakeholder engagement? A review of the evidence from both Australia and overseas is presented. The article also considers how the commissions, federal and state, will organise their relationships productively to avoid duplication and promote synergy. What of those jurisdictions without commissions? Is this genuine national reform or merely more piecemeal activity in mental health? The authors have been informed by the varying structures and functions of mental health commissions internationally and were part of the New South Wales taskforce to establish a mental health commission. They had the opportunity to visit the Western Australian and New Zealand Commissions as part of this process. CONCLUSION: Addressing mental illness requires a joined up approach to government and services. Commissions offer a new organisational structure designed to deliver this contiguity. There is also evidence that nascent and established commissions are delivering real reforms, including in terms of additional resources and influence. Without concerted efforts to coordinate activity, the intersection between federal and state commissions will be confused and duplications might arise. The paper calls for a new network of commissions to be established across Australia and New Zealand, to share resources and common tasks, clarify roles and build common approaches.

It's raining mental health commissions: prospects and pitfalls in driving mental health reform.

OBJECTIVE: Partly in response to ongoing concerns about the state of mental health care, several jurisdictions across Australia, including the federal government, are hoping to drive change via the establishment of a mental health commission. This is the first of two articles in a series which aims to describe the background to this new trend. The commissions are being established with different powers and structures. This variety is explored and considered against a typology of commissions. Some consistent themes and goals emerge. The paper then provides a contemporary assessment of the 'state of play' of the nascent commissions and describes important emerging issues and differences between the models. CONCLUSION: There are significant differences not only in the construct of the respective commissions but also in the political circumstances in which each must work. At the same time, the problems facing mental health in Australia are ubiquitous and profound. For commissions to be successful they will require not only astute leadership but also durable, bipartisan political support and an enduring capacity to generate new resources for the mental health sector.

The future of community-centred health services in Australia: 'When too many beds are not enough'.

The authors welcome a constructive debate on the future of community-centred health services. Therefore, we have written this piece in response to an article published by Cunningham in the previous edition of the Australian Health Review (Cunningham, Australian Health Review 2012; 36: 121-124), which was a very limited analysis and misleading critique of our previous contribution to this journal (Rosen et al. Australian Health Review 2010; 34: 106-115). The focus here is necessarily brief and does not stand in for a detailed analysis of the evidence base. The aim instead, is to draw attention back to the broader political economic and social dimensions of how the retreat from community health services has affected clinical care. We also outline a response to a longstanding assumption, or belief, that too many hospital beds are not enough and may never be enough. How we understand the problem of resource allocation in healthcare shapes the remedies that are considered realistic. We explain that the reasons for the systematic underdevelopment of community health services are complex, historical, and largely relate to political and economic factors, but they are still amenable to change.

The wonder of their voices: The 1946 Holocaust interviews of David Boder (New York: Oxford, 2010).

Writing a study of psychologist David Boder's 1946 displaced persons (DP) interview project gave me a chance to further document the substantial early response to the Holocaust. This was clearly one important piece of my study, and one that was eminently straightforward. Yet much of the research on Boder's project at the point in time that I carried it out was elliptical, partly because the primary interview materials were coming to light at an astonishing pace, partly because the archive collections were virtually untapped, and partly because of the misconception of Boder and his interview project itself.

Co-leadership to co-design in mental health-care ecosystems: what does it mean to us?

PURPOSE: This study aims to demonstrate how service providers, service users and their families should be able to share the co-leadership, co-auspicing, co-ownership, and co-governance, of a the mental health-care ecosystem, at every level, as it develops upwards and wider, in a process of inclusivity, conviviality and polyphonic discourse, via the overlapping phases of co-creativity, codesign, co-production, co-delivery, co-evaluation, co-research and co-replication, to achieve outcomes of co-communal or organisational well-being. DESIGN/METHODOLOGY/APPROACH: "Co-design" is shorthand code for encouraging multiple pathways and trajectories toward forming and sustaining a sparkling web or vibrant network of inclusive opportunities for stakeholder participation and a collaborative partnership in organizational development, in these circumstances, for more effective mental health services (MHSs). FINDINGS: In a co-design framework, all partners should be entitled to expect and "to have and to hold" an ongoing equal stake, voice and power in the discourse from start to finish, in a bottom-up process which is fostered by an interdisciplinary leadership group, providing the strong foundation or nutrient-rich and well-watered soil and support from which a shared endeavor can grow, blossom and generate the desired fruit in ample quality and quantity. ORIGINALITY/VALUE: The authors should be working toward co-design and co-production of contemporary MHSs in a mental health-care ecosystem.