Prolactin ordering patterns in psychiatric inpatients and the impact this has on patient management.

OBJECTIVE: Guidelines stipulate that baseline prolactin be ordered prior to commencing antipsychotic treatment to facilitate investigation of any subsequent hyperprolactinaemic symptoms. The aim was to observe when and why prolactin levels are ordered for psychiatry inpatients commencing or continuing antipsychotics and how this alters clinical management. METHODS: Psychiatry inpatients admitted to the Alfred Hospital, Melbourne, Australia, in 2018 with the diagnoses of psychosis, schizophrenia, schizo-affective disorder or bipolar affective disorder were retrospectively analysed. Results and clinical history data were collected in patients in whom prolactin was ordered during or within 12 months of the relevant admission. RESULTS: Of 592 patients admitted during this period, 90 had prolactin ordered. Eight (8.9%) of the 90 tests were for hyperprolactinaemic symptoms, while the remainder were routine blood work. The results altered clinical management in 10 of the 90 (11.1%) patients. Of these 10, 8 were symptomatic. In the six patients with first episode psychosis, only one had prolactin ordered prior to antipsychotic commencement. CONCLUSIONS: Adherence to guideline recommendations of baseline prolactin testing was poor. When established on antipsychotics, measuring prolactin rarely changed management in asymptomatic patients; however, it did in those with hyperprolactinaemic symptoms. Measuring prolactin in asymptomatic patients on antipsychotics appears unhelpful.

Reflection of a 2-year journey since the introduction of psychiatric behaviour of concern (Psy-BOC) call, a medical emergency team (MET) call equivalent for the deteriorating mental health of patients.

OBJECTIVE: To reflect on the challenges encountered and the resultant cultural changes that occurred during the implementation of psychiatric behaviour of concern (Psy-BOC), a medical emergency team (MET) equivalent for the deteriorating mental health of patients within an adult psychiatric inpatient unit. CONCLUSIONS: Implementing Psy-BOC on an adult psychiatric inpatient unit has been challenging, but it has successfully embedded a systematic approach to early escalation and capacity building to prevent and manage harmful behaviours.

Exploring behaviours of concern including aggression, self-harm, sexual harm and absconding within an Australian inpatient mental health service.

OBJECTIVE: Patients admitted to mental health services may exhibit behaviours of concern (BOCs) such as aggression, self-harm, absconding and sexual harm. BOCs can lead to restrictive interventions, which have adverse effects on patients, carers and staff. This paper aims to explore the nature and outcome of BOCs within an adult inpatient mental health setting. METHODS: A retrospective audit was conducted at a metropolitan inpatient service between 1 August 2016 and 31 July 2017. The frequency, nature and outcomes of BOC episodes were described and thematic analysis was used to summarise BOC antecedents. RESULTS: A BOC was documented for 179 (18.2%) patients who also showed high rates of drug abuse, homelessness and longer admission. Most self-harm and sexual harm events occurred outside of normal business hours. Medications and verbal de-escalation were commonly used interventions. Episodes of deliberate self-harm were likely to result in patient and staff injury or mechanical restraint, whereas aggression was associated with seclusion. Mental state, care engagement, physiological stress and situational stressor were identified as BOC antecedents. CONCLUSION: Multiple forms of BOCs were experienced with mental state, physical and interpersonal contributors identified. Improving multidisciplinary input into early assessment and treatment of BOC causes is needed to improve safety.

Perspectives on the Mental Health Act 2014 (Vic).

OBJECTIVE: This article will consider the potential impact of Victoria's new Mental Health Act 2014 (Vic) from the perspectives of consumers, careers and members of the treating team. This article will examine how some of the more drastic legal reforms will impact clinical processes, procedures and decision making. CONCLUSIONS: The new Act takes significant steps towards empowering consumers. However, its practical application will take some time to appraise. Only time will reveal how the Mental Health Tribunal handles its newfound powers, whether consumers will benefit from a more collaborative approach to clinical decision making and ultimately whether the Act will empower consumers.

Sudden Cardiac Death in People With Schizophrenia: Higher Risk, Poorer Resuscitation Profiles, and Differing Pathologies.

BACKGROUND: People with schizophrenia account for approximately 1.0% of the population and seem to experience increased rates of sudden cardiac death (SCD). OBJECTIVES: This study sought to determine characteristics of increased SCD in people with schizophrenia. METHODS: The End Unexplained Cardiac Death (EndUCD) prospective state-wide registry compared people aged 15 to 50 years with and without schizophrenia who experienced SCD within a 2-year time period and were referred for forensic evaluation. RESULTS: We identified 579 individuals, of whom 65 (11.2%) had schizophrenia. Patients with schizophrenia were more commonly smokers (46.2% vs 23.0%; P < 0.0001), consumed excess alcohol (32.3% vs 21.4%; P = 0.05), and used QTc-prolonging medications (69.2% vs 17.9%; P < 0.0001). They were less likely to arrest while exercising (0.0% vs 6.4%; P = 0.04). Unfavorable arrest-related factors included lower rates of witnessed arrest (6.2% vs 23.5%; P < 0.0001), more likely to be found in asystole (92.3% vs 73.3%; P < 0.0001), and being more likely to be found as part of a welfare check after a prolonged period of time (median 42 hours vs 12 hours; P = 0.003). There was more frequent evidence of decomposition, and they more commonly underwent autopsy (41.2% vs 26.4%; P = 0.04 and 93.8% vs 82.5%; P = 0.05), with a diagnosis of nonischemic cardiomyopathy being more common (29.2% vs 18.1%; P = 0.04). CONCLUSIONS: People with schizophrenia account for 11% of young SCD patients referred for forensic investigations, exceeding population rates by 11-fold. They have a higher preexisting cardiac risk factor burden, unfavorable resuscitation profiles, and higher rates of nonischemic cardiomyopathy. Strategies targeting biopsychosocial support may deliver not only psychological benefits, but also help to decrease unwitnessed cardiac arrest.