Hematological and Other Cancers in People Using Clozapine: Analysis of Australian Spontaneous Reports Between 1995 and 2020.

BACKGROUND: Recent observational study evidence suggests that clozapine, unlike other antipsychotics, may be associated with a small increased risk of hematological malignancy. This study described characteristics of hematological and other cancers in those taking clozapine reported to the Australian Therapeutic Goods Administration. METHODS: We analyzed public case reports for "clozapine," "Clozaril," or "Clopine" from January 1995 to December 2020 classified as "neoplasm benign, malignant and unspecified" by the Australian Therapeutic Goods Administration. Data on age, sex, dose, clozapine start and cessation dates, Medical Dictionary for Regulatory Activities reaction terms, and date of cancer were extracted. RESULTS: Overall, 384 spontaneous reports of cancers in people taking clozapine were analyzed. The mean age of patients was 53.9 years (SD, 11.4 years), and 224 (58.3%) were male. The most frequent cancers were hematological (n = 104 [27.1%]), lung (n = 50 [13.0%]), breast (n = 37 [9.6%]), and colorectal (n = 28 [7.3%]). The outcome was fatal for 33.9% of cancer reports. Lymphoma comprised 72.1% of all hematological cancers (mean patient age, 52.1 years; SD, 11.6 years). The median daily dose of clozapine at the time of hematological cancer report was 400 mg (interquartile range, 300-543.8 mg), and the median duration of clozapine use before hematological cancer diagnosis was 7.0 years (interquartile range, 2.8-13.2 years). CONCLUSIONS: Lymphoma and other hematological cancers are overrepresented in spontaneous adverse event reports compared with other cancer types. Clinicians should be aware of the possible association with hematological cancers and monitor for and report any hematological cancers identified. Future studies should examine histology of lymphomas in people using clozapine and corresponding blood level of clozapine.

Fatal poisonings involving clozapine: A 16-year review of Australian coronial investigations.

OBJECTIVE: Concerns about intentional and unintentional poisoning present a barrier to wider use of clozapine in treatment-resistant schizophrenia. The objective of this study was to investigate decedent demographics and trends in fatal poisonings in Australia involving clozapine. METHODS: This was a retrospective case series of all fatal drug toxicity reported to an Australian coroner between 1 May 2000 and 31 December 2016 where toxicological analysis detected clozapine. Cases were identified using the National Coronial Information System. Demographics extracted included age and gender of the decedent, year and location of death, cause and manner of death and drugs detected in post-mortem samples. RESULTS: There were 278 poisoning deaths where clozapine was detected in toxicological analyses. Three-quarters of all cases (n = 207) involved men and the median age at death was 38.5 years (interquartile range: 16 years). Three-quarters of the deaths occurred in the home. Overall, 15.8% of deaths were deemed intentional, 57.5% unintentional and 24.5% of unknown intent. While the annual number of intentional self-poisonings remained constant with <5 per year, the overall number of fatalities increased due to an increase in unintentional poisonings. Multiple drug toxicity was reported in 55.0% of cases and clozapine alone in 45.0% of cases. The most common co-reported medications were antidepressants, benzodiazepines and opioids detected in 47.1%, 44.4% and 41.2% of multiple drug toxicities, respectively. CONCLUSION: This was the first Australia-wide review of all fatal drug poisonings reported to a coroner involving clozapine. Fatalities were most common in men and occurred at home. Multiple drug toxicity generally involved psychotropic, sedative or opioid analgesic medications. Despite increasing clozapine use, rates of intentional poisoning have remained constant and low. Developing a better knowledge of unintentional fatalities presents an opportunity to minimise harm.

'You just lose the people you know': relationship loss and mental illness.

The purpose of this qualitative study was to explore the nature, scope and consequences of losses resulting from mental illness. This paper presents findings from a key theme of this study-the loss of relationships. Thematic analysis revealed two categories: loss of intimate relationships, which included subcategories of (i) spouses/partners, (ii) children/parenthood, (iii) family, and (iv) friends; and (2) people within the community, such as people at church and support groups. Relationships are seen as one of the most crucial yet challenging elements to recovery and wellbeing for people affected by mental illness.

A systematic review of personality disorder amongst people with intellectual disability with implications for the mental health nurse practitioner.

AIMS AND OBJECTIVES: This paper reviews and summarises the literature on assessment, diagnosis and management of personality disorder in people with intellectual disability. It will proceed to argue the implications of a mental health nurse practitioner in clinical practice. BACKGROUND: Personality disorder is a potentially severe and disabling condition causing significant distress as well as presenting considerable challenges for service providers. Diagnosis in people with intellectual disability is controversial. However, it is considered that this population is at greater risk of these disorders. There is, however, little research on which to base clinical interventions or service planning. DESIGN: Systematic review. METHODS: A literature search of electronic data was undertaken in April 2007 using CINAHL, AMED, Medline, PsycINFO, EMBASE and Cochrane Library. Other sources included Google Scholar, hand searching of reference lists and texts and search of relevant websites. RESULTS: The literature on personality disorder in intellectual disability is notable for its paucity. The limited evidence available suggests that this population is at greater risk of personality disorder and that assessment and diagnosis is complex and often overshadowed by the intellectual disability. Few papers address treatment, there are no trial-based studies and it has not been established whether results can be extrapolated from research in the general population. CONCLUSIONS: The issue of personality disorder in people with intellectual disability is shrouded in controversy with a dearth of robust evidence to inform assessment or therapeutic care. Personality disorder does, however, provide a basis for decisions on type and intensity of support required for this population who have significant levels of unmet need. RELEVANCE TO CLINICAL PRACTICE: Some people with an intellectual disability and personality disorder can live in the community with specialist support. The mental health nurse practitioner has the potential to provide people with dual diagnostic support needed to enhance the capacity of the service system to meet the needs of this complex and difficult population.

Lethal hopelessness: Understanding and responding to asylum seeker distress and mental deterioration.

The mental deterioration of the so called 'legacy caseload' (asylum seekers who arrived in Australia by boat between August 2012-December 2013) has become a national concern and is garnering international attention. Prolonged uncertainty is contributing to mental deterioration and despair. There have been at least 11 deaths by suicide since June 2014. Social support services have been limited and legal assistance in short supply; this is associated with lengthy delays with visa applications. Thwarted belongingness, purpose and identity, a shortage of available services, and barriers to legal support for processes attendant upon Refugee Status Determination increase the likelihood that the mental health of asylum seekers will deteriorate further, potentially developing into worsening decline, which will lead to increased self-harm and suicide. This article summarises recent suicide deaths in Australia, positing practical assistance and support for asylum seekers living in the community. Therapeutic engagement should be trauma-informed wherever possible, helping asylum seekers to reframe their sense of lethal hopelessness.

The Effectiveness of Suicide Prevention Education Programs for Nurses.

BACKGROUND: Education to improve health professionals' responses to suicide is considered an important suicide prevention strategy. However, the effectiveness of this approach for nurses is unclear. AIM: To systematically review the peer-reviewed literature regarding the effectiveness of suicide prevention education programs for nurses. METHOD: Nine academic databases (CINAHL, Cochrane Reviews & Trials, Embase, Informit Health Collection, Joanna Briggs Institute, Medline, PsycINFO, Scopus, and Web of Science) were searched in November 2016, utilizing search terms related to suicide, education, and nurses, with no limits placed on publication date or study design. RESULTS: The search yielded 5,456 identified articles, 11 of which met the inclusion criteria. Studies were primarily quantitative (RCTs n = 3; quasi-experimental n = 6; qualitative n = 2), and involved nurses (range = 16-561) working in a diversity of settings, particularly hospitals (n = 9). Studies revealed positive changes in nurses' competence, knowledge, and attitudes associated with training over the short term. LIMITATIONS: The heterogeneity of education programs and methodological weaknesses of included studies limit the conclusions drawn. CONCLUSION: There is a moderate body of evidence to support the effectiveness of suicide prevention education programs for nurses. Future research should examine longer-term changes in clinical practice and strategies for continuing education, with more rigorous study designs.

Mentoring for population health in general practice divisions.

This paper describes the implementation and evaluation of a three-way model of service development mentoring. This population health mentoring program was funded by the Commonwealth Department of Health and Ageing to enable staff from eight Divisions of General Practice in South Australia to gain a sound understanding of population health concepts relevant to their workplace. The distinguishing features of service development mentoring were that the learning was grounded within an individual's work setting and experience; there was an identified population health problem or issue confronting the Division of General Practice; and there was an expectation of enhanced organisational performance. A formal evaluation found a consensus among all learners that mentoring was a positive and worthwhile experience, where they had achieved what they had set out to do. Mentors found the model of learning agreeable and effective. Division executive officers recognised enhanced skills among their "learner" colleagues, and commented positively on the benefits to their organisations through the development of well researched and relevant projects, with the potential to improve the efficiency of their population health activities.

Engaging with culturally and linguistically diverse communities to reduce the impact of depression and anxiety: a narrative review.

Culturally and linguistically diverse (CALD) communities in Australia face significant challenges in terms of reducing barriers to information and support for depression and anxiety. Increased stigma surrounding mental ill-health in some cultures and related concerns about trust and confidentiality all impact upon timely access to information, services and support for consumers and carers from CALD backgrounds. For health services, there is a need to understand how to better engage CALD communities in mental healthcare. The objective of this narrative review was to identify examples of evidence-based, best practice for what works effectively for engaging with CALD communities to reduce the impact of depression and anxiety. In January 2014, we searched Academic Search Premier, CINAHL, Health-Source Consumer Edition, PsycARTICLES, PsycINFO (all databases within the EbscoHost platform) and PubMed for peer-reviewed articles published between 1994 and 2014. The search revealed a total of 706 records contained within the EbscoHost platform and 689 records in PubMed; 15 matched the inclusion criteria. Six key themes were identified: (i) setting the scene for engagement; (ii) cultural values and preferences; (iii) language considerations; (iv) 'engagers' in the therapeutic process; (v) opening out engagement to include others; and (vi) engaging through the use of technology and alternative mediums. The literature obtained provides a small body of evidence regarding approaches to engaging CALD communities, with findings highlighting the importance of processes which are tailored to the CALD community of interest and which take into account different cultural explanatory models of mental ill-health. Review findings are also discussed within the framework of intersectionality, in which broader structural inequalities and power imbalances - in areas such as gender and social class - collectively impact on help-seeking and mental health outcomes. This review supports further enquiry into how such societal issues influence engagement - and disengagement - in mental health services for CALD communities.

Community educators as supporters in ethnographic research.

The present article describes ethnographic research on the structure and function of bilingual community educators (CEs) as brokers of information involving culturally and linguistically diverse (CALD) communities. An important aspect of CE involvement was supporting the chief investigator to engage CALD communities to interpret their understanding of mental health and mental illness, and make appropriate choices about their health care. CEs advised the chief investigator on the appropriate use of language when dealing with mental and emotional health issues so that CALD community people were not isolated from the research process. The author contends that the benefit of CEs in ethnographic research is to help research teams synthesize different viewpoints to shape research questions and create workable solutions in local situations.

Emergency mental health nursing for self-harming refugees and asylum seekers.

This article describes the structure and function of emergency mental health nursing practice for self-harming refugees and asylum seekers on Temporary Protection Visas. Emergency nurses working in accident and emergency departments or as part of crisis intervention teams will see self-harming refugees and asylum seekers at the very point of their distress. This clinical paper is intended to support nurses in their practice should they encounter an adult asylum seeker needing emergency mental health care. Practical strategies are highlighted to help mental health nurses assess, care, and comfort refugees and asylum seekers in this predicament. Mental health nurses should, where possible, work closely with asylum seekers, their support workers, and accredited interpreters and translators to ensure the appropriate use of language when dealing with mental and emotional health issues without further isolating the asylum seeker from appropriate services. To help strengthen continuity and integration of mental health supports for refugees and asylum seekers, well-resourced care must be experienced as coherent and connected. A coherent, interdisciplinary and team-orientated approach will synthesize different viewpoints to shape clinical practice and create workable solutions in local situations.

Providing emergency mental health care to asylum seekers at a time when claims for permanent protection have been rejected.

In total, 90% of 'boat people' who make it to Australia's migration zone are assessed as legitimate refugees and given Temporary Protection Visas (TPV) allowing them to stay in Australia for 3 years in the first instance. With an increasing number of individuals and families on TPV having their claims for a Permanent Protection Visa (PPV) rejected, this paper argues using the National Mental Health Plan 2003-2008 as a guide, for interventions that are culturally and linguistically appropriate, thus, aiming to minimize risk from exposure to extreme mental stressors in the event of an application for a PPV being rejected. Continuity and integration of mental health care involving key stakeholders is best achieved by bridging discrete elements through preparing for visa appeals and reviews, news from home and ongoing psychosocial stressors--in the context of different episodes, interventions by different providers, and changes in mental distress. To help strengthen continuity and integration of mental health supports for TPV holders, well resourced care must be experienced as connected and coherent.