Systematic review of tobacco smoking prevalence among young people in treatment for first-episode psychosis.

To determine whether smoking prevalence in first-episode psychosis (FEP) is different than in people with established psychosis in long-term treatment. A systematic review of cross-sectional, case-control and cohort studies identified from searches of PubMed, Embase, CINAHL and PsycINFO up to 12 August 2023. 20 studies out of 2773 screened titles were included. There was no clear pattern of smoking by diagnosis as smoking rates in people with FEP ranged from 43% to 78%, while in those with established psychosis, it ranged from 19% to 76%. The wide range of smoking levels in both populations precluded conclusions as to whether smoking rates are different between people with FEP and established psychosis suggesting that factors other than the time course of the illness influence smoking levels.

Associations between child maltreatment and hospital admissions for alcohol and other substance use-related disorders up to 40 years of age: Results from the Childhood Adversity and Lifetime Morbidity study.

BACKGROUND AND AIMS: Evidence on the associations between child maltreatment (CM), alcohol use disorders (AUDs) and other substance use disorders (SUDs) comes largely from retrospective studies. These rely on self-reported data, which may be impacted by recall bias. Using prospective CM reports to statutory agencies, we measured associations between CM notifications and inpatient admissions for AUDs and SUDs up to 40 years of age. DESIGN, SETTING AND PARTICIPANTS: Observational study linking administrative health data from Queensland, Australia to prospective birth cohort data comprising both agency-reported and substantiated notifications of CM. MEASUREMENTS: Outcomes were inpatient admissions for AUDs and SUDs based on ICD-10-Australian modification (AM)-coded primary diagnoses. Unadjusted and adjusted logistic regression analyses were undertaken. FINDINGS: Ten per cent (n = 609) of the cohort had a history of agency-reported or substantiated CM notifications before age 15. These individuals had higher adjusted odds of being admitted for AUDs and SUDs. For AUDs, the adjusted odds of inpatient admission were 2.86 [95% confidence interval (CI) = 1.73-4.74] greater where there was any previous agency-reported CM and 3.38 (95% CI = 1.94-5.89) greater where there was any previous substantiated CM. For SUDs, the adjusted odds of inpatient admission were 3.34 (95% CI = 2.42-4.61) greater where there was any previous agency-reported CM and 2.98 (95% CI = 2.04-4.36) greater where there was any previous substantiated CM. CONCLUSIONS: People with a history of child maltreatment appear to have significantly higher odds of inpatient admissions for alcohol use disorders and other substance use disorders up to 40 years of age compared to people with no history of child maltreatment.

The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses.

AIMS: Community treatment orders have been introduced in many jurisdictions with increasing use over time. We conducted a rapid umbrella review to synthesise the quantitative and qualitative evidence from systematic reviews and/or meta-analyses of their potential harms and benefits. METHODS: A systematic search of Medline, PubMed, Embase and PsycINFO for relevant systematic reviews and/or meta-analyses. Where available, participants on community treatment orders were compared with controls receiving voluntary psychiatric treatment. This review is registered with PROSPERO (CRD42023398767) and the Open Science Framework (https://osf.io/zeq35). RESULTS: In all, 17 publications from 14 studies met the inclusion criteria. Quantitative synthesis of data from different systematic reviews was not possible. There were mixed findings on the effects of community treatment orders on health service use, and clinical, psychosocial or forensic outcomes. Whereas uncontrolled evidence suggested benefits, results were more equivocal from controlled studies and randomised controlled trials showed no effect. Any changes in health service use took several years to become apparent. There was evidence that better targeting of community treatment order use led to improved outcomes. Although there were other benefits, such as in mortality, findings were mostly rated as suggestive using predetermined and standardised criteria. Qualitative findings suggested that family members and clinicians were generally positive about the effect of community treatment orders but those subjected to them were more ambivalent. Any possible harms were under-researched, particularly in quantitative designs. CONCLUSIONS: The evidence for the benefits of community treatment orders remains inconclusive. At the very least, use should be better targeted to people most likely to benefit. More quantitative research on harms is indicated.

Admissions for psychosis following agency-notified child maltreatment at 40-year-follow-up: Results from the Childhood Adversity and Lifetime Morbidity (CALM) cohort.

There is substantial evidence of an association between self-reported child maltreatment (CM) and subsequent psychosis in retrospective data. Such findings may be affected by recall bias. Prospective studies of notifications to statutory agencies address recall bias but are less common and subject to attrition bias. These studies may therefore be underpowered to detect significant associations for some CM types such as sexual abuse. This study therefore linked administrative health data to a large birth cohort that included notifications to child protection agencies. We assessed psychiatric outcomes of CM as measured by inpatient admissions for non-affective psychoses (ICD10 codes F20-F29) to both public and private hospitals in Brisbane, Australia. Follow-up was up to 40 years old. There were 6087 cohort participants whose data could be linked to the administrative health data. Of these, 10.1 % had been the subject of a CM notification. Seventy-two participants (1.2 %) had been admitted for non-affective psychosis by 40-year follow-up. On adjusted analysis, all notified and substantiated types of CM were associated with admissions for non-affective psychosis. This included neglect, physical, sexual or emotional abuse, as well as notifications for multiple CM types. For instance, there was a 2.72-fold increase in admissions following any agency notification (95 % CI = 1.53-4.85). All maltreatment types therefore show a significant association with subsequent admissions for psychosis up to the age of 40. Screening for CM in individuals who present with psychosis is, therefore, indicated, as well as greater awareness that survivors of CM may be at higher risk of developing psychotic symptoms.

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.

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.

Exploring the relationships between pathogen-specific prenatal infections requiring inpatient admission and domains of offspring behaviour at age 5.

BACKGROUND: Research exploring the relationship between prenatal infection and child behavioural outcomes would benefit from further studies utilising full-population samples with the scale to investigate specific infections and to employ robust designs. We tested the association among several common infections requiring inpatient admission during and after pregnancy with a range of childhood behavioural outcomes, to determine whether any negative impact was specific to the period of foetal development. METHODS: The sample included all mother-offspring pairs from the Australian state of New South Wales (NSW) for whom the child commenced their first year of full-time schooling in 2009 (~age 5 years; n = 77,302 offspring), with records linked across four health administrative data sets including the NSW perinatal data collection (PDC), the NSW admitted patient data collection (APDC) and the NSW component of the 2009 Australian Early Development Census (AEDC). Multivariable linear regression was used to test associations between a number of infections requiring inpatient admission during and after pregnancy with a range of teacher assessed behavioural outcomes. RESULTS: Associations specific to the prenatal period were only found for streptococcus A although this would need to be reproduced in external samples given the low prevalence. Otherwise, 12 out of 15 selected infections either showed no association prenatally or also demonstrated associations in the 12 months after pregnancy. For example, prenatal hepatitis C, influenza and urinary E. coli infections were associated with lower scores of several domains of childhood behaviour, but even stronger associations were found when these same maternal infections occurred after pregnancy. CONCLUSIONS: The prenatal infections we tested appeared not to impact childhood behaviour by altering foetal neurodevelopment. Rather, the strong associations we found among infections occurring during and after pregnancy point to either residual socioeconomic/lifestyle factors or a shared familial/genetic liability between infections and behavioural problems.

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.

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.

Evaluating the epidemiology of clozapine-associated neutropenia among people on clozapine across Australia and Aotearoa New Zealand: a retrospective cohort study.

BACKGROUND: Clozapine is associated with the risk of serious neutropenia. However, this risk might decrease over time, meaning that indefinite absolute neutrophil count (ANC) monitoring could be unnecessary. We aimed to determine the epidemiology and timing of clozapine-associated neutropenia outcomes, to investigate variables that might contribute to the odds of neutropenia, and to determine risk of competing neutropenic events during clozapine treatment. METHODS: We performed a retrospective analysis of the Australian and New Zealand Viatris Pharmacovigilance system (one of two monitoring databases for these two countries) between June 6, 1990, and Oct 25, 2022. Patients were excluded from analysis if they commenced clozapine before 1990, did not have a haematology test within 2 weeks of commencement date, or had no follow-up. We measured minor neutropenia (ANC 1·0-1·5 × 109 per L) and serious neutropenia (ANC <1·0 × 109 per L) leading to cessation of clozapine within 6 weeks of the neutropenic event. We determined the rates of minor and serious neutropenia and calculated odds ratios (ORs) for the likelihood of neutropenia leading to cessation. For serious neutropenia leading to cessation, we used time-to-event to calculate rolling weekly averages and to perform competing risk analysis of outcomes using Cox proportional hazards models and a Fine-Gray subdistribution hazards regression model. For the subset of data where information on previous clozapine use was available, we did an analysis for participants who did and did not have previous clozapine exposure. FINDINGS: We included 26 630 people, with 2·6 million ANC values. Within the total cohort, 17 585 people (66%) were male, 9025 (33·9%) female, and 20 (0·1%) other gender, and the mean age was 36·1 years (SD 13·7). We did not have data on race or ethnicity. Of the 26 630 people taking clozapine, 1146 (4·3%) had minor neutropenia, 313 (1·2%) had serious neutropenia leading to cessation, and 223 (0·8%) had serious neutropenia unrelated to clozapine without cessation. In people with no previous exposure to clozapine (n=15 973), the cumulative incidence of serious neutropenia leading to cessation was 0·9% at 18 weeks and 1·4% at 2 years; the weekly incidence rate for serious neutropenia leading to cessation peaked at 9 weeks (0·128%) and fell to a rolling average weekly incidence of 0·001% by 2 years. For minor neutropenia, the cumulative incidence was 1·7% at 18 weeks and 3·5% at 2 years; the weekly incidence rate peaked at 9 weeks (0·218%) and fell to a stable rolling average of 0·01%. The median time to a serious neutropenic event leading to cessation was 17 weeks (IQR 9·96-102). Previous clozapine exposure reduced the risk of serious neutropenia leading to cessation (OR 0·19, 95% CI 0·12-0·31; p <0·0001). INTERPRETATION: Most serious neutropenia leading to clozapine cessation occurs within 18 weeks of treatment and becomes negligible after 2 years. Weekly haematological monitoring after the first 18 weeks could be safely reduced to once every 4 weeks and ceased after 2 years unless clinically indicated. Clozapine retrial after interruption with 2 cumulative years of unremarkable testing might not require further haematological monitoring. A serious neutropenia ANC threshold of ≤1·0 × 109 per L could be used in more jurisdictions. FUNDING: None.

Gender differences in cardiovascular disease risk: Adolescence to young adulthood.

BACKGROUND AND AIMS: Gender differences in cardiovascular disease (CVD) have been well documented but rarely for young adults and the extent to which gender related lifestyle differences may contribute to gender differences in CVD risk experienced by young adults have not been reported. METHODS AND RESULTS: Data are from a long-running cohort study, the Mater-University of Queensland Study of Pregnancy (MUSP). We track gender differences in CVD related behaviours at 21 and 30 years (consumption of a Western Diet/Health-Oriented Diet, cigarette smoking, vigorous physical exercise, heavy alcohol consumption). At 30 years we compare males and females for CVD risk, and the extent to which lifestyle behaviours at 21 and 30 years contribute to CVD risk. At both 21 and 30 years of age, males more frequently consume a Western Diet and less often a Health Oriented Diet. By contrast, males are also much more likely to report engaging in vigorous physical activity. On most CVD markers, males exhibit much higher levels of risk than do females at both 21 and 30 years. At 30 years of age males have about five times the odds of being at high risk of CVD. Some lifestyle behaviours contribute to this additional risk. CONCLUSION: Young adult males much more frequently engage in most CVD related risk behaviours and males have a higher level of CVD risk. Gender differences in CVD risk remain high even after adjustment for CVD lifestyles, though dietary factors independently contribute to CVD risk at 30 years.

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.

Self-Reported and Agency-Notified Child Abuse as Contributors to Suicidal Behaviour in a Population-Based Birth Cohort Study at 30-Year-Follow-Up.

This was a record-linkage analysis of a birth cohort to examine the association between self-reported self-harm in adulthood and childhood maltreatment (CM) as prospectively notified to authorities and self-reported on the Child Trauma Questionnaire. There were 2507 participants at 30-year follow-up with data on both CM and self-reported self-harm including an intent to die. Of the participants, 304 (12.1%) had self-harmed at some time in their lives while 150 (4.2%) had wanted to die. The prevalence of self- and agency-reported maltreatment was 513 (20.5%) and 143 (5.7%) respectively. On adjusted analyses, CM irrespective of reporting source showed significant associations with both suicidal outcomes. Physical and emotional abuse showed the strongest associations while findings for neglect were mixed. The only association for sexual abuse was for self-reported maltreatment and intent to die but numbers may have been under-powered.

What have been the clinical outcomes of the Project Synergy/InnoWell digital health platform?

Project Synergy is a digital mental health tool for assessment, referral and follow-up of people with mental health problems. The Australian federal government Department of Health entered an AUD33 million formal funding arrangement with InnoWell, a proprietary company vehicle (primarily the consultancy firm PwC and University of Sydney) to continue development of Project Synergy. This followed an initial federal National Health and Medical Research Council grant of AUD5.5 million over the previous 3 years. However, based on the assessment of peer-reviewed research data, the Project Synergy/InnoWell platform does not seem to have demonstrated clinical outcomes of healthcare value to date.

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.

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.

Prevalence of frailty in severe mental illness: findings from the UK Biobank.

BACKGROUND: Severe mental illness (SMI) is associated with significant morbidity. Frailty combines biological ageing, comorbidity and psychosocial factors and can predict adverse health outcomes. Emerging evidence indicates that frailty is higher in individuals with SMI than in the general population, although studies have been limited by sample size. AIMS: To describe the prevalence of frailty in people with SMI in a large cohort using three different frailty measures and examine the impact of demographic and sociodemographic variables. METHOD: The UK Biobank survey data, which included individuals aged 37-73 years from England, Scotland and Wales from 2006 to 2010, with linked in-patient hospital episodes, were utilised. The prevalence of frailty in individuals with and without SMI was assessed through three frailty measures: frailty index, physical frailty phenotype (PFP) and Hospital Frailty Risk Score (HFRS). Stratified analysis and dichotomous logistic regression were conducted. RESULTS: A frailty index could be calculated for 99.5% of the 502 412 UK Biobank participants and demonstrated greater prevalence of frailty in women and an increase with age. The prevalence of frailty for those with SMI was 3.19% (95% CI 3.0-3.4), 4.2% (95% CI 3.8-4.7) and 18% (95% CI 15-23) using the frailty index, PFP and HFRS respectively. The prevalence ratio was between 3 and 18 times higher than in those without SMI. CONCLUSIONS: As a measure, frailty captures the known increase in morbidity associated with SMI and may potentially allow for earlier identification of those who will benefit from targeted interventions.

Health economics-informed planning of psychiatric care: A primer and curriculum framework for psychiatrists.

OBJECTIVE: Contemporary medical education lacks a strong focus on health economics which guides major decisions in private and public health services. We briefly outline the rationale, guiding principles, main analytic methods, and a suggested framework for health economics education in psychiatry. CONCLUSIONS: Health economics aims to improve the efficiency of healthcare. Some analytic methods can be harnessed by psychiatrists to better plan clinical care. Health economic methods will also assist psychiatrists in translating their expertise and clinical priorities more effectively to policy-makers, governments, and private insurers motivated by economic reasoning.