Enhanced self-harm presentation reporting using additional ICD-10 codes and free text in NSW emergency departments.

OBJECTIVES: Understanding and responding to emergency department (ED) presentations for suicide and self-harm is a major health system priority. Reporting using routinely collected ED diagnoses or presenting problem codes leads to significant underestimation of rates. We aimed to implement an enhanced method for reporting ED self-harm presentations in New South Wales (NSW), Australia. METHODS: An enhanced method was developed based on a literature review and clinical consultation. For NSW ED data collection records from 2005-2020, presenting problem codes were mapped to International Classification of Diseases version 10 (ICD-10). Self-harm codes (ICD-10 X60-84, Y87.0) were combined with additional codes for poisoning with medications commonly used in overdose and automated keyword searching of presenting problem text. Enhanced ED diagnoses were validated against hospital diagnoses for presentations resulting in hospital admission. RESULTS & DISCUSSION: Core ICD-10 self-harm codes identified 21 797 suicide and self-harm-related presentations per year to NSW EDs, of which 79% were for suicide-related ideation (R45.81). The enhanced method increased estimated annual presentations to 51 822 and increased sensitivity for suicide-related behaviours from 12.2% to 73.9%, while retaining high specificity (99.4%). Results matched known demographics of ED self-harm, and revised estimates were consistent with population rates reported by other jurisdictions. Service feedback and data sharing during the coronavirus disease 2019 (COVID-19) pandemic suggest that estimates from the enhanced method are plausible and sensitive to change. CONCLUSIONS: In NSW ED data, standard presenting problem codes recorded by clinicians detect less than half of presentations for self-harm or suicidal ideas. An enhanced method using additional codes and free text searching is computationally simple and increases sensitivity for monitoring trends and service performance. The method will continue to be refined as new data items become available.

Psychostimulant use and the brain.

Psychostimulant users are typically young adults. We have conducted a narrative review of neuropsychiatric harms associated with the psychostimulants methamphetamine/amphetamine, cocaine and 3,4-methylenedioxymethamphetamine (MDMA), focusing on epidemiological factors, common clinical presentations, underlying causal mechanisms and treatment options. The major neuropsychiatric harms of psychostimulant use are stroke, neurocognitive impairment, Parkinson's disease, seizures and psychotic illness. These arise through a combination of acute monoamine release, longer-term neurotransmitter effects and indirect effects. These effects are moderated by factors in the individual and in the pattern of substance use. Neuropsychiatric harms associated with psychostimulant use can thus lead to severe long-term impairment.

Six years of national mental health seclusion data: the Australian experience.

OBJECTIVES: Reducing or eliminating seclusion from mental health care settings has been a national priority for Australia since 2005. This paper describes Australia's national seclusion data collection, and summarises changes in seclusion rates in Australian public mental health services. METHODS: Seclusion events per 1000 patient days were calculated from 2009-2010 to 2014-2015 utilising state and territory administrative data sources. Combined national data were used to calculate results for a number of service characteristics, such as target population and location of the service. RESULTS: The rate of seclusion events decreased by 43% over the 6 years. Child and adolescent services reported consistently higher rates of seclusion, but a shorter duration of seclusion episodes, compared with other service types. There is high variation in seclusion rates between individual services (range 0.0-53.0 seclusion events per 1000 bed days in 2014-2015). CONCLUSIONS: Seclusion event rates in Australia's specialised public acute mental health hospital services are declining. The use of existing administrative data was instrumental in establishing a national data source to facilitate the monitoring and reporting of progress of seclusion reduction strategies.

Trends in diagnosis of bipolar disorder: Have the boundaries changed?

OBJECTIVE: There are concerns that the diagnostic boundaries of bipolar disorder have expanded. This study seeks evidence of change in diagnostic practice at three boundaries: the 'lower' boundary with subclinical mood conditions, the 'lateral' boundary with other mental health conditions (psychotic, anxiety, substance and personality disorders) and the 'internal' boundary within affective disorders. METHODS: Diagnoses recorded in health system administrative data collections were used as a measure of clinician diagnostic behaviour. We examined all diagnoses made by public (state operated) inpatient and community mental health services in New South Wales, Australia, from 2003 to 2014. RESULTS: A total of 31,746 people had at least one recorded diagnosis of bipolar disorder in the period. There was a significant upward trend in the age-standardised population rate of diagnosis of bipolar disorder. Bipolar disorders made up an increasing proportion of psychosis diagnoses. There was no increase in the rate of comorbid diagnosis of bipolar disorders with non-psychotic disorders or in the likelihood of diagnosis of bipolar disorder at first or subsequent episodes of depression. There were significant reductions in diagnoses of schizophrenia, particularly in younger people. CONCLUSION: There may be some increase in diagnoses of bipolar disorder in New South Wales public mental health services. However, some changes in diagnosis, particularly in younger adults, may reflect movement away from diagnoses of schizophrenia towards a range of other diagnoses, rather than specific movement towards bipolar disorder. Expansion of bipolar disorder may have been more marked in private practice settings and may have involved the poorly defined bipolar II subtype.

Stimulant use disorders in people with psychosis: a meta-analysis of rate and factors affecting variation.

OBJECTIVE: Stimulant abuse and dependence often complicate the care of people with psychotic disorders. This study systematically reviews the prevalence estimates reported for stimulant abuse and dependence in people with psychotic disorders, and examines personal, clinical, regional and methodological factors which explain variation in these rates. METHODS: PsychINFO, EMBASE and MEDLINE (1946-2013) were searched systematically for studies reporting on stimulant drug use disorders in representative samples of people with psychotic disorders. Random effects models estimated the pooled rate of a stimulant use disorder, defined to include stimulant abuse and stimulant dependence. Study characteristics associated with heterogeneity in rates of stimulant use disorder were examined by subgroup analyses for categorical variables, by meta-regression for continuous independent variables and by multiple meta-regression. RESULTS: Sixty-four studies provided 68 estimates of lifetime or recent stimulant use disorders in 22,500 people with psychosis. The pooled rate of stimulant use disorder was 8.9% (95% CI 7.4%, 10.5%). Higher rates of stimulant use disorders were reported in studies of affective psychosis, studies from inpatient settings, studies from the USA and Australia, and studies with higher rates of cannabis disorder; in multiple meta-regression analysis these factors explained 68% of between-study variance. Rates of stimulant use disorder were stable over time, and unrelated to age, sex, stage of psychosis, type of stimulant drug or study methodology factors. CONCLUSIONS: Reported rates of stimulant use disorder in people with psychosis are much higher than in the general population but vary widely and are associated with regional, service setting and clinical differences between studies. It is likely that stimulants contribute to the overall burden of psychosis, and that social and environmental factors combine with drug and illness-related factors to influence stimulant use in psychosis.

The impact of cannabis and stimulant disorders on diagnostic stability in psychosis.

BACKGROUND: Substance abuse adds to diagnostic uncertainty in psychosis and may increase the risk of transition from brief and affective psychoses to schizophrenia. This study examined whether comorbid substance disorder was associated with diagnostic instability and progression from other psychosis diagnoses to schizophrenia and whether effects differed for cannabis and stimulant-related disorders. METHOD: We identified 24,306 individuals admitted to hospital with an ICD-10 psychosis diagnosis between 2000 and 2011. We examined agreement between initial diagnosis and final diagnosis over 2-5 years and predictors of diagnostic change toward and away from a final diagnosis of schizophrenia. RESULTS: Nearly half (46%) of participants with initial brief, atypical, or drug-induced psychoses were later diagnosed with schizophrenia. Persisting illicit drug disorders did not increase the likelihood of progression to schizophrenia (OR = 0.97; 95% CI, 0.89-1.04) but increased the likelihood of revision of index psychosis diagnosis away from schizophrenia (OR = 1.55; 95% CI, 1.40-1.71). Cannabis disorders predicted an increased likelihood of progression to schizophrenia (OR =1.12; 95% CI, 1.01-1.24), while stimulant disorders predicted a reduced likelihood (OR = 0.81; 95% CI, 0.67-0.97). Stimulant disorders were associated with greater overall diagnostic instability. CONCLUSIONS: Many people with initial diagnoses of brief and affective psychoses are later diagnosed with schizophrenia. Cannabis disorders are associated with diagnostic instability and greater likelihood of progression to schizophrenia. By contrast, comorbid stimulant disorders may be associated with better prognosis in psychosis, and it may be important to avoid premature closure on a diagnosis of schizophrenia when stimulant disorders are present.

Stimulant and other substance use disorders in schizophrenia: prevalence, correlates and impacts in a population sample.

OBJECTIVES: Stimulants may worsen psychotic symptoms but there is limited evidence about the impact of stimulant abuse in people with schizophrenia. This study examined the prevalence and correlates of stimulant and other drug disorders in a population-based sample of people with schizophrenia, examining associations with frequent service use, physical health comorbidities and accommodation instability. METHODS: New South Wales (NSW) hospital, community mental health and emergency department data were used to examine health service contact over 5 years in 13,624 people with a diagnosis of schizophrenia. Associations of stimulant disorders were examined with multinomial logistic regression, comparing people with no substance disorders to those with cannabis disorders, stimulant disorders or both. RESULTS: Of people with schizophrenia, 51% had substance disorders, including 14% with stimulant disorders. Stimulant disorders were more common in young adults and in urban areas, less common in migrants, and unrelated to initial social disadvantage. More than 80% of those with stimulant disorders also had cannabis disorders. Service use and harms were most common in this group, including frequent mental health admissions (59%), frequent emergency department presentations (52%), admissions with injury or self-harm (44%), infectious disease diagnoses (22%), multiple changes of residence (61%), movement to more disadvantaged locations (42%) and periods of homelessness (18%). People with stimulant disorders alone had higher rates of self-harm, infectious disease and non-mental health admissions than people with cannabis disorders alone. CONCLUSIONS: Stimulant disorders occur in people with schizophrenia and in first-episode psychosis at rates more than 10 times that of the broader population. Stimulant disorders are likely to worsen the burden of psychosis, and strategies are needed to engage and support the highly disadvantaged group of people with schizophrenia who have cannabis and stimulant disorders.

Cannabis and stimulant disorders and readmission 2 years after first-episode psychosis.

BACKGROUND: Few studies have examined the impact of stimulant use on outcome in early psychosis. Ceasing substance use may lead to positive outcomes in psychosis. AIMS: To examine whether baseline cannabis or stimulant disorders and ongoing drug use predict readmission within 2 years of a first psychosis admission. METHOD: Predictors of readmission were examined with Cox regression in 7269 people aged 15-29 years with a first psychosis admission. RESULTS: Baseline cannabis and stimulant disorders did not predict readmission. A stimulant disorder diagnosis prior to index psychosis admission predicted readmission, but a prior cannabis disorder diagnosis did not. Ongoing problem drug use predicted readmission. The lowest rate of readmission occurred in people whose baseline drug problems were discontinued. CONCLUSIONS: Prior admissions with stimulant disorder may be a negative prognostic sign in first-episode psychosis. Drug use diagnoses at baseline may be a good prognostic sign if they are identified and controlled.

The global epidemiology and burden of psychostimulant dependence: findings from the Global Burden of Disease Study 2010.

AIMS: To estimate the global prevalence of cocaine and amphetamine dependence and the burden of disease attributable to these disorders. METHODS: An epidemiological model was developed using DisMod-MR, a Bayesian meta-regression tool, using epidemiological data (prevalence, incidence, remission and mortality) sourced from a multi-stage systematic review of data. Age, sex and region-specific prevalence was estimated for and multiplied by comorbidity-adjusted disability weightings to estimate years of life lost to disability (YLDs) from these disorders. Years of life lost (YLL) were estimated from cross-national vital registry data. Disability-adjusted life years (DALYs) were estimated by summing YLDs and YLLs in 21 regions, by sex and age, in 1990 and 2010. RESULTS: In 2010, there were an estimated 24.1 million psychostimulant dependent people: 6.9 million cocaine and 17.2 million amphetamines, equating to a point prevalence of 0.10% (0.09-0.11%) for cocaine, and 0.25% (0.22-0.28%) for amphetamines. There were 37.6 amphetamine dependence DALYs (21.3-59.3) per 100,000 population in 2010 and 15.9 per 100,000 (9.3-25.0) cocaine dependence DALYs. There were clear differences between amphetamines and cocaine in the geographic distribution of crude DALYs. Over half of amphetamine dependence DALYs were in Asian regions (52%), whereas almost half of cocaine dependence DALYs were in the Americas (44%, with 23% in North America High Income). CONCLUSION: Dependence upon psychostimulants is a substantial contributor to global disease burden; the contribution of cocaine and amphetamines to this burden varies dramatically by geographic region. There is a need to scale up evidence-based interventions to reduce this burden.

Stimulant use and stimulant use disorders in Australia: findings from the National Survey of Mental Health and Wellbeing.

OBJECTIVES: To describe the prevalence of lifetime and 12-month stimulant use disorders in the Australian population, and to compare the prevalence estimates from a population survey with prevalence estimates derived using indirect methods. DESIGN AND SETTING: Data were drawn from the 2007 National Survey of Mental Health and Wellbeing, which sampled 8841 residents of private dwellings in Australia in 2007. Interviews were conducted by lay interviewers using the Composite International Diagnostic Interview. MAIN OUTCOME MEASURES: Lifetime and 12-month rates of stimulant use and stimulant use disorders (abuse, dependence) diagnosed according to the Diagnostic and statistical manual of mental disorders, 4th edition. RESULTS: Lifetime prevalence of stimulant use disorders was 3.3%, and 12-month prevalence was 0.6%, equating to more than 97 000 Australians. Nearly half of those who had used stimulants on more than five occasions met criteria for a lifetime disorder. More than 8% of men aged 16-29 years met criteria for a lifetime stimulant use disorder. Prevalence estimates were consistent with recent estimates using indirect methods. CONCLUSIONS: Stimulant use disorders affect a significant number of Australians, and are most common in the age groups at greatest risk for development of psychosis.