Utility of pharmacogenetic testing to optimise antidepressant pharmacotherapy in youth: a narrative literature review.

Pharmacogenetics (PGx) is the study and application of how interindividual differences in our genomes can influence drug responses. By evaluating individuals' genetic variability in genes related to drug metabolism, PGx testing has the capabilities to individualise primary care and build a safer drug prescription model than the current "one-size-fits-all" approach. In particular, the use of PGx testing in psychiatry has shown promising evidence in improving drug efficacy as well as reducing toxicity and adverse drug reactions. Despite randomised controlled trials demonstrating an evidence base for its use, there are still numerous barriers impeding its implementation. This review paper will discuss the management of mental health conditions with PGx-guided treatment with a strong focus on youth mental illness. PGx testing in clinical practice, the concerns for its implementation in youth psychiatry, and some of the barriers inhibiting its integration in clinical healthcare will also be discussed. Overall, this paper provides a comprehensive review of the current state of knowledge and application for PGx in psychiatry and summarises the capabilities of genetic information to personalising medicine for the treatment of mental ill-health in youth.

Mental Health Status, Risk and Protective Factors for Healthcare Staff Prior to the First Major COVID-19 Outbreak in Western Australia.

Objectives: Western Australia's unique public health response delayed the first wave of community COVID-19 transmission for 2 years. We aimed to determine the status of post-traumatic stress (PTSS), depressive, and anxiety symptoms among healthcare staff in major tertiary hospitals, together with associated risk and protective factors prior to the first substantial outbreak of COVID-19. Methods: A cross-sectional study was conducted with 431 healthcare staff immediately prior to the Western Australian border re-opening in 2022. Staff were recruited via notices in email newsletters, at four tertiary hospitals and a public mental health clinic in metropolitan Perth. Validated and original questionnaires were administered via Qualtrics. Results: Moderate levels of PTSS (22.3%), depression (21.9%), and anxiety (25.9%) were reported. Pathway analyses indicated that sleep difficulties, workplace stressors, and infectious disease training were associated with higher PTSS, depression and anxiety symptoms, and younger age was associated with higher levels of depression and anxiety. Nursing roles were associated with higher PTSS. Social support and workplace support were associated with lower levels of depression and anxiety but were not associated with PTSS. Conclusion: The findings illustrate high levels of resilience, but indicate a need for structural supports within the health system to foster staff mental health prior to the onset of emergencies.

Rates and Reasons for Clozapine Treatment Interruptions: Impact of the Frequency of Hematologic Monitoring and Cardiac Adverse Events.

BACKGROUND: Differing rates and reasons for interruptions of clozapine treatment have been reported globally. This article evaluated the rates and reasons for clozapine therapy interruptions in Australia and explored the impact of the frequency of hematological monitoring on these parameters. METHODS: Data of the patients who were newly commenced on clozapine at three metropolitan public mental health services in Western Australia over 11 years were retrospectively collated. The rate and reasons for clozapine therapy interruptions and their association with the frequency of hematological monitoring, age, sex, and treatment site were analyzed using parametric, nonparametric, and correlational analyses. RESULTS: Of the 457 patients whose data were collected, 69.6% had an interruption of treatment with 41.2% of those occurring during the period of mandatory weekly hematological monitoring in the first 18 weeks. Nonadherence (57.4%) and adverse effects (28.8%) were the 2 main reasons for the treatment interruptions. Cardiac issues accounted for the majority of the interruptions (61.8%) due to specified adverse effects, and these occurred significantly more commonly within the first 18 weeks. Location, age, and sex did not predict the possibility of treatment interruptions. CONCLUSIONS: The high rates of clozapine treatment interruption observed during the period of weekly monitoring point toward the need to address the burden of frequent hematological monitoring for patients. Disproportionately higher rates of interruption due to cardiac adverse effects observed in this study compared with research from non-Australian settings raise the possibility of geographical differences in the adverse effects leading to treatment discontinuation.

Demographic and clinical characteristics of patients who recommence clozapine following therapy interruptions.

OBJECTIVE: The proportion of patients who recommence clozapine after cessation, the time taken to resume clozapine post-cessation, and distinguishing demographic and clinical characteristics of this group have been poorly researched. We evaluated these in the current study. METHOD: We retrospectively extracted selected demographic and clinical variables and clozapine treatment interruption and recommencement data up to December 2018 of a cohort of 458 patients who first commenced clozapine between 2006 and 2016. The study was conducted at three Australian health services. RESULTS: Of the 310 (69%) patients who had at least one interruption of clozapine treatment, 170 (54.8%) did not resume clozapine, and 140 (45.2%) recommenced it after the first interruption. More than half of those who recommenced did so within a month and 80% by 12 months. Cox regression analysis revealed that age was significantly associated with recommencement, with a 2% decrease in the likelihood of restarting after an interruption for each year later that clozapine was initially commenced (HR = 0.98 95%CI: 0.97, 0.997, p = 0.02). Those who ceased clozapine due to adverse effects were less likely to restart than those who ceased due to noncompliance (HR = 0.63 95%CI: 0.41, 0.97, p = 0.03). More time on clozapine prior to interruption increased the likelihood of restarting it, with each additional month on clozapine increasing this likelihood by 1% (HR = 1.01 95%CI: 1.01, 1.02, p < 0.001). CONCLUSION: If the distinguishing demographic and clinical characteristics of the group identified in this study are corroborated through further research, this could further validate the need to identify treatment resistance and commence clozapine early in people with schizophrenia and provide appropriate interventions to those more at risk of permanent discontinuation of clozapine.

Improving the physical health of the mentally ill: recent advances.

PURPOSE OF REVIEW: This review of the literature examines the most recent advances in the battle to improve the physical health of people with severe mental illness. Covering the 2018/2019 time period, the article offers a glance of future healthcare models and research directions. RECENT FINDINGS: A systematic search of the PubMed and Cochrane databases, along with additional journal articles available online but not yet allocated to a journal edition, produced a total of 24 journal articles suitable for review. The review period was from January 2018 to December 2019. The four main themes of investigation, intervention, integration and training emerged. SUMMARY: The uptake and integration of primary care into mental health services for people with SMI is still facing many barriers. Healthy lifestyle and physical activity interventions need to run alongside medical treatment for both mental and physical health in order to provide holistic care. To do this, clarification of professional roles and responsibility need to be defined and adhered to, along with additional training for staff and coordination of services.

The Wellness Clinic: A retrospective Quasi-experimental, longitudinal study of physical health support in an Australian mental health service setting.

The poor physical health of patients with severe/chronic mental illness is now well-known, yet little has been done to address the issue. Adverse medication effects, lifestyle, and social factors can all contribute to high morbidity and mortality rates when compared to the general population. To arrest poor physical health, a Wellness Clinic within a mental health hospital was developed to provide continuity of care when patients were discharged from the hospital. A retrospective, within-subjects, quasi-experimental, longitudinal time-series study was conducted analysing the demographics and physical health parameters of 57 patients who remained with the service over a four and a half year time period. Assessments were taken at baseline, 12, 24, and 36 months for each individual. Despite increasing levels of psychotropic and other health medication over time, physical health parameters were generally held stable for most measures across the four time periods. HDL-C levels were significantly improved between baseline and 36 months. This stability over time suggests that ongoing assessment, monitoring, and treatment is necessary to arrest the downward trajectory of poor physical health in mental health and opens the door for future research to invest in interventions to run alongside the Wellness Clinic and improve patient physical health.

The physical health Wellness Clinic model of care for patients with mental health issues who are 'hard to engage'.

OBJECTIVE: People with chronic and severe mental health issues die 15-25 years earlier than people in the general population - the main reason for this is poor physical health. An innovative treatment model for the management of primary care within a mental health service setting for 'hard to engage' patients is presented. CONCLUSION: The Wellness Clinic model provides the final level of care, where individuals who are at risk will receive a thorough physical health check and be referred for any additional tests and scans that are needed ensuring that any health issues are addressed. Ongoing monitoring and treatment occurs with the overall aim of reintegrating individuals back into the community through linking them in with community GPs.

The physical health of Indigenous people with a mental illness in the Kimberley: is ongoing monitoring effective?

OBJECTIVE: The aim of this paper is to evaluate the effectiveness of ongoing physical health monitoring for Indigenous Australians with mental health issues in the Kimberley region of Western Australia. METHOD: This longitudinal, within-groups investigation assessed physical health parameters such as blood pressure and blood glucose levels at baseline and at 18 months for the same cohort. No standardised intervention was in place, but action was taken if results were found to be abnormal. RESULTS: Most measures of physical health remained stable, with mean lipid and fasting glucose levels remaining abnormal over the entire assessment period. Systolic blood pressure showed a significant improvement. CONCLUSIONS: More needs to be done to improve the physical health of Indigenous mental health patients - culturally appropriate and secure interventions incorporating holistic models of care are needed.

The 'Fit for Life' exercise programme: improving the physical health of people with a mental illness.

People with a mental illness have very poor physical health parameters when compared to the general population. This paper outlines an exercise programme developed to improve overall fitness and curb weight gain. Seventy-two mental health service inpatients completed the general or individualised gym exercise programme within 12 weeks. Baseline and end of course physical health parameters were recorded, along with test results on a number of fitness, strength and agility tasks. No statistically significant differences were found between average pre and post programme weight scores, and weight did not increase over time. Significant differences were found on strength and agility tasks, and a decrease was observed in average resting and post exercise heart rates. Average blood pressure did not change, but the number of baseline readings indicating hypertension reduced from 14 to 8 people. The exercise programme was successful in improving the physical capacity of the individuals who participated.

Mind (is) your body.

The majority of people who experience mental health issues also have poor physical health resulting in decreased life expectancy. Fortunately, many physical health issues can be identified and rectified by monitoring various health indicators over a time period. The Physical Health Diary is a tool that people can use by themselves and/or with others to track, monitor and improve their physical health over time.

Kimberley Indigenous mental health: An examination of metabolic syndrome risk factors.

OBJECTIVE: There is an increased risk of physical health comorbidities in people with a mental illness. This paper examines the metabolic syndrome parameters for the general population, indigenous Australians and people with a mental illness, and compares them to a sample of predominantly indigenous adults with mental health problems. DESIGN: A longitudinal (24 month) audit of patient medical records was conducted between February 2011 and March 2013. SETTING: The Kimberley Mental Health and Drug Service in Broome, Western Australia. PARTICIPANTS: Largely indigenous adults with a mental illness. Sample numbers increased from 56 at baseline (80% indigenous) to 136 at 18 months (70% indigenous). MAIN OUTCOME MEASURES: Waist circumference, blood pressure, fasting lipids, and fasting blood glucose. RESULTS: Preliminary assessment of the data indicates a high percentage of abnormalities at baseline and at the 18 month period on all four parameters, yet not all patients were assessed on a regular basis. CONCLUSIONS: Abnormalities in metabolic profiles consistent with the non-Indigenous mental health population were found. There are considerable challenges to implementing regular monitoring of physical and metabolic profiles of indigenous people in rural and remote communities.

The impact of lifestyle factors on the physical health of people with a mental illness: a brief review.

BACKGROUND: People with a mental illness are much more likely to experience poor physical health when compared to the general population, showing a higher propensity to develop the metabolic syndrome. Past focus has predominantly been upon individuals treated with antipsychotics, yet poor physical health is occurring across diagnoses. PURPOSE: The purpose of this paper is to draw attention to the major factors within the domain of lifestyle in order to support the need for more detailed and rigorous physical health assessment and ongoing monitoring for people with a mental illness. METHOD: This paper reviews existing evidence relating to lifestyle factors such as low exercise levels, poor diet and nutrition, high cholesterol levels, tobacco smoking and poor dental care, contributing to poor physical health such as a higher incidence of cardiovascular disease and type 2 diabetes. An integrative review was conducted from a multi-disciplinary search of online databases and journals, focusing upon mental illness and lifestyle issues predominant in the literature. RESULTS: The findings reviewed here suggest that greater attention should be paid to the physical health assessment and ongoing monitoring of all people with mental health disorders so that preventable illness does not result in higher levels of morbidity and mortality for this disadvantaged population. CONCLUSION: Early identification aids preventive interventions and assists clinicians and mental health staff to more effectively treat emergent physical health problems.

Assessing overweight and obesity across mental disorders: personality disorders at high risk.

PURPOSE: The aim of the present investigation is to assess the prevalence of obesity in people diagnosed as having a mental illness and to investigate differences between disorders. This adds to the paucity of research in this particular population of people and assists with preventative knowledge to obtain optimum physical health. METHODS: Data were collected for all 508 male and female inpatients (new and already existing) in a public mental health service centre in Western Australia between January and December 2008. Current weight for all patients and weight gain for some patients were calculated to obtain a body mass index (BMI) value, and diagnostic information was aligned to one of the six major categories of mental illness. RESULTS: The percentage of obese inpatients (30.3%) was much higher than that of the general population (21.4%), with females showing a higher propensity toward obesity than males. Most diagnostic categories had a mean BMI in the overweight range, whereas Personality Disorders had a mean BMI in the obese range (30.07). A gradual increase in weight over a 9-month time period can be seen in most patients who were assessed on more than one occasion. CONCLUSIONS: The proportion of obese people within the mental health system far exceeds that of the general population, with these people at a much greater risk of becoming obese. The highest level of obesity was found in people with a personality disorder rather than in people with psychosis. Further research is needed to ease out the mitigating factors behind weight gain occurring across disorders.

Obesity, cardiovascular disease and type 2 diabetes in people with a mental illness: a need for primary health care.

People with a mental illness show a growing incidence of obesity, and higher rates of metabolic syndrome when compared with the general population. This paper reviews research on obesity, cardiovascular disease and type 2 diabetes, with the aim of directing clinical attention towards the improvement of patient physical health. A systematic search of cross-discipline databases and journals provided peer-reviewed research for analysis, and national statistics allowed for the investigation of differences in rates of occurrence between people experiencing a mental illness and the general population. Treatment effects via psychotropic medications and lifestyle factors such as poor diet and low levels of exercise suggest that ongoing monitoring is necessary to prevent major physical disorders in people experiencing a mental illness. To aid clinicians, a comprehensive set of clinical guidelines have been developed for the physical assessment and ongoing monitoring of mental health patients.

Fostering psychiatry in Ghana: the impact of a short review course through an international collaboration.

OBJECTIVE: The aim of the current study was to evaluate a short review course in psychiatry conducted at the Kwame Nkrumah University of Science and Technology medical school and any change in student interest in a career in psychiatry. METHOD: Students were asked to complete a general psychiatric knowledge questionnaire before and immediately after the course. They were also asked to rate their attitude toward psychiatry as a career. The same questionnaire was readministered 1 month later. RESULTS: The average results on the knowledge test pre-course was 52% (N=129) and post-course was 78% (N=122), constituting a 50% increase in knowledge for the average student. The proportion of students showing considerable interest in a psychiatric career increased from 19% pre-course to 32% post-course. At 1-month follow-up, the average result for the knowledge test was 76%, and considerable interest in psychiatry as a career was noted at 21%. CONCLUSION: Results indicate that the course significantly improved core psychiatric knowledge and that this improvement was retained after 1 month. An initial increase in interest in psychiatry as a career decreased almost to baseline at 1-month follow-up. Study limitations include the use of the same questionnaire at each stage knowledge was tested and the absence of a control group.

Clinical guidelines for the physical care of mental health consumers: a comprehensive assessment and monitoring package for mental health and primary care clinicians.

OBJECTIVES: People with a mental illness are more likely to experience poor physical health as compared to the general population. Currently, Australian mental health patients experience a relatively low level of physical health appraisal, prompting the development of the Clinical guidelines for the physical care of mental health consumers assessment and monitoring package. METHOD: The Clinical guidelines package takes an holistic approach, with a focus on the key dimensions of medication effects, lifestyle, existing or developing physical disorders, alcohol and illicit drug use, and psychosocial factors. RESULTS: The package consists of a metabolic syndrome algorithm wall chart, a Clinician handbook, a Psychosocial assessment booklet, and a set of three screening forms. CONCLUSIONS: By taking a user-friendly, flexible, evidence-based approach, the resource can be used by all clinicians involved in the healthcare of people with a mental illness.