Australian & New Zealand Journal of Psychiatry

Substance use disorders co-occurring with other mental health disorders are common and harmful. Clinical guidelines often recommend substance use screening and brief intervention though evidence about screening practice in mental health services is limited. This systematic review of routine clinical practice in adult mental health services aims to identify (a) proportions of screening and brief intervention, (b) how they are practised and (c) their outcomes.

We searched MEDLINE, PsycINFO and Embase and relevant Cochrane databases for articles until 31 July 2021 reporting on adults in English, regardless of geographical location. Backward snowball methods were used to locate additional articles. Screening, brief intervention and mental health services were defined. Data were extracted and variables compared related to setting, period, patient cohort, substances routine substance use disorder care pathways, and study quality was assessed.

We identified 17 articles reporting routine screening within adult mental health services. Studies in community settings mainly reported on screening for alcohol and other substance use disorders, while studies from inpatient settings reported mainly on tobacco. There was marked variation in methods and screening proportions. Only two studies reported on brief intervention.

This systematic review shows marked variation in mental health services routine screening practices with early focus on alcohol but more recently tobacco screening. We suggest approaches to enhancing implementation of screening and brief intervention in routine care, particularly using electronic health records.

To review studies reporting on the effectiveness of psychiatry service delivery for older people and people with dementia in hospital and residential aged care.

A systematic search of four databases was conducted to obtain peer-reviewed literature reporting original research published since June 2004 evaluating a psychiatry service for older people (aged 60 years and over) or people with dementia in inpatient or residential aged care settings.

From the 38 included studies, there was consistent low-to-moderate quality evidence supporting the effectiveness of inpatient older persons’ mental health wards (n = 14) on neuropsychiatric symptoms, mood, anxiety and quality of life. Inpatient consultation/liaison old age psychiatry services (n = 9) were not associated with improved depression, quality of life or mortality in high-quality randomised studies. However, low-quality evidence demonstrated improved patient satisfaction with care and reduced carer stress. The highest quality studies demonstrated no effect of psychiatric in-reach services to residential aged care (n = 9) on neuropsychiatric symptoms but a significant reduction in depressive symptoms among people with dementia. There was low-quality evidence that long-stay intermediate care wards (n = 6) were associated with reduced risk for dangerous behavioural incidents and reduced costs compared to residential aged care facilities. There was no effect of these units on neuropsychiatric symptoms or carer stress.

The scarcity of high-quality studies examining the effectiveness of old age psychiatry services leaves providers and policy-makers to rely on low-quality evidence when designing services. Future research should consider carefully which outcomes to include, given that staff skill and confidence, length of stay, recommendation uptake, patient- and family-reported experiences, and negative outcomes (i.e. injuries, property damage) are as important as clinical outcomes.

There is evidence of disparities between non-Indigenous and Indigenous incidence of psychotic disorders. Despite these disparities being a clear signpost of the impact of structural racism, there remains a lack of evidence to target institutional factors. We aimed to investigate non-Indigenous and Indigenous differences in government service use prior to first episode diagnosis as a means of identifying points of intervention to improve institutional responses.

We used a previously established national New Zealand cohort of 2385 13 to 25-year-old youth diagnosed with psychosis between 2009 and 2012 and a linked database of individual-level multiple government agency administration data, to investigate the differences in health, education, employment, child protection and criminal-justice service use between non-Indigenous (60%) and Indigenous youth (40%) in the year preceding first episode diagnosis. Further comparisons were made with the general population.

A high rate of health service contact did not differ between non-Indigenous and Indigenous youth (adjusted rate ratio 1.0, 95% confidence interval [0.9, 1.1]). Non-Indigenous youth had higher rates of educational enrolment (adjusted rate ratio 1.2, 95% confidence interval [1.1, 1.3]) and employment (adjusted rate ratio 1.2, 95% confidence interval [1.1, 1.3]) and were 40% less likely to have contact with child protection services (adjusted rate ratio 0.6, 95% confidence interval [0.5, 0.8]) and the criminal-justice system (adjusted rate ratio 0.6, 95% confidence interval [0.5, 0.7]). Both first episode cohorts had a higher risk of criminal justice contact compared to the general population, but the difference was greater for non-Indigenous youth (risk ratio 3.0, 95% confidence interval [2.7, 3.4] vs risk ratio 2.0, 95% confidence interval [1.8, 2.2]), explained by the lower background risk.

The results indicate non-Indigenous privilege in multiple sectors prior to first episode diagnosis. Indigenous-based social disparities prior to first episode psychosis are likely to cause further inequities in recovery and will require a response of health, education, employment, justice and political systems.

Little research has examined the physical and mental comorbidities, and health service use patterns, of people diagnosed with psychotic disorder subtypes other than schizophrenia spectrum disorders. This study aims to examine the physical and mental comorbidities, and subsequent hospital service use patterns, of individuals previously hospitalised with various psychotic disorder subtypes using linked health service data.

We included individuals hospitalised with a psychotic disorder in New South Wales, Australia, between 1 July 2002 and 31 December 2014 (N = 63,110). We examined the demographic profile of the cohort and rates of subsequent acute hospital care and ambulatory mental health service use. We compared the rates of subsequent hospital admissions, emergency department presentations and ambulatory mental health treatment days of people hospitalised with different psychotic disorder subtypes to people hospitalised with schizophrenia spectrum disorders using Poisson regression.

People most recently hospitalised with mood/affective disorders and psychotic symptoms had a higher rate of subsequent hospital admissions than those most recently hospitalised with schizophrenia spectrum and delusional disorders (adjusted incident rate ratio = 1.06; 95% confidence interval = [1.02, 1.10]), while people most recently hospitalised with drug-induced and other organic (adjusted incident rate ratio = 1.19; 95% confidence interval = [1.12, 1.27]) and acute psychotic disorders (adjusted incident rate ratio = 1.10; 95% confidence interval = [1.03, 1.18]) had more subsequent emergency department presentations than those most recently hospitalised with schizophrenia spectrum and delusional disorders. All three groups had fewer subsequent mental health ambulatory days than those most recently hospitalised with schizophrenia spectrum and delusional disorders (adjusted incident rate ratios = 0.85–0.91).

The health profiles and subsequent hospital service use patterns of people previously hospitalised with different psychotic disorder subtypes are heterogeneous, and research is needed to develop targeted health policies to meet their specific health needs.

Schizophrenia-spectrum disorder (SSD) is associated with increased premature death, with emerging data suggesting early illness course as a high-risk period for excess mortality. This study aimed to examine mortality rate in patients with incident SSD and differential mortality risk between inpatient-diagnosed and outpatient-diagnosed subsamples within 5 years of first diagnosis.

This population-based cohort study identified 8826 patients aged 18–39 years receiving first-recorded SSD diagnosis upon service entry, comprising 3877 inpatient-diagnosed and 4949 outpatient-diagnosed patients, between 2006 and 2012 in Hong Kong using a territory-wide medical record database of public health care services. All-cause, natural-cause, and unnatural-cause mortality risks within 5 years after first diagnosis were quantified by standardized mortality ratios (SMRs) relative to the general population. We also directly compared mortality rates between inpatient and outpatient subsamples over 5-year follow-up.

SSD patients exhibited markedly elevated all-cause (SMR: 12.28, 95% confidence interval [CI]: [10.83, 13.88]), natural-cause (SMR: 3.76, 95% CI: [2.77, 4.98]) and unnatural-cause (SMR: 20.64, 95% CI: [17.49, 24.20]) mortality during first 5 years of diagnosis. Increased mortality rate was most pronounced in the first year of treatment, especially for unnatural deaths (SMR 32.2, 95% CI: [24.08, 42.22]). Discharged inpatient-diagnosed patients displayed significantly higher all-cause and unnatural-cause mortality rates than outpatient-diagnosed counterparts within first 3 years of treatment, and differential mortality risks on all-cause (adjusted hazard ratio [aHR]: 7.05, 95% CI: [2.02, 24.64]) and unnatural-cause (aHR: 5.15, 95% CI: [1.38, 19.19]) deaths were the highest in the first month of follow-up.

Substantial increase in early mortality risk among people with incident SSD, particularly in the first year of diagnosis and the time shortly after discharge, underscores an urgent need of targeted early intervention for effective suicide prevention and physical health improvement to minimize mortality gap.

This study investigated research capacity and culture in people with lived experience of mental health challenges by developing a quantitative tool that measures capacity to engage in research.

A cross-sectional, correlational methodology was employed, which comprised of three phases: lived experience consultations for item development (n = 15), item refinement (n = 20) and tool piloting. Items were adapted from, and extended, an existing research capacity and culture tool for healthcare workers. People (N = 112) with lived experience as mental health consumers, carers, peer workers and/or advocates aged 18–75 years took part in the tool piloting survey.

Overall, participants rated their individual research capacity and culture skills as moderate (mean = 5.41, standard deviation = 2.04). The most commonly reported barriers to research engagement related to lack of knowledge, familiarity or experience with the research process. The most commonly reported enablers were altruistic, such as using their experiences to improve services and help others. Research capacity and culture significantly correlated with current research activities (rs = 0.25–0.41; ps < 0.05), but not with being a research participant (r = 0.09; p > 0.05), suggesting that building research capacity of people with lived experience requires them to be active members of research teams.

The Lived Experience research capacity and culture tool developed in this study revealed that people with lived experience of mental health challenges are intrinsically motivated to engage in research to improve consumer outcomes. The tool may be useful to assess self, research team and organisational preparedness to conduct genuinely co-designed research, and to assess changes in lived experience research capacities and culture over time.

This paper compares the evolution of the psychosocial sector in two Australian regions pre and post introduction of the National Disability Insurance Scheme – a major reform to the financing, planning and provision of disability services in Australia, intended to create greater competition and efficiency in the market, and more choice for service users.

We used a standardised service classification instrument based on a health ecosystems approach to assess service availability and diversity of psychosocial services provided by non-government organisations in two Primary Health Network regions.

We identified very different evolutionary pathways in the two regions. Service availability increased in Western Sydney but decreased in the Australian Capital Territory. The diversity of services available did not increase in either Primary Health Network 4 years after the reform. Many services were experiencing ongoing funding uncertainty.

Assumptions of increased efficiency through organisational scaling up, and a greater diversity in range of service availability were not borne out.

This study shows the urgent need for evaluation of the effects of the NDIS on the provision of psychosocial care in Australia. Four years after the implementation of the NDIS at vast expense key objectives not been met for consumers or for the system as a whole, and an environment of uncertainty has been created for providers. It demonstrates the importance of standardised service mapping to monitor the effects of major reforms on mental health care as well as the need for a focus at the local level.

Apathy is a common symptom in dementia, though can be difficult to distinguish from depression due to shared features and frequent co-occurrence. As such, a significant limitation of much previous research on apathy is the failure to control for depression. The current study sought to address this by examining the trajectory and clinical correlates of apathy after controlling for depression.

Seven hundred and seventy-nine patients with dementia were recruited from nine memory clinics around Australia. Measures of dementia severity, cognition, functional ability, neuropsychiatric symptoms, caregiver burden and medication use were completed at baseline and at regular intervals over a 3-year period. Driving and institutionalisation data were obtained throughout the study. Mortality data were obtained from state registries 8 years after baseline.

Of the 662 patients with completed measures of neuropsychiatric symptoms, 342 (51.7%) had apathy and 332 (50.2%) had depression at baseline, while 212 (32.0%) had both. Whereas apathy increased over time, depression remained relatively stable. Apathy, but not depression, was associated with greater dementia severity, poorer cognition and function, driving cessation and mortality. Both apathy and depression were associated with greater neuropsychiatric symptoms, psychosis, caregiver burden and institutionalisation.

Apathy increases over the course of dementia and is associated with worse clinical outcomes independent of depression. Distinguishing apathy and depression appears important given their different implications for prognosis and management.

Anti-dementia medications such as acetylcholinesterase inhibitors are an important part of the management pathway for dementia. However, there are limited data in New Zealand that have examined the rates and patterns of use of funded anti-dementia medication and how use differs with ethnicity, age and sex.

This was a retrospective population-based descriptive study. Using the Integrated Data Infrastructure, we identified individuals of all ages coded for a diagnosis of dementia and estimated the proportion dispensed funded anti-dementia medication – donepezil tablets and rivastigmine patches – between 1 July 2016 and 30 June 2020. Rates of medication use in five main ethnic groups (Māori, Pacific peoples, Asian, European, and Middle Eastern, Latin American and African) in the <65, 65–79 and 80 and over (80+) age groups were compared and also between males and females in all sub-groups. Log-binomial models were used to calculate relative risks to determine any differences in anti-dementia medication use in the five ethnic groups and the three age groups and between males and females in each of the four study years.

Overall, one-third of the dementia population received a funded anti-dementia medication in the total population (all ages) between 2016 and 2020. Donepezil tablets were dispensed in 31.6–34.0% and rivastigmine patches in 1.4–2.1% across the four study years. Compared to people of European ethnicity, Māori, Pacific peoples, and Middle Eastern, Latin American and African groups were less likely to be dispensed an anti-dementia medication (Māori: relative risk = 0.79–0.81, p < 0.0001; Pacific peoples: relative risk = 0.72–0.74, p < 0.0001; Middle Eastern, Latin American and African: relative risk = 0.73–0.78, p < 0.05). Compared to the age 80+ group, the 65–79 age group was more likely (relative risk = 1.50–1.54, p < 0.0001), while the age <65 group was less likely (relative risk = 0.67–0.71, p < 0.0001) to be dispensed an anti-dementia medication. There were no statistically significant differences in anti-dementia medication use between males and females.

This study provides important information about funded anti-dementia medication use in New Zealand and how this differs by ethnicity, age and sex. Despite higher dementia prevalence in Māori and Pacific peoples, these groups were less likely to receive funded anti-dementia medication.

It is well established that First Nations Peoples in Australia are overrepresented within the criminal justice system. However, First Nations Peoples appear to be comparatively underrepresented in the forensic mental health system, and little is known about their outcomes once released from secure care.

To compare the characteristics and rates of repeat criminal justice contact for a criminal charge of First Nations and non-First Nations forensic patients in New South Wales.

Data on the sample were extracted from the New South Wales Mental Health Review Tribunal paper and electronic files matched to the Bureau of Crime Statistics and Research Reoffending Database. Characteristics of First Nations and non-First Nations patients were compared using univariate logistic regression analysis. Univariate and multivariate Cox proportional hazard regression was used to determine predictors of post-release criminal charges.

Key differences in the sociodemographic, clinical and forensic characteristics of First Nations compared with non-First Nations forensic patients were identified. The time to first criminal justice contact following release was significantly shorter for First Nations forensic patients (p < 0.01).

The findings of this study confirm that First Nations forensic patients have distinct and complex needs that are apparent at entry to the forensic mental health system and that their poorer criminal justice contact rates following release from secure care indicate that these needs are not being adequately met either during treatment or once in the community. Responses to these study findings must consider the complex and continuing impact of colonisation on First Nations Peoples, as well as the need for solutions to be culturally safe.

The aim of the study was to estimate the annual health care cost by number of comorbid mental and somatic disorders in persons with a mental disorder.

All persons living in Denmark between 2004 and 2017 with a hospital diagnosis of a mental disorder were identified. We investigated the cost of different health care services: psychiatric hospitals, somatic hospitals, primary health care (e.g. general practitioners, psychologists and so on) and subsidised prescriptions. Within those with at least one mental disorder, we examined the costs for people with (a) counts of different types of mental disorders (e.g. exactly 1, exactly 2 and so on up to 8 or more) and (b) counts of different types of somatic disorders (e.g. no somatic disorders, exactly 1, exactly 2 and so on up to 15 or more). The estimates are reported in average cost per case and nationwide annual cost in Euro 2017.

In total, 447,209 persons (238,659 females and 208,550 males) were diagnosed with at least one mental disorder in the study period. The average annual health care cost per case and nationwide cost was 4471 Euros and 786 million Euro, respectively, for persons with exactly one mental disorder, and 33,273 Euro and 3.6 million Euro for persons with eight or more mental disorders. The annual health care cost was 4613 Euro per case and 386 million Euro for persons without any somatic disorders, while the cost per case was 16,344 Euro and 0.7 million Euro in nationwide cost for persons with 15 or more disorders. The amount and proportion of the different health care costs varied by type of comorbidity and count of disorders.

The annual health care cost per case was higher with increasing number of comorbid mental and somatic disorders, while the nationwide annual health care cost was lower with increasing number of comorbid disorders for persons with a mental disorder in Denmark.