Australian and New Zealand Journal of Psychiatry最新文献

Background: The transition out of inpatient mental health is a crucial time for adults experiencing concurrent mental illness and homelessness, yet evidence regarding effective support options is mixed. Choices is an intensive 3-month psychosocial outreach and crisis accommodation support programme for adults experiencing mental illness and homelessness, delivered by Baptcare in Tasmania, Australia. This study examined the effect of Choices on adults' psychosocial functioning, clinical symptomology and psychiatric readmissions in comparison to standard care only.

Method: Participants were adults aged 18-64 years experiencing mental illness and homelessness, recruited upon discharge from a psychiatric admission. Intervention participants (n = 124) received the Choices programme. Control participants (n = 122) received standard care, clinical assessment and treatment from hospital-based Mental Health Services. Outcomes were psychosocial functioning (primary), clinical symptomology, hospital readmission rate and readmission length of stay. Outcomes were assessed at programme commencement and closure (3 months) and 3 months post-closure (intervention group only). Analysis of covariance was used to analyse differences between groups at closure, while controlling for baseline differences.

Results: Intervention participants had significantly improved social functioning (encompassing living conditions, social relationships, self-esteem/confidence), overall psychosocial functioning, symptoms of depression and anxiety and shorter hospital readmission length of stay in comparison to the control group. Intervention participants experienced further improvements in social and overall psychosocial functioning 3 months post-closure.

Conclusion: The Choices programme is effective in enhancing the psychosocial functioning of adults experiencing concurrent mental illness and homelessness. These findings support the ongoing delivery of this combined accommodation and wrap-around psychosocial model of intensive support.

Objective: Suicide is a leading cause of death in males aged 25-44 years, an age which often coincides with becoming a father. This review aims to synthesise the evidence of the prevalence of suicidal and self-harm ideation in fathers during the perinatal, postnatal and early parenting period.

Methods: Five databases were searched (PsycINFO, Medline, Web of Science, PubMed and the Cochrane Database of Systematic Reviews) to identify papers published between 1 January 2000 and 9 March 2023. A meta-analysis was conducted to estimate the prevalence of suicidality and self-harm ideation across the included studies. Subgroup and sensitivity analyses were conducted to explore potential sources of heterogeneity.

Results: A total of 4215 articles were identified, with 14 studies included in the review. The combined pooled prevalence of suicidal and self-harm ideation was 4.2% (95% CI [2.6%, 6.2%]). Prevalence estimates were higher for self-harm ideation at 5.1% (95% CI [2.6%, 6.2%]) than for suicidality at 3% (95% CI [0.9%, 6.1%]).

Conclusions: This review found that a considerable proportion of fathers experience suicidal and self-harm ideation during the early years of parenting. However, the paucity of rigorous prevalence studies indicates that further research in this area is needed urgently.

Objective: The prevalence of treatment-resistant schizophrenia (TRS) among people with first-episode schizophrenia (FES) has been sub-optimally researched in Australia and internationally. We evaluated the prevalence of TRS among a cohort of FES patients and compared their sociodemographic and clinical characteristics to those with FES who were treatment responsive.

Methods: Over 2 years, we collated demographic, clinical and treatment-related data of all patients with ICD-10 (International Classification of Diseases, Tenth revision) diagnosis of schizophrenia who were active in October 2020 at four early psychosis intervention services (EPIS) in Western Australia. We used a modified version of Suzuki et al. criteria to diagnose TRS. The data were analysed utilising descriptive statistics, the Mann-Whitney U test, Student's t-test and the False-Discovery Rate method.

Results: The prevalence of TRS among the 167 patients diagnosed with FES was 41.3%, and the rates did not differ significantly between the services (p = 0.955). Those in the TRS group were less independent (p = 0.011), had more prolonged unemployment (p = 0.014) and were more likely to be on disability pension (p = 0.011) compared to the treatment responsive group. Furthermore, they had greater severity of symptoms (p = 0.002), longer duration of psychiatric symptoms (p = 0.019), more hospitalisations (p = 0.002) and longer cumulative admission durations (p = 0.002).

Conclusions: Our study revealed that treatment resistance to antipsychotics is prevalent among people with FES managed at EPIS. Notably, it establishes an association between TRS and heightened clinical severity and psychosocial and treatment burden. These findings highlight the imperative for early detection of treatment resistance and timely and specialised interventions for this condition in mental health services.

Background: The higher rate of mental illness, including severe psychotic disorders, among people in prisons compared to the general community is well-established. However, there have been no reviews or attempts to pool data on the reported prevalence of mental illness across prisons in Australia and New Zealand.

Methods: A systematic search of electronic databases from 1966 to the end of 2020 was conducted to identify studies reporting rates of 'any' mental illness, and separately rates of psychotic illness, among adult men and women in Australian and New Zealand prisons. A meta-analysis was performed according to PRISMA guidelines (PROSPERO ID: CRD42021241946), with separate analyses conducted for lifetime and current prevalence rates.

Results: Seventeen studies, with a total of 10,209 people in prison, met inclusion criteria. The pooled lifetime prevalence of 'any' mental illness was 69.0% (95% confidence interval = [0.56, 0.79]), and the pooled lifetime prevalence for psychosis was 9.1% (95% confidence interval = [0.07, 0.12]). Meanwhile, the pooled prevalence for 'any' current mental illness was 54.0% (95% confidence interval = [0.39, 0.68]) and for any current psychosis was 6.4% (95% confidence interval = [0.04, 0.10]). There was substantial heterogeneity between studies, with evidence that lifetime rates of psychosis have increased over time, with true prevalence estimates in 95% of all comparable populations falling between 2.7% and 26.4%.

Conclusion: The prevalence of mental illness, including severe psychotic illness, is high in Australian and New Zealand prisons. Furthermore, there is evidence that the prevalence of psychosis may be increasing over time, indicating more effort is needed to ensure diversion of people with mental illness away from the criminal justice system and into healthcare pathways.

Objective: To determine whether completion of an online mental health self-assessment by patients who are waiting in the emergency department can save clinician time taken to complete clinical assessment and documentation.

Methods: Patients presenting to a psychiatric emergency department for a period of 6 months were allocated by week of presentation to either the intervention arm (online mental health self-assessment, followed by a clinical interview) or the control arm (usual assessment) arm on a random basis. Time at the beginning and end of the interview was recorded and used to derive interview time. Similarly, time at the beginning and end of the clinical documentation was recorded and used to derive the time to complete clinical documentation.

Results: Of 168 patients who presented during the study period, 69 (38.55%) agreed to participate, 33 completed the usual assessment and 30 completed the online mental health self-assessment followed by a clinical interview. Patients receiving usual care had a statistically significant, t(61) = 2.15, p = 0.035, longer interview duration (M = 48.7 minutes, SD = 19.8) compared with those in the online mental health self-assessment arm (M = 38.9 minutes, SD = 15.9). There was no statistically significant difference between groups for documentation time, t(61) = -0.64, p = 0.52.

Conclusion: Online mental health self-assessment was associated with a statistically significant reduction in interview time by approximately 10 minutes without increasing documentation time. While online mental health self-assessment is not appropriate for all patients in the emergency department setting, it is likely to yield greater benefits in less acute settings.

Aim: To understand the themes for Māori subjected to compulsory community treatment orders.

Background: The Mental Health (Compulsory Assessment and Treatment) Act 1992 has been utilised in Aotearoa New Zealand for more than three decades. Despite Māori having higher rates of being subject to community treatment orders, there is little research examining their perspectives of its benefits and harms.

Methods: Thematic analysis of a purposive sample of Māori in Hawke's Bay, New Zealand.

Results: Five themes were developed. Māori described community treatment orders as restrictive and stigmatising. Some Māori described being poorly informed of the structures surrounding the use of community treatment orders and saw it as a mechanism to circumvent information-giving regarding treatment. Counterbalancing these, Māori described community treatment orders as mandating support and saw them as a mechanism to access care. Finally, some described their compulsory treatment status as unimportant and irrelevant.

Conclusions: Thematic analysis identified five clear themes from interview participants. Conceptualisation of community treatment orders was largely negative, although Māori acknowledged that being subject to community treatment orders demanded more support from services. Themes of stigma and restriction are common in the literature, however, conception of the use of community treatment orders to bypass consent is novel. The literature describes community treatment orders as providing support, however, in this study, the interpretation suggests a need to lose personal autonomy to receive care, a potentially 'slippery slope' towards a two-tier type service. These findings remind services of the importance of attending to cultural elements of care, being clear around the process of consent. In terms of policy, weaving in cultural understanding appears to be important from an Indigenous perspective.

Background: Vitamin D status in pregnancy may affect offspring neurodevelopment.

Objective: The objective was to investigate the association between serum 25-hydroxyvitamin D in cord blood and pregnancy and symptoms of attention-deficit hyperactivity disorder in 5-year-old offspring.

Method: In Odense Child Cohort, Denmark, 944 mother-child pairs had data on pregnancy or cord serum 25-hydroxyvitamin D and parent-rated attention-deficit hyperactivity disorder symptom score by Child Behavior Checklist for ages 1.5-5 years. Adjusted multiple linear regression and two-stage exposure analyses were performed for serum 25-hydroxyvitamin D associations to the attention-deficit hyperactivity disorder symptom score.

Results: The mean (standard deviation) serum 25-hydroxyvitamin D in cord blood was 48.0 (21.8) nmol/L; early pregnancy was 65.5 (20.2) nmol/L and late pregnancy was 79.3 (25.7) nmol/L. The median (interquartile range) age of child at examination was 5.2 (5.1-5.4) years and median (interquartile range) attention-deficit hyperactivity disorder symptom score was 2 (0-3) points. In adjusted analyses, serum 25-hydroxyvitamin D of <25 nmol/L and <32 nmol/L in cord blood and <25 nmol/L in early pregnancy was associated with 0.9 [95% confidence interval: 0.4, 1.3], 0.5 [0.1, 0.9] and 2.1 [0.8, 3.4] points higher attention-deficit hyperactivity disorder symptom score vs reference. In the two-stage exposure analysis, attention-deficit hyperactivity disorder symptom score decreased by 0.4 points per 25 nmol/L increase in serum 25-hydroxyvitamin D. Moreover, serum 25-hydroxyvitamin D of <25 nmol/L in early pregnancy and cord was associated with a five-fold and a two-fold risk of attention-deficit hyperactivity disorder symptom score ⩾90th percentile, adjusted odds ratio [95% confidence interval] = 4.9 [1.3, 19.0] and 2.2 [1.2, 3.9].

Conclusion: In this cohort, serum 25-hydroxyvitamin D <25 nmol/L in cord blood and early pregnancy were risk factors for higher attention-deficit hyperactivity disorder symptom score in 5-year-old children, suggesting a protective effect of vitamin D on attention-deficit hyperactivity disorder traits at preschool age.

Objective: As highlighted in Australia's Productivity Commission Inquiry into mental health, subgroups of individuals are failing to have their needs met, or are 'falling through the cracks' in the current system - a phenomenon increasingly referred to as the 'missing middle'. A barrier to devising solutions is that the term 'missing middle' is not clearly defined. Using the Delphi method, we aimed to define the term and explore acceptability.

Method: Three expert groups were recruited: carers and young people with a lived experience of mental ill-health; clinicians and service providers; researchers, policymakers and commissioners of mental health services. Using a three-stage Delphi process, we elicited definitions, refined and developed a consensus definition.

Results: Ten subthemes describing the 'missing middle' were identified, with four endorsed across all expert groups from the outset: service gap, inflexibility, inadequate service quality and duration, and social disadvantage. Additional subthemes were later endorsed. Feedback was sought on a consensus-driven definition that encompassed the original four endorsed subthemes. Findings supported a shift to a systemic focus - framing the 'missing middle' as a care gap.

Conclusions: A consensus definition was developed, repositioning the term to a systems lens, describing a 'missing middle service gap'. The definition represents the 'missing middle' as a term to describe a gap in care where existing mental health services are not meeting the needs of individuals in a meaningful way. Research was carried out in relation to youth mental health in Australia and the definition may need to be adapted for other contexts.