Psychosis prevalence and physical, metabolic and cognitive co-morbidity: data from the second Australian national survey of psychosis

Physical Health and Health Behaviours of Australians with Psychosis

People living with psychosis live up to 20 years less compared to the general population. Cardiometabolic ill-health and barriers to health-related behaviour are significant contributors. This is a cross-sectional descriptive study of cardiometabolic health and health behaviours of consumers attending a public community mental health service in an Australian city. One hundred and fourteen consumers currently living with psychosis participated. Standard measures of cardiometabolic health, quality of life and, health-related behaviours were utilised. Data were analysed using descriptive statistics. The cohort reported higher fruit intake and physical activity, and lower excess alcohol use compared to previous studies. Health-related behaviours including smoking and vegetable intake were poorer than previously reported. Participants had low levels of cardiometabolic health (e.g. abnormal lipids). Physical and mental quality of life was also lower than for general populations. Improved efforts to address physical health for people with mental health conditions are urgently needed.

Exploring barriers to the COVID-19 vaccine in people with psychoses in Western Australia

Objectives

We explored barriers to coronavirus (COVID-19) vaccination among people with psychoses and used these to propose expert recommendations to enhance vaccine uptake in this population.

Methods

A mixed-methods, cross-sectional survey was conducted in Perth, Australia, between September 2022 and September 2023 with 233 adults with psychoses. Participants responded to a short telephone survey comprising questions regarding vaccination status, sources of health information, motivations for vaccine acceptance or refusal, and other factors influencing vaccination decisions.

Results

Most respondents (217, 93.1 %) reported being fully vaccinated, however many described barriers to vaccination that reflected their experiences as people living with mental illness. Over half (126, 54.1 %) said they were not contacted by anyone about getting vaccinated for COVID-19. All participants refusing vaccination denied receiving information on vaccine safety, while almost half of those fully vaccinated had received such information. Unvaccinated participants reported lower levels of trust in general practitioners and psychiatrists compared to those who were vaccinated yet, simultaneously, reported higher levels of trust in other healthcare professionals. Vaccinated individuals cited preventing illness, following recommendations, and compliance with mandates as motivators, while reasons for refusal included vaccine efficacy and side-effect concerns.

Conclusion

Despite limited outreach, participants overcame access barriers, with only those who deliberately sought to refuse the vaccines remaining unvaccinated. Mandates appear to have been a significant contributor to vaccine uptake. Recommendations for encouraging future pandemic and routine vaccinations include upskilling nurses and case managers to provide vaccine information and offering vaccination in mental health facilities and at routine clinical appointments.

Integrating Virtual Reality, Neurofeedback, and Cognitive Behavioral Therapy for Auditory Verbal Hallucinations (Hybrid): Protocol of a Pilot, Unblinded, Single-Arm Interventional Study

BACKGROUND

Current treatments for schizophrenia and other psychotic disorders have limited efficacy, with high rates of nonresponse to "gold standard" treatments. New approaches are therefore urgently required.

OBJECTIVE

The aims of this pilot study are to investigate the feasibility, acceptability, safety, and usability of Hybrid treatment (primary aim); and to explore Hybrid's treatment efficacy and engagement of treatment targets (secondary aim). The primary aim will be assessed via face-to-face user experience surveys on a (self-assessed) 5-point Likert scale (and qualitative open-ended questions) examining: (1) acceptability, (2) helpfulness, (3) engagement, and (4) perceived safety. We will also examine consent and completion rates, and the number of sessions attended. Our threshold for moving on to efficacy trials will be at least 70% of our participants to rate 3 and above (which corresponds to agree or strongly agree) that the intervention package was acceptable, feasible, and safe. The secondary aims will be assessed by observing whether individuals achieve self-directed modulation of high-β neurophysiological activity (neural target) and progression upwards through the VR-based exposure hierarchy (psychological target), and by assessing symptom change scores. This study developed a new treatment approach for auditory verbal hallucinations, a major symptom of psychotic disorders, that integrates advances in psychological therapy (cognitive behavioral therapy for psychosis), technology (virtual reality, VR), and neuroscience (electroencephalography-based neurofeedback).

METHODS

Hybrid takes a "symptom capture" approach using individually tailored VR-based exposure exercises. Participants (N=10) will receive the intervention package weekly over 12 face-to-face sessions. Here, participants will be progressively exposed to symptom triggers and develop methods of downregulating neural activity associated with these symptoms (neurofeedback component) while concurrently receiving clinician-delivered cognitive behavioral therapy for psychosis.

RESULTS

As of February 2025, Hybrid has commenced (unblinded) recruitment activities from Orygen clinical services in Northwestern Melbourne, Australia. A total of 75 individuals have been approached and 64 individuals have been prescreened (41 individuals were deemed eligible, 15 individuals were ineligible, and 8 individuals declined or did not respond to contact attempts) and 5 individuals have been included in the study. Of the 5 individuals who have commenced the Hybrid treatment, 4 are actively engaged in the program and 1 individual has withdrawn. We expect recruitment to conclude in July 2025 and for the results to be published in 2026.

CONCLUSIONS

The Hybrid study is piloting a novel approach that has the potential to address the shortcomings of current treatments for psychotic symptoms. If there is favorable evidence for the acceptability, feasibility, safety and usability of Hybrid, the study team will move on to efficacy trials.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12624000357550; https://tinyurl.com/24ey8hpy.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/63405.

The experience of loneliness among people with psychosis: Qualitative meta-synthesis

BACKGROUND

Loneliness can be a significant challenge for people living with psychosis. We currently lack evidence about how to help with this. Understanding the origins, experience, and impact of loneliness in this group is helpful in developing strategies to reduce it. We therefore aimed to conduct a meta-synthesis of the qualitative literature exploring the nature of loneliness, and the factors contributing to the development and maintenance of loneliness, among people living with psychosis.

METHODS

We searched four electronic databases (MEDLINE, Embase, PsycINFO and Web of Science) for studies meeting pre-defined eligibility criteria. We adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines, and appraised the quality of each eligible study using the Critical Appraisal Skills Programme (CASP) checklist. We conducted thematic synthesis to combine the included qualitative findings to generate key overarching themes.

RESULTS

We included 41 articles and our analysis generated six meta-themes: (1) loneliness in the form of disconnection, (2) a rejecting and stigmatising external world, (3) loneliness and acute psychotic episodes and symptoms, (4) thwarted longing for connection, (5) paradoxes of loneliness and psychosis, and (6) well-being embedded in the social world. Our findings suggest a vicious cycle in which loneliness, psychosis and social withdrawal can be mutually reinforcing. Reciprocity of and continuity in relationships were valued by those with psychosis, while self-stigma and experiences of rejection appeared to exacerbate loneliness and impede recovery.

CONCLUSION

Our meta-synthesis offers insights into how people living with psychosis are affected by loneliness. Tailored interventions are needed, which should focus on supporting people in overcoming internal barriers to connection and low self-esteem, challenging stigma and self-stigma, and linking people to social support according to needs and preferences.

Burden of care in caregivers of patients with schizophrenia in Greater Noida, U.P., India

Background

Schizophrenia is a serious mental illness that causes major functional impairments, raises the risk of disability, and reduces life expectancy. It affects around 7 in 1000 people b/w the age of 15 and 35 years. Schizophrenia poses a great challenge not only for the patient but also for the people and the society around the patient. Family members who serve as informal primary carers may suffer personal expenses as a result of providing care for those who have major mental illnesses. One outcome that is regularly studied is the caregiver burden or the challenges encountered in providing care.

Aims

Burden of care in caregivers of patients with schizophrenia in Greater Noida, U.P, India.

Methods

This cross-sectional study was carried out at the School of medical sciences and Research, Sharda University. We enrolled 100 caregivers and it is assessed through the burden assessment scale.

Results

Caregivers ranged in age from 20 to 85, with a mean age of 47 (SD=14.1). The male-to-female ratio was 1.7, with 63 men and 37 women present. The majority of the caregivers were parents (n=54), siblings (n=9), spouses (n=10), or their children (n=5). On the burden assessment scale, the severity of the burden was found on the basis of mild, moderate, severe, and very severe.

Conclusion

It is important to understand the mental health of caregivers in order to develop an appropriate intervention to deal with their mental health problems. Therefore, this study highlighted the need for psychological interventions not only for the patients but also for caregivers.

Adaptation of the Barriers, Attitudes, Confidence, and Knowledge Scale (M-BACK-Tr) into Turkish culture to assess the metabolic health of psychiatric professionals and investigation of Its psychometric characteristics

AIM

The aim was to evaluate the validity and reliability of the "Barriers, Attitudes, Confidence, and Knowledge Scale for Assessing Metabolic Health" (M-Back-Tr) to determine the barriers, attitudes, confidence, and knowledge status of psychiatry professionals in the assessing of metabolic syndrome.

METHODS

This methodological study was conducted with 304 psychiatric nurses who were working in public and private healthcare institutions between March and June 2023. Translation and back-translation were made into the Turkish language during the adaptation process and it was found that there was no semantic shift between the versions. While the validity of M-Back-Tr was tested with content validity, construct validity, and convergent validity, its internal reliability and Split-Half Test Reliability were examined for reliability.

RESULTS

The structure of M-Back-Tr, which consists of 4 dimensions (i.e., Barriers, Attitudes, Confidence, Knowledge) and 16 items, was confirmed in Turkish culture. This structure can explain 73 % of the variance in the related concept. The minimum score that can be taken from each sub-dimension is 4 and the maximum is 20. The Cronbach α value of the sub-dimensions of the scale was found to be between 0.79 and 0.91.

CONCLUSION

The study findings showed that the M-Back-Tr is a valid and reliable measurement tool that can be used in Turkish culture.

On- and off-label utilisation of antipsychotics in Australia (2000-2021): Retrospective analysis of two medication datasets

OBJECTIVE

To determine antipsychotic utilisation patterns in Australian adults from 2005 to 2021, with a focus on on-label and off-label prescriptions.

METHODS

We examined antipsychotic dispensing trends in adults from 2005 to 2021 using a 10% sample of the Pharmaceutical Benefits Scheme (PBS) dataset, which contains patient-level information on medicines dispensed throughout Australia. The lack of diagnostic information in PBS was substituted by analysing BEACH (Bettering the Evaluation And Care of Health) dataset, a cross-sectional national survey from 2000 to 2016, consisting of data from general practitioner-patient encounters.

RESULTS

There were 5.6 million dispensings for 164,993 patients in PBS throughout this period; 69% patients had >1 dispensing, with a median of 6 per patient. Calculating the estimated period of exposure gave a total of 693,562 treatment episodes, with a median duration of 80 days. There were steady increases in both the incidence and prevalence of antipsychotic dispensings, mainly due to oral second-generation antipsychotics. The most commonly prescribed antipsychotics were quetiapine, olanzapine and risperidone, with a significant portion of patients receiving low-dose quetiapine without dose titration. Analysis of diagnostic indications from BEACH indicated that 27% of antipsychotic prescriptions were off-label for indications such as depression, dementia, anxiety and insomnia, at much lower prescribed daily dosages.

CONCLUSION

The increasing prescribing and off-label use highlights concerns about chronic adverse effects caused by antipsychotics. The combined analysis of medication dispensings and the diagnostic indications for which they are prescribed is a novel approach and throws a spotlight on the need for additional monitoring of antipsychotics.

The prevalence of vitamin D deficiency and associated factors in first-episode psychosis

AIM

Vitamin D deficiency is prevalent in people with established psychotic disorders, but less is known about vitamin D levels in people with first-episode psychosis (FEP). This study aimed to determine the prevalence of vitamin D deficiency in people with FEP and identify the factors associated with vitamin D status.

METHODS

This was a prospective cohort study nested within a randomized controlled trial, which included 37 young people with an FEP with minimal antipsychotic medication exposure.

RESULTS

Twenty-four percent of participants were vitamin D deficient, and a further 30% were vitamin D insufficient. There was no association between vitamin D and demographic factors or clinical symptoms (positive, negative, general psychopathology and depressive symptoms) or cognition and functioning. However, vitamin D levels were associated with season of sampling.

CONCLUSIONS

Considering the longer-term adverse effects associated with vitamin D deficiency, it is warranted to ensure this clinical population receives supplementation if indicated.

Antipsychotics and Mortality in Adult and Geriatric Patients with Schizophrenia

Patients with schizophrenia have a high mortality risk, and the role of antipsychotic medications remains inconclusive. In an aging society, older patients with schizophrenia warrant increased attention. This study investigated the association of antipsychotic medication dosages with mortality in patients with schizophrenia by using data from Taiwan's National Health Insurance Research Database from 2010 to 2014. This study included 102,964 patients with schizophrenia and a subgroup of 6433 older patients in addition to an age- and sex-matched control group. The findings revealed that among patients with schizophrenia, the no antipsychotic exposure group had the highest mortality risk (3.61- and 3.37-fold higher risk for overall and cardiovascular mortality, respectively) in the age- and sex-adjusted model, followed by the high, low, and moderate exposure groups. A similar pattern was observed in the older patients with schizophrenia. High exposure to antipsychotics was associated with the highest risks of overall and cardiovascular mortality (3.01- and 2.95-fold higher risk, respectively). In conclusion, the use of antipsychotics can be beneficial for patients with schizophrenia with recommended exposure levels being low to moderate. In older patients, high antipsychotic exposure was associated with the highest mortality risk, indicating that clinicians should be cautious when administering antipsychotic medications to such patients.

Examining the quality of news media reporting of complex mental illness in relation to violent crime in Australia

PURPOSE

News reporting on mental illness can perpetuate stigma. An understanding of the current picture of such reporting is important to identify areas for improvement. This study investigated the quality of Australian news media coverage of complex mental illness in the context of crime and violence over a 2-year period, prior to the release of new media guidelines.

METHODS

This research utilised a systematic search of Australian news articles that were published between July 2018 and July 2020 and reported on mental illness in relation to violent crime. Researchers developed a Mental Illness and Crime Reporting Quality Framework to determine quality scores for news articles according to 11 relevant factors in media guidelines. An additional 11 characteristics of articles were extracted for further descriptive analysis.

RESULTS

One-hundred and twenty-eight Australian news articles met inclusion criteria. The average quality score was 50 (SD = 13.91) out of a possible maximum score of 100 (range 11-78). Strengths and weaknesses were identified as some criteria were consistently met, and other criteria were met rarely or not at all. There were emerging trends between quality scores and article characteristics, including publication source, though these analyses were not statistically significant.

CONCLUSION

The findings indicate that Australian news coverage of complex mental illness and violent crime met half of the criteria of reporting guidelines that minimises risk of perpetuating or reinforcing stigma. This demonstrates significant opportunity to improve the overall quality of media reporting on crime and mental illness. Future research should evaluate the impact of the guidelines on the quality of news reporting after their implementation by utilising a similar methodology, using these findings as a baseline measure.

Exploring the relationship between baseline health-related quality of life (AQoL-4D utility values) and mortality during long-term follow-up for people living with a psychotic disorder

Holistic summary measures of health-related quality of life (HRQoL) could provide useful information for screening and/or monitoring high-risk individuals. This study explores the association of baseline HRQoL (AQoL-4D values) with death from natural and external causes (such as suicide, overdose, or accident) in a prevalent cohort over a mean follow-up of 6.9-years. Baseline data were obtained from the 2010 National Survey of High Impact Psychosis (SHIP) and its 2012 sister survey, the North-Metro Survey of High Impact Psychosis. Follow-up data were obtained from the National Deaths Index (to January 18, 2018). Associations between baseline HRQoL (and the 12 individual items of the AQoL-4D) and deaths by cause, stratified by sex were investigated using multivariable Cox Proportional Hazards models, with age used as the time scale. Overall, 7.6 % of the cohort (137 of 1805 people meeting ICD-10 criteria for a psychotic disorder and agreeing to linkage) died, 4.2 % from natural causes (primarily heart disease and cancer) and 3.4 % from external causes. There was an association between low HRQoL (AQoL-4D ≤ 0.20) and mortality due to natural causes, primarily driven by difficulties with mobility and vision in men, and difficulty with household tasks in women. No significant associations were obtained between AQoL-4D utilities and death from external causes. Sleep problems were associated with death from external causes for men only. As people with psychotic disorders experience multiple causes of death with complex associations which are difficult to quantify, monitoring for low HRQoL using the AQoL-4D could be a useful indicator of increased mortality risk in this population. TWITTER: Monitoring for low HRQoL (AQoL-4D ≤ 0.20) could be a useful indicator of increased mortality risk from natural causes in people living with psychotic disorders, with differing but specific items of relevance to men and women.

Cognitive remediation therapy - implementation and translation into clinical practice in rural and metropolitan New South Wales mental health services

OBJECTIVE

Cognitive Remediation Therapy (CRT) is an effective intervention in managing the significant cognitive deficits experienced by those living with psychosis. Given its strong evidence base CRT is recommended in Australian and international guidelines for rehabilitation of people with psychosis, however, access to CRT remains limited. In this commentary, we describe recent efforts to implement CRT programs within NSW mental health services. Development of CRT delivery has been successfully achieved in both rural and metropolitan settings, utilising both face-to-face and telehealth methods.

CONCLUSIONS

The delivery of CRT in public mental health services is feasible and adaptable to diverse settings. We strongly advocate for sustainable implementation of CRT into routine clinical practice. This will require policy and practice change to enable resources for CRT training and delivery to become embedded in the roles of the clinical workforce.

Exposure to psychotropic medications and mortality in schizophrenia: a 5-year national cohort study

BACKGROUND

Relatively few studies have explored the differential contributions of the accumulative dosage of psychotropic medications on mortality in patients with schizophrenia.

METHODS

We aimed to explore the effects of the exposure dosage of psychotropic medications on mortality during a follow-up period of 5 years with a national cohort of individuals with schizophrenia in 2010. Causes of death were linked through Taiwan's National Mortality Registry. The mean defined daily dose of antipsychotics, antidepressants, mood stabilizers, and sedative-hypnotics, were calculated and survival analyses were conducted.

RESULTS

A total of 102 964 individuals (54 151 men, 52.59%) with schizophrenia were included. Compared to patients with no exposure to antipsychotics, those with antipsychotic exposure had better survival outcomes, regardless of antipsychotic dosage. Antidepressant exposure, in low and moderate dosage, was associated with decreased all-cause mortality; exposure to mood stabilizers appeared to be associated with an increase in all-cause mortality. Although 89.7% of the patients had been prescribed sedative-hypnotics, exposure to sedative-hypnotics was associated with dose-related increased mortality risk [hazard ratio (HR) in low dose group: 1.16, 95% confidence interval (CI) 1.07-1.27; HR in moderate dose: 1.32, 95% CI 1.21-1.44; HR in high dose: 1.83, 95% CI 1.67-2.01)].

CONCLUSIONS

The results indicate that in the treatment of schizophrenia, antipsychotics and antidepressants are associated with lower mortality when using adequate dosages and mood stabilizers and sedative-hypnotics with higher mortality compared with no use. Furthermore, exposure to sedative-hypnotics is associated with a dose-related increased mortality risk which warrants clinical attention and further study.

Experiences of decision making about psychotropic medication during pregnancy and breastfeeding in women living with severe mental illness: a qualitative study

PURPOSE

The aim of this study was to explore the experiences of women living with severe mental illnesses making decisions about psychotropic medication use in pregnancy and breastfeeding, and what helped or hindered the decision-making process.

METHODS

We report on a qualitative study from 12 women who attended the pregnancy service between May 2018 and June 2019. Interviews occurred at 4-6 weeks postpartum on women with severe mental illnesses, which was nested within a larger mixed-methods study.

RESULTS

Three main themes were elicited from the participants' transcriptions and included (i) the decision-making process with subthemes of shared decision-making, consistency and complete care, collaboration and clear communication, and challenges of managing medication; (ii) how information is given, with subthemes of information delivery and communication breakdown; and (iii) breastfeeding dilemmas with subthemes of lithium and breastfeeding choice and autonomy regarding breastfeeding on medication.

CONCLUSION

Findings offer understanding of patients' experiences in the decision-making and use of psychotropic medication during pregnancy and breastfeeding. Women living with severe mental illnesses, such as bipolar and psychosis, face difficult medication decisions due to uncertainty around use in pregnancy, potentially causing conflict with their dual role as both persons with a diagnosed mental illness but also new mothers. The clinician needs to provide comprehensible and concise information, giving space for a woman's voice to be heard to guide them from a position of hesitancy to one of assurance. Collaboration within a multidisciplinary team and external care providers combined with consistency of care assists this process.

Mortality and excess life-years lost in patients with schizophrenia under community care: a 5-year follow-up cohort study

OBJECTIVE

Mortality rate is a general indicator which can be used to measure care and management of schizophrenia. This cohort study evaluated the standardized mortality ratios (SMRs) of all-cause mortality and life-years lost (LYLs) in patients with schizophrenia under a community care program in China.

METHODS

Data were obtained from the National Community Care Program System for Severe Mental Disorders. A total of 99,214 patients diagnosed with schizophrenia were enrolled before December 2014 and followed between 2015 and 2019. A total of 9,483 patients died. Crude mortality rates (CMRs) and SMRs were then stratified by natural vs. unnatural causes, and major groups of death were standardized according to the 2010 National Population SMRs. The corresponding LYLs at birth were also calculated by gender and age.

RESULTS

The SMRs of patients with schizophrenia were significantly elevated during the study period, with an overall SMR of 4.98 (95%CI 2.67-7.32). Neoplasms, cardiovascular diseases, cerebrovascular diseases, external injuries, and poisonings were the most significant causes of death among patients with schizophrenia compared to the general population. The mean LYLs of patients with schizophrenia were 15.28 (95%CI 13.26-17.30). Males with schizophrenia lost 15.82 life-years (95%CI 13.48-18.16), and females lost 14.59 life-years (95%CI 13.12-16.06).

CONCLUSIONS

Patients with schizophrenia under community care had a high mortality rate in our study, even though mental health services have been integrated into the general healthcare system in China to narrow treatment gaps in mental health for > 10 years. In terms of mortality outcome indicators, effective and quality mental health services still have a long way to go. The current study demonstrates the potential for improved prevention and treatment of individuals with schizophrenia under community care.

The physical health nurse consultant and mental health consumer: An important therapeutic partnership

People diagnosed with mental illness (hereon referred to as consumers) experience a disproportionately lower life expectancy of up 30 years compared to the general population. Systemic issues such as diagnostic overshadowing and stigma from healthcare professionals have inhibited the development of positive therapeutic partnerships that enable consumers to seek and engage support for their physical health concerns. Consumers have called for healthcare professionals to skillfully develop and prioritize therapeutic partnerships whilst coordinating and providing physical healthcare. The aim of this qualitative descriptive research was to explore consumer views and experiences of their interactions with a specialist mental health nursing role, the Physical Health Nurse Consultant. Semi-structured interviews were conducted with 14 consumers from a large public Community Mental Health Service in the Australian Capital Territory. Interviews were transcribed and thematically analysed. Therapeutic partnerships were an overarching theme identified from the data and included three sub-themes: personal attributes of the Physical Health Nurse Consultant; behaviour change engagement strategies; and impact of the therapeutic partnership. Consumers described the personal and professional attributes of the Physical Health Nurse Consultant that enabled the establishment and maintenance of their highly valued therapeutic partnership. This therapeutic partnership was perceived to positively impact their personal and clinical outcomes. With increasing support from consumers, clinical practice settings should move towards embedding a Physical Health Nurse Consultant role in routine practice. Further research exploring the co-development of health behaviour change goals and, barriers and facilitators experienced by the consumers regarding the Physical Health Nurse Consultant is required to further role development.

Genome-wide methylation analysis of treatment resistant schizophrenia

Various studies have investigated the relationship between genetic polymorphisms of antipsychotic drug-metabolizing agents and drug response. DNA methylation is a form of epigenetic modification that regulates gene expression. Few studies have analyzed the relationship between genome-wide methylation patterns and treatment resistance schizophrenia. The primary aim of this pilot study is to investigate the association between treatment resistance status and genome-wide DNA methylation in schizophrenia patients. Treatment resistance status was determined for 109 patients with schizophrenia. Treatment resistance was the primary outcome variable in a model, including methylation status of white blood cells using the Illumina 450 array. The genome-wide DNA methylation levels in 109 Schizophrenia subjects did not show that DNA methylation sties were associated with resistance status. From our study, it is evident the importance of continuing to investigate the relationship between DNA methylation and antipsychotic response to personalize treatment in schizophrenia. Future studies require larger prescription databases to build on the results presented in this pilot study.

A comparative review of the epidemiology of mental disorders in Australia and India

Mental illness and substance use disorders have been increasing worldwide. Mental illness has a significant impact upon the lives of the individual as well as their loved ones. Mental disorders are known to result in a high level of disability. This article provides a comparative review of the epidemiology of mental disorders in Australia and India, summarizing and comparing prevalence rates in both countries based upon available data. Overall, it is evident that Australia has higher prevalence rates of mental disorders than India, across most diagnostic groups. Australia has the highest prevalence of anxiety disorders whereas India has the highest prevalence of substance use disorders; including tobacco use disorders. The next most prevalent mental disorders in India are depressive disorders. However, there are demographic parameters such as gender and age as well as service-provision differences across the countries that need to be factored into any interpretation of the data. There are also problems associated with different diagnostic instruments with language and cultural nuances that may impact comparisons. We suggest that a joint epidemiological survey between the two countries would help better understand and delineate the key similarities pertaining to the epidemiology of mental disorders in Australia and India. This will in turn assist with the development of policy and treatment of mental disorders.

Health-related quality of life in people with psychotic disorders: The role of loneliness and its contributors

BACKGROUND

Perception of loneliness has been identified as the strongest predictor of health-related quality of life assessed with the Assessment of Quality of Life-4D in people with psychotic disorders. We aimed to establish contributors to perceived loneliness, and ascertain the mediating role of loneliness in the relationship between identified contributors to loneliness and other known predictors of health-related quality of life with health-related quality of life.

METHODS

Data for 1642 people collected as part of the 2010 Australian National Survey of Psychosis were analysed. Health-related quality of life was assessed using the Assessment of Quality of Life-4D, and loneliness through a single-item five-level categorical variable. To identify independent contributors to loneliness, a statistical model was constructed with reference to a theoretical model comprising 23 variables. A predictive model with health-related quality of life as the dependent variable was then developed and tested to assess the mediating role of loneliness.

RESULTS

Nine contributors to loneliness were found (social dysfunction, experienced stigma, contact with friends, diagnosis, depressive symptoms, anxiety, mental health service utilisation, arthritis and traumatic events in childhood), with social dysfunction the strongest. In the prediction of health-related quality of life, all contributors to loneliness were partially mediated through loneliness (except service utilisation) as were negative symptoms and use of psychotropic/anticholinergic medications.

CONCLUSION

Assuming a plausible causal model of mediation, loneliness was found to have direct and indirect effects on health-related quality of life in people with psychotic disorders. Findings add impetus to efforts to develop and trial strategies aimed at reducing loneliness in this population, and, in turn, improving their health-related quality of life.

Mental health consumers' perspectives of physical health interventions: An integrative review

Consumers of mental health services experience poor physical health compared to the general population, leading to long-term physical illness and premature death. Current research and policy activity prioritizes the physical health of consumers yet few of these recommendations have translated to practice. This implementation gap may be influenced by the paucity of literature exploring consumer perceptions and experiences with physical healthcare and treatment. As a result, little is understood about the views and attitudes of consumers towards interventions designed to improve their physical health. This integrative review aims to explore the literature regarding consumer perspectives of physical healthcare and, interventions to improve their physical health. A systematic search was undertaken using (i) CINAHL, (ii) MEDLINE, (iii) PsycINFO, (iv) Scopus, and (v) Google Scholar between September and December 2021. Sixty-one papers comprising 3828 consumer participants met the inclusion criteria. This review found that consumers provide invaluable insights into the barriers and enablers of physical healthcare and interventions. When consumers are authentically involved in physical healthcare evaluation, constructive and relevant recommendations to improve physical healthcare services, policy, and future research directions are produced. Consumer evaluation is the cornerstone required to successfully implement tailored physical health services.

Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review

BACKGROUND

Lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment. However, despite a considerable amount of research, the impact of psychotic symptoms on BD remains unclear, and there are very few systematic reviews on the subject.

AIM

To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. An electronic literature search of six English-language databases and a manual search was undertaken to identify published articles on psychotic symptoms in BD from January 1940 to December 2021. Combinations of the relevant Medical Subject Headings terms were used to search for these studies. Articles were selected after a screening phase, followed by a review of the full texts of the articles. Assessment of the methodological quality of the studies and the risk of bias was conducted using standard tools.

RESULTS

This systematic review included 339 studies of patients with BD. Lifetime psychosis was found in more than a half to two-thirds of the patients, while current psychosis was found in a little less than half of them. Delusions were more common than hallucinations in all phases of BD. About a third of the patients reported first-rank symptoms or mood-incongruent psychotic symptoms, particularly during manic episodes. Psychotic symptoms were more frequent in bipolar type I compared to bipolar type II disorder and in mania or mixed episodes compared to bipolar depression. Although psychotic symptoms were not more severe in BD, the severity of the illness in psychotic BD was consistently greater. Psychosis was usually associated with poor insight and a higher frequency of agitation, anxiety, and hostility but not with psychiatric comorbidity. Psychosis was consistently linked with increased rates and the duration of hospitalizations, switching among patients with depression, and poorer outcomes with mood-incongruent symptoms. In contrast, psychosis was less likely to be accompanied by a rapid-cycling course, longer illness duration, and heightened suicidal risk. There was no significant impact of psychosis on the other parameters of course and outcome.

CONCLUSION

Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.

Hospital service utilisation of people previously hospitalised with different subtypes of psychotic disorder: A record linkage study

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

Age of onset by sex in schizophrenia: Proximal and distal characteristics

BACKGROUND

Earlier schizophrenia onset in men relative to women has been a consistent finding in the literature, but a nuanced understanding of underlying reasons remains elusive. Further consideration should be given to factors associated with sex differences in age of onset.

METHOD

Participants with schizophrenia were derived from the 2010 Australian Survey of High Impact Psychosis (n = 857). The SHIP survey constituted a representative, population-based study of almost 1.5 million Australian adults seen at various mental health services, and assessed personal health information, psychiatric comorbidities as well as psychosis illness and treatment. Hierarchical clustering was employed to identify age of onset by sex. Within-sex comparisons on distal and proximal factors affecting age of onset were conducted.

RESULTS

Using modal age, two and three clusters were respectively found in men (early versus late onset) and women (early versus mid versus late onset). Early onset groups in both sexes had an increased family history of psychosis compared to older onset, but other risk factors were not consistent across the sexes. Less premorbid impairment was noted in females with middle to later onset schizophrenia.

CONCLUSION

These findings further inform our understanding of the pathogenesis of schizophrenia. Added explorations of trends in older onset schizophrenia cohorts is especially important.

A systematic review comparing caregiver burden and psychological functioning in caregivers of individuals with schizophrenia spectrum disorders and bipolar disorders

BACKGROUND

Informal primary caregivers provide crucial supports to loved ones experiencing serious mental illnesses with profound outcomes for the caregivers themselves. A comprehensive understanding of how different serious mental illnesses change the caregiving experience may provide important insight into the ways in which caregivers can be better supported in their role. The aim of this review was to synthesize the comparative literature examining caregiver burden and psychological functioning (anxiety, depression, distress, and psychological wellbeing) between caregivers of people with schizophrenia spectrum disorders and bipolar disorder.

METHODS

Studies were included if they compared caregivers across both diagnostic groups and used measures assessing either caregiver burden or psychological functioning of caregivers. Databases searched up until 11th of January 2022 included: Medline COMPLETE, Embase, PsycINFO and CINAHL. Reference list scans and grey literature searches across government, organisational and dissertation databases were also conducted.

RESULTS

Twenty-eight studies comprising 6166 caregivers were included. Fourteen studies suggested that caregiving burden was comparable across both groups. The effects of caring on caregiver mental health and stress were comparable across both groups. However, methodological limitations were noted, including a reliance on cross-sectional studies, multiple and sometimes competing definitions of caregiving burden, variable sample sizes, and variation in measures used.

CONCLUSION AND IMPLICATIONS

The experience of providing care is multidimensional and complex. Symptoms and functional difficulties experienced by people being cared for may affect caregivers more so than diagnosis. Caregivers play a vital role in helping people with serious mental illness. Supporting caregivers by reducing their burden and improving their psychological functioning may help them to continue to provide support, and cope with, the challenges of providing care.

Observational Study of the Association between Hyponatremia and Rhabdomyolysis in Patients Presenting to Hospital

Hyponatremia may be a risk factor for rhabdomyolysis, but the association is not well defined and may be confounded by other variables. The aims of this study were to determine the prevalence and strength of the association between hyponatremia and rhabdomyolysis and to profile patients with hyponatremia. In a cross-sectional study of 870 adults admitted to hospital with rhabdomyolysis and a median peak creatine kinase of 4064 U/L (interquartile range, 1921−12,002 U/L), glucose-corrected serum sodium levels at presentation showed a U-shape relationship to log peak creatine kinase. The prevalence of mild (130−134 mmol/L), moderate (125−129 mmol/L), and severe (<125 mmol/L) hyponatremia was 9.4%, 2.5%, and 2.1%, respectively. We excluded patients with hypernatremia and used multivariable linear regression for analysis (n = 809). Using normal Na+ (135−145 mmol/L) as the reference category, we estimated that a drop in Na+ moving from one Na+ category to the next was associated with a 25% higher creatine kinase after adjusting for age, alcohol, illicit drugs, diabetes, and psychotic disorders. Multifactorial causes of rhabdomyolysis were more common than single causes. The prevalence of psychotic and alcohol use disorders was higher in the study population compared to the general population, corresponding with greater exposure to psychotropic medications and illicit drugs associated with hyponatremia and rhabdomyolysis. In conclusion, we found an association between hyponatremia and the severity of rhabdomyolysis, even after allowing for confounders.

Physical illness comorbidity and its influencing factors among persons with severe mental illness in Rural China

BACKGROUND

Comorbid physical illness is a common cause of death in people with severe mental illness (SMI) worldwide. In rural China, the prevalence of physical illness comorbidity among persons with SMI remains unclear. This study aimed to examine non-communicable physical illness comorbidity and its risk factors among people with SMI in a rural area of China.

METHODS

A mental health survey, using the International Classification of Disease (ICD-10), was conducted in six townships of Xinjin District, Chengdu, China in 2015.

RESULTS

A total of 724 persons with SMI were included in this study, and 37.8% of them had at least one physical illness. The most common physical illnesses were hypertension (10.5%) and diabetes (5.8%). More physical comorbidity was reported among persons with affective disorders than persons with schizophrenia. Many participants (37.4%) had never received antipsychotic treatment, and of those, 51.6% reported having a physical illness comorbidity. Significant associations were found between physical illness comorbidity and participants' family economic status, family size, age at onset of mental disorder, treatment status, and symptom severity.

CONCLUSIONS

Our findings indicate the need of an integration of medical and psychiatric care in primary care. It also suggests that poverty and having never received treatment for mental health problems negatively affect the health of persons with SMI, which deserve more attention. Researchers and policymakers can take these findings into account to develop health policies and improve the mental and physical health care in rural China.

Obstructive Sleep Apnea Is Treatable With Continuous Positive Airway Pressure in People With Schizophrenia and Other Psychotic Disorders

Obstructive sleep apnea (OSA) is a highly prevalent condition in people living with schizophrenia or other psychotic disorder. Its treatment with continuous positive airway pressure therapy (CPAP) can dramatically improve daytime and physical health function. People with a psychotic disorder, however, are rarely diagnosed and treated and there are no large-scale studies showing evidence of successful treatment with CPAP. Using a retrospective case-control study approach (N = 554), we examined adherence to and effectiveness of a CPAP trial in individuals with comorbid psychotic disorder and OSA (psychosis group, n = 165) referred for a CPAP trial at the West Australian Sleep Disorders Research Institute. Given that antipsychotic medication is an important confounder, we included a psychiatric (non-psychosis) comparison group taking antipsychotic medication (antipsychotic group, n = 82), as well as a nonpsychiatric control group (OSA control group, n = 307) also diagnosed with OSA and referred for CPAP. Variables included OSA symptom response, CPAP engagement, and usage at 3 months. The Psychosis group had the most severe OSA at baseline and they attended fewer clinic appointments overall. However, there were no other group differences either in CPAP adherence or treatment response. CPAP was equally effective in normalizing OSA symptoms and daytime sleepiness in all groups. CPAP usage was longer per night in the Psychosis and Antipsychotic groups, perhaps suggesting a role of sedation from antipsychotic medications. In conclusion, OSA is treatable and CPAP feasible in people with severe mental illness and antipsychotic medications are not a barrier to treatment response.

Link workers, activities and target groups in social prescribing: a literature review

Purpose

Social prescribing is a model of integrated care, in which primary healthcare staff can link patients to the social care sector. However, social prescribing can occur in different forms. To better understand the concept of social prescribing, this literature review examines the role of the link workers, activities and target groups.

Design/methodology/approach

A literature review was conducted. Studies before May 2020 were considered. In total, 1,700 studies were identified using the databases Pubmed, PsycInfo, Cinahl, Web of Science and Cochrane Library. After eligibility checks, 16 studies were included in the final analysis.

Findings

A few studies warned of a deeper engagement of the link worker due to service dependency, but most studies encouraged an active and supportive role of the link worker. Participants engaged in social, physical and counseling activities. The majority of studies emphasized the importance of linking group activities with personal preferences and identity needs. The main target groups were composed of individuals with psychosocial needs, but some studies also included patients with physical or mental illnesses.

Originality/value

Social prescribing is widely advocated as an innovative model of integrated care. However, few studies have looked into the complex system of social prescribing. This study analyzes the linking processes, activities and target groups in extant social prescribing programs.

Predictive value of cardiometabolic biomarkers and depressive symptoms for symptom severity and quality of life in patients with psychotic disorders

BACKGROUND

Patients with psychotic disorders show higher rates of the metabolic syndrome (MS) between the cluster of severe mental illnesses. Depressive symptoms can worsen outcomes of individuals with psychotic disorders. However, research on the association between MS and depression in psychotic disorders and their relevance to outcomes is lacking.

METHODS

We investigated the association between depression and cardiometabolic biomarkers in psychotic disorders and the predictive value of depressive symptoms on psychopathological severity and quality of life (QoL). 406 patients with psychotic disorders were recruited as part of the Improving Physical Health and Reducing Substance Use in Severe Mental Illness randomised controlled trial. Depression, psychotic symptoms, QoL, waist circumference, triglycerides, high-density lipoprotein cholesterol (HDL-C), blood pressure, and fasting glucose of patients were assessed at baseline and 12 months. Sensitivity analyses were conducted to test the effect of treatment.

RESULTS

More severe baseline symptoms of depression significantly predicted worse 12-month psychotic symptoms and lower mental health related QoL at 12 months. These associations held after controlling for alcohol use, gender, ethnicity, education, and mental health related QoL Baseline. Depressive symptoms also correlated with waist circumference at both baseline and 12 months, after controlling for multiple testing.

CONCLUSION

Individuals with psychotic disorders experiencing more severe depressive symptoms are more likely to have larger waist circumference contemporaneously and 12 months later, as well as more severe psychotic symptoms and worse QoL at follow-up. This highlights the need for evaluation of strategies to address depression in the management of psychotic disorders.

Understanding the Treatment Preferences of People Living with Schizophrenia in Australia; A Patient Value Mapping Study

PURPOSE

To examine the treatment and long-term outcome preferences for people living with schizophrenia.

PATIENTS AND METHODS

Sixty-six Australian adults, living with schizophrenia completed a novel online survey with six sections: Demographic characteristics; Disease history; Quality-of-life; Patient support programmes; Discrete Choice Experiment, and Best-Worst Scaling exercise.

RESULTS

Participants indicated that they preferred to be involved in treatment decision with their doctor. A minority of participants reported having been previously involved in a patient support programme (28.8%) and only one in six participants had a National Disability Insurance Scheme (NDIS) package (16.7%) with over a third of participants indicating that they were ineligible (37.9%). Participants' average quality-of-life score was 60%.

CONCLUSION

Recent hospitalisation influenced the relative importance of treatment attributes, with effectiveness on hearing voices being the most important treatment attribute. The most important long-term goals were having a stable place to live, being independent, and physical health. People with schizophrenia care about their long-term functional recovery outcomes, rating symptom control and independence as their highest priority. They want to be part of the treatment conversation with their doctors. Therefore, psychiatrists are encouraged to use shared decision-making to establish the treatment course that best aligns with individuals' long-term goals.

Self-reported needs of people living with psychotic disorders: Results from the Australian national psychosis survey

Person-centered care is a collaborative approach to health care. To provide effective, person-centered care to people living with severe mental illness, it is necessary to understand how people view their own needs. The Perceived Need for Care Questionnaire (PNCQ) was used in the Australian National Survey of High Impact Psychosis (SHIP) to deepen understanding and evaluate, at a population level, the needs of Australian adults living with psychotic illness. SHIP participants were 1,825 adults, aged 18-65 years, living with psychotic illness and in contact with public specialized mental health services across Australia in 2010. The survey package included demographic and clinical items, and various scales including the PNCQ appraising a comprehensive range of life domains. Logistic regressions measured the impact that various demographic, clinical and psychosocial independent variables (e.g., loneliness, health-related quality of life, disability, accommodation type) had on the likelihood of inadequately met PNCQ domain-related need. Over two-thirds of people living with psychosis reported at least two areas of unmet need for care despite most being in contact with mental health services. Work or using one's time and socializing, counseling, and self-care domains had the largest proportion of inadequately met needs (range between 49 and 57%). Feelings of loneliness and/or social isolation were significantly associated with unmet needs across all PNCQ domains, except for financial needs. Health-related quality of life was significantly associated with unmet needs across all domains, except for housing needs. Disability was significantly associated with unmet social, occupation (work or time use), housing and medication-related needs. Consumers view their needs for care as unmet across many life areas despite being in contact with mental health services. Loneliness, unmet psychosocial needs, and health-related quality of life appear strongly interconnected and warrant greater attention in the delivery of person-centered care for people living with psychosis. Support to address social, work or time use and housing related needs among people living with psychosis appears less well targeted toward those with disability. Results underscore the link between quality of life, recovery and needs. These inter-relationships should be considered in mental health services research and evaluation.

Factors that contribute to urban-rural gradients in risk of schizophrenia: Comparing Danish and Western Australian registers

INTRODUCTION

An association between schizophrenia and urbanicity has long been observed, with studies in many countries, including several from Denmark, reporting that individuals born/raised in densely populated urban settings have an increased risk of developing schizophrenia compared to those born/raised in rural settings. However, these findings have not been replicated in all studies. In particular, a Western Australian study showed a gradient in the opposite direction which disappeared after adjustment for covariates. Given the different findings for Denmark and Western Australia, our aim was to investigate the relationship between schizophrenia and urbanicity in these two regions to determine which factors may be influencing the relationship.

METHODS

We used population-based cohorts of children born alive between 1980 and 2001 in Western Australia (N = 428,784) and Denmark (N = 1,357,874). Children were categorised according to the level of urbanicity of their mother's residence at time of birth and followed-up through to 30 June 2015. Linkage to State-based registers provided information on schizophrenia diagnosis and a range of covariates. Rates of being diagnosed with schizophrenia for each category of urbanicity were estimated using Cox proportional hazards models adjusted for covariates.

RESULTS

During follow-up, 1618 (0.4%) children in Western Australia and 11,875 (0.9%) children in Denmark were diagnosed with schizophrenia. In Western Australia, those born in the most remote areas did not experience lower rates of schizophrenia than those born in the most urban areas (hazard ratio = 1.02 [95% confidence interval: 0.81, 1.29]), unlike their Danish counterparts (hazard ratio = 0.62 [95% confidence interval: 0.58, 0.66]). However, when the Western Australian cohort was restricted to children of non-Aboriginal Indigenous status, results were consistent with Danish findings (hazard ratio = 0.46 [95% confidence interval: 0.29, 0.72]).

DISCUSSION

Our study highlights the potential for disadvantaged subgroups to mask the contribution of urban-related risk factors to risk of schizophrenia and the importance of stratified analysis in such cases.

Prevalence of food insecurity in people with major depression, bipolar disorder, and schizophrenia and related psychoses: A systematic review and meta-analysis

People with severe mental illness (SMI), such as major depression, bipolar disorder, and schizophrenia, experience numerous risk factors that may predispose them to food insecurity; however, the prevalence of food insecurity and its effects on health are under-researched in this population group. This systematic review and meta-analysis aimed to describe the prevalence and correlates of food insecurity in people with SMI. A comprehensive electronic search was conducted up to March 2021. Random effects meta-analysis was employed to determine the prevalence of food insecurity in SMI, and odds ratio (OR) of food insecurity in people with SMI compared to non-psychiatric controls/general population. Twenty-nine unique datasets (31 publications) were included. Prevalence estimate of food insecurity in people with SMI was 40% (95% CI 29-52%, I² = 99.7%, N = 27). People with SMI were 2.71 (95% CI 1.72-3.25) times more likely to report food insecurity than the comparator group (Z = 11.09, p < 0.001, I² = 95%, N = 23). The odds of food insecurity in SMI were higher in high/high-middle income countries compared to low/low-middle income countries, likely due to the high food insecurity rates in the general population of lower income countries. There was no difference in food insecurity rates by diagnosis. Food insecurity should be a consideration for health professionals working with community-dwelling people with SMI.

The association between vitamin D and symptom domains in psychotic disorders: A systematic review

BACKGROUND

Vitamin D deficiency is prevalent among people with psychosis and may play a role in the aetiology of psychotic disorders. However, its impact on clinical symptom severity has not been independently reviewed.

METHODS

We conducted a systematic search of randomized trials and observational studies that assessed the relationship between vitamin D and symptom domains (positive and negative psychotic symptoms, total and general psychopathology, cognitive and depressive) in people with a psychotic disorder.

RESULTS

1040 articles were identified, of which 29 were eligible for inclusion: 26 observational studies and 3 randomized trials. Five studies included people with First-Episode Psychosis (FEP) and 24 included people with enduring psychosis. Most observational studies found that vitamin D was inversely associated with negative symptoms (57%; 13/23), positively associated with cognitive performance (63%; 5/8), and bore no association with positive symptoms (68%; 15/22), total psychopathology (64%; 7/11), general psychopathology (57%; 4/7) or depressive symptoms (64%; 9/14). Randomized controlled trials indicated that vitamin D supplementation improved cognitive performance (100%; 1/1) and, in some cases, reduced total psychopathology (50%; 1/2), general psychopathology (50%; 1/2) and negative symptoms (30%; 1/3), but had no effect on positive (100%; 3/3) or depressive (100%; 3/3) symptoms. Some positive associations were attenuated when controlled for potential confounders.

CONCLUSION

Low vitamin D was found to be inversely associated with more severe clinical symptoms in some, but not all symptom domains in people with psychosis. These preliminary findings warrant further exploration, particularly in regard to cognitive performance and negative symptoms.

Prevalence of food insecurity in community-dwelling people living with severe mental illness

AIM

The present study aimed to measure the prevalence and severity of food insecurity in people with a severe mental illness, defined as schizophrenia and related psychoses, and bipolar disorder; and explore relationships between food insecurity status, and sociodemographic and clinical characteristics.

METHODS

This cross-sectional study recruited community-dwelling people with severe mental illness receiving clozapine and/or a long-acting injectable antipsychotic medication within three mental health services in Sydney, Australia. Participants completed the 18-item Household Food Insecurity Access Scale. Sociodemographic and medical information was obtained from participants' medical records. Independent samples t-test and chi-square analyses were used to test for between group differences based on food insecurity status. Binary logistic regression analyses adjusting for age and gender were used to determine the odds ratio.

RESULTS

One-hundred and eighty-eight people completed the assessment: 63% were male, mean age was 49.2 ± 12.4 years, and the majority (85%) had a diagnosis of schizophrenia. Food insecurity was detected in 31% of participants. Of those who were food insecure, 12% were classified as severe, 13% as moderate and 7% as mild. Tobacco smoking was higher in food insecure people compared to food secure people (odds ratio = 3.1, 95% CI 1.3 to 7.1, p = 0.01). Food insecurity status was not associated with demographic, diagnostic or other clinical data.

CONCLUSIONS

Food insecurity is highly prevalent among community-dwelling people with severe mental illness receiving clozapine and/or long-acting injectable antipsychotic medication. Food security screening should be considered as routine care for this population group.

Stratification by Sex and Hormone Level When Contrasting Men and Women in Schizophrenia Trials Will Improve Personalized Treatment

BACKGROUND

Sex and gender differences have been reported in the prevalence, expression, treatment response, and outcome of schizophrenia, but most reports are based on relatively small samples that have not been stratified for the impact of sex hormone levels. This literature review aims to show how women's hormone levels can impact the results of male/female comparisons.

METHODS

This is a narrative review of data from publications of the last decade.

RESULTS

Epidemiologic evidence, reports of the impact of hormones on cognition, results of sexually dimorphic responses to treatment, and male/female trajectories of illness over time all suggest that female hormone fluctuations exert major effects on male/female differences in schizophrenia.

CONCLUSIONS

Information on hormonal status in women participants is rarely available in clinical studies in schizophrenia, which makes male/female comparisons largely uninterpretable. These are the current challenges. Opportunities for individualized treatment are growing, however, and will undoubtedly result in improved outcomes for both women and men in the future.

Mental health recovery and physical health outcomes in psychotic illness: Longitudinal data from the Western Australian survey of high impact psychosis catchments

OBJECTIVE

There is a dearth of longitudinal data on outcomes in prevalent cases of psychotic illness across a range of ages and levels of chronicity. Our aim was to describe changes over time in mental and physical health outcomes, as well as patterns of service utilisation that may have influenced outcomes, in a representative prevalence sample of 641 Western Australians with a psychotic illness who, at Wave 1, were part of the National Survey of High Impact Psychosis.

METHODS

In Wave 1 (2010, 2012), a two-phase design was employed to ensure representativeness: Phase 1 psychosis screening took place in public mental health and non-government organisation services, while, in Phase 2, a randomised sample was interviewed. In Wave 2, 380/641 (59%) of participants were re-interviewed, with interviews staggered between 2013 and 2016 (follow-up time: 2.3-5.6 years). Data collection covered mental and physical health, functioning, cognition, social circumstances and service utilisation. Mental health outcomes were categorised as symptomatic, functional and personal recovery. Physical health outcomes covered metabolic syndrome and its component criteria.

RESULTS

In mental health, there were encouraging improvements in symptom profiles, variable change in functional recovery and some positive findings for personal recovery, but not quality of life. Participants ranked physical health second among challenges. Metabolic syndrome had increased significantly. While treatment for underlying cardiovascular risk conditions had improved, rates of intervention were still very low. More people were accessing general practices and more frequently, but there were sharp and significant declines in access to community rehabilitation, psychosocial interventions and case management.

CONCLUSION

Although we observed some positive outcomes over time, the sharp decline in access to evidence-based interventions such as community rehabilitation, psychosocial interventions and case management is of great concern and augurs poorly for recovery-oriented practice. Changes in service utilisation appear to have influenced the patterns found.

Mental illness as a predictor of patient attendance and anthropometric changes: observations from an Australian publicly funded obesity management service

OBJECTIVE

Obesity is associated with co-morbid mental illness. The Canberra Obesity Management Service (OMS) supports adults with severe obesity who have the psychosocial capacity to engage. This study will determine whether mental illness is a predictor of OMS attendance and anthropometric changes.

METHOD

A retrospective audit was performed from July 2016 to June 2017. Baseline characteristics, attendance and anthropometrics were stratified according to the presence of mental illness. Outcomes included weight stabilisation and clinically significant weight loss. Descriptive analyses were performed.

RESULTS

Mental illness was present in 60/162 patients (37%). Attendance was similar for those with and without mental illness. Patients with mental illness had twice as many co-morbidities (p = .001). Depressive disorders were most common (n = 28, 47%). Anxiety, schizophrenia spectrum and other psychotic disorders, and trauma- and stressor-related disorders also featured. Weight stabilisation was achieved by 25 patients (66%) with mental illness and 25 (35%) without. Clinically significant weight loss was observed in 10 patients (26%) with and 26 (40%) without mental illness.

CONCLUSION

The presence of mental illness did not impact OMS attendance or weight stabilisation. The higher rate of co-morbidities in those with mental illness highlights the challenges faced by this vulnerable population.

Proposing a causal pathway for health-related quality of life in people with psychotic disorders

This study aimed to establish independent predictors for health-related quality of life (HRQoL) in people with psychotic disorders, and the mediating role of global functioning in those relationships. Data for 1642 people collected as part of the second Australian National Survey of Psychosis were analyzed. The Assessment of Quality of Life (AQoL)-4D and the Personal and Social Performance scale were used for assessing HRQoL and global functioning respectively. The study commenced with a theoretical model comprised of 26 sociodemographic and clinical variables. A predictive model for HRQoL was built up using a purposeful selection strategy to arrive at a set of clinically meaningful, independent predictors. The mediating effect of global functioning was then assessed. Seven variables were found to have an independent effect on HRQoL: perception of loneliness, number of negative symptoms, use of psychotropic and anticholinergic medications, course of disorder, lifetime histories of chronic pain and cardiovascular disease and living arrangements at the time of the interview. All variables except perceived loneliness and chronic pain were partially mediated through global functioning. This final model explained 46% of the variance in HRQoL, with loneliness and number of negative symptoms the strongest predictors. Evidence in support of a credible causal pathway for HRQoL in people with psychotic disorders, mediated by global functioning was presented. The importance of the quality of social relationships was highlighted, and potential targets for improving the HRQoL of this population identified.

The interplay between functioning problems and symptoms in first episode of psychosis: An approach from network analysis

The relationship between psychotic symptoms and global measures of functioning has been widely studied. No previous study has assessed so far the interplay between specific clinical symptoms and particular areas of functioning in first-episode psychosis (FEP) using network analysis methods. A total of 191 patients with FEP (age 24.45 ± 6.28 years, 64.9% male) participating in an observational and longitudinal study (AGES-CM) comprised the study sample. Functioning problems were assessed with the WHO Disability Assessment Schedule (WHODAS), whereas the Positive and Negative Syndrome Scale (PANSS) was used to assess symptom severity. Network analysis were conducted with the aim of analysing the patterns of relationships between the different dimensions of functioning and PANSS symptoms and factors at baseline. According to our results, the most important nodes were "conceptual disorganization", "emotional withdrawal", "lack of spontaneity and flow of conversation", "delusions", "unusual thought content", "dealing with strangers" and "poor rapport". Our findings suggest that these symptoms and functioning dimensions should be prioritized in the clinical assessment and management of patients with FEP. These areas may also become targets of future early intervention strategies, so as to improve quality of life in this population.

Excess mortality in patients with schizophrenia spectrum disorders in Malaga (Spain): A cohort study

AIMS

There is evidence that patients with schizophrenia spectrum disorders present higher mortality in comparison with the general population. The aim of this study was to analyse the causes of mortality and sociodemographic factors associated with mortality, standardised mortality ratios (SMRs), life expectancy and potential years of life lost (YLL) in patients with schizophrenia spectrum disorders in Spain.

METHODS

The study included a cohort of patients from the Malaga Schizophrenia Case Register (1418 patients; 907 males; average age 42.31 years) who were followed up for a minimum of 10 years (median = 13.43). The factors associated with mortality were analysed with a survival analysis using Cox's proportional hazards regression model.

RESULTS

The main causes of mortality in the cohort were circulatory disease (21.45%), cancer (17.09%) and suicide (13.09%). The SMR of the cohort was more than threefold that of the population of Malaga (3.19). The life expectancy at birth was 67.11 years old, which is more than 13 years shorter than that of the population of Malaga. The YLL was 20.74. The variables associated with a higher risk of mortality were age [adjusted hazard ratio (AHR) = 1.069, p < 0.001], male gender (AHR = 1.751, p < 0.001) and type of area of residence (p = 0.028; deprived urban zone v. non-deprived urban area, AHR = 1.460, p = 0.028). In addition, receiving welfare benefit status in comparison with employed status (AHR = 1.940, p = 0.008) was associated with increased mortality.

CONCLUSIONS

There is excess mortality in patients with schizophrenia spectrum disorders and also an association with age, gender, socioeconomic inequalities and receiving welfare benefits. Efforts directed towards improved living conditions could have a positive effect on reducing mortality.

A comparison of Australian chronic disease prevalence estimates using administrative pharmaceutical dispensing data with international and community survey data

Introduction

Chronic disease (CD) is a leading cause of population mortality, illness and disability. Identification of CD using administrative data is increasingly used and may have utility in monitoring population health. Pharmaceutical administrative data using World Health Organization, Anatomic Therapeutic Chemical Codification (ATC) assigned to prescribed medicines may offer an improved method to define persons with certain CD and enable the calculation of population prevalence.

Objective

To assess the feasibility of Australian Pharmaceutical Benefits Scheme (PBS) dispensing data, to provide realistic measures of chronic disease prevalence using ATC codification, and compare values with international data using similar ATC methods and Australian community surveys.

Methods

Twenty-two chronic diseases were identified using World Health Organization (WHO) formulated ATC codes assigned to treatments received and recorded in a PBS database. Distinct treatment episodes prescribed to individuals were counted annually for prevalence estimates. Comparisons were then made with estimates from international studies using pharmaceutical data and published Australian community surveys.

Results

PBS prevalence estimates for a range of chronic diseases listed in European studies and Australian community surveys demonstrated good correlation. PBS estimates of the prevalence of diabetes, cardiovascular disease and hypertension, dyslipidemia, and respiratory disease with comparable Australian National Health Survey in older adults showed correlations of between (r = 0.82 - 0.99) and a range of percentage error of -11% to 59%. However, other conditions such as psychological disease and migraine showed greater disparity and correlated less well.

Conclusions

Although not without limitations, Australian administrative pharmaceutical dispensing data may provide an alternative perspective on population health and a useful resource to estimate the prevalence of a number of chronic diseases within the Australian population.

Non-psychiatric hospitalization length-of-stay for patients with psychotic disorders: A mixed methods study

OBJECTIVE

Patients with psychotic disorders experience higher rates of chronic and acute non-psychotic diseases and have frequent non-psychiatric hospitalizations which result in both longer and more varied length-of-stay (LoS) than other patients. This study seeks to use a patient-centered perspective to examine LoS.

METHODS

This article reports Phase Two of a mixed methods, exploratory sequential study on non-psychiatric hospitalizations for individuals with psychotic disorders. Patients' experiences were used to guide a quantitative analysis of LoS using a general linear model.

RESULTS

Medical comorbidities were the patient characteristics which had the largest effect on LoS. Certain processes of care highlighted by patients from Phase One were also associated with longer LoS, including: physical restraints (105%), psychiatric consults (20%) and continuous observation (133%). Only recent in-system outpatient appointments were associated with shorter LoS. Data integration highlighted that factors which were important to patients such as partner support, were not always quantitatively significant, while others like medical comorbidities and use of physical restraints were points of congruence.

CONCLUSIONS

Medical comorbidities were highly associated with LoS but processes relating to longer LoS are those that are used to manage symptoms of acute psychosis. Clinicians should develop policies and procedures that address psychosis symptoms effectively during non-psychiatric hospitalizations. Further research is needed to understand which patients with psychotic disorders are at highest risk of extended length-of-stay.

Physical health assistance in early recovery of psychosis: Study protocol for a randomized controlled trial

AIM

Young people with psychotic disorders have poorer physical health compared to their healthy peers, a state compounded by the metabolic side-effects of antipsychotic medications. To address this, Orygen Youth Health has introduced physical health services including exercise physiologists and dieticians. These services are typically coordinated by the case manager and doctor. It is not yet known whether a treating team member dedicated to physical health will improve engagement, adherence and outcomes with these services. Hence, the protocol is presented here for a trial to evaluate the effect of including a physical health nurse in the care of young people with first-episode psychosis.

METHODS

This will be a single-blind randomized controlled trial that includes 15- to 24-year-olds with first-episode psychosis who have just commenced (within 30 days) antipsychotic medication. The primary outcome will be the event of clinically significant weight gain (≥7% body weight). Participants will be assigned either a physical health nurse in their treating team (in addition to the case manager and doctor) for a 12-week period, or treatment as usual (case manager and doctor). Research assessments will be conducted at baseline, 12 and 26 weeks. Activity trackers worn by participants for the study's duration will measure sleep and physical activity.

CONCLUSION

The present study will determine whether a physical health nurse will facilitate participants in attending and engaging in physical health interventions and whether this will be associated with physical health improvements or the prevention of worsening physical health.

The assertive cardiac care trial: A randomised controlled trial of a coproduced assertive cardiac care intervention to reduce absolute cardiovascular disease risk in people with severe mental illness in the primary care setting

BACKGROUND

Cardiovascular disease (CVD) accounts for 40% of the excess mortality identified in people with severe mental illness (SMI). Modifiable CVD risk factors are higher and can be exacerbated by the cardiometabolic impact of psychotropic medications. People with SMI frequently attend primary care presenting a valuable opportunity for early identification, prevention and management of cardiovascular health. The ACCT Healthy Hearts Study will test a coproduced, nurse-led intervention delivered with general practitioners to reduce absolute CVD risk (ACVDR) at 12 months compared with an active control group.

METHODS/DESIGN

ACCT is a two group (intervention/active control) individually randomised (1:1) controlled trial (RCT). Assessments will be completed baseline (pre-randomisation), 6 months, and 12 months. The primary outcome is 5-year ACVDR measured at 12 months. Secondary outcomes include 6-month ACVDR; and blood pressure, lipids, HbA1c, BMI, quality of life, physical activity, motivation to change health behaviour, medication adherence, alcohol use and hospitalisation at 6 and 12 months. Linear mixed-effects regression will estimate mean difference between groups for primary and secondary continuous outcomes. Economic cost-consequences analysis will be conducted using quality of life and health resource use information and routinely collected government health service use and medication data. A parallel process evaluation will investigate implementation of the intervention, uptake and outcomes.

DISCUSSION

ACCT will deliver a coproduced and person-centred, guideline level cardiovascular primary care intervention to a high need population with SMI. If successful, the intervention could lead to the reduction of the mortality gap and increase opportunities for meaningful social and economic participation. Trial registration ANZCTR Trial number: ACTRN12619001112156.

Loneliness and its association with health service utilization in people with a psychotic disorder

BACKGROUND

Loneliness is common in people with psychotic disorders and associated with reduced health and well-being. The relationship between loneliness in psychosis and health service use is unclear. This study examined whether loneliness predicts increased health care utilization in this population, independently of sociodemographics, health and functioning.

METHODS

We used cross-sectional data from the Second Australian National Survey of Psychosis. Loneliness was assessed using a single-item question, rated on a 4-point scale (not lonely; lonely occasionally; some friends but lonely for company; socially isolated and lonely). Health service use (past 12-months) was measured by the number of general practitioner (GP), emergency department (ED) and outpatient visits, inpatient admissions, and home visits by mental health professionals. Frequent hospital users comprised those in the top 15% of users of at least two services.

RESULTS

Negative binomial regression analysis showed that loneliness was associated with an increased number of GP visits, ED visits and inpatient admissions, only. Socially isolated and lonely survey participants were more than twice as likely (OR = 2.6) of being 'frequent users' compared to non-lonely responders. Following stringent adjustment for covariates, loneliness remained significantly associated with being a 'frequent user' and showed a non-significant trend to an increased number of GP visits and inpatient admissions.

CONCLUSIONS

Loneliness is a complex social and personal problem for people with psychosis, related to greater use of some health services. Better strategies for identifying and responding to loneliness in this population have the potential to increase well-being and contain health service utilization costs.

Prevalence and correlates of food insecurity in community-based individuals with severe mental illness receiving long-acting injectable antipsychotic treatment

People with severe mental illness (SMI) have numerous risk factors that may predispose them to food insecurity (FI); however, the prevalence of FI and its effects on health are under-researched in this population. The present study aimed to describe the prevalence of FI and its relationship to lifestyle factors in people with SMI. This cross-sectional study recruited people with SMI receiving long-acting injectable (LAI) antipsychotic medication from community services at three sites in Sydney, Australia. Assessments were completed on physical health and lifestyle factors. χ2 Tests, independent-samples t tests and binary logistic regression analyses were calculated to examine relationships between lifestyle factors and FI. In total, 233 people completed the assessments: 154 were males (66 %), mean age 44·8 (sd 12·7) years, and the majority (70 %) had a diagnosis of schizophrenia. FI was present in 104 participants (45 %). People with FI were less likely to consume fruits (OR 0·42, 95 % CI 0·24, 0·74, P = 0·003), vegetables (OR 0·39, 95 % CI 0·22, 0·69, P = 0·001) and protein-based foods (OR 0·45, 95 % CI 0·25, 0·83, P = 0·011) at least once daily, engaged in less moderate to vigorous physical activity (min) (OR 0·997, 95 % CI 0·993, 1·000, P = 0·044), and were more likely to smoke (OR 1·89, 95 % CI 1·08, 3·32, P = 0·026). FI is highly prevalent among people with SMI receiving LAI antipsychotic medications. Food-insecure people with SMI engage in less healthy lifestyle behaviours, increasing the risk of future non-communicable disease.

Correlates of Physical Activity and Cardiorespiratory Fitness in Racially and Ethnically Diverse People with Serious Mental Illness in Supportive Housing

We examined demographic, health, and mental health correlates of physical activity and cardiorespiratory fitness (CRF) in racially and ethnically diverse people with serious mental illness (SMI) living in supportive housing. We used baseline data from 314 people with SMI enrolled in a randomized effectiveness trial of a peer-led healthy lifestyle intervention. Sedentary behavior and physical activity were measured with the International Physical Activity Questionnaire. CRF was measured with the 6-min walking test (6MWT). Correlates were identified via ordinary least squares and logistic regressions. Participants were mostly male and racial/ethnic minorities. Thirty-four percent engaged in at least 150-min-per-week of at least moderate-intensity physical activity. On average, participants walked 316.8 m in the 6MWT. Our models show that physical activity and CRF were not evenly distributed in racially and ethnically diverse people with SMI and are associated with multiple demographic, mental health, and health factors. Our findings suggest subgroups and factors that can be targeted to develop health interventions to improve the physical health of people with SMI.

Rates, types and associations of sexual risk behaviours and sexually transmitted infections in those with severe mental illness: a scoping review

The aim of this scoping review was to: (i) determine rates and types of sexual risk behaviours and sexually-transmitted infections (STIs) in those with severe mental illness (SMI); and (ii) delineate correlates of poor sexual health outcome. The online databases OVID MedLine and PsycINFO were searched from databases inception to February 2018 for any literature with a focus on sexual risk behaviours (inconsistent condom use, multiple sexual partners, substance use and transactional sexual acts) or STIs in SMI populations. Fourteen studies were identified; the quality of these studies ranged from poor to moderate. Outcome definitions were heterogeneous, precluding meta-analysis. We found rates of sexual risk behaviours and STIs to be more common among those with SMI than the rates in the general Australian population. Current studies do not acknowledge the relationship of sexual risk behaviours and STI risk and hence do not provide a full model of sexual health outcomes in those with SMI. In order to improve sexual health outcomes in SMI populations, further research is required of greater methodological rigor, with consensus in the definition of sexual risk behaviours, clarifying causal relationships and where in the course of SMI that these outcomes emerge.