A descriptive interview with 64 patients discharged from an acute-psyciatric-inpatient service

Background Acute-mental-health services receive hundreds of admissions every year. Some of these patients will continue to be case-managed by community mental-health teams on discharge from the acute unit while others will not remain in contact with the mental-health service. This study compares the findings of comprehensive interviews conducted with current and past patients of the community mental-health service 3 or more years following case closure from the community ambulatory service.
Methods Between 1 July 1999 and 30 June 2001, there were 2245 closed cases identified at Barwon Health. Letters of invitation to participate in a research project were sent to people who had suffered from psychotic illnesses, and had been case-closed by community mental-health services between the above dates and had not been in contact with the Community and Mental Health Service for at least 6 months. A second group of participants was recruited from people who had also been case-closed by community mental health teams in Barwon Health during the 1999–2001 2-year-time window but whose cases had been re-opened and who were in case management with Barwon Health at the time of the study. All participants were interviewed using the Diagnostic Interview for Psychosis.
Results Letter responses were received from 17 men and 18 women, aged 40.7 ± 12.0 (mean ± SD), who were interviewed. A second group of 17 men and 12 women, aged 40.9 ± 9.6 (mean ± SD) of currently case-managed patients was interviewed. All interviewees reported a detailed history of mental illness. Persistent social dysfunction and impaired quality of life were reported in both groups.
Conclusion Patients suffering from psychotic disorders who had been case-closed by community mental-health teams and had been discharged to the care of their general practitioners or elsewhere continued to show evidence of significant impairment due to mental illness 3 years after being case-closed.

Correlates of aggressive behavior in dementia

Background and Objective: A review of current literature was undertaken in order to summarize some of the possible biopsychosocial contributions to the development of aggressive behavior in elderly people with dementia. It was intended that such a summary would provide a useful clinical aid when assessing patients with behavioral symptoms and a starting point for undertaking research in this area. Method: Information was gathered from literature searches conducted on several occasions between 1995 and 2001 using 3 databases (Medline, CINHAL and PsycINFO), as well as journals and books available from the libraries of the authors and from Monash University, Melbourne, Australia. Results: Associations between various conditions and the development of aggressive behavior were found, including the contributions of degrees of cognitive impairment, personality, sensory change, physical illness, language impairment, brain pathology, affective and psychotic disorders. The role of gender, sexuality and disruption of circadian rhythms is also discussed, as is the importance of environmental factors. Conclusion: Identification of correlates of aggressive behavior may assist clinicians to understand and manage aggressive behavior more effectively.

Costs of psychosis in 2010: findings from the second Australian national survey of psychosis

Objectives
To estimate the annual costs of psychosis in Australia from societal and government perspectives and assess whether average costs per person differ by principal service provider at time of census.

Methods
Costs of psychosis encompassing health sector costs, other sector costs, and productivity losses were assessed for 2010 using a prevalence-based, bottom-up approach. Resource use data were obtained from the second Australian National Survey of Psychosis and unit costs were from government and non-government organization (NGO) sources. Costs to society were assessed by principal service provider at census: public specialized mental health services (PSMHS) and NGOs during the census month (current clients), and PSMHS in the 11 months preceding census (recent clients), and any differences were ascertained.

Results
The average annual costs of psychosis to society are estimated at $77,297 per affected individual, comprising $40,941 in lost productivity, $21,714 in health sector costs, and $14,642 in other sector costs. Health sector costs are 3.9-times higher than those for the average Australian. Psychosis costs Australian society $4.91 billion per annum, and the Australian government almost $3.52 billion per annum. There are significant differences between principal service providers for each cost category. Current PSMHS clients had the highest health sector costs overall, and the highest mental health ambulatory, inpatient, and antipsychotic medication costs specifically. NGO clients had the highest other sector costs overall and the highest NGO assistance, supported employment, and supported accommodation costs. Recent PSMHS clients had the lowest productivity losses for reduced participation and the highest costs for absenteeism and presenteeism.

Conclusions
The costs of psychosis are broad ranging and very high. Development and implementation of cost-effective prevention, treatment, and support strategies is critical to maximizing the efficiency of service delivery. A needs-based framework based on principal service provider and recency of contact may facilitate this process.

A collaborative approach to the treatment alliance in bipolar disorder.

The treatment alliance is the arena in which psychopharmacological and other therapeutic interventions occur. The nature and quality of the treatment alliance may affect adherence to treatment and the realization of the benefits of effective pharmacological treatment in clinical practice. It is an area that has attracted little systematic study, despite the available evidence suggesting that it plays a measurable role in clinical outcomes.

Role of muscarinic receptors in the activity of N-desmethylclozapine: reversal of hyperactivity in the phospholipase C knockout mouse

Activity of the cholinergic muscarinic system is associated with modulation of locomotor activity, although the precise mechanism remains unclear. The phospholipase C-[beta]1 knockout mouse displays both M1 muscarinic receptor dysfunction and a hyperactive locomotor phenotype. This mouse serves as an ideal model for the analysis of muscarinic modulation of locomotor activity. The clozapine metabolite N-desmethylclozapine (NDMC) has shown some promise as an alternative or adjunct treatment for psychotic disorders. NDMC shows strong muscarinic acetylcholine receptor affinities, which may contribute to the clinical efficacy of clozapine and account for the correlation between NDMC/clozapine ratio and treatment response. Administration of NMDC reversed a striking hyperactive phenotype in the phospholipase C-[beta]1 knockout mouse, whereas no significant effects were observed in wild-type animals. This highlights the potential role of muscarinic activity in the behavioural response to NDMC. The M1 muscarinic antagonist pirenzepine, however, also reduced the hyperactive phenotype of these mice, emphasizing the importance of muscarinic function in the control of locomotor behaviour, but also calling into question the specific mechanism of action of NMDC at muscarinic receptors.

Physical health comorbidities in women with personality disorder: data from the Geelong osteoporosis study

BACKGROUND: Associations between common psychiatric disorders, psychotic disorders and physical health comorbidities are frequently investigated. The complex relationship between personality disorders (PDs) and physical health is less understood, and findings to date are varied. This study aims to investigate associations between PDs with a number of prevalent physical health conditions. METHODS: This study examined data collected from women (n=765;≥25years) participating in a population-based study located in south-eastern Australia. Lifetime history of psychiatric disorders was assessed using the semi-structured clinical interviews (SCID-I/NP and SCID-II). The presence of physical health conditions (lifetime) were identified via a combination of self-report, medical records, medication use and clinical data. Socioeconomic status, and information regarding medication use, lifestyle behaviors, and sociodemographic information was collected via questionnaires. Logistic regression models were used to investigate associations. RESULTS: After adjustment for sociodemographic variables (age, socioeconomic status) and health-related factors (body mass index, physical activity, smoking, psychotropic medication use), PDs were consistently associated with a range of physical health conditions. Novel associations were observed between Cluster A PDs and gastro-oesophageal reflux disease (GORD); Cluster B PDs with syncope and seizures, as well as arthritis; and Cluster C PDs with GORD and recurrent headaches. CONCLUSIONS: PDs were associated with physical comorbidity. The current data contribute to a growing evidence base demonstrating associations between PDs and a number of physical health conditions independent of psychiatric comorbidity, sociodemographic and lifestyle factors. Longitudinal studies are now required to investigate causal pathways, as are studies determining pathological mechanisms.

Niacin skin sensitivity is increased in adolescents at ultra-high risk for psychosis

BACKGROUND: Most studies provide evidence that the skin flush response to nicotinic acid (niacin) stimulation is impaired in schizophrenia. However, only little is known about niacin sensitivity in the ultra-high risk (UHR) phase of psychotic disorders.

METHODS: We compared visual ratings of niacin sensitivity between adolescents at UHR for psychosis according to the one year transition outcome (UHR-T n = 11; UHR-NT n = 55) with healthy controls (HC n = 25) and first episode schizophrenia patients (FEP n = 25) treated with atypical antipsychotics.

RESULTS: Contrary to our hypothesis niacin sensitivity of the entire UHR group was not attenuated, but significantly increased compared to the HC group, whereas no difference could be found between the UHR-T and UHR-NT groups. As expected, niacin sensitivity of FEP was attenuated compared to HC group. In UHR individuals niacin sensitivity was inversely correlated with omega-6 and -9 fatty acids (FA), but positively correlated with phospholipase A2 (inPLA2) activity, a marker of membrane lipid repair/remodelling.

CONCLUSIONS: Increased niacin sensitivity in UHR states likely indicates an impaired balance of eicosanoids and omega-6/-9 FA at a membrane level. Our findings suggest that the emergence of psychosis is associated with an increased mobilisation of eicosanoids prior to the transition to psychosis possibly reflecting a "pro-inflammatory state", whereas thereafter eicosanoid mobilisation seems to be attenuated. Potential treatment implications for the UHR state should be further investigated.

A prospective cohort study of antipsychotic medications in pregnancy: the first 147 pregnancies and 100 one year old babies

BACKGROUND: Many women diagnosed with varying psychiatric disorders take antipsychotic medications during pregnancy. The safety of antipsychotic medications in pregnancy is largely unknown.

METHODS: We established the National Register of Antipsychotic Medications in Pregnancy in 2005. Women who are pregnant and taking an antipsychotic medication are interviewed every 6 weeks during pregnancy and then followed until their babies are one year old. The baby's progress is closely followed for the first year of life.

FINDINGS: As of April 18 2012, 147 pregnancies had been followed through to completion. There were 142 live births and data is available for 100 one year old babies. 18% of babies were born preterm, with a higher dose of antipsychotic medication correlating to an increased likelihood of premature delivery; 43% of babies required special care nursery or intensive care after birth; 37% had any degree of respiratory distress and 15% of babies developed withdrawal symptoms. Congenital anomalies were seen in eight babies. Most pregnancies resulted in the birth of live, healthy babies. The use of mood stabilisers or higher doses of antipsychotics during pregnancy increased the likelihood of babies experiencing respiratory distress or admission to Special Care Nursery or Neonatal Intensive Care Units.

CONCLUSION: There is a great need for safety and efficacy information about the use of antipsychotic medications in pregnancy. Live, healthy babies are the most common outcome following the use of antipsychotic medication in pregnancy, but clinicians should be particularly mindful of neonatal problems such as respiratory distress.

Relationship between erythrocyte fatty acid composition and psychopathology in the Vienna omega-3 study

This study investigated the relationship between erythrocyte membrane fatty acid (FA) levels and the severity of symptoms of individuals at ultra-high risk (UHR) for psychosis. Subjects of the present study consisted of 80 neuroleptic-naïve UHR patients. Partial correlation coefficients were calculated between baseline erythrocyte membrane FA levels, measured by gas chromatography, and scores on the Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning Scale, and Montgomery-Asberg Depression Rating Scale (MADRS) after controlling for age, sex, smoking and cannabis use. Subjects were divided into three groups according to the predominance of positive or negative symptoms based on PANSS subscale scores; membrane FA levels in the three groups were then compared. More severe negative symptoms measured by PANSS were negatively correlated with two saturated FAs (myristic and margaric acids), one ω-9 monounsaturated FA (MUFA; nervonic acid), and one ω-3 polyunsaturated FA (PUFA; docosapentaenoic acid), and were positively correlated with two ω-9 MUFAs (eicosenoic and erucic acids) and two ω-6 PUFAs (γ-linolenic and docosadienoic acids). More severe positive symptoms measured by PANSS were correlated only with nervonic acid. No associations were observed between FAs and MADRS scores. In subjects with predominant negative symptoms, the sum of the ω-9 MUFAs and the ω-6:ω-3 FA ratio were both significantly higher than in those with predominant positive symptoms, whereas the sum of ω-3 PUFAs was significantly lower. In conclusion, abnormalities in FA metabolism may contribute to the neurobiology of psychopathology in UHR individuals. In particular, membrane FA alterations may play a role in negative symptoms, which are primary psychopathological manifestations of schizophrenia-related disability.

Randomised controlled trial of a digitally assisted low intensity intervention to promote personal recovery in persisting psychosis: SMART-Therapy study protocol

BACKGROUND: Psychosocial interventions have an important role in promoting recovery in people with persisting psychotic disorders such as schizophrenia. Readily available, digital technology provides a means of developing therapeutic resources for use together by practitioners and mental health service users. As part of the Self-Management and Recovery Technology (SMART) research program, we have developed an online resource providing materials on illness self-management and personal recovery based on the Connectedness-Hope-Identity-Meaning-Empowerment (CHIME) framework. Content is communicated using videos featuring persons with lived experience of psychosis discussing how they have navigated issues in their own recovery. This was developed to be suitable for use on a tablet computer during sessions with a mental health worker to promote discussion about recovery.

METHODS/DESIGN: This is a rater-blinded randomised controlled trial comparing a low intensity recovery intervention of eight one-to-one face-to-face sessions with a mental health worker using the SMART website alongside routine care, versus an eight-session comparison condition, befriending. The recruitment target is 148 participants with a schizophrenia-related disorder or mood disorder with a history of psychosis, recruited from mental health services in Victoria, Australia. Following baseline assessment, participants are randomised to intervention, and complete follow up assessments at 3, 6 and 9 months post-baseline. The primary outcome is personal recovery measured using the Process of Recovery Questionnaire (QPR). Secondary outcomes include positive and negative symptoms assessed with the Positive and Negative Syndrome Scale, subjective experiences of psychosis, emotional symptoms, quality of life and resource use. Mechanisms of change via effects on self-stigma and self-efficacy will be examined.

DISCUSSION: This protocol describes a novel intervention which tests new therapeutic methods including in-session tablet computer use and video-based peer modelling. It also informs a possible low intensity intervention model potentially viable for delivery across the mental health workforce.

Melatonin : an overlooked factor in schizophrenia and in the inhibition of anti-psychotic side effects

This paper reviews melatonin as an overlooked factor in the developmental etiology and maintenance of schizophrenia; the neuroimmune and oxidative pathophysiology of schizophrenia; specific symptoms in schizophrenia, including sleep disturbance; circadian rhythms; and side effects of antipsychotics, including tardive dyskinesia and metabolic syndrome. Electronic databases, i.e. PUBMED, Scopus and Google Scholar were used as sources for this review using keywords: schizophrenia, psychosis, tardive dyskinesia, antipsychotics, metabolic syndrome, drug side effects and melatonin. Articles were selected on the basis of relevance to the etiology, course and treatment of schizophrenia. Melatonin levels and melatonin circadian rhythm are significantly decreased in schizophrenic patients. The adjunctive use of melatonin in schizophrenia may augment the efficacy of antipsychotics through its anti-inflammatory and antioxidative effects. Further, melatonin would be expected to improve sleep disorders in schizophrenia and side effects of anti-psychotics, such as tardive dyskinesia, metaboilic syndrome and hypertension. It is proposed that melatonin also impacts on the tryptophan catabolic pathway via its effect on stress response and cortisol secretion, thereby impacting on cortex associated cognition, amygdala associated affect and striatal motivational processing. The secretion of melatonin is decreased in schizophrenia, contributing to its etiology, pathophysiology and management. Melatonin is likely to have impacts on the metabolic side effects of anti-psychotics that contribute to subsequent decreases in life-expectancy.

Psychiatric disorders and unmet needs in Australian police cells

To determine the prevalence of current psychiatric disorders and unmet needs in a sample of police cell detainees in Victoria. A cross-sectional descriptive study was conducted, including data linkage with the Victoria Police database and the Victorian Psychiatric Case Register. In Melbourne, Australia, 150 detainees were recruited from two busy metropolitan police stations. Outcome measures included estimated rates of psychiatric disorders, using the Structured Clinical Interview for DSM-IV-TR, and individual needs, using the Camberwell Assessment of Need – Forensic Version. One quarter (n = 32, 25.4%) of detainees had a prior admission to a psychiatric hospital, and three quarters met current criteria for a diagnosable mental disorder. The most common disorders were substance dependence (n = 81, 54%) and mood disorders (n = 60, 40%). A third met diagnostic criteria for both a mental illness and a substance use disorder. The odds of being classified with mood (OR = 10.1), anxiety (OR = 2.2), psychotic (OR = 15.4) and substance use disorders (OR = 26.3) were all significantly higher in the current sample as compared with the general population. Detainees with a mental illness identified significantly more needs and significantly more unmet needs (e.g. psychological distress) than those who did not rate as having a current mental illness. There remains a pressing need to evaluate standardized screening tools for mental illnesses in police cells to provide timely access to assessment and treatment services. The need for functional interagency collaborations are highlighted and discussed.