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In this paper, the case study of ketamine as a new treatment for severe depression is used to outline the challenges of repurposing established medicines and we suggest potential solutions. The antidepressant effects of generic racemic ketamine were identified over 20 years ago, but there were insufficient incentives for commercial entities to pursue its registration, or support for non-commercial entities to fill this gap. As a result, the evaluation of generic ketamine was delayed, piecemeal, uncoordinated, and insufficient to gain approval. Meanwhile, substantial commercial investment enabled the widespread registration of a patented, intranasal s-enantiomeric ketamine formulation (Spravato®) for depression. However, Spravato is priced at $600–$900/dose compared to ~$5/dose for generic ketamine, and the ~AUD$100 million annual government investment requested in Australia (to cover drug costs alone) has been rejected twice, leaving this treatment largely inaccessible for Australian patients 2 years after Therapeutic Goods Administration approval. Moreover, emerging evidence indicates that generic racemic ketamine is at least as effective as Spravato, but no comparative trials were required for regulatory approval and have not been conducted. Without action, this story will repeat regularly in the next decade with a new wave of psychedelic-assisted psychotherapy treatments, for which the original off-patent molecules could be available at low-cost and reduce the overall cost of treatment. Several systemic reforms are required to ensure that affordable, effective options become accessible; these include commercial incentives, public and public–private funding schemes, reduced regulatory barriers and more coordinated international public funding schemes to support translational research. [ABSTRACT FROM AUTHOR]

Objectives: Differentiating schizophrenia from mania in acutely psychotic patients can be difficult, but is important in determining immediate and subsequent management. Such differentiation is generally addressed by clinical interviews, but an observational approach may assist. This paper therefore describes the development of a relevant observational measure. Methods: We developed a provisional list of 49 items (weighting features with suggested specificity to schizophrenia and mania) for independent completion by two nurses and judged its ability to predict diagnosis provided by consultant psychiatrists. Results: Eighty-seven psychotic patients were recruited, and 173 completed data sets were analysed. We refined the item set to two sets of 10 items that best-differentiated schizophrenia from mania and vice versa. Optimal differentiation was achieved with a score of at least 7 on both the schizophrenia and mania item sets. Difference scores (i.e. schizophrenia items affirmed minus mania items affirmed) were also generated, with a difference score of +1 (i.e. one or more schizophrenia items being affirmed than mania items) showing optimal differentiation (sensitivity 0.67, specificity 0.82) between the two conditions. Evaluating all potential difference scores, we demonstrated that, as difference scores increased, diagnostic accuracy in identifying each condition was very high. Conclusion: Analyses allow the properties of an observational measure (the 20-item Sydney Psychosis Observation Tool) to be described. While a single cut-off difference score was derived with acceptable discriminatory ability, we also established the capacity of varying difference scores to assign both schizophrenia and mania diagnoses with high accuracy. [ABSTRACT FROM AUTHOR]

Objective: Cross-sectional studies have demonstrated that people with disability have substantial inequalities in mental health compared to people without disability. However, it is not known if these inequalities have changed over time. This study compared the mental health of people with and without disability annually from 2003 to 2020 to investigate time trends in disability-related mental health inequalities. Methods: We use annual data (2003–2020) of the Household, Income and Labour Dynamics in Australia Survey. Mental health was measured using the five-item Mental Health Inventory. For each wave, we calculated population-weighted age-standardised estimates of mean Mental Health Inventory scores for people with and without disability and calculated the mean difference in Mental Health Inventory score to determine inequalities. Analyses were stratified by age, sex and disability group (sensory or speech, physical, intellectual or learning, psychological, brain injury or stroke, other). Results: From 2003 to 2020, people with disability had worse mental health than people without disability, with average Mental Health Inventory scores 9.8 to 12.1 points lower than for people without disability. For both people with and without disability, Mental Health Inventory scores decreased, indicating worsening mental health, reaching the lowest point for both groups in 2020. For some subpopulations, including young females and people with intellectual disability, brain injury or stroke, mental health inequalities worsened. Conclusion: This paper confirms that people with disability experience worse mental health than people without disability. We add to previous findings by demonstrating that disability-related inequalities in mental health have been sustained for a long period and are worsening in some subpopulations. [ABSTRACT FROM AUTHOR]

Australia's Fifth National Mental Health Plan required governments to report, not only on the progress of changes to mental health service delivery, but to also plan for services that should be provided. Future population demand for treatment and care is challenging to predict and one solution involves modelling the uncertain demands on the system. Modelling can help decision-makers understand likely future changes in mental health service demand and more intelligently choose appropriate responses. It can also support greater scrutiny, accountability and transparency of these processes. Australia has an emerging national capacity for systems modelling in mental health which can enhance the next phase of mental health reform. This paper introduces concepts useful for understanding mental health modelling and identifies where modelling approaches can support health service planners to make evidence-informed decisions regarding planning and investment for the Australian population. [ABSTRACT FROM AUTHOR]

Objectives: This paper compares the evolution of the psychosocial sector in two Australian regions pre and post introduction of the National Disability Insurance Scheme – a major reform to the financing, planning and provision of disability services in Australia, intended to create greater competition and efficiency in the market, and more choice for service users. Methods: We used a standardised service classification instrument based on a health ecosystems approach to assess service availability and diversity of psychosocial services provided by non-government organisations in two Primary Health Network regions. Results: We identified very different evolutionary pathways in the two regions. Service availability increased in Western Sydney but decreased in the Australian Capital Territory. The diversity of services available did not increase in either Primary Health Network 4 years after the reform. Many services were experiencing ongoing funding uncertainty. Conclusion: Assumptions of increased efficiency through organisational scaling up, and a greater diversity in range of service availability were not borne out. Implications: This study shows the urgent need for evaluation of the effects of the NDIS on the provision of psychosocial care in Australia. Four years after the implementation of the NDIS at vast expense key objectives not been met for consumers or for the system as a whole, and an environment of uncertainty has been created for providers. It demonstrates the importance of standardised service mapping to monitor the effects of major reforms on mental health care as well as the need for a focus at the local level. [ABSTRACT FROM AUTHOR]

Background: Hypertensive disorders of pregnancy are associated with longer term cardiovascular risk. Understanding if depression or antidepressant use in pregnancy is associated with HDP is important in identifying those potentially vulnerable to poorer health in later life. This study examines if depression and antidepressants are associated with HDP. Methods: In all, 815 pregnant women were recruited within an Australian pregnancy cohort study at less than 20 weeks of pregnancy, all undertook the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and were assigned to four groups for this paper: those with unmedicated depression meeting criteria for current depression (n = 97), those taking selective serotonin reuptake inhibitors in early pregnancy (n = 101), those taking serotonin and noradrenaline reuptake inhibitors in early pregnancy (n = 31), and those without depression or taking antidepressant medication (control; n = 586). Women were then assessed again following birth. Hypertensive disorders of pregnancy were diagnosed according to the Society of Obstetric Medicine in Australia and New Zealand Guidelines. Results: Use of serotonin and noradrenaline reuptake inhibitors (SNRIs) (adjusted risk ratio = 9.10, 95% confidence interval = [3.82, 21.67]) and unmedicated depression (adjusted risk ratio = 3.11, 95% confidence interval = [1.32, 7.35]) were independently associated with significantly higher risk for developing hypertensive disorders of pregnancy compared to controls. Selective serotonin reuptake inhibitors (SSRIs) use did not confer any increased risk. Higher doses of SNRIs, but not selective serotonin reuptake inhibitors, were associated with significantly higher risk for developing HDP (adjusted risk ratio = 4.83, 95% confidence interval = [1.50, 15.58]). Conclusions: Our findings suggest that those with depression in pregnancy and/or on an serotonin and noradrenaline reuptake inhibitor should have closer surveillance for the development of hypertensive disorders of pregnancy. These findings support treatment of depression in pregnancy, however, also the consideration of class of antidepressant. [ABSTRACT FROM AUTHOR]

Many fields of medicine have benefitted from the formation of clinical trials networks, whereby researchers come together on a large scale to identify high-priority questions and implement coordinated clinical trials. Clinical trials networks in the field of mental health, however, have been rare and largely absent from the Australian context. Here, we present an overview of the newly formed Growing Minds Australia Clinical Trials Network, which represents the first comprehensive clinical trials network in child and youth mental health in Australia. The 60 principal members of the Growing Minds Australia Clinical Trials Network represent teams across 19 diverse areas related to specific forms of psychopathology (e.g. internalising, externalising, neurodevelopmental disorders, early psychosis, substance use), specific research methods and processes (e.g. health economics, eHealth, implementation science) and specialised areas of practice (e.g. school-based systems, parenting interventions, Indigenous mental health, refugee families). Core functions of the Growing Minds Australia Clinical Trials Network include collaborative trial protocol development; peer review, prioritisation and endorsement of proposed trials; training; development of clinical guidelines; and consumer representation. The research by the clinical trials network will encompass the populations typically accessing youth mental health services, while placing a key emphasis on the early periods of life, and the role of parents and caregivers as critical partners in the co-design of research and the delivery of intervention and prevention strategies. The structures and processes built into the network are designed to coordinate collaboration between diverse stakeholders and ensure that provisions for translation are integrated into research from the outset. In this paper, we examine the potential for a dedicated clinical trials network to initiate fundamental improvement in child and youth mental health systems, and discuss the unique and complex challenges associated with establishing such an initiative. [ABSTRACT FROM AUTHOR]

Objective: COVID-19 has led to disruptions to the lives of Australian families through social distancing, school closures, a temporary move to home-based online learning, and effective lockdown. Understanding the effects on child and adolescent mental health is important to inform policies to support communities as they continue to face the pandemic and future crises. This paper sought to report on mental health symptoms in Australian children and adolescents during the initial stages of the pandemic (May to November 2020) and to examine their association with child/family characteristics and exposure to the broad COVID-19 environment. Methods: An online baseline survey was completed by 1327 parents and carers of Australian children aged 4 to 17 years. Parents/carers reported on their child's mental health using five measures, including emotional symptoms, conduct problems, hyperactivity/inattention, anxiety symptoms and depressive symptoms. Child/family characteristics and COVID-related variables were measured. Results: Overall, 30.5%, 26.3% and 9.5% of our sample scored in the high to very high range for emotional symptoms, conduct problems and hyperactivity/inattention, respectively. Similarly, 20.2% and 20.4% of our sample scored in the clinical range for anxiety symptoms and depressive symptoms, respectively. A child's pre-existing mental health diagnosis, neurodevelopmental condition and chronic illness significantly predicted parent-reported child and adolescent mental health symptoms. Parental mental health symptoms, having a close contact with COVID-19 and applying for government financial assistance during COVID-19, were significantly associated with child and adolescent mental health symptoms. Conclusion: Our findings show that Australian children and adolescents experienced considerable levels of mental health symptoms during the initial phase of COVID-19. This highlights the need for targeted and effective support for affected youth, particularly for those with pre-existing vulnerabilities. [ABSTRACT FROM AUTHOR]

Objective: The Zero Suicide Framework, a systems approach to suicide prevention within a health service, is being implemented across a number of states in Australia, and internationally, although there is limited published evidence for its effectiveness. This paper aims to provide a description of the implementation process within a large health service in Australia and describes some of the outcomes to date and learnings from this process. Method: Gold Coast Mental Health and Specialist Services has undertaken an implementation of the Zero Suicide Framework commencing in late 2015, aiming for high fidelity to the seven key elements. This paper describes the practical steps undertaken by the service, the new practices embedded, emphasis on supporting staff following the principles of restorative just culture and the development of an evaluation framework to support a continuous quality improvement approach. Results: Improvements have been demonstrated in terms of processes implementation, enhanced staff skills and confidence, positive cultural change and innovations in areas such as the use of machine learning for identification of suicide presentations. A change to 'business as usual' has benefited thousands of consumers since the implementation of a Suicide Prevention Pathway in late 2016 and achieved reductions in rates of repeated suicide attempts and deaths by suicide in Gold Coast Mental Health and Specialist Services consumers. Conclusion: An all-of-service, systems approach to suicide prevention with a strong focus on cultural shifts and aspirational goals can be successfully implemented within a mental health service with only modest additional resources when supported by engaged leadership across the organisation. A continuous quality improvement approach is vital in the relentless pursuit of zero suicides in healthcare. [ABSTRACT FROM AUTHOR]

Introduction: Globally, Indigenous populations have higher rates of suicidal behavior and psychological distress compared to non-Indigenous populations. Indigenous populations also report high rates of exposure to discrimination, which could potentially contribute to poor mental health outcomes. The objectives of this paper were to estimate the prevalence of discrimination among Aboriginal and Torres Strait Islander males in Australia and to examine the role of discrimination in the association between Aboriginal and Torres Strait Islander status and suicidal thoughts and depressive symptoms. Methods: We used cross-sectional data on 13,697 males aged 18–55 years from the Australian Longitudinal Study on Male Health. We undertook a Poisson regression with robust standard error analyses to examine Aboriginal and Torres Strait Islander status and self-perceived exposure to discrimination in the past 2 years as correlates of recent suicidal ideation. We used zero-inflated negative binomial regression to assess Aboriginal and Torres Strait Islander status and self-perceived exposure to discrimination as correlates of recent depressive symptoms. Results: Aboriginal and Torres Strait Islander males have a twofold higher prevalence of self-perceived discrimination (39.2% vs 19.3%, p < 0.001), suicidal ideation (21.8% vs 9.4%, p < 0.001) and moderate or worse depressive symptoms (24.0% vs 12.2%, p < 0.001) as compared to their non-Indigenous counterparts. After adjusting for sociodemographics and substance use, Aboriginal and Torres Strait Islander status was significantly associated with suicidal thoughts (odds ratio = 1.49, p = 0.019) and depressive symptoms (prevalence rate ratio = 1.19, p = 0.018). About 15.3% and 28.7% of the association between Aboriginal and Torres Strait Islander status and suicidal thoughts and depressive symptoms, respectively, was explained by discrimination. Conclusion: Our analyses add to evidence that discrimination is a contributor to mental health disparities between Aboriginal and Torres Strait Islander and non-Indigenous populations in Australia. Reducing discrimination ought to be considered as part of strategies to improve the social and emotional well-being of Aboriginal and Torres Strait Islander people. [ABSTRACT FROM AUTHOR]

Aims and context: This paper reports the evaluation of the Doorway program (2015-18) in Melbourne, Australia. Doorway extends the original Housing First (HF) model in providing housing support to people with precarious housing at-risk of homelessness with Serious and Persistent Mental Illnesses (SPMIs) receiving care within Victoria's public mental health system. Doorway participants source and choose properties through the open rental market, and receive rental subsidies, assistance, advocacy and brokerage support through their Housing and Recovery Worker (HRW). The aim of this study is to estimate Doorway's impact on participants' housing, quality of life and mental health service use. Methodology: The study employed a a quasi-experimental study design with a comparison group, adjusted for ten potential confounders. The primary outcome measure was days of secure housing per participant. Secure housing status, health service usage and quality of life (HoNOS) data were extracted from participants' electronic hospital and Doorway records in deidentified, non-reidentifiable form. Analysis for continuous outcome variables was based on multivariate GLM modelling. Results: Doorway housed 89 (57%) of 157 accepted participants. The 157 Doorway participants overall were also housed for significantly more days (119.4 extra days per participant) than control participants, albeit after some delay in locating and moving into housing (mean 14 weeks). There was a significant, positive Doorway effect on health outcomes (all and one dimension of the HoNOS). Doorway participants had significantly reduced length of stay during acute and community hospital admissions (7.4 fewer days per participant) compared with the control group. Conclusion: The Doorway model represents a new and substantial opportunity to house, enhance health outcomes and reduce mental health service use for people with SPMIs from the public mental health sector and at-risk of homelessness. [ABSTRACT FROM AUTHOR]

Background: Mental disorders often have their first onset during youth, which justifies targeting treatment services at this age group. Australia has had a substantial increase in youth mental health services since the introduction of the Medicare Better Access scheme and headspace services in 2006–2007. This paper examines trends in the mental health of Australian youth before and after this time using available national and state datasets. Methods: The following data were examined for age groups available in the age range of 12–25 years: use of mental health services per 100,000 population provided under Medicare by GPs, psychiatrists, clinical psychologists, other psychologists and allied health professionals; per capita accessing of headspace services; and prevalence of high and very high psychological distress (using the K10) in youth age groups in the National Health Survey, the Victorian Population Health Survey and the New South Wales Population Health Survey between 2001 and 2018. Results: There has been a large increase in use of mental health services since the introduction of Better Access and headspace. No significant improvement in youth mental health was evident following the introduction of these schemes. Rather, there appeared to be a worsening of youth mental health from around 2015 onwards. Conclusion: Despite a large increase in the provision of mental health services to Australian youth, there has not been a detectable reduction in the prevalence of psychological distress. There may be other factors that have worsened youth mental health in recent years. [ABSTRACT FROM AUTHOR]

Early learning services and schools provide unique settings for mental health promotion and early intervention due to the potential for population-level dosage and reach in terms of reducing multiple risk factors and enabling protective factors among young people. Educators play a key role in supporting children and young people's experiences of, and access to mental health promotion opportunities, and hold unparalleled opportunity in terms of creating mental health–promoting learning environments. In 2018, the Australian National Mental Health in Education Initiative, Be You, was launched. Be You is a multi-million-dollar Australian government–supported initiative, freely available to all 24,000 early learning services, primary and secondary schools throughout Australia. The potential for subsequent population reach is proposed to potentially exceed that of any mental health promotion initiative for children and young people previously observed in Australia. Be You aims to foster mentally healthy learning communities across Australia through building capacity among educators to embed mental health promotion strategies. The Initiative was developed based on a review and integration of previous national mental health promotion frameworks, with an overall alignment to existing state and territory education, social and emotional well-being frameworks, and the Australian Curriculum. In delivering facilitated support from specialised consultants to early learning services and schools participating in the initiative, Be You draws on professional learning principles designed to build capacity in educators and educational systems relating to mental health promotion. It uses an updated, multi-module online platform providing interactive, evidence-based resources. This paper presents the Be You framework, describes the evidence sources used to inform the underlying principles and objectives, discusses the specific components that form the initiative, details the professional learning modules and content, and discusses potential implications for population mental health and prevention efforts. [ABSTRACT FROM AUTHOR]

Background: Children and adolescents with intellectual disability are at risk of developing psychiatric symptoms and disorders; yet, the estimates reported in the literature have been inconsistent, presenting a potential barrier for service planning and delivery. Sources of variability could arise from differences in measurement instruments as well as subgroup membership by severity of intellectual disability, gender and age. This systematic review aimed to address these gaps. Method: MEDLINE and PsycINFO databases were searched from inception to 2018 and selected studies were reviewed. Studies were included if they reported point prevalence estimates of mental health symptomology or diagnoses in a general population of 6- to 21-year-old individuals with intellectual disability. The Joanna Briggs Institute Prevalence Critical Appraisal Checklist was applied to eligible papers to appraise their scientific strength. Pooled prevalence for mental health symptomology was determined using a random-effects meta-analysis. Results: A total of 19 studies were included, including 6151 children and adolescents. The pooled prevalence estimate captured by the Developmental Behaviour Checklist was 38% (95% confidence interval = [31, 46]), contrasting with 49% (95% confidence interval = [46, 51]) captured by the Child Behaviour Checklist; both rates were higher than a non-intellectual disability population. Severity of intellectual disability did not significantly influence the Developmental Behaviour Checklist risks. Insufficient data were available to conduct statistical analyses on the effects of age, gender and socioeconomic status. Of diagnosed psychiatric disorders, attention deficit/hyperactivity disorder (30%), conduct disorder (3–21%) and anxiety disorders (7–34%) were the most prevalent conditions. Conclusion: This review consists of the largest sample hitherto evaluated. In the intellectual disability population, mental health comorbidities could be better detected by a symptom phenotype than a psychiatric diagnostic phenotype. Crucially, future research needs to address the effect of measurement validity in the intellectual disability population. Estimated prevalence rates were high compared to the general population, indicating the importance of systematic screening, case detection and appropriate management. [ABSTRACT FROM AUTHOR]

Background: In December 2014, after a 16-hour siege of the Lindt café in Sydney, Iranian-born gunman Man Haron Monis shot dead a hostage precipitating the police action which broke the siege. Objective: This paper reviews the demographic and other factual details of Monis as documented by the NSW Coroner's Inquest and critically analyses the published findings of the Coroner particularly in relation to the role of the psychiatrist who advised senior police and negotiators during the siege. Results: At the time of the siege, there was no formal protocol that delineated the role of a psychiatrist in hostage negotiations. Despite the psychiatrist's credentials including his extensive experience with siege-hostage incidents and his counter-terrorist training, the Coroner was unfairly critical of the psychiatrist. Conclusion: The Coroner's censure of the psychiatrist was clearly prejudiced by hindsight bias. During the siege, the psychiatrist properly considered and evaluated all the available intelligence and other information known about the gunman. As the psychiatrist advised, Monis was a narcissist and the siege was not an Islamic State-inspired terrorist attack. Given that he announced he was armed with a bomb, Monis represented a ' credible threat ' to the hostages. The psychiatrist's endorsement of the police strategy to ' contain and negotiate ' was prudent in the circumstances. The Coroner's disparagement of the senior psychiatrist may have the unintended consequence that psychiatrists may be reluctant to assist in hostage-sieges or other critical incidents. [ABSTRACT FROM AUTHOR]

Objective: The current international trend is to create large datasets with existing data and/or deposit newly collected data into repositories accessible to the scientific community. These practices lead to more efficient data sharing, better detection of small effects, modelling of confounders, establishment of sample generalizability and identification of differences between any given disorders. In Australia, to facilitate such data-sharing and collaborative opportunities, the Neurobiology in Youth Mental Health Partnership was created. This initiative brings together specialised researchers from around Australia to work towards a better understanding of the cross-diagnostic neurobiology of youth mental health and the translation of this knowledge into clinical practice. One of the mandates of the partnership was to develop a protocol for harmonised prospective collection of data across research centres in the field of youth mental health in order to create large datasets. Methods: Four key research modalities were identified: clinical assessments, brain imaging, neurocognitive assessment and collection of blood samples. This paper presents the consensus set of assessments/data collection that has been selected by experts in each domain. Conclusion: The use of this core set of data will facilitate the pooling of psychopathological and neurobiological data into large datasets allowing researchers to tackle important questions requiring very large numbers. The aspiration of this transdiagnostic approach is a better understanding of the mechanisms underlying mental illnesses. [ABSTRACT FROM AUTHOR]

The new RANZCP guidelines for the treatment of schizophrenia and related disorders highlights what we know works. In this paper, we examine why patients so often fail to benefit from this knowledge and why clinical practice falls so far short of the recommended standard. Instead of the continuous improvement that we expect of health care in general, in psychiatry we face an accelerating decline in systems of care. There has been a sustained underinvestment in public mental health care and a shared failure by State and Federal governments to construct and commit to a governance and funding model that can deliver the standard of care that is available in other major non-communicable diseases, and which we know is equally possible for severe mental illness. This paper sets out some of the reasons for the poor quality of care received by many people with schizophrenia and related disorders in Australia, and describes ways that care could be improved. In particular, we recommend an explicit statement of what constitutes an adequate standard of care, for people at all stages of these illnesses. This would help provide transparency about whether the care provided by mental health services achieves these benchmarks, and enable publication of results comparing the performance of different states and regional services. Patients and families, as well as professional, consumer and carer organizations would then be able to see clearly where the deficits are and demand resources and care that match the recommendations. [ABSTRACT FROM AUTHOR]

Objective: Dementia with Lewy bodies is the second most common form of neurodegenerative dementia in older age yet is often under-recognised and misdiagnosed. This review aims to provide an overview of the clinical features of dementia with Lewy bodies, discussing the frequent challenges clinicians experience in diagnosing dementia with Lewy bodies, and outlines a practical approach to the clinical management, particularly in the Australian setting. Methods: This paper is a narrative review and a semi-structured database (PubMed and MEDLINE) search strategy was implemented. Articles were screened and clinically relevant studies were selected for inclusion. Results: Dementia with Lewy bodies is clinically characterised by complex visual hallucinations, spontaneous motor parkinsonism, prominent cognitive fluctuations and rapid eye movement sleep behaviour disorder. Neuropsychiatric features and autonomic dysfunction are also common. The new diagnostic criteria and specific diagnostic biomarkers help to improve detection rates and diagnostic accuracy, as well as guide appropriate management. Clinical management of dementia with Lewy bodies is challenging and requires an individualised multidisciplinary approach with specialist input. Conclusion: Dementia with Lewy bodies is a common form of dementia. It often presents as a diagnostic challenge to clinicians, particularly at early stages of disease, and in patients with mixed neuropathological changes, which occur in over 50% of people with dementia with Lewy bodies. Prompt diagnosis and comprehensive treatment strategies are important in improving patients' care. [ABSTRACT FROM AUTHOR]

Objective: Insomnia and anxiety commonly co-occur, yet the mechanisms underlying this remain unclear. The current paper describes the impact of an Internet-based intervention for insomnia on anxiety, and explores the influence of two cognitive-behavioural constructs – dysfunctional beliefs about sleep and sleep-threat monitoring. Methods: A large-scale, 9-week, two-arm randomised controlled trial (N = 1149) of community-dwelling Australian adults with insomnia and elevated yet subclinical depression symptoms was conducted, comparing a cognitive behavioural therapy–based online intervention for insomnia (Sleep Healthy Using The Internet) with an attention-matched online control intervention (HealthWatch). Symptoms of anxiety were assessed at pretest, posttest, and 6-month follow-up. Dysfunctional beliefs about sleep and sleep threat monitoring were assessed only at pretest. Results: Sleep Healthy Using The Internet led to a greater reduction in anxiety symptoms at both posttest (t724.27 = –6.77, p < 0.001) and at 6-month follow-up (t700.67 = –4.27, p < 0.001) than HealthWatch. At posttest and follow-up, this effect was found to moderated by sleep-threat monitoring (t713.69 = –2.39, p < 0.05 and t694.77 = –2.98, p < 0.01 respectively) but not by dysfunctional beliefs about sleep at either posttest or follow-up (t717.53 = –0.61, p = 0.55 and t683.79 = 0.22, p = 0.83 respectively). Participants in the Sleep Healthy Using The Internet condition with higher levels of sleep-threat monitoring showed a greater reduction in anxiety than those with lower levels from pretest to posttest, (t724.27 = –6.77, p < 0.001) and through to 6-month follow-up (t700.67 = –4.27, p < 0.001). This result remained after controlling for baseline anxiety levels. Conclusion: The findings suggest that online cognitive behavioral therapy interventions for insomnia are beneficial for reducing anxiety regardless of people's beliefs about their sleep and insomnia, and this is particularly the case for those with high sleep-threat monitoring. This study also provides further evidence for cognitive models of insomnia. [ABSTRACT FROM AUTHOR]

Objective: To assess depression literacy, help-seeking and help-offering to others in members of the police force in the state of Victoria, Australia. Methods: All staff in police stations involved in a cluster randomised controlled trial of an integrated workplace mental health intervention were invited to participate. Survey questions covered sociodemographic and employment information, recognition of depression in a vignette, stigma, treatment beliefs, willingness to assist co-workers with mental health problems, help-giving and help-seeking behaviours, and intentions to seek help. Using the baseline dataset associated with the trial, the paper presents a descriptive analysis of mental health literacy and helping behaviours, comparing police station leaders and lower ranks. Results: Respondents were 806 staff, comprising 618 lower-ranked staff and 188 leaders. Almost 84% of respondents were able to correctly label the problem described in the vignette. Among those who had helped someone with a mental health problem, both lower ranks and leaders most commonly reported ‘talking to the person’ although leaders were more likely to facilitate professional help. Leaders’ willingness to assist the person and confidence in doing so was very high, and over 80% of leaders appropriately rated police psychologists, general practitioners, psychologists, talking to a peer and contacting welfare as helpful. However, among both leaders and lower ranks with mental health problems, the proportion of those unlikely to seek professional help was greater than those who were likely to seek it. Conclusion: Knowledge about evidence-based interventions for depression was lower in this police sample than surveys in the general population, pointing to the need for education and training to improve mental health literacy. Such education should also aim to overcome barriers to professional help-seeking. Interventions that aim to improve mental health literacy and help-seeking behaviour appear to be suitable targets for better protecting police member mental health. [ABSTRACT FROM AUTHOR]

Objective: Deep brain stimulation can be of benefit in carefully selected patients with severe intractable obsessive-compulsive disorder. The aim of this paper is to describe the outcomes of the first seven deep brain stimulation procedures for obsessive-compulsive disorder undertaken at the Neuropsychiatry Unit, Royal Melbourne Hospital. The primary objective was to assess the response to deep brain stimulation treatment utilising the Yale-Brown Obsessive Compulsive Scale as a measure of symptom severity. Secondary objectives include assessment of depression and anxiety, as well as socio-occupational functioning. Methods: Patients with severe obsessive-compulsive disorder were referred by their treating psychiatrist for assessment of their suitability for deep brain stimulation. Following successful application to the Psychosurgery Review Board, patients proceeded to have deep brain stimulation electrodes implanted in either bilateral nucleus accumbens or bed nucleus of stria terminalis. Clinical assessment and symptom rating scales were undertaken pre- and post-operatively at 6- to 8-week intervals. Rating scales used included the Yale-Brown Obsessive Compulsive Scale, Obsessive Compulsive Inventory, Depression Anxiety Stress Scale and Social and Occupational Functioning Assessment Scale. Results: Seven patients referred from four states across Australia underwent deep brain stimulation surgery and were followed for a mean of 31 months (range, 8–54 months). The sample included four females and three males, with a mean age of 46 years (range, 37–59 years) and mean duration of obsessive-compulsive disorder of 25 years (range, 15–38 years) at the time of surgery. The time from first assessment to surgery was on average 18 months. All patients showed improvement on symptom severity rating scales. Three patients showed a full response, defined as greater than 35% improvement in Yale-Brown Obsessive Compulsive Scale score, with the remaining showing responses between 7% and 20%. Conclusion: Deep brain stimulation was an effective treatment for obsessive-compulsive disorder in these highly selected patients. The extent of the response to deep brain stimulation varied between patients, as well as during the course of treatment for each patient. The results of this series are comparable with the literature, as well as having similar efficacy to ablative psychosurgery techniques such as capsulotomy and cingulotomy. Deep brain stimulation provides advantages over lesional psychosurgery but is more expensive and requires significant multidisciplinary input at all stages, pre- and post-operatively, ideally within a specialised tertiary clinical and/or academic centre. Ongoing research is required to better understand the neurobiological basis for obsessive-compulsive disorder and how this can be manipulated with deep brain stimulation to further improve the efficacy of this emerging treatment. [ABSTRACT FROM AUTHOR]

Objectives: We compare the prevalence of suicidal thoughts and attempts between Indigenous and non-Indigenous males in urban and regional Australia, and examine the extent to which any disparity between Indigenous and non-Indigenous males varies across age groups. Methods: We used data from the baseline wave of The Australian Longitudinal Study on Male Health (Ten to Men), a large-scale cohort study of Australian males aged 10–55 years residing in urban and regional areas. Indigenous identification was determined through participants self-reporting as Aboriginal, Torres Strait Islander or both. The survey collected data on suicidal thoughts in the preceding 2 weeks and lifetime suicide attempts. Results: A total of 432 participants (2.7%) identified as Indigenous and 15,425 as non-Indigenous (97.3%). Indigenous males were twice as likely as non-Indigenous males to report recent suicidal thoughts (17.6% vs 9.4%; odds ratio = 2.1, p < 0.001) and more than three times as likely to report a suicide attempt in their lifetime (17.0% vs 5.1%; odds ratio = 3.6; p < 0.001). The prevalence of recent suicidal thoughts did not differ between Indigenous and non-Indigenous males in younger age groups, but a significant gap emerged among men aged 30–39 years and was largest among men aged 40–55 years. Similarly, the prevalence of lifetime suicide attempts did not differ between Indigenous and non-Indigenous males in the 14- to 17-years age group, but a disparity emerged in the 18- to 24-years age group and was even larger among males aged 25 years and older. Conclusion: Our paper presents unique data on suicidal thoughts and attempts among a broad age range of Indigenous and non-Indigenous males. The disparity in the prevalence of suicidal thoughts increased across age groups, which is in contrast to the large disparity between the Indigenous and non-Indigenous suicide rates in younger age groups. [ABSTRACT FROM AUTHOR]

Objective: The MindSpot Clinic provides online mental health services to Australian adults with anxiety and depression. This paper describes users of MindSpot between January 2013 and June 2015. Outcomes are considered against three key objectives: improving access to mental health services, improving public awareness of how to access services and providing evidence-based treatments. Method: Website traffic data were examined to determine patterns of use. Demographic characteristics, past service utilisation and reasons for contacting MindSpot were analysed. Outcomes for patients enrolled in a MindSpot treatment course were also analysed. Primary outcomes were scores on the 9-Item Patient Health Questionnaire, Generalised Anxiety Disorder 7-Item, Yale–Brown Obsessive Compulsive Scale and Post-Traumatic Stress Disorder Checklist–Civilian Version, administered at assessment, post-treatment and 3-month follow-up. Results: The website was visited by almost 500,000 Australians, of which 33,990 adults started assessments, and 25,469 people completed assessment and were eligible for analysis. Mean age was 36.4 years (standard deviation = 13.3 years; range = 18–94 years), and 72% were female. The proportion living in rural or remote regions and who identified as Aboriginal and Torres Strait Islander closely matched national statistics. The majority (82%) reported that they were not currently in contact with mental health services. Most patients sought an assessment, information about treatment options, or referral to another service, and only 24% of those completing an assessment commenced a MindSpot treatment course. Of these, large clinical effects (d: 0.7–2.4; average symptom reductions: 25.5% to 61.6%) were found from assessment to follow-up on all outcome measures. Deterioration ranged from 1.0% to 4.3%. Conclusion: Based on the number of website visits, completed assessments and treatment outcomes, MindSpot achieved its three programme objectives. This model of service provision has considerable value as a complement to existing services, and is proving particularly important for improving access for people not using existing services. [ABSTRACT FROM AUTHOR]

Personality disorders have received limited recognition as a public health priority, despite the publication of treatment guidelines and reviews showing effective treatments are available. Inclusive approaches to understanding and servicing personality disorder are required that integrate different service providers. This viewpoint paper identifies pertinent issues surrounding early intervention, treatment needs, consumer and carer experiences, and the need for accurate and representative data collection in personality disorder as starting points in mental health care reform. [ABSTRACT FROM AUTHOR]

Objectives: Anorexia nervosa is a severe psychiatric disorder with high mortality rates. While its aetiology is poorly understood, there is evidence of a significant genetic component. The Anorexia Nervosa Genetics Initiative is an international collaboration which aims to understand the genetic basis of the disorder. This paper describes the recruitment and characteristics of the Australasian Anorexia Nervosa Genetics Initiative sample, the largest sample of individuals with anorexia nervosa ever assembled across Australia and New Zealand. Methods: Participants completed an online questionnaire based on the Structured Clinical Interview Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) eating disorders section. Participants who met specified case criteria for lifetime anorexia nervosa were requested to provide a DNA sample for genetic analysis. Results: Overall, the study recruited 3414 Australians and 543 New Zealanders meeting the lifetime anorexia nervosa case criteria by using a variety of conventional and social media recruitment methods. At the time of questionnaire completion, 28% had a body mass index ⩽ 18.5 kg/m2. Fasting and exercise were the most commonly employed methods of weight control, and were associated with the youngest reported ages of onset. At the time of the study, 32% of participants meeting lifetime anorexia nervosa case criteria were under the care of a medical practitioner; those with current body mass index < 18.5 kg/m2 were more likely to be currently receiving medical care (56%) than those with current body mass index ⩾ 18.5 kg/m2 (23%). Professional treatment for eating disorders was most likely to have been received from general practitioners (45% of study participants), dietitians (42%) and outpatient programmes (42%). Conclusions: This study was effective in assembling the largest community sample of people with lifetime anorexia nervosa in Australia and New Zealand to date. The proportion of people with anorexia nervosa currently receiving medical care, and the most common sources of treatment accessed, indicates the importance of training for general practitioners and dietitians in treating anorexia nervosa. [ABSTRACT FROM AUTHOR]

Objective: The objective is to summarise recent findings from the 2010 Australian Survey of High Impact Psychosis (SHIP) and examine their implications for future policy and planning to improve mental health, physical health and other circumstances of people with a psychotic disorder. Methods: Survey of High Impact Psychosis collected nationally representative data on 1825 people with psychotic illness. Over 60 papers have been published covering key challenges reported by participants: financial problems, loneliness and social isolation, unemployment, poor physical health, uncontrolled symptoms of mental illness, and lack of stable, suitable housing. Findings are summarised under the rubric of participant-ranked top challenges. Results: The main income source for the majority (85%) of participants was a government benefit. Only one-third was employed, and the most appropriate employment services for this group were under-utilised. High rates of loneliness and social isolation impacted mental and physical health. The rate of cardiometabolic disease was well above the general population rate, and associated risk factors were present from a very young age. Childhood abuse (30.6%), adult violent victimisation (16.4%) and alcohol and substance abuse/dependence (lifetime rates of 50.5% and 54.5%, respectively) complicated the clinical profile. Treatment with medication was suboptimal, with physical health conditions undertreated, a high rate of psychotropic polypharmacy and underutilisation of clozapine in chronic persistent psychotic illness. Only 38.6% received evidence-based psychosocial therapies. In the previous year, 27.4% had changed housing and 12.8% had been homeless, on average for 155 days. Conclusion: Money, social engagement and employment are the most important challenges for people with psychotic illness, as well as good physical and mental health. An integrated approach to recovery is needed to optimise service delivery and augment evidence-based clinical practice with measures to improve physical health and social circumstances. Meeting these challenges has the potential to reduce costs to government and society, as well as promote recovery. [ABSTRACT FROM AUTHOR]

Objective: There is growing awareness of the range of psychosocial, lifestyle, and sociodemographic factors related to self-harm, however this research is often limited by using cross-sectional or convenience samples. And while we generally assume that young adults who self-harm experience poorer long-term outcomes, longitudinal research is needed. This paper builds on prior research using a large, representative, longitudinal sample. Methods: 5765 Australian women completed 5 surveys (age 18–23 to 31–36). Six-month self-harm was measured by self-report. We had two aims: firstly to predict future self-harm, separately for women with and without prior self-harm. Secondly, to identify outcomes 3 and 6 years following self-harm. Results: Six-month self-harm prevalence was 2.5%. Predictors among women without recent self-harm included depression, dieting behaviours, number of male sexual partners, and abuse. Among women with recent or current self-harm, predictors were number of dieting behaviours, tiredness of life, and stress. Women who self-harmed reported poorer outcomes, namely greater difficulties in relationships at 3- and 6-year follow-up. Conclusions: Longitudinal risk factors for self-harm differed depending on prior self-harm status, and included depression, dieting behaviours, tiredness of life and stress. These factors may serve as warning signs for new or continued self-harm. This study offers new insight into long-term outcomes up to six years after self-harm, particularly with relationships. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic trends herald what many describe as the Asian Century, whereby Asian economic, political and cultural influence is in global ascendency. Broadening relevant ties between Australia and Asia is evident and logical and may include strengthening alliances in mental health systems. Aim: We argue the importance of strengthening Asian mental health systems and some of the roles Australian mental health workers could have in promoting strengthening the Asian mental health system. Methods: This paper is a narrative review which sources data from reputable search databases. Results: A well-articulated Australian strategy to support strengthening the mental health system in Asia is lacking. While there are active initiatives operating in this space, these remain fragmented and underdeveloped. Coordinated, collaborative and culturally respectful efforts to enhance health education, research, policy, leadership and development assistance are key opportunities. Conclusion: Psychiatrists and other mental health professionals have a unique opportunity to contribute to improved mental health outcomes in Asia. [ABSTRACT FROM AUTHOR]

Objectives: There is accumulating evidence about effectiveness of a number of suicide prevention interventions, and a multilevel systems approach seems promising in reducing suicide risk. This approach requires that components ranging from individual-level to public health interventions are implemented simultaneously in a localised region. This paper presents estimated reductive effects on suicide attempts and deaths that might be expected in Australia if active components of the systems approach were to be implemented. Method: The study estimated population preventable fractions which indicate the extent to which suicide attempts and deaths might be decreased if the each of the proposed interventions was fully implemented. The population preventable fractions were based on the best available evidence available in the literature for the risk ratio for each intervention. Prevalence estimates were assessed for each component of the proposed systems approach: reducing access to suicide means, media guidelines, public health campaigns, gatekeeper programmes, school programmes, general practitioner training, psychotherapy and co-ordinated/assertive aftercare. Results: There was insufficient evidence available for the impact of a number of strategies, including frontline staff gatekeeper training, on either suicide attempts or deaths. Taking prevalence of exposure to the intervention into consideration, the strategies likely to bring about the strongest reduction in suicide attempts were psychosocial treatments and co-ordinated/assertive aftercare. The greatest impact on reductions in suicide deaths was found for psychosocial treatment, general practitioner training, gatekeeper training and reducing access to means of suicide. Conclusion: The evidence regarding the overall efficacy of the systems approach is important in identifying what strategies should be prioritised to achieve the biggest impact. The findings of the population preventable fraction calculations indicate that the systems approach could lead to significant reduction in suicide attempts and suicide deaths in Australia. Potential synergistic effects between strategies included in the approach could further increase the impact of implemented strategies. [ABSTRACT FROM AUTHOR]