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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. [ABSTRACT FROM AUTHOR]

Objective: The interplay between genetic and environmental factors on risk for psychotic illness remains poorly understood. The aim of this study was to estimate independent and combined effects of familial liability for schizophrenia and exposure to obstetric complications on risk for developing psychotic illness, covarying with exposure to other environmental stressors. Methods: This whole-population birth cohort study used record linkage across Western Australian statewide data collections (midwives, psychiatric, hospital admissions, child protection, mortality) to identify liveborn offspring (n = 1046) born 1980–1995 to mothers with schizophrenia, comparing them to offspring of mothers with no recorded psychiatric history (n = 298,370). Results: Both maternal schizophrenia and pregnancy complications were each significantly associated with psychotic illness in offspring, with no interaction. Non-obstetric environmental stressors significantly associated with psychotic illness in offspring included the following: being Indigenous; having a mother who was not in a partnered relationship; episodes of disrupted parenting due to hospitalisation of mother, father or child; abuse in childhood; and living in areas of greatest socioeconomic disadvantage and with elevated rates of violent crime. Adjustment for these other environmental stressors reduced the hazard ratio for maternal schizophrenia substantially (from hazard ratio: 5.7, confidence interval: 4.5–7.2 to hazard ratio: 3.5, confidence interval: 2.8–4.4), but not the estimate for pregnancy complications (hazard ratio: 1.1, confidence interval: 1.0–1.2). The population attributable fraction for maternal schizophrenia was 1.4 and for pregnancy complications was 2.1. Conclusion: Our finding of a substantial decrease in risk of psychotic illness associated with familial liability for psychosis following adjustment for other environmental stressors highlights potentially modifiable risk factors on the trajectory to psychotic illness and suggests that interventions that reduce or manage exposure to these risks may be protective, despite a genetic liability. [ABSTRACT FROM AUTHOR]

Objective: Children of mothers with severe mental illness are at significantly increased risk of developing intellectual disability. Obstetric complications are also implicated in the risk for intellectual disability. Moreover, children of mothers with severe mental illness are more likely to be exposed to obstetric complications. The purpose of this study was to examine the independent and joint contributions of familial severe mental illness and obstetric complications to the risk of intellectual disability.Method: Record linkage across Western Australian whole-population psychiatric, inpatient, birth, and midwives' registers identified 15,351 children born between 1980 and 2001 to mothers with severe mental illness and 449,229 children born to mothers with no mental illness. Multivariable models were adjusted for paternal psychiatric status, parental intellectual disability, and other family and sociodemographic covariates.Results: The risk of intellectual disability was increased among children of mothers with severe mental illness compared with children of unaffected mothers. The impact varied across maternal diagnostic groups. For children of mothers with schizophrenia, the unadjusted odds ratio was 3.8 (95% CI=3.0, 4.9) and remained significant after simultaneous adjustment for exposure to obstetric complications and other covariates (odds ratio=1.7, 95% CI=1.3, 2.3). The odds ratio for exposure to obstetric complications also remained significant after adjustment (odds ratio=1.7, 95% CI=1.6, 1.8). For intellectual disability of a genetic basis, the adjusted odds ratio for maternal schizophrenia was elevated but not statistically significant. Among children with intellectual disability, 4.2% later developed a psychotic disorder, compared with 1.1% of children without intellectual disability.Conclusions: Maternal severe mental illness and exposure to obstetric complications contribute separately to the risk of intellectual disability, suggesting potentially different causal pathways. [ABSTRACT FROM AUTHOR]

Purpose: Our aim was to establish the 12-month prevalence of violent victimisation in a large sample of adults with psychotic disorders (N = 1825), compare this to population estimates, and examine correlates of violent victimisation.Methods: The Australian national psychosis survey used a two-phase design to draw a representative sample of adults aged 18-64 years with psychotic disorders. Interview questions included psychopathology, cognition, sociodemographics, substance use, criminality, and childhood and adult victimisation. Multivariable logistic regression models were used to examine the independent contributions of known risk factors, clinical profile and childhood abuse, on risk of violent victimisation. Differences between men and women were examined.Results: Among adults with psychotic disorders, 12-month prevalence of any victimisation was 38.6% (males 37.4%, females 40.5%), and of violent victimisation was 16.4% (males 15.2%; females 18.3%). Violent victimisation was 4.8 times higher than the population rate of 3.4% (6.5 times higher for women; 3.7 times higher for men). Significant correlates of violent victimisation were established sociodemographic and behavioural risk factors predicting victimisation in the general community: younger age, residence in the most disadvantaged neighbourhoods, homelessness, lifetime alcohol abuse/dependence, and prior criminal offending. Among clinical variables, only mania and self-harm remained significant in the multivariable model. Childhood abuse was independently associated with violent victimisation.Conclusions: Rates of violent victimisation are high for people with psychotic disorders, especially women, compared to population rates. Greater exposure to sociodemographic and behavioural risks may render them particularly vulnerable to victimisation. Social cognition as a valuable treatment target is discussed. [ABSTRACT FROM AUTHOR]

Objectives: To describe from the perspective of people living with psychotic illness their use of general practitioner services over a 12-month period and the experiences, attitudes and challenges general practitioners face providing health care to this population. Methods: A two-phase design was used. Phase 1, screening for psychosis, occurred in public specialised mental health services and non-government organisations within seven catchment sites across Australia. In Phase 2, 1825 people who were screened positive for psychosis were randomly selected for interview which included questions about frequency and reason for general practitioner contact in the 12 months prior to interview. General practitioners (1473) of consenting participants were also surveyed. Results: Almost all (90.3%) survey participants had consulted a general practitioner in the 12-month period, on average 8.9 times, and 28.8% of attenders had consulted 12 times or more. The majority (83.5%) attended one general practitioner practice. Most (77.6%) general practitioners wanted to be involved in the mental health care of their patient. Although 69.1% said the management of their patient was not problematic for their practice, one in five general practitioners reported issues related to patient non-compliance with treatment and non-attendance at scheduled appointments; time constraints; and lack of feedback from treating mental health services. Conclusion: People with psychotic disorders consult general practitioners, some very frequently. Most Australian general practitioners believe they have a responsibility to review the physical and mental health of their patients. Improved communication between general practitioners and mental health services, and easier access to mental health support, may help general practitioners manage the complex mental, physical and social problems of their patients. [ABSTRACT FROM AUTHOR]

Health-related quality of life (HRQoL) can be assessed through measures that can be generic or disease specific, encompass several independent scales, or employ holistic assessment (i.e., the derivation of composite scores). HRQoL measures may identify patients with differential risk profiles. However, the usefulness of generic and holistic HRQoL measures in identifying patients at higher risk of death is unclear. The aim of the present study was to undertake a scoping review of generic, holistic assessments of HRQoL as predictors of mortality in general non-patient populations and clinical sub-populations with specified conditions or risk factors in persons 18 years or older. Five databases were searched from 18 June to 29 June 2020 to identify peer-reviewed published articles. The searches were updated in August 2022. Reference lists of included and cited articles were also searched. Of 2552 articles screened, 110 met criteria for inclusion. Over one-third of studies were from North America. Most studies pertained to sub-populations with specified conditions and/or risk factors, almost a quarter for people with cardiovascular diseases. There were no studies pertaining to people with mental health conditions. Nearly three-quarters of the studies used a RAND Corporation QoL instrument, predominantly the SF-36, and nearly a quarter, a utility instrument, predominantly the EQ-5D. HRQoL was associated with mortality in 67 of 72 univariate analyses (92%) and 100 of 109 multivariate analyses (92%). HRQoL was found to be associated with mortality in the general population and clinical sub-populations with physical health conditions. Whether this relationship holds in people with mental health conditions is not known. HRQoL assessment may be useful for screening and/or monitoring purposes to understand how people perceive their health and well-being and as an indicator of mortality risk, encouraging better-quality and timely patient care to support and maximize what may be a patient's only modifiable outcome. [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]

Congenital/early blindness is reportedly protective against schizophrenia. Using a whole-population cohort of 467,945 children born in Western Australia between 1980 and 2001, we examined prevalence of schizophrenia and psychotic illness in individuals with congenital/early blindness. Overall, 1870 children developed schizophrenia (0.4%) while 9120 developed a psychotic illness (1.9%). None of the 66 children with cortical blindness developed schizophrenia or psychotic illness. Eight of the 613 children with peripheral blindness developed a psychotic illness other than schizophrenia and fewer had developed schizophrenia. Our results support findings from small case studies that congenital/early cortical but not peripheral blindness is protective against schizophrenia. [ABSTRACT FROM AUTHOR]

Objective: Engagement with secondary mental health services after an emergency department presentation with suicidal behaviours may be an important strategy for reducing the risk of repeat attempts. Our aim was to examine secondary mental health service contact following a presentation to emergency department with suicidal behaviours. Methods: A systematic review of papers published between 2000 and 2020 was undertaken. This identified 56 papers relating to 47 primary studies. Data were extracted and summarised separately by age group: (1) young people, (2) older adults and (3) adults and studies with participants of 'all ages'. Results: Studies in young people (n = 13) showed, on average, 44.8% were referred and 33.7% had contact with secondary mental health services within 4 weeks of emergency department discharge. In comparison, in adult/all ages studies (n = 34), on average, 27.1% were referred to and 26.2% had mental health service contact within 4 weeks. Only three studies presented data on contact with mental health services for older adults, and proportions ranged from 49.0% to 86.0%. Conclusion: This review highlights poor utilisation of secondary mental health service following emergency department presentation for suicidal behaviours, and further research is needed to identify the reasons for this. Crucially, this information could assist in the allocation of resources to facilitate the timely implementation of suicide prevention services. [ABSTRACT FROM AUTHOR]

Introduction: It remains uncertain whether schizoaffective disorder (SAD) is a discrete diagnostic entity, is a variant of either a psychotic mood disorder such as bipolar disorder (BDP) or schizophrenia (SCZ), or exists on a spectral continuum between these disorders. The present study examined whether SCZ, SAD, and BDP differed qualitatively on demographic and clinical variables based on a large Australian dataset.Methods: This study examined data from the Australian Survey of High Impact Psychosis (SHIP), in which 1469 of the 1825 participants in who had an ICD-10 diagnosis of SCZ (n=857), SAD (n=293), and BDP (n=319) were assessed across a broad range of variables.Results: When compared to patients with SCZ, those with SAD reported more current delusional and thought disorder symptoms, a greater number of lifetime depression, mania, and positive symptoms, and fewer negative symptoms. Relative to the BPD group, the SAD group were younger, endorsed more current positive, delusional, and thought disorder symptoms, fewer lifetime mania symptoms, more lifetime psychotic, hallucination, and delusional symptoms, and recorded lower premorbid IQ scores. Compared to patients with BPD, those with SCZ were significantly younger, endorsed more current psychotic and hallucination symptoms, fewer lifetime depression and mania symptoms, more lifetime psychotic, hallucination, and delusional symptoms, reported more negative symptoms and had lower premorbid IQ and psychosocial functioning scores.Limitations: Validated psychometric measures of psychotic or mood symptoms were not used.Conclusion: This pattern of results is consistent with the conceptualisation of a spectrum of disorders, ranging from BDP at one end, to SAD in the middle, and SCZ at the other end. [ABSTRACT FROM AUTHOR]

The article describes recent trends in the use of medications in the management of psychotic disorders and explores adherence, side effects and treatment efficacy from the participant's perspective based on the second Australian national survey of psychosis. The survey revealed that the majority of participants were using antipsychotic medication and a considerable number of people were taking antidepressants, mood stabilizers and anxiolytics/hypnotics.

The article discusses the finding from the Survey of High Impact Psychosis (SHIP) 2010, the second such survey from Australia, and provides an overview of comparisons with the first psychosis survey. The finding from the survey suggested that people with psychotic illness face multiple challenges. Comparisons with data from the 1997−98 survey indicate that things have improved for these people but there are still major areas of concern.

A population-based record linkage case cohort of 239,995 births, to 119,214 women, born in Western Australia from 1980 to 2001 inclusive, was used to measure the recording of selected indicators of maternal health (current and prior) during pregnancy. We compared records of women with singleton pregnancies with that in twin pregnancies Mothers of first- and second-born singletons (n = 117,647) were compared with women with a first-born singleton followed by twins (n = 1,567). Binary indicators were used to calculate population prevalence of medical conditions, pregnancy complications and birth outcomes. Infant outcomes included stillbirth, low birthweight, preterm birth and birth defects. Women with twins were significantly older and taller, with similar rates of medical conditions and pregnancy complications during first singleton pregnancies compared with women with two consecutive singletons. However, during their second pregnancy, women with twins had significantly higher rates of essential hypertension, pre-eclampsia, threatened abortion, premature rupture of the membranes and ante partum hemorrhage with abruption than women with singletons. For both groups, maternal conditions in the first pregnancy were underreported in the second pregnancy, including diabetes, epilepsy, asthma, chronic renal dysfunction and essential hypertension. At the second birth, twins were 3 times more likely to be stillborn, 17 times more likely to be low birthweight and 4 times more likely to be delivered preterm compared with singletons. This research demonstrates the importance for epidemiologists and others, of having access to a complete maternal medical history for analyses of risks associated with maternal, infant and childhood morbidity. [ABSTRACT FROM AUTHOR]

Objective: To examine how women differ from men in their expression and experience of psychosis. Method: Using an epidemiological sampling frame, 1090 cases of psychosis (schizophrenia, schizoaffective disorder, affective psychoses, and other psychoses) were randomly selected from a catchment of 1.1million people as part of the Australian Study of Low Prevalence (Psychotic) Disorders. Women and men were compared with respect to their premorbid functioning, onset and course of illness, symptomatology, levels of disability and service utilization. Results: Results within diagnostic groupings confirm differences in how men and women experience and express their illness. Within each diagnostic group, women reported better premorbid functioning, a more benign illness course, lower levels of disability and better integration into the community than men. They were also less likely to have a chronic course of illness. There were no significant differences in age at onset. Differences between women across the diagnostic groups were more pronounced than differences between women and men within a diagnostic group. In particular, women with schizophrenia were severely disabled compared to other women. Conclusions: These comparisons across diagnostic groupings are among the most systematic and comprehensive in the literature. It is likely that several mechanisms are needed to explain the differences. Greater social integration and functioning in women across diagnostic groups may well reflect culturally and socially determined gender differences. In contrast, variability and attenuated findings with respect to symptom profiles beg the question of biological mechanisms with some degree of specificity. [ABSTRACT FROM AUTHOR]

Objective: Relatively little has been published on dynamic, that is, modifiable, as opposed to static risk factors for hospitalization in the research literature on risk factors for hospitalization in serious mental illness. The aim of this study was to develop a model to determine modifiable predictors of hospitalization using data from the Australian National Study of Low Prevalence (Psychotic) Disorders. Method: The Study of Low Prevalence Disorders used a two-phase design to estimate the prevalence of psychoses and identify characteristics of people with psychotic illness. This paper compares people hospitalized at the time of census and those using outpatient services. Logistic regression was used to examine the relative impact of dynamic characteristics including service utilization, symptom profile and risky behaviours on a base model for risk of hospitalization. Results: In the base model, course of disorder and age but not type of psychosis were significantly associated with hospitalization. Among symptoms, delusions (but not hallucinations) and negative symptoms significantly increased the odds of hospitalization. Service utilization, especially case management, reduced the odds significantly and substantially. Results for risky behaviours (e.g. substance abuse, offending) were ambiguous. Conclusions: The results highlight the impact of dynamic factors, particularly case management, over and above static factors in reducing the risk of hospitalization in psychosis, and point to a potential for targeted interventions to avert some of the burden, both emotional and financial, associated with the hospitalization of people with psychotic disorders. These findings have important clinical and policy implications. [ABSTRACT FROM AUTHOR]

Morgan VA, Mitchell PB, Jablensky AV. The epidemiology of bipolar disorder: sociodemographic, disability and service utilization data from the Australian National Study of Low Prevalence (Psychotic) Disorders. Bipolar Disord 2005: 7: 326–337. © Blackwell Munksgaard, 2005 Data from the Australian National Study of Low Prevalence (Psychotic) Disorders were used to describe the clinical and sociodemographic profile of individuals with bipolar disorder, their levels of impairment and disability, and use of medication and treatment services. A 1-month census of contacts with mental health services, private psychiatric and general practices, as well as contact points in marginalized settings, was conducted in a national catchment of 1.1 million adults. The census yielded 3,800 individuals who screened positive for psychosis, of whom a random sample of 980 were administered a comprehensive semi-structured interview schedule. Results are presented on 112 persons with an ICD-10 diagnosis of bipolar disorder. Overall, 69.6% of the 112 persons who met the ICD-10 criteria for bipolar disorder reported a recurrent episodic illness, 25.0% had a chronic course without clear remissions, and 5.4% had a single episode of mania. Assessed on a lifetime basis, suicidal ideation was common (78.6%) and levels of drug and alcohol abuse/dependence were high (32.1%). The majority (84.8%) had had at least one contact with inpatient, outpatient or emergency services in the previous year. Those with serious impairment had levels of service utilization similar to the rest of the sample, but were more likely to report a poorer quality of life and unmet service needs. While the percentage experiencing social and occupational dysfunction was substantial and similar for both sexes, women appeared to be better integrated socially than men. Comparisons with schizophrenia patients within the same survey sample highlighted less chronic impairment but equal or greater utilization of services by bipolar patients. Despite low levels of chronicity, the burden of social disablement associated with bipolar disorder is high. The data suggest a number of important gaps in the provision of services for this predominantly treated population. [ABSTRACT FROM AUTHOR]

This study examined variables associated with having aonce-only contactwith the out-patient department of two community mental health services in Italy and Australia.Two 8-year cohorts of patients, who had a new episode of care with out-patient psychiatric departments in South Verona and in Western Australia, were followed-up for 3 months after the first contact, to identify those patients who had no further contact with services. Potential determinants ofonce-only contactwere analysed.Thirty percent of new episodes of care for persons who met the inclusion criteria of the study wereonce-only contactswith the service in South Verona. In Western Australia, the figure was 24%. Moreover, the proportion ofonce-only contactpatients has increased over time in South Verona whereas, in Western Australia, it has remained stable. In Western Australia,once-only contactpatients were younger whereas in South Verona they tended to be older. At both research sites, patients who had aonce-only contactwere more likely to be male and to have a less severe mental illness.The results of this study suggest that only clinical characteristics were significant determinants of this pattern of contact with services consistently at both sites: the less severe the patient's diagnosis, the more likely the patient is to have aonce-only contact. This may well indicate good screening at the initial point of contact by both sets of mental health service providers. Prospective studies are necessary to clarify the problem of‘once-only contact’ and to organize a proper psychiatric care. [ABSTRACT FROM AUTHOR]

Este estudio determinó la incidencia de complicaciones durante el embarazo, y el parto y las características neonatales de los hijos de mujeres con esquizofrenia, trastorno bipolar o depresión mayor en una cohorte de base poblacional. Método: Basándose en un enlace entre registros (record linkage) de pacientes psiquiátricos y en datos obstétricos recopilados prospectivamente, el estudio comprendió a mujeres con esquizofrenia o trastornos afectivos mayores que habían dado a luz a 3. 174 niños entre 1980 y 1992 en Australia Occidental. Se seleccionó, de forma aleatorizada, una muestra de control de 3. 129 hijos de mujeres sin diagnóstico psiquiátrico entre todas las mujeres que habían dado a luz entre 1980 y 1992. Las complicaciones fueron puntuadas con la escala de McNeil-Sjostram. Se calcularon las razones de probabilidad para determinadas incidencias del proceso de procreación. Resultados: Los pacientes con trastornos esquizofrenico o afectivo tenían mayor riesgo de complicaciones durante el embarazo, el parto y el período neonatal, incluyendo problemas placentarios, hemorragias preparto y sufrimiento fetal. Las mujeres con esquizofrenia tenían una probabilidad significativamente mayor de presentar un desprendimiento prematuro de la placenta, dar a luz a hijos con un peso y un índice de crecimiento situados en el percentil más bajo de la población o tener hijos con alteraciones congénitas cardiovasculares. Las complicaciones neonatales tenían una probabilidad significativamente mayor de presentarse en invierno; el bajo peso de nacimiento alcanzó los valores máximos en primavera. Otras complicaciones, diferentes del bajo peso y de las alteraciones congénitas, fueron más frecuentes en los embarazos que siguieron a una enfermedad psiquiátrica que en los embarazos que precedieron al diagnóstico. Conclusiones: Aunque la predisposición genética y las interacciones genético ambientales pueden explicar algunas de las complicaciones, los factores de riesgo maternos y los factores biológicos y comportamentales que acompañan a una enfermedad mental grave son los principales factores determinantes del aumento de la patología de la procreación en esta cohorte. Las oportunas intervenciones prenatales y posnatales deberían reducir el riesgo en estos grupos vulnerables. [ABSTRACT FROM PUBLISHER]

Objective: This study ascertained the incidence of complications during pregnancy, labor, and delivery and the neonatal characteristics of infants born to women with schizophrenia, bipolar disorder, or major depression in a population-based cohort. Method: Based on records linkage across a psychiatric case register and prospectively recorded obstetric data, the study comprised women with schizophrenia or major affective disorders who had given birth to 3,174 children during 1980-1992 in Western Australia. A comparison sample of 3,129 births to women without a psychiatric diagnosis was randomly selected from women giving birth during 1980-1992. Complications were scored with the McNeil-Sjöström Scale. Odds ratios were calculated for specific reproductive events. Results: Both schizophrenic and affective disorder patients had increased risks of pregnancy, birth, and neonatal complications, including placental abnormalities, antepartum hemorrhages, and fetal distress. Women with schizophrenia were significantly more likely to have placental abruption, to give birth to infants in the lowest weight/growth population decile, and to have children with cardiovascular congenital anomalies. Neonatal complications were significantly more likely to occur in winter; low birth weight peaked in spring. Complications other than low birth weight and congenital anomalies were higher in pregnancies after psychiatric illness than in pregnancies preceding the diagnosis. Conclusions: While genetic liability and gene-environment interactions may account for some outcomes, maternal risk factors and biological and behavioral concomitants of severe mental illness appear to be major determinants of increases in reproductive pathology in this cohort. Risk reduction in these vulnerable groups may be achievable through antenatal and postnatal interventions. [ABSTRACT FROM AUTHOR]

Objective: To describe patterns of self-reported medication use in a population-based sample of people with psychotic disorders; to establish correlates with clinical variables; to determine perceived side-effect burden; and investigate patient perception of efficacy for different classes of antipsychotic agent. Methods: Using the Australian Low Prevalence (Psychosis) Study database we analysed patterns of psychotropic medication and examined their clinical correlates. We also determined rates of reported side-effects and perceived benefit or otherwise associated with the different antipsychotic drugs. Results: Of the 1126 persons interviewed, 88.6% were on psychotropic medication; 54.3% were using ‘typical’ antipsychotics (24.8% in depot form), while 8.3% were on clozapine, 13.3% on risperidone, and 8.8% on olanzapine. Around 30% of women, and 20% of men, were on mood stabilizers or antidepressants. Over half of respondents were on more than one agent. Of those on only one agent, nearly 80% reported at least one side-effect; the mean number of side-effects was 3.9 for typical antipsychotics, and 3.3 for atypicals. Atypicals, notably clozapine, tended to be rated by patients as more efficacious than typicals; depot preparations, in particular, tended to be seen as unhelpful, and were associated with a higher side-effect burden. Conclusions: This study presents an insight into patients’ perception of efficacy and side-effects of antipsychotic medications. The findings have implications for clinicians, and can inform treatment options in people with psychotic disorders. [ABSTRACT FROM AUTHOR]

Discusses the concept of impact factor of a journal based on the Science Citation Index of the Institute for Scientific Information. Definition and basis of the journal's impact factor; Usage of the impact factor; Limitations in the use of impact factors; Implications of impact factors limitation on its usage as a measure of quality; Effect on editorial policy of the impact factor.

Evidence about the association between maternal mental health disorders and stillbirth and infant mortality is limited and conflicting. We aimed to examine whether maternal prenatal mental health disorders are associated with stillbirth and/or infant mortality. MEDLINE, Embase, PsycINFO, and Scopus were searched for studies examining the association of any maternal prenatal (occurring before or during pregnancy) mental health disorder(s) and stillbirth or infant mortality. A random-effects meta-analysis was used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). The between-study heterogeneity was quantified using the I2 statistic. Subgroup analyses were performed to identify the source of heterogeneity. Of 4487 records identified, 28 met our inclusion criteria with 27 contributing to the meta-analyses. Over 60% of studies examined stillbirth and 54% of them evaluated neonatal or infant mortality. Thirteen studies investigated the association between maternal depression and anxiety and stillbirth/infant mortality, pooled OR, 1.42 (95% CI, 1.16–1.73; I2, 76.7%). Another 13 studies evaluated the association between severe maternal mental illness and stillbirth/infant mortality, pooled OR, 1.47 (95% CI, 1.28–1.68; I2, 62.3%). We found similar results for the association of any maternal mental health disorders and stillbirth/infant mortality (OR, 1.59; 95% CI, 1.43–1.77) and in subgroup analyses according to types of fetal/infant mortality. We found no significant evidence of publication bias. Maternal prenatal mental health disorders appear to be associated with a moderate increase in the risk of stillbirth and infant mortality, although the mechanisms are unclear. Efforts to prevent and treat these disorders may reduce the scale of stillbirth/infant deaths. [ABSTRACT FROM AUTHOR]

Objective: Effective implementation of mobile applications into the mainstream of mental health care cannot be imposed without acknowledging consumers' perspectives. This study investigated the willingness of mental health consumers and clinical staff to adopt new technology in their treatment. Method: A total of 74 mental health consumers and 116 clinical staff were recruited for the study. Survey data for consumers were collected using hard copies and for staff using the REDCap data management platform. Results: Both consumers and clinical staff reported positive attitudes towards the use of mobile applications in mental health care, emphasising their validity, ease of use and cost. Consumers were more likely to use apps supporting relaxation and time management than those targeting complex problems (alcohol, smoking, hearing voices). However, about half of consumers expressed concerns regarding privacy, and about 40% of them felt uncomfortable about providing personal information to clinicians. There was no association between demographic and clinical factors with the readiness to use mobile apps. Discussion: Findings from this study provided valuable recommendations for the implementation of mobile applications into health care services. [ABSTRACT FROM AUTHOR]

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. 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. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Severe mental illness and work - What can we do to maximise employment opportunities for individuals with psychosis?," by S.B. Harvey and colleagues in the May 2013 issue.

A letter to the editor is presented in response to the article related to prenatal exposure to influenza and major affective disorder.

Background: Children of parents with mental illness face a number of adversities, potentially contributing to poor health. Aim: The aim of this study was to quantify the association between maternal severe mental illness and children's hospital admissions. Method: Record linkage cohort study of 467,945 children born in Western Australia between 1 January 1980 and 31 December 2001. Follow-up was from age 28 days until fifth birthday. Linked registers captured information on potential confounders. Rate ratios and adjusted rate ratios measured relative change in the numbers of admissions and total days of stay, while rate differences measured absolute change in outcomes. Cause-specific increases were calculated for ICD-9 chapters and for 'potentially preventable' conditions. Results: After adjusting for potential confounders, children of mothers with severe mental illness had a 46% relative increased rate in hospital admissions (95% confidence interval = [38%, 54%]) and an absolute increase in 0.69 extra days in hospital per child, per year (95% confidence interval = [0.67, 0.70]). The relative increase in admissions was greatest in the child's first year of life (adjusted rate ratio = 1.76, 95% confidence interval = [1.64, 1.88]; rate difference = 0.32, 95% confidence interval = [0.30, 0.34]). Rates of admissions were increased for a range of causes, particularly injuries, infections and respiratory disease, and for conditions classified as 'potentially preventable'. Conclusion: Children of mothers with severe mental illness have a substantial excess in hospital use compared to children of well mothers. This vulnerable group should be targeted with interventions to avert preventable morbidity and premature mortality in later life. [ABSTRACT FROM AUTHOR]

For people with psychotic disorders, the negative outcomes associated with continuing cannabis use would suggest that discontinuing such use may be beneficial for their symptomatic and functional recovery. However, existing evidence that discontinuation is associated with better clinical outcomes is inconsistent and it remains unclear whether discontinuing use is associated with improvements in outcomes for people with an established psychotic disorder. In this 3–5-year longitudinal study we examined baseline and follow-up symptomatic and functional profiles of 371 people with an established psychotic disorder, comparing those who continued to use cannabis with those who discontinued use after baseline assessment. At follow-up, one third (33.3 %) of baseline cannabis users had discontinued use. Discontinuation was associated with significantly lower odds of past-year hallucinations and a mean improvement in level of functioning (Personal and Social Performance Scale) compared to a decline in functioning in continuing users. No significant differences in severity of negative symptoms were observed. With few longitudinal studies examining symptomatic and functional outcomes for people with established psychotic disorders who continue to use cannabis compared to those who discontinue use, our findings that discontinuing cannabis was associated with significant clinical improvements fill gaps in the evidence-base. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: The co-occurrence of type 2 diabetes and psychosis is an important form of medical comorbidity within individuals, but no large-scale study has evaluated comorbidity within families. The aim of this study was to determine whether there is evidence for familial comorbidity between type 2 diabetes and psychosis. Method: Data were analysed from an observational study of a nationally representative sample of 1642 people with psychosis who were in contact with psychiatric services at the time of survey (The 2010 Australian National Survey of Psychosis). Participants were aged 18–64 years and met World Health Organization’s International Classification of Diseases, 10th Revision diagnostic criteria for a psychotic disorder (857 with schizophrenia, 319 with bipolar disorder with psychotic features, 293 with schizoaffective disorder, 81 with depressive psychosis and 92 with delusional disorder or other non-organic psychoses). Logistic regression was used to estimate the association between a family history of diabetes and a family history of schizophrenia. Results: A positive family history of diabetes was associated with a positive family history of schizophrenia in those with a psychotic disorder (odds ratio = 1.35, p = 0.01, adjusted for age and gender). The association was different in those with an affective versus non-affective psychosis (odds ratio = 0.613, p = 0.019, adjusted for age and gender) and was significant only in those with a non-affective psychosis, specifically schizophrenia (odds ratio = 1.58, p = 0.005, adjusted for age and sex). Adjustment for demographic factors in those with schizophrenia slightly strengthened the association (odds ratio = 1.74, p = 0.001, adjusted for age, gender, diagnosis, ethnicity, education, employment, income and marital status). Conclusion: Elevated risk for type 2 diabetes in people with schizophrenia is not simply a consequence of antipsychotic medication; type 2 diabetes and schizophrenia share familial risk factors. [ABSTRACT FROM AUTHOR]

Objective: Existing evidence on factors associated with community treatment order placement is largely restricted to administrative data. We utilised the data from a large nationally representative sample to compare the demographic, clinical, social functioning, substance use and service utilisation profiles of people living with psychosis under community treatment orders with those who were not. Methods: Participants were grouped based on whether they had been subject to a community treatment order in the past 12 months or not. We conducted logistic regressions to examine demographic, clinical, social functioning, substance use and service utilisation profiles associated with the two groups. Results: People who had recently been subject to community treatment orders were more likely to be treated with long-acting injectable antipsychotics and lacked insight but were less likely to report suicidal ideation. They also had higher psychiatric inpatient admission rates but a lower frequency of general practitioner visits. Conclusion: People on community treatment orders in Australia may differ from those who are not under a community treatment order in their treatment needs. Resources and care provision must match the needs of this particularly vulnerable group. [ABSTRACT FROM AUTHOR]

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

Objective: Antipsychotic drug treatment alters status on key risk factors for cardiovascular disease. The aim of this study was to test whether cardiovascular risk factor associations differ in adults with psychosis and adults from the general community. Method: Data were analysed for those aged 25–64 years from a nationally representative psychosis sample (n = 1,457) and a national comparator sample (n = 8,866). The Pearson correlation coefficient was used to estimate the association among tobacco use, body mass index, waist circumference, diastolic and systolic blood pressure and fasting total-, LDL- and HDL-cholesterol, triglycerides and plasma glucose. The robust Levene test was used to test for sample differences in variance. Results: Correlations among cardiovascular risk indicators and between cardiovascular risk indicators and age were often significantly weaker in those with psychosis than in those from the national comparator sample. This was not due to a reduction in variance within the psychosis sample. Conclusions: Risk prediction that synthesizes multivariate risk indicator data needs to be connected to verified cardiovascular morbidity and mortality in those with psychosis to determine if standard risk calculators adequately discriminate those at high, medium and low future risk of cardiovascular morbidity and mortality. Until then the clinical implications of low or absent correlations among cardiovascular risk indicators and their low or absent association with increasing age is unclear but may indicate that risk equations commonly used in the general population may not be applicable for those with treated psychosis. [ABSTRACT FROM AUTHOR]

Purpose: The early postnatal period is a time of increased risk for psychiatric admission. However, there is scope to further examine if this increase in risk extends to the entire perinatal period (pregnancy and first postnatal year), and how it compares to admission outside of the perinatal period. Methods: Data were linked across birth and hospital admission registers from July 2000 to December 2009. The study cohort, consisting of all pregnant and childbearing women with a psychiatric history, was divided into two groups: case women (at least one perinatal principal psychiatric admission in the study period) (38%) and comparison women (no perinatal principal psychiatric admissions) (62%). Outcomes were admission rate and length of stay adjusted for diagnosis, socio-demographic factors and timing of admission. Results: Antenatal and postnatal admissions rates were both higher than non-perinatal admission rates for case women for all diagnoses. There was little evidence that women with perinatal admissions were at an increased risk of admissions at other times. Socially disadvantaged women had significantly fewer and shorter admissions than their respective counterparts. Conclusions: The entire perinatal period is a time of increased risk for admission across the range of psychiatric disorders, compared to other times in a woman's childbearing years. Reduced admission rate and length of stay for socially disadvantaged women suggest lack of equity of access highlighting the importance of national perinatal mental health policy initiatives inclusive of disadvantaged groups. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: This study investigates (1) the proportion of people with psychosis who are on long-acting injectable antipsychotics; (2) the difference in the demographic, clinical, substance use and adverse drug reaction profiles of people taking long-acting injectables compared to oral antipsychotics; and (3) the differences in the same profiles of those on first-generation antipsychotic versus second-generation antipsychotic long-acting injectables. Methods: Data were collected as part of the Survey of High Impact Psychosis. For this study, participants with diagnoses of schizophrenia or schizoaffective disorder who were on any antipsychotic medication were included (N = 1049). Results: Nearly a third (31.5%) of people with psychosis were on long-acting injectables, of whom 49.7% were on first-generation antipsychotic long-acting injectables and 47.9% were on second-generation antipsychotic long-acting injectables. This contrasts with oral antipsychotics where there was a higher utilisation of second-generation antipsychotics (86.3%). Of note, compared to those on the oral formulation, people on long-acting injectables were almost four times more likely to be under a community treatment order. Furthermore, people on long-acting injectables were more likely to have a longer duration of illness, reduced degree of insight, increased cognitive impairment as well as poor personal and social functioning. They also reported more adverse drug reactions. Compared to those on first-generation antipsychotic long-acting injectables, people on SGA long-acting injectables were younger and had had a shorter duration of illness. They were also more likely to experience dizziness and increased weight, but less likely to experience muscle stiffness or tenseness. Conclusion: Long-acting injectable use in Australia is associated with higher rates of community treatment order use, as well as poorer insight, personal and social performance, and greater cognitive impairment. While long-acting injectables may have the potential to improve the prognosis of people with psychosis, a better understanding of the choices behind the utilisation of long-acting injectable treatment in Australia is urgently needed. [ABSTRACT FROM AUTHOR]

Objective : The aim of this study was to examine early signs of psychosis in patients suffering from both drug dependence and schizophrenia, compared to a control group of drug-addicted patients without a comorbid psychotic disorder, and to assess whether the presence of these signs was related to changes in the pattern of substance abuse. Method : In a rehabilitation hospital for young addicts, 32 patients with a comorbid diagnosis of schizophrenia and 30 patients without the diagnosis of a psychotic disorder, were assessed using the Interview for the Retrospective Assessment of the Onset of Schizophrenia. Information relating to 64 signs of early psychosis was collected from every patient. From the 64 signs, five groups of symptoms were defined: non-specific and precursor symptoms; non-specific and depressive symptoms; negative symptoms; positive symptoms; and impaired social adjustment. The semiquantitative pattern of substance abuse for each 1-year interval over the previous 10 years was investigated using the categories of chapter F1 of ICD-10 and including an additional category‘biological drugs’. The relationship between the pattern of substance abuse and the presence of early signs was assessed usinganova and non-parametric statistical methods. Results : The results indicate that the defined pathological symptomatology greatly influences the pattern of consumption of psychoactive substances in both the psychosis group and the control group. The group factor exerted the greatest influence within the categories‘biological drugs’ and‘other stimulants’, where the‘psychosis and addiction group’ consumed significantly more than the control group. Conclusions : There is a subgroup of non-psychotic addicted patients whose pattern of psychoactive substance abuse is similar to that found in addicted patients suffering from schizophrenia. It may be helpful to systematically identify this subgroup with regard to possible therapeutic implications, particularly with regard to possible pharmacological treatment options. Australian and New Zealand Journal of Psychiatry 2005; 39:467–472 [ABSTRACT FROM AUTHOR]

Background A range of adversities have been implicated as risks for schizophrenia. Adversities often cluster, with synergistic impact, which may vary by age of exposure. We expand on current understanding, and propose a method for ranking combinations of adversities associated with risk of schizophrenia, to derive a risk prediction measure. Methods We used prospectively collected data for 430,000 children born 1980–2001 in Western Australia, and their parents. Follow up continued until 2015 using linked State registers, identifying 1,620 children with schizophrenia. Five domains of adversity exposure to age 10 were considered. Using Cox modeling of a 40% training data subset, we categorised adversity exposure by associated rates of schizophrenia. Firstly, for each domain separately, numerous constructs of adversity exposure were screened for independent association with schizophrenia. Those with p < =0.2 were combined, using augmented backwards elimination, to define a minimal domain set of jointly associated constructs. Combination was summarised as the linear predictor corresponding to the optimum Cox model. Secondly, these domain summaries were combined with each other to form a global Cox model, predictive of association with schizophrenia. Harrell's Concordance was calculated using a 30% assessment sample which did not overlap with our training sample. Prognostic categories were defined and tested. Results Harrell's Concordance was 0.655. Dose response was observed. Conclusions Our scale combines many adversity measures into a single construct. It displays dose response and predicts association considerably above chance. Key messages EAS-SZ allows a range of adversity exposure profiles to be ranked according to association with schizophrenia. [ABSTRACT FROM AUTHOR]

Background: Trajectory analysis has been used to study long-term offending patterns and identify offender subgroups, but few such studies have included people with psychotic disorders (PDs) and these have been restricted to adult offenders.Aims: To compare offending trajectories among 10-26-year-olds with PDs with those with other mental disorders (OMDs) or none (NMD) and identify associated risk factors.Methods: This is a record-linkage study of 184,147 people born in Western Australia (WA) 1983-1991, drawing on data from WA mental health information system, WA corrective services and other state-wide registers. Group-based trajectory modelling was used to identify offending trajectories.Results: Four offender groups were identified in each mental health status group: G1-no/negligible offending; G2-early onset, adolescent, desisting by age 18; G3-early onset, low rate, offending into early adulthood; and G4-very early onset, high rate, peaking at age 17, continuing into early adulthood. The PDs group had the lowest proportion of individuals with no or negligible offending histories-84% compared with 88.5% in the OMDs group and 96.6% in the no mental disorder group. Within mental health status offender groups, the PDs group was characterised by early or very early onset offending persisting into adulthood, accounting for 5.4% and 3.7% of the group respectively (OMD: 3.8%, 1.5%; NMD: 1.0%, 0.5%). Gender, indigenous status, substance use problems, childhood abuse and parental offending were generally associated with trajectory group membership, although among those with PDs childhood abuse and parental offending were only significant in the early onset-life-course-persistent group.Conclusions: While most people with PDs never offend, some are disproportionately vulnerable from a particularly early age. If the offending subgroup is to be helped away from criminal justice involvement, interventions must be considered in childhood. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]