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Competing Interests: Declaration of interests PDM is a founding director, patron, and former founding board member of headspace. He is the executive director of Orygen, Australia's National Centre of Excellence in Youth Mental Health and lead agency for five headspace centres across northwest Melbourne. He is a past President of the International Association for Youth Mental Health, and a past President of the IEPA; Early Intervention in Mental Health and of the Schizophrenia International Research Society. S-JB has provided paid expert witness work for UK charities and legal organisations. She is the author of two books related to the brain, education, and learning, for which she receives royalties. She gives talks in schools in the state and private sector, at education conferences, for education organisations, and for other public, private, and third sector organisations (some talks are remunerated). She is a member of the Rethinking Assessment group, the Steering Committee of the Cambridge Centre of Science Policy, the Technical Advisory Group for the UK Government Department of Education's Education and Outcomes Panel-C Study, the Singapore Government National Research Foundation Scientific Advisory Board, and the Singapore Government Human Potential Scientific Advisory Board. She was a member of the Times Education Commission (2021–22). IBH has received honoraria for consultancy and educational activities from Janssen Cilag. He was a member of the Clinical Advisory Group for the evaluation of the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule initiative, and is a member of Mental Health Reform Advisory Committee (Department of Health). He is the Chief Scientific Advisor to and a 3·2% equity shareholder in InnoWell, which aims to transform mental health services through the use of innovative technologies. FAEA has received honoraria for consultancy from Grand Challenges Canada and is a past member of the World Economic Forum's Global Future Council on Mental Health. AMC is a director of headspace, Australia's National Youth Mental Health Foundation, and the National Education Alliance for Borderline Personality Disorder. AD is the Academic Secretary for the Royal College of Psychiatrists’ Faculty of Child and Adolescent Psychiatry, a research advisory group member of the UK National Society for the Prevention of Cruelty to Children, a member of the UK Trauma Council, and an evidence panel member of the Early Intervention Foundation. TF's research group receives funding for consultancy to Place2Be, a third sector organisation that provides mental health training, support, and interventions to schools across the UK. JH is executive director of Youth Wellness Hubs Ontario and receives funding from Graham Boeckh Foundation and other donors through the Centre for Addiction and Mental Health Foundation. AJ is a trustee of the Samaritans and MQ. She has received fees for lecturing from the Scottish Association of Mental Health. She is an advisory board member of Our Future Health, UK. FK-L's work is the subject of publishing contracts with multiple companies in the EU, Magellan, Cobalt Therapeutics in the USA, and the National Health Service in the UK. Although she has received no remuneration to date, she might receive royalties in the future. She is a non-executive director of Orygen. CK is the founder of Wida, a digital mental health platform. He has received consulting fees from the UN Children's Fund. He has received grants from MQ: Transforming Mental Health in the UK, the Royal Academy of Engineering in the UK, the National Institutes of Health in the USA, the Medical Research Council in the UK, and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul in Brazil. DR is a Chief Scientific Advisor to headspace, Australia's National Youth Mental Health Foundation. JT receives book royalties from Simon and Schuster, legal consulting fees from Bergman and Little and the Attorney General's office of the State of Tennessee, and honoraria for speaking engagements. EK is the immediate past President of the IEPA: Early Intervention in Mental Health, and during the period of the Commission was the President elect and President. All other authors declare no competing interests.

INTRODUCTION Screening tools assist primary care clinicians to identify mental health, addiction and family violence problems. Electronic tools have many advantages, but there are none yet available in the perinatal context. AIM To assess the acceptability and feasibility of the Maternity Case-finding Help Assessment Tool (MatCHAT), a tool designed to provide e-screening and clinical decision support for depression, anxiety, cigarette smoking, use of alcohol or illicit substances, and family violence among pre- and post-partum women under the care of midwives. METHODS A co-design approach and an extensive consultation process was used to tailor a pre-existing electronic case-finding help assessment tool (eCHAT) to a maternity context. Quantitative MatCHAT data and qualitative data from interviews with midwives were analysed following implementation. RESULTS Five midwives participated in the study. They reported that MatCHAT was useful and acceptable and among the 20 mothers screened, eight reported substance use, one depression and five anxiety. Interviews highlighted extensive contextual barriers of importance to the implementation of maternity-specific screening. DISCUSSION MatCHAT has potential to optimise e-screening and decision support in maternity settings, but in this study, use was impeded by multiple contextual barriers. The information from this study is relevant to policymakers and future researchers when considering how to improve early identification of common mental health, substance use and family violence problems.

Objectives: Suicide is the leading cause of maternal death in New Zealand particularly amongst Māori and Pacific. We explored current maternal mental health (MMH) screening practices and supports., Methods: Qualitative research included interviews and focus groups with maternity carers and mothers of Māori and Pacific descent. Thematic analysis used a general inductive approach., Results: Both mothers and carers reported that MMH screening is ad hoc and discussed multilevel barriers that hamper screening and access to supports., Conclusion: There are gaps in MMH services, and service improvements need to be targeted at patient, provider, and systems levels., (© 2019 John Wiley & Sons Australia, Ltd.)

Objective: To determine whether contemporary sex-specific cardiovascular disease (CVD) risk prediction equations underestimate CVD risk in people with severe mental illness from the cohort in which the equations were derived., Methods: We identified people with severe mental illness using information on prior specialist mental health treatment. This group were identified from the PREDICT study, a prospective cohort study of 495,388 primary care patients aged 30 to 74 years without prior CVD that was recently used to derive new CVD risk prediction equations. CVD risk was calculated in participants with and without severe mental illness using the new equations and the predicted CVD risk was compared with observed risk in the two participant groups using survival methods., Results: 28,734 people with a history of recent contact with specialist mental health services, including those without a diagnosis of a psychotic disorder, were identified in the PREDICT cohort. They had a higher observed rate of CVD events compared to those without such a history. The PREDICT equations underestimated the risk for this group, with a mean observed:predicted risk ratio of 1.29 in men and 1.64 in women. In contrast the PREDICT algorithm performed well for those without mental illness., Conclusions: Clinicians using CVD risk assessment tools that do not include severe mental illness as a predictor could by underestimating CVD risk by about one-third in men and two-thirds in women in this patient group. All CVD risk prediction equations should be updated to include mental illness indicators., Competing Interests: The authors have declared that no competing interests exist.

Schizophrenia is a heterogeneous disorder exhibiting variable responsiveness to treatment between individuals. Previous work demonstrated that white matter abnormalities may relate to antipsychotic response but no study to date has examined differences between first-line treatment responders (FLR) and clozapine-eligible individuals receiving first-line antipsychotics. The current study aimed to establish whether differences in white matter structure exist between these two cohorts. Diffusion-weighted images were acquired for 15 clozapine-eligible and 10 FLR participants. Measures of fractional anisotropy (FA), radial diffusivity (RD) and axial diffusivity (AD) were obtained and between-group t-tests interrogating differences in FA were conducted. To investigate the neural basis of a decrease in FA, the significant cluster from FA analysis was masked and used to obtain mean RD and AD measures for that region. Those who were clozapine-eligible had significantly lower FA in the body of the corpus callosum (p < 0.05), associated with a significant increase in mean RD compared with FLR (p < 0.001). No difference in mean AD was observed for this region. These data reveal differences in diffusion measures between FLR and those eligible for clozapine and suggest that lower FA and greater RD in the corpus callosum could exist as a biomarker of treatment resistance in people with schizophrenia., (Copyright © 2018. Published by Elsevier B.V.)

Schizophrenia is a heterogeneous disorder that exhibits variable responsiveness to treatment between individuals. Here we conducted a resting-state functional magnetic resonance imaging (rs-fMRI) study to determine whether resistance to first-line antipsychotics is reflected in resting-state connectivity. rs-fMRI data were collected from 15 people who had failed to respond to first-line antipsychotics (clozapine-eligible) and 10 first-line treatment responders (FLR). Image pre-processing and analysis were performed using FMRIB's software library (FSL). Data was decomposed into spatial and temporal components using independent components analysis. Connectivity within each independent component was compared between groups using t-tests and the Bonferroni correction for multiple comparisons. Gender was added as a covariate. Clozapine-eligible individuals exhibited enhanced functional connectivity within the sensorimotor network compared with FLR. Those eligible for clozapine showed additional connectivity with the precuneus compared with FLR. No other comparisons reached statistical significance and no effect of gender was observed. These data reveal differences in functional connectivity between FLR and those eligible for clozapine and suggest that greater connectivity between the SMN and precuneus may be indicative of treatment resistance in people with schizophrenia., (Copyright © 2018. Published by Elsevier B.V.)

Aim: To audit New Zealand district health boards' (DHBs) metabolic monitoring policies in relation to consumers prescribed second-generation antipsychotic medications using a best practice guideline., Methods: Metabolic monitoring policies from DHBs and one private clinic were analysed in relation to a best practice standard developed from the current literature and published guidelines relevant to metabolic syndrome., Results: Fourteen of New Zealand's 20 DHBs currently have metabolic monitoring policies for consumers prescribed antipsychotic medication. Two of those policies are consistent with the literature-based guideline. Eight policies include actions to be taken when consumers meet criteria for metabolic syndrome. Four DHBs have systems for measuring their rates of metabolic monitoring. There is no consensus on who is clinically responsible for metabolic monitoring., Conclusions: Metabolic monitoring by mental health services in New Zealand reflects international experience that current levels of monitoring are low and policies are not always in place. Collaboration across the mental health and primary care sectors together with the adoption of a consensus guideline is needed to improve rates of monitoring and reduce current rates of physical health morbidities., Competing Interests: Aimee Staveley reports grants from The University of Auckland Faculty of Medical and Health Sciences during the conduct of the study. Dr O'Brien reports summer scholarship from University of Auckland during the conduct of the study.

New Zealand has an established history of mental health legislation that sits within a framework of human rights, disability and constitutional protections. We outline a brief history of mental health legislation in New Zealand since its inception as a modern state in 1840. The current legislation, the Mental Health (Compulsory Assessment and Treatment) Act 1992, defines mental disorder and the threshold for compulsory treatment. We describe its use in clinical practice and the wider legal and constitutional context which psychiatrists need to be aware of in their relationships with patients.

Aim: Increasing pressure is being placed to facilitate Community Mental Health (CMH) patients' discharge to primary care. However, engagement following discharge is an under-researched area. This audit aimed to measure engagement and explore the factors that are associated with engagement in primary care following discharge from CMH., Method: Primary care teams for 55 service users discharged from Auckland District Health Board CMH centres between July and December 2012 were approached as part of an audit and asked to provide information regarding engagement with general practitioners., Results: From the 50 responses received, the median number of GP visits per year was 3.7 and the mean was 4.41. 72% of the sample had contact with their GP at least every 3-4 months, however 8% did not engage with their primary care team. Differences in attendance following discharge based on age, diagnosis or socioeconomic status were not found. There was a suggestion that where GPs had responsibility for ongoing prescribing individuals engaged more frequently., Conclusion: Generally, discharged individuals engage with their primary care team well, and at a level many clinicians would be comfortable with. There is a proportion of the population that does not engage at this level, which requires further study.