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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.

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.

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.

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.

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.

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.

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.

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.

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.

Objectives: The recently published RANZCP guidelines for schizophrenia and related disorders reviewed recent scientific evidence, and, where lacking, referred to clinical expertise to supply a template for raising the standard of care. This paper builds on the guidelines and recommends how they might be used to improve outcomes., Methods: The guidelines call for evidence-based mental health policies, inclusive of mobilising affected families, communities and the public in support of policies that ensure better care and protect the wellbeing of people with severe mental disorders. The process of preparing the guidelines highlighted the limits of our scientific understanding of schizophrenia and shortcomings in the care currently provided., Results: Writing the guidelines evinced the need for a culture of measuring outcomes and response to treatment, and harnessing such data to monitoring and optimising patient care., Conclusions: We recommend creation of a national case cohort for mental health research involving a collaborative network of clinical research centres, using the guidelines and generating scientific evidence for translation into clinical practice protocols that enable personalised treatment plans for patients and criteria for the performance of clinical services.

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.

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., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

Objective: To evaluate the impact of the National Perinatal Depression Initiative on access to Medicare services for women at risk of perinatal mental illness., Method: Retrospective cohort study using difference-in-difference analytical methods to quantify the impact of the National Perinatal Depression Initiative policies on Medicare Benefits Schedule mental health usage by Australian women giving birth between 2006 and 2010. A random sample of women of reproductive age enrolled in Medicare who had not given birth where used as controls. The main outcome measures were the proportions of women giving birth each month who accessed a Medicare Benefits Schedule mental health items during the perinatal period (pregnancy through to the end of the first postnatal year) before and after the introduction of the National Perinatal Depression Initiative., Results: The proportion of women giving birth who accessed at least one mental health item during the perinatal period increased from 88 to 141 per 1000 between 2007 and 2010. The difference-in-difference analysis showed that while there was an overall increase in Medicare Benefits Schedule mental health item access as a result of the National Perinatal Depression Initiative, this did not reach statistical significance. However, the National Perinatal Depression Initiative was found to significantly increase access in subpopulations of women, particularly those aged under 25 and over 34 years living in major cities., Conclusion: In the 2 years following its introduction, the National Perinatal Depression Initiative was found to have increased access to Medicare funded mental health services in particular groups of women. However, an overall increase across all groups did not reach statistical significance. Further studies are needed to assess the impact of the National Perinatal Depression Initiative on women during childbearing years, including access to tertiary care, the cost-effectiveness of the initiative, and mental health outcomes. It is recommended that new mental health policy initiatives incorporate a planned strategic approach to evaluation, which includes sufficient follow-up to assess the impact of public health strategies., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

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., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

Objective: The objective of this study was to identify factors associated with poor dietary intake (less than four servings of fruit and vegetables daily) in a large nationally representative sample of adults with psychotic disorders., Methods: The sample comprised 1286 adults aged 18-64 years who took part in the second Australian national survey of psychosis. Dietary information was obtained using a standardised questionnaire; all participants provided fasting blood samples. Variables that may be related to diet and nutritional intake were investigated; these included demographics, physical health outcomes, physical activity, substance use, symptom severity and financial difficulty. Dietary status was explored by sex, age and body mass index using univariate analyses, while a multivariate analysis was performed to identify predictors of low nutritional intake., Results: Approximately 74% of participants ate less than four servings of fruit and vegetables daily. This was associated with a lower body mass index (p<0.05), lower levels of physical activity (p<0.05), sedentary behaviour (p<0.05), substance use (p<0.001), more negative symptoms (p<0.05), eating less frequently (p<0.001), consuming whole fat milk compared to low fat milk (p<0.05), adding salt to food (p<0.05) and financial difficulty (p<0.05). Male sex and younger age (18-34 years) were also associated with lower fruit and vegetable intake (p<0.001). A multivariate regression analysis showed that current smoking (p<0.001) and alcohol (p<0.01) and cannabis abuse (p<0.05) were risk factors for lower fruit and vegetable intake., Conclusion: The findings suggest that poor diet in people with psychosis, as reflected by less than four servings of fruit and vegetables daily, is accompanied by other unhealthy behaviours, which has important implications for the development of effective interventions. Importantly, current smoking is a significant predictor of dietary inadequacy., (© The Royal Australian and New Zealand College of Psychiatrists 2014.)

Objective: This paper reports patterns of health service utilisation in the second Australian national survey of psychosis corresponding with changes in available services of this period., Method: Semi-structured interviews were carried out of an age-stratified random sample of adults who screened positive for psychosis. Multivariate logistic regressions were used to identify predictors of service use for a sample of 1825 individuals., Results: Use of psychiatric inpatient services was associated with higher symptom levels, suicidal ideation, poor social functioning and younger age. High users of emergency mental health services similarly reported higher symptom levels, poor functioning and younger age, and also reported being married or in a de facto relationship. Recipients of general practitioner services had greater anxiety symptoms and suicidal thoughts, fewer negative symptoms, single marital status and English as their first language. Rehabilitation service use was associated with greater anxiety symptoms, unemployment, younger age of illness onset, living alone and having no dependent children living at home. Last, outpatient/community services were more frequently used by younger people with good premorbid adjustment, hallucinations and a less severe course of illness., Conclusions: Service utilisation patterns vary with the clinical and socio-demographic features of those who use them - inpatient and emergency service users being similar in such features and differing from users of other services. Comparison with the first national survey of psychosis revealed a significant decline in acute inpatient service use and a substantial increase in the use of outpatient/community and rehabilitation services over the past 10 years.

Objectives: To assess differences in costs of psychosis between the first and second Australian national surveys of psychosis and examine them in light of policy developments., Method: Cost differences due to changes in resource use and/or real price rises were assessed by minimizing differences in recruitment and costing methodologies between the two surveys. For each survey, average annual societal costs of persons recruited through public specialized mental health services in the census month were assessed through prevalence-based, bottom-up cost-of-illness analyses. The first survey costing methodology was employed as the reference approach. Unit costs were specific to each time period (2000, 2010) and expressed in 2010 Australian dollars., Results: There was minimal change in the average annual costs of psychosis between the surveys, although newly included resources in the second survey's analysis cost AUD$3183 per person. Among resources common to each analysis were significant increases in the average annual cost per person for ambulatory care of AUD$7380, non-government services AUD$2488 and pharmaceuticals AUD$1892, and an upward trend in supported accommodation costs. These increases were offset by over a halving of mental health inpatient costs of AUD$11,790 per person and a 84.6% (AUD$604) decrease in crisis accommodation costs. Productivity losses, the greatest component cost, changed minimally, reflecting the magnitude and constancy of reduced employment levels of individuals with psychosis across the surveys., Conclusions: Between 2000 and 2010 there was little change in total average annual costs of psychosis for individuals receiving treatment at public specialized mental health services. However, there was a significant redistribution of costs within and away from the health sector in line with government initiatives arising from the Second and Third National Mental Health Plans. Non-health sector costs are now a critical component of cost-of-illness analyses of mental illnesses reflecting, at least in part, a whole-of-government approach to care.

Objectives: To estimate the annual costs of psychosis in Australia from societal and government perspectives and assess whether average costs per person differ by principal service provider at time of census., Methods: Costs of psychosis encompassing health sector costs, other sector costs, and productivity losses were assessed for 2010 using a prevalence-based, bottom-up approach. Resource use data were obtained from the second Australian National Survey of Psychosis and unit costs were from government and non-government organization (NGO) sources. Costs to society were assessed by principal service provider at census: public specialized mental health services (PSMHS) and NGOs during the census month (current clients), and PSMHS in the 11 months preceding census (recent clients), and any differences were ascertained., Results: The average annual costs of psychosis to society are estimated at $77,297 per affected individual, comprising $40,941 in lost productivity, $21,714 in health sector costs, and $14,642 in other sector costs. Health sector costs are 3.9-times higher than those for the average Australian. Psychosis costs Australian society $4.91 billion per annum, and the Australian government almost $3.52 billion per annum. There are significant differences between principal service providers for each cost category. Current PSMHS clients had the highest health sector costs overall, and the highest mental health ambulatory, inpatient, and antipsychotic medication costs specifically. NGO clients had the highest other sector costs overall and the highest NGO assistance, supported employment, and supported accommodation costs. Recent PSMHS clients had the lowest productivity losses for reduced participation and the highest costs for absenteeism and presenteeism., Conclusions: The costs of psychosis are broad ranging and very high. Development and implementation of cost-effective prevention, treatment, and support strategies is critical to maximizing the efficiency of service delivery. A needs-based framework based on principal service provider and recency of contact may facilitate this process.

Objective: The 2010 Survey of High Impact Psychosis (SHIP) is Australia's second national psychosis survey. This paper provides an overview of its findings, including comparisons with the first psychosis survey and general population data., Methods: The survey covered 1.5 million people aged 18-64 years, approximately 10% of Australians in this age group. A two-phase design was used. In phase 1, screening for psychosis took place in public mental health services and non-government organizations supporting people with mental illness. In phase 2, 1825 of those screen-positive for psychosis were randomly selected and interviewed. Data collected included symptomatology, substance use, functioning, service utilization, medication use, education, employment, housing, and physical health including fasting blood samples., Results: The estimated 1-month treated prevalence of psychotic disorders in public treatment services was 3.1 people per 1000 population; the 12-month treated prevalence was 4.5 people per 1000. The majority (63.0%) of participants met ICD-10 criteria for schizophrenia/schizoaffective disorder. One-half (49.5%) reported attempting suicide in their lifetime and two-thirds (63.2%) were rated as impaired in their ability to socialize. Over half (54.8%) had metabolic syndrome. The proportion currently smoking was 66.1%. Educational achievement was low. Only 21.5% were currently employed. Key changes in the 12 years since the first survey included: a marked drop in psychiatric inpatient admissions; a large increase in the proportion attending community mental health clinics; increased use of rehabilitation services and non-government organizations supporting people with mental illness; a major shift from typical to atypical antipsychotics; and large increases in the proportions with lifetime alcohol or drug abuse/dependence., Conclusion: People with psychotic illness face multiple challenges. An integrated approach to service provision is needed to ensure that their living requirements and needs for social participation are met, in addition to their very considerable mental and physical health needs.

Background: Most people diagnosed with a psychotic disorder will be prescribed psychotropic medication. The second Australian national survey of psychosis provided a unique opportunity to examine the pharmacological treatment of psychotic disorders from the perspective of the consumer. The aim of this paper is to report on medication use, adherence and perceived efficacy, and to describe side effect profiles., Method: Data on self-reported medication use in the 4 weeks prior to interview, including type, duration, adherence, side effects and helpfulness was collected from participants interviewed in the course of the second Australian national survey of psychosis., Results: The majority (91.6%) of participants were using psychotropic medication: 89.0% of people aged 18-34 years and 93.5% of people aged 35-64 years. The most commonly used class of medication was antipsychotic medication (81.6%). In addition, 37.4% were using antidepressants, 26.7% were using mood stabilisers and 17.8% were using anxiolytics/hypnotics. Polypharmacy was common with almost two-thirds (63.4%) using more than one class of medication and over a quarter (28.1%) of people with schizophrenia using more than one antipsychotic. Many participants (84.4%) reported experiencing side effects. The side effect profile of people using atypical antipsychotics was on average better than that of people using typical antipsychotics. Most people (85.2%) felt their medication relieved their mental health symptoms and most (88.2%) medication was taken as prescribed., Conclusions: Many people with a psychotic disorder are receiving antipsychotics, with a substantial proportion also taking antidepressants, mood stabilisers and anxiolytics/hypnotics. Medication use differs by age group, diagnostic group and course of illness. Many people using antipsychotics describe significant impairment in their everyday life as a result of medication side effects. Users of typical antipsychotics reported more side effects and more impairment than people using atypical antipsychotics. Most of our participants were prescribed psychotropic medications, and most reported that they were taking them.

Objective: Participation in mainstream education and employment facilitates both the recovery and the social inclusion of people with psychotic disorders. As part of the second Australian survey of psychosis, we assessed labour force activity and participation in formal education among working age adults with psychotic disorders., Method: Data were drawn from a large national community prevalence survey of adults with psychotic disorders. Known as the Survey of High Impact Psychosis (SHIP), it was conducted in seven Australian catchment areas during March to December 2010. Current and past year labour force activity, current employment, past year participation in formal education and vocational training, and key clinical and demographic characteristics were examined in a sample of 1825 participants., Results: Only 22.4% of people with psychotic disorders were found to be employed (either full-time or part-time) in the month prior to the survey. In the previous 12 months, 32.7% were employed at some time. Of those in competitive employment, the majority worked part-time (63.9%), while a quarter worked 38 or more hours per week (23.4%). In terms of educational attainment, 18.4% reported difficulties with reading or writing, while 31.9% completed high school, which represents 12 years of formal education., Conclusions: The proportion currently employed has remained stable at 22% since the last national survey in 1997. Policy makers and service providers could do more to ensure people with psychotic disorders obtain access to more effective forms of assistance with respect to both their continuing education and employment. More effective vocational and educational interventions for people with psychotic disorders appear to be urgently needed.

Objective: To determine the prevalence of cardiometabolic risk factors in Australian adults with a psychotic disorder., Method: Data were collected during the interview phase of the second Australian survey of psychosis, a population-based survey of Australians aged 18 to 64 years with a psychotic disorder. Body mass index, waist circumference and blood pressure were measured. Participants were asked about diagnoses of relevant medical conditions, medications, smoking and physical activity. Fasting blood samples were analysed for glucose, high-density lipoprotein cholesterol, total cholesterol and triglycerides. The prevalence of metabolic syndrome was determined using the harmonized criteria developed by the International Diabetes Federation and other bodies., Results: A total of 1087 men (60%) and 738 women (40%) participated. Their mean age was 38.36 (SD 11.16) years; 773 (42%) were aged 18-34 years and 1052 (58%) 35-64 years. Three-quarters were overweight or obese and 82% had abdominal obesity. Almost half were hypertensive. Two-thirds were current smokers and 81% had a lifetime history of smoking. Levels of physical activity were very low. About 30% reported a diagnosis of hypertension or high cholesterol, 20% knew they had diabetes or high blood sugar and 18% had cardiovascular disease. Half of those with self-reported hypertension were taking antihypertensive drugs, and about 40% with hypercholesterolemia or hyperglycaemia were receiving medication for these conditions. Seventy per cent (N = 1286) of participants provided fasting blood samples. Abnormal levels of high-density lipoprotein cholesterol and triglycerides were each found in almost half of participants and almost one-third had elevated fasting glucose. More than half of participants (54.8%) met criteria for metabolic syndrome., Conclusions: Australians living with psychosis have high rates of cardiometabolic risk factors. There are a number of obvious targets for prevention and treatment, including obesity (especially in women), smoking (more prevalent in men), hypertension, hyperlipidaemia and sedentary lifestyle.

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 1.1 million 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.