The prevalence of mental illness in young people in custody over time: a comparison of three surveys in New South Wales.

Few studies have examined the prevalence of mental illness in young people over time within the same jurisdiction. In the current study, we compared data from three large surveys of youth in custody in New South Wales, conducted in 2003, 2009 and 2015. We examined rates of mental illness, self-harm and suicidal behaviours, substance use and childhood trauma and found little consistent change over time, though some fluctuations were observed regarding certain mental illnesses and substance use. We also descriptively compared findings with observed rates for the general population and found that young people in custody showed higher levels of all examined variables. In sum, these data suggest little improvement in the well-being of young people in custody in New South Wales over time. Better identification and treatment of these issues are vital if young people are to be prevented from becoming enmeshed in the criminal justice system.

Psychiatric admissions in young people after expiration of criminal justice supervision in Australia: a retrospective data linkage study.

BACKGROUND: Mental health services are available for young people involved with the criminal justice system. However, they have unmet mental health needs after the expiration of criminal justice supervision. OBJECTIVE: To determine the incidence rate and identify predictors of psychiatric hospitalisations within 24 months after the expiration of criminal justice supervision among young people involved with the New South Wales (NSW) criminal justice system. METHODS: Retrospective data from 1556 individuals aged 14-22 years who participated in four surveys of justice-involved young people in NSW were harmonised and linked to four NSW data collections. We calculated the incidence rates of psychiatric hospitalisations within 24 months postsupervision and identified predictors of these hospitalisations using a competing risks regression analysis. RESULTS: Within 24 months postsupervision, 11.4% had a psychiatric hospitalisation compared with 3.5% during supervision. 20.7% of those admitted had a known history of mental illness and engaged with community-based and outpatient mental health services postsupervision. Predictors of psychiatric hospitalisations were: female sex (adjusted subdistribution HR (asHR) 1.84, 95% CI 1.24 to 2.73); previous incarceration (highest asHR for ≥4 episodes 1.67, 95% CI 1.01 to 2.78); head injury (asHR 1.63, 95% CI 1.20 to 2.21); personality disorder (asHR 3.66, 95% CI 2.06 to 6.48) and alcohol and substance use disorder (asHR 1.89, 95% CI 1.29 to 2.77). CONCLUSION: Justice-involved youth have higher rates of psychiatric admissions after criminal justice supervision. Engagement with mental health services postsupervision is important in addressing emerging or persisting mental health needs.

Youth custody is no place for mentally ill children and young people.

OBJECTIVE: We review issues with incarcerating mentally ill children and young people in Australia, highlighting key demographics, rates of mental disorders, consideration of brain development, developmental trauma and children's experiences of custody. METHODS: Population relevant literature will be outlined as applicable. RESULTS: Children and adolescents in custody have high rates of mental illness, cognitive impairment and comorbid diagnoses. Childhood adversity and trauma impacts on psychosocial development from an early age. Almost half of all young people in custody are First Nations children, a 20 times over-representation. Youth custody is frequently experienced as an additional trauma for young people. Mental health diversion into community treatment is effective and reduces costs to young people, their families, communities and society generally. CONCLUSION: Youth custody is an inappropriate setting for children and young people with mental disorders, and can be further traumatising. Economic and health benefits for mental health diversion away from youth custody are manifest.

A six-session group-based pilot intervention for alcohol and other drug use in hospitalised mentally ill young offenders.

OBJECTIVE: This study aims to evaluate a group-based intervention for alcohol and other drug (AOD) use offered to incarcerated youth hospitalised with mental illness. METHODS: A six-session group-based intervention for AOD use was offered to young offenders with mental illness, hospitalised in the Adolescent Unit of the Forensic Hospital, Sydney, between June 2015 and May 2017. Pre- and post-intervention measures were collected using the Brief Psychiatric Rating Scale (BPRS), Treatment Entry Questionnaire, Drug-Related Locus of Control (DRLOC) and Drug-Taking Confidence Questionnaire, short version. RESULTS: Pre- and post-intervention measures were compared utilising paired t-tests. Following the intervention, there was a significant reduction in the severity of psychiatric symptoms rated using the BPRS and a significant difference in DRLOC measures, reflecting increased internal locus of control. CONCLUSIONS: Improved internal drivers for reducing AOD use and improvement in symptoms of mental illness suggest similar interventions may be beneficial and may not impact recovery even during episodes of acute illness.

[International Consensus Statement for the Screening, Diagnosis, and Treatment of Adolescents with Concurrent Attention-Deficit/Hyperactivity Disorder and Substance Use Disorder]. / Internationale Konsenserklärung zu Screening, Diagnostik und Behandlung von Jugendlichen und Heranwachsenden mit Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung und gleichzeitigen Störungen durch Substanzgebrauch.

International Consensus Statement for the Screening, Diagnosis, and Treatment of Adolescents with Concurrent Attention-Deficit/Hyperactivity Disorder and Substance Use Disorder Abstract. Background: Childhood attention-deficit/hyperactivity disorder (ADHD) is a risk factor for substance misuse and substance use disorder (SUD) in adolescence and (early) adulthood. ADHD and SUD also frequently co-occur in treatment-seeking adolescents, which complicates diagnosis and treatment and is associated with poor treatment outcomes. Research on the effect of treatment of childhood ADHD on the prevention of adolescent SUD is inconclusive, and studies on the diagnosis and treatment of adolescents with ADHD and SUD are scarce. Thus, the available evidence is generally not sufficient to justify robust treatment recommendations. Objective: The aim of the study was to obtain a consensus statement based on a combination of scientific data and clinical experience. Method: A modified Delphi study to reach consensus based upon the combination of scientific data and clinical experience with a multidisciplinary group of 55 experts from 17 countries. The experts were asked to rate a set of statements on the effect of treatment of childhood ADHD on adolescent SUD and on the screening, diagnosis, and treatment of adolescents with comorbid ADHD and SUD. Results: After 3 iterative rounds of rating and adapting 37 statements, consensus was reached on 36 of these statements representing 6 domains: general (n = 4), risk of developing SUD (n = 3), screening and diagnosis (n = 7), psychosocial treatment (n = 5), pharmacological treatment (n = 11), and complementary treatments (n = 7). Routine screening is recommended for ADHD in adolescent patients in substance abuse treatment and for SUD in adolescent patients with ADHD in mental healthcare settings. Long-acting stimulants are recommended as the first-line treatment of ADHD in adolescents with concurrent ADHD and SUD, and pharmacotherapy should preferably be embedded in psychosocial treatment. The only remaining no-consensus statement concerned the requirement of abstinence before starting pharmacological treatment in adolescents with ADHD and concurrent SUD. In contrast to the majority, some experts required full abstinence before starting any pharmacological treatment, some were against the use of stimulants in the treatment of these patients (independent of abstinence), while some were against the alternative use of bupropion. Conclusion: This international consensus statement can be used by clinicians and patients together in a shared decision-making process to select the best interventions and to reach optimal outcomes in adolescent patients with concurrent ADHD and SUD.

Keeping COVID out: a collaborative approach to COVID-19 is associated with a significant reduction in self-harm in young people in custody.

OBJECTIVE: To describe the collaboration between Youth Justice New South Wales (YJNSW) and Justice Health and Forensic Mental Health Network (JHFMHN) during the early COVID-19 Response (CR) across the six Youth Justice centres in NSW, and the reduced incidence of self-harm noted over this period. METHODS: Narrative article with analysis of self-harm incident data during the initial CR period of March to May 2020, compared to the same period in 2019. RESULTS: During the initial CR period (March to May 2020), there was a highly significant, four-fold reduction in self-harming incidents recorded by both YJNSW and JHFMHN compared with the equivalent time period in 2019 (p < .00001). CONCLUSION: The greater than four-fold reduction in self-harm by young people during the early CR may relate to the 'interagency response', with an increase in positive interactions between staff, and between staff and young people. The reduction in self-harm and improvements in mental health will be further explored through standardised interviews with the young people and staff.

Neutropenia in Incarcerated Adolescents Secondary to Intranasal Quetiapine Misuse.

Objective: Between April 2015 and May 2016, a number of young males incarcerated at a Youth Justice center in New South Wales, Australia, were noted to have unexplained and significant neutropenia. None of the adolescents were prescribed quetiapine; however, it was prescribed for other young people in the center for this time period. The authors undertook a case series review to investigate the cause of this neutropenia. Methods: Case series review, including review of all pathology, electrocardiograms, medication charts, and medical file notes. Results: Quetiapine was used in the center; however, none of the young people with neutropenia were prescribed quetiapine (or any other medication causing neutropenia). During the assessments of these young people, it was found that the administration of quetiapine had changed during this time period to using pulverized quetiapine powder, administered after hours to young people when there were no health center staff available to supervise. On questioning, two neutropenic young people admitted to "snorting" diverted quetiapine powder. All instances of neutropenia resolved once the medication was removed from the center. Conclusions: Quetiapine has a high potential for abuse, especially in custodial settings. Quetiapine should never be crushed as this increases the potential for diversion, misuse, and serious side effects. Quetiapine misuse should be considered part of the differential diagnosis of unexplained neutropenia, especially in a setting where the drug is available.

International Consensus Statement for the Screening, Diagnosis, and Treatment of Adolescents with Concurrent Attention-Deficit/Hyperactivity Disorder and Substance Use Disorder.

BACKGROUND: Childhood attention-deficit/hyperactivity disorder (ADHD) is a risk factor for substance misuse and substance use disorder (SUD) in adolescence and (early) adulthood. ADHD and SUD also frequently co-occur in treatment-seeking adolescents, which complicates diagnosis and treatment and is associated with poor treatment outcomes. Research on the effect of treatment of childhood ADHD on the prevention of adolescent SUD is inconclusive, and studies on the diagnosis and treatment of adolescents with ADHD and SUD are scarce. Thus, the available evidence is generally not sufficient to justify robust treatment recommendations. OBJECTIVE: The aim of the study was to obtain a consensus statement based on a combination of scientific data and clinical experience. METHOD: A modified Delphi study to reach consensus based upon the combination of scientific data and clinical experience with a multidisciplinary group of 55 experts from 17 countries. The experts were asked to rate a set of statements on the effect of treatment of childhood ADHD on adolescent SUD and on the screening, diagnosis, and treatment of adolescents with comorbid ADHD and SUD. RESULTS: After 3 iterative rounds of rating and adapting 37 statements, consensus was reached on 36 of these statements representing 6 domains: general (n = 4), risk of developing SUD (n = 3), screening and diagnosis (n = 7), psychosocial treatment (n = 5), pharmacological treatment (n = 11), and complementary treatments (n = 7). Routine screening is recommended for ADHD in adolescent patients in substance abuse treatment and for SUD in adolescent patients with ADHD in mental healthcare settings. Long-acting stimulants are recommended as the first-line treatment of ADHD in adolescents with concurrent ADHD and SUD, and pharmacotherapy should preferably be embedded in psychosocial treatment. The only remaining no-consensus statement concerned the requirement of abstinence before starting pharmacological treatment in adolescents with ADHD and concurrent SUD. In contrast to the majority, some experts required full abstinence before starting any pharmacological treatment, some were against the use of stimulants in the treatment of these patients (independent of abstinence), while some were against the alternative use of bupropion. CONCLUSION: This international consensus statement can be used by clinicians and patients together in a shared decision-making process to select the best interventions and to reach optimal outcomes in adolescent patients with concurrent ADHD and SUD.

Combination long-acting injectable (LAI) antipsychotic medication in adolescents with severe psychosis and aggression: a case series.

OBJECTIVES: We examine the use of combination long-acting injectable (LAI) antipsychotic medication for adolescents with severe psychosis and aggression. We discuss benefits and risks with this approach, for a highly challenging small group of young people. METHODS: A clinical summary is given of three adolescents admitted to a secure adolescent forensic inpatient unit, and the literature is reviewed. RESULTS: In these adolescents with severe psychosis, aggression and violent offending, combination LAI antipsychotics effectively treated psychosis and enabled transfer to less restrictive settings. Brief Psychiatric Rating Scale (BPRS) scores decreased significantly with treatment, without any severe adverse effects. CONCLUSIONS: Combination LAI antipsychotics may be an effective treatment for adolescents with severe psychosis and aggression where clozapine is not a realistic therapeutic option. Close monitoring for side-effects, clear documentation of clinical reasoning and appropriate safeguards are important.

Psychiatric impairment ratings in children and adolescents.

OBJECTIVES: It is accepted practice in Australia and New Zealand for psychiatric impairment rating scales to be applied for persons claiming psychiatric injury. These scales were derived for adults, not children. There is less clarity as to whether and how these scales may be applied for children claiming psychiatric injury. METHODS: We review Australian and New Zealand guidelines and methods for assessing permanent psychiatric impairment, as they apply to children and adolescents. RESULTS: With significant caution, psychiatric impairment rating scales can be administered for children. Guidance and recommendations in this regard are provided. For some, the effects of psychiatric injury may not be stable, and permanent impairment assessment should be delayed until sufficient maturity occurs. CONCLUSIONS: Psychiatric impairment rating scales are widely applied for adults claiming psychiatric injury, however caution must be exercised when these scales are used in children.

Treatment for youth paraphilic disorders: opportunities to reduce harm.

OBJECTIVE: To outline current understanding and recommended treatments for paraphilic or sexual deviant disorders in adolescents and youth. METHOD: An overview of the diagnosis, development and scope of paraphilic disorders. Evidence and an algorithm for pharmacological treatments in youth are outlined. RESULTS: Paraphilic disorders are relatively common in adolescents and youth, with fantasies and urges preceding the onset of deviant behaviour by a handful of years. Research in youth is sparse, but the available evidence supports that paraphilic disorders respond favourably to psychological and pharmacological treatments. CONCLUSIONS: The detection of paraphilic disorders in adolescents and youth presents a window of opportunity, where treatment may be provided before deviant behaviour occurs, potentially reducing the future incidence of sexual abuse.

Evaluation of olanzapine pamoate depot in seriously violent males with schizophrenia in the community.

OBJECTIVES: Olanzapine is a well established treatment for schizophrenia. The olanzapine pamoate depot (long-acting injectable) formulation improves compliance and clinical trials have shown it to be effective. However, there are no previously published reports evaluating olanzapine depot in violent patients with schizophrenia in the community. We evaluated the clinical efficacy of olanzapine depot, its effect on violence, hospitalization and incarceration in community patients with schizophrenia and prior history of serious violence. METHODS: This was a retrospective service evaluation in a community forensic psychiatry service where patients had schizophrenia spectrum disorder and a significant history of violence. Treatment resistance, substance use disorders and antisocial personality disorder were common. Nine deidentified patient records were audited for 12 months pre and 12 months post olanzapine depot initiation to identify any clinical changes, breaches of (legislated) psychiatric treatment orders, hospital admission days, days incarcerated and emergency presentations. RESULTS: Community forensic psychiatric patients treated with olanzapine depot showed an improvement in psychotic symptoms (p = 0.008) with overall decreases in violence, supported by reductions in hospitalization days (p = 0.018) and days incarcerated (p = 0.043). Several patients had reduced psychiatric treatment order breaches and emergency presentations. CONCLUSIONS: Community forensic psychiatric patients with schizophrenia responded to olanzapine depot with decreased violence and reduced hostility. A depot antipsychotic medication that reduces violence and improves engagement has significant implications for greater effective community management of forensic patients with schizophrenia.

Presser - the forgotten story.

OBJECTIVE: Regina v Presser [1958] VR 45, is the most seminal case regarding fitness to plead for accused persons in Australia and New Zealand. It is not widely understood that Presser was a 14-year-old boy with intellectual disability. We aim to describe a clearer narrative regarding Edward John Presser. METHOD: Review of attainable newspaper reports framed within an historical context of fitness and relevant case law. RESULTS: Presser's narrative is described in greater detail than previously understood by clinicians and lawyers. Ramifications for fitness assessment are discussed including doli incapax and human rights considerations. CONCLUSIONS: The Presser criteria are widely applied; however, the case involved a 14-year-old boy with intellectual disability. Greater awareness of Presser's narrative assists clinicians providing expert evidence regarding fitness to plead for adolescents and persons with intellectual disability.

Predictors of rapid reincarceration in mentally ill young offenders.

OBJECTIVE: Describe characteristics of mentally ill young offenders released from custody and predictors of those who rapidly returned to custody. METHOD: Ambidirectional cohort study of 51 young males with mental disorders released from the largest New South Wales Juvenile Justice Centre (2005-2007), a health file audit at time of release and prospective determination of reincarceration. RESULTS: Overall 47% were Aboriginal, 43% originated from regional communities, substance disorders were highly prevalent and only 12% accessed prior community mental health care. Over half (57%) satisfied diagnostic criteria for schizophrenia spectrum disorder. In custody, 39% were suicidal and 18% were homicidal. A majority (90%) returned to custody over a median of 28 months; half within five months of release. Schizophrenia/schizophreniform disorder (p<.001), bipolar disorder (p=.001) and schizoaffective disorder (p=.005) predicted rapid reincarceration, with shorter community survival than those without those diagnoses (p=.009). Antipsychotic treatment (p=.006) and treatment duration in custody (p=.006) predicted longer community survival. Aboriginality, younger age, prior incarceration and substance disorders were not predictive of rapid reincarceration. CONCLUSIONS: Serious mental illness was a significant predictor of rapid reincarceration in young offenders. Treatment improved community survival. The findings highlight the need for optimal psychiatric treatment and post-release care for young offenders with mental illness.

Assessing the risk of imminent aggression in mentally ill young offenders.

OBJECTIVES: Aggression in adolescents presents a significant problem for psychiatric units. The Dynamic Appraisal of Situational Aggression (DASA) is an empirically validated measure designed to appraise the risk of imminent aggression (within the next 24 hours) in adult patients. Our aim was to examine the predictive validity of the DASA: Youth Version (DASA:YV) with youth-specific items, in young offenders hospitalised with a mental illness. METHODS: This prospective validation study involved 4440 DASA:YV ratings of mentally ill adolescents in a secure hospital. At 24 hours post-assessment, the nursing staff documented whether patients had behaved aggressively: physically, verbally or towards property. Predictive accuracy was assessed using the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. RESULTS: The DASA:YV significantly predicted any imminent aggression (AUC = 0.754). Additional youth-specific items conferred a greater predictive yield, as compared to adult-derived items (p = 0.014). CONCLUSIONS: It is possible to monitor the risk state of hospitalised mentally ill youth, so that heightened states can be detected early, thus facilitating interventions to reduce the risk of violence.