Seven decades of antipsychotic drugs: Why is the life of Australians with schizophrenia still so suboptimal?

The advent of dopamine (D2) receptor-blocking medications over 70 years ago, ushered in a new era of biological treatment for schizophrenia. However, we argue that little subsequent progress has been made in translating this into fulfilled and fulfilling lives for people with schizophrenia. This Viewpoint asks why this is the case, and suggests ways forward for capitalising on extant and emerging new treatments for psychotic disorders, to the betterment of the lives of people living with schizophrenia.

The Australian evidence-based clinical practice guideline for attention deficit hyperactivity disorder.

OBJECTIVE: The objective of this article was to provide an overview of the development and recommendations from the Australian evidence-based clinical practice guideline for attention deficit hyperactivity disorder (ADHD). The guideline aims to promote accurate and timely identification and diagnosis, and optimal and consistent treatment of ADHD. METHODS: Development integrated the best available evidence with multidisciplinary clinical expertise and the preferences of those with lived experience, underpinned by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. The 23 guideline development group members included psychiatrists, paediatricians, general practitioners, psychologists, speech pathologists, occupational therapists, educators, Indigenous psychologists, and people with a lived experience; with two independent chairs and a methodologist. Where appropriate, evidence reviews from the National Institute for Health and Care Excellence (NICE) 2018 'Attention Deficit Hyperactivity Disorder: Diagnosis and Management' guideline were updated. Fifty prioritised clinical questions were addressed in 14 systematic reviews (new and updated from NICE 2018) and 28 narrative reviews. RESULTS: The 113 clinical recommendations apply to young children (5 years and under), children, adolescents and adults. They provide guidance for clinicians on identification, screening, diagnosis, multimodal treatment and support, including pharmacological and non-pharmacological interventions. The guideline and supporting information are available online: https://adhdguideline.aadpa.com.au/. CONCLUSIONS: The guideline was approved by the National Health and Medical Research Council (NHMRC) of Australia and relevant medical and allied health professional associations. It is anticipated that successful implementation and uptake of the guideline by organisations, health care providers and other professionals will increase delivery of evidence-based treatment and improve health outcomes for the more than 800,000 Australians with ADHD.

Neuroscience in gambling policy and treatment: an interdisciplinary perspective.

Neuroscientific explanations of gambling disorder can help people make sense of their experiences and guide the development of psychosocial interventions. However, the societal perceptions and implications of these explanations are not always clear or helpful. Two workshops in 2013 and 2014 brought together multidisciplinary researchers aiming to improve the clinical and policy-related effects of neuroscience research on gambling. The workshops revealed that neuroscience can be used to improve identification of the dangers of products used in gambling. Additionally, there was optimism associated with the diagnostic and prognostic uses of neuroscience in problem gambling and the provision of novel tools (eg, virtual reality) to assess the effectiveness of new policy interventions before their implementation. Other messages from these workshops were that neuroscientific models of decision making could provide a strong rationale for precommitment strategies and that interdisciplinary collaborations are needed to reduce the harms of gambling.

Revisiting the hypothesis-driven interview in a contemporary context.

OBJECTIVE: The "hypothesis-driven interview" was articulated by George Engel as a method of raising and testing hypotheses in the process of building a biopsychosocial formulation and determining the most likely diagnosis. This interview was a forerunner of the modern medical interview as well as the contemporary psychiatric assessment. The objective of this article is to describe the hypothesis-driven interview and to explore its relationship with the contemporary medical interview. METHOD: The literature on the medical and hypothesis-driven interview was reviewed. Key features of each were identified. RESULTS: The hypothesis-driven interview shares much with the contemporary medical interview. In addition, it enhances the application of communication skills and allows the interviewer to develop a formulation during the course of the assessment. CONCLUSION: The hypothesis-driven interview is well suited to the aims of a contemporary psychiatric assessment.

Community treatment orders and antipsychotic long-acting injections.

BACKGROUND: The community treatment order (CTO) is the legal framework by which people in the community are compelled to accept treatment. Both antipsychotic long-acting injections (LAIs) and CTOs are used to address treatment non-adherence. AIMS: To investigate the relationship between CTOs and LAI use in patients with schizophrenia. METHOD: Prescribing, demographic and CTO data were collected for patients from four community mental health clinics in Melbourne, Australia, in 1998 and 2002. RESULTS: Against a background of increasing use of oral second-generation antipsychotic (SGA) medication and decreasing use of LAIs, the rates of CTO implementation doubled from 13% to 26% of patients with schizophrenia between 1998 and 2002. Proportionally more patients with a CTO are prescribed LAIs rather than oral SGAs. CONCLUSIONS: The relationship between receiving an LAI and being subject to a CTO is significant, and reflects the consideration given to enhancing adherence in a community mental health setting.

Community mental health care in the Asia-Pacific region: using current best-practice models to inform future policy.

The reporting of child sexual abuse (CSA) and physician-patient sexual relationships (PPSR) are currently the focus of professional, legal and media attention in several countries. This paper briefly reviews mental health policies on these issues and reports on a WPA survey of them. While the WPA Madrid Declaration permits breaching confidentiality for mandatory reporting of CSA and clearly prohibits PPSR, it is not known how or to what extent these policies are implemented in WPA Member Societies' countries. It is also not known whether policies or laws exist on these topics nationally or to what extent psychiatrists and the public are aware of them. Representatives of WPA Member Societies were e-mailed a survey about issues pertaining to CSA and PPSR. Fifty-one percent of 109 countries replied. All reporting countries had laws or policies regarding the reporting of CSA, but this was often voluntary (63%) and without protection for reporting psychiatrists either by law (29%) or by Member Societies (27%). A substantial number of psychiatric leaders did not know the law (27%) or their Society's policy (11%) on these matters. With respect to PPSR, some reporting countries lacked laws or policies about PPSR with current (17%) or past (56%) patients. Fewer than half of responding representatives believed that their Society's members or the public were well informed about the laws and policies pertaining to CSA or PPSR. There is clearly a wide range of laws, policies and practices about CSA and PPSR in WPA Member Societies' countries. There is a need in some countries for laws or supplemental policies to facilitate the protection of vulnerable child and adult patients through clear, mandatory reporting policies for CSA and PPSR. Mechanisms to protect and support reporting psychiatrists should also be developed where they do not already exist. There is also a need in some countries to develop strategies to improve the education of psychiatrists, trainees, and the public on these issues.

Psychiatric education and training in Asia.

Psychiatric education and training, whilst playing a pivotal role in addressing the burden of mental illness in Asia, is very variable in quality and quantity across the continent. In this article formal postgraduate programmes in Indonesia, Thailand, Philippines, Singapore and India are described. The special situation in China where both basic and advanced psychiatric training receives particular attention, including the role of Asia Australia Mental Health in assisting the process, similarly the long hard road of re-establishing psychiatric training in Cambodia following the tragedy of the Pol Pot era are described. The article concludes with an overview of common issues involving education and training across the region.

World Psychiatric Association Pharmacopsychiatry Section statement on comparative effectiveness of antipsychotics in the treatment of schizophrenia.

Data from two major government-funded studies of comparative antipsychotic effectiveness in schizophrenia contradict the widely prevalent belief that the newer second-generation medications are vastly superior to the older first-generation drugs. This has caused uncertainty among patients, clinicians and policy-makers about the relative utility of first- and second- generation antipsychotic agents in its treatment. To reduce confusion and provide a contextual understanding of the new data, the World Psychiatry Association Section on Pharmacopsychiatry comprehensively reviewed the literature on the comparative effectiveness of different antipsychotic treatments for schizophrenia and developed this update. Utilizing data from the approximately 1,600 randomized controlled trials of antipsychotic treatment in schizophrenia, we applied the two indirect and one direct method to comparing the effectiveness of 62 currently-available antipsychotic agents. The subclasses of 51 first-generation and 11 second-generation antipsychotics were both found to be very heterogeneous, with substantial differences in side-effect profiles among members. Second-generation antipsychotic agents were found to be inconsistently more effective than first-generation agents in alleviating negative, cognitive, and depressive symptoms and had a lower liability to cause tardive dyskinesia; these modest benefits were principally driven by the ability of second-generation antipsychotics to provide equivalent improvement in positive symptoms along with a lower risk of causing extrapyramidal side-effects. Clozapine was found to be more efficacious than other agents in treatment-refractory schizophrenia. There were no consistent differences in efficacy among other second-generation antipsychotic agents; if such differences exist, they are likely small in magnitude. Dosing was found to be a key variable in optimizing effectiveness of both first- and second- generation antipsychotic agents. There was enormous individual variability in antipsychotic response and vulnerability to various adverse effects. In contrast to their relatively similar efficacy in treating positive symptoms, there were substantial differences among both first- and second- generation antipsychotic agents with regard to their propensity to cause extrapyramidal, metabolic and other adverse effects; second-generation agents have a lower liability to cause acute extrapyramidal symptoms and tardive dyskinesia along with a tendency to cause greater metabolic side-effects than first-generation agents. Based on these data about the comparative effectiveness of different antipsychotic treatment options, we summarize elements of current best antipsychotic practice for the treatment of schizophrenia and discuss the role of government and the pharmaceutical industry in obtaining and disseminating information which can facilitate best practice.

Why are community psychiatry services in Australia doing it so hard?

Since the National Mental Health Policy was implemented in 1992, dissonance between mental health professionals and the general public on the success of the deinstitutionalization components of the strategy has grown. Many of the premises on which the deinstitutionalization components were based are false, and this has led to many problems in the system. Community psychiatry is not fundamentally flawed, and what has been learned in the past 15 years can be used to build on the foundations that have been laid. Better cooperation between state and federal governments is needed to effect real change.

Multiple-family group treatment for English- and Vietnamese-speaking families living with schizophrenia.

OBJECTIVE: This study, which was the first evaluation in Australia of multiple-family group treatment, explored the effectiveness of this approach for a newly arrived non-English speaking migrant group, first-generation Vietnamese families, and for English-speaking families. METHODS: Thirty-four pairs of English-speaking consumers and family members and 25 Vietnamese-speaking pairs were randomly assigned to a multiple-family group or a control group. All consumers had a diagnosis of schizophrenia. The multiple-family group intervention (26 sessions over 12 months) was delivered as an adjunct to case management services, which all consumers received. Outcomes, which were measured immediately after treatment and 18 months later, included the number of relapse episodes; the presence and severity of symptoms, as measured by the Brief Psychiatric Rating Scale (BPRS) and the Scale for the Assessment of Negative Symptoms; and social functioning, as measured by the Family Burden Scale, the Health of the Nation Outcome Scale, and the Quality of Life Scale. RESULTS: Relapse rates immediately after treatment were significantly lower for the multiple-family group than for the control group (12 and 36 percent), and relapse rates were also lower during the follow-up period (25 and 63 percent). BPRS ratings were significantly lower for participants in the multiple-family group, and vocational outcomes also improved. The reductions in relapse and symptoms were similar for the English-speaking and the Vietnamese-speaking family groups; sample size precluded statistical analysis of differences. CONCLUSIONS: Multiple-family group treatment is an effective cognitive-behavioral intervention in the treatment of schizophrenia. The findings suggest continued application of and research on family interventions for non-English speaking migrant populations.

Development of clinical guidelines for the pharmacological management of behavioural disturbance and aggression in people with psychosis.

OBJECTIVE: To describe the process underpinning the development of clinical guidelines for the management of behavioural disturbance in psychosis. METHOD: A structured process was followed, encompassing a literature review, focus groups with key staff, and pilot testing and monitoring of the guidelines in an acute psychiatric setting. RESULTS: The process was well accepted by staff and was found useful in monitoring outcomes in a naturalistic setting. The final guidelines proved safe and effective in the acute setting. CONCLUSIONS: The incorporation of a monitoring system for interventions for the management of behavioural disturbance in acute psychiatric settings is beneficial for staff and patients alike.

The National Health Performance Framework: an evaluation model for use by psychiatrists.

OBJECTIVES: To demonstrate the use of the National Health Performance Framework as an evaluation framework for clinical interventions and service outcomes in mental health. CONCLUSIONS: Evaluation is not a complex process. What is required is a willingness to be accountable for outcomes of care. It does not require complex data systems but openness to scrutiny through reflective practices and a commitment to continue to explore the possibilities of making things better.

A case study in the globalization of medical education: assisting overseas-born students at the University of Melbourne.

Over the past decade there has been a remarkable increase in ethnic diversity among Australian medical students. This phenomenon has been driven by two forces: the disproportionate school-level academic success achieved by first-generation migrant and refugee-origin youth, and the rapid globalization of Australia's tertiary education system, in a context where reduced government funding has accelerated the development of 'academic capitalism' (Slaughter & Leslie, 1997 ). This paper briefly examines each trend, prior to exploring select pedagogical implications of these changes for the University of Melbourne, the destination of choice by 2001 for 30% of all international students electing to study medicine in Australia. Two key questions are addressed: (1) What are the potential problems in delivering Western-style medical education to culturally and linguistically disparate groups?; (2) What model of international student support has been developed by the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne? The paper suggests the model may have potential relevance for other universities, in the context of the accelerating globalization of medical education.

Partnerships between academic psychiatry and the pharmaceutical industry: the Lilly MAP Initiative.

OBJECTIVE: To examine the relationship between academic psychiatry and the pharmaceutical industry, focusing on a partnership between academics in Melbourne and Eli Lilly and Company (Lilly Melbourne Academic Psychiatry). CONCLUSIONS: Relationships between the pharmaceutical industry and the medical profession (including psychiatry) are under scrutiny as never before. Despite the complex nature of the relationship, the present paper argues that partnerships with external corporations such as pharmaceutical companies are of increasing importance for academic departments of psychiatry and research institutes, in environments in which core funding for tertiary institutes is being reduced. The partnership between Melbourne psychiatric academics and Eli Lilly and Company shows that benefits accrue to both parties, and suggests that there is a worthwhile place for other industry- academic collaborations of a similar nature in Australia.

Impairment of olfactory identification ability in individuals at ultra-high risk for psychosis who later develop schizophrenia.

OBJECTIVE: Previous investigation has revealed stable olfactory identification deficits in neuroleptic-naive patients experiencing a first episode of psychosis, but it is unknown if these deficits predate illness onset. METHOD: The olfactory identification ability of 81 patients at ultra-high risk for psychosis was examined in relation to that of 31 healthy comparison subjects. Twenty-two of the ultra-high-risk patients (27.2%) later became psychotic, and 12 of these were diagnosed with a schizophrenia spectrum disorder. RESULTS: There was a significant impairment in olfactory identification ability in the ultra-high-risk group that later developed a schizophrenia spectrum disorder but not in any other group. CONCLUSIONS: These findings suggest that impairment of olfactory identification is a premorbid marker of transition to schizophrenia, but it is not predictive of psychotic illness more generally.