Antidepressant Prescribing and Suicide/Self-Harm by Young Australians: Regulatory Warnings, Contradictory Advice, and Long-Term Trends.

In 2004, the US Food and Drug Administration (FDA) controversially issued a black box warning that antidepressants were associated with an increased risk of suicidal thoughts and behaviours in people aged under 18 years. In 2007, the warning was expanded to include young adults aged under 25 years. In 2005, the Australian Therapeutic Goods Administration responded to the FDA warning by requiring Product and Consumer Information leaflets to be updated to reflect the risk. However, there was considerable debate, and at times emotive backlash, in academic journals and the international media. Prominent US and Australian mental health organisations and psychiatrists challenged the FDA warning. They argued that, on balance, antidepressant use was likely to reduce the risk of suicide. Several ecological studies were cited misleadingly as evidence that decreasing antidepressant use increases suicide risk. From 2008 to 2018, Australian per-capita child, adolescent and young adult antidepressant dispensing (0-27 years of age) and suicide (0-24 years) rates have increased approximately 66% and 49%, respectively. In addition, there was a 98% increase in intentional poisonings among 5 to 19 year-olds in New South Wales and Victoria between 2006 and 2016, with substantial overlap between the most commonly dispensed psychotropics and the drugs most commonly used in self-poisoning. These results do not support claims that increased antidepressant use reduces youth suicide risk. They are more consistent with the FDA warning and the hypothesis that antidepressant use increases the risk of suicide and self-harm by young people. Causal relationships cannot be established with certainty until there is a vast improvement in post-marketing surveillance. However, there is clear evidence that more young Australians are taking antidepressants, and more young Australians are killing themselves and self-harming, often by intentionally overdosing on the very substances that are supposed to help them.

Look west for Australian evidence of the relationship between amphetamine-type stimulant prescribing and meth/amphetamine use.

AIMS: To investigate Western Australian (WA) data on the relationship between the prescription of Amphetamine-Type Stimulants (ATS), and the non-medical use of prescription ATS and other forms of meth/amphetamine, for both adults (18+) and minors (<18). DESIGN AND METHODS: Two WA specific data sources were identified. The Stimulant Regulatory Scheme provided comprehensive ATS prescribing data from 2004 until 2017, and Australian Secondary School Alcohol and Drug (ASSAD) surveys provided details of non-medical prescription ATS use by WA adolescents (12-17). Other data sources included National Drug Strategy Household Surveys (NDSHS), the Pharmaceutical Benefits Scheme (PBS), and the National Wastewater Drug Monitoring Program (NWDMP). RESULTS: Over 95% of WA ATS prescribing has been for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). WA adults have consistently received prescription ATS at a much higher rate than other Australian adults. The most recent published data reported that in 2017 WA adults were 2.6 times as likely as other Australian adults to be supplied an ATS for ADHD. Drug treatment, NDSHS and NWDMP data indicate that WA adult rates of non-medical meth/amphetamine use have also regularly exceeded the Australian rate. Furthermore, the little data that exist on the non-medical use of prescription ATS by Australian adults suggests that it may also be disproportionately common in WA. From 1993 until 2002 the proportion of WA minors prescribed ATS grew rapidly and was the highest in Australia. Following regulatory reforms prescribing rates declined. By 2010 they were approximately half the 2002 rate. Over a similar timeframe there was a 72% fall in WA adolescent self-reported, past-week, non-medical amphetamine use. Since 2011 WA minor ATS prescribing rates have rebounded significantly. Unfortunately, useful data on adolescent meth/amphetamine use since 2011 is not available. Nonetheless, two ASSAD snapshots, in 2005 and 2017, suggest that more WA adolescents use prescription ATS non-medically than medically. DISCUSSION AND CONCLUSION: The data for WA adults suggest a correlation, but does not establish a causal connection, between ATS prescribing and the non-medical use of ATS and other forms of meth/amphetamine. Although it is clear that there is significant illicit prescription ATS use by WA adolescents, little is known about the contribution that the prescription of ATS makes to subsequent meth/amphetamine and other drug use. There is a critical need for research that investigates long-term, population-wide patterns and individual experiences of both those prescribed ATS and the broader population, to inform policy, prevention and treatment responses.

Identifying the cultural heritage of patients during clinical handover and in hospital medical records.

OBJECTIVE: To examine the frequency of and rationale for hospital doctors mentioning a patient's cultural heritage (ethnicity, national heritage, religion) during medical handovers and in medical records. DESIGN: Four-phase observational study, including the covert observation of clinical handovers in an acute care unit (ACU) and analysis of electronic medical records (EMRs) of ACU patients after their discharge to ward-based care. SETTING, PARTICIPANTS: 1018 patients and the doctors who cared for them at a tertiary hospital in Western Australia, May 2016 - February 2018. MAIN OUTCOME MEASURE: References to patients' cultural heritage by ACU doctors during clinical handover (written or verbal) and by ward-based doctors in hospital EMRs (written only), by geographic ethnic-national group. RESULTS: In 2727 ACU clinical handovers of 1018 patients, 142 cultural heritage identifications were made (ethnicity, 84; nationality, 41; religion, 17); the rate was highest for Aboriginal patients (370 [95% CI, 293-460] identifications per 1000 handovers). 14 505 EMR pages were reviewed; 380 cultural heritage identifications (ethnicity, 257; nationality, 119; religion, 4) were recorded. A rationale for identification was documented for 25 of 142 patients (18%) whose ethnic-national background was mentioned during handover or in their EMR. Multivariate analysis (adjusted for demographic, socio-economic and medical factors) indicated that being an Aboriginal Australian was the most significant factor for identifying ethnic-national background (handovers: adjusted odds ratio [aOR], 21.7; 95% CI, 7.94-59.4; hospital EMRs: aOR, 13.6; 95% CI, 5.03-36.5). 44 of 75 respondents to a post-study survey (59%) were aware that Aboriginal heritage was mentioned more frequently than other cultural backgrounds. CONCLUSIONS: Explicitly mentioning the cultural heritage of patients is inconsistent and seldom explained. After adjusting for other factors, Aboriginal patients were significantly more likely to be identified than patients with other backgrounds.

Attention deficit hyperactivity disorder late birthdate effect common in both high and low prescribing international jurisdictions: a systematic review.

BACKGROUND: Multiple studies have found that the youngest children in a classroom are at elevated risk of being diagnosed with, or medicated for, ADHD. This systematic review was conducted to investigate whether this late birthdate effect is the norm and whether the strength of effect is related to the absolute risk of being diagnosed/medicated. METHODS: A literature search of the PubMed and ERIC databases and snowball and grey literature searching were conducted. RESULTS: A total of 19 studies in 13 countries covering over 15.4 million children investigating this relationship were identified. Three other studies exploring related topics were identified. The diversity of methodologies prevented a meta-analysis. Instead a systematic review of the 22 studies was conducted. A total of 17 of the 19 studies found that the youngest children in a school year were considerably more likely to be diagnosed and/or medicated than their older classmates. Two Danish studies found either a weak or no late birth date effect. There was no consistent relationship between per-capita diagnosis or medication rates and the strength of the relative age effect, with strong effects reported in most jurisdictions with comparatively low rates. CONCLUSIONS: It is the norm internationally for the youngest children in a classroom to be at increased risk of being medicated for ADHD, even in jurisdictions with relatively low prescribing rates. A lack of a strong effect in Denmark may be accounted for by the common practice of academic 'redshirting', where children judged by parents as immature have a delayed school start. Redshirting may prevent and/or disguise late birthdate effects and further research is warranted. The evidence of strong late birthdate effects in jurisdictions with comparatively low diagnosis/medication rates challenges the notion that low rates indicate sound diagnostic practices.

Understanding advocacy practice in mental health: a multidimensional scalogram analysis of case records.

BACKGROUND: Few studies have examined mental health consumers' motives for seeking advocacy assistance. AIMS: This study aimed to identify factors that influenced mental health consumers' use of advocacy services. METHODS: The analysis was based on 60 case records that were sourced from a community advocacy service. Each record was dichotomously coded across 11 variables to generate a series of categorical data profiles. The data set was then analysed using multidimensional scalogram analysis to reveal key relationships between subsets of variables. RESULTS: The results indicated that mental health consumers commonly reported a sense of fear, which motivated them to contact the advocacy service in the hope that advocates could intervene on their behalf through effective communication with health professionals. Advocates often undertook such intervention either through attending meetings between the consumer and health professionals or contacting health professionals outside of meetings, which was typically successful in terms of achieving mental health consumers' desired outcome. The resolution of most concerns suggests that they were often legitimate and not the result of a lack of insight or illness symptoms. CONCLUSION: Health professionals might consider exploring how they respond when consumers or carers raise concerns about the delivery of mental health care.