Psychiatry i01

MEDICINAL CANNABIS IN PSYCHIATRY? Australia is arguably a little late in the game when it comes to marijuana as medicine

BURDEN OF THE PANDEMIC ON THE YOUNG & VULNERABLE PAG E S

2 –3

KEEPING THE ELDERLY CONNECTED PAG E S

4 – 5

PAG E

1 5

OPPORTUNITIES & RISKS TO CONSIDER IN TELEHEALTH PAG E S

1 2 – 1 3

2021 USHERS IN NEW BEGINNINGS FOR MENTAL HEALTH This is the first in a series of publications addressing current topics in psychiatry. The intended audience is clinicians and the focus of the first issue is the impact of COVID-19 on the mental health of Australians.

Professor David Castle CONSULTANT PSYCHIATRIST ST. VINCENT’S HOSPITAL AND PROFESSORIAL FELLOW, THE UNIVERSITY OF MELBOURNE

F

ew of us will look back with much joy on the year 2020.

For Australians, it started with devastating bushfires followed by the COVID pandemic and all the disruptions it continues to cause to our daily lives. Our first two articles (by Caitlin Yolland and Susan Rossell, from Swinburne University in Melbourne) address trends in key mental health parameters at a general population level, under COVID. Of concern are the rising rates of anxiety and depression and increased rates of the use of alcohol and

other drugs. Of particular note is the impact on young people and those with an established mental illness.

These vulnerable groups require concerted attention to ensure they are receiving appropriate and timely mental health care. It is thus concerning that people with existing severe mental illnesses, such as schizophrenia and borderline personality disorder, may be making less than usual contact with mental health services during this pandemic.

This is reflected by data reported from the St Vincent’s Mental Health Service, at least for the first three months of the first lockdown. GPs and other providers need to ensure such individuals do not ‘fall between the cracks’ in terms of service provision, not only for their mental health needs, but also their physical health.

Another group that has been particularly impacted by COVID and the associated lockdowns is the elderly. The relative lack

of access to technology that allows interaction with others, visitor restrictions and their high risk of a serious outcome following COVID-19 infection, make it all the more difficult for this age group. In this issue, Terry Chong from St Vincent’s Hospital and The University of Melbourne explores the key issues of COVID-19 specific to the older members of our community, and provides tips for practitioners about how best to care for them, even in the presence of COVIDimposed constraints.

The impact of the bushfires and COVID-19 in terms of ‘stressful events’ is covered by John Cooper and Andrea Phelps from Phoenix Australia. They detail the short- and long-term adversity that can arise from traumatic events, and suggest brief screening measures to aid front-line clinicians to detect those at risk. They also suggest pathways to appropriate care for those in need.

Not everything about the

COVID-19 pandemic has been dire. Australians have been fortunate to have a wide availability of online health resources and telehealth. In her article, Helen Wilding provides a practical overview of telepsychiatry, with suggestions about how to ensure the best ‘user experience’ from both a patient and clinician perspective. It will be interesting to track the use of telepsychiatry beyond COVID19; certainly some patients report finding the approach to break down barriers and enable access harder, especially for those geographically distanced from their healthcare providers.

The final article is a ‘special topic’, addressing medicinal cannabis. The potential therapeutic uses of various components of the cannabis plant are weighed against risks for some people who might be vulnerable to side effects (for example, tetrahydrocannabinol making

psychotic symptoms worse in people with schizophrenia).

Judicious use of medicinal cannabis holds great promise in terms of the alleviation of certain mental health symptoms and will likely become part of our therapeutic armamentarium. Which patients and which symptoms will be most suited, however, remains to be fully elucidated.

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MENTAL HEALTH DURING COVID-19 IN AUSTRALIA Dr Caitlin Yolland SWINBURNE UNIVERSITY, MELBOURNE, VIC

Tracking the mental health impact of the COVID-19 pandemic and associated lockdowns revealed that, compared to preCOVID times, Australians experienced increased rates of depression, anxiety and stress, notably in those under the age of 25 years.

Moreover, the psychological burden of the pandemic was especially felt among individuals with an existing mental health problem, as reflected in high levels of symptom worsening during this period.

Background

Trends across time

The COVID-19 and you: mental health in Australia now survey (COLLATE) project is an ongoing mental health survey, which aims to identify and track mental health in Australian adults throughout the COVID-19 pandemic. This article will summarise the key findings from COLLATE and COVIDrelated studies, including the impact on the general population and identification of at-risk groups.

Levels of depression, anxiety and stress have remained relatively stable across 2020.

An increase in negative mood and decrease in quality of life occurred in Victoria in August, when COVID-19 case numbers increased.

This appears to have slightly improved in September to early October (see Figure 2).1

General population Across the general population, levels of depression, anxiety and stress were 3 times higher in 2020, compared with levels from previous years. Roughly 20% of people are experiencing clinically significant depression, anxiety and stress above usual levels.1 Figure 1 shows the levels of depression, anxiety and stress across the general population and those with a mental illness early in the pandemic.

Major concerns In April, primary concerns in the general population were for their loved ones getting infected or dying from COVID. More recently, in both September and November, this appears to have changed to more general health and wellbeing concerns.1

Demand for mental health services In previous years, approximately 20% of the population typically sought psychological support. Across 2020, this has substantially increased: May = 24%; August = 31%; November = 26%.

This additional ~5–10% of the population seeking psychological support will require extra staff, staff hours and facilities to service this need in Australia. Of additional concern is the fact that 20% of the survey respondents who sought psychological support had not yet managed to secure it.

At-risk groups

Alcohol use

The COLLATE data have revealed individuals that are at particularly high risk of poor mental health due to COVID-19:

24% of Victorians confirmed they were drinking more than before March 2020, and 19% of respondents from other states also reported increased drinking.2

Individuals with a pre-existing mental health condition Those with a mental health diagnosis were experiencing

between 5 and 5.5 times higher levels of depression, anxiety and stress (also see Figure 1).3 Psychological distress in individuals with mood disorders was heightened. Levels of stress and depression were on average higher in respondents with bipolar disorder, in comparison to those with depression.4 In individuals with obsessive-compulsive disorder (OCD), specific OCD symptoms were not substantially increased, although levels of depression, anxiety and stress were significantly higher than in the general population.

These negative emotions also uniquely predicted worse OCD symptoms.

In individuals with eating disorders, there was increased restricting, binge eating, purging, and exercise behaviours during this time.5 Due to the increased use of video conferencing, those with high dysmorphic concerns were fixating on their own face more and were highly distressed at the closure of beauty services.6

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FIGURE 2. Levels of negative emotions in Victoria across 2020

FIGURE 1. Negative emotions by age and mental health status Note. Pre-COVID levels based on normative data. Early-COVID data collected from the COLLATE study in early April

1 8 – 24

MEAN

S COR ES

25

25–90

AG E

Depression

Pre-COVID General Population Early-COVID General Population Pre-COVID Mental Health Diagnosis

20

15

Anxiety

Stress

10

10 5

5

0

Depression

Anxiety

Stress N EG ATI V E

Depression

Anxiety

Stress

EMOTIONS

0

Apr

May

Jun

Jul

Aug

TABLE 1. Major concerns throughout 2020

a

95% CI

15

Sep

Oct

References

APRIL (WAVE 1)

SEPTEMBER (WAVE 2a)

NOVEMBER (MOST RECENT)

PRIMARY CONCERN

Loved one dying from COVID

Implications for health and wellbeing of family/loved ones

Implications for health and wellbeing of family/loved ones

SECONDARY CONCERN

Loved ones getting infected with COVID

Implications for health and wellbeing of society

Loved ones getting infected with COVID

TERTIARY CONCERN

Implications for health and wellbeing of family/loved ones

Implications for health and wellbeing of self

Australian Economy

More details on the COLLATE project can be found via these QR codes.

To scan, open the camera on your device or QR code scanner app and hover over the code for a few seconds.

A notification will appear linking to the relevant article 1. Tan, et al. 2020

Note: Wave 2 of COVID infections predominantly affected Victorian respondents.

Young people (aged 18–24 years) have been particularly adversely affected by COVID, with increased suicidal ideation and higher levels of depression, anxiety and stress.

2. Neill, et al. 2020

3. Rossell, et al.

2020

Youth Young people (aged 18–24 years) have been particularly adversely affected by COVID, with increased suicidal ideation and higher levels of depression, anxiety and stress.7 Further groups that were experiencing significantly higher levels of negative emotion are: • Carers • Parents • Healthcare and other essential workers • Older individuals

Take-home messages • Depression, anxiety and stress levels are currently elevated.

Therefore, increased screening for these symptoms is critical, particularly for at-risk groups. Early and immediate intervention increases positive outcomes, and prevents further long-term mental health consequences • Past literature suggests that the mental health effects of pandemics worsen over

the following 12 months post-pandemic. Putting in place screening tools and resources to deal with this is important for the prevention and treatment of mental illness in the future • T here is a need to re-assess mental health plans for those with pre-existing mental health conditions • Older individuals may need extra support when seeking professional mental health services • Youth specific services, such as Kids Helpline, headspace or Beyond Blue, may need to be accessed for vulnerable young people, including increased capacity in these services amid referrals from clinicians • Promote adaptive coping strategies, including seeking professional health support, focussing on what one is grateful for, reaching out to loved ones and reassurance that some things in life are still certain, can help protect against negative mental health outcomes

Key points for practice Recognise that 1 in 5 have experienced heightened levels of depression, anxiety and stress during the COVID-19 pandemic Individuals especially vulnerable to poor mental health during this time include: • Those with an existing mental health condition • Young (18–24 years) and senior citizens • Health workers • Carers and parents Screen for (deteriorating) symptoms in your patients to allow for timely intervention and management Recommend adaptive coping strategies to help protect against negative mental health outcomes

4. Van Rheenen, et al. 2020

5. Phillipou, et al. 2020

6. Pikoos, et al.

2020

7. Curnow and Knight, 2020

04 R E V I E W

IMPACT OF COVID-19 ON THE MENTAL HEALTH OF OLDER AUSTRALIANS COVID-19 infection does not discriminate – it affects people of all races, ages and social demographics, acknowledging that some people are more at risk than others.

This also holds true for the mental health toll associated with the pandemic, with our older population being particularly vulnerable. Being socially isolated and technologically naïve means that their sense of connectedness and belonging may be lacking. Approaches to improve or establish community links are, therefore, a key priority for this cohort moving into 2021.

Dr Terence Chong UNIVERSITY OF MELBOURNE AND ST VINCENT’S HOSPITAL, MELBOURNE, VIC

W

e have all witnessed the profound and myriad impact of COVID-19 on the mental health of older Australians.

This has been particularly marked in Victoria, where there has been a second wave.

Globally, older adults have been impacted both by being at greater risk of serious physical complications from COVID19, as well as the restrictions instituted to mitigate this risk. Trying to find the balance between the two is an ongoing challenge and is likely to continue for quite some time.

If we look to history, we can see that after the influenza pandemic a century ago, there were suggestions of an increase in psychosis and suicide in the aftermath.1 More recently

and with more contemporary research methodology, there have been a number of studies undertaken in Hong Kong during and after the Sudden Acute Respiratory Syndrome (SARS) outbreak. These studies found an increase in post-traumatic stress disorder and suicide rates.2,3 A review of the effects of quarantine published in The Lancet this year showed that quarantine in the general population is associated with an increase in post-traumatic stress symptoms, confusion and anger.4 Evidence is now emerging about the effects of “social distancing” for COVID-19 on older adults.

A narrative review found that anxiety, depression, sleep quality and physical activity were all adversely affected in older adults.5 We have observed that older adults have felt disconnected from their social networks, usual activities and support networks. This is exacerbated by the “digital divide”, and our anecdotal experience is that it is often those who are the most vulnerable that have the least access to digital means of connecting to others. We

have also seen older adults delaying medical tests or interventions due to fear of contracting COVID-19.

Residential aged care facilities have been affected in an unprecedented manner, leading to them being referred to as “besieged castles”.6 In Australia, approximately threequarters of COVID-19 mortality has been in aged care residents based on data from JanuaryOctober 2020. All facilities have faced the challenge of adapting to the infection control requirements of the COVID-19 world. Visitor restrictions have had major impacts on the mental health of residents. It also has physical impacts with visitors often being informal “care partners” of residents, for example, assisting with meals or mobility. The issue of visitor restrictions has been deemed of such importance that it has received attention from the Australian Prime Minister and Chief Medical Officer.

The environment is also very different with staff wearing personal protective equipment, along with staff shortages and the resulting need to use staff who do not know the residents.

Dementia is another factor

that becomes more prevalent in older age groups. We have seen challenges such as people who have dementia not being able to understand or remember the restrictions or risks, and consequently being at risk of contracting COVID-19 or being fined by authorities. The reduction in support services either due to COVID-19 changes or concerns of family, have also made it more difficult for people with dementia to live independently in the community and placed additional strain on already stressed carers.

Despite all these challenges, it is important to look for positives that we can build on and give us hope for the future.

A study in Hong Kong during SARS showed that older adults demonstrated more adaptive coping when compared to younger adults.7 We postulate that this may relate to living through past adversity which has contributed to increased resilience. Looking towards the future, there is an opportunity to harness this resilience.

We have also observed remarkable adaptability in older adults. Many older adults have started to increase their use of information and

Recommendations for optimising mental health in older adults •M aintain or increase social connectedness •B e physically active •C onsume a healthy diet • Optimise sleep •R egular mindfulness practice •E ngage in pleasurable activities •A void consuming excessive media coverage of COVID-19 •A void or reduce drugs and alcohol •S ee your health professional and consider referral to a psychologist/ psychiatrist if needed

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We have observed that older adults have felt disconnected from their social networks, usual activities and support networks.

Key points for practice Consider how, in the capacity of a clinician, your older adult patients can increase their social connection Encourage healthy lifestyle behaviours, such as physical activity, balanced diet and quality sleep Discourage alcohol and smoking, and minimise focus on media coverage of COVID-19

communications technology, particularly those who have initial support to do so. We have seen older adults engage with telehealth, video calls and activities via videoconferencing technology such as exercise classes. Video calls have become standard in many residential aged care facilities.

Mental health services like the St Vincent’s Hospital Melbourne service where I work, have been lending devices such as iPads to vulnerable

or isolated consumers. There had already been a gradual whole community shift towards increasing the use of technology in health, but this has been dramatically accelerated by necessity that has arisen from the COVID-19 pandemic.

As a community, we need to be responding to the mental health wave of the COVID-19 pandemic that has already started and is likely to persist after the pandemic. Key preventative strategies would

involve targeting the underlying social disconnection that is at the root of many problems.

As a society, we urgently need to think outside the box to find and fund novel ways for older adults to connect in a COVID-safe manner. We also need to be encouraging lifestyle interventions such as physical activity, healthy diet, quality sleep, mindfulness and pleasurable activities, as well as avoidance or reduction of drugs and alcohol, and

excessive media consumption about COVID-19. This will help to optimise mental health and reduce the risk of developing mental health conditions.

As clinicians, we need to be aware of this growing mental health wave and focus on early identification and intervention to reduce the risk of developing chronic mental health conditions.

Most importantly, we need to bolster resilience and above all, instil hope for the future.

References 1. Chong TWH, et al.

Mental health of older adults during the COVID-19 pandemic: lessons from history to guide our future. Int Psychogeriatr., 2020; 32(10):1249–1250.

2. Cheung YT, Chau PH and Yip PSF. A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong. International Journal of Geriatric Psychiatry, 2008; 23:1231–1238.

3. Lee TMC, et al. Ageing and psychological response during the post-SARS period. Aging and Mental Health, 2006; 10(3):303–311.

4. Brooks SK, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet, 2020; 395, 912–920.

5. Sepúlveda-Loyola W, et al. Impact of Social Isolation Due to COVID-19 on Health in Older People: Mental and Physical Effects and Recommendations.

Journal of Nutrition Health and Aging, 2020; 1–10.

6. Trabucchi M and De Leo D. Nursing homes or besieged castles: COVID-19 in northern Italy. The Lancet Psychiatry, 2020; 7(5):387–388.

7. Yeung DYL and Fung HH. Age differences in coping and emotional responses towards SARS: a longitudinal study of Hong Kong Chinese. Aging and Mental Health, 2007; 11(5): 579–587.

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IMPACT OF COVID-19 ON EMERGENCY MENTAL HEALTH SERVICES TRENDS & UNMET NEEDS A single-centre assessment of emergency mental health visits, pre- and post-first lockdown in VIC (23 March 2020), revealed an increase in the number of people seeking help for anxiety problems but a decrease in the number of depression, psychosis and borderline personality disorder (BPD)-related issues. The latter is of concern as it may reflect an under-servicing of this vulnerable group of individuals during a time of great stress. As well as a gap in addressing the psychological effects, the data also suggest that physical health status associated with schizophrenia, for example, may also not have been adequately addressed during the pandemic lockdown.

I Dr Louise Curtis ST. VINCENT’S HOSPITAL, MELBOURNE, VICTORIA

Ms Zoe Jenkins ST. VINCENT’S HOSPITAL & THE UNIVERSITY OF MELBOURNE, MELBOURNE, VICTORIA

Dr Mark Bevan THE UNIVERSITY OF MELBOURNE, MELBOURNE, VICTORIA

Professor David Castle ST. VINCENT’S HOSPITAL & THE UNIVERSITY OF MELBOURNE, MELBOURNE, VICTORIA

t has been suggested that the COVID-19 pandemic has “caused a parallel epidemic of fear, anxiety and depression”, which will likely impact people with pre-existing mental illness as well as precipitate mental distress in people without pre-existing mental illness.1 Policies such as social distancing, quarantine and isolation have changed the way people interact with one another, leading to increased loneliness and social isolation.

Quarantine and lockdown can induce boredom, irritability and disrupt sleep-wake cycles, all of which can negatively impact pre-existing mental illness, as well as precipitate first episodes of mental illness.

The authors reviewed the impact of COVID-19 lockdown on presentations to Emergency Department Mental Health (EMH) at St. Vincent’s Hospital, Melbourne, 3 months preand post- the first lockdown (23/3/2020) to observe patterns in presentation and reasons for contact (see Table 1).

In summary, we observed no overall change in frequency of contacts to EMH pre- and post-lockdown, however, there was a striking increase in the proportion of people making contact because of anxiety. The contributors to this are understandable, for instance; stressors and concerns surrounding fear of contamination, spreading the virus to family or loved ones, access to supplies, socioeconomic consequences

TABLE 1. Contacts to mental health services pre- and post-COVID lockdown Variable

Pre-COVID N (%)

Number of contacts

Post-COVID p-value N (%)

1085

989

Method of contact

0.614

Telephone

551 (50.8%)

Direct

527 (48.6%) 455 (46.0%)

528 (53.4%)

Referral source Client/self

0.679 484 (44.6%)

425 (43.0%)

341 (31.4%)

291 (29.4%)

Police

101 (9.3%)

95 (9.6%)

Other health service

56 (5.2%)

69 (7.0%)

Family/friend

40 (3.6%)

51 (5.1%)

Acute health

37 (3.4%)

26 (2.6%)

Ambulance

26 (2.4%)

32 (3.2%)

Emergency department

Triage Scale

0.907

A/B

110 (10.2%)

114 (11.5%)

C

155 (14.3%)

152 (15.4%)

D

203 (18.7%)

183 (18.5%)

E

207 (19.1%)

186 (18.8%)

F

135 (12.4%)

118 (11.9%)

G

275 (25.3%)

236 (23.9%)

163 (15.0%)

166 (16.8%)

>.05

117 (10.8%)

80 (8.1%)

0.034

66 (6.1%)

36 (3.6%)

0.011

100 (9.2%)

142 (14.4%)

<.001

12 (1.1%)

19 (1.9%)

>.05

Borderline Personality Disorder

88 (8.1%)

50 (5.1%)

0.006

Suicidal ideation/ deliberate self-harm

158 (14.6%)

129 (13.0%)

>.05

Alcohol/other substance use

150 (13.8%)

142 (14.4%)

>.05

Other/missing

231 (21.3%)

225 (22.8%)

>.05

Primary reason Enquiry Psychosis Depression Anxiety Poor sleep

<.001

and uncertainty can all contribute to increased anxiety. It has been shown that while people with pre-existing anxiety disorders are more likely to self-isolate, they also report higher rates of COVID-related distress than those with no history of mental illness.3 Of particular concern was the decrease in depression, psychosis and borderline personality disorder (BPD) related contacts to EMH services following the lockdown. The authors believe that this is not a reflection of improved mental health of the general population, but rather a reflection of decreased support-seeking.

The immediate circumstances of restricted social interaction and curtailment of exercise and recreational options will have a detrimental impact on levels of depression in the general population, and will accumulate as restrictions continue. As recovery remains in a state of constant uncertainty, and without a definite availability of a vaccine, mental resilience can wear thin. Moreover, the secondary impacts of the pandemic include the socioeconomic effect of the policies used to manage the pandemic, with increased unemployment likely to increase psychological distress.

Indeed, general population surveys have shown that individuals are more concerned about both financial difficulties

The results have been published in summary elsewhere. 2

References 1. Yao H, Chen J-H, Xu Y-F. Patients with mental health disorders in the COVID-19 epidemic. The Lancet Psychiatry. 2020;7(4):e21.

2. Curtis LM, et al. Response to: What’s the psychiatrist’s role in the COVID-19 outbreak? The Australian and New Zealand Journal of Psychiatry.

2020:4867420962858–.

3. Asmundson GJ, et al. Do pre-existing anxietyrelated and mood disorders differentially impact COVID-19 stress responses and coping? Journal of Anxiety Disorders. 2020:102271.

4. Holmes EA, et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The Lancet Psychiatry.

2020; 7(6):547–560.

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BOX 1: Symptoms of psychosis deterioration

BOX 2: Physical health risks associated with schizophrenia

•P atients often report non-psychotic symptoms initially such as depression, anxiety, reduced self-care/hygiene and poor sleep, which may occur over a period of up to 4 weeks prior to relapse

•T hose suffering mental health conditions are disproportionately affected by medical comorbidities, with 60% of the mental health population suffering one or more chronic physical health conditions.

This translates to: •A reduced life expectancy by 14–23 years •S ix times more likely to die from cardiovascular disease •F our times more likely to die from a respiratory disease

•6 0–70% of patients with schizophrenia relapse when they cease medication over the course of 1 year, which leads to an increase in residual psychotic symptoms, reduced effectiveness of antipsychotic medication, and greater social disability over time

and their mental wellbeing than becoming unwell with COVID-19.4 Boredom, isolation and financial uncertainty will cause distress; people who are in lockdown or isolation should be provided with practical advice on positive coping and stress management strategies, as well as provided with a referral for mental health support for ongoing management if desired.

The observed decrease in contacts to EMH by patients with primary concerns of psychosis points to a potential problem associated with underservicing. It has now been more than 6 months since healthcare undertook a mass transition to telehealth, which has demonstrated high levels of satisfaction for patients with severe mental illness,5 yet may also initially disrupt the continuity of care for individuals with schizophrenia and related disorders.

Abrupt changes to delivery of mental health services may increase disengagement, medication non-adherence and distress, all of which can lead to potential relapse.

Moreover, due to the poor communication of body language and the increased tendency for distraction (on both sides) afforded by telehealth, it is imperative that clinicians have heightened awareness of monitoring not only the psychological, but also the physical health risks associated with schizophrenia.

GPs play an important role in

recognition, engagement and continuity of care, yet should be aware of deterioration of symptoms and when a referral to a mental health professional is warranted.

We also observed a reduction in BPD presentations, a psychiatric population that requires high clinical support and often demonstrate poor personal strategies to deal with stress.

Given that individuals with BPD often experience intense loneliness, social isolation will only serve to exacerbate this.

The pre-existing vulnerability associated with BPD means it is likely this population are experiencing distress and carry a high risk of suicide and self-harm without access to support services.

It will be important for GPs to ensure that telehealth services and supports include active listening, relaxation, problem-solving skills and psychoeducation, as well as referrals for treatment such as dialectical behaviour therapy when necessary, for individuals with BPD. Overall, our results suggest that certain vulnerable individuals, notably those with psychosis and BPD, may be slipping through the cracks in terms of accessing care. It will be important for GPs to monitor mental health symptoms of all patients, with particular attention paid to signs of deterioration in individuals with pre-existing mental illness.

5. Hulsbosch AM, et al. Videoconferencing in a mental health service in The Netherlands: A randomized controlled trial on patient satisfaction and clinical outcomes for outpatients with severe mental illness. J Telemed Telecare.

2017;23(5):513–20.

•D evelopment of early warning signs is a useful strategy where the patient, carers and clinicians record various behaviours, thoughts and perceptions characteristic of an impending psychotic relapse, and intervene before development of a full psychotic relapse. Examples include: • Assist with poor sleep • Assistance with reducing or avoiding illicit substances/alcohol if comorbid use • Help with psychosocial stressors • Medication adjustments/reviews • Ongoing psychoeducation of patient and carers • Referral to community mental health

BOX 3: Symptoms of BPD deterioration •P atients with BPD have increased risk of self-harm and suicidal ideation chronically, however these feelings intensify and may manifest as severe disturbance of thinking, mood, aggression, hopelessness, increase in transient psychotic symptoms, and poor impulse control •P atients with comorbid substance or alcohol abuse issues are at higher risk of impulsivity, and therefore should have a lower threshold for inpatient admission.

Harm minimisation strategies or assistance with avoiding substances should be provided •E stablishment of a stable, supportive relationship between clinician and patient remains at the core of managing personality disorders in the community, including: • Good communication with consistent boundaries, such as protocol for contacting service and accessing out of hours care • Maintaining a calm approach • Preparing patient adequately for any changes in care, i.e., holidays/ telehealth to avoid defence mechanisms such as splitting • I f at risk of harming self or others, patients with BPD benefit from a brief, structured hospital admission (48–72 hours)

•W hilst schizophrenia affects only 1% of the population, we see a disproportionate 50% of those with schizophrenia present with comorbid substance use problems •K ey physical health areas to consider: •M etabolic side effects of medication • Dental health • Blood-borne viruses •S moking and chronic lung diseases •C omplications associated with substance use including alcohol and IV substances

BOX 4: When and how to refer to a mental health professional • R eferral to a psychiatrist is appropriate if there is no significant improvement in mental health over a 6-month time frame through primary care and psychologist interventions • R oyal Australian and New Zealand College of Psychiatrists (RANZCP) introduced the Better Access to Psychiatrists, Psychologists and General Practitioners, with the view to tackle the low treatment rates for common mental disorders: www.health.vic.gov.au/ mentalhealthservices/ • S upport with diagnosis, education, medication recommendations and management plans can be accessed through a Medicare item 291 Assessment

Key points for practice Screen patients for deteriorating psychosis symptoms, especially those with schizophrenia Assess physical health risks of patients with existing mental health conditions, especially those with schizophrenia Refer to a mental health specialist where appropriate

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THE EFFECT OF COVID-19 ON SUBSTANCE USE IN AUSTRALIA

Early reports of deteriorating mental health status among Australians during the COVID-19 pandemic also raised questions about substance use (e.g., alcohol, tobacco, illicit substances) and how individuals may have changed their habits over the course of 2020. Worryingly, one in three reported an increase in alcohol consumption; and cannabis, which remained the most commonly used illicit substance, was found to have been used more by a quarter of users.

Gaps in accessing treatment services for drug and alcohol problems were also reported.

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The COVID-19 and you: mental health in Australia now survey (COLLATE) project is an ongoing mental health survey, which aims to identify and track mental health in Australian adults throughout the COVID-19 pandemic.

This article will summarise the key findings from COLLATE and other COVIDrelated studies assessing substance use and specific risk factors associated with substance use consumption.

had the largest proportion of individuals reporting that their use has either remained stable or decreased.

From July to September, 25% of cannabis users reported increased use compared to before March 2020, 65% reported no change, and 10% reported their use had decreased.3 For those individuals who reported increased cannabis consumption from April to June 2020, almost 3 in 5 (58%) reported that their use remained elevated throughout the pandemic (from July to September) as compared to pre-COVID levels.

However, the remaining 2 in 5 (42%) individuals reported that by July to September, their cannabis consumption had either decreased or returned to pre-COVID consumption levels.3

Key findings

Personal concerns

International data suggest that a large proportion of individuals have either started or increased substance use, presumably to cope with the increased stress or negative emotions related to COVID-19.1

Certain individuals mentioned substance use (or abuse) as amongst their greatest concern, including the fear that they would return to substance use after a period of sobriety, or increased dependence. For example, when asked “What is your greatest concern in regard to your own mental health due to COVID-19?”, amongst those who mentioned substance use, the following responses were received:

Dr Caitlin Yolland SWINBURNE UNIVERSITY, MELBOURNE, VIC

Background

Alcohol In early April 2020, 31% of Australians stated that they were drinking more compared to their typical alcohol consumption habits; 56% reported no change, and the remaining 13% reported that their drinking had decreased.

In October 2020, 24% of Victorians stated that they were drinking more than they were in early April 2020.

Similarly, 18% of respondents from other states reported drinking more in October, when compared with April, 2020.

Smoking Rates of smoking have not gone up significantly around the country since April 2020, but there has been a trend towards increased smoking in Victoria compared with other states.

Illicit substances Amongst Australians who reported using illicit substances, cannabis has been the most commonly used substance (71–81%). It was also the preferred substance for 42% of Australians who used illicit substances from July to September 2020.

This was followed by MDMA (11%) and cocaine (9%).3 Cannabis has the largest proportion of people reporting increased use since March 2020, although this has declined over the course of the pandemic.

MDMA, cocaine and ketamine

“Returning to substance abuse and smoking”

pandemic, included job loss, eating more, changes to sleep, as well as stress and depression.

Additionally, women reported increased drinking in comparison to men. This may be contributed to by the increased demands in child-rearing and remote learning while in lockdown.

Take-home messages • A lcohol use appears to have increased for a substantial proportion of Australians 2 • G enerally, smoking has not changed throughout

70%

Risk factors Some individual factors were related to increased alcohol use, including heavier drinking pre‐pandemic, middle age, and average or higher income. Proximal factors that were related to increased drinking during the COVID-19

Victoria

60%

Other states

50% 40% 30% 20% 10% 0 Increased

No change

FIGURE 2. Preferred substances during COVID-19 from July to September 2020 MDMA

11%

Cannabis

42%

9%

Cocaine

8%

“...increasing dependence on various illegal substances” Amongst those who reported using substances, 47% accessed mental health services across July to September 2020. Of concern, 5% were unable to access professional mental health support at this time despite attempting to.3 This is consistent with large numbers of the general population who have also been unable to secure mental health services in 2020.

• Individuals with a pre-existing mental health condition • Individuals with a history of substance use • Individuals who have experienced job loss or other major stressors •M ental health plans and referrals to mental health professions may be necessary for individuals who are at risk. It is important that these individuals can access the support required to mitigate current and ongoing substance use

FIGURE 1. Self-reported drinking behaviours in October 2020 compared to April 1st, 2020 in Australia

“The thought that I might drink or smoke again [after] 12 years off all substances”

Access to treatment

the pandemic in Australia, with the possible exception of Victoria • Cannabis use appears to have increased in a large proportion of Australians who use illicit substances.

In contrast, MDMA, cocaine and ketamine consumption in general either remained stable or decreased for most users 3 • Screening for increased substance use may be particularly important for individuals at greater risk including:

7% Other

17%

6%

Alcohol

LSD

Methamphetamine

Decreased

Key points for practice Screening for increased substance use (e.g., alcohol, tobacco, illicit substances) is important for identifying deteriorating mental health Support the patient to access appropriate health services (e.g., addiction clinic) through appropriate referral pathways

Note. Figure adapted from data published by Sutherland et al. ‘Other’ category included benzodiazepines, ketamine, and pharmaceutical opioids.

3

FIGURE 3. Cannabis use among Australians from July to September 2020 compared to pre-March 2020 70% 60%

References 1. Mark É. et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep. 69(32): 1049–1057.

2. Neill, E., et al. Alcohol use in Australia during the early days of the COVID-19 pandemic: Initial results from the COLLATE project.

Psychiatry and Clinical Neuroscience. 74: 542–549.

50% 40%

3. Sutherland, R., et al.

Key findings from the ‘Australians’ Drug Use: Adapting to Pandemic Threats (ADAPT)’ Study Wave 2. ADAPT Bulletin no.2. Sydney: National Drug and Alcohol Research Centre, UNSW Sydney.

30% 20% 10% 0 Increased

No change

Note. Figure adapted from data published by Sutherland et al.3

Decreased

10 R E V I E W

COVID & PTSD RECOGNITION & TREATMENT COVID-19 has placed an undeniable amount of stress on people in 2020. The stress has been pleomorphic and multifaceted including: fear of the virus itself and contracting it, its impact on daily life routines, as well as loss of social contact and livelihood. For those who became infected with COVID-19, the stress was immense, particularly when hospitalised and/or requiring treatment in an intensive care environment. These can individually or cumulatively result in distressing and concerning long-term mental health problems, including post-traumatic stress symptoms. Being alert to the evolution of cardinal trauma-related symptoms (e.g., nightmares, avoidance behaviours, startle response, detachment, self-blame) and instituting appropriate treatment or facilitating on-referral, is important to reduce the likelihood of long-term sequelae.

Dr John Cooper and Professor Andrea Phelps PHOENIX AUSTRALIA – CENTRE FOR POSTTRAUMATIC MENTAL HEALTH, DEPARTMENT OF PSYCHIATRY, UNIVERSITY OF MELBOURNE, VIC

The COVID-19 pandemic has also created predicaments, particularly for health care workers, that cause ethical dilemmas and cognitive dissonance that has been examined through the lens of “moral injury”.

T

he COVID-19 pandemic has produced a maelstrom of stressors.

At the most severe end of the adversity-spectrum have been life and death situations that are unequivocally traumatic and have caused post-traumatic stress disorder (PTSD). At the less severe end of the spectrum, non-traumatic stressors include lockdown and social isolation, concerns for safety with fear of infection, and financial difficulties from loss of employment. These will not cause PTSD, but they certainly can and have exacerbated pre-existing PTSD. We know that both traumatic and non-traumatic stressors can also cause and exacerbate a range of mental health problems other than PTSD, such as depression, anxiety disorders and substance abuse.

The COVID-19 pandemic has also created predicaments, particularly for health care workers, that cause ethical dilemmas and cognitive dissonance that has been examined through the lens of “moral injury”.1 Examples of these situations include: the conflict between helping sick patients but wanting to

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stay safe and protect loved ones; observing critically unwell and dying patients deprived of human contact and the support from their families; and in some countries whose healthcare systems have been overwhelmed, the rationing of scarce lifesaving medical resources.

PTSD, either with a recent onset or an exacerbated presentation in the COVID-19 context, can be missed by GPs and mental health clinicians, leading to delays in effective treatment. These delays lead to greater social impairment, complexity through comorbidities, and occasionally treatment resistance.

Clinicians can reduce the likelihood of missing a patient’s PTSD by: • Considering the likelihood of exposure to traumatic events in at risk patients e.g., recovering from COVID-19, family member with COVID19, recent bereavement, front line health care workers • Being aware that psychologically traumatised patients might have multiple presentations in general practice settings with vague,

often somatic presentations • Using screening instruments (see Box 1)2 The range of effective and evidence-based treatments for PTSD are comprehensively covered in the recently published third edition of the Australian PTSD Treatment Guidelines.3 The most effective treatments are psychological interventions that: • Enable the patient to confront distressing memories (imaginal exposure) • Manage avoidance responses (in vivo exposure) • Assist the person to address the thoughts and interpretations of what happened and what it means about themselves, others or the world, that are blocking recovery (cognitive therapy/ cognitive processing therapy) • Reduce and manage associated arousal and distress These interventions include trauma-focussed cognitive behavioural therapy (TF-CBT), prolonged exposure (PE), cognitive processing therapy (CPT), trauma-focussed cognitive therapy (CT) and Eye Movement Desensitisation and Reprocessing (EMDR).

While GPs and generalist mental health clinicians can provide psychoeducation and some of the elements of these evidence-based treatments, specialist referral greatly increases the likelihood that a patient presenting with COVID-19-related PTSD will get effective treatment.

The strongest evidence in relation to using pharmacotherapy to treat PTSD in adults, is that it should not be used ahead of evidencebased psychological treatments.

There are situations where medications should be used including: • W hen psychological treatments are unavailable • T he patient’s preference is for medication • Psychological treatment has not been effective, or • T here are comorbidities e.g., major depression, that require medication There has been a paucity of recent quality research into the pharmacotherapy of PTSD. The strongest

research has been with selective serotonin reuptake inhibitors (SSRIs), specifically fluoxetine, sertraline and paroxetine, and the selective noradrenaline reuptake inhibitor (SNRI) venlafaxine.

Our experience in using these classes of antidepressants to treat depression is that there is an equivalency in their effectiveness and tolerability.

It is therefore reasonable to extrapolate to PTSD and assume that any medication from these classes could be helpful in a patient with PTSD. Similarly, other antidepressants that have not been well studied as treatments for PTSD e.g., moclobemide, mirtazepine, may need to be considered as second-line options if the side-effects of SSRIs and SNRIs prove intolerable.

Older antidepressants (tricyclic antidepressants and monoamine oxidase inhibitors) can also be very helpful as potential third-line options.

The addition of a second medication to augment an antidepressant may be necessary if there is a partial response to the antidepressant.

Although the evidence base is mixed, prazosin is often used, particularly for prominent traumatic nightmares and insomnia. Prazosin is usually well-tolerated, even at higher dosages, with hypotension the most common limiting side-effect. Similarly, there is mixed evidence for using atypical antipsychotic and anticonvulsant medications as augmentation of the antidepressant. Given the relatively low-quality research evidence and the significant side-effect profiles of these medications, patients should actively participate in a risk-benefit analysis before commencing these treatments.

We see then that the COVID-19 pandemic can both cause PTSD and exacerbate pre-existing PTSD. Early detection and referral for evidence-based treatment are important in order to reduce severity, chronicity and complex comorbidities. The construct of “moral injury” may be a useful model to understand some of the more ethically challenging traumatic experiences.

There are established local treatment guidelines that inform evidencebased clinical practice.

BOX 1. Primary care PTSD screen for DSM-5 (PC-PTSD-5) Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: • Serious accident or fire • Physical or sexual assault or abuse • Earthquake or flood • Seeing someone be killed or seriously injured • Having a loved one die through homicide or suicide Have you ever experienced this kind of event?

YES NO

In the past month have you:

YES NO

1. Had nightmares about it or thought about it when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. W ere constantly on guard, watchful or easily startled?

4. F elt numb or detached from others, activities, or your surroundings?

5. F elt guilty or unable to stop blaming yourself or others for the event or any problems the event may have caused?

Preliminary results from validation studies suggest that responding YES to three or more questions indicates probable PTSD and the person should be assessed further for trauma symptoms. This is the optimally sensitive cut point (minimises false negatives).

Key points for practice Acknowledge the spectrum of stressors associated with PTSD Recognise ‘red flags’ of PTSD onset and deteriorating PTSD, and how to screen for PTSD Consult the Australian PTSD Treatment Guidelines for effective psychological strategies to manage this condition Pharmacotherapy to treat PTSD in adults should not be considered ahead of psychological treatments

References 1. Phoenix Australia – Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence – PTSD (2020) Moral Stress Amongst Healthcare Workers During COVID-19: A Guide to Moral Injury. Phoenix Australia – Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence – PTSD, ISBN online: 978–0–646–82024–8

2. Prins, A., Bovin, M.J., Smolenski, D.J. et al. The Primary Care PTSD Screen for DSM–5 (PC–PTSD–5): Development and Evaluation Within a Veteran Primary Care Sample. J Gen Intern Med 2016; 31:1206–1211.

3. Phoenix Australia – Centre for Posttraumatic Mental Health. Australian guidelines for the prevention and treatment of acute stress disorder, posttraumatic stress disorder and complex PTSD. Melbourne, Vic: Phoenix Australia, 2020

12 P E R S P E C TI V E

COVID-19 & TELEPSYCHIATRY OPPORTUNITIES & RISKS The COVID-19 pandemic and associated lockdowns have presented a major challenge for accessing healthcare services. However, telehealth has been a boon in terms of being able to have audio and visual contact with patients, and telepsychiatry in particular has seen a substantial uptake. It is important that practitioners are aware of what constitutes ‘good practice’ when employing telehealth, and also ensure that they are aware of its limitations and, where feasible, offer face-to-face appointments to those who prefer them or where a full clinical assessment is not possible, remotely.

Ms Helen Wilding ST VINCENT’S HOSPITAL, MELBOURNE, VICTORIA

A

sking for help with mental health issues is hard at any time, but coronavirus added telehealth to the equation. If you struggle to discuss personal struggles with a stranger at the best of times, how would you manage if you couldn’t see that person face-to-face? Would it help or hinder? Would it be a relief to talk from the comfort of your own home with your cat on your lap? Or would the fear of housemates overhearing add to your anxiety? Would virtual consultations free up time for practitioner and client alike, or would the need to become tech savvy add another hurdle?

COVID-19 has pushed Australians rapidly into telehealth, ready or not, and telepsychiatry is part of that shift. The June 2020 Household Impacts of COVID-19 Survey found that:1 • 20% of Australians had

used a telehealth service in the previous four weeks • 47% (mostly younger people under 65) said they would continue after restrictions eased • T he main benefits identified were convenience, saving time and not having to travel • 87% of respondents who did not want to use telehealth in the future preferred to speak to health professionals in person and 5% said it wasn’t suitable for their condition.

Telehealth consultations are here to stay, but they clearly don’t suit every person, or every situation. So how does that translate to mental health?

Medicare claims for telepsychiatry in Australia increased from 22,119 in the third quarter of 2019 to 35,166 a year later.2 These don’t include the myriad of other telemental health consultations with GPs and allied health professionals from psychologists to art therapists, many of which could not have been imagined before COVID-19.

Telehealth has been found to be a feasible and effective way to deliver mental health care,3 but it is not without challenges. It provides a fresh opportunity to support people who are unable to access faceto-face supports such as those

vulnerable to infection, in custody, geographically isolated or unable to leave home. It is especially attractive to younger people who have grown up with mobile phones, but some people struggle with technology and may not have internet access. Telepsychiatry enables continuity of care during the pandemic, and access to quick consultations, but cyber security adds a new level of risk around patient confidentiality.

Preference for face-to-face consultations is common, and sometimes it is essential, such as for monitoring adverse effects of medication.

Telephone or video technology provide completely different experiences. Videoconferencing is closer to an in person consultation, but you can’t pass a tissue through a screen or make eye contact on a telephone call. How do you know someone is crying if you can’t see them? How do you communicate with a patient who is so unwell that they can’t speak?

Therapeutic alliance is especially important in mental health, and concerns include: • Establishing trust and rapport • Missing visual cues such as facial expressions and body language

How do you know someone is crying if you can’t see them?

How do you communicate with a patient who is so unwell that they can’t speak?

• Making eye contact • Conveying empathy •D ifficulty in expressing emotions verbally, without body language •D isconnection, a feeling of being impersonal •U nspoken communication, such as being able to offer a tissue It’s important to remember that these are issues for both practitioner and client.

“I didn’t know what to expect”,4 sums up the importance of exploring patient perspectives and good communication right from the very beginning. The simplest misunderstandings can create a barrier – for example suggesting that a person ‘go to talk to someone’ immediately conjures up a face-to-face meeting. A faceless stranger on the other end of the phone can be anxiety provoking. A belief that telehealth practitioners are less qualified might need to be addressed. In a pandemicfree world, many of these might be resolved during an initial face-to-face meeting, but that isn’t always possible.

Change is hard for everyone, and telehealth in Australia has been introduced in a rush, during an emergency situation.

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TABLE 1. Opportunities and risks to consider in telemental health

We are still learning how to do it well. These suggestions might help: • Preparing the patient e.g., explain the process, the need for a private place to talk, how to connect • A sk about any concerns around using telehealth – these may be simply overcome • Professional development of telehealth skills, such as how to engage over telephone or video • Extending the same skills to professional supervision and peer consultations • Offering a choice between telehealth and face-to-face meetings (when safe to do so) Telepsychiatry is not black and white. Opportunities create risk and vice versa. Lack of eye contact may be unsettling to one person, while enabling another to talk more freely.

Tackling new technology may overwhelm one, and empower another. Many challenges can be turned around by an open attitude, good communication and training. During a pandemic there may be no alternative, but as face-toface appointments return, telepsychiatry can offer choice and convenience. That means putting effort into making it a viable and attractive option to practitioner and client alike.

Key points for practice Telehealth consultations are appropriate for: • Vulnerable populations who will be at high risk if they contract COVID-19 •P roviding medical certificates or issuing repeat prescriptions •M ental health consultations including counselling •R outine chronic disease check-ups • COVID-19-related conditions Approaches to consider that may help patients feel comfortable with using telehealth: •P repare the patient e.g., explain the process, the need for a private place to talk, how to connect •A sk the patient about any concerns with using telehealth •O ffer a choice between telehealth and face-toface meetings (if and when safe to do so)

Opportunities

Risks

Access

• Increased access e.g., time poor, housebound, geographically isolated • Flexibility/convenience • No travel/time saving • Continuity of care • Increased appointment attendance • Increased choice of providers (for clients) • Lower cost

• Decreased access e.g., elderly, homeless • Engaging new clients • Continuity of Medicare rebates

Technology

• Technology widely available • Mobility – not tied to office • Empowerment

• Choice of technology – telephone/ video • Access to technology - mobile phone (and credit), computer, internet, wifi, software, webcam, headphones • Usability – level of difficulty • Competence • Troubleshooting

Safety

• Infection control/reduced exposure • No need for masks, PPE, disinfection, physical distancing, COVID-19 screening • Decreased violence in the workplace • Brief interventions in crisis

• Personal safety – self harm (clients) • High-risk clients/suicide risk

Confidentiality

• Clear practitioner/client agreements

• Patient confidentiality • Cyber security • Recording and sharing without permission • Privacy – location and interruptions • Ethical and legal issues • Informed consent

Workforce

• Professional development • Peer consultations and supervision

• Resistance to change • Training and supervision • Impact of long screen hours – tedium, loss of concentration, physical discomfort

Preparation

• Simplified appointments • Limited office set up

• Communicating consultation process • Increased admin - assisting client set up

Consultation Practitioner experience

• Visual cues via video better than masked • Insight into home environment for context (with permission) • Shorter consultation times • Easier to conclude consultation

• Metabolic/physical health monitoring • Missing visual cues/body language • Establishing trust/rapport • Therapeutic alliance • Miscommunication • Distractions - incoming mail, alerts, temptation to browse, interruptions • Can’t use unspoken language such as offering a tissue • Confidence in making diagnosis/ risk assessment without visual cues • Eye contact, keeping focus

Consultation Client experience

• Convenience • Access from a comfortable, safe space • Less stigmatising (not seen to attend) • Perceived anonymity on telephone • Not feeling judged based on appearance

• Resistance to change • Lack of face-to-face contact • Less connected, more impersonal • Difficulty expressing feelings verbally • Finding a private space

References 1.Australian Bureau of Statistics.

Household Impacts of COVID-19 Survey: 24-29 June 2020, 2020.

2.Services Australia. Medicare Item Reports [2019Q3-2020Q3 MBS Items 288,353,355359,361,364,366,367,369,370], 2020.

3.Reay RE, Looi JC, Keightley P, Telehealth mental health services during COVID-19: summary of evidence and clinical practice.

Australasian Psychiatry 2020; 28:514-516.

4. Rushton K, Ardern K, Hopkin E, Welsh C, Gellatly J, Faija C, Armitage CJ, Lidbetter N,

Lovell K, Bower P, Bee P, ‘I didn’t know what to expect’: Exploring patient perspectives to identify targets for change to improve telephone-delivered psychological interventions. BMC Psychiatry Vol 20 2020, ArtID 156 2020; 20.

* ®

*The only melatonergic antidepressant1,2

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nia o d e h n /A d o Mo ion ht t g c i We al fun u Sex ion t a p u e Sle contin dis toms o N ymp s

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S P E C I A L

TO P I C

MEDICINAL CANNABIS IN PSYCHIATRY? Professor David Castle CONSULTANT PSYCHIATRIST ST. VINCENT’S HOSPITAL AND PROFESSORIAL FELLOW, THE UNIVERSITY OF MELBOURNE

T

he use of cannabis or cannabis derivatives for various medical maladies has a long history, including, for example, to stimulate appetite in people with HIV/ AIDS; to reduce spasticity in multiple sclerosis; to reduce nausea associated with chemotherapy; and to ameliorate pain and potentially to ‘spare’ the use of opiates. The cannabis plant contains numerous chemicals, with different actions.

Those of most medicinal interest to date are delta-9tetrahydrocannabinol (THC) – the major psychotomimetic – and cannabidiol (CBD).

Australia is arguably a little late in the game when it comes to marijuana as medicine, but we are playing ‘catch up’ and certainly there is substantial interest in the local cannabis industry. We can also learn from other jurisdictions which have had access to medicinal cannabis over extended periods. Victoria led the way with making medicinal cannabis available in Australia, and the Therapeutic Goods Administration (TGA) rescheduled THC from schedule 9 to schedule 8; cannabidiol is a schedule 4 compound, thus has different restrictions from THC. THC can technically be prescribed by any medical practitioner on a named patient basis using the TGA’s Special Access Scheme, but most prescriptions in Australia are written by ‘authorised prescribers’ of medicinal cannabis.

Psychiatric uses of cannabis

are beginning to gain traction but there is understandable concern in our profession about potential adverse effects, mostly informed by experience with plant product used recreationally. For example, an association between cannabis consumption and depression has long been noted, but closer interrogation of the literature points to this mostly being due to reverse causality, with depression leading to cannabis use rather than the other way around. What has been very evident to psychiatrists dealing with people with psychotic disorders such as schizophrenia is the dangers of the use of cannabis by such individuals, as they are highly vulnerable to psychotic relapse and a worsening longitudinal illness trajectory on exposure to cannabis. There are also concerns about the use of high potency cannabis in young people, with an impact on cognitive processes at crucial times in brain development and the laying down of the bedrock of learning.

But such factors should not lead us to dismiss the potential use of cannabis to alleviate psychiatric suffering. One of the important distinctions is between recreational use of plant product in an unsupervised manner, and the medical use of particular formulations for particular

indications. The cannabis plant contains myriad different chemical compounds with sometimes opposing effects.

For example, THC is the major psychotomimetic and can worsen psychotic symptoms in people with schizophrenia (see above), whilst CBD seems to have some antipsychotic effects (see below).

In terms of clinical trials of cannabis products for psychiatric conditions, there is an emerging literature and many current and planned trials, but it is fair to say that there is as yet a paucity of high quality large scale trials in the literature.

Sarris and colleagues (2020) recently reviewed published studies, which I have summarised elsewhere (Castle, 2020), thus (for details of original articles and references, see Sarris et al., 2020):

1) Anxiety disorders A small (n=24) but encouraging trial of CBD (600mg) for social anxiety disorder, where the CBD was taken 1.5 hours before a public speaking engagement; there are no studies of generalised anxiety disorder, and also note that THC causes tachycardia and can induce panic in people who have a predisposition

2) PTSD

7) ADHD

Many people with PTSD find Cannabis sativa assists sleep and reduces arousal/anxiety and this was largely confirmed in a retrospective self-report study (n=80) as well in a retrospective case study (n=11) using CBD (mean dose 49mg)

RCT of 30 adults randomised to nabiximols of placebo showed some benefit for the active compound, in term of core ADHD symptoms

3) Depression Secondary analysis of patients (n=263) with cancer and pain who received nabiximols with some benefit for pain but no benefit for mood: indeed, higher doses associated with lowering of mood

4) Insomnia A case study using CBD (25mg capsule plus 6–25mg liquid); nabiximols or delta9-THC in patients (n=43) with advanced cancer and pain; and a retrospective analysis of patients (n=72) prescribed CBD (25mg) for anxiety all showed benefit for sleep (secondary outcome)

5) Schizophrenia Early small study (n=42) found CBD (600–800mg) to be as effective as amisulpride over 4 weeks; larger RCT (n=88) compared CBD (1000mg) with placebo as add-on therapy to antipsychotics over 6 weeks and found greater improvement in positive symptoms in the CBD group; but a further 6-week add-on RCT (n=36) was negative

6) Bipolar disorder Only case reports published using CBD, with no consistent benefit

In my reading of the literature and listening to patients, I believe there is most likely going to be a place for the medical use of CBD in particular for anxiety, PTSD, sleep problems and possibly schizophrenia (as an adjunct to antipsychotics). THC needs to be used with caution and is arguably contraindicated for people with an existing psychotic illness or bipolar disorder, but appears to have a place in a number of medical conditions, and particularly for chronic pain syndromes where it might be able to free people from the use of opiates. But as Black et al. (2019) in their thorough review and metaanalysis of “cannabinoids for the treatment of mental disorders and symptoms of mental disorders” opine, “..further high-quality studies directly examining the effect of cannabinoids of treating mental disorders are needed”.

Australia is in a position now to enhance the evidencebase regarding medicinal cannabis, and to help refine its place in clinical practice.

References Black N, Stockings E, Campbell G, et al.

(2019) Cannabinoids for the treatment of mental disorders and symptoms of mental disorders: a systematic review and meta-analysis. Lancet Psychiatry doi. org/10.1016/S2215-0366(19)30401-8 Castle D (2020) What is the role of medicinal cannabis in psychiatry?

Mindcafe 2020; 64: 3 Sarris J, Sinclair J, Karamacoska D, Davidson M, Firth J (2020) Medicinal cannabis for psychiatric disorders: a clinically focussed systematic review.

BMC Psychiatry 20: 24

16 M A S T E R C L A S S

INSIDE PRACTICE WEBINAR HIGHLIGHTS PART ONE

Caring for carers, front-line health workers & mental health The COVID-19 pandemic with its associated lockdowns, physical distancing and quarantine measures has had a major impact on the mental health and wellbeing of many Australians, not least our community carers and healthcare heroes.

As the year 2020 drew to a close, it was timely to reflect on the pandemic experience, review what we have learnt about the burden on patients and healthcare providers, and reset our minds and practices to become better equipped in managing this public health crisis, moving forward.

In the first of a twopart series, Inside Practice hosted the webinar, “Caring for carers, front-line health workers and mental health”, which explored the effects of COVID-19 on mood disorders, with a particular focus on depression in the general Australian population and healthcare workers.

Chairing the proceedings, Prof. Castle provided a brief preview of the topics covered.

While the impact of COVID-19 on depression was the key discussion point, additional ramifications of the COVID-19 response, for example on substance use, were also of interest. Moreover, the scope of the discussion in understanding the impact of the pandemic went beyond patients, acknowledging the toll on frontline workers.

With differing public health responses across Australian states and jurisdictions, it was anticipated that the experiences of health professionals would also vary not only from a practice perspective but also a psychological perspective.

“In Australia we have been relatively lucky with fewer number of COVID-19 active cases, but nevertheless we have been touched by it especially as healthcare professionals.”

P R O F. C A S T L E

FACULTY

Professor David Castle Professor Susan Rossell Professor Malcolm Hopwood

The COLLATE project – tracking mental health in Australia during COVID-19 pandemic Insights into the effect of COVID-19 at a community level were provided by Prof.

Susan Rossell. Her interest in improving cognition in those with cognitive disorders and recognising the role that anxiety and depression plays on cognitive abilities, led her to set up the COLLATE project. This is a cohort study tracking the mental health of Australians during the COVID-19 pandemic, an event that was clearly generating a lot of psychological stress from the fear of infection and the resulting social restrictions. The objective was to understand how this threat was impacting the general population and vulnerable individuals, such as those with pre-existing mental health conditions.

The study was initiated in April 2020 and has since generated a wealth of data, which has helped to inform governmental policies and initiatives to support the mental health of Australians.

What is COLLATE? It is a series of monthly (up to 1 year) then yearly online surveys involving individuals ≥18 years of age.

Accompanying a core set of questions that are asked each month, are additional questions that are more relevant to the context at the time of the survey.

Snowball sampling using social networks, has been used to recruit survey participants. Demographic data as well as COVID-19-related concerns and psychological status are captured. At the time of the webinar (1st December 2020), approximately 8,000 people had been recruited.

What have we learnt from COLLATE so far?

Concerns are changing over time In April 2020, the key areas of concern in the short- and long-term were identified as: • Social isolation • Concern for loved ones • Work/home balance • Losing job and financial stress • Mental health Over the course of 2020, the survey revealed that the hierarchy of these concerns had changed, and

by November 2020 when the nation was getting a little closer to normality, concerns about the economy were starting to emerge.

Government restrictions are negatively impacting mental health On the 1st April 2020, when the survey participants were asked about how the government restrictions (instituted in March 2020 across the country) were affecting their mental health, approximately 60% responded ‘negatively’ or ‘very negatively’. Prof. Rossell commented that while this figure remained similar, in a more recent glance of the data, there were large variations across the different states, being disproportionately higher in Victoria for instance.

Levels of depression, anxiety and stress are higher in all respondents Using the depression, anxiety, stress scales (DASS), a selfreporting instrument that has good correlation between self-report and diagnosis of a mood or anxiety disorder, the survey found that the

general population had 3 times higher levels of depression, anxiety and stress compared to previous years (Figure 1, below right).

In individuals with an existing diagnosed mental health condition, the prevalence of depression, anxiety and stress was 5–5.5 times higher than in those without. This was particularly evident among men with bipolar disorder.

While typically, 10% of those with a mental health disorder will report severe negative emotions in a given year, the survey revealed that as many as a third had moderate-toextremely severe depression, anxiety, and stress. This was especially evident among those with eating disorders who universally had higher levels of moderate, severe and extremely severe depression, anxiety and stress compared to the general population.

Many young adults (18–24 years) are reporting suicidal ideation In terms of predicting who are most likely to be at risk of experiencing negative emotions, age was found to be a major factor, especially youth (18–24 years old) and the elderly, being female and having a mental illness.

“Suicidal ideation appears to be sat at expected levels for most of the population except our youth.”

P R O F. R O S S E L L

In the period between May and June 2020, youth (18–24 years old) reported extremely high levels of suicidal ideation

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with 40% reporting they would be better off dead or wishing they were dead.

Prof. Rossell remarked that although the figures have come down since, they still remain worryingly high.

Demand for mental health services is higher than pre-pandemic period In a typical year, approximately

20% of the population is referred to mental health services by GPs. According to the survey in May 2020, there was little change, although

by August 2020 this had risen to 31%. While this reduced to 26% by September 2020, Prof.

Rossell indicated that the number of individuals accessing mental health services remains reasonably high.

“Of concern, 1 in 5 have been unable to secure mental health assistance at the moment.”

P R O F. R O S S E L L

BOX 1.

Teaching patients ‘adaptive coping’

FIGURE 1. Australian mental health (Apr)

M EAN

DASS

S CO R ES

60

50

40

30

1 8 – 24

25–90

AG E

General population 3x higher

CCEPT that it is ok to A be anxious

Norms No MH Diagnosis MH Diagnosis

MH diagnosis 5-5.5x higher

Focusing on the positives of the pandemic As well as assessing the concerns and negative impact of COVID-19, the survey also captured what people felt were positive experiences of the pandemic. The top three positive influences were: the ability to complete jobs around the house, have more downtime and time with the family.

FOCUS on what one is grateful for EACH out to loved R ones

21-35% showed moderate-to-extremely severe depression, anxiety and stress

REASSURE that some things in life are still certain

20

MAINTAIN a routine 10

0

SEEK professional health support Depression Anxiety

Stress

Total DASS DASS

Depression Anxiety

MEASURES

Stress

Total DASS

Key points for practice I ncrease screening for depression, anxiety and stress, especially of those with an existing mental disorder, youth and the elderly Intervene early to minimise long-term mental health effects Continue to monitor for symptoms 12-months post pandemic Implement screening tools and mental health resources as a matter of course Review and reassess existing mental health plans of vulnerable patients Familiarise yourself with youth mental health services e.g., Kids Helpline, Beyond Blue and headspace Promote adaptive coping (See Box 1, left)

18 DEPRESSION DURING THE PANDEMIC PRACTICAL SUGGESTIONS FOR CLINICAL PRACTICE Exploring the associations of depression and COVID-19 further and extending on the practical suggestions, Prof. Hopwood drew on the literature and learnings from other historical coronavirus outbreaks to help unravel whether COVID-19 infection predisposes an individual to depression.

Is there evidence of psychopathology of COVID-19 infection itself?

Based on a review conducted mid-2020, most of the data available was confined to those with severe COVID-19 infection.

For instance, patients who had become severely unwell were reported to have experienced delirium and agitation; and a small study signalled dysexecutive syndrome on discharge in patients who contracted COVID-19 infection.

While there have also been case reports of encephalitis associated with COVID-19, this association is still under debate.

What can we learn from other coronavirus infection outbreaks?

Drawing on experience from MERS and SARS infections, there is a large body of evidence of their association with low mood disorders, particularly depression, well beyond the phase of infection. Moreover, the rates of depression, anxiety and post-traumatic stress disorder persisted at much higher rates than those in the general population.

“In terms of the pandemic, we may think about phases where the main problem moves away from one of acute viral infection to, in essence, a mental health pandemic of subsequent disorders.”

P R O F. H O P W O O D

How is COVID-19 driving depression and anxiety?

There are multiple stressors

TABLE 1. What is the link of COVID-19 to depression and anxiety?

• Community stressor

• General stressor

• Traumatic stressor

• Systemic illness

• ?CNS involvement

• ?Role of inflammatory

• Side effect of treatment • ?At risk groups including healthcare workers

TABLE 2. Key messages • Information is key; people who are quarantined need to understand the situation • Effective and rapid communication is essential • Supplies (both general and medical) need to be provided • The quarantine period should be short and the duration should not be changed unless in extreme circumstances • Most of the adverse effects come from the imposition of a restriction of liberty; voluntary quarantine in associated with less distress and fewer long-term complications • Public health officals should emphasise the altruistic choice of self-isolating

driving COVID-related mood disorders (Table 1).

The type of stressor depends on an individual’s context, but it is evident that healthcare workers are exposed to many stressors, not least the trauma of treating patients, the emotional toll of mortality and communicating bad news to families and loved ones. This burden should not be underestimated.

“We [healthcare providers] are an atrisk group because we aren’t traditionally good at self-care and, where necessary, seeking out professional support.”

P R O F. H O P W O O D

For individuals who become infected, the stressors are related to the risk and development of systemic symptoms and the side effects of treatment.

Quarantine and social isolation negatively impact mood A literature review revealed a large number of studies looking at the psychological impact of quarantine, although worth noting only a few are wellcontrolled studies. Nevertheless, they provide some insights into the negative effects as reflected in the emergence of posttraumatic stress symptoms, confusion and feelings of anger.

These appear to be fuelled by a longer duration of quarantine, fears of infection, frustration, boredom, insufficient supplies and information. So how can these stressors be better managed? Prof. Hopwood outlined the key takeaways from this review (Table 2).

Economic recession will likely add to the mental health burden Based on previous data on economic recessions and their impact, it is estimated that

Key points for practice Care for yourself.

Healthcare providers are not immune to depression, stress, anxiety and substance abuse Seek early professional help. Recognise the symptoms and act on them before they become a long-term problem Restrict media consumption. Relevant to both the general community and healthcare providers Communicate with patients. Provide information that clearly explains the rationale for the public health response; and detail what support services are available

an extra 750–1000 additional suicides may eventuate if the economic impact of the pandemic is as bad as initially thought, with high rates continuing for up to five years. The most vulnerable are expected to be those who are young and those living in rural and regional Australia. Such estimates have led a call to action for the Commonwealth Government to ensure an appropriate mental health response that would see an increase in availability and accessibility of services and resources.

Increased demand for mental health care is likely to fall on GPs While it is unknown exactly how many individuals who experience an increase in mental health burden will actually present to GPs, it is anticipated that there will be an increase in the demand for services. Early signals of

increased number of mental health care plans suggest that these individuals are presenting already. Depression, anxiety and substance abuse are likely to be the main reasons for presentation, although for the most part, these are not going to be related directly to COVID-19 infection in Australia.

In terms of management of this cohort of individuals, Prof. Hopwood believed the approaches would not be much different to situations presenting outside of the context of the pandemic.

Lifestyle, psychological and pharmacotherapy approaches to managing mood disorders The challenge is that for new onset mood disorders developed during the time of the pandemic, many may attribute this to the pandemic and not see it as a condition that merits a health visit in its own right.

Consequently, seeking timely treatment may be compromised.

Nevertheless, psychosocial and lifestyle changes (including psychoeducation) should be the foundation of managing mood disorders and should be discussed with the patient on every occasion.

Pharmacotherapy should not be considered as a first-line approach automatically. A shared-care decision approach is important where the choice of antidepressant is based on the patient’s clinical profile and preference together with the safety (side effects) and efficacy of the medication.

“Only 40% of people have a clear response to firstline pharmacotherapy.

The rates with CBT aren’t actually that much higher.”

P R O F. H O P W O O D

To watch the webinar highlights, scan the QR code

Brintellix® enables patients with major depressive disorder (MDD) to:

1–6

Feel better*

Think better*

Function better* *Brintellix demonstrated superior efficacy on depressive symptoms (MADRS, HAM-D24) and improved cognitive symptoms (DSST, RAVLT) and functional capacity (UPSA) in MDD (statistically significant vs. placebo, p<0.05).

PBS Information: This product is not listed on the PBS.

Please review the full Product Information before prescribing. Product Information is available by calling Lundbeck on 1300 721 277.

Minimum Product Information: Brintellix (vortioxetine hydrobromide). Pharmacology: BRINTELLIX has multimodal activity, which is a combination of two pharmacological modes of action: direct modulation of serotonin receptor activity and inhibition of the serotonin transporter. Nonclinical data suggest that this leads to modulation of neurotransmission in several systems, including serotonin, norepinephrine, dopamine, histamine, acetylcholine, GABA and glutamate systems. Indications: Treatment of major depressive disorder in adults including prevention of relapse. Vortioxetine is not indicated for paediatric use. Dosage & Administration: To be taken with or without food. Adults: 10 mg once daily; depending on individual response maximum 20 mg once daily or reduced to 5 mg once daily. Elderly (≥65 years): 5 mg once daily; increase to 10 mg once daily if required. Dosage adjustment may be required for strong CYP2D6 inhibitors or CYP450 inducers. Treatment for at least 6 months is recommended for consolidation of response.

Contraindications: Hypersensitivity to any component of BRINTELLIX. Concomitant treatment with MAOIs or treatment within 14 days of MAOIs. Precautions: Clinical worsening and suicide risk; Neuroleptic Malignant Syndrome; Serotonin Syndrome; activation of mania/hypomania; seizures; haemorrhage; hyponatraemia; severe hepatic impairment; severe renal impairment; raised intraocular pressure; angle-closure glaucoma; pregnancy (Category B3); electroconvulsive therapy; breastfeeding is not recommended.

Interactions: MAOIs (see full PI for details); serotonergic medicines including tramadol and triptans; St John’s Wort; Cytochrome P450 inducers e.g. rifampicin; Cytochrome P450 inhibitors e.g. bupropion; antiplatelets; anticoagulants; lithium; tryptophan; medicines lowering the seizure threshold including SSRIs, SNRIs, tricyclics, neuroleptics, mefloquine, tramadol. Adverse Effects: nausea; vomiting; diarrhoea; constipation; decreased appetite; sedation; generalised pruritus; hyponatraemia*. For all other adverse events see full PI. Date of TGA approval: 31 March 2014. Date of TGA update: 21 September 2020. Date of Minimum PI: 12 Nov 2020. *Please note changes to minimum product information in italics.

GLOSSARY: DSST: Digit Symbol Substitution Test; HAM-D24: 24-item Hamilton Depression Scale; MADRS: Montgomery-Åsberg Depression Rating Scale; MDD: major depressive disorder; RAVLT: Rey Auditory Verbal Learning Test; UPSA: University of San Diego Performance-Based Skills Assessment. REFERENCES: 1. Katona C, et al. Int Clin Pyschopharmacol 2012; 27(4):215–223. 2. Alvarez E, et al. Int J Neuropsychopharmacol 2012; 15:589–600. 3. Brintellix Australian Approved Product Information. 4. McIntyre RS, et al. Int J Neuropsychopharmacol 2014; 17(10):1557–1567. 5. Mahableshwarkar AR, et al. Neuropsychopharmacol 2015; 40(8):2025–2037.

6. McIntyre RS, et al. Int J Neuropsychopharmacol 2016; 19(10):1–9.

Lundbeck Australia Pty Ltd ABN 86 070 094 290. Ground Floor, 1 Innovation Road, North Ryde NSW 2113. Ph: +61 2 8669 1000. Fax: +61 2 8669 1090. Medical Information: 1300 721 277. Brintellix is a registered trademark of H. Lundbeck A/S. AU-BRIN-0300. February 2021. 000649_Inside_Practice. ®

®

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20 M A S T E R C L A S S

INSIDE PRACTICE WEBINAR HIGHLIGHTS PART TWO

COVID-19: Severe mental illness implications & challenges In the second of the twopart series, Inside Practice hosted the webinar, “COVID-19: Implications and challenges for those with severe mental illness”, which explored the effects of COVID-19 specifically on psychotic disorders such as schizophrenia.

FACULTY

Professor David Castle Ms Zoe Jenkins Dr Mahesh Jayaram

Prof. Castle opened the session by providing valuable practical tips to the participants on how to look after patients’ mental health, as well as their own as healthcare providers.

Among the tools discussed was FACE COVID, an acronym developed by Dr Russ Harris (Author, The Happiness Trap) and based on the acceptance and commitment therapy:

F Focus on what’s in your control A Acknowledge your thoughts & feelings C Come back into your body E Engage in what you’re doing C Committed action O Opening up V Values I Identify resources D Disinfect & distance

Prof. Castle continued with tips from self-care, such as having a sleep, diet and exercise routine, doing yoga or a home gym workout as well as meditation; to tips on ensuring social connectedness e.g., engaging with family members by playing board games or watching TV/movies together; catching up with friends and extended family over the phone or video; or joining online communities; through to creating positive distractions and environments, such as using passive media e.g., reading books or active media or tackling those jobs that kept being put off. It was important to be able to look back and feel positive about what was achieved during the pandemic.

“Make your environment reflect how you want to feel, rather than how you do feel.”

P R O F. C A S T L E

NEUROPSYCHIATRIC ASPECTS OF COVID-19 Widening the discussion on the impact of COVID19, Dr. Jayaram explored the neurological and neuropsychiatric complications of COVID19, which could present in the primary care or emergency settings.

Our understanding of the neuropsychiatric impact of COVID-19 has evolved over time Based on an early case series of patients with COVID-19 infection, apart from the commonly associated respiratory symptoms and high temperatures (fever >38.5ºC), researchers began to notice other features such as agitation, cognitive distortions and dysexecutive syndrome. Changes in the brain were detected on MRI scans e.g., inflammation and CSF analyses revealed elevated IgG, while more recent studies have detected the SARS-CoV-2 in CSF and brain tissue.

“Up to 84% of individuals with COVID-19 infection presented with neurological issues.”

DR. JAYA R A M

While it was clear early on in the pandemic that the COVID-19 virus predominantly affects the respiratory system and potentially the cardiovascular and renal systems, its impact on the central nervous system (CNS) began to gain traction from April 2020 onwards.

Younger people appear more vulnerable to neuropsychiatric complications than older individuals Findings from the UK-based CoroNerve study revealed how younger people (≤60 years of age) with COVID-19 were more likely to experience neuropsychiatric complications than older populations (>61 years), who in turn were more likely to

experience cerebrovascular complications (Figure 2). This increased risk of clotting, commonly manifested as ischaemic strokes, although haemorrhagic strokes have been described.

Other complications include encephalopathies; and worryingly, many reports reveal how fast symptoms can deteriorate. Dr. Jayaram commented that this rapid decline may reflect a sudden onset of stroke due to an increased risk of clotting.

Infants as young as 3 months have shown neurological deficits In one study, infants (<3 months of age) who were found to test positive for COVID-19 exhibited neurological symptoms such as: axial hypotonia, drowsiness and abnormal moaning sounds.

It was unknown whether the infection had been transmitted during pregnancy or if it was acquired after birth. The parents of these

infants had not been tested, limiting the interpretation of these findings.

COVID-19 may lead to parkinsonian symptoms In a case report of a man who recovered from the acute symptoms of COVID-19 infection was subsequently found to exhibit motor deficits at day 21 manifesting as changes in writing and development of a tremor and had become confused.

Anosmia (loss of smell) and ageusia (loss of taste) are common neurological features of COVID-19 infection Dr. Jayaram discussed the role of the olfactory nerve and bulb in the transmission of COVID-19 into the CNS. An earlier study of human coronavirus revealed how it could reach the brain and CSF through the olfactory nerve and olfactory bulb within 7 days and cause inflammation and demyelination. Indeed,

Key points for practice Be aware of the spectrum of neurological and neuropsychiatric symptoms that may present pre- and postCOVID-19 infection Be cognisant of the age effects – younger (≤60 years of age) are more likely to manifest in neuropsychiatric symptoms Monitor and support patients with long COVID disease

animal studies showed how the removal of the olfactory bulb restricted coronavirus invasion of the CNS. Recent MRI findings of enlarged olfactory clefts in COVID-19 infected patients further corroborated its role.

Neuropsychiatric effects are common during acute and recovery phases of COVID-19 infection During the acute phase of

21

ISSUE 01 /// insidepractice.com.au

CLINICAL PERSPECTIVE TELEPSYCHIATRY

FIGURE 2. Age distribution of CoroNerve surveillance study Varatharaj et al., Jun 2020 Lancet Psychiatry – CoroNerve Study Group

35 Neuropsychiatic Cerebrovascular

PAT IE NTS

( %)

30

“Telepsychiatry enables continuity of care during the pandemic, and access to quick consultations.”

25

MS. JENKINS & PROFFESSOR CASTLE

20 15

Ensuring patient connectedness during telepsychiatry is becoming increasingly recognised. To facilitate this, guidance has been issued by RANZCP:

10

Setting up your digital space appropriately Preparing the person having the consultation

5 0

Adapting your therapeutic technique for a video consultation 10–20

21–30

31–40

41–50 AG E

COVID-19, many patients experience insomnia, anxiety, impaired concentration and memory, depressed mood, confusion, emotional lability, altered consciousness and pressured speech. However, during recovery, suicidality, fatigue, frequent recall of traumatic events, sleep disorder and psychosis manifest.

51–60

61–70

71–80

81–90

>90

(YEARS)

These disorders are becoming increasingly associated with long COVID disease, as is the emerging issue of brain fog.

In a survey of patients with long COVID, the key themes that emerged from their experiences included: the ‘hard and heavy work’ that was needed to deal with the symptoms and seek care;

Managing clinical risks Capturing and recording clinical details Setting up appropriate billing structures

the fear of the unknown; uncertainty of recovery; and the importance of finding a GP that was understanding, supportive and empathetic to their situation.

To watch the webinar highlights, scan the QR code

However, it may be that some patients will need or prefer to have a face-to-face consultation. One scenario would be a patient with schizophrenia who is struggling with compliance to medication and may be a suitable candidate for a long-acting injectable (LAI). Clinicians would need to see the patient to make an assessment and administer the medication. Of note, LAIs should be initiated by a mental health specialist.

For more information, visit the RANZP website (www.ranzcp.org) or scan the QR code

22

Inside Practice Psychiatry acknowledgements

EDITOR- IN - CHIEF Professor David Castle

THE IMPACT OF COVID-19 ON EMERGENCY MENTAL HEALTH SERVICES TRENDS & UNMET NEEDS

david.castle@svha.org.au

EDITOR Dr Beejal Vyas-Price (PhD) beejal.price@gmail.com

PRODUCTION EDITOR Rachael Lewis rachael@insidepractice.com.au

Continuing on the theme from the first webinar in understanding the impact of COVID-19 on mental health, Ms Zoe Jenkins presented data on the frequency and features of patients who presented at emergency mental health contact points within St Vincent’s Hospital, Melbourne, VIC. This was a retrospective audit that spanned the 3 months prior and post the first city-wide lockdown in Melbourne, instituted on the 23rd March 2020. Patients who had made contact with the emergency department; triage (24/7 phone advice); PACER – police, ambulance and clinical early responder; and CATT – crisis assessment and treatment team, were included. The data captured included reason for admission, patient demographics and service utilisation.

What did we learn about mental health emergency presentations pre- and post-first lockdown?

There were a similar number of emergency mental health contacts pre- and post- first lockdown. Patients didn’t differ on demographic variables e.g., in age, local government area, indigenous status or interpreter requirement. There was no difference on referral source or acuity of the contacts.

However, at 3 months postlockdown, marked increases were observed in people making contact because of anxiety (Table 3). In contrast,

TABLE 3. Contacts to mental health services pre- and post-COVID lockdown Reason for contact

Pre-lockdown N=1085

Post-lockdown N=989

p-value

Enquiry

163 (15.0%)

166 (16.8%)

>.05

Anxiety

100 (9.2%)

142 (14.4%)

<.001

Psychosis

117 (10.8%)

80 (8.1%)

0.034

Borderline personality disorder

88 (8.1%)

50 (5.1%)

0.006

Depression

66 (6.1%)

36 (3.6%)

0.011

158 (14.6%)

129 (13.0%)

>.05

12 (1.1%)

19 (1.9%)

>.05

Alcohol/other substance use

150 (13.8%)

142 (14.4%)

>.05

Other/missing

231 (21.3%)

225 (22.8%)

>.05

Suicidal ideation/deliberate self-harm Poor sleep

For partnership enquiries, please contact: rachael@insidepractice.com.au Inside Practice Psychiatry is a publication of Inside Practice Australia Pty Limited

A DV E R T I S E R S I N D E X Servier Valdoxan Page 14 Lundbeck Brintellix Page 19 Janssen

there were significant decreases in those making contact because of psychosis, borderline personality disorder and depression.

No differences in suicidal ideation, self-harm, substance use or poor sleep were noted during these time periods.

“As recovery remains in a constant state of uncertainty, mental resilience can wear thin.”

M S. J E N K I NS

On further exploration, the increased presentation of anxiety was related to fear of contamination and spreading the virus to family and loved ones. It was suggested that those with pre-existing anxiety disorders were likely to experience higher COVID-related distress.

The data revealed that there was a 30% reduction in the number of presentations for psychosis post-first lockdown.

This was not reflecting an improvement in the mental health status of the general population but rather likely reflects underservicing. The lack of service engagement, reduced monitoring of both the physical and lifestyle risks, and stopping treatment or treatment breaks, places the vulnerable individual with a psychotic condition, such as schizophrenia, in jeopardy of a relapse. Continuity of care is therefore of vital importance.

“The mental health impacts of COVID-19 will be higher for people with schizophrenia.

Changes to access can precipitate crises.”

of borderline personality disorder (BPD)?

A 45% reduction in emergency presentations was observed among those with BPD. These individuals require high clinical support and demonstrate poor strategies in dealing with stress. Pre-existing vulnerability associated with BPD means they have a high risk of self-harm and suicide in the absence of support.

What are the implications for the fewer presentations

Page 23

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Special announcement

Key points for practice Look out for vulnerable individuals who may be slipping through the cracks Monitor signs and symptoms of mood disorders in existing patients

M S. J E N K I NS

What are the implications for the fewer presentations of psychosis?

Invega Trinza & Invega Sustenna

Monitor physical and lifestyle factors

Professor David Castle will shortly be taking up a new role as Scientific Director, Centre for Complex Interventions, Centre for Addictions and Mental Health, Toronto, Canada; and Professor, University of Toronto

Supporting people with schizophrenia

on their journey to possibility.

Daily

Monthly

4-per-year

1,2

ORALS

Invega Trinza PBS Information: Authority required (STREAMLINED) 6832 Schizophrenia.

Invega Sustenna PBS Information: Authority required (STREAMLINED) 4246 Schizophrenia.

Please review the full product information before prescribing.

Please review the full product information before prescribing.

INVEGA TRINZA MINIMUM PRODUCT INFORMATION. INDICATIONS: INVEGA TRINZA , a 3-month injection, is indicated for the maintenance treatment of schizophrenia in adult patients who have been adequately treated with the 1-month paliperidone palmitate injectable product for at least four months. CONTRAINDICATIONS: Hypersensitivity to either paliperidone or risperidone, or to any of the excipients in the INVEGA TRINZA® formulation.

PRECAUTIONS: Elderly and elderly patients with dementia; Extrapyramidal symptoms, especially with concomitant psychostimulants; Pregnancy; QT prolongation; Neuroleptic malignant syndrome; Tardive dyskinesia; Hypersensitivity reactions; Hyperglycaemia and diabetes mellitus; Weight gain; Hyperprolactinaemia; Orthostatic hypotension and syncope; Leukopenia, neutropenia and agranulocytosis; Venous thromboembolism; Intraoperative floppy iris syndrome; Potential for cognitive and motor impairment; Seizures; Dysphagia; Suicide; Parkinson’s disease; Lewy bodies dementia, Antiemetic effect, Priapism; Disruption of body temperature regulation; Administration (avoid inadvertent injection into a blood vessel); Cardiovascular disease; Renal/hepatic impairment; Lactation; Paediatric and Alcohol. INTERACTIONS: Centrally acting drugs and alcohol; medicines that cause QT prolongation; medicines containing risperidone or oral paliperidone; psychostimulants; levodopa and other dopamine agonist; medicines that induce orthostatic hypotension; carbamazepine. ADVERSE EFFECTS: Weight increased/decreased, anxiety, schizophrenia, insomnia, depression, agitation, suicidal idealisation, nasopharyngitis, upper respiratory tract infection, urinary tract infection, influenza, akathisia, headache, irritability, cough, decreased appetite, injection site induration/pain, fatigue, diarrhoea, hyperglycaemia, hypertension, local injection site reaction, nausea, somnolence/ sedation, tremor, Parkinsonism, tachycardia, musculoskeletal pain, back pain, amenorrhea, menstrual disorder, transaminases increased. Others see full PI. DOSAGE AND ADMINISTRATION: INVEGA TRINZA® is to be used only after the 1-month paliperidone palmitate injectable product has been established as adequate treatment for at least four months. In order to establish a consistent maintenance dose, it is recommended that the last two doses of the 1-month injection be the same dosage strength before starting INVEGA TRINZA®. Initiate INVEGA TRINZA® at the time when the next 1-month paliperidone palmitate dose was to be scheduled with an INVEGA TRINZA® dose based on the previous 1-month injection dose. INVEGA TRINZA® may be administered up to 7 days before or after the monthly time point of the next scheduled paliperidone palmitate 1-month dose. Following the initial INVEGA TRINZA® dose, INVEGA TRINZA® should be administered every 3 months. If needed, dose adjustment can be made every 3 months in increments within the range of 175 mg to 525 mg based on individual patient tolerability and/or efficacy. Due to the long-acting nature of INVEGA TRINZA®, the patient’s response to an adjusted dose may not be apparent for several months. See full PI for switching information from other oral and long-acting injectable antipsychotics; dosage in special populations; maintenance therapy and missed doses.

VERSION ADMINISTRATION: Consult full PI for instructions for use. Date of Preparation: 31 October 2018. REFERENCES: 1. INVEGA SUSTENNA Approved Product Information. 2. INVEGA TRINZA Approved Product Information. ®

®

1.0

INVEGA SUSTENNA® Minimum Product Information. Indication: INVEGA SUSTENNA® is indicated for the acute and maintenance treatment of schizophrenia in adults. Contraindications: Hypersensitivity to either paliperidone or risperidone, or to any of the excipients in the INVEGA SUSTENNA® formulation. Precautions: Elderly; Elderly patients with dementia; Extrapyramidal symptoms, with or without concomitant psychostimulants; use in pregnancy; QT prolongation; Neuroleptic malignant syndrome; Tardive dyskinesia, Hypersensitivity reactions, Hyperglycaemia and diabetes mellitus; Weight gain; Hyperprolactinaemia; Orthostatic hypotension and syncope; Leukopenia, neutropenia and agranulocytosis; Venous thromboembolism; Intraoperative floppy iris syndrome; Antiemetic effect; Potential for cognitive and motor impairment; Seizures; Dysphagia; Suicide; Priapism; Disruption of body temperature regulation; administration (avoid inadvertent injection into a blood vessel); use in patients with concomitant illness (Lewy body dementia; Parkinson’s disease; Cardiovascular disease); Renal/ hepatic impairment; Alcohol; Pregnancy; Lactation; Children & adolescents <18 years. Interactions with other medicines: Centrally acting drugs and alcohol; medicines that cause QT prolongation; medicines containing risperidone or oral paliperidone; psychostimulants; levodopa and other dopamine agonist; medicines that induce orthostatic hypotension; carbamazepine. Adverse Reactions: Insomnia, headache, agitation, somnolence/ sedation, agitation, anxiety, dizziness, injection site reaction/pain, akathisia, Parkinsonism, vomiting, abdominal discomfort/pain, constipation, diarrhoea, dry mouth, nausea, toothache, asthenia, fatigue, upper respiratory tract infection, urinary tract infection, skin laceration, alanine aminotransferase increased, weight gain, back pain, musculoskeletal stiffness/pain, myalgia, pain in extremity, extrapyramidal disorder, nightmare, suicidal idealisation, cough, hypertension, nasopharyngitis. Others see full PI. Dosage: Recommended initiation dose of 150 mg on day 1 and 100 mg one week later (day 8), both administered in the deltoid muscle. The recommended subsequent monthly dose is 75 mg; this can be increased or decreased in the range of 25 to 150 mg based on individual patient tolerability and/or efficacy. Missed doses can be avoided by giving the second dose 4 days before or after the one-week (day 8) timepoint. Following the second initiation dose, monthly doses can be administered in either the deltoid or gluteal muscle. Adjustment of the maintenance dose may be made monthly. When making dose adjustments, the prolonged-release characteristics of INVEGA SUSTENNA® should be considered, as the full effect of the dose adjustment may not be evident for several months. See full PI for switching information from other oral and long-acting injectable antipsychotics; dosage in special populations; maintenance therapy and missed doses. Administration: Consult full PISIGNATURES for instructions DATE for use. Date of Preparation: 09 November JOB STATUS SIGNATURES2020.

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