Mental health

Consistent national mental health policy and planning are needed to adequately care for their special needs

John Allan

Focusing on people at particular risk of self-harm and assault with firearms could reduce injury and death rates

Joel Negin · Jane Bell · Lorraine Ivancic · Philip Alpers · Natasha Nassar

To the Editor: Despite the rapid uptake of telemedicine during the coronavirus disease 2019 (COVID‐19) pandemic,1 it is important to identify the barriers that hinder the delivery of alternate modes of care among specific populations. We share our reflections on the challenges of implementing telemedicine in a tertiary addiction medical clinic in Melbourne, providing treatment for about 105 patients each month. At the start of the COVID‐19 pandemic in February 2020, videoconferencing appointments were encouraged, supported by technical assistance from a clinician. During the Stage 4 lockdown period (August to September 2020 inclusive), appointments were switched to videoconferencing, with face‐to‐face only offered where clinically necessary (eg, for long‐acting injectable opioid agonist treatment). For patients unable to access videoconferencing, telephone appointments were offered. The uptake of videoconferencing was low, comprising 21% (n = 47) of appointments conducted during lockdown versus 57% (n = 128) via telephone (Box). After the lockdown (November 2020 to February 2021), there was a gradual return to face‐to‐face appointments. Seven per cent (n = 28) of appointments were done via videoconferencing while 40% (n = 155) remained via telephone. Difficulties in connecting to the videoconferencing platform, poor audiovisual quality and time spent troubleshooting contributed to the low uptake of videoconferencing. While telemedicine has been a convenient mode of health care delivery during the COVID‐19 pandemic,3 not all patients benefit from it. People accessing specialist addiction treatment are often from sociodemographic groups that are digitally excluded, such as the unemployed and people with low income or with disabilities.4 We found several barriers to telemedicine in our patient cohort. Many patients did not own a computer, had poor digital literacy, could not afford internet access or did not have privacy for consultations. Telephone appointments raise clinical gaps, with physical signs, mental state and visual cues unable to be assessed. Digital inequality further marginalises an already vulnerable population. Access, affordability and digital ability issues need to be managed for telemedicine to be a viable option.4 Examples of how this might be achieved include the establishment of hubs with telemedicine facilities, technical support and private spaces, located at local community health centres for practicality and accessibility, along with providers offering more affordable internet plans for health care card holders. Box – Modality of clinic appointments by month during the coronavirus disease 2019 (COVID‐19)‐related restrictions in Melbourne, Victoria (total monthly COVID‐19 Victorian cases also shown2)

Anthony Hew · Shalini Arunogiri · Dan I Lubman

It is critical primary care clinicians dedicate specific attention to the management of both depression and insomnia when they co-occur

Alexander Sweetman · Leon Lack · Emer Van Ryswyk · Andrew Vakulin · Richard L Reed · Malcolm W Battersby · Nicole Lovato · Robert J Adams

A comprehensive and coordinated approach to overdose prevention by national and state governments and professional groups is needed

Adrian J Dunlop · Buddhima Lokuge · Nicholas Lintzeris

Objectives: To describe the population characteristics of people with intellectual disability in New South Wales; to quantify and compare public mental health service use and costs for people with and without intellectual disability in NSW during 2014‒15. Design: Retrospective cohort data linkage analysis. Setting, participants: People using publicly funded in‐ or outpatient (admitted or non‐admitted) mental health services in NSW, 2014‒15. Main outcome measures: Numbers of bed days (inpatient mental health services), and treatment days (ambulatory mental health); costs of publicly funded mental health services. Results: People with intellectual disability comprised 1.1% of the NSW population, but 6.3% of people who used public mental health services; 12% of public mental health costs during 2014–15 were for people with intellectual disability. Compared with metropolitan local health districts (LHDs), overall public mental health service costs were lower for rural and regional LHDs (adjusted incidence rate ratio [aIRR], 0.8; 95% CI, 0.8–0.9) and higher for specialty networks (aIRR, 1.2; 95% CI, 1.1–1.3). Per person costs for people with intellectual disability were higher than for those without intellectual disability (aIRR, 2.6; 95% CI, 2.2–3.0). Conclusion: People with intellectual disability use public mental health services to a greater degree than other people. They should be explicitly considered by all tiers of mental health policy and service planning in Australia. Population health planning for the needs of people with disabilities would be assisted by including disability identifiers in all health administrative data sets.

Preeyaporn Srasuebkul · Rachael Cvejic · Theresa Heintze · Simone Reppermund · Julian N Trollor

Opioid agonist therapy should be normalised as a routine part of opioid dependence treatment

Pallavi Prathivadi · Elizabeth A Sturgiss

Cultural participation can be a buffer to racism and a tool to heal

Raymond W Lovett · Makayla‐May Brinckley

To the Editor: Sexual incidents involving patients in hospitals are prevalent and are distressing for patients and staff alike, but they are poorly managed.1 Such incidents are frequently perpetrated by people with acute mental illness (eg, mania, psychosis), substance misuse, personality vulnerabilities, and cognitive impairment (eg, delirium, dementia). Sexual incidents span the age range, although lack of staff's understanding of sexuality and sexual behaviour in older adults2 mandates practice improvement. Sexual safety is defined in health care settings as “recognition, maintenance and mutual respect of the physical [including sexual], psychological, emotional and spiritual boundaries between people”.3 Sexual incidents include sexual offences (criminal offences such as sexual assault) and inappropriate sexual behaviour, ranging from suggestive language to removing clothing, exposure, and public masturbation. State public mental health services have sexual safety policies and guidelines, but no such policies exist for general hospitals. The scholarly literature is similarly limited. Our experience of sexual safety in health care can be described as “a neglected area, there is no training, no one is talking about it and there seems little interest until something happens,” particularly involving older people.1 A hypothetical case based on clinical experience (Box) demonstrates the trivialisation and minimisation of sexual incidents in health care and the associated risks and ramifications. This phenomenon is aligned with the “dirty old man” stereotype, a reflection of ageist societal attitudes towards sex in older people as inappropriate, shameful or funny.4 Consequences of these attitudes for clinical management include poor documentation and communication, inconsistent responses to patient behaviour, and multiple victims, particularly staff. Sexual harassment is both under‐reported by staff5 and dealt with superficially, despite having significant effects on physical and psychological health and burnout.6 These issues are compounded in aged care, where staff ignore or minimise the impact of sexual behaviour, which is often excused by cognitive impairment4 or dismissed as harmless due to frailty or advanced age.5 Aged care staff may feel shame, guilt, confusion and even responsibility for causing the behaviour.5 Conversely, a tension exists between a cognitively impaired person’s right to sexual expression and the health care worker’s right to a safe workplace. Education of health care staff and development of guidelines with response pathways are needed to ensure sexual behaviour is understood and dealt with consistently and respectfully.4 In this situation, ageism trivialises risk and harm, which may have an adverse impact on a safe health care environment. Box – Hypothetical case based on clinical experience describing the trivialisation and minimisation of sexual incidents in health care and the associated risks and ramifications Warren is a 73‐year‐old single man treated in a geriatric ward in a general hospital for delirium. He has a history of cognitive impairment due to long term alcohol misuse and has a guardian for medical decision making. The delirium is slow to resolve and after a few weeks he starts propositioning nursing staff for sex and making sexual comments. Warren often has an erection when nurses assist with personal care and he masturbates on his bed, visible to patients, visitors and staff. He is moved to a single room and a minimum of two staff are present for any clinical interaction. Three female staff members are grabbed on their breasts while providing Warren with care. This is inconsistently documented in his medical record. His sexual behaviour is discussed with some derision in staff handovers. There is no disclosure of his behaviour to non‐ward staff involved in his care (eg, consulting teams), among whom further assaults occur. A security guard is stationed at his door to keep him in his room. He is commenced on a specific serotonin reuptake inhibitor with the aim of reducing libido. Warren continues to be sexually disinhibited in behaviour and comments, a barrier to securing a nursing home placement. General principles: Management must include behaviour assessment and addressing underlying issues (eg, delirium, unmet sexual needs) with practical environmental and governance measures such as formal handover of behaviour between shifts and for consulting teams and clinicians, clear and easily accessible management plans, and support for staff, visitors and other patients. Consider the use of sexual harassment measurement tools for reporting and awareness raising.

Anne PF Wand · Carmelle Peisah

To the Editor: There is a new player in the treatment of opioid use disorder: extended‐release depot buprenorphine. This has been hailed “a game changer”1 and has proven to be of great benefit, particularly during the current coronavirus disease 2019 (COVID‐19) pandemic. Depot buprenorphine has an impact on presentations to hospital and health services, meaning that all clinicians must be familiar with the advantages and disadvantages (Box) as well as the formulations. Opioid use disorder is a complex, chronic, relapsing health condition that requires lengthy management and is over‐represented in incarcerated people. Opioid treatment successfully reduces illicit use, overdose deaths, and costs. In Australia, there are opioid treatment programs for incarcerated persons, improving individual and community wellbeing and social functioning following release. However, until recently, the treatment perpetuated a daily drug pattern and risks, such as diversion to others, injecting opioid treatments, overdose risks and violent behaviour.2 What changed the game and model of care in Australia is the development of extended‐release depot buprenorphine. The Australian game has two products: one is available as weekly and monthly injection options and the other as a monthly injection. Depot buprenorphine is a subcutaneous injection and must be administered by a health care professional, as inadvertent injection into other structures forms a depot gel that will not provide slow release of the medication and depot gels in a vein may cause serious, life‐threatening health problems.3 Weekly or monthly doses of depot buprenorphine are provided following stabilisation using sublingual buprenorphine, most often for 7 days, and may be started the day after the last daily sublingual buprenorphine. Dose conversion tables exist to match depot buprenorphine to the sublingual buprenorphine dose. Steady state equilibrium is achieved after three to four doses.3 Hospital and health service clinicians must be aware that all buprenorphine formulations complicate routine opioid analgesia for acute pain management, and consideration of other non‐opioid‐adjuvant analgesics is needed (Box).3 Uptake of depot buprenorphine has been welcomed by patients, the community and correctional programs, with many who have transitioned reporting positive outcomes, including reduction in cravings, anxiety, improved attitude, relationships, and general mood.4 The timing of this game changing depot buprenorphine has enabled remote health care and ongoing availability of opioid therapy in the context of the COVID‐19 pandemic.5 Box – Advantages and disadvantages of depot buprenorphine Advantages of depot buprenorphine: it provides greater convenience and does not require attendance for daily dosing it reduces the treatment cost for clients and service providers it has less risk of diversion and non-medical use of the medication it has greater medication adherence and enhanced treatment outcomes it opens opportunities for normal life and to consider employment, study and travel it removes risks related to takeaway opioid treatment doses it reduces stigma and discrimination and has a positive impact on the way that people with opioid use problems are perceived Disadvantages of depot buprenorphine: ul#arrow { position: relative; list-style: none; } ul#arrow li::before { content: '▶ '; position: relative; left: 0; } it complicates routine opioid analgesia in the management of severe acute pain: it may require the use of higher doses of traditional opioids such as morphine; and it may require the use of a mu opioid receptor super agonist such as fentanyl and/or the use of non-opioid analgesic approaches (eg, ketamine infusions or regional analgesia) it provides reduced patient health care, social interactions and support opportunities it results in a loss of control over how the patient manages their dose (especially takeaways)

Katerina Lagios

People with existing mental health problems or living in difficult circumstances may be at particular risk

Helen Herrman · Christian Kieling

Objectives: To examine associations between community cultural connectedness indicators and suicide mortality rates for young Aboriginal and Torres Strait Islander people. Study design: Retrospective mortality study. Setting, participants: Suicide deaths of people aged 10‒19 years recorded by the Queensland Suicide Register, 2001‒2015. Main outcome measures: Age‐standardised suicide death rates, by Indigenous status, sex, and age group; age‐standardised suicide death rates for young First Nations people by area level remoteness and Index of Relative Socioeconomic Advantage and Disadvantage, and by cultural connectedness indicators (at statistical area level 2): cultural social capital index score, community Indigenous language use, and reported discrimination. Results: The age‐specific suicide rate was 21.1 deaths per 100 000 persons/year for First Nations young people and 5.0 deaths per 100 000 persons/year for non‐Indigenous young people (rate ratio [RR], 4.3; 95% CI, 3.5‒5.1). The rate for Aboriginal and Torres Strait Islander young people was higher in areas with low levels of cultural social capital (greater participation of community members in cultural events, ceremonies, organisations, and community activities) than in areas classified as having high levels (RR, 1.8; 95% CI, 1.2‒2.7), and also in communities with high levels of reported discrimination (RR, 2.7; 95% CI, 1.7‒4.3). Associations with proportions of Indigenous language speakers and area level socio‐economic resource levels were not statistically significant. Conclusion: We found that suicide mortality rates for Aboriginal and Torres Strait Islander young people in Queensland were influenced by community level culturally specific risk and protective factors. Our findings suggest that strategies for increasing community cultural connectedness at the community level and reducing institutional and personal discrimination could reduce suicide rates.

Mandy Gibson · Jaimee Stuart · Stuart Leske · Raelene Ward · Robert Tanton

To the Editor: Doctors’ wellbeing is an important agenda for reducing doctors’ burnout and its consequences. It is often confused with wellbeing related to personal lives that is not controlled by workplaces. My observation is that systems are implementing symbolic solutions, which undermine the efforts of advocacy for system solutions. I see wellness through my experience during teenage years, growing up in the middle of a war. I suffered emotional trauma; more than that, moral injury that was inflicted by the hypocrisy of the system that violated my human rights. Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs.1 All I wanted was for someone to stop the war; I was not expecting to be sent to a wellness officer or to wellness and resilience training workshops. In the past 22 years as a doctor, I am seeing the emergence of the term “moral injury” in health care settings and is linked to doctors’ wellbeing.1 I feel that moral injury within health care settings occurs when workers’ rights, expectations of doctors, and the organisational values and purpose are met with contradictions at workplaces.1 The literature is clear that doctors’ wellness is related to the culture and environment of the workplace rather than issues with the individuals’ resilience (Box).2 Of course, training to fine‐tune skills to manage emotionally challenging clinical situations and self‐care is important, but resilience training should not be about how to tolerate situations that cause moral injury. It will be difficult for systems to address workload‐related stress driven by doctors’ own choices. While some of the system’s problems can only be solved through organisational alignment of values and purpose, medical leaders of all levels need to take ownership of the doctors’ wellness agenda. They need to advocate for removing situations that cause moral injury and focus on cultural and structural solutions within their work teams and units, fostering a sense of belonging, cohesion and autonomy among colleagues, promoting self‐care and minimising burnout. This may create psychologically safe and joyful work teams. Box – Examples of contradictions that may cause moral injury at workplaces Expectations Contradictions Accreditation standards call for better workload and fatigue management Vacancies are not filled in a timely manner to manage the workload Front‐line staff are keen to help patients and colleagues Not enough personal protective equipment sourced Clinicians are keen to adopt Choosing Wisely and patient‐centred models Efficiency not rewarded by enhancing clinicians’ capabilities or supporting their initiatives Research as core business of organisations Prohibitive and time‐consuming regulatory processes for research Clinical directors are expected to lead change Clinical directors are not given necessary support or time to drive change Organisational values call for consultation and engagement with staff Decisions are made unilaterally by colleagues and leaders Nurses and doctors ask for help when patients with violent behaviours pose a threat to their safety Nurses and doctors get told to sort it out themselves

Sabe Sabesan

Objectives: To estimate initial levels of symptoms of depression and anxiety, and their changes during the early months of the COVID‐19 pandemic in Australia; to identify trajectories of symptoms of depression and anxiety; to identify factors associated with these trajectories. Design, setting, participants: Longitudinal cohort study; seven fortnightly online surveys of a representative sample of 1296 Australian adults from the beginning of COVID‐19‐related restrictions in late March 2020 to mid‐June 2020. Main outcome measures: Symptoms of depression and anxiety, measured with the Patient Health Questionnaire (PHQ‐9) depression and Generalised Anxiety Disorder (GAD‐7) scales; trajectories of symptom change. Results: Younger age, being female, greater COVID‐19‐related work and social impairment, COVID‐19‐related financial distress, having a neurological or mental illness diagnosis, and recent adversity were each significantly associated with higher baseline depression and anxiety scores. Growth mixture models identified three latent trajectories for depression symptoms (low throughout the study, 81% of participants; moderate throughout the study, 10%; initially severe then declining, 9%) and four for anxiety symptoms (low throughout the study, 77%; initially moderate then increasing, 10%; initially moderate then declining, 5%; initially mild then increasing before again declining, 8%). Factors statistically associated with not having a low symptom trajectory included mental disorder diagnoses, COVID‐19‐related financial distress and social and work impairment, and bushfire exposure. Conclusion: Our longitudinal data enabled identification of distinct symptom trajectories during the first three months of the COVID‐19 pandemic in Australia. Early intervention to ensure that vulnerable people are clinically and socially supported during a pandemic should be a priority.

Philip J Batterham · Alison L Calear · Sonia M McCallum · Alyssa R Morse · Michelle Banfield · Louise M Farrer · Amelia Gulliver · Nicolas Cherbuin · Rachael M Rodney Harris · Yiyun Shou · Amy Dawel

Community naloxone supply to prevent fatal overdose needs to consider patients using pharmaceutical opioids Pharmaceutical Benefits Scheme (PBS) opioid prescriptions in Australia have increased from 2.4 million in 1992 to 7 million in 2007 to 15 million prescriptions in 2016.1 The corresponding rate of opioid mortality over this time almost doubled from 3.8 deaths per 100 000 Australians in 2007 to 6.7 in 2017,2 with fatal opioid overdoses increasing from 482 in 2002 per 100 000 Australians to 900 in 2018.3 Most of these deaths involved prescription opioids, and contrary to what many assume, only one‐third of prescription opioid‐related deaths involved intravenous drug use.4 Among deaths associated with common prescription opioids (including fentanyl, morphine, oxycodone, tramadol and codeine), 49% involved people with chronic pain.4 Naloxone, a rapidly acting semi‐synthetic opioid antagonist, has an important role in reducing opioid overdoses by acting as an emergency reversal agent.5 It is currently available in Australia for intramuscular injection or nasal spray. The intranasal formulation was listed on the PBS in November 2019 as an unrestricted General Schedule medication. New South Wales, Western Australia and South Australia are trialling a program of take‐home naloxone available free to people using prescription or illicit opioids and at risk of opioid‐related death or those who may witness an overdose.5 Various aspects of patient history including current opioid medications (especially if the opioids are higher doses or slow release preparations) and comorbidities (such as complex diseases, mental illnesses or respiratory conditions) can help identify people who should be recommended to carry naloxone.5 Take‐home naloxone provided to laypeople to administer in the event of overdose was found to successfully reverse more than 96% of community overdoses in a systematic review.6 The evidence of naloxone’s therapeutic effect and life‐saving role has resulted in the drug being carried in most emergency medical kits and included on the World Health Organization Model Lists of Essential Medicines (https://www.who.int/groups/expert-committee-on-selection-and-use-of-essential-medicines/essential-medicines-lists). Community members, general practitioners and pharmacists frequently perceive naloxone as a medication for people who use illicit opioids, namely heroin.7 However, opioid‐related mortality in people taking pharmaceutical opioids for chronic pain is common. There is a clear evidence–practice gap demonstrating the need for increased discussion about opioid‐related risks and naloxone in this population. In the context of rising pharmaceutical opioid harm, the United States Centers for Disease Control and Prevention provided recommendations for co‐prescribing naloxone for at‐risk patients with chronic pain; such patients include those taking an oral daily morphine equivalent dose of 50 mg or more, taking concurrent benzodiazepines with opioids, having a history of substance use disorder, or having a history of overdose.8 Using these indications, an Australian study reported that 78% of patients on Schedule 8 opioids for chronic non‐cancer pain qualified for take‐home naloxone.8,9 Yet current national data show that less than 3% of all naloxone supplied is on individual PBS prescriptions, with most naloxone prescriptions accounted for by harm reduction programs.10 An additional negligible amount of naloxone is sold over the counter by pharmacists.10 Between 2014 and 2018, an estimated 10 642 units of naloxone were supplied in Australia. Even if a large proportion of this were dispensed to people taking pharmaceutical opioids for chronic pain, it would be vastly insufficient given the 300 000 Australians receiving long term opioids each year.10,11 The majority of Australian patients on pharmaceutical opioids who are at risk of overdose do not appear to be prescribed this emergency medication. Health care provider attitudes towards pharmaceutical opioid‐related risk may be contributing to low naloxone prescribing rates. In qualitative work, Australian GPs described hesitancy in prescribing opioids to younger and middle‐aged patients with chronic pain due to perceived risks of opioid‐related harm.12 In contrast, GPs were more comfortable prescribing opioids for older patients, as they believed there was a lower risk of serious opioid‐related harm in this population.12 These findings highlight doctors’ subjective judgements of overdose risk, which may be a barrier to recognising patients who would benefit from take‐home naloxone. Similar qualitative work highlighted that the biggest barriers to naloxone prescribing were low levels of awareness about naloxone, and unwillingness by doctors to prescribe it.7 This may be driven by incorrect beliefs that patients on pharmaceutical opioids are at low risk of overdose, lack of knowledge, and incorrect patient reporting of actual opioid use.7 GPs and pharmacists are ideally placed to provide and advocate for routine take‐home naloxone. GPs prescribe just over half of all opioids in Australia13 and are the main health care professional seen regularly by people taking opioids for chronic pain. Conversations about naloxone initiated by health care providers present an opportunity to highlight proactive steps to reduce opioid‐related risk, and also raise awareness of overdose management. Unfortunately, community knowledge about opioid‐related risk is low, and most people prescribed opioids for pain are unable to identify common signs of potentially fatal opioid toxicity.14 Improved naloxone prescribing alone is therefore unlikely to be effective without education and increased awareness of opioid overdose signs by patients, family members, friends and carers — who are the expected administrators of naloxone in the event of overdose. One commonly cited barrier to prescribing take‐home naloxone is fear that patients may be offended by the offer or recommendation.7,14 However, Australian research shows that when informed about naloxone, most people prescribed opioids for pain would want or in fact expect their doctor to prescribe it to them.14 Sensitivity around language is key to openly communicating with patients about this issue. Terms like “overdose” still carry considerable stigma and are poorly understood by laypeople. A more patient‐centred approach (and to avoid having important health messages dismissed as irrelevant by patients), might involve changing our language to use terms like “severe opioid‐related side effects” or “life‐threatening opioid toxicity” instead of “drug overdose” to explain the same concept. Discussing naloxone may also help patients recognise the level of harm associated with non‐indicated opioids. The therapeutic benefit of opioids for chronic pain is limited and guidelines strongly caution their use.13 Presenting naloxone as a necessary medication for people on long term opioids may help patients better understand the implications of taking these strong analgesics. This may intuitively encourage patients to request opioid deprescribing or dose reductions. Conversely, increased prescribing of naloxone may risk providers (and patients) justifying high dose opioid prescriptions by relying on naloxone as a safety net. These fears are common with opioid harm minimisation efforts but are not supported by evidence6 and should not detract from the expected number of lives that could be saved by naloxone. A novel approach may be to consider routine co‐prescription of naloxone for patients on strong long term opioids. Laxatives and antiemetics are commonly co‐prescribed with opioids by providers cognisant of common opioid side effects; however, this concept does not seem to extend to naloxone. Take‐home naloxone for people on opioids is analogous to intramuscular glucagon for patients with diabetes on insulin, or auto‐injectable adrenaline for anaphylaxis. Most people are unlikely to need these emergency medications, but in the case of profoundly dangerous adverse events, naloxone, like glucagon or adrenaline, has a life‐saving role. Changing the narrative around take‐home naloxone from “overdose treatment” to “routinely prescribed emergency medication” may help provider attitudes and encourage the normalisation of naloxone prescribing. Our conservative estimate suggests that about 200 000 naloxone scripts would be indicated annually using this approach, at a cost of $40–50 each on the PBS.8 This is comparable with the PBS cost of an adrenaline auto‐injector or glucagon, which are both listed at $40.15 The estimated volumes of naloxone required would also be similar to combined PBS prescription volumes of glucagon (about 44 000 prescriptions) and adrenaline auto‐injectors (about 110 000 adult prescriptions and 28 000 paediatric prescriptions) according to Medicare statistics of PBS prescriptions from July 2019 to June 2020, excluding doctor’s bag prescriptions.15 We present these comparisons between naloxone and other widely accepted emergency medications to show the severity of current naloxone under‐prescribing. From a health economics perspective, increased naloxone prescribing at the rates we suggest would cost the Australian a similar amount to glucagon and adrenaline combined through PBS reimbursement. Further, naloxone would still cost only a fraction of current PBS‐subsidised opioid prescriptions (oxycodone alone costing over $61 million in 2018–201915) and overdose‐related hospitalisation costs. Naloxone may assist with reducing opioid prescription rates and cost, and most importantly would save lives. GPs and pharmacists should consider discussing and co‐prescribing take‐home naloxone with opioids for patients with chronic pain. Australia’s increasing prescription opioid overdoses demands this conversation. However, normalising the role of naloxone as a routinely co‐prescribed emergency medication will require major changes in community and health care provider attitudes, improved awareness of the role of naloxone, and reduction of overdose‐associated stigma. Ongoing collaborative efforts are needed to embrace higher prescribing and dispensing of naloxone.

Pallavi Prathivadi · Suzanne Nielsen

Objective: To assess the association between having a serious mental illness and surgical outcomes for adults, including in‐hospital and 30‐day mortality, post‐operative complications, and hospital length of stay. Study design: Systematic review and meta‐analysis of publications in English to 30 July 2018 of studies that examined associations between having a serious mental illness and surgical outcomes for adults who underwent elective surgery. Primary outcomes were in‐hospital and 30‐day mortality, post‐operative complications, and length of hospital stay. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. Studies were grouped by serious mental illness diagnosis and outcome measures. Odds ratios (ORs) or mean differences (MDs), with 95% confidence intervals (CIs), were calculated in random effects models to provide pooled effect estimates. Data sources: MEDLINE, EMBASE, PsychINFO, and the Cochrane Library. Data synthesis: Of the 3824 publications identified by our search, 26 (including 6 129 806 unique patients) were included in our analysis. The associations between having any serious mental illness diagnosis and having any post‐operative complication (ten studies, 125 624 patients; pooled effect: OR, 1.44; 95% CI, 1.15–1.79) and a longer stay in hospital (ten studies, 5 385 970 patients; MD, 2.6 days; 95% CI, 0.8–4.4 days) were statistically significant, but not those for in‐hospital mortality (three studies, 42 926 patients; OR, 1.21; 95% CI, 0.69–2.12) or 30‐day mortality (six studies, 83 013 patients; OR, 1.85; 95% CI, 0.86–3.99). Conclusions: Having a serious mental illness is associated with higher rates of post‐operative complications and longer stays in hospital, but not with higher in‐hospital or 30‐day mortality. Targeted pre‐operative interventions may improve surgical outcomes for these vulnerable patients. Systematic review registration: PROSPERO, CRD42018080114 (prospective).

Kate E McBride · Michael J Solomon · Paul G Bannon · Nicholas Glozier · Daniel Steffens

To the Editor: Despite death being common in aged care, bereavement support for family and others is not part of care.1 In contrast, palliative care inherently extends to the patient’s family members, including after death.2 Coronavirus disease 2019 (COVID‐19)‐related deaths in aged care have left many families bereft. This is a consequence of forced separation in the final stage of life, the family member being transferred to an acute hospital, the question of whether the patient died alone, and limitations on traditional rituals and practices surrounding funerals.3,4 Like many community palliative care services, Melbourne City Mission’s Palliative Care (MCMPC) services have a well established aged care consultative team that provides advice on complex end‐of‐life issues. At the beginning of the COVID‐19 pandemic, MCMPC started to receive referrals for bereavement support — rapid referrals for residents in aged care facilities in the terminal phase of illness to speak with their families both before and after the patient’s death. Examples of catastrophic grief resulting from the COVID‐19‐related deaths in aged care facilities overseas prompted MCMPC’s preparation to respond to traumatised relatives.5 This work simply involved a phone call to families after the patient’s death. What was heard was sobering, summed up by one family member as “it was not meant to be this way”. Families expressed disappointment that the resident had contracted COVID‐19, stating they should have been safe in their home. The bereaved spoke of their enormous loss, having not been able to be with their loved one, in some cases, for a period of over 7 months. While most families were realistic about the frailty of their family member, they also said that “it was not their time,” that COVID‐19 unfairly changed the trajectory of how they expected their last days or months to go. Palliative care has much in common with aged care, notably the care of patients who are facing the final stage of their life. For staff it has been important to give each bereaved person a chance to capture their individual story, to give identity to the person who died, so they are not just another of the many deaths in aged care. In validating family members’ experiences, this simple phone intervention may mitigate poor bereavement outcomes5 by providing a space to honour their loss.

Margaret O’Connor · Bronwyn Wilson

Many patients had persistent symptoms two months after diagnosis, including fatigue, chest pain, and breathlessness

David R Darley · Gregory J Dore · Lucette Cysique · Kay A Wilhelm · David Andresen · Katrina Tonga · Emily Stone · Anthony Byrne · Marshall Plit · Jeffrey Masters · Helen Tang · Bruce Brew · Philip Cunningham · Anthony Kelleher · Gail V Matthews

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has raised concerns of a subsequent increase in suicides,1 but limited empirical data are available on this topic.2,3 We analysed numbers of suicidal presentations (including suicidal ideation, non‐suicidal self‐injury and suicide attempts) to emergency departments (EDs) within the Gold Coast Hospital and Health Service before and since the spread of COVID‐19 in Queensland, Australia. Cases were identified from ED administrative data through relevant diagnoses, presenting problems and keywords, followed by a manual investigation of triage narratives to exclude false positive cases, such as non‐deliberate injuries or poisonings. The numbers of ED visits between January and August 2020 were compared with the projected numbers, calculated by applying an annual increase of 13.5%4 to presentations during the same period in 2019. From March 2020 onwards, a marked divergence between observed and projected numbers is noted, corresponding to the oscillations in the numbers of diagnosed COVID‐19 cases in Queensland (Box). At the peak of the pandemic, the reductions in suicidal presentations were the largest (29.8% in March and 23.6% in April 2020). Over the next 2 months, daily numbers of diagnosed COVID‐19 cases remained low and the difference between observed and projected numbers gradually narrowed (20.8% in May and 14.6% in June 2020). In July 2020, observed numbers exceeded projected numbers by 11.4%, but then declined again in August 2020, coinciding with another resurgence of COVID‐19. Between March and August 2020, the Gold Coast Hospital and Health Service had 554 less suicidal presentations than expected. The well documented negative impact of COVID‐19 on all aspects of society, including mental health,5 suggests that a substantial reduction of suicide risk during this time is unlikely. Instead, our results may reflect changes in help‐seeking behaviour, with fewer people willing to seek help for suicidality through in‐hospital consultations due to fears of contracting COVID‐19.6 Ongoing promotion of telehealth and enabling safe hospital presentations or alternatives to ED7 is therefore needed to prevent the adverse outcomes of the COVID‐19 pandemic due to delayed access to care. Limitations of this work include potential underestimations of suicidal presentations due to coding issues8 and the inability to differentiate between types of suicidal presentations. Box – Numbers of suicidal presentations to the Gold Coast Hospital and Health Service in 2019 and 2020, and numbers of daily coronavirus disease 2019 (COVID‐19) cases in Queensland, Australia Error ranges for the projected 2020 numbers are 95% confidence intervals.

Jerneja Sveticic · Nicolas JC Stapelberg · Kathryn Turner

A multilayered action plan is needed for a substantial, timely and sustained investment in dementia prevention In 2012, the Australian Government declared dementia as the ninth National Health Priority Area. Eight years later, dementia is the greatest cause of disability in Australians aged over 65 years, the second leading cause of mortality, and the highest in women.1 Today, more than 459 000 Australians live with dementia, and this number is expected to exceed one million by 2056.2 The societal, economic and health care burden of dementia is unprecedented, with significant impacts on individuals, caregivers and families. In addition to therapeutic advances, improved and timely diagnosis and coordinated person‐centred care, dementia prevention and risk‐factor management are our best chance to make a difference.3 How do we tackle dementia prevention cost‐effectively in the post‐pandemic era? Between 40% and 48% of dementia risk is considered modifiable.4,5 In Australia, the population‐attributable risk of dementia risk factors, in descending order, are physical inactivity (17.9%), mid‐life obesity (17.0%), low educational attainment in early life (14.7%), mid‐life hypertension (13.7%), depression (8.0%), smoking (4.3%), and diabetes mellitus (2.4%).5 In addition, the 2020 Lancet Commission report on dementia prevention, intervention and care4 includes hearing loss, traumatic brain injury, alcohol use, social isolation, and air pollution as risk factors. Emerging research suggests that a suboptimal diet,6 cognitive inactivity7 and sleep–wake disturbance8 also influence the modifiable dementia risk. We urge substantial, timely, and sustained investment in dementia prevention via a multilayered action plan with eight recommendations (Box). 1. Create public health and clinical practice guidelines for dementia prevention across the lifespan for the Australian setting. In 2019, the World Health Organization released dementia risk‐reduction guidelines stating that “the existence of potentially modifiable risk factors means that prevention of dementia is possible through a public health approach”.9 These guidelines focus on “interventions that delay or slow cognitive decline or dementia,” with the strongest recommendations being applied to addressing physical inactivity, tobacco cessation, hypertension and diabetes mellitus.9 Yet, in Australia, we do not have dementia prevention guidelines, with the clinical practice guidelines for dementia from the National Health and Medical Research Council (NHMRC) and the Australian Cognitive Decline Partnership Centre (CDPC) focusing on diagnosis and management.10 Since then, Australia has made significant progress by including dementia prevention guidelines for general practitioners in the CDPC’s Care guide for general practice.11 We recommend extending guidelines beyond primary care, including secondary prevention in memory clinics, prioritising educational attainment in early life, and developing occupational and environmental policy to reduce hearing loss, traumatic brain injury, and air pollution. 2. Equip and resource primary care providers to be the clinical spearheads for dementia prevention throughout life. Primary care is the usual entry point and key coordinator of care within the health care system and is well positioned to spearhead dementia prevention throughout life. The Medicare Benefits Schedule should increase focus on dementia prevention, enabling primary care, specialists, and allied health professionals more time, resources and team care. This could be achieved through new Medicare Benefits Schedule item numbers and modification of existing items, such as the 45–49‐year‐old health check for individuals at risk of chronic conditions. Private health insurers could complement this by expanding the scope of preventive health services to target dementia risk factors and rewarding individuals who participate with lower insurance premiums or greater rebates for health services. 3. Support multidisciplinary memory clinics and specialists to implement secondary prevention programs for those at high risk. Memory clinics and specialists should focus on secondary prevention for people at higher risk, such as those with mild cognitive impairment.12 The Australian Dementia Network (ADNeT) aims to unite and build the network of memory clinics, establish practice guidelines, harmonise assessments, and implement dementia prevention tools and strategies. ADNeT will also facilitate access to clinical trials, improve diagnostic accuracy to aid secondary prevention approaches and introduce a Clinical Quality Registry. 4. Fund research for evidence‐based interventions for modifiable risk factors for dementia across the life cycle to reduce the evidence‐to‐practice gap. While there has been increasing funding for dementia prevention research and the establishment of the International Research Network on Dementia Prevention as part of the Australian Government’s commitment to the World Dementia Council,13 urgent funding is still required to address critical evidence‐to‐practice gaps. The current evidence base includes observational studies and intervention trials that have generally focused on cognitive outcomes, rather than dementia incidence, given the long time frames needed. We need to strengthen the evidence base on managing risk factors across different phases of the lifespan, such as the most effective doses and forms of interventions in large‐scale trials. Rigorously evaluated multidomain prevention trials that simultaneously target multiple risk factors may present the best value for money if shown to be effective and sustainable, particularly as they address risk factors that have an established evidence base for preventing other conditions. A number of these trials are already underway in Australia. 5. Implement findings from dementia risk reduction and implementation research through translation into health promotion programs. Implementation research will be key to translating the increasing evidence base for dementia risk reduction interventions into effective health promotion programs. The science of behaviour change will be critical given the evidence‐to‐practice gap. This emphasises the importance of co‐design to empower individuals to modify their risk. For health professionals, education and training on dementia risk factors and skills in motivational interviewing and behaviour change principles should be prioritised. 6. Strengthen dementia prevention public health campaigns embracing Australians’ diversity, particularly Aboriginal and Torres Strait Islander Australians. Australian‐specific dementia prevention guidelines that inform public health campaigns need to appeal to all Australians, embracing geographic, socio‐economic, cultural, linguistic, social, ethnic, age, gender, and sexual diversity. This is particularly important for Aboriginal and Torres Strait Islander people, for whom dementia prevalence is three to five times higher than the general population. These measures need to be equitable and not disadvantage vulnerable groups that may already have reduced access to resources. 7. Resource and coordinate a whole‐of-community approach including government, public and private health care, community services and education sectors to operationalise guidelines and multifaceted dementia prevention programs throughout life. Dementia prevention is everyone’s business. Successful public health and disease prevention campaigns have required a coordinated effort across all levels of the health sector, government, policy makers, non‐government organisations, research, education, industry and the community. Yet, many Australians do not believe that dementia risk can be reduced.14 Dementia prevention is complex due to stigma, literacy, and multifactor risks throughout life. The success of widely known public health campaigns in Australia (eg, Quit for Life and Slip, Slop, Slap) is attributable to their focus on behaviour change using a single behaviour or risk factor, informed by knowledge of barriers and enablers. The Dementia Australia Your Brain Matters campaign was targeted at raising public awareness for dementia, but this was not sustained beyond the funding period (2012–2015). The report from the Lancet Commission identifies educational attainment in early life as an impactful risk factor4 and this should be prioritised given its broader socio‐economic benefits. There are specific mid‐life (hearing loss, traumatic brain injury, hypertension, alcohol intake, obesity) and late‐life factors (smoking, depression, social isolation, physical inactivity, diabetes, air pollution) which offer opportunities for risk reduction across the lifespan.4 From a practical perspective, as many dementia risk factors are shared with other chronic conditions, particularly vascular risk factors, these may present the best opportunity for greatest impact. 8. Mobilise peak health advocacy bodies to promote and coordinate public health messaging on dementia risk factors that cut across chronic conditions. How do we ensure value for money and sustainability of dementia prevention public health campaigns? A unified approach with clear messaging communicated through media, community organisations, and health professionals promoting shared responsibility is crucial. An initial focus on risk factors with the highest population‐attributable risk (physical inactivity and midlife obesity) is recommended to improve wellbeing and reduce risk for multiple chronic conditions. They are also ideal for integrated programs given their overlap with vascular risk factors and successful campaigns (eg, smoking cessation). A key step is the coordination and pooling of resources between peak advocacy bodies such as Dementia Australia, Diabetes Australia, and the Heart Foundation, with clear messaging focusing on single risk factors that have multiple benefits. In clinical practice, this facilitates approaches that are tailored to an individual’s experiences and motivation. For example, motivation for increasing physical activity for one individual may arise from receiving a result of impaired glucose tolerance, while for another it may be the experience of having a family member living with heart disease or dementia. Australia has excellent health infrastructure and an international reputation for dementia prevention due to our depth of clinical, research, and knowledge translation expertise. If we are committed to achieving the ambitious targets of reduced dementia prevalence and incidence, we must shine a spotlight on dementia prevention across all levels of society. To achieve this, the National Health and Medical Research Council National Institute for Dementia Research (NNIDR) Dementia Prevention Special Interest Group proposes this Dementia Prevention Action Plan for Australia. It is time for a call to action in the fight against dementia: dementia prevention needs to be the next international public health area of focus, with Australia playing a leading role. Box – Dementia Prevention Action Plan

For the NHMRC National Institute for Dementia Research, Dementia Prevention Special Interest Group*

To the Editor: Fetene and colleagues1 describe refusal to prescribe or dispense prescriptions to some of their study cohort of people who inject drugs (PWIDs) and concern that their mental health treatment needs may not be met due to SafeScript, Victoria’s real time prescription monitoring system. SafeScript is a live electronic database providing information about the prescribing and dispensing of monitored medicines to each patient, instantly available in real time on a prescriber’s or pharmacist’s desktop (https://www2.health.vic.gov.au/safescript). SafeScript alerts prescribers and pharmacists to the risk of uncoordinated treatment by multiple providers or to the overdose risk of drug–drug interactions. Prescribers and pharmacists may have responded appropriately by offering more effective treatments instead of providing a continued supply of the medication. For instance, benzodiazepines are not recommended for first line or prolonged treatment of anxiety. Many people who misuse drugs have comorbid mental health disorders and need medical support. SafeScript is helping to identify this group of at‐risk patients so they can receive the appropriate medical treatment they require. SafeScript provides a clinical decision support system for prescribers and pharmacists, enabling more informed decisions for safer prescribing or dispensing of high risk monitored medicines. By providing proactive alerts, strong real time prescription monitoring systems, such as SafeScript, reduce overdose deaths from prescription opioids2 and decrease the number of opioid prescriptions, diversion, and opioid‐related morbidity and substance use disorder outcomes.3 Since the rollout of SafeScript, the number of multiple provider episodes and the average morphine equivalent dose have both been trending gradually but consistently downwards. SafeScript was designed with the lessons learnt from the United States. The implementation of this system included several measures to encourage and support a professional response for high risk patients, such as podcasts and face to face and online training, in which more than 4500 prescribers and pharmacists have participated. Furthermore, the SafeScript implementation included upgrading the Drug and Alcohol Clinical Advisory Service, providing trained general practitioner clinical advisors to offer peer support, a consumer pharmaceutical helpline, and increased funding to support professionals and consumers manage benzodiazepine problems. In addition, $273.1 million were invested in drug treatment, support and harm reduction services in 2019–2020,4 representing a 65% increase in investment through the last five Victorian state budgets. This new initiative helps prescribers and pharmacists provide the appropriate clinical care and professional response needed by high risk patients.

Malcolm Dobbin

Careful planning is required to ensure new resources for mental health lead to better consumer care Both the Productivity Commission into Mental Health1 and the Royal Commission into Victoria’s Mental Health System (RCVMHS)2 acknowledge that mental health services have been in the grip of a protracted resourcing drought. The RCVMHS identified that, until recently, Victoria’s public mental health services have fared particularly badly,3 with the 2015–2016 per capita funding to public mental health services being the lowest of any state. The impacts of chronic under‐resourcing, including a predominant focus on managing risk, underutilisation of evidence‐based therapies, and a lack of individualised care, were all reported by service users in testimonies highlighted in the RCVMHS interim report.2 After years of stagnation, in 2020 Victorian mental health services experienced some funding growth.4 These resources have allowed our team to strengthen existing services; bring on new staff, including expanding our lived experience workforce; and initiate new programs, including the Hospital Outreach Post‐Suicidal Engagement (HOPE) initiative, intensive community packages of care, the pre‐hospital response of mental health and paramedic team (PROMPT), and a mental health, alcohol and other drugs hub in our emergency department. In addition, our service is currently planning new mental health beds and rolling out an innovative hospital‐in‐the‐home program stemming from the recommendations of the RCVMHS interim report. We anticipate the final recommendations, due in February 2021, will bring even more new resources. Like sudden heavy rain on degraded soils after drought, such an inundation is welcome, but not without its own risks and challenges. Our recent implementation efforts have highlighted several challenges in managing rapid funding growth, including issues with human resources, leadership capacity, change management competency and stakeholder engagement, which will need consideration across the system to ensure services can translate funding into better consumer care. Human resources Delivering care requires staff who are difficult to find. There are insufficient mental health nurses5 and psychiatrists6 to fill current roles, particularly in regional and rural areas, and with an ageing workforce,7 problems with staffing are predicted to worsen.6 While international recruitment may assist, these processes come with lengthy delays and high administrative burdens. As a consequence, program implementation may be delayed due to recruitment challenges, or may adversely affect the operations of other service areas when clinicians shift between roles. Significant investment in training and recruitment pathways are required to prevent workforce shortages becoming a barrier to the pace of reform. Diversification of disciplines, grades and programs that encourage qualified staff to enter mental health care will all be required.1 Leadership capacity and competency in change management The presence of effective leadership and competency in change management principles are critical for successful health reform.8,9 Rapid growth can stretch existing leadership capacity. Health leaders already face significant challenges at system (eg, demographic changes, increasing demands, advancing technology), organisational (eg, human resources, changes to organisational structures and processes, intensification of frontline and middle management roles) and individual levels (eg, lack of role clarity, lack of training in managerial and leadership capabilities).10 For leaders already managing the challenge of daily operations, additional responsibilities to enact significant reform quickly carries a risk of overload. A key potential outcome of overload is loss of focus on the consumer.11 Therefore, as the pace of desired reform increases, a focus on developing current and future mental health leaders should be prioritised.2,12 Engaging stakeholders meaningfully Meaningful stakeholder engagement is crucial to successful change.9 As outlined by the RCVMHS, the “necessary changes to the mental health system cannot … be achieved by government alone”.2 The implementation of new programs requires engagement with diverse stakeholders including consumers, carers, staff, hospital executives, government and industrial bodies. Such stakeholders often have different interests, and forging and maintaining alignment is critical to progress. Meaningful engagement is vital to achieving this and subsequent success,9 but it is also resource intensive. Enacting multiple reforms quickly carries the risk that meaningful stakeholder engagement may be sacrificed. For this reason, timelines for delivery need to balance urgency with getting things right. The appropriate urgency for implementation articulated in the initial recommendations from the RCVMHS (eg, operation of an additional 170 acute mental health beds by mid‐2022) will only be achieved if those leading the change are supported and those affected by the change are included. Harnessing a generational opportunity for reform The RCVMHS calls for transformational change2 to our mental health system. The pace of this change and the other challenges involved must be managed carefully by system leaders to ensure that the intended reform occurs and results in provision of better care to the community.

Steven Moylan

We need more robust strategies with targeted, customised approaches, and increased funding for evidence-based interventions

Michael J Dudley · Ping-I Lin

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has raised multiple health challenges for Australian society. In addition to the direct impacts of infection, there will be broader health impacts caused by physical and social distancing and the collapse in economic activity leading to the loss of employment and income. Interventions by the federal government, including JobKeeper, increased JobSeeker payments, the introduction of telehealth, and increased mental health spending, have made an important initial contribution to addressing the health impacts for individuals, families, and communities.1,2 A by‐product of these interventions, however, has been a rapid increase in government debt.3 We are now seeing increased calls to enact austerity policies. Such policies prioritise rapid reductions in government debt usually through cuts to health and social services. These calls should cause concern. Economic crises can damage mental health, increase the misuse of alcohol and other drugs, and increase suicidal behaviour.4 Austerity policies are likely to worsen these effects.4 Such concerns are illustrated by the effects of austerity policies in Europe and the United Kingdom made in response to the global financial crisis, which had serious health‐related consequences.5 For example, a study on the impact of austerity measures on health reported that austerity policies were implicated in worsening mental health, increased suicide rates, heightened mortality in older age groups, and greater unmet health care needs.6 Indeed, despite relatively progressive government interventions during the global financial crisis in Australia, we still had a rise in suicide rates among employed and unemployed Australians.7 If enacted in Australia, austerity policies have the potential to lead to health‐damaging effects. It is important not to compound the health impacts of the pandemic with austerity programs focused on short term reductions in government debt. Health and social services are critical buffers against economic shocks,8 and austerity is likely to undermine these buffers. Policies that prioritise economic and social supports as well as increasing access to care are likely to reduce the health impacts of economic crises.4 In particular, European countries that invested most in social protections during the global financial crisis suffered the least harms to their populations’ wellbeing.5,6 It is also crucial to recognise that austerity policies are a choice. There are alternatives for managing high levels of government debt to cutting public spending on services,6 and austerity policies are not widely endorsed by economists.9 Government spending on health, education, and social supports has the potential to increase economic growth.10 Taking a longer term view and avoiding austerity measures will better serve the health of Australia’s population, and indeed the health of the nation.

Shane A Kavanagh · Anthony D LaMontagne · Sharon Brennan‐Olsen