Midlife women are given no specific mention in the recently published Grading of Recommendations, Assessment, Development and Evaluation guidelines for schizophrenia, likely due to the lack of randomised controlled trial-level research or even consensus guidelines dedicated to this overlooked group. We argue here that midlife women with schizophrenia have specific needs which require tailored individualised care.

Background: The literature suggests that a substantial proportion of individuals diagnosed with primary psychosis may have underlying anti-N-methyl-D-aspartate receptor (NMDAR) antibody-mediated encephalitis. We ascertained NMDAR-positive prevalence in a large cohort of individuals with a history of a psychotic illness and employed machine learning to establish which variables most accurately distinguish NMDAR-positive and -negative cases. Methods: The Australian National Survey of High Impact Psychosis (SHIP) collected nationally representative data from individuals with psychosis, with n=463 having plasma samples. A recombinant indirect immunofluorescence test was performed to investigate the prevalence of NMDAR autoantibodies. Using a 60/40 random train/validation split, machine learning was performed with nine of 120 variables—selected from sociodemographic, medical history, psychiatric diagnosis, and current symptom domains—that were positively associated with NMDAR status. Outcomes: Of 10 machine learning models gradient boosting showed the best identification of NMDAR positive status. There were 57 NMDAR-positive cases (12·3%), most of whom were diagnosed with schizophrenia /schizoaffective disorder and depressive psychosis; they were least likely to be diagnosed with bipolar disorder with psychotic features. Further, they were more likely to have had a single psychotic episode with good recovery; and to report anxiety / autonomic symptoms (dizziness, light headedness, feeling faint, unsteady gait). Restricted affect was more common and poverty of speech less common, and none had a history of epilepsy. Interpretation: In a representative sample of people with a psychotic disorder, we identified key clinical features associated with anti-NMDAR receptor encephalitis. These data can help with clinical profiling and inform antibody testing regimes.

Objective: The current Guidelines aim to provide evidence-based management recommendations for treatment of people living with schizophrenia in Australia and Aotearoa New Zealand. Methods: The Australian and New Zealand Journal of Psychiatry (ANZJP) commissioned a panel of experts to establish these Guidelines. The existing literature was reviewed to address key health questions. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, and the strength of the recommendation was determined by the panel. Results: The ANZJP GRADE Guidelines examined the current evidence base for a range of areas relevant to treatment for people with schizophrenia including: initial physical health assessment; pharmacological treatment; psychological and psychosocial interventions; family, whānau and carers; psychiatric comorbidities; physical health and lifestyle interventions; and special populations. Conclusions: It is hoped that the current Guidelines provide useful recommendations in important aspects of care for people living with schizophrenia and their family, whānau and carers in Australia and Aotearoa New Zealand, both at the individual and systemic levels.

The ANZJP Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines for the management of schizophrenia provide strong recommendations when high-level evidence is available. For many clinical scenarios, however, there is insufficient evidence meaning that only weak recommendations can be made using the GRADE process. Concurrent methamphetamine use in people experiencing psychosis is one such scenario. The ANZJP GRADE guidelines offer only one weak recommendation, that people with comorbid schizophrenia and substance misuse be offered psychosocial interventions. Many clinicians would value additional recommendations for this common challenge in Australian mental health services. We consider the extent of the problem of methamphetamine-related psychosis in Australia and the heterogeneity of presentations that may be managed in clinical services. We summarise the existing evidence on treatment and highlight why research in this area remains scarce. Finally, we propose the development of a consensus framework to guide treatment of methamphetamine-related psychosis and, in so doing, to enable development of high(er)-level evidence with utility in real-world clinical settings.

ObjectiveProlonged Emergency Department (ED) Length of Stay (LOS) for mental health patients adversely impacts bed flow. This study evaluated the Psychiatric Extended Care (PEC) model's PEC-C pathway, implemented at Lyell McEwin Hospital in June 2022, which transfers select patients to the Mental Health Short Stay Unit (MHSSU) before psychiatric review.MethodsThis retrospective audit compared ED LOS and Total LOS between "pre-PEC" (January-April 2022) and "post-PEC" (January-April 2024) cohorts meeting PEC-C criteria (voluntary patients meeting predefined safety and medical screening criteria presenting for mental health reasons). Primary outcomes were ED LOS and Total LOS (combined ED plus MHSSU LOS).ResultsIn 2022, 28/686 (4.1%) ED psychiatric referrals met PEC-C criteria; in 2024, 29/679 (4.3%) met criteria. For patients meeting PEC-C criteria, ED LOS decreased from 18.2 hours (IQR: 13.4-22.9) pre-PEC to 9.4 hours (IQR: 6.3-12.5) post-PEC (U = 102.5, p < .001). Total LOS showed no significant difference (69.4 hours [IQR: 7.3-131.5] vs 64.9 hours [IQR: 38.6-91.2], U = 406, p = 1.00). No adverse safety events occurred for patients meeting PEC-C criteria.ConclusionA significant reduction in ED LOS was observed following PEC implementation; Total LOS was unchanged. The quasi-experimental design limits causal inference, warranting prospective evaluation.

INTRODUCTION:This article summarises the recently published 'Australian and New Zealand Journal of Psychiatry (ANZJP) Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Guidelines for the Management of Schizophrenia in Australia and Aotearoa New Zealand' (https://journals.sagepub.com/doi/10.1177/00048674251406058). METHODS:We used the GRADE approach to evaluate the certainty of existing evidence and the strength of the recommendation was determined by the panel. The Guidelines are organised into seven sections: (1) physical health assessment; (2) pharmacological treatment; (3) psychological and psychosocial interventions; (4) family, whānau and carer involvement; (5) psychiatric comorbidities; (6) physical health and lifestyle interventions; and (7) special populations. MAIN RECOMMENDATIONS:A comprehensive yet tailored clinical assessment should be undertaken to identify treatable physical health comorbidities early, particularly for people with early psychosis. Pharmacotherapy should aim for the lowest effective dose with a tolerable and manageable adverse-effect profile (e.g., first-line pharmacotherapy with aripiprazole, brexpiprazole, cariprazine or lurasidone). Lifestyle interventions, particularly physical activity and multimodal lifestyle programmes, should be routinely offered to people with schizophrenia. Psychological and psychosocial interventions are essential components of care for people with schizophrenia, especially during the maintenance phase of illness. Clinicians should actively involve people with schizophrenia and their family, whānau and carers in shared decision-making. Comorbid psychiatric symptoms and conditions should be assessed and managed according to standard treatment approaches until more robust evidence base specific to schizophrenia becomes available. CHANGES IN ASSESSMENT AND MANAGEMENT AS A RESULT OF THE GUIDELINES: The ANZJP GRADE Guidelines synthesise the current evidence base across key domains relevant to the management of people with schizophrenia, offering practical recommendations that can be implemented in both clinical and systemic contexts. General practitioners have a pivotal role, especially in supporting the physical health and overall wellbeing of people with schizophrenia and assisting them to navigate complex healthcare pathways.

BACKGROUND:Accelerated forms of repetitive transcranial magnetic stimulation (rTMS) are proving to be a safe and effective for treatment-resistant depression (TRD). However, the likelihood of treatment response remains difficult to predict. It is possible to assess inadequate treatment responses early in treatment courses to predict eventual non-response by course end. METHODS:Post-hoc analysis of prospective clinical trial data was conducted (N = 298). Participants were randomized to one of three treatment arms: daily, unilateral 10 Hz rTMS to the left dorsolateral prefrontal cortex or accelerated bilateral theta-burst stimulation (TBS) at either 80 % or 120 % resting motor threshold stimulation intensity. Clinical response was assessed using the Quick Inventory of Depressive Symptomatology (QIDS). Negative predictive values (NPVs) were generated at week 1 using various QIDS percentage improvement cut-offs to predict eventual non-response. RESULTS:Participants who showed a ≤ 10 % or ≤ 20 % improvement in QIDS score by week 1 had NPVs ranging from 70.0 % to 97.5 %. Higher NPVs were found for participants randomized to low-intensity accelerated TBS than 10 Hz daily rTMS at week 1. LIMITATIONS:Accelerated TBS and standard rTMS courses featured relatively short courses of 20 sessions. Analyses predict eventual treatment response using only change in QIDS severity without subscale analysis. CONCLUSIONS:Early treatment non-response potentially has predictive utility, including in an accelerated TBS protocol. Further studies should determine whether there is clinical benefit in reviewing and/or adapting treatment protocols in view of these findings.

Introduction: To examine access to health care among the Narikuravar community and identify distinct challenges for delivering existing healthcare resources, a mixed-methods study was conducted among local Narikuravar community people in Poonjeri village, Tamil Nadu, India. Methods: Data were collected from 81 Narikuravar individuals using a structured questionnaire describing demographic characteristics, health-seeking behaviour and the availability of government-issued healthcare cards. Qualitative one-on-one interviews were conducted. Content analysis of the transcribed data was performed to achieve a deeper insight into determinants of healthcare access. Results: Most participants (82%) had no knowledge of the processes required for procuring healthcare services and privileges. They demonstrated significant hospital utilisation, with a majority (58%) having recently visited a hospital. There was 100% attendance for child and maternal immunisation. Despite their remarkably low incomes, which typically did not require a tax card, 76% of the individuals were issued one. However, 77% lacked a government-issued free healthcare card. This financial constraint limited their access to needed healthcare services. Conclusion: In spite of the Narikuravar people's significant hospital utilisation and 100% immunisation attendance, this study indicates a persistent lack of awareness about how to access free health care for other conditions, which contributes to widening disparities in health outcomes. This gap, potentially magnified by historical marginalisation, underscores the need for targeted interventions. Improving health literacy and raising knowledge of available services through collaborative efforts with the Narikuravar people is an essential step toward ensuring equitable access to health care for all.

PURPOSE:Metabolic syndrome (MetS) is common in schizophrenia and drives cardiovascular risk. While cannabis use and potency are increasing, the impact of cannabis on cardiometabolic health in schizophrenia remains unclear. This study assessed the association between objectively measured cannabis use and MetS prevalence in a large schizophrenia cohort. METHODS:We conducted a cross-sectional analysis of 988 participants with DSM-IV schizophrenia from the CATIE study. Cannabis use was measured via hair testing for tetrahydrocannabinol (THC), the gold standard for long-term use detection. MetS was defined per International Diabetes Federation criteria using physical and biochemical data. Multivariable logistic regression, adjusting for demographic, clinical, and lifestyle confounders, assessed the association between THC use and MetS. RESULTS:THC-positive participants (14.8 %) exhibited a significantly lower prevalence of MetS compared to non-users (42.5 % vs. 60.5 %, p < 0.001). After adjusting for confounders including age, sex, ethnicity, smoking, and other substance use, cannabis use remained independently associated with reduced odds of MetS (adjusted OR 0.64, 95 %CI 0.44-0.93, p = 0.02). Among MetS components, cannabis users had significantly lower odds of elevated waist circumference after adjustment (adjusted OR 0.61, 95 %CI 0.41-0.91, p = 0.02). Cannabis use was also associated with lower weight, BMI and triglycerides and higher HDL in unadjusted analyses. No significant differences were found in blood pressure or fasting glucose. CONCLUSIONS:In schizophrenia, cannabis use was associated with lower rates of both metabolic syndrome and central obesity. While these findings support emerging evidence of metabolic differences in cannabis users, the cross-sectional design precludes conclusions regarding causality. Longitudinal studies are needed to clarify long-term metabolic effects and guide targeted interventions.

ObjectiveThe northern suburbs of Adelaide, South Australia, are characterised by marked socio-economic disadvantage. Through private practice agreements, psychiatrists employed by this region's public health service accept referrals from General Practitioners (GPs) to undertake Medicare-Benefits-Scheme Item 291 Psychiatric Assessments (MBS-291s). This study reports the clinical characteristics of people in this region who received an assessment under this initiative.MethodData was collected from 169 consumers aged 18-65 years, who attended MBS-291s with one psychiatrist between 2017 and 2021. Data included demographics, diagnoses, comorbidities, management challenges, engagement with other services, and the psychiatrist's recommendations.ResultsOf 169 consumers, 32% were aged 18-25. Mood (37%) and trauma-related (36%) disorders predominated. Psychiatric comorbidity was common (37% had ≥2 diagnoses). Adverse experiences were reported by 92%, including psychological abuse (60%) and suicidality (51%). Medication recommendations were provided in 99% of cases, alongside psychotherapy (75%), referrals to other services (88%), and lifestyle recommendations (70%).ConclusionsThis study highlights the complex clinical and psychosocial characteristics of those referred for MBS-291s in the northern suburbs of Adelaide, South Australia. We discuss the range of specialist recommendations and comment on the value and sustainability of providing these assessments in the Australian healthcare context.

Objective Women face considerable barriers in pursuing careers in academic psychiatry.Methods A group of Australian and New Zealand academic women psychiatrists convened in September 2022 to identify and propose solutions to increase opportunities for women in academic psychiatry.Results Limiting factors were identified in pathways to academia including financial support, engagement and coordination between academia and clinical services, and flexible working conditions. Gender biases and the risk of burnout were additional and fundamental barriers. Potential solutions include offering advanced training certificates to enable trainees to commence a PhD and Fellowship contemporaneously; improved financial support; expanding opportunities for research involvement; establishing mentoring opportunities and communities of practice; and strategies to enhance safety at work and redress gender bias and imbalance in academia.Conclusions Support for women in research careers will decrease gender disparity in academic psychiatry and may decrease problematic gender bias in research. Fellows and trainees, the RANZCP, universities, research institutes, governments, industry and health services should collaborate to develop and implement policies supporting changes in working conditions and training. Facilitating the entry and retention of women to careers in academic psychiatry requires mentoring and development of a community of practice to provide and enable support, role modelling, and inspiration.

Objective To explore the attitudes of Royal Australian and New Zealand College of Psychiatrists (RANZCP) consultants and registrars towards recruitment of patients in mental health research. Specifically, we aimed to measure potential barriers and facilitators for recruitment and comment on strategies for improvement.Method A survey was distributed to 287 consultant and trainee psychiatrists working across South Australian public mental health services. The survey was hosted via SurveyMonkey and ran for 5 weeks from April to June 2023. Participant's attitudes were recorded through use of Likert scale, yes/no and free-text response.Results In total, 88 responses were collected, corresponding to a 30.7% response rate. Participants were interested in mental health research, with 90.7% reading articles and 61.4% reporting personal research engagement. The factors that rated most highly as recruitment barriers were unawareness of current studies, competing clinical demands and not prioritising recruitment. Factors felt most strongly to facilitate recruitment included the presence of an onsite research assistant and the clinician viewing the trial as clinically relevant.Conclusions While attitudes towards research were generally positive, many barriers to recruitment were identified. Increased advertising of current studies, presence of an onsite research assistant and reduction in clinicians' workload are likely to improve clinicians' capacity to recruit.

OBJECTIVE:To investigate the effect of concomitant use of benzodiazepines on the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with treatment-resistant major depressive disorder (TR-MDD). METHODS:This is a retrospective study comparing rTMS treatment outcomes between patients taking benzodiazepines (n = 59) and those who were not (n = 136). Participants completed the HAM-A, HAM-D17, MADRS and ZUNG at baseline and at the end of treatment. RESULTS:Patients taking benzodiazepines during rTMS treatment did not show any difference in partial response, response or remission rates compared to patients not treated with benzodiazepines. There was a significant decrease (p < .0001) in depression and anxiety scores from baseline to post-treatment among both groups. CONCLUSIONS:Concomitant benzodiazepine treatment had no effect on the efficacy of rTMS treatment of TRD, contrary to previous research.

BACKGROUND AND HYPOTHESES:Previous studies revealed innate immune system activation in people with schizophrenia (SZ), potentially mediated by endogenous pathogen recognition receptors, notably Toll-like receptors (TLR). TLRs are activated by pathogenic molecules like bacterial lipopolysaccharides (TLR1 and TLR4), viral RNA (TLR3), or both (TLR8). Furthermore, the complement system, another key component of innate immunity, has previously been linked to SZ. STUDY DESIGN:Peripheral mRNA levels of TLR1, TLR3, TLR4, and TLR8 were compared between SZ and healthy controls (HC). We investigated their relationship with immune activation through complement expression and cortical thickness of the cingulate gyrus, a region susceptible to immunological hits. TLR mRNA levels and peripheral complement receptor mRNA were extracted from 86 SZ and 77 HC white blood cells; structural MRI scans were conducted on a subset. STUDY RESULTS:We found significantly higher TLR4 and TLR8 mRNA levels and lower TLR3 mRNA levels in SZ compared to HC. TLRs and complemental factors were significantly associated in SZ and HC, with the strongest deviations of TLR mRNA levels in the SZ subgroup having elevated complement expression. Cortical thickness of the cingulate gyrus was inversely associated with TLR8 mRNA levels in SZ, and with TLR4 and TLR8 levels in HC. CONCLUSIONS:The study underscores the role of innate immune activation in schizophrenia, indicating a coordinated immune response of TLRs and the complement system. Our results suggest there could be more bacterial influence (based on TLR 4 levels) as opposed to viral influence (based on TLR3 levels) in schizophrenia. Specific TLRs were associated with brain cortical thickness reductions of limbic brain structures.

Research suggests there is a widespread stigma among clinicians towards patients with borderline personality disorder (BPD) and that this contributes to poor treatment outcomes. Given the influence of learning environments in shaping perceptions, this study investigated the attitude of South Australian psychiatry trainees towards patients with BPD. A questionnaire was distributed to 89 South Australian doctors, from both The Adelaide Prevocational Psychiatry Program (TAPPP) and psychiatry trainees of The Royal Australian and New Zealand College of Psychiatrists (RANZCP). This questionnaire investigated the domains of treatment optimism, clinician attitude and empathy towards patients with BPD. Results indicated that psychiatry trainees near the end of training scored significantly lower across all domains, indicating a more negative perception of patients with BPD, when compared to early- and mid-stage trainees. This study identifies a need to understand why trainees closer to qualifying as psychiatrists have increased stigma towards patients with BPD. Improved education and training surrounding patients with BPD is warranted to reduce negative stigma and improve clinical outcomes.

BACKGROUND:Clinical trials of anti-inflammatories in schizophrenia do not show clear and replicable benefits, possibly because patients were not recruited based on elevated inflammation status. Interleukin 1-beta (IL-1β) mRNA and protein levels are increased in serum, plasma, cerebrospinal fluid, and brain of some chronically ill patients with schizophrenia, first episode psychosis, and clinical high-risk individuals. Canakinumab, an approved anti-IL-1β monoclonal antibody, interferes with the bioactivity of IL-1β and interrupts downstream signaling. However, the extent to which canakinumab reduces peripheral inflammation markers, such as, high sensitivity C-reactive protein (hsCRP) and symptom severity in schizophrenia patients with inflammation is unknown. TRIAL DESIGN:We conducted a randomized, placebo-controlled, double-blind, parallel groups, 8-week trial of canakinumab in chronically ill patients with schizophrenia who had elevated peripheral inflammation. METHODS:Twenty-seven patients with schizophrenia or schizoaffective disorder and elevated peripheral inflammation markers (IL-1β, IL-6, hsCRP and/or neutrophil to lymphocyte ratio: NLR) were randomized to a one-time, subcutaneous injection of canakinumab (150 mg) or placebo (normal saline) as an adjunctive antipsychotic treatment. Peripheral blood hsCRP, NLR, IL-1β, IL-6, IL-8 levels were measured at baseline (pre injection) and at 1-, 4- and 8-weeks post injection. Symptom severity was assessed at baseline and 4- and 8-weeks post injection. RESULTS:Canakinumab significantly reduced peripheral hsCRP over time, F(3, 75) = 5.16, p = 0.003. Significant hsCRP reductions relative to baseline were detected only in the canakinumab group at weeks 1, 4 and 8 (p's = 0.0003, 0.000002, and 0.004, respectively). There were no significant hsCRP changes in the placebo group. Positive symptom severity scores were significantly reduced at week 8 (p = 0.02) in the canakinumab group and week 4 (p = 0.02) in the placebo group. The change in CRP between week 8 and baseline (b = 1.9, p = 0.0002) and between week 4 and baseline (b = 6.0, p = 0.001) were highly significant predictors of week 8 change in PANSS Positive Symptom severity scores. There were no significant changes in negative symptoms, general psychopathology or cognition in either group. Canakinumab was well tolerated and only 7 % discontinued. CONCLUSIONS:Canakinumab quickly reduces peripheral hsCRP serum levels in patients with schizophrenia and inflammation; after 8 weeks of canakinumab treatment, the reductions in hsCRP are related to reduced positive symptom severity. Future studies should consider increased doses or longer-term treatment to confirm the potential benefits of adjunctive canakinumab in schizophrenia. Australian and New Zealand Clinical Trials Registry number: ACTRN12615000635561.