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Objectives: To identify the prevalence and profile of amphetamine-type-substance-related presentations to the Emergency Department Mental Health Team of a local health district in Australia., Methods: Data was collected from medical records of all amphetamine-type-substance presentations to the Emergency Department Mental Health Team over a 1-year period, between 1 January 2015 and 31 December 2015., Results: Of all presentations referred to the Emergency Department Mental Health Team, 0.15% ( N  = 189) were amphetamine-type-substance related. Of these, the majority were male, the average age was 32, 19.0% engaged in intravenous drug use, some were aggressive and 15.9% required tranquilisation. The most common presenting issues were psychosis and suicidal threats, intent and behaviour (including intentional overdose). Multiple comorbid conditions were identified. On discharge, 34.4% were admitted into a psychiatric hospital and 32.8% were referred to Community Mental health teams., Conclusions: Amphetamine-type-substance users suffer from multiple comorbidities and pose a significant burden on emergency services.

Objectives: To examine the relationship between a regional economic downturn (indicated by the rise of population unemployment rate) and the rate of psychoactive-substance-induced psychiatric hospital admissions in the population in a rural/regional setting., Methods: Hospital admission records from January 2013 to December 2016 were reviewed retrospectively. All patients with admissions to the Mackay inpatient psychiatric unit with diagnosis of mental and behavioural disorders due to psychoactive substance use were recorded using (ICD-10) F10-F19 codes. The relationship between the regional unemployment rate and the hospital admission rate was analysed using linear regression analysis., Results: A statistically significant regression was found (F(1,46) = 39.46, p < 0.0001), R 2  = 0.46). The predicted number of admissions per 100,000 population in a month was observed to increase on average by 3.13 per month (95% CI = 2.12-4.13, p < 0.0001) for each percentage increase in the regional unemployment rate., Conclusions: There was a statistically significant association between the population unemployment rate and the rate of substance induced psychiatric hospital admissions. Implications for regional Australian service provision and unmet needs were discussed. Further research is required to confirm this observation.

Objective: Amphetamine use and availability have increased in Australia and there are concerns that this has led to more frequent hospital admissions with amphetamine-related psychosis. This study examines whether amphetamine-related admissions to mental health units are more common at times of greater amphetamine availability., Methods: We conducted an ecological study using aggregate crime and health service data for NSW, Australia, from January 2000 to March 2015. Amphetamine-related criminal incidents (arrests or cautions for possession or use) were used as an indirect measure of amphetamine availability. Semiparametric time series analysis was used to compare monthly arrest rates to monthly hospitalisation rates for (1) amphetamine abuse or dependence, (2) amphetamine-related psychosis and (3) any psychosis., Results: Amphetamine-related admissions to NSW mental health units have increased four- to fivefold since 2009 and comprised approximately 10% of all admissions to these units in early 2015. There was a significant association between arrests and amphetamine-related admissions. After adjustment for seasonal variation, this effect demonstrated a time lag of 1-2 months. There was no relationship between amphetamine arrests and overall admissions for psychosis., Conclusion: Greater amphetamine availability significantly predicts admissions for amphetamine use disorders and amphetamine-related psychosis. Better treatment strategies are needed to break the nexus between drug availability and drug-related harm.

Objectives: Despite research showing higher use of amphetamine-type stimulants (ATS) in rural areas, limited research has examined the epidemiology of ATS-related presentations and admissions to remote regional centres. To determine the epidemiology of ATS-related (a) Emergency Department (ED) presentations and (b) inpatient admissions over a five-year period at the Hedland Health Campus (HHC) in remote Western Australia., Methods: A retrospective review of medical records was conducted. Demographic data including gender, age and indigenous status were captured., Results: Four hundred and eighty-two ATS-related hospital presentations were identified during the study period. The most common reason for ED presentation was mental and behavioural problems. Of those presenting, 66% were male and 69% identified as Aboriginal. ATS-related ED presentations increased seven-fold over the study period. Ninety-nine ATS-related inpatient admissions were identified during the study period. Psychotic disorder was the most common reason for admission. Males made up 75% of admissions and 53% identified as Aboriginal., Conclusions: This study showed a disproportionally high burden of ATS-related harm among Aboriginal people. The number of ATS-related ED presentations and inpatient admissions increased significantly over the study period.

Objective: Chronic methamphetamine use is commonly associated with the development of psychotic symptoms. The predictors and correlates of methamphetamine-associated psychosis are poorly understood. We sought to systematically review factors associated with psychotic symptoms in adults using illicit amphetamine or methamphetamine., Methods: A systematic literature search was performed on MEDLINE (OVID), PsycINFO and EMBASE databases from inception to 8 December 2016. The search strategy combined three concept areas: methamphetamine or amphetamine, psychosis and risk factors. Included studies needed to compare adults using illicit methamphetamine or amphetamine, using a validated measure of psychosis, on a range of risk factors. Of 402 identified articles, we removed 45 duplicates, 320 articles based on abstract/title and 17 ineligible full-text articles, leaving 20 included studies that were conducted in 13 populations. Two co-authors independently extracted the following data from each study: country, setting and design; participant demographic and clinical details; sample size; measure/s used and measures of association between psychosis outcomes and risk factors. Individual study quality was assessed using a modified Newcastle-Ottawa Scale, and strength of evidence was assessed using GRADE criteria., Results: Frequency of methamphetamine use and severity of methamphetamine dependence were consistently found to be associated with psychosis, and sociodemographic factors were not. There was inconsistent evidence available for all other risk factors. Individual study quality was low-moderate for the majority of studies. Heterogeneity in study outcomes precluded quantitative synthesis of outcomes across studies., Conclusion: The most consistent correlates of psychotic symptoms were increased frequency of methamphetamine use and dependence on methamphetamine. The findings of this review highlight the need for targeted assessment and treatment of methamphetamine use in individuals presenting with psychosis.

Objectives: Few people who use stimulants seek clinical treatment. This study sought to describe a cohort of stimulant users who attended a stimulant-specific treatment service, Access Point, in Melbourne, Australia between 2008 and 2014., Methods: A retrospective audit of the records of adults ( n = 175) who sought treatment for stimulant use at a stimulant-specific outpatient treatment service was conducted., Results: Service users had a median age of 32 (range = 19-54). Most stimulant users were in part- or full-time employment (53.6%) and had stable accommodation (85%). There was a high rate of mental health comorbidity, with over half (52%) reporting a previous history of mental health problems, while one-third (33%) reported previous suicide attempts. There was a high rate (48%) of previous methamphetamine-associated psychosis, which was significantly correlated with frequency of use ( x 2 = 13.698, p = 0.008)., Conclusions: This study supports the potential of a targeted and specialised treatment service as a means of early intervention for stimulant users. The high prevalence of methamphetamine-associated psychosis history in this group suggests that frequent use of stimulants increases the risk of psychosis, even among high-functioning individuals.

Objective: Compared to the substantial body of research examining links between cannabis use and psychosis, there has been relatively little attention to the role of tobacco as a potential risk factor for psychosis. This study explored the association between age at first tobacco use and psychosis-related outcomes in a birth cohort., Method: This study is based on a large birth cohort (the Mater-University Study of Pregnancy). At approximately 21 years of age, cohort members (N = 3752) were assessed for three psychosis-related outcomes (International Classification of Diseases non-affective psychosis, the presence of any hallucination and total count of delusional-like experiences) with the Composite International Diagnostic Interview and the Peters Delusional Inventory. Associations between age at first tobacco use and psychosis-related outcomes were examined using logistic regression in a model (a) adjusted for sex and age and (b) in a second model excluding all respondents who had a history of past problematic and current cannabis use., Results: When adjusted for age and sex, those who commenced tobacco at 15 years of age or younger were significantly more likely to (a) have non-affective psychosis, (b) be in the highest quartile of total score of the Peters Delusional Inventory and (c) report hallucinations. After excluding all those with a history of a cannabis use disorder, or who were current (last month) cannabis users, a significant association between age at first tobacco use and the presence of hallucinations persisted., Conclusion: There is an association between age at first tobacco use and subsequent psychosis-related outcomes in young adults. While the findings cannot be used to deduce causality, it adds weight to the hypothesis that early tobacco use may contribute to the risk of developing psychosis-related outcomes., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

Objective: To explore the epidemiology of amphetamine type stimulant (ATS)-related admissions over six years in a regional centre, and to observe changes over time and compare demographics to national trends., Method: A retrospective audit of patients admitted with an International Classification of Diseases-10 (ICD-10) code relating to ATS use from 2008 to 2013 at Albany Health Campus. Age, gender and reason for admission were compared across each year, including repeat presentations. Concomitant codes during admission were noted., Results: One hundred and fifty two ATS-related hospital episodes were identified during the study period, 55% male and 45% female, with an age range from 16 to 50. Admission numbers increased over time. Patients with multiple admissions made up 35% of episodes. The most common reasons for admission were harmful use (F15.1) and psychotic disorder (F15.5). Sixty-nine percent of admissions had a concomitant ICD-10 code for mental health, 18% another medical code and 28% another factor influencing health status., Conclusion: The number of recognised ATS-related presentations is increasing at Albany Health Campus. A broad age range and comparatively high proportion of women were hospitalised. These patients have complex needs and many had multiple ATS-related admissions., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

Objective: There is considerable evidence to suggest that the abuse of illicit drugs, particularly cannabis and methamphetamine, has aetiological roles in the pathogenesis of psychosis and schizophrenia. Factors that may increase susceptibility to the propsychotic effects of these drugs include the age at which the abuse starts as well as family history of genetic polymorphisms relevant to the pathophysiology of this disorder. However, the neurobiological mechanisms involved in drug abuse-associated psychosis remain largely unclear., Methods and Results: This paper presents an overview of the available evidence, including clinical, animal model, and molecular studies, with a focus on brain regions and neurotransmitters systems, such as dopamine and glutamate, previously implicated in psychosis., Conclusion: It is clear that further studies are urgently needed to provide a greater insight into the mechanisms that mediate the long-term and neurodevelopmental effects of cannabis and methamphetamine. A dialogue between basic science and clinical research may help to identify at-risk individuals and novel pathways for treatment and prevention.

Objective: Clinicians have raised concerns about the impact of amphetamines on demand for mental health services. However, evidence for this link is limited. This study explores whether changes in the availability of amphetamines in NSW in the last decade have been associated with variations in admission to mental health units for amphetamine related conditions and for psychoses more generally., Method: The study examined admissions from community settings to NSW acute mental health units from 2000 to 2009. Quarterly rates of hospital admission with primary or comorbid diagnoses of stimulant use disorders, stimulant-induced psychoses and non-drug-related psychoses were compared to quarterly rates of criminal incidents of amphetamine possession and use, which provide an indirect measure of the community availability of amphetamines. Analysis was confounded by increases in mental health beds over the period. Linear regression predicted admission rates on the basis of amphetamine availability, adjusting for changing mental health bed numbers., Results: Amphetamine availability and admissions for psychoses increased steadily from 2000 to a peak in early 2007, but have declined since. Regression models including both amphetamine availability and bed numbers predicted 34% of variation in stimulant use disorders admission rates and 50% of variation in stimulant induced psychoses admission rates. There was no significant effect of amphetamine availability on admissions for schizophrenia and other non-drug-induced psychoses after controlling for changing bed numbers., Conclusions: Increased amphetamine availability appears to have been one factor increasing demand for mental health admission in NSW over the last decade. However, there appears to have been a recent downward trend in both amphetamine availability and amphetamine-related admissions. Policies which reduce the community availability of amphetamines may result in reduced admissions for amphetamine-related mental health conditions, including amphetamine-induced psychoses. Further research is needed regarding effects of amphetamine availability on admissions for schizophrenia.

Background: Traditional treatment approaches for the management of restless legs syndrome (RLS) and Parkinson's disease (PD) include the use of medications that either directly or indirectly increase dopamine levels. In turn, a potential adverse event that could be expected is the development or exacerbation of psychiatric-related symptoms., Objective: To evaluate and describe the incidence of psychosis and associated behavioral features in patients taking ropinirole for RLS or PD., Methods: Patients were identified from a computerized database search of outpatients being treated with ropinirole for 1 of 2 medical conditions: PD or RLS. Data were collected in a retrospective manner from 95 patients who were tracked over the course of their therapy to determine whether psychosis or associated behavioral symptoms developed as a result and whether an intervention was needed to adjust ropinirole dosing or if additional medications had to be added to control features associated with psychosis., Results: A total of 284 patients being treated for RLS or PD were identified; of this group, 95 patients were identified as being treated for PD or RLS with ropinirole. Of the 95 patients being treated with ropinirole, 13 developed psychotic features that required therapeutic intervention with either the use of an antipsychotic or dose adjustment of ropinirole. PD patients included in this study were numerically more likely to develop psychotic features compared with RLS patients; however, the difference was not statistically significant (p = 0.122). The results do suggest that this risk is increased when ropinirole is used as part of a dual therapy approach with dopamine agonists in the treatment of either PD or RLS (p = 0.003)., Discussion: Dopamine agonists have long been used as preferred treatment in the management of PD and RLS. When treating either PD or RLS in the psychiatric population, the concern arises that increased activity at dopamine receptors may induce or exacerbate psychiatric features. A potential clinical concern with the use of ropinirole is the potential for patients to develop psychiatric features, although there are few data available to demonstrate whether stimulation of targeted individual dopamine receptors is linked to the development or exacerbation of psychotic features. It is also undetermined whether concurrent antipsychotic treatment provides any protective benefit against psychosis, especially in patients already being treated for psychotic symptoms., Conclusions: Our findings suggest that ropinirole may play a role in inducing or exacerbating psychosis and its associated features, although a number of confounding variables prevent the determination of a clear association and suggest that further investigation is warranted in controlled clinical trials.

Objective: This paper sought to review current knowledge about the relationship between substance misuse and early psychosis., Methods: A literature search was conducted using Medline and restricting the search to articles after 1996. Additional articles were sourced from reference lists of relevant articles., Results: There is a high prevalence of substance misuse among persons with early psychosis, with cannabis and alcohol featuring prominently. Substance misuse is associated with earlier onset and possibly more positive symptoms, although apparently not with greater cognitive impairment. Cannabis appears to confer an increased likelihood of developing schizophrenia in biologically vulnerable individuals. Amphetamines also cause psychosis which may become chronic, although specific vulnerability to this effect is less well established. Many cases of so-called 'drug-induced psychosis' become diagnosed as schizophrenia in later years. Specific intervention programs report positive outcomes with regard to substance misuse and the course of psychosis., Conclusions: Substance misuse should always be assessed in this patient group, bearing in mind the potential interactive causes of psychopathology. Intervention is of value in improving outcomes.

Objective: To describe and discuss the implications for treatment of 3 cases of dually diagnosed patients with a primary psychotic disorder who have developed persisting, cannabis-oriented delusional systems., Method: Psychiatric assessment and daily observation on an acute inpatient psychiatric unit., Results: Abstinence appears to be particularly difficult to attain for a patient with psychosis who hold delusional beliefs that cannabis is a conduit for supernormal experiences with positive affective content, grandiose themes and a sense of enhanced self-efficacy., Conclusion: This phenomenon poses special challenges in the treatment of dual diagnosis patients. Modifications to existing CBT protocols for the treatment of substance abuse in psychosis might be useful in such patients.

Objective: This paper evaluates evidence for two hypotheses about the relationship between cannabis use and psychosis: (i) that heavy cannabis use causes a 'cannabis psychosis', i.e. a psychotic disorder that would not have occurred in the absence of cannabis use and which can be recognised by its pattern of symptoms and their relationship to cannabis use; and (ii) that cannabis use may precipitate schizophrenia, or exacerbate its symptoms., Method: Literature relevant to drug use and schizophrenia is reviewed., Results: There is limited clinical evidence for the first hypothesis. If 'cannabis psychoses' exist, they seem to be rare, because they require very high doses of tetrahydrocannabinol, the prolonged use of highly potent forms of cannabis, or a preexisting (but as yet unspecified) vulnerability, or both. There is more support for the second hypothesis in that a large prospective study has shown a linear relationship between the frequency with which cannabis had been used by age 18 and the risk over the subsequent 15 years of receiving a diagnosis of schizophrenia., Conclusions: It is still unclear whether this means that cannabis use precipitates schizophrenia, whether cannabis use is a form of 'self-medication', or whether the association is due to the use of other drugs, such as amphetamines, which heavy cannabis users are more likely to use. There is better clinical and epidemiological evidence that cannabis use can exacerbate the symptoms of schizophrenia.

Objective: The purpose of this study was to examine the level of cannabis use in psychotic patients admitted to two acute admission wards in New Zealand. Symptomatology was investigated using the Brief Psychiatric Rating Scale (BPRS)., Method: During a 1 -month period, all acute admissions to Tokanui Hospital with psychosis were interviewed and symptoms rated on the BPRS (n = 35). Cannabis use was recorded with a questionnaire and urine test. Those positive for cannabis were compared to those negative., Results: Thirty patients (86%) had tried cannabis at least once and 11 (31%) were positive on urine screen. Those with positive urine tests were significantly more likely to use cannabis most days (p < 0.001). This positive urine test group was less likely to be thought disordered, suspicious or deluded (as measured by the BPRS)., Conclusions: Cannabis use was widespread in this sample of patients with psychosis and may affect their symptomatology. Larger studies are needed to examine these associations in more detail.

It is known that there is an association between cannabis use and psychosis. Clinically we had thought that there were increasing numbers of patients admitted to hospital who were using cannabis and that this was affecting their illness. A study was therefore undertaken to determine the extent of cannabis use and its relationships over a one month period. The findings and their implications for junior doctors on-call are also discussed.