Full length articleEscalating patterns of emergency health care prior to first admission with amphetamine psychosis: A window of opportunity?
Introduction
Psychostimulant use is a significant contributor to the global burden of disease, and in South East Asia and Australasia methamphetamine is the most commonly used stimulant (Degenhardt et al., 2014). Australia has experienced a significant increase in health system contacts for amphetamine related harms (Degenhardt et al., 2017), leading to significant public concern and an increased policy focus (Department of Health, 2017).
One of the most serious health consequences of amphetamine use is psychosis (Darke et al., 2008). Amphetamine-related psychotic experiences range from brief and transient psychotic symptoms, to more severe episodes of psychosis lasting days or weeks and requiring community or inpatient mental health care. A brief amphetamine-related psychosis of sufficient severity to require hospital admission may be a first step towards developing a more enduring psychotic disorder. Estimates of the rate of progression from drug-induced psychosis to a later diagnosis of Schizophrenia range from 17% to 46% (Alderson et al., 2017, Niemi-Pynttari et al., 2013, Sara et al., 2014). Young adults admitted to hospital with any methamphetamine-related condition have a 10-fold increased risk of later development of Schizophrenia compared with matched controls admitted with appendicitis (Callaghan et al., 2012). In Australian population studies, more than one third of young adults admitted for amphetamine-related psychoses receive a diagnosis of Schizophrenia at their first hospital admission (Sara et al., 2013).
Psychotic symptoms in amphetamine users are associated with high dose, long term and dependent use, intravenous administration, use of the crystal methamphetamine form, and concurrent use of other substances including cannabis (Lappin et al., 2016, McKetin et al., 2010, McKetin et al., 2013, McKetin et al., 2006). These factors are also likely to be associated with other health-related harms. Therefore, people hospitalised for amphetamine-related psychoses are likely to have had prior contact with health services for a range of health conditions. These contacts may provide the opportunity for detection of substance use problems and referral for early intervention. Clinical staging models of psychosis propose detection and intervention during the earliest “at risk” states to prevent development of acute episodes of psychosis, or progression to more enduring psychotic disorders such as Schizophrenia (Insel, 2010, McGorry et al., 2010).
Little is known about health contacts prior to a first episode of amphetamine-related psychosis. In people with early psychosis, co-occurring substance use is associated with acute onset and short duration of untreated illness (O’Callaghan et al., 2010). We have previously found that nearly half (49%) of young adults admitted for stimulant-related psychoses had no prior inpatient or community mental health care (Sara et al., 2013). However, no studies have systematically examined broader patterns of health system contact prior to admission with amphetamine-related psychosis.
This study uses a population dataset to identify a cohort of people with a first psychosis admission complicated by amphetamine use disorder, and describes care in the two years prior to their first admission. We examined where care occurred (hospital, emergency department and community mental health care), why it occurred (psychiatric, substance and/or medical diagnoses) and when it occurred (over the two years prior to admission). We hypothesized that people experiencing a first hospital admission with amphetamine-related psychoses would have a high likelihood of prior contact with mental health, physical health and emergency services, providing potential opportunities for earlier detection and intervention.
Section snippets
Material and methods
The study used routinely collected health service data from government (“public”) hospital and community mental health services in the state of New South Wales (NSW), Australia, population 7.2 million. In Australia, public health services provide most acute and emergency care, and all acute and involuntary mental health care. Data use was approved by the NSW Population and Health Services Research Ethics Committee.
Results
We identified 62,831 first psychosis admissions in the study period. We excluded 12,677 persons aged younger than 16 or older than 65 and 2580 who were not NSW residents at the time of first admission, providing a final study group of 47,574 first psychosis admissions. Of these 6130 (12.9%) had an amphetamine use disorder and formed the “Amphetamine-related psychosis” group. This included 3411 with a diagnosis of amphetamine-induced psychosis and 2719 with concurrent diagnoses of another
Discussion
This is the first study to examine health service contacts prior to a first hospital admission for amphetamine-related psychosis. In this population-based sample of more than six thousand adults admitted for the first time with amphetamine-related psychosis, more than two-thirds had health service contact in the preceding two years.
People with amphetamine-related psychoses were more likely to have prior ED presentations, or hospital admissions with accidents, injuries and infectious diseases
Conclusion
In conclusion, most people admitted to NSW hospitals for a first episode of amphetamine-related psychosis have prior health service contact, often with evidence of problematic use of amphetamines or other substances, or with probable health consequences of substance use. Emergency department contacts and hospital admissions for physical health problems are particularly common. There are opportunities for screening, education and referral which could prevent some later episodes of
Conflict of interest
No authors have conflicts to declare.
Role of funding source
Nothing declared. The study was conducted by A/Prof Sara in his role as a salaried employee of NSW Ministry of Health. No specific funding was received for the study. NSW Ministry of Health played no other role study design; collection, analysis and interpretation of data; writing of the report; or the decision to submit the article for publication. The content is solely the responsibility of the authors and does represent the official view of the funding agency.
Contributors
GS and JL conceived of and designed the study. TD and LD provided advice on statistical analysis and design. GS conducted data extraction and statistical analyses. GS and JL prepared a draft manuscript. All authors reviewed and contributed to the final manuscript.
Acknowledgement
Nil.
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