Abstract
After a decade of active service reform and system change, quality data that allow us to examine changes in clinical outcomes over time are of profound importance. In this context, this issue of the Journal contains a number of key papers reporting findings from the Survey of High Impact Psychosis (SHIP). The SHIP was a nationwide study that recruited 1825 individuals sampled across five states (Morgan et al., 2012). It is a follow-up to the first Australian National Study of Low Prevalence (Psychotic) Disorders, which took place between 1997-1998 (Jablensky et al., 2000). It is doubly important as it provides a snapshot not only of the present but also allows comparisons across time, having used comparable populations and metrics.
Substantive changes between the two time points have already been reported – some positive and some that are cause for concern. Most heartening, is the change in the proportions of individuals in terms of outcome, with a higher proportion in the ‘good’ than in the ‘poorer’ outcome categories. If this is indeed a generalisable finding, it needs to be celebrated as a systems success. This improvement is seemingly associated with a decrease in psychiatric inpatient admissions and a shift to community care, an increase in the use of non-governmental organisation resources and rehabilitation services, and appears to be linked to prescription shifts from typical to atypical antipsychotic agents (Morgan et al., 2012).
In this issue, Harvey and colleagues (2012) explored the housing needs of individuals with psychotic disorders in the SHIP study. Housing is a highly ranked perceived need amongst individuals with psychosis and inadequate housing is an impediment to engagement with care and recovery. In the study, half of the participants were living in rented housing, approximately one quarter were waiting for public housing, 5% of participants were currently homeless and almost 13% had been homeless in the previous 12 months. Interestingly, this is an improvement compared with the 1997–1998 survey. However, the portion of individuals struggling with homelessness or housing instability remains a cause for concern, especially in younger people. Greater use of supported housing was suggested as a way forward to further remedy this unmet need.
Stain and colleagues (2012) explored the social costs of psychosis in the SHIP cohort. They reported distressingly high rates of social exclusion and isolation. Loneliness was an almost universal experience, with the majority of men not ever having had a long-term relationship, and more women than men struggling with social anxiety. Stigma was reported as a barrier by almost half the participants, and two thirds had not attended any social activity in the previous year. Of note, social isolation and social role impairment had not changed significantly since the 1997–1998 survey, suggesting that it remains an unmet need.
Being a parent is a particular challenge for people with disabilities, especially those with severe mental illnesses (Campbell et al., 2012). They are more likely to be single parents, experience relationship failures or have custody issues. Compared with the 1997–1998 survey, the current survey shows an increasing number of parents with psychosis, and of people living with dependent children, which stands in contrast with a declining rate of parenthood in the broader population. This needs to be seen as a proxy of success in terms of social reintegration. However, the authors point out quite correctly that this increases the need for a range of supportive social, sexual health and perinatal services. Given the rates of disability that remain in this cohort, the needs of these individuals’ offspring are a particular priority.
Cooper and colleagues (2012) document the ubiquitous yet oft ignored relationship between smoking and mental health in the SHIP cohort. They replicated the very high prevalence of smoking, particularly among those with schizophrenia and schizoaffective disorder, where almost three quarters of individuals were smokers, also finding that smoking was correlated with poorer physical health, more substance use comorbidity and mental health symptoms, a finding that reinforces prior findings (Dodd et al., 2010). In particular, smokers had an earlier age of onset, more positive and negative symptoms, and greater psychosocial disability. While smoking rates have declined in the general population, unsurprisingly no difference in smoking rates were seen between the SHIP and 1997–1998 studies, concordant with smoking not being a particularly active intervention area over the last decade.
Unfortunately, some problems appear to be worsening. In this Journal, Moore and colleagues (2012) noted that not only was alcohol and illicit drug use highly prevalent in the study sample, but there was a worrying increase in the rates of substance abuse and dependence since the first study. They found that 51% of individuals were diagnosed with alcohol abuse and dependence, 51% with cannabis abuse/dependence and 32% with other illicit drug abuse/dependence. These figures are approximately double those found in the earlier survey in which 28%, 23% and 12% had the same issues, respectively. Indeed, the improvements in many of the outcome domains in the SHIP study need to be seen against the worsening of this major risk factor.
In concert, these findings suggest that the outcomes of psychosis are plastic over time, and that they are associated with systems changes and reform. This is a shot in the arm for those who have advocated for systems reform, and for those who have implemented it. However, substantive unmet needs remain. The evident successes noted above should re-energise the field to target these unmet needs, in the knowledge that evidence-based best practice indeed does make a difference.