Volume 216 Issue 5

Recent legal changes are negatively affecting provision of timely medical care to Australian transgender youth

Fiona Kelly · Simona Giordano · Michelle M Telfer · Ken C Pang

Predicted reintroduction of influenza into Australia as COVID-19 restrictions lift provides a unique opportunity to learn important lessons

Evelyne Leeuw · Aryati Yashadhana · Danielle Hitch

Medical educators and representatives of medical student associations in Australia and New Zealand are collaborating on an initiative on climate change and health in medical education

Diana L Madden · Graeme L Horton · Michelle McLean

The laws governing treatment consent in gender dysphoria have rapidly evolved in the past two decades, with the uncertainty, and at times confusion, regarding the law resulting in volatility in clinical practice

Calina Ouliaris

My senior colleague is starting to wind down toward retirement and hasn’t fully adjusted to having our department meetings on Zoom

Mark Lavercombe

It has been a tremendous privilege to lead the Journal

Nicholas J Talley

Older people and those who are frail or have chronic diseases are at particular risk of multiple complications

Bernice Redley · Helena Romaniuk

Reasons for inconsistencies need to be investigated to reduce the levels of medications that go missing

Valentina Lichtner

We must consider how structural inequities, such as housing availability and affordability, lack of adequate social protection, and marginalisation from health systems, may further entrench disadvantage in the face of long COVID

Kanta Subbarao

Complication rates reflect casemix and patient characteristics more than hospital factors and quality of care

Graeme J Duke · John L Moran · Andrew D Bersten · Shailesh Bihari · Owen Roodenburg · Jonathan Karnon · Steven Hirth · Paul Hakendorf · John D Santamaria

Almost 20% of units supplied to medical and surgical wards and emergency department were not administered to patients

Kimberly Walker · Andrew M Harding · Julina Tran · Paul Wembridge · Kent Garrett · Kent MacMillan · Olivia Rofe · Nicholas Jones · David Taylor

Clinical guidelines must be continually updated and tailored to specific populations, including children and adolescents.

Clinical care of children and adolescents with COVID-19: recommendations from the National COVID-19 Clinical Evidence Taskforce

To the Editor: We must clarify that the findings of Iorfino and colleagues1 do not apply to headspace clients. This understandable misperception comes from the article’s title, “early intervention mental health services”, and participants coming from “clinics” that “provide both primary care services (headspace) and more specialised services”. Quotes from an InSight+ article2 and the accompanying editorial3 infer that the findings generalise to headspace, but they do not. Although some participants in the Iorfino study came from two headspace‐branded centres, they also included young people accessing specialised services. This is evident in the limitations: “our sample was restricted to young people who remained in contact with the service for at least two years … biasing our sample towards people who required ongoing care and were accordingly more likely to have poorer outcomes”. Generally, headspace does not provide care over a period of two years or more; centres typically provide brief episodes of care, befitting young people with mild to moderate presentations for common mental health problems. The average number of sessions is 4.4 (standard deviation [SD], 6.2); 98% of clients receive 20 sessions or fewer. A negligible 0.4% of clients are still receiving care at two years. Average time between the first and last session is 73.7 days (SD, 120), about 2.5 months (headspace 2015–2021, national unpublished data). Clarification that the findings are not representative of, nor generalisable to, headspace clients is essential; the headspace initiative is not targeted at young people who need more sustained mental health care. The results are inconsistent with reported outcomes for 24 034 headspace clients from 55 fully established centres.4 Significant improvement in the Social and Occupational Functioning Assessment Scale (SOFAS) scores was evident for 37.1% of headspace clients, 43.4% had no significant change, and 19.5% significantly deteriorated. Updated outcomes are forthcoming. Importantly, multiple outcomes must be considered for headspace clients; these are young people with diverse early intervention needs — the single‐item, clinician‐rated SOFAS is insufficient to ascertain meaningful outcomes. Despite the inability to generalise from Iorfino’s study to the national headspace centre network, we agree that young people with complex and persisting mental health conditions require more resource‐intensive responses than headspace primary care services were designed for.

Debra J Rickwood · Jason Trethowan · Annette Carruthers

To the Editor: Iorfino and colleagues1 reported that “two in three young people with emerging mental disorders did not experience meaningful improvement in social and occupational functioning during two years of early intervention care”. Their sample was drawn from two headspace sites. This sounds alarming, especially considering that the study is exemplary in its longitudinal design, large sample size, and robust statistical analyses. Nevertheless, clinicians should be mindful of making too much of these results. The primary weakness of this study is the measure used: the Social and Occupational Functioning Assessment Scale (SOFAS). A systematic review of measures of functioning considered evaluating the SOFAS, yet excluded it based on the grounds that “the SOFAS has been superseded by the Personal and Social Performance Scale (PSP), which demonstrates stronger psychometric performance”.2 A study in 2007 stated that “the PSP scale is proposed as an improvement over the [Global Assessment of Functioning] and SOFAS because of its clear operational instructions on how to rate the severity of disability and its distinction between levels of impairment”.3 A similar issue was noted in 2000.4 Suffice to say, the SOFAS is a superseded measure of social and occupational functioning. This is apparent at the theoretical level. The SOFAS is a single item measure, rated on a scale of 0–100, for both social and occupational functioning. How is a clinician meant to score this measure when a young person presents functioning highly in their schooling, yet poorly in their social life? Or when things are going well with friends, yet poorly with their family? With this in mind, it is no surprise that three out of the four trajectories for young people’s mental health journeys identified by Iorfino and colleagues1 demonstrated no significant improvement. This is indicative of a broader issue identified in a systematic review of 189 articles, which reported that only nine mental health outcome measures in the published literature examined functional outcomes. Of these, “no measures were designed specifically for young people aged 12 to 25 years”.5 In short, the SOFAS is an out‐of‐date, adult measure with poor inter‐rater reliability. The study by Iorfino et al1 is what we need, but not what we are ready for. There is an urgent need in youth mental health services to have valid, reliable measures of social and occupational functioning that have good construct validity. There is an urgent research need for the development of such measures that have robust psychometric properties and clinical utility. Until this issue is resolved, attempting to predict pathways of care, or measure the efficacy of these services at a population level, will remain a guessing game. Future studies should focus on the development and evaluation of these measures. The collateral damage if researchers continue to use these measures will be the young people in need of early intervention.

Peter J Lenehan

In reply

Frank Iorfino · Elizabeth M Scott · Ian B Hickie