General medicine

Christmas Offerings MJA 2000; 173: 659-660

Brian J Fotheringham

Christmas Offerings Olympic couch potatoes MJA 2000; 173: 664 The Sydney Olympic Games were captivating. Hordes of people flocked to the torch relay, the sports stadiums and entertainment venues. When not out and about, most of us spent a considerable amount of time glued to the action on television, a pastime not without potential complications. During the Games, my wife, a pharmacist at a large teaching hospital, reported that a newly admitted patient had been given a diagnosis of "TV vegetation". Was this a new syndrome, comprising stiffness, visual impairment, insomnia and blunted mind, the culmination of countless hours of TV viewing? Had the condition been described in Atlanta or Barcelona? Was SOCOG about to be bombarded with compensation claims? Had the consultant been too frivolous and abusive of medical terminology, or was he "sharing the spirit" and participating appropriately in the Olympic banter? None of the above. The patient, a young intravenous drug user, had "tricuspid valve vegetation", and had been admitted with a high fever and renal failure. He eventually made a full recovery. Garry Walter Acting Director Child, Adolescent and Family Mental Health Services Central Sydney Area Health Service, Sydney, NSW

Garry Walter

Christmas Offerings The Internist MJA 2000; 173: 664 There used to be a General Physician Of eminent commanding disposition. His morbid knowledge was completely awesome, From ventral to the lateral and dorsum. There was no system he could not expound on, Nor any body part he was unsound on. Inspection, palpation, percussion, auscultation Were basic to routine examination. The brain, the heart, the kidney, lung or colon, Or any joint or organ that was swollen. Each viscus with a membrane, duct or lumen Would stimulate his medical acumen. But nowadays Physicians have decided That multisystem medicine's misguided, Thereby opting for a demarcation And introducing strict sub-specialisation. Now patients with a medical condition, In seeking out a competent Physician, No longer have the slightest comprehension Of whom they should consult for intervention. For folk without approved medical training, I proffer information thus pertaining, Whereby they may indulge, even rejoice in, A doctor whom they may have little choice in! Len Green Radiologist, Bondi Junction Radiology Rose Bay, NSW

Len Green

Matters Arising Australian general practice: the need for leaders and vision An editorial in the General Practice Issue (MJA, 17 July 2000) called for leadership and vision to guide Australian general practice MJA 2000; 173: 668

James A Dickinson

Matters Arising R&D in general practice: time to move forward An editorial in the General Practice Issue (MJA, 17 July 2000) called for leadership and vision to guide Australian general practice MJA 2000; 173: 668-669

David P Weller

Matters Arising The current situation of general practice An editorial in the General Practice Issue (MJA, 17 July 2000) called for leadership and vision to guide Australian general practice MJA 2000; 173: 669

Editorial Domestic violence The healthcare sector could become agents of change MJA 2000; 173: 513-514 The recent series of review papers on domestic violence in the Journal has dealt with a number of important themes: the impact of domestic violence on individuals;1 characteristics of perpetrators;2 presentation of domestic violence in clinical settings;3 and what can be done about domestic violence.4 The prevalence of domestic violence is difficult to estimate because of the variability of definitions and ways of measuring it and the lack of systematic epidemiological studies. Rates tend to be high among patients presenting to general practitioners,5 antenatal clinics,6 emergency departments7 and mental health services,8 but in each of these settings detection is poor. While studies are often developed within a feminist frame of reference and have mostly emphasised the impact on women, men may also be subject to violence from women, as may partners in same-sex relationships. Its impact on children is also substantial, both through witnessing violence and experiencing the effects of abused and abusing parents.9 Focusing on physical abuse as the key indicator may fail to identify far more damaging emotional abuse. There are major health and economic costs of domestic violence.10 Both physical and mental health are affected, increasing the risk of suicide-related behaviours, the drain on healthcare resources and negative perceptions of health status.8,10 Domestic violence in a cultural context Cultural factors have an important impact on the prevalence of domestic violence. These include stereotyped attitudes about "ownership" of women and their value and place in the family and in society; attitudes that define social status in terms of power over others; and the belief of some people that violence is a normal and acceptable way to resolve conflict. The phenomenon of psychological "splitting" is relevant in many situations of domestic violence: people in relationships may unconsciously separate their own good and bad qualities, projecting the hated parts of themselves onto their partner, who is then abused. Understanding violence in families should always encompass an understanding of the importance and complexity of intimate relationships, the making and breaking of affectional bonds and the basic human needs they reflect. These attachments are central to human well-being. It is also vital to take into account social determinants and the particular adversities of social disadvantage that will add cumulative risk. Domestic violence and clinical care Patients are more likely to disclose domestic violence if they receive clear signals that their doctor does not condone violence and will approach the problem in a sensitive way.3,4 A number of questionnaires, including one that has been tested in Australian general practice,5 have been developed to screen for domestic violence. However, they tend to focus only on women, and some are too long to serve as a practical screening tool. In some cases, a single question or a few queries may be all that is required to bring about disclosure of domestic violence if the clinician is alert to its possibility. A high index of suspicion is appropriate if a patient presents with low self-esteem, vague somatic complaints, signs of bruising or other injury and a level of defensiveness. The doctor should question the patient about fear, abuse, depression, and suicidal thoughts. Some victims of domestic violence may even be suffering from a form of post-traumatic stress disorder.11,12 Support, protection, and treatment of acute problems are the first priorities. Effective mental health interventions are available, but should not be provided until the person is in a safe situation. It is also important to remember that children are often traumatised by domestic violence, even if not directly subject to abuse. Feelings of powerlessness, helplessness, and shame often make it difficult for victims of violence to speak of their experience, and they may feel that they are somehow to blame or have "deserved" the abuse. The review of perpetrator issues2 highlights the complexity of this behaviour, the lack of adequate data and the need for evidence of effective interventions. Joint counselling for the couple is usually not recommended because of the late recognition of most cases of domestic violence, the entrenched damaging behaviours and the critical requirement for safety. However, partner programs involving early intervention to reduce negative interaction and interpersonal hostility in relationships could be beneficial.13 Barriers to effective clinical identification and management of domestic violence by health professionals include lack of training, fears for the safety of the victim, or even of the self, identification with victims or perpetrators from the doctor's own social group and, above all, deeply entrenched social attitudes about the privacy of the family.4 Health services and social policy Health services have responded to domestic violence with a range of policies.14 The highest priority for health services is to ensure that victims are protected from further harm. Health professionals need to know about the relevant State legislation, contact details for refuges, and local protocols for appropriate responses when domestic violence is suspected or confirmed. They must be well informed about how to make timely and appropriate referrals.15 The effectiveness of current and proposed programs needs to be evaluated. There are a number of social and health-related policies and programs that could potentially influence the prevalence of and response to domestic violence. Policies that focus directly on domestic violence include: The National Campaign Against Violence and Crime.16 This has programs aimed at preventing violence in schools, rural communities and domestic settings, and programs for dealing with perpetrators. Partnerships Against Domestic Violence.17 This is an agreement between the Federal Government and the States and Territories to work together to prevent domestic violence across Australia. Legislation relating to child protection, family law and orders against violence. Specific policies of States and Territories relating to women's services and the provision of care and protection for women and children who are victims of violence. Other, more general initiatives that may have an effect on domestic violence include National Crime Prevention's "Pathways to Prevention",18 the National Action Plan for Mental Health Promotion and Prevention,19 the Stronger Families and Communities Strategy,20 national policies on alcohol and other drugs, and policies aimed at preventing child abuse and neglect. The complex interface of social policy and health is very relevant in this field. Social variables may far outweigh other factors in the aetiology of domestic violence, but the healthcare sector could become the driving force for change. Beverley Raphael Professor, and Director, Mental Health Services New South Wales Health Department, Sydney, NSW Astbury J, Atkinson J, Duke JE, et al. The impact of domestic violence on individuals. Med J Aust 2000; 173: 427-431. Romans SE, Poore MR, Martin JL. The perpetrators of domestic violence. Med J Aust 2000; 173: 484-488. Hegarty K, Hindmarsh ED, Gilles MT. Domestic violence in Australia: definition, prevalence and nature of presentation in clinical practice. Med J Aust 2000; 173: 363-367. Mazza DM, Lawrence JM, Roberts GL, Knowlden SM. What can we do about domestic violence? Med J Aust 2000; 173: 532-535. Hegarty K. Measuring a multi-dimensional definition of domestic violence: prevalence of partner abuse in women attending general practice. Brisbane: Department of Social and Preventive Medicine, University of Queensland, 1999: 246. Webster J, Sweett S, Stolz T. Domestic violence in pregnancy: a prevalence study. Med J Aust 1994; 161: 466-470. Roberts GL, O'Toole BI, Lawrence JM, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1993; 159: 307-310. Roberts GL, Lawrence JM, Williams GM, Raphael B. The impact of domestic violence on women's mental health. Aust N Z J Public Health 1998; 22: 796-801. Campbell JC, Lewandowski LA. Mental and physical health effects of intimate partner violence on women and children. Psychiatr Clin North Am 1997; 20: 353-374. Resnick HS, Acierno R, Kilpatrick DG. Health impact of interpersonal violence. 2: Medical and mental health outcomes. Behav Med 1997; 23: 65-78. Kemp A, Green BL, Hovanitz C, Rawlings EI. Incidence and correlates of posttraumatic stress disorder in battered women: shelter and community samples. J Interpersonal Violence 1995; 10: 43-55. Herman JL. Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. J Trauma Stress 1992; 5: 377-391. Halford WK. Marriage and the prevention of psychiatric disorder. In: Raphael B, Burrows G, editors. Handbook of studies on preventive psychiatry. Amsterdam: Elsevier, 1995: 121-137. Review of NSW Health domestic violence policy. Discussion paper. NSW Health Department, 1999. Roberts GL, Lawrence JM, O'Toole BI, Raphael B. Domestic violence in the emergency department. 2: detection by doctors and nurses. Gen Hosp Psychiatry 1997; 19: 12-15. National Campaign Against Violence and Crime (NCAVAC). Canberra: Attorney-General's Department, 1998. Partnerships Against Domestic Violence. Information available at: <http://padv.dpmc.gov.au>. Accessed 11 October 2000. Pathways to prevention. Canberra: National Crime Prevention, Attorney General's Department, 1999. Mental Health Promotion and Prevention National Action Plan. Canberra: Commonwealth Department of Health and Aged Care, 1998. Stronger Families and Communities Strategy. Canberra: Commonwealth Department of Family and Community Services, 2000. Make a comment

Beverley Raphael

Medicine and the Community What can we do about domestic violence? Danielle Mazza, Joan M Lawrence, Gwenneth L Roberts and Sheila M Knowlden MJA 2000; 173: 532-535 See Articles 1, 2 and 3 of this series For editorial comment, see Raphael Abstract - What can individual doctors do? - What can be done in the institutional or hospital setting? - What can governments do? - Conclusions - References - Authors' details - - More articles on General practice and primary care Abstract Domestic violence is a complex issue at both an individual and public health level. Barriers to disclosure often lie with the doctor rather than the victim. Assessment of risk and devising a safety plan are important steps for the doctor to undertake with the victim. Recommendations for joint counselling or marriage guidance for the couple are usually not appropriate. The efficacy of population screening for domestic violence has not yet been demonstrated. More limited opportunistic screening is recommended, especially in the emergency department, mental health and obstetric settings, and general practice. Health professionals can be a bridge to resources within the community, but this requires knowledge of and liaison with those services. Domestic violence is a social, economic and political issue that has ramifications for the health of the whole community. It affects not only the physical and mental health of up to 20% of women at some stage of their lives,1 but also the health of children living with domestic violence.2There is increasing awareness of the benefits of taking a public health approach to domestic violence -- in considering it analogous to a chronic and complex condition, the burden of care on individual doctors can be lessened and the healthcare system can take a more constructive approach to this difficult issue. We examine here the role of individual practitioners, healthcare institutions and government in managing domestic violence, and propose some preventive strategies. What can individual doctors do? Doctors often fail to suspect domestic violence. In one study of a family practice in which the prevalence of domestic violence was 7% for physical abuse and 23% for emotional abuse, only 1% of doctors' files documented the abuse.3 In another study of 492 patients who completed a questionnaire after presenting at a hospital emergency department (ED), 22% admitted to being victims of domestic violence, but ED records identified only 5% of these victims.4It may be that some doctors who are aware of abuse experienced by their patients fail to document it. However, documentation is essential for the patient in case legal action ensues. Easteal and Easteal5 surveyed 96 Australian general practitioners on their attitudes and practices towards victims of domestic violence. The most common reasons given for suspecting spouse abuse were physical signs and injuries (56.3%), excess alcohol consumption by the patient and/or partner (11.0%), and the patient's case history (11.5%). Only about a third of doctors reported that they look for emotional problems as "symptoms" when determining assault cases. In a similar Canadian study of 505 physicians, respondents estimated that 14%-17% of their female patients had been victims of abuse, but over 70% of respondents believed that they identified fewer than half of these patients in their practice. The most common reasons given for failure to uncover domestic violence were patient unresponsiveness, lack of physician initiative and infrequent visits by the patients.6 Doctors perceive spouse abuse to be a complex and multifaceted problem.7 Many feel powerless to deal with domestic violence,8 and fear that in broaching the subject they are "opening Pandora's box".7 Barriers to instituting helpful intervention in cases of domestic violence include: close identification by doctors with patients of similar background, which may preclude the consideration of domestic violence as a differential diagnosis;9 a perception, especially among female doctors, that dealing with patients' domestic violence issues will expose their own fear of vulnerability and lack of control;9 a fear of offending patients by asking questions about a subject culturally defined as "private";9 reluctance to accept a patient's claims of domestic violence without corroboration from an outside source;9 time constraints in a busy practice that make it difficult to deal with complex problems such as domestic violence;7,10 lack of training of doctors in the area of domestic violence.9,11 Abused women are more likely to disclose domestic violence to their GP than to other health workers and, when they do, the GP needs to be prepared. Useful advice for doctors on dealing with domestic violence, and an illustrative case scenario, are given in Boxes 1 and 2. What can be done in the institutional or hospital setting? Research over the past decade has demonstrated the high prevalence of domestic violence and the physical and psychological consequences that bring victims into contact with the hospital system.4,21,22 Failure to identify and manage these victims appropriately has led to some changes in management within the hospital setting and in the integration of care between the hospital and the wider community. However, further changes are needed. The effectiveness of population screening of women for domestic violence has not been proven,23 and at this stage the more limited goals associated with opportunistic screening are recommended. Routine screening should only be undertaken in situations where there is likely to be a high prevalence, such as among people attending hospital EDs, antenatal clinics and psychiatric services. Routine screening within the hospital setting will raise ethical and practical issues. An important ethical issue is the acceptability of asking people directly about their experience of domestic violence. Studies conducted in EDs demonstrate high response rates to screening questionnaires by women and men.24 The current pilot study being conducted by Queensland Health Domestic Violence Initiative to introduce routine screening in EDs and antenatal clinics has met with strong acceptance from the women being surveyed (Ms J Webster, Co-manager, The Domestic Violence Initiative, personal communication). Screening will require the choice of appropriate tools and training of staff. Staff will need broader knowledge in the areas of documentation of history and injuries, photographs, safety of the victim, confidentiality, legal rights, and reporting of attempted or suspected criminal assault. (Reporting of violence is a controversial issue -- for example, several states in the United States have mandatory reporting of domestic violence, but there are concerns about patient autonomy and risk of retaliation for the victim.25) Training also needs to deal with the barriers to enquiry about domestic violence, including negative attitudes of health professionals towards victims. Staff who have themselves experienced domestic violence may require particular care. Knowledge of the dynamics of domestic violence is important -- staff need to understand that domestic violence can manifest as both mental and physical injury, and to accept that there is often no immediate solution to the problem (eg, a victim may return to a violent partner). Hospitals need to assess their resources for dealing with domestic violence and devise policies and protocols for the use of those resources. Health professionals can be a bridge to services in the community if they are familiar with the appropriate referral services within the hospital and in the wider community. For years, legal and community advocacy services have acted as community resources for women seeking help with domestic violence problems. A recent development in the United States has been to enlist the help of advocates in medical settings.26While this is not common practice in Australian hospitals, the service is worthy of consideration given the success of other services such as breast cancer volunteer visitors (ie, women who, having experienced the condition themselves, give support and comfort to other women with breast cancer). Advocates can assist victims with legal information and safety planning, and help them develop independence. What can governments do? Domestic violence is an important issue for government not only because of its effect on the physical and mental health of the community, but because of the costs it incurs for the healthcare system, especially as victims of violence are often misidentified and incorrectly treated.22Governments can enact policies aimed at prevention, supply resources for effective management of perpetrators and victims of domestic violence, and educate the community about domestic violence. Government policy can also target the training that medical, nursing and allied health personnel receive to ensure that all clinicians are aware of their role in managing domestic violence, know how and when to screen for domestic violence and know which management strategies are likely to be effective.22 Governments could also ensure that the different departments dealing with domestic violence and child abuse are able to work together effectively and communicate information on cases they have in common. This is because the strategies for managing child abuse in this context are different from those required for dealing with other forms of child abuse. When asked how government services relating to domestic violence could be improved, women have suggested improving the responsiveness of individual police members when dealing with domestic violence; ensuring that a wider range of organisations and professional services are aware of domestic violence issues and how to manage them; increasing awareness of how to access the domestic violence services that are available; increasing the services in remote and rural areas; and providing more practical support with housing, employment and the law.15,27 Governments also need to address the continuing shortage of refuge accommodation,28 and to examine the effect of recent changes to legal aid funding that have made it available only for cases going through the Family Court. Conclusions There are no simple solutions to the problem of domestic violence. Like other public health issues, it must be tackled at all levels of the healthcare system. Doctors, both in general practice and in the hospital system, should be more proactive in diagnosing situations where domestic violence is occurring. Multidisciplinary approaches that cut through bureaucratic divides need to be put in place to support victims and their children, and funds should be invested in teaching and research so that health professionals can be informed about what is best practice. References Roberts GL, Lawrence JM, Williams GM, Raphael B. The impact of domestic violence on women's mental health. Aust N Z J Public Health 1998; 22: 796-801. Carroll J. The protection of children exposed to marital violence. Child Abuse Review 1994; 3: 6-14. Martins R, Holzapfel S, Baker P. Wife abuse: are we detecting it? J Womens Health 1992; 1: 77-80. Goldberg WG, Tomlanovich MC. Domestic violence victims in the emergency department. New findings. JAMA 1984; 251: 3259-3264. Easteal PW, Easteal S. Attitudes and practices of doctors toward spouse assault victims: an Australian study. Violence Vict 1992; 7: 217-228. Ferris LE, Tudiver F. Family physicians' approach to wife abuse: a study of Ontario, Canada, practices. Fam Med 1992; 24: 276-282. Brown JB, Sas G. Focus groups in family practice research: an example study of family physicians' approach to wife abuse. Family Practice Research Journal 1994; 14: 19-28. Hegarty KL. Barriers to disclosure of domestic violence in general practice. Final Report. General Practice Evaluation Program. Canberra: Department of Health and Aged Care, 1997. Sugg NK, Inui T. Primary care physicians' response to domestic violence. Opening Pandora's box. JAMA 1992; 267: 3157-3160. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992; 24: 283-287. Kurz D, Stark E. Not so benign neglect: the medical response to battering. In: Yllo K, Bograd M, editors. Feminist perspectives on wife abuse. Newbury Park, California: Sage Publications, 1988: 249-266. Hegarty K, Hindmarsh ED, Gilles MT. Domestic violence in Australia: definition, prevalence and nature of presentation in clinical practice. Med J Aust 2000; 173: 363-367. White DG. Wearing a wife-assault-prevention button: impact on a family practice. CMAJ 1991; 145: 1005-1012. Friedman L, Samet J, Roberts M, Hans P. Inquiry into victimisation experiences: a survey of patient preferences and physician practice. Arch Intern Med 1992; 152: 1186-1190. Gerbst B, Abercrombie P, Carfers N, et al. How health care providers help battered women: the survivor's perspective. Women Health 1999; 29: 115-135. Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence against women: a general practice-based prevalence study. Med J Aust 1996; 164: 14-17. Romans SE, Poore MR, Martin JL. The perpetrators of domestic violence. Med J Aust 2000; 173: 484-488. Roberts GL, Williams GM, Lawrence JM, Raphael B. How does domestic violence affect women's mental health? Women Health 1998; 28: 118-129. Rittmayer J, Roux G. Relinquishing the need to "fix it": medical intervention with domestic abuse. Qual Health Res 1999; 2: 66-81. Roberts GL, Lawrence JM, O'Toole BI, Raphael B. Domestic violence in the emergency department: two case-control studies of victims. Gen Hosp Psychiatr 1997; 19: 5-12. Eisenstat SA, Bancroft L. Domestic violence. N Engl J Med 1999; 341: 886-892. Kilpatrick D, Resnick H, Acierno R. Health impact of interpersonal violence. 3: Implications for clinical practice and public policy. Behav Med 1997; 23: 79-85. Lawler VA. Routine screening for domestic violence: A review of the literature [dissertation]. Melbourne: University of Melbourne; 1996. Roberts GL, O'Toole BI, Lawrence JM, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1993; 159: 307-310. Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence: do they promote patient well-being? JAMA 1995; 273: 1781-1787. Worcester N. Health systems response to battered women: our "successes" are creating new challenges. National Women's Health Network News 1995; 20(2): 1-6. Against the odds: how women survive domestic violence. Canberra, Office of the Status of Women, Department of Premier and Cabinet, 1998. Supported Accommodation Report 1997/98. Canberra: Australian Institute of Health and Welfare, 1998. Authors' details Royal Australian College of General Practitioners, South Melbourne, VIC. Danielle Mazza, MD, FRACGP, Director of Quality Assurance and Continuing Education. Watkins Medical Centre, Brisbane, QLD. Joan M Lawrence, AM, FRANZCP, Adjunct Professor of Psychiatry. Research Unit, Department of Psychiatry, CYMHS, Fortitude Valley, QLD. Gwenneth L Roberts, PhD, B Bus (Health Admin), Research Manager. Department of General Practice, University of New South Wales, Kensington, NSW. Sheila M Knowlden, MB BS, FRACGP, Senior Lecturer. Reprints will not be available from the authors. Correspondence: Danielle Mazza, MD, FRACGP, Director of Quality Assurance and Continuing Education, Royal Australian College of General Practitioners, 1 Palmerston Crescent, South Melbourne, VIC 3205. danielle.mazzaATracgp.org.au Make a comment 1: Advice for doctors on dealing with domestic violence Learn to recognise the typical symptoms (both physical and emotional),12 and be alert to the possibility of domestic violence. Display posters and brochures about domestic violence in the waiting room or in toilet facilities, or wear a lapel badge showing you do not condone domestic violence. This increases patients' willingness to discuss their situation.13 If domestic violence is suspected, ask the patient about it in a direct manner. Abused women often feel relieved when asked about the violence, provided the questioning is handled sensitively and their response is validated by the doctor (eg, by reassuring the woman that domestic violence is common and that she has been very courageous in disclosing the information).14-16 Document any injuries in detail (even if the patient does not, at the time, wish to take legal action), and provide treatment if necessary. Assess the immediate and short-term risks to the patient. Questions that could be asked include what has the pattern of violence been? have you ever feared for your life? what is the worst assault you have suffered? does your partner have a gun or other weapon at home? has your partner ever used a weapon against you? Assist in devising a safety plan, which should include asking the patient about support persons (who are they? are they easily accessible? are they aware of what is going on?); establishing whether the patient has the financial resources to leave; giving the patient an excuse, if needed, to come back for regular follow-up visits; providing contact details for a refuge service and explaining how the system works. Planning for a worst-case scenario ahead of time can provide practical support for a person who chooses to stay with an abusive partner. Be ready in advance with information about appropriate resources, support services, women's shelters, legal advice and restraining orders, to help victims if and when they decide to leave their abusive partner. Information about local contacts can be obtained from local community health centres, sexual assault centres, women's health centres and legal aid organisations. If you feel comfortable doing so, provide supportive and educative counselling for victims of domestic violence (see example in Box 2); otherwise, refer patients to a social worker, psychologist, or psychiatrist (while accepting the patient's right to refuse the referral). If the perpetrator admits to the violence and agrees to attend counselling, arrange assistance for that person. Recommendations for joint counselling or marriage guidance for the couple are not usually appropriate unless issues of violence have already been directly addressed and the relationship continues. If both the victim and the perpetrator are your patients, issues of confidentiality, disclosure and management of the possible competing needs of the couple can present real difficulties. In this situation, try to arrange for another doctor to take on the care of either the victim or the perpetrator. If the victim consents to your raising the issue with the perpetrator,17 inform both parties that your highest priority is the safety of all concerned and that violence is illegal. Accept that there is no simple solution to the problem, and respect the patient's autonomy, even if you do not agree with his or her decision. It is the patient who must decide whether to stay in a violent relationship or leave.18 Counselling about substance misuse may be indicated. Avoid prescribing medication with habit-forming properties (eg, benzodiazepines) in view of the identified increased rates of substance-use disorders in victims of violence.1,19,20 Remember that doctors are obliged, under "mandatory reporting" legislation, to report situations in which children are at risk of violence and abuse. Back to text 2: Case scenario for dealing with domestic violence in general practice "Margaret" is a 35-year-old woman who lives on a dairy farm, which she manages with her husband of 10 years. They have three children aged between eight and three years. Over the time that she has been consulting you she has presented repeatedly with soft tissue injuries that she acknowledges have been inflicted by her husband. She believes that her husband only becomes violent when he drinks. She is isolated on the farm and says she is unable to leave her husband or to seek support in the local community because she feels ashamed and because her husband is good friends with the local policeman. One day she attends requesting "counselling" for her husband. At that initial consultation you offer Margaret support and acknowledge her efforts in trying to get the violence to stop. You point out that domestic violence is common and that you have dealt with other women experiencing similar problems. You explore with her the degree of risk she feels and whether there is any child abuse occurring. Over the course of several consultations you discuss with Margaret the dynamics of domestic violence and the history of violence perpetrated by her husband. You challenge her beliefs about the nature of domestic violence by asking why her husband is never violent with his male companions in the pub but only at home with her. You provide her with the name and number of the domestic violence outreach worker with the local women's health service and offer her patient information brochures. You discuss with her the nature of support she might receive from friends, family and government should she choose to leave her partner and whether or not she has discussed the violence with anyone else. After a particularly violent episode, Margaret takes the children and goes to stay with her parents for a few weeks. Fearing that more people will find out about his violence and that Margaret might leave for good, her husband agrees to attend counselling to placate her. Margaret decides to return to the family home. Back to text

Danielle Mazza · Joan M Lawrence · Gwenneth L Roberts · Sheila M Knowlden

New Drugs, Old Drugs Forty years of combined oral contraception: the evolution of a revolution Ian S Fraser MJA 2000; 173: 541-544 Abstract - A historical perspective - Revolutions, evolutions and controversies - Conclusions - References - Authors' details - - More articles on Obstetrics & gynaecology and women's health Abstract The combined oral contraceptive (COC) pill has become an integral part of fertility choice in almost every country since its introduction in 1960 in the United States. It was the first contraceptive method to provide sexual freedom of choice for women through reliable personal, private control of fertility. Modern, very low-dose pills have maintained a high degree of contraceptive efficacy, but the margin for error in pill-taking appears much smaller. These COCs have a much lower incidence of side effects and serious complications than early high-dose COCs. Serious health risks from venous thromboembolism are rare, and not measurably higher for pills containing third-generation compared with earlier progestogens. Most women feel very well taking modern COCs, but myths about these drugs still abound. Most non-contraceptive health benefits of COCs are still not widely appreciated in spite of much evidence. Controversy still persists over the association between COC use and breast cancer. Although slightly more breast cancers are detected in current COC users (relative risk 1.24; 95% CI, 1.15-1.33), they are less advanced and less aggressive. Some women have pre-existing medical risk factors for COC use, and a detailed history for cardiovascular risk factors is one of the most important precautions. One of the most far-reaching events of the 20th century occurred in May 1960 with the marketing of the first combined oral contraceptive (COC) in the United States. The trade name of this daily combination of mestranol (150 µg) and ethynodiol diacetate (10 mg) was Enovid (marketed by G D Searle), but the popular name had already been coined by Aldous Huxley in Brave new world revisited -- "the Pill".1 Huxley had foreseen the infinite complexity of the role of the oral contraceptive in birth control: "It is not merely a problem in medicine, in chemistry, in biochemistry, in physiology; it is also a problem in sociology, in psychology, in theology, and in education."2 He went on to discuss the difficulties of gaining population acceptance of such complex ideas: "The English Fabians, Beatrice and Sidney Webb, made an historical study of the average time it took for an idea which, at its first enunciation, seemed revolutionary and revolting, to be taken for granted and to be acted upon by the whole population. They concluded that the average time is 28 years -- roughly the length of a generation. It is very difficult to persuade adults to change their points of view; they have to die off before a new generation can accept new ideas."2 Although uptake of the Pill was rapid by a minority, acceptance and understanding by the majority took at least two to three decades. The Pill still faces opposition from some religious groups, and some controversies about its safety, albeit minor, persist. A historical perspective The possibility of contraception by use of reproductive hormones was first suggested by Ludwig Haberlandt, a physiologist at the University of Innsbruck, who first showed in the 1920s that injections of extracts of the corpus luteum would render rabbits infertile. With remarkable foresight he suggested that similar extracts might provide an ideal method of birth control in women.3 The first clinical evidence of this came with the demonstration in 1940 that dysmenorrhoea could be relieved and ovulation simultaneously inhibited by administration of oestrogens.4The development of modern hormonal contraception awaited synthesis of orally effective progestogens and oestrogens in the early 1950s. Pincus, Rock and Garcia then showed that ovulation in women could be suppressed with these compounds, which were first marketed in the US in 1957 for "menstrual regulation".5 After further refinement and political lobbying, Enovid was marketed as a contraceptive in mid-1960.5 These early versions of the Pill contained much higher doses of both oestrogen and progestogen than were pharmacologically necessary to suppress ovulation, and the subsequent history of the Pill has been dominated by a progressive and continuing reduction in dosage. This has been driven by the desire to reduce perceived side effects and the requirements of pharmaceutical companies to have clearly marketable characteristics for their new preparations. The newest COCs in Australia have a daily oestrogen (ethinyloestradiol) content of 20 µg and a daily progestogen (levonorgestrel) content of 100 µg.6 This total steroid intake is only 1.2% of the original daily intake, and the modern combinations are just as effective as contraceptives, although the margin for error in tablet-taking may be less. A brief profile of COCs is shown in Box 1. Revolutions, evolutions and controversies This pharmacological revolution has been accompanied by equally impressive social and sexual revolutions. Oral contraception provided women, for the very first time, with the possibility of reliably controlling their fertility. This gave women the opportunity to separate career choices from relationships and family planning, and to begin to compete with men in the career marketplace. It also gave them the opportunity to express their full sexuality with minimal risk of an unwanted pregnancy. Women were at last able to consider their opportunities on an equal basis to men. However, controversy has never been far away, and the Pill has probably engendered more articles, opinions, research studies and research investment than any other single class of drug. The progressive evolution of the Pill has, in addition to the dramatic reduction in dosage, been accompanied by an increasing awareness of a range of positive and negative attributes. Contraceptive effects COCs have extraordinarily high contraceptive reliability, if taken meticulously (including protection against ectopic pregnancies)7 (E1) (see Box 2 for an explanation of level-of-evidence codes). However, there is a considerable difference between the very low contraceptive failure rates in clinical trials and the high failure rates in general use, caused by missed pills and factors which interfere with absorption.9 Compliance can be optimised by good counselling, health education and effective packaging. Non-contraceptive health benefits COCs have remarkable non-contraceptive health benefits.10 These include dramatic reductions in lifetime risk of ovarian and endometrial cancer,11 and more variable reductions in colorectal cancer, benign breast disease,12 uterine myomata (fibroids),13 endometriosis,14,15 acute episodes of pelvic inflammatory disease,16 benign ovarian cysts,12 toxic shock syndrome, androgenic skin conditions such as acne, and perhaps even rheumatoid arthritis and some thyroid diseases (E32). COCs greatly reduce the risk of infertility17 (presumably through protection against acute pelvic inflammatory disease, ectopic pregnancy and endometriosis). They also appear to have a beneficial effect on bone density. In many of these conditions, benefits become more marked with longer duration of COC use. In most women, COCs are also able to provide amazingly effective control of menstrual cycle symptoms,10,12 such as menorrhagia (E2), dysmenorrhoea (E1), premenstrual syndrome (E1) and perimenstrual symptoms (E32) (eg, migraine, epilepsy, depression, toxic shock syndrome, and diarrhoea) and mid-cycle pain (E32). COCs can be used to treat these menstrual symptoms and, sometimes, the symptoms of endometriosis, uterine myomata, recurrent ovarian cysts and adenomyosis. Decreased menstrual blood loss reduces iron-deficiency anaemia (E1). COCs are not as effective in preventing transmission of sexually transmitted diseases (STDs) as in preventing pregnancy. Although they reduce the risk of acute upper genital tract pelvic inflammatory disease (E32),16 they do not prevent cervical colonisation, and those at risk of encountering STDs are best advised to use condoms as well as COCs. Adverse effects Side effects are still poorly understood by the general public, who appear to believe long-standing myths about COCs. Several well executed, randomised, double-blind, placebo studies have shown that the incidence of so-called "minor" side effects differs little between the placebo group and the active COC-taking group (E1).18,19 In modern double-blind clinical trials, the incidence of these so-called side effects is almost always quite high in women taking placebo (E2), and this seems to mirror preconceived expectations. The only side effects which have slightly higher incidence in the COC group are mild nausea (in early cycles), breast tenderness, chloasma and occasional mild effects on mood and sexual function. Contrary to popular belief, weight change does not differ between COC users and control subjects (E32). For most women, feelings of well-being are usually greater when taking the Pill. For the few women who do experience minor adverse effects, it usually means that the particular preparation does not suit them. They may do well with a different preparation or may sometimes need to consider an alternative contraceptive. Of more importance is the incidence of potentially serious complications. The main serious, albeit rare, complication is venous thromboembolism, which has a spontaneous incidence of 1-2 per 10 000 women per year. Incidence increases to 3-4 per 10 000 women per year in COC users,20 much less than originally described, because of the reduction in hormone dosage and better identification of women with risk factors. The 1995 "scare" about increased risk of venous thromboembolism with COCs containing third-generation progestogens has been largely discounted by substantial subsequent epidemiological work identifying biases and risk factors in the original studies.2 Many women who develop venous thromboembolism while using COCs have evidence of an inheritable thrombophilia, and there does appear to be a significant adverse interaction between the thrombophilias and COC use (E32). This complex and ongoing debate was recently well summarised.21 For many years, it has been recognised that cardiovascular diseases such as myocardial infarction and stroke are exacerbated by COC use, but considerable research has demonstrated that this risk is almost entirely confined to women who smoke cigarettes and those with hypertension (E32).22,23 Women using Pills containing third-generation progestogens may actually have a reduced risk of acute myocardial infarction (E32).24 Certain liver conditions may be exacerbated in predisposed individuals (eg, obstetric cholestasis and congenital hepatic enzyme disorders such as Dubin-Johnson syndrome). Breast cancer is one of the most emotive conditions in our cancer-phobic society, and the media have publicised scientific articles that suggest a possible increase in risk of breast cancer in COC users. The largest epidemiological study ever undertaken in the field of reproduction was a thorough reanalysis of 54 epidemiological studies of the relationship between COC and breast cancer.25 This did indeed show that more breast cancers were detected in current COC users than in control women, and that the relative risk was 1.24 (95% CI, 1.15-1.33). However, the tumours in COC users were clinically less advanced and less aggressive, and the relative risk had disappeared within a few years of stopping COC use. There is no evidence that COCs cause breast cancer, but they may have a subtle modulating effect on the rate of tumour growth. The important clinical messages are that all women are at some risk of breast cancer, and that appropriate screening techniques should be undertaken depending on age and other risk factors. There are a number of other rare associations with COC use, including a significant increase in benign hepatic adenomas (E32).26 COCs may also be a weak cofactor for cervical cancer, but this is uncertain because of the difficulty of adequately controlling for sexual risk factors (E32).27 Conclusions Modern oral contraceptives are remarkably effective and safe drugs for long-term use by women without cardiovascular risk factors. The World Health Organization and others have developed a series of evidence-based guidelines to assess medical eligibility criteria for initiating and continuing use of COCs and other contraceptive methods.28,29 This evidence suggests that there are only two prerequisites for the safe provision of COCs: a careful personal and family medical history, with particular attention to risk factors for venous and arterial cardiovascular disease; and an accurate blood pressure measurement. To this we would generally add an annual review with blood pressure measurement, breast check and pelvic examination with a cervical smear every second year. References Huxley A. Brave new world revisited. New York: Harper and Row, 1958: 138-139. Huxley A. The population explosion. In: The human situation, a series of lectures delivered at the University of California, Santa Barbara, in 1969. London: Chatto and Windus, 1978: 40-55. Haberlandt L. Hormonal sterilisation of female animals. Munchner Med Wochenschr 1921; 68: 1577-1588. Sturgis SH, Albright R. Mechanism of estrin therapy in the relief of dysmenorrhoea. Endocrinol 1940; 26: 68-73. Diczfalusy E. Gregory Pincus and steroidal contraception: a new departure in the history of mankind. J Steroid Biochem 1979; 11: 3-11. Archer DF, Maheux R, Del Conte A, O'Brien FB. A new low-dose monophasic combination oral contraceptive with levonorgestrel 100 µg and ethinyl oestradiol 20 µg. Contraception 1997; 55: 139-144. Ketting G. The relative reliability of oral contraceptives: findings of an epidemiological study. Contraception 1988; 37: 343-353. National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra: NHMRC, AusInfo, 1999. Jones ES, Forest JD. Contraceptive failure in the United States: revised estimates from the 1982 National Survey of Family Growth. Fam Plann Perspect 1989; 21: 103-109. Fraser IS. Benefits and risks of steroidal contraception. In: Salamonsen LA, editor. Hormones and women's health: the reproductive years. Amsterdam: Harwood Academic Publishers, 2000: 161-171. Schlesselman JJ, Collins JA. The influence of steroids on gynecologic cancers. In: Fraser IS, Jansen RPS, Lobo RA, Whitehead MI, editors. Estrogens and progestogens in clinical practice. London: Churchill Livingstone, 1998: 831-864. Mishell DR Jr. Non-contraceptive health benefits of oral steroidal contraceptives. Am J Obstet Gynecol 1982; 142: 809-818. Ross RK, Pike MC, Vessey MP, et al. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. BMJ 1986; 293: 359-362. Vessey MP, Villard-Mackintosh L, Painter R. Epidemiology of endometriosis in women attending family planning clinics. BMJ 1993; 306: 182-184. Chiaffarino F, Parazzini F, LaVecchia C, et al. Oral contraceptive use and benign gynecologic conditions. Contraception 1998; 57: 11-18. Rubin GL, Ory HW, Layde PM. Oral contraceptives and pelvic inflammatory disease. Am J Obstet Gynecol 1982; 144: 640-649. Bagwell MA, Coker AL, Thompson SJ, et al. Primary infertility and oral contraceptive steroid use. Fertil Steril 1995; 63: 1161-1166. Goldzieher JW, Moses LE, Averkin E, et al. A placebo-controlled, double-blind crossover investigation of the side-effects attributed to oral contraception. Fertil Steril 1971; 22: 609-618. Graham CA, Ramos R, Bancroft J, et al. The effects of steroidal contraceptives on the well-being and sexuality of women. Contraception 1995; 52: 363-370. Farmer RDT, Lawrenson RA, Todd JC, et al. Oral contraceptives and venous thromboembolic disease. Analyses of the UK General Practice Research Data Base and the UK MediPlus Data Base. Hum Reprod Update 1999; 5: 688-706. Edwards RG, Cohen J, editors. Reproductive choices in 2000: the relative safety of current oral contraceptives. Hum Reprod Update 1999; 5: 563-771. Croft P, Hannaford P. Risk factors for acute myocardial infarction in women. BMJ 1995; 298: 165-168. Thorogood M. Stroke and steroidal hormonal contraception. Contraception 1998; 57: 157-167. Carr BA, Ory HW. Estrogen and progestin components of oral contraception: relationship to vascular disease. Contraception 1997; 55: 267-272. Collaborative Group on Hormonal Risk Factors in Breast Cancer. Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53,297 women with breast cancer and 100,239 women without breast cancer from 54 epidemiological studies. Lancet 1996; 347: 1713-1727. Rooks JB, Ory HW. Epidemiology of hepatocellular adenoma: the role of oral contraceptive use. JAMA 1979; 242: 644-648. Irwin KL, Rosero-Bixby L, Oberle MW, et al. Oral contraceptives and cervical cancer risk in Costa Rica: detection bias or causal association? JAMA 1988; 259: 59-66. World Health Organization, Family and Reproductive Health. Improving access to quality care in family planning: medical eligibility criteria for initiating and continuing use of contraceptive methods. Geneva: World Health Organization, 1995. Hannaford P, Webb A. Evidence-guided prescribing of combined oral contraceptives: a consensus statement. Contraception 1996; 54: 125-129. Authors' details Department of Obstetrics and Gynaecology, University of Sydney, NSW. Ian S Fraser, MD, FRACOG, Professor in Reproductive Medicine, and Head, Department of Reproductive Endocrinology and Infertility, King George V and Royal Prince Alfred hospitals, Sydney, NSW. Reprints will not be available from the author. Correspondence: Professor I S Fraser, Department of Obstetrics and Gynaecology, University of Sydney, NSW 2006. helenaATobsgyn.usyd.edu.au Make a comment 1: Profile of combined oral contraceptives Action: Combined oral contraceptives (COCs) act predominantly at a hypothalamic level to block the cyclical release of gonadotropin-releasing hormone and prevent follicular development and ovulation. Secondary actions on the corpus luteum, endometrium and cervical secretions may contribute. Dosage: This is based on the daily ethinyloestradiol content, which varies from 20µg to 50µg in current Australian COCs. The oestrogen is balanced by an appropriate dosage of one of six progestogens in a variety of formulations known as monophasic, biphasic or triphasic. Tablet-taking: Most COC packages are 28-day (every day) bubble-pack designs containing seven inactive or placebo tablets, designed to assist meticulous daily tablet-taking (at about the same time each day), with an exact seven-day break between successive cycles of active tablets. Starting: Most packs are designed to begin tablet-taking in the placebo section on Day 1 of the last normal menstrual period. Most experts recommend condom use during the first 10-14 days of initial COC use in case of breakthrough ovulation. However, if "active" tablets are taken from Day 1, then full contraceptive action begins immediately. Metabolism: Peak plasma levels are achieved in 1-2 hours and a gradual decline occurs over the next 36 hours or so. Metabolism occurs during gastrointestinal absorption and during the first pass through the liver. Drug interactions: Numerous subtle interactions occur with several drug groups, but the most important clinical interactions are with several anticonvulsant drugs (not including sodium valproate and gabapentin) and with the antibiotics rifampicin and griseofulvin, which reduce serum levels of the contraceptive steroids and may lead to breakthrough bleeding, ovulation and contraceptive failure. Contraceptive efficacy: This is extremely high if tablets are taken optimally (less than one failure per 500 women per year), but is much higher in general use, when missed pills, absorption problems (caused by diarrhoea and vomiting) and drug interactions may play a greater role. Non-contraceptive health benefits: These are increasingly recognised as important in the benefit-risk equation, with significant reductions in incidence of ovarian, endometrial and colon cancer, acute episodes of pelvic inflammatory disease, infertility, iron-deficiency anaemia, benign breast lumps, benign ovarian cysts, uterine myomata and severe cyclical menstrual symptoms. There are probably also reductions in endometriosis. Adverse effects: Mild side effects are commonly reported but are often not caused by the COC. The most important (but very rare) complication is venous thromboembolism. Other cardiovascular diseases, such as hypertension, myocardial infarction and stroke, are either not, or only minimally, increased by modern low-dose COCs. Slightly more breast cancers are detected in current COC users, but the tumours are less aggressive and less advanced than in controls. Back to text 2: Level-of-evidence codes Evidence for the statements made in this article is graded according to the NHMRC system8 for assessing the level of evidence. E1 Level I: Evidence obtained from a systematic review of all relevant randomised controlled trials. E2 Level II: Evidence obtained from at least one properly designed randomised controlled trial. E31 Level III-1: Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method). E32 Level III-2: Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case-control studies, or interrupted time series with a control group. E33 Level III-3: Evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group. E4 Level IV: Evidence obtained from case-series, either post-test, or pre-test and post-test. Back to text 3: Important messages for patients Modern low-dose combined oral contraceptives (COCs) are highly effective contraceptives if taken meticulously COCs are remarkably free of side effects and serious complications, but some very rare complications, such as venous thromboembolism, can occur. They may not be suitable for some women with pre-existing medical risk factors. They have some very important, non-contraceptive health benefits. Back to text

Ian S Fraser

Personal Perspective Depression: dispirited or spiritually deprived? Craig S Hassed MJA 2000; 173: 545-547 The 20th century has seen a widespread decline in mental health in Western society. One important factor may be the lack of meaning and spiritual fulfilment that is part of our increasingly secular and materialistic society. In medical education and practice, religious issues are often marginalised or "pathologised", despite consistent evidence from the literature of the protective effect of "religiosity" or "spirituality" on mental and physical health. Spirituality and religiosity - Spirituality and mental health - Relevance to clinical medicine - References - Authors' details - - More articles on General practice and primary care The increasing incidence of mental illness, especially depression, in the 20th century1,2probably reflects both increased recognition and an absolute rise in prevalence. World Health Organization figures released in 1996 revealed that depression was expected to be a leading contributor to the burden of disease in the 21st century.1 Recent figures suggesting that depression is the most important component of the disability burden in Australia would tend to support that prediction.3 Approximately 20% of adults are expected to have a major depressive episode at some time in their lives, and 16% of people aged over 65 years have persistent symptoms.4 Stress levels, whether real or perceived, among people living a "Western" lifestyle have risen by approximately 45% over the past 30 years.5 Youth suicide rates are particularly alarming,2 and one Australian study revealed that 20% of 15-24-year-olds had contemplated suicide in the preceding fortnight.6 In keeping with our predominant "illness model" we are more often concerned with risk factors for depression, youth suicide, substance misuse and violence than the less-publicised protective factors, which include "connectedness" and "spirituality".7 Spirituality and religiosity The terms used most commonly in the medical literature are "religious commitment" or "religiosity", referring to the "participation in or endorsement of practices, beliefs, attitudes, or sentiments that are associated with an organised community of faith".8 One can be "extrinsically religious" in adopting the trappings, religious behaviours and attitudes, but if one holds a strong inner belief then one is "intrinsically religious". "Spirituality" generally refers to concepts that are much harder to define and measure, such as "personal views and behaviours that express a sense of relatedness to the transcendental dimension or to something greater than the self".9 Spirituality can encompass belief in a higher being, the search for meaning, and a sense of purpose and connectedness. Obviously, there can be a wide overlap between religiosity and spirituality. Spirituality and mental health For many years science and ethics have tended to become increasingly secular, thus neglecting or "pathologising" spiritual issues. Sigmund Freud, for example, saw religion as "a universal obsessional neurosis", and described the mystical experience of unity as a "regression to primary narcissism".10 Carl Jung, on the other hand, saw the search for spiritual enlightenment as the central, but often ignored, core of human experience. He described the lack of meaning in life as a "soul-sickness" whose full import our age had not yet begun to comprehend. This was one of the main reasons why these two pioneers of psychology parted company. The observation that Freudian psychoanalysis is probably associated with negative effects on people's health may, however, throw into question Freud's understanding of human nature.11 Nevertheless, many of Freud's attitudes have deeply etched their way into psychiatric theory and practice: Mainstream psychiatry, in its theory, research and practice, as well as its diagnostic classification system, has tended to either ignore or pathologise the religious and spiritual issues that clients bring into treatment.12 The negative attitude towards religiosity in many quarters of contemporary medicine and psychiatry is out of keeping with the weight of evidence which clearly shows that it has a beneficial effect on mental and physical health.8 The findings are consistent across prospective and retrospective studies, whether or not they control for other lifestyle and socioeconomic factors, and whether they examine prevention of illness, coping with illness, or recovery (see Box). Many studies have linked a lack of religiosity to depression. Religious commitment is associated with a reduced incidence of depression13 and a quicker recovery from depressive illness for the elderly.15 Two separate reviews of the literature have supported this: those with high levels of "religious involvement", "religious salience" and "intrinsic religious motivation" were at reduced risk,14 and religious commitment was inversely related to suicide risk in 13 of 16 studies reviewed.13 One study showed a fourfold increased risk of suicide for non-churchgoers compared with regular attenders,22 and no study has shown an increased risk of suicide among churchgoers. Other data suggest that religiosity protects against drug and alcohol misuse, one of the most commonly used and maladaptive ways for dealing with depression. One study showed that 89% of alcoholics (but only 20% of the control group) had lost interest in religious issues during their teenage years.20 In another study it was found that doctors (who are a high-risk group for substance misuse) were less likely to develop an alcohol problem in later life if they had had a religious commitment while in medical school.21 Religious affiliation, even if accompanied by alcohol misuse, seemed to protect against heavy use or the associated extreme clinical and social consequences. The reasons why people with a sense of religious commitment are less likely to become depressed may include a feeling of social connectedness, exposure to messages about healthy living, or perhaps the reduced exposure to drug-taking behaviour. However, studies controlling for these factors have still found religiosity to be independently protective. So there may be other reasons, such as the comfort that comes from believing in a benevolent and caring God, the view that justice always prevails in the end, or that adverse events always have a meaning and a message. Such attitudes would buffer enormously against the ill-effects of life stresses and the depression that often follows. The important role that mental health plays in the development and progression of physical illness goes part way to explaining why religious commitment is associated with reduced risk of conditions such as hypertension, heart disease and cancer.26,27,29,30 A population study over nine years showed that all-cause mortality was significantly reduced and life expectancy increased (to 82 years v. 75 years) for regular churchgoers. The findings were not explainable by the accepted lifestyle and social variables,24 and were consistent with other data.25 Unfortunately, examples of the negative effects of religion are generally more newsworthy in the medical and general press than the positive ones. For example, in a review of a series of preventable paediatric deaths, it was found that some parents' religious views played an important part in delaying the seeking of medical care.31 Sometimes this negative press is for a good reason, but this is not an argument against spirituality, but rather against blind faith unsupported by reason. Relevance to clinical medicine The rise in mental illness seems paradoxical in view of our unprecedented levels of physical health, relative affluence, technological advancement and social freedom. Also paradoxical is the fact that suicide rates generally fall in times of adversity, such as during major wars.2 Although one doesn't generally court adversity, it can teach us something about ourselves if we pay attention to the lesson. As William Shakespeare so aptly put it: This is no flattery: these are counsellors That feelingly persuade me what I am. Sweet are the uses of adversity, Which, like the toad, ugly and venomous, Wears yet a precious jewel in his head. (As You Like It; Act 2, Scene 1) Gauging a patient's spiritual awareness, at very least, should form an important part of a thorough history. One can not really be said to know another person without an understanding of his or her responses to the most important questions that human beings ask themselves. Without this knowledge, treatment of especially sensitive conditions like depression or terminal illness will take place in the dark. Broaching philosophical and spiritual issues requires considerable sensitivity, cultural tolerance and the ability to be non-dogmatic. When done effectively, it can facilitate counselling and psychotherapy enormously,32 but each doctor and patient needs to explore these issues in his or her own way. Even if we are not religious ourselves, we should invite discussion in a respectful way, taking care not to push a line of thought, whether it be religious or secular. Religious sensitivities and biases, like political ones, can make discussion divisive and difficult. More in-depth questions about spirituality and religion should probably be referred to culturally appropriate "non-medical experts". At present, despite the large body of evidence on the connection between religiosity and health, little if any reference is made to this issue in medical education and practice. If a physical factor was found to be of as much importance to health it would certainly not be ignored, but then science is always most comfortable with what it can most easily measure. It is reasonable for medical students and practitioners to be aware of this field of evidence so that they can provide a more holistic approach to information giving, psychotherapy and treatment. Unfortunately, a perceived lack of holism is a central reason why many people look outside the biomedical model for their healthcare.33 For many people, especially the young, the search for meaning is becoming a rarer pursuit in the bustle of modern material life. People pursue meaning and fulfilment by as many paths as there are people, but perhaps we often search in places which can not provide it. If the search is misdirected, disappointment, stress, depression and social conflict may be inevitable sequelae of such existential pain. Perhaps these issues will become increasingly relevant for future generations, for whom the lack of meaning will come at an increasing cost. Maybe a balanced form of spirituality which is not scientifically naive nor culturally intolerant may be a prerequisite for the mental and material wellbeing of an all too often dispirited community and healing profession. "Science without religion is lame, religion without science is blind" (Albert Einstein).34 References Murray C, Lopez A. The global burden of disease. Cambridge, Massachusetts: Harvard School of Public Health, on behalf of the World Health Organization and the World Bank, 1996. Cantor C, Neulinger K, De Leo D. Australian suicide trends 1964-1997: youth and beyond? Med J Aust 1999; 171: 137-141. Mathers CD, Vos ET, Stevenson CE, Begg SJ. The Australian Burden of Disease Study: measuring the loss of health from diseases, injuries and risk factors. Med J Aust 2000; 172: 592-596. Rey J. The Epidemiological Catchment Area (ECA) study: implications for Australia. Med J Aust 1992; 156: 200-203. Miller M, Rahe R. Life changes scaling for the 1990s. J Psychosom Res 1997; 43: 279-292. McKelvey R, Davies L, Pfaff J, et al. Psychological distress and suicidal ideation among 15-24 year olds presenting to a general practice: a pilot study. Aust N Z J Psychiatry 1998; 32: 344-348. Resnick M, Bearman P, Blum R, et al. Protecting adolescents from harm: findings from the National Longitudinal Study on Adolescent Health. JAMA 1997; 278: 823-832. Matthews D, McCullough M, Larson D, et al. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med 1998; 7: 118-124. Reed P. Spirituality and wellbeing in terminally ill hospitalised patients. Res Nurs Health 1987; 9: 35-41. Freud S. Civilisation and its discontents. In: Strachey J, editor. The standard edition of the complete psychological works of Sigmund Freud. Vol. 20. London: Hogarth, 1959. Grossarth-Maticek R, Eysenck H. Prophylactic effects of psychoanalysis on cancer-prone and coronary heart disease-prone probands, as compared with control groups and behaviour therapy groups. J Behav Ther Exp Psychiatry 1990; 21: 91-99. Lukoff D, Fu FG, Turner R. Cultural considerations in the assessment and treatment of religious and spiritual problems. Psychiatr Clin North Am 1995; 18(3): 467-485. Gartner J, Larson D, Allen G. Religious commitment and mental health: a review of the empirical literature. J Psychol Theol 1991; 19: 6-25. McCullough M, Larson D. Religion and depression: a review of the literature. Twin Research 1999; 2(2): 126-136. Koenig H, George L, Peterson B. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry 1998; 155: 536-542. Oxman T, Freeman D, Manheimer E. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosom Med 1995; 57: 5-15. Saudia TL, Kinney MR, Brown KC, et al. Health locus of control and helpfulness of prayer. Heart Lung 1991; 20: 60-66. Koenig H, Cohen H, Blazer D, et al. Religious coping and depression in elderly, hospitalised medically-ill men. Am J Psychiatry 1992; 149: 1693-1700. Williams D, Larson D, Buckler R, et al. Religion and psychological distress in a community sample. Soc Sci Med 1991; 32: 1257-1262. Larson D, Wilson W. The religious life of alcoholics. South Med J 1980; 73: 723-727. Moore R, Mead L, Pearson T. Youthful precursors of alcohol abuse in physicians. Am J Med 1990; 88: 332-336. Comstock G, Partridge K. Church attendance and health. J Chronic Dis 1972; 25: 665-672. Propst LR, Ostrom R, Watkins P, et al. Comparative efficacy of religious and nonreligious cognitive-behavioral therapy for the treatment of clinical depression in religious individuals. J Consult Clin Psychol 1992; 60: 94-103. Hummer R, Rogers R, Nam C, et al. Religious involvement and U. S. adult mortality. Demography 1999; 36: 273-285. Clark K, Friedman H, Martin L. A longitudinal study of religiosity and mortality risk. Journal of Health Psychology 1999; 4: 381-391. Fraser G, Sharlik D. Risk factors for all-cause and coronary heart disease mortality in the oldest old: the Adventist Health Study. Arch Intern Med 1997; 157: 2249-2258. Kune G, Kune S, Watson L. Perceived religiousness is protective for colorectal cancer: data from the Melbourne Colorectal Cancer Study. J R Soc Med 1993; 86: 645-647. Larson DB, Koenig HG, Kaplan BH, et al. The impact of religion on men's blood pressure. J Religion Health 1989; 28: 265-278. Levin J, Vanderpool H. Is frequent religious attendance really conducive to better health? Toward an epidemiology of religion. Soc Sci Med 1987; 24: 589-600. Craigie F, Larson D, Liu I. References to religion in the Journal of Family Practice: dimensions and valency of spirituality. J Fam Pract 1990; 30: 477-480. Asser S, Swan R. Child fatalities from religion motivated medical neglect. Pediatrics 1998; 101: 625-629. Hassed C. Western psychology meets Eastern philosophy. Aust Fam Physician 1999; 28: 1057-1058. Astin J. Why patients use alternative medicine: results of a national study. JAMA 1998; 279: 1548-1553. Einstein A. Out of my later years. New York: Philosophical Library, 1950. Authors' details Department of Community Medicine and General Practice, Monash University Craig S Hassed, MB BS, FRACGP, Senior Lecturer. Reprints will not be available from the author. Correspondence: Dr C S Hassed, Department of Community Medicine and General Practice, Monash University, 867 Centre Road, East Bentleigh, VIC 3165. craig.hassedATmed.monash.edu.au Make a comment Apparent relationships between religiosity and health* Mental health Reduced incidence of depression7,8,13,14 Quicker recovery from depression15 Better recovery from major surgery,16with less depression17 Improved coping with disability,18 illness and stress19 Reduced substance misuse, including misuse of alcohol and illicit drugs20,21 Reduced suicide risk in adolescents22 Facilitation of psychotherapy23 Improved coping with serious illness8 Physical health Reduced all-cause mortality24,25 Greater longevity24,25 Reduced incidence of heart disease and hypertension26 Improved recovery from cardiac surgery16 Reduced incidence of and longer survival with cancer27 Modification of physical risk-factors with associated reductions in lifestyle-related illnesses such as emphysema and cirrhosis22,28 * Causal relationships between religiosity and health are sometimes hard to define, although many studies control for other known physical and socioeconomic risk factors. Refining methodology and further research are required to more fully elucidate the relationship. Back to text

Craig S Hassed

Research Recent trends in the use of antidepressant drugs in Australia, 1990-1998 Peter McManus, Andrea Mant, Philip B Mitchell William S Montgomery, John Marley and Merran E Auland MJA 2000; 173: 458-461 For editorial comment, see Parker Abstract - Introduction - Methods - Results - Discussion - Acknowlegdements - References - Authors' details - - - More articles on General practice and primary care Abstract Objective: To determine the pattern of use of antidepressant drugs in the Australian community, 1990-1998, and to compare this with those of other developed countries. Design: Retrospective analyses of prescription and sales data, together with information about patient encounters for depression (from an ongoing survey of service provision by general practitioners) and population-based prevalence estimates for affective disorders (from community health surveys). Main outcome measures: National and international consumption of antidepressants, expressed in defined daily doses (DDDs) per 1000 population per day. Changes in both the frequency of general practice patient encounters for depression and population-based prevalence estimates for affective disorders. Results: Dispensing of antidepressant prescriptions through community pharmacies in Australia increased from an estimated 12.4 DDDs/1000 population per day in 1990 (5.1 million prescriptions) to 35.7 DDDs/1000 population/day in 1998 (8.2 million prescriptions). There has been a rapid market uptake of the selective serotonin reuptake inhibitors (SSRIs), accompanied by a decrease of only 25% in the use of tricyclic antidepressants (TCAs). In 1998, the level of antidepressant use in Australia was similar to that of the United States, while the rate of increase in use between 1993 and 1998 was second only to that of Sweden. In Australia, depression has risen from the tenth most common problem managed in general practice in 1990-91 to the fourth in 1998-99, and the number of people reporting depression in the National Health Surveys (1995 v 1989-90) has almost doubled. Of the prescriptions dispensed in 1998 for antidepressant drugs subsidised by the Pharmaceutical Benefits Scheme, 85% were written by general practitioners, and 11.2% by psychiatrists. Conclusions: As in most developed countries, antidepressant use increased between 1990 and 1998. The rapid market uptake of the new antidepressants, particularly SSRIs, is likely to have been driven by increased awareness of depression, together with availability and promotion of new therapies. Introduction The World Health Organization report on the global burden of disease placed major depression fourth among the leading causes of disease burden in the developing world in 1990, and predicted that it would rise to second by the year 2020.1 In parallel with the increasing awareness of depression as an important health issue, the past decade has seen an increase in the pharmacotherapy options for managing depression with the arrival of several new classes of antidepressants. To review trends in antidepressant use in Australia, the Drug Utilisation Sub-Committee (DUSC) of the Pharmaceutical Benefits Advisory Committee, Department of Health and Aged Care, convened a working group in 1998. The working group, which comprised representatives from the DUSC and from the Australian Pharmaceutical Manufacturers Association (APMA), reviewed Australian and international data on antidepressant sales and dispensing. The aim was to determine patterns of antidepressant use in Australia between 1990 and 1998 and to compare Australian patterns with those in similar developed countries. To assist in interpretation of Australian drug use trends, the group reviewed changes in both the frequency of general practice patient encounters for depression and in population-based prevalence estimates for affective disorders. Methods Prescription and sales data Prescription dispensing data were obtained from the database maintained by the DUSC that monitors the dispensing of prescription medicines through community pharmacies in Australia.2 No data on public hospital use are included in this database. The measurement units used are either prescription volumes or the number of defined daily doses (DDDs) per 1000 population per day. The DDD is based on the assumed average daily dose of the drug when used for its main indication by adults. It is the unit approved by the World Health Organization (WHO) for drug use studies, and allows for comparisons independent of differences in price, preparation and quantity per prescription.3 Within the data on dispensing of antidepressant drugs subsidised by the Pharmaceutical Benefits Scheme (PBS), it is also possible to determine the major specialty of the prescribing doctor. Data on total sales of antidepressants from wholesalers to retail and hospital pharmacies for all countries, except Sweden, were obtained from IMS Health Incorporated. IMS Health is the leading international provider of information on drug usage to the pharmaceutical and healthcare industries.4 Data were retrieved as kilograms of active ingredient and then converted to DDDs per 1000 population per day. Excluded were the use of lithium, Hypericum (St John's wort) or tryptophan, and combinations involving these drugs or their active constituents. Utilisation data for Sweden, where separate local arrangements apply, were supplied by the Swedish Association of the Pharmaceutical Industry (LIF). The 1999 WHO defined daily doses (DDDs) were used in calculations. Drugs unique to particular markets that did not have DDDs available were provisionally assigned values using standard references and information provided by drug information centres in the countries involved.5 Prescriber surveys Information related to general practice patient encounters for depression was obtained from the General Practice Statistics and Classification Unit of the Family Medicine Research Centre (FMRC), University of Sydney, which is conducting an ongoing survey of service provision by general practitioners (GPs).6 This involves 1000 randomly selected, active, recognised GPs per year, each recording details of 100 consecutive consultations on structured encounter forms. Rolling recruitment ensures that the recording weeks are distributed evenly over the year and that there is constant change in participants. These data can be compared with the findings of an earlier FMRC study of morbidity and treatment in general practice that used simpler but compatible methods.7 Information on prescribing by specialists is not included in these GP surveys. Community health surveys The 1995 National Health Survey was a household survey conducted by the Australian Bureau of Statistics to obtain national benchmark information on a range of health-related issues and to enable the monitoring of trends in health over time.8 A previous health survey, collecting broadly comparable data, was conducted in 1989-90.9The 1997 National Survey of Mental Health and Wellbeing of Adults was also conducted by the Australian Bureau of Statistics and used a representative sample of people aged 18 years or over living in private dwellings.10 The survey was interview-based with a diagnostic component administered through a modified version of the WHO Composite International Diagnostic Interview (CIDI). The CIDI translates the criteria of the Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV),11 and the International classification of diseases, 10th edition (ICD-10),12 into sets of questions that can be readily answered by the general adult population. Specific combinations of symptoms may indicate a specific mental disorder. Results Antidepressant use in Australia The dispensing of prescriptions for antidepressants through community pharmacies in Australia increased from an estimated 12.4 DDDs/1000 population per day in 1990 (5.1 million prescriptions) to 35.7 DDDs/1000 population per day in 1998 (8.2 million prescriptions). Trends in the use of the selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), moclobemide, venlafaxine and nefazodone between 1990 and 1998 are shown in Box 1. The market uptake of the SSRIs has been rapid and accompanied by a decrease of only 25% in the use of the TCAs. Other new agents included moclobemide (a reversible monoamine oxidase type A inhibitor), nefazodone (a 5-HT2 antagonist) and venlafaxine (a serotonin-noradrenaline reuptake inhibitor). The 10 most commonly dispensed antidepressants in Australia in 1998 were, in descending order, sertraline, dothiepin, paroxetine, amitriptyline, fluoxetine, doxepin, moclobemide, imipramine, venlafaxine and citalopram. Of these, only the four tricyclic antidepressants were on the market in 1990, with dothiepin alone maintaining or improving its position over this period. Of the PBS-subsidised prescriptions dispensed for antidepressants in 1998, 85% were written by GPs, while 11.2% were written by psychiatrists. International comparisons We compared retail and hospital sales of antidepressants in Australia and seven major developed countries for the years 1993 and 1998 (Box 2). In 1998, sales of antidepressants in Australia (34.2 DDDs/1000 population per day) were similar to those of the United States (34.2 DDDs/1000 population per day), less than in Sweden (37.1 DDDs/1000 population per day) and France (36 DDDs/1000 population per day) and higher than in Canada (30.8 DDDs/1000 population per day) and the United Kingdom (30.4 DDDs/1000 population per day). Germany and Italy had considerably lower usage levels (12 and 9.9 DDDs/1000 population per day, respectively). The rate of increase in Australia between 1993 and 1998 was second only to that of Sweden. For these same countries in 1998, Box 3 shows the percentage split (based on DDDs/1000 population per day) of the antidepressant market by drug class. There was considerable variability in the percentage that TCAs represented of overall antidepressant use, from a low level of 11% in Sweden through to a high of 67% in Germany. Australia, Canada and France had a similar profile, with TCAs representing about 20% of antidepressant use. Venlafaxine was marketed in all eight of the countries surveyed and ranged between 1.5% and 5.2% of the total use. Mianserin had a low level of use in most countries, except for France and Italy, where it represented about 4% of antidepressant use. It was not available in North America. Similarly, moclobemide had a low level of use in most countries, except in Australia, where it represented 12% of the antidepressant market. Prescriber surveys Surveys conducted in 1990-91 and 1998-99 by the Family Medicine Research Centre have shown the increasing prominence of depression as a problem managed in general practice.6,7 In 1998-99, depression ranked as the fourth most common general practice problem, compared with the tenth in 1990-91. The rate of patient encounters involving depression per 100 encounters has increased from 2.1 in 1990-91 to 3.5 in 1998-99. In 1998-99, compared with 1990-91, antidepressants were more likely to be prescribed per every 100 encounters for depression (58.4 prescriptions [95% CI, 56.1-60.8] v 52.3 prescriptions [95% CI, 49.2-55.5]). Comparisons with age and sex demographics for total general practice encounters (women, 58.7%) suggest that female patients were over-represented at encounters for depression. The most frequent patient age group in encounters at which a tricyclic antidepressant was prescribed was 45-64 years (38%), whereas for encounters at which SSRIs were prescribed it was 25-44 years (43%). Sex distribution was similar for both drug groups, with about a third of the patients being men. Depression was the most common problem for which TCAs and SSRIs were prescribed in 1998-99, although the proportion of TCAs prescribed for depression (48.8% [95% CI, 44.3%-53.3%]) was lower than that of SSRIs (81.9% [95% CI, 79.7%- 84.1%]). Other specific problems managed with TCAs were sleep disturbance (7%), anxiety (5%) and back complaints (4.5%). For the SSRIs, these were anxiety (5.8%) and phobia/compulsive disorder (1.7%). When used for depressive disorders, TCAs had a prescribed daily dose consistently lower than the WHO DDD. The prescribed daily doses and DDDs for the most commonly dispensed TCAs were amitriptyline (mean, 59 mg; median, 50 mg; DDD, 75 mg), doxepin (mean, 61 mg; median, 50 mg; DDD, 100 mg) and dothiepin (mean, 85 mg; median, 75 mg; DDD, 150 mg). The prescribed daily doses for the most commonly dispensed SSRIs were much closer to the DDD: fluoxetine (mean, 24 mg; median, 20 mg; DDD, 20 mg), paroxetine (mean, 23 mg; median, 20 mg; DDD, 20 mg) and sertraline (mean, 72 mg; median, 50 mg; DDD, 50 mg). Community health surveys The 1997 National Mental Health and Wellbeing Profile of Adults identified a 5.8% prevalence of affective disorders (depression, 5.1%; dysthymia, 1.1%) during the 12 months before the survey among people aged 18 years or over.10 Women were more likely than men to have experienced affective disorders (7.4% compared with 4.2%). Although based on self-reports, household surveys conducted by the Australian Bureau of Statistics in 1989-90 and 1995 identified marked changes in the number of people reporting current or previous depression. In the 1995 National Health Survey, 8.1 persons per 1000 population reported depression as a long term condition, compared with 2.8 persons per 1000 in the 1989-90 survey. For depression as a recent illness, 11.4 per 1000 population reported this in 1995, compared with 5.8 per 1000 in 1989-90.8,9 Discussion The past decade has seen a remarkable change in the number of people recognised with and managed for depression, in the range of drug therapy options available, and in the volume of antidepressants prescribed. Previously, depression had been reported as under-recognised and undertreated.13-15Prominent among the likely reasons for this change are increased community awareness of depression as an important health issue, and attempts, most notably through government and community campaigns, to reduce the stigma of mental illness and the gaps in professional expertise inhibiting adequate recognition and treatment of depression.16,17 Coincident with these campaigns, important treatment recommendations were released in the United Kingdom in 1992 (the Royal College of General Practitioners and the Royal College of Psychiatrists) and, in the United States, in 1993 (Agency for Health Care Policy and Research).13,18 In Australia, the Psychotropic drug guidelines19 are the endorsed national standard, and the National Health and Medical Research Council has published clinical practice guidelines for managing depression in young people.20,21 The 1995 Australian National Health Survey showed that the number of people reporting depression as a recent and/or long term condition had nearly doubled compared with the earlier survey conducted in 1989-90. Such a change in the true underlying prevalence of disease is unlikely over a relatively short period of time, and the increase is far more likely to reflect a greater awareness of depression, with patients being more comfortable about coming forward for help and doctors, particularly in general practice, being more willing to provide it. This increased awareness of depression by doctors and patients, together with the availability and promotion of new drug therapy options (between 1990 and 1998, five SSRIs have been approved for PBS subsidy together with moclobemide, venlafaxine and nefazodone), accounts for the rise from the tenth to the fourth most common problem managed in general practice between 1990-91 and 1998-99. In 1998-99, encounters for depression were also more likely to generate a prescription for an antidepressant. This change is reflected in drug utilisation statistics. The market uptake of the SSRIs has been rapid and, remarkably, accompanied by only a relatively small decrease in the use of the TCAs. As a result, the overall antidepressant market has expanded greatly, with utilisation (as defined by DDDs/1000 population per day) being nearly three times greater in 1998 than in 1990. Prescription rates, however, have risen only 60% over that time, as the newer antidepressants are more likely to be dosed closer to the DDD than the older tricyclic antidepressants. TCAs are prescribed for sleep disturbance in a small proportion (7%) of patients, which is not the case for SSRIs. Most developed countries have seen similar trends, with sales in Australia consistent with US sales and slightly higher than those in the UK. The percentage that the SSRIs represented of total antidepressant use in Australia in 1998 was similar to that in the United Kingdom. The considerably lower levels of antidepressant use in Germany are probably related to Germany's strong tradition of use of complementary medicines (substantial use of Hypericum preparations [St John's wort] were not included in the comparisons); and the lower levels in Italy may be because, in 1994-98, SSRIs were not reimbursed by the national health system in Italy, but were fully paid for by the patient (Dr Alberto Vaccheri, Associate Professor, Department of Pharmacology, University of Bologna, personal communication, June 1999). Although there are interesting differences between countries, the rapid uptake of the new antidepressants is likely to have been driven by increased awareness, together with the availability and promotion of new therapies. The drug utilisation patterns, supported by evidence from population and general practice surveys, showed that there has been growth in the actual market rather than just redistribution within the market. Public health benefits of this major change in drug use (eg, reductions in suicide rates) are anticipated in the long term, but measuring population-level outcomes from changes will not be easy. Acknowledgements Other members of the Antidepressants Working Group who helped prepare these data were the Australian Pharmaceutical Manufacturers Association and the pharmaceutical industry (Susan Alexander, Mark Bradley, Michelle Burke, Liz Campbell, Victoria Croker, Marnie Firipis, Deborah Monk, Michael Ortiz, Ruth Stokes, Nick Williams). Drug Utilisation Sub-Committee secretariat (John Dudley). General Practice Statistics and Classification Unit, Family Medicine Research Centre, University of Sydney (Helena Britt and Geoff Sayer, who conducted the analyses of the depression data from BEACH). Disclosure: Philip B Mitchell has been a member of scientific advisory boards for Eli Lilly, SmithKline Beecham and Wyeth. References Murray CJ, Lopez AD. The global burden of disease: summary. Cambridge, Mass: Harvard School of Public Health, Harvard University Press (on behalf of the World Health Organization and the World Bank), 1996. Edmonds DJ, Dumbrell DM, Primrose JG, et al. Development of an Australian drug utilisation database: a report from the Drug Utilization Sub-Committee of the Pharmaceutical Benefits Advisory Committee. PharmacoEconom 1993; 3: 427-432. World Health Organization Collaborating Centre for Drug Statistics Methodology. Guidelines for ATC classification and DDD assignment. 2nd edition. Oslo, Norway: WHO, 1998. Hurley SF, McNeil JJ, Berbatis CG. Sources of Australian pharmacoepidemiology data. Commun Health Stud 1988; 12(1): 82-96. World Health Organization Collaborating Centre for Drug Statistics Methodology. ATC Index with DDDs, 1999. Oslo, Norway: WHO, 1998. Britt H, Sayer GP, Miller GC, et al. BEACH (Bettering the Evaluation And Care of Health): a study of general practice activity, six-month interim report. AIHW Catalogue No. GEP 1. Canberra: Australian Institute of Health and Welfare (General Practice series no.1). Bridges-Webb C, Britt H, Miles D, et al. Morbidity and treatment in general practice in Australia 1990-1991 [Errata in Med J Aust 1993; 158: 72, 652]. Med J Aust 1992; 157 (Suppl Oct 19): S1-S56. Australian Bureau of Statistics. 1995 National Health Survey: use of medications, Australia. Canberra: ABS, 1995. (Catalogue No. 4377.0.) Australian Bureau of Statistics. 1989-90 National Health Survey: summary of results, Australia. Canberra: ABS, 1991. (Catalogue No. 4364.0.) Australian Bureau of Statistics. 1997 Mental Health and Wellbeing: profile of adults. Canberra: ABS, 1997. (Catalogue No. 4326.0.) American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV). Washington, DC: APA, 1994. World Health Organization. International classification of diseases, 10th edition (ICD-10). Geneva: World Health Organization, 1993. Paykel ES, Priest RG. Recognition and management of depression in general practice: a consensus statement. BMJ 1992; 305: 1198-1202. Hirschfeld RMA, Keller MB, Pamico S, et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA 1997; 277: 333-340. Kendrick T. Prescribing antidepressants in general practice: watchful waiting for minor depression, full dose treatment for major depression. BMJ 1996; 313: 829-830. Paykel ES, Tylee A, Wright A, et al. The Defeat Depression Campaign: psychiatry in the public arena. Am J Psychiatry 1997; 154 (6 Suppl): 59-65. The National Mental Health Strategy. Community Awareness Program: a review. Canberra: Commonwealth Department of Health and Aged Care, November 1998. US Department of Health and Human Services. Agency for Health Care Policy and Research (AHCPR). Depression in primary care: Vol 11. Treatment of major depression. Rockville, Md: AHCPR, 1993. Psychotropic drug guidelines. 4th edition. Melbourne: Therapeutic Guidelines, 2000. National Health and Medical Research Council. Depression in young people. A guide for general practitioners. Canberra: NHMRC, 1997. National Health and Medical Research Council. Depression in young people. A guide for mental health professionals. Canberra: NHMRC, 1997. (Received 5 May, accepted 31 Aug, 2000) Authors' details Drug Utilisation Sub-Committee, Department of Health and Aged Care, Canberra, ACT. Peter McManus, MMedSc, BPharm, Secretary. South Eastern Sydney Area Health Service, Sydney, NSW. Andrea Mant, MD, FRACGP, MA, Area Adviser, Quality Use of Medicines; and Associate Professor, School of Community Medicine, University of New South Wales, Sydney, NSW. School of Psychiatry, University of New South Wales, NSW. Philip B Mitchell, MD, FRANZCP, FRCPsych, Professor; and Administrative Director, Mood Disorders Unit, Prince of Wales Hospital, Sydney, NSW. Health Economics and Outcomes Research, Eli Lilly Australia Pty Ltd, Sydney, NSW. William S Montgomery, BPharm, DipHospPharm, GradCertHealthEcon, Health Outcomes Research Manager. Department of General Practice, University of Adelaide, Adelaide, SA. John Marley, MD, MB ChB, Professor. Health Economics and Pricing Department, SmithKline Beecham (Australia) Pty Ltd, Melbourne, VIC. Merran E Auland, PhD, Health Economist. No reprints will be avaliable from the authors. Correspondence: Mr P McManus, Secretary, Drug Utilisation Sub-Committee, Mail Drop Point 83, Department of Health and Aged Care, GPO Box 9848, Canberra, ACT 2601. peter.mcmanusAThealth.gov.au Make a comment Back to text Back to text Percentage split of antideprssant sales (based on defined daily doses per 1000 population per day) by drug class in 1998 (data for all countries, except Sweden, from IMS Health; Swedish data from the Swedish Association of the Pharmaceutical Industry). SSRI = selective serotonin reuptake inhibitor. TCA = tricyclic antidepressant. Back to text

Peter McManus · Andrea Mant · Philip B Mitchell · William S Montgomery · John Marley · Merran E Auland

Medicine and the Community The perpetrators of domestic violence Sarah E Romans, Marion R Poore and Judy L Martin MJA 2000; 173: 484-488 See Articles 1, 2 and 4 of this series Abstract - Our understanding - Why? - Who? - Problems with research - What can be done? - Issues - Treatment - How effective? - Conclusions - References - Authors' details - - More articles on General practice and primary care

Sarah E Romans · Marion R Poore · Judy L Martin

Editorial What's in a name? The labelling of back pain We need a taxonomically correct term for back pain that reassures patients that they can confidently resume normal activities MJA 2000; 173: 400-401 When compiling the second edition of the taxonomy of pain,1 the taxonomy subcommittee of the International Association for the Study of Pain (IASP) wrestled with the diagnosis of spinal pain. It recognised that many diagnostic labels were illegitimate, inappropriate, or fanciful. Nevertheless, it allowed certain labels drawn from the osteopathic, physical medicine, and mainstream literature. In doing so, however, the subcommittee stipulated strict criteria that had to be satisfied if a particular diagnostic label was to be used. The purpose of doing so was to ensure consistent, disciplined and accountable use of terms. However, in many instances, the criteria were such that they could not be satisfied using history and examination alone, or even conventional investigations. The purpose of setting such stringent criteria was to highlight the deficiencies of contemporary practice and to indicate the need for research into the reliability and validity of traditional diagnostic practices. In effect, the exercise established that it was essentially impossible to render any conventional or traditional diagnosis for low back pain. The means to do so were simply not available, not reliable, or not valid. Consequently, the subcommittee argued that the only intellectually and clinically honest diagnosis for most cases of low back pain was "lumbar spinal pain of unknown or uncertain origin".1 This rubric serves well enough for purposes of classification and coding, but it is cumbersome and unappealing for everyday use. Despite its accuracy and honesty, the term is long and conveys the sense that the doctor does not know what is going on. Against this background it is not surprising that general practitioners lack a decent vocabulary for labelling a patient's back pain. The study of Schönstein and Kenny,2 of this issue of the Journal, highlights the implicit difficulties that GPs have in this regard when completing workers compensation certificates. Their sample showed considerable variation in the terms used. Yet, we cannot blame GPs; they are doing as best they can in the absence of a satisfying, official term. Nevertheless, the study reveals the need for standardisation. Diagnostic labels are important in the management of patients. Patients expect a name for their condition. A label shows that the doctor knows what is wrong. But such labels should not be incorrect or specious, lest they lead to therapeutic misadventure. Zygapophysial joint pain and discogenic pain can not be diagnosed clinically3,4 and are, at best, suppositions. Other labels, such as "segmental dysfunction", are only metaphors, with no established biological correlates. Some labels are simply wrong and can have deleterious effects. "Degenerative disc disease" conveys to patients that they are disintegrating, which they are not. Moreover, disc degeneration, spondylosis and spinal ostoearthrosis correlate poorly with pain and may be totally asymptomatic.5 They are age changes and do not constitute diagnoses. For this reason they were not admitted by the IASP.2 "Nominated treating doctors", in recording a diagnosis for back and neck pain, can at least approach standardisation by avoiding these presumptive and specious labels. "Sprain" or "strain" are inferences about what caused the back pain, but are based on what the patient reports. They can not be proven clinically and therefore may or may not be correct inferences. Nevertheless, these labels convey the notion that the pain and its cause are not serious. This is the issue that Schönstein and Kenny raise.2 Because it is not possible to render a pathoanatomical diagnosis of back pain, it becomes imperative to distinguish serious from non-serious conditions. In this regard, it has become conventional to refer to serious conditions as "red flag" conditions, the red flags being aspects of history or examination that should warn doctors of the possibility of a tumour or infection being the cause of pain. Mercifully, these conditions are rare. Another term that has emerged is "yellow flags". This pertains to certain beliefs, attitudes and responses that patients may have to their pain that are counterproductive to recovery. They include believing that activity will make their condition worse, blaming work for their pain, avoiding social activity, and relying on passive therapy.6 These are psychosocial features that are unrelated to the cause of pain, and can occur even with simple causes of pain; but they require attention lest they impede, retard or prevent recovery. What is lacking, however, is a term for back pain that is not associated with red flags or yellow flags. Such a term should be more than taxonomically correct. It should positively reassure patients that they can confidently resume normal activities, without developing fears or inappropriate behaviours. It is such a term that Schönstein and Kenny are looking for.2 In the context of workers compensation certificates such a term would provide more than a convenient label. It would indicate a favourable prognosis and convert the certificate from a disconcerting or confusing document to a propitious and enabling one. The terms "simple back pain" or "uncomplicated back pain" lack these latter properties. The challenge remains to help Schönstein and Kenny, and others, find a new term: one that is palatable to doctors, satisfying to patients, and which not only means that there is nothing seriously wrong, but also conveys the message that the patient has no grounds for fear, and can expect recovery with straightforward, even minimal, management. Nikolai Bogduk Newcastle Bone and Joint Institute University of Newcastle, Royal Newcastle Hospital, Newcastle, NSW mgillamATmail.newcastle.edu.au Merskey H, Bogduk N, editors. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms, 2nd edition. Seattle: IASP Press, 1994. Schönstein E, Kenny DT. Diagnoses and treatment recommendations on workers compensation medical certificates. Med J Aust 2000; 173: 419-422. Torgerson WR, Dotter WE. Comparative roentgenographic study of the asymptomatic and symptomatic lumbar spine. J Bone Joint Surg Am 1976; 58: 850-853. Schwarzer AC, Aprill CN, Derby R, et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 1995; 20: 1878-1883. Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994; 19: 1132-1137. Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. Wellington, NZ: Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National Health Committee. Make a comment

Nikolai Bogduk

Medicine and the Community Diagnoses and treatment recommendations on workers compensation medical certificates Eva Schönstein and Dianna T Kenny MJA 2000; 173: 419-422 For editorial comment, see Bogduk Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Occupational health Abstract Objective: To review the diagnostic descriptions and treatment recommendations for back and neck pain on the new workers compensation medical certificates and compare these with evidence-based guidelines. Design: Retrospective analysis of 251 medical certificates of workers with compensable neck and back pain held by a workers compensation insurer. Main outcome measures: Diagnoses given and treatments prescribed by the nominated treating doctors. Results: The diagnoses most frequently used were "sprain/strain" and "pain/ache". Physiotherapy was the most frequently prescribed treatment, followed by rest and medication. Rest was prescribed for 68 (27%) workers, 87% of whom were classified as having an acute injury. Activity-based treatments were prescribed for 45 (18%) workers. Conclusions: Not all doctors used diagnostic terms consistent with recommended anatomical taxonomy. The drug therapy prescribed was consistent with current evidence-based treatment guidelines. However, the prescribing of rest, and the omission, in most cases, of explicit recommendations to resume normal activities, including work, are not consistent with current guidelines. The cost of managing workplace back injuries is increasing. Figures for 1997-98 show that back injuries accounted for 30% of the cost of all workplace injuries (gross cost, $224 million),1 while comparable figures for 1996-97 were 36% and $212.5 million.1,2In an effort to reverse the growing WorkCover Authority (WCA) debt ($1.7 billion at the time of writing),3 the 1997 Grellman Report4 made recommendations which resulted in the Workplace Injury Management and Workers Compensation Act 1998 (NSW). A new medical certificate intended to streamline reporting and management of compensable work-related injuries was introduced, as well as the concept of the "nominated treating doctor" (NTD) -- a general practitioner nominated by the injured worker who agrees to provide continuity of care until a return to work is achieved (Box 1). In recent years, national and international guidelines and systematic reviews -- some evidence-based -- have established standards for diagnosis and treatment of people with back or neck pain,5-10 including the most recent National Health and Medical Research Council (NHMRC) guide to acute pain management11 and the definitive publication on classification of pain by the International Association for the Study of Pain (IASP).12 To streamline management and reduce the costs associated with prolonged disability and time off work, it is important that the NTDs' diagnoses and treatment recommendations conform with evidence-based guidelines. We compared the diagnoses and treatments given on Part 1 of a sample of medical certificates of workers (who had work-related back or neck pain) with the taxonomic guidelines for diagnosis and the emerging guidelines for management. Methods We examined retrospectively all the medical certificates related to neck and back pain of a NSW workers compensation insurer for the period 1 October 1998 - 15 February 1999. Medical certificate entries were de-identified. Diagnosis and treatment were coded according to the most common wording used by doctors. Diagnoses were further grouped into those indicating and those not indicating a specific pathological condition. Treatments were further coded according to the amount of rest and/or activity prescribed. Active treatments involved exercise, work conditioning/work hardening, and maintenance of normal activity (including work). Diagnoses were then compared with taxonomic guidelines, and treatments were compared, wherever possible, with evidence-based guidelines for the management of spinal pain. According to the time between the date of injury on the certificates and the date of the medical certificate, the worker's condition was classified as acute (< 6 weeks), subacute (6-12 weeks) or chronic (> 12 weeks). Ethical approval: Approval for the study was obtained from the Human Ethics Committee, The University of Sydney. Results Diagnosis On 227 of 251 certificates examined (90%), doctors did not specify a patho-anatomical diagnosis: on 92 certificates (37%) the diagnosis was sprain/strain; on 68 (27%) ache/pain; and on 67 (26%) injury (mechanical, lumbago, dysfunction, whiplash, discopathy, myalgia). The location of the pain was lumbar spine (131; 52%), back (42; 17%), cervical spine (39; 16%), and other (39; 16%). Thirty-four doctors (14%) used at least two diagnostic descriptors, and, of these, six used at least three. Examples included "back pain due to low back strain", "thoracolumbar spinal pain, right sciatica", and "lumbar disc degeneration, right low back pain, and right sciatica pain". Treatment The most frequently prescribed treatments (Box 2) were physiotherapy (116; 46%); rest (68; 27%); non-steroidal anti-inflammatory drugs (NSAIDs) (64; 25%); and analgesia, analgesics or "painkillers" (56; 22%). Specific active management advice, such as exercise, a return to work, suitable duties, work conditioning, hydrotherapy or work rehabilitation, was recommended for 45 (18%) workers. Many had more than one treatment prescribed, with the total sample of 251 being prescribed 455 treatments. Most workers were seen by their doctors in the acute phase of injury (208; 83%), with the remainder in the subacute (18; 7%) or chronic (21; 8%) categories. Of the workers prescribed rest, 87% were classified as having an acute injury. Fifty-six workers (22%) were certified fit for suitable duties, 24 of these (43%) on their initial visit to their NTD. Ninety-two workers (37%) were deemed unfit for work. This information was not included on the remaining certificates. Of the 92 workers deemed unfit for work, 59 (64%) were on their first visit to their doctor, 13 (14%) were being issued with a progress medical certificate, and 8 (9%) were making their final visit. The remaining 20 (22%) certificates did not have this information. The treatments prescribed on the medical certificates and available evidence for their efficacy are summarised in Box 3. Wherever possible, the evidence is presented according to the NHMRC level-of-evidence ratings. Discussion We found that doctors completing medical certificates for workers with back and neck pain generally did not indicate a specific pathoanatomical diagnosis. This is consistent with epidemiological evidence:6,7 in 85%-90% of back complaints, a pathoanatomical diagnosis can not be made from the history, examination or even medical imaging. One of the primary aims of the initial assessment is to exclude "red flag" conditions such as tumours, fractures, disc prolapses, herniations, or infections. According to the NHMRC,11 this exclusion is the key to managing acute spinal pain, and for this purpose the history is the most valid tool.13 The diagnoses given on medical certificates for back and neck pain should explicitly reflect the exclusion of "red flag" conditions, and the presence of a benign, self-limiting condition which generally resolves within four weeks of onset of pain.14The certificates showed that the doctors used a variety of (implicit) taxonomic systems to describe "non red flag pain"; for example, anatomical (eg, "back pain", "thoracolumbar spinal pain"), aetiological or mechanical (eg, "mechanical back pain", "injury"), or descriptive pathological (eg, "sprain", "tear", "degeneration"). Only anatomical classification is consistent with the IASP classification.12 However, the precise terminology used to describe pain of this type is contentious. Terms such as "non-specific back pain",6,15 "simple back pain",14 or "back pain of unknown or uncertain origin"12 have been proposed. NSAIDs and analgesics were the most frequently prescribed medical therapy. Their use for spinal pain is consistent with current evidence-based practice,9 but support for the use of NSAIDs is limited and applies only in the short term.9,11 Although physiotherapy, either alone or in combination with other treatments, was the most frequently prescribed treatment, the NTD generally did not specify the exact nature of the physiotherapy intervention. While scientific evidence for the efficacy of specific physiotherapy treatments for neck and back pain has been published,8,9,16 there is great variability in treatments among physiotherapists,17,18 and the extent to which they adhere to evidence-based practice has not been studied. The Australian Physiotherapy Association has made a concerted effort to educate and inform its members by producing position statements on neck pain and back pain. These as yet unpublished statements are based on randomised controlled trials and systematic reviews (some by the Cochrane Collaboration). A Physiotherapy Evidence Database has also been created (PEDro).19 When reviewing their patients, doctors need to consider the evidence for the efficacy of the specific physiotherapy treatment received. "Rest" was the second most common word included in treatment recommendations (27% of cases), and most workers for whom rest was prescribed were in the acute phase of their injury. In contrast, activity-based treatments were recommended in only 18% of cases. Both in terms of what was prescribed and what was omitted, this is contrary to current evidence. There is now Level I evidence that bed rest should not be prescribed for acute back pain;20 and Level II evidence that advising patients to return to normal activity (including work),21-24 providing reassurance, and discouraging fear of activity and illness behaviour, are effective for managing acute and subacute spinal pain. It is acknowledged that the use of the word "rest" may not necessarily mean "bed rest". However, even when used in combination with an activity-based treatment, the word "rest" may be construed to mean a cessation of all, most, or some of a person's normal functional and work activities. Recommendations As a result of our study, we recommend that: The new workers compensation medical certificates should be changed to assist nominated treating doctors (NTDs) to indicate that "red flag" conditions have been excluded. The use of the word "rest" on medical certificates should be restricted and the resumption of normal functional and work activities should be explicitly included. There should be a taxonomic standard for describing neck and back pain which clearly communicates that the condition is benign and has a good prognosis. This should reduce fear-avoidance and illness behaviours in workers,25 and assist employers to provide suitable temporary duties for workers. The medical profession and other appropriate authorities need to encourage dissemination and use of evidence-based guidelines and best practice in the management of compensable spinal pain. Acknowledgements We thank HIH Insurance (Injury Management Department) for providing access to workers compensation medical certificates, and Dr C Maher and Dr J Latimer, from the School of Physiotherapy, Faculty of Health Sciences, The University of Sydney, for their support and helpful comments. Competing interests: No conflict of interest exists and the study received no funding. References WorkCover NSW. Statistical bulletin. NSW workers compensation. Sydney: WorkCover NSW, 1997-1998. WorkCover NSW. Back injuries statistical profile, 1996/1997. WorkCover NSW, 1997/98 Annual Report. Sydney: WorkCover NSW, 1998. Grellman RJ. Inquiry into workers compensation system in NSW. Sydney: KPMG, 1997. Agency for Health Care Policy and Research (AHCPR). Clinical Practice Guidelines Number 14. Acute low back problems in adults. Rockville, Md: AHCPR, 1994. Fordyce WE, editor. Back pain in the workplace. Management of disability in nonspecific conditions. International Association for the Study of Pain. Seattle, Wash: IASP Press, 1995. Victorian WorkCover Authority. Guidelines for the management of employees with compensable low back pain. Melbourne: Victorian WorkCover Authority, 1996. Gross A, Aker P, Goldsmith CH, Peloso P. Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ 1996; 313: 1291-1296. Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain. A systemic review of randomized controlled trials of the most common interventions. Spine 1997; 22: 2128-2156. Waddell G, Feder G, McIntosh A, et al. Low back pain evidence review. London: Royal College of General Practitioners, 1998. National Health and Medical Research Council. Acute pain management: scientific evidence. Canberra: NHMRC, 1999. Merskey H, Bogduk N, editors. Classification of chronic pain. International Association for the Study of Pain. Seattle, Wash: IASP Press, 1994. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992; 268: 760-765. Croft PR, Macfarlane GJ, Papageorgiou AC, et al. Outcome of low back pain in general practice: a prospective study. BMJ 1998; 316: 1356-1359. Cedraschi C, Nordin M, Nachemson AL, Vischer TL. Health care providers should use a common language in relation to low back pain patients. Baillieres Clin Rheumatol 1998; 12: 1-15. Gross A, Aker P, Goldsmith C, Peloso P. Physical medicine modalities for mechanical neck disorders (Cochrane Review). Cochrane Library; Issue 1, 2000. Van der Valk RWA, Dekker J, van Baar ME. Physical therapy for patients with back pain. Physiotherapy 1995; 81: 345-351. Jette AM, Smith K, Haley SM, Davis KD. Physical therapy episodes of care for patients with low back pain. Phys Ther 1994; 74: 101-114. The Physiotherapy Evidence Database (PEDro). May 2000. <http://ptwww.cchs.usyd.edu.au/pedro/> (accessed 6 September 2000). Koes BW, van den Hoogen HMM. Efficacy of bed rest and orthoses of low back pain. A review of randomized clinical trials. Eur J Phys Med Rehabil 1994; 4: 96-99. Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain -- bed rest, exercise or ordinary activity? N Engl J Med 1995; 332: 351-355. Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine 1995; 20: 473-477. Lindstrom I, Ohlund C, Eek C, et al. Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain. A randomized prospective clinical study with a behavioural therapy approach. Spine 1992; 17: 641-652. Lindstrom I, Ohlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioural approach. Phys Ther 1992; 72: 279-293. Loeser JD, Sullivan M. Doctors, diagnosis and disability: a disastrous diversion. Clin Orthop Rel Res 1997; 336: 61-66. (Received 3 Sep 1999, accepted 31 Jul 2000) Authors' details Faculty of Health Sciences, The University of Sydney, Sydney, NSW. Eva Schönstein, BAppSc(Phty), MHPEd, Lecturer, School of Physiotherapy. Dianna T Kenny, PhD, MAPsS, Associate Professor of Psychology. Reprints will not be available from the authors. Correspondence: Ms Eva Schönstein, School of Physiotherapy, Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe 1825. E. SchonsteinATcchs.usyd.edu.au Make a comment 1: The new medical certificate Part 1: Requires the nominated treating doctor (NTD) to give a diagnosis, recommend treatment and determine the worker's fitness for work and suitable duties, including specific restrictions. It must be completed for those who are likely to return to pre-injury or suitable duties within 7 days of injury. Part 2: Requires doctors to specify nature and restrictions to proposed suitable duties (only completed for workers expected to return to work after more than 7 days from the date of injury). Part 3 (Return to Work Form): Requires recommendations on when the worker should resume work and the restrictions on activities arising from the work-related injury (must be completed for all workers who need a graded return to pre-injury or other permanent duties). Back to text 2: Treatments most commonly prescribed on the 251 medical certificates Treatment (examples) Number (%) Physiotherapy only 48 (19%) Physiotherapy + activity 12 (5%) (Physiotherapy and exercise, or rehabilitation, or hydrotherapy, or modified duties, or graded return to work) Physiotherapy + passive treatment 56 (22%) (Physiotherapy and medication or rest or massage or heat or ice or a combination of these) Medication only 25 (10%) (Analgesics, NSAID, drug not specified, Brufen [Knoll], Voltaren [Novartis], Panadeine Forte [Sanofi- Synthelabo]) Medication + activity 9 (4%) (Analgesia and home exercises , paracetamol and back exercises, NSAID and light duties) Medication + rest 24 (9%) (NSAID or analgesics and rest) Rest only 6 (2%) (Rest, bed rest) Rest + activity 12 (5%) (Rest and exercise or modified duties or return to work) Specified single treatment other than rest, medication or physiotherapy 17 (7%) (Acupuncture, chiropractic, manipulation) Other combinations of two or more treatments 8 (3%) (NSAID and heat and massage, rest and local heat and massage) Other treatment descriptors not elsewhere classifiable 17 (7%) ("Conservative management", "restricted daily", "nil", "rehabilitation medicine") Treatment not specified 17 (7%) Total 251 (100%) Back to text 3: Treatments recommended on more than one of the 251 medical certificates and NHMRC levels of evidence for their efficacy (wherever possible)* Treatment prescribed n (%) RCGP10 Van Tulder et al9 Physiotherapy 116 (46%) -- -- Rest, bed rest 68 (27%) Ineffective, Level I Ineffective, Level I NSAID 64 (25%) Effective, Level I Effective, Level I Analgesics, analgesia 56 (22%) Effective, Level III Effective, Level II Exercise, swimming 29 (12%) Ineffective, Level I Ineffective, Level I Light, modified duties, gradual return to work 13 (5%) Effective, Level IV -- Massage 11 (4%) -- -- Manipulation, mobilisation, chiropractic 11 (4%) Effective, Level I Effective, Level III Heat (electromagnetic or source unspecified) 9 (7%) -- -- Ice 4 (2%) -- -- Muscle relaxants 3 (1%) Effective, Level I Effective, Level I Ultrasound 3 (1%) -- -- Work conditioning 2 (0.8%) Effective, Level III -- Acupuncture 2 (0.8%) -- -- Victorian WCA7 Gross et al8 IASP6 AHCPR5 Beneficial -- -- -- Beneficial (48 hours) -- Ineffective Ineffective, Level I Beneficial Inconclusive Effective Effective, Level II Beneficial Inconclusive Effective Effective, Level III Beneficial -- Effective Effective, Level III Beneficial -- Effective Effective, Level IV Beneficial -- -- -- Beneficial Effective short term, Level I Effective Effective, Level II Beneficial Effective short-term Level I Ineffective Self-application, Level IV Beneficial -- -- Self-application Level IV Beneficial short term Inconclusive Ineffective Effective, Level III -- -- -- -- -- -- -- -- Beneficial Inconclusive Ineffective Ineffective, Level IV *For some of the guidelines cited (IASP6 and Victorian WCA7) levels of evidence were not given. For others (RCGP10 and AHCPR5), the levels of evidence given were converted to match the NHMRC levels. Back to text

Eva Schonstein · Dianna T Kenny

Medicine and the Community The impact of domestic violence on individuals Jill Astbury, Judy Atkinson, Janet E Duke, Patricia L Easteal Susan E Kurrle, Paul R Tait and Jane Turner MJA 2000; 173: 427-431 See Articles 1, 3 and 4 of this series Abstract - Children - Pregnant women - Elderly people - Indigenous people - People of non-English-speaking background - The need for change - References - Authors' details - - More articles on Aboriginal health Abstract There is extensive evidence of the adverse effects of domestic violence across all age groups and cultural backgrounds. The impact of domestic violence may be long-term, affecting emotional adjustment, physical health and subsequent relationships. Health professionals should be aware of the confounding effect of youth, age and cultural diversity on presentation. Shame and isolation militate against disclosure. Specific, sensitive questioning that incorporates awareness of cultural and social issues is essential to detect domestic violence and initiate appropriate assistance. If the idea of "home" implies physical and psychological safety and security as well as shelter, then a child, adult or older person affected by domestic violence experiences a hidden "homelessness".1 Domestic violence occurs across the lifespan2 and across most cultures. Women are at a disproportionately high risk of physical, sexual and psychological violence from an intimate person such as a partner or ex-partner.3 Many children, too, are likely to experience violence from someone they know or be witnesses to violence within their families.4 Domestic violence may be physical, sexual or psychological, but all three can be present. What is subjectively defined and identified as "domestic violence" by victims can be strongly mediated by cultural beliefs, values and previous experience of abuse and may not coincide with standard clinical or research definitions. Domestic violence is always characterised by the use of coercive control and psychological abuse.5,6 Victimisation is associated with alterations in the perception of the perpetrator, especially a belief in his or her omnipotence, and alterations in the victim's perception of self. Feelings of self-blame, shame and loss of self-esteem are extremely common. At the same time, psychological defenses used to cope with violence include denial of its existence and minimisation of its severity.7 Acts of contrition and intermittent kindness by the perpetrator can maintain the relationship and give false hope to the abused person that the violence will end. In addition to the common features of domestic violence, there are important aspects of domestic violence that are characteristic of specific groups in society, such as children, pregnant women, the elderly, Indigenous people, and people of non-English-speaking background. Here we examine some of the specific problems of each of these groups in more detail. Children Children can be at risk of experiencing and witnessing violence within the family or from those known to them.8 The perpetrator is usually in a caring role or a position of trust in relation to the child. Children can be the direct targets of physical violence or can get hurt when they try to protect another family member, often the mother, or try to stop their parents from fighting. It is becoming increasingly apparent that domestic violence results in a similar outcome for many children, whether they are direct victims or only witnesses of the violence. A number of authors have pointed to a clear link between domestic violence and child abuse, with one being a predictor of the other: it has been estimated that children living in domestic violence situations are up to 15 times more likely to be abused or neglected than children from non-violent homes.9-11 Behavioural and psychological consequences of childhood violence include poor school performance, bedwetting, aggression (particularly among males), temper tantrums, oppositional behaviour, self-blame, guilt for the violence between parents, isolation from peers, self-harming behaviour, running away, psychosomatic symptoms, stealing, over-eating, depression, sleep disturbances and excessive anxiety symptoms (see Box 1). Violence by a person in a position of trust impairs the child's ability to trust others and increases the risk of victimisation in later life.12 Recent research has shown that there are significant and possibly persistent neurobiological effects of trauma experienced in early childhood. Work by Perry and others13,14 has demonstrated the importance of critical periods of exposure to secure parenting: exposure to recurring traumatic experiences in early childhood places a child at much greater risk of long-term psychological, emotional and behavioural problems. The type of violence is not the primary factor determining long-term outcome. More important predictors are the duration of violence, its severity and frequency. The cumulative impact of exposure to multiple adverse experiences (eg, violence, psychological or sexual abuse, substance misuse) in childhood is predictive of adverse health outcomes in adult life. In a large US study it was found that exposure to four or more categories of adverse childhood experiences was associated with a 4-12-fold increased risk of alcoholism, drug abuse, depression and attempted suicide.15 Protective factors include a healthy relationship with a primary carer, good social support and positive subsequent life experiences.8,12 Pregnant women The number of unwanted or unplanned pregnancies and terminations is higher among women experiencing domestic violence.16,17 Pregnancy itself is a time of heightened risk and the abdomen is targeted more frequently and more severely in pregnant women.18,19 The Women's Safety Australia survey4 found that, of all the women who reported violence occurring at some time in their lives, 42% were pregnant at the time. Twenty per cent reported that violence occurred for the first time during the pregnancy, although the strongest predictor of violence occurring during pregnancy is a prior history of abuse.12 Furthermore, women abused during pregnancy are at even greater risk of violence in the postpartum period.19 Women experiencing violence during pregnancy often obtain minimal or late antenatal care.20 They are at increased risk of having poor weight gain, anaemia, infections, or preterm labour; of bearing a low birthweight infant; and experiencing postnatal depression.18,21-23 They are also more likely to engage in behaviours harmful to health, such as smoking, drinking excessive amounts of alcohol, and substance misuse.18,21-23 Elderly people Abuse of elderly people is the most recent form of familial violence to come to public attention but it remains a largely hidden problem. Most community-based studies have shown that similar proportions of older men and women are victimised (in contrast to the younger population, in which the number of women experiencing domestic violence is greater than the number of men).24 Close family members (the victim's spouse, adult child or other relative) constitute the majority of abusers and usually live with the victim.25 The reasons for elder abuse are often related to their dependence on others (due to physical or mental impairment, particularly dementia), psychopathology in the abuser, or a long history of family violence26 (see Box 2). Many instances of elder abuse are "victim-victim" situations in which abusers may themselves be worn-out carers. Physical consequences include the actual injuries inflicted (eg, bruising, lacerations, fractures, or burns) as well as the results of neglect, such as malnutrition, decubitus ulceration, and inappropriate use of medication. Older people who are frail may sustain major injuries from an apparently minor cause -- for instance, a shove leading to a fall may result in a fatal subdural haemorrhage. Abuse may also have psychological consequences: feelings commonly experienced are a sense of powerlessness, shame at having to admit that the abuse is occurring at the hands of close family members, fear of retaliation from the abuser, and particularly fear of institutionalisation if the abuse is reported. Such fears increase the victim's reluctance to report abuse,27 often causing a self-imposed isolation. Control by the abuser may be exercised financially through the improper use of an older person's property or finances or misuse of a power of attorney, or may take the form of neglect whereby the necessities of life (adequate food, clothing, medication, or other care) are withheld by a caregiver.28 Indigenous people Domestic violence in Indigenous families and communities in Australia is presently at a level for serious concern.29,30 In 1990, an Aboriginal and Torres Strait Islander Commission briefing document advised the Australian Aboriginal Affairs Council that "the increasing injuries and fatalities as a result of interpersonal violence have risen to levels which not only impair life but also threaten the continued existence of Australian Indigenous peoples".31 Physical assault is commonly associated with psychological abuse, and Indigenous victims of domestic violence (who are mainly women) may view themselves as being of little worth, incompetent, and deserving of abuse.32 The situation becomes more complex when racism and discrimination in social control structures are intertwined with domestic violence32 (see Box 3). Domestic violence in Indigenous communities can only be understood in the context of the historical, political, social and cultural environments in which it occurs.34 Colonisation has had a disastrous impact on the lives of Indigenous people: it has created complex and cumulative forms of traumatic stress that may be articulated as physical, emotional and spiritual distress; misuse of alcohol and other drugs; and violent behaviour arising from a rage that is directed towards the self and other close family members.35 With the breakdown of cultural lore, behaviours that were previously functional in conflict resolution processes have become unstructured and damaging when used under the influence of alcohol or other drugs.36 John Cawte, a psychiatrist and anthropologist, identifies Indigenous communities as suffering from "gross stress", a form of post-traumatic stress disorder in which individuals express their loss and bewilderment as emotional and behavioural disorders.37 Indigenous women are less likely than non-Indigenous women to report an assault, and less likely to seek medical help unless they have severe injuries.38 Historical interactions with police, who were used by the state to forcibly remove Indigenous children under government assimilation policies, and deaths of Indigenous people in custody continue to engender a deep mistrust of law enforcement officials.39 Indigenous women fear for their own safety40 and the safety of other family members if police or social welfare officials become involved. While some Indigenous women may call the police to intervene in violent situations, they are less likely than non-Indigenous women to want to lay charges, and there is a general belief that charging or incarcerating Indigenous men does not reduce male violence. Indigenous women are more likely to ask for other interventions in which their partner also receives help for his drinking and/or violent behaviour.32 People who have been traumatised through violence are more likely to be treated as if they are mentally ill or unstable than to be provided with programs that will meet their needs; however, recent program initiatives in Australia are beginning to respond to the specific and unique needs of Indigenous peoples.29 People of non-English-speaking background The extent of domestic violence experienced in Australia by people of non-English-speaking background has not been extensively studied. However, research suggests that overseas-born males are more likely to commit partner homicide than would be expected from their numbers in the general community.41 This may reflect a higher rate of domestic violence among overseas-born women. Alternatively, these women may be less likely to leave violent situations, and therefore experience escalating violence. For those who are migrants, the strain of migration may compound the problem. However, in most cases in which a couple migrated together, the abuse preceded migration.42 Once in Australia, however, the migrant family may undergo further stresses as traditional gender roles shift. This may encompass unemployment or downward shifts in employment status for men, and paid employment for women. Assimilation of the younger generation into the broader Australian culture may further erode traditional hierarchies based on age and sex. Women who may be at particular risk include Asian women sponsored by non-Asian men,43 and Middle Eastern women brought to Australia for arranged marriages to Middle Eastern men already residing here.42 Such women have not only left behind their family and supports, but have joined partners whose established community networks may not recognise their needs. In some instances, their partner's extended family may collude in the violence, overtly or indirectly, by not offering support.42 Disclosure of domestic violence towards women of non-English-speaking background is inhibited if they have poor command of English (Box 4). For some women, however, the issue is more fundamental -- their concept of sexual assault within marriage may be very different from current Australian values and norms.44 Over 70% of migrant women have minimal knowledge of the legal rights of victims of domestic violence,45 which further inhibits disclosure, and many know little about support services or refuges. Women from Middle Eastern and Latin American cultural backgrounds who experience domestic violence are often reluctant to contact police, in part because they have witnessed oppression or torture at the hands of police in their country of origin.42 Domestic violence often creates a feeling of shame. There may be considerable pressure for a woman to maintain a marriage, and she may fear being deported.46 She may feel the burden of providing financial support for family in her country of origin,47 and consider that their plight outweighs any consideration of personal needs. The erosion of self-esteem accompanying domestic violence is compounded if the woman is isolated by virtue of limited English and lack of family and friends in whom to confide. The adverse health effects are similar to those experienced by abused women in the broader Australian society, although they may be exacerbated by longer delay in disclosure. The need for change Each of the specific groups examined has characteristic issues related to their experience of domestic violence. Nevertheless, the need for change applies equally to all groups. Patients are reluctant to disclose violence if not asked,48 but sensitive questioning can legitimate and encourage disclosure. As the Council on Scientific Affairs of the American Medical Association has observed, knowledge of a history of abuse can provide "the starting point from which to disentangle a confusion of presenting complaints and symptoms".49 Clinical practice and medical education programs in Australia have been slow to respond to the large body of research confirming the harmful health effects of domestic violence. Failure by healthcare providers to detect and treat those affected by domestic violence exacerbates the harm done in several ways. Firstly, the complexity of violence-related negative health outcomes increases if abuse remains undetected. Secondly, the drain on healthcare resources increases as victims present repeatedly to primary and emergency healthcare providers. (Conversely, victims' uptake of preventive healthcare is considerably lower than average, and the role of violence in their "non-compliance" with preventive health behaviours can easily be missed.) Thirdly, non-detection ensures that treatments are necessarily directed at the symptoms rather than the cause.1 A thorough understanding of the multiple adverse health effects and high rate of physical and psychological comorbidity associated with domestic violence must be acquired by all healthcare professionals. Training is required in every aspect of treatment, including initial questioning, counselling and responding to those who do disclose violence, and providing appropriate assistance, including safety plans and advocacy on behalf of patients. A number of our medical colleges have begun this necessary task. In clinical care, the concept of meaningful assistance to patients with health needs associated with domestic violence deserves to be strongly promoted. References Burke T. Housing and poverty. In: Fincher R, Nieuwenhuysen J, editors. Australian poverty. Melbourne: Melbourne University Press, 1998: 165-184. Kleinschmidt KC. Elder abuse: a review. Ann Emerg Med 1997; 30: 463-472. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52: 1048-1060. Australian Bureau of Statistics. Women's safety, Australia, 1996. Canberra: ABS, 1996. Ratner P. The incidence of wife abuse and mental health status in abused wives in Edmonton, Alberta. Can J Public Health 1993; 84: 246-249. Campbell JC, Lewandowski LA. Mental and physical health effects of intimate partner violence on women and children. Psychiatr Clin North Am 1997; 20: 353-374. Martin J, Anderson J, Romans S, et al. 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Killing the beloved: homicide between adult sexual intimates. Canberra: Australian Institute of Criminology, 1993: 47. Easteal P. Shattered dreams -- marital violence among the overseas-born in Australia. Melbourne: Bureau of Immigration and Multicultural Population Research, 1996. Elliott and Shanahan Research. Summary of background research for the development of a campaign against domestic violence, conducted for the Office of the Status of Women, Department of the Prime Minister and Cabinet. Canberra: 1988. Quarter way to equal. A report on barriers to access to legal services for migrant women. Sydney: Law Foundation of New South Wales, 1994. Public violence: a report of violence in Victoria. Melbourne: Victorian Community Council against Violence, 1992. Hansen D, Le Sueur M. Separating mothers and children: Australia's gendered immigration law and policy. Alternative Law Journal 1996; 21: 203-206. Lawton K. Needs of NESB women in women's refuges: a perspective from a remote rural area in the north west of Western Australia. BIR Bulletin 1992; 6: 30-33. Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence against women: a general practice-based prevalence study. Med J Aust 1996; 164: 14-17. American Medical Association, Council on Scientific Affairs. Violence against women: relevance for medical practitioners. JAMA 1992; 267: 3184-3189. Authors' details Key Centre for Women's Health in Society, University of Melbourne, Carlton, VIC. Jill Astbury, MEd, PhD, Associate Professor. Cooperative Research Centre for Rainforest Ecology and Management, Cairns, QLD. Judy Atkinson, PhD, Senior Research Officer, Aboriginal Liaison. Harley Medical Chambers, Fitzroy, VIC. Janet E Duke, FRANZCOG, FRCOG. Faculty of Law, Australian National University, Canberra, ACT. Patricia Easteal, PhD, Visiting Fellow. Rehabilitation and Aged Care Service, Hornsby Ku-ring-gai Hospital, Hornsby, NSW. Susan E Kurrle, MB BS, DipGerMed, Director and Senior Staff Specialist. Child Protection Unit, New Children's Hospital, Westmead, NSW. Paul R Tait, MB BS, FRACP, Head. Department of Psychiatry, Royal Brisbane Hospital, Herston, QLD. Jane Turner, MB BS, FRANZCP, Senior Lecturer. Reprints will not be available from the authors. Correspondence: Associate Professor J Astbury, Key Centre for Women's Health in Society, 720 Swanston Street, Carlton, VIC 3053. j.astburyATkcwh.unimelb.edu.au ©MJA 2000 Make a comment Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 2000 Medical Journal of Australia. We appreciate your comments. 1: Illustrative case of domestic violence involving children Nine-week-old baby "Lee" was taken to the family's general practitioner by her mother, "Anna", who stated that Lee was waking throughout the night and hard to settle. The GP noted some old and new bruising on Lee's head and trunk and asked Anna about these. She stated that Lee had tipped out of a bassinet down some stairs and also tended to bruise easily. Concerned about the possibility of child abuse, the GP referred Lee to the local hospital emergency department and notified the Department of Community Services. Lee was found to have skull and rib fractures and a subdural haematoma. Coagulation studies were normal. Anna was depressed and tearful on presentation. She admitted to the social worker that on several occasions she had "lost it" with Lee and thrown her down into her cot. She said her husband was away for long hours at work and she felt isolated. She later disclosed a long history of verbal, physical and sexual assault by her husband. He was often short-tempered and verbally intimidating towards her and their two-year-old son (who was described as being "very scared" of his father). She had had postnatal depression following the delivery of her first child. It was later learned that Anna had grown up in a family where domestic violence had occurred regularly. Back to text 2: Illustrative case of domestic violence involving an elderly person "Mrs Jones" is an 84-year-old widow with moderate Alzheimer disease. Until recently, she had been living alone, and was managing quite well with assistance from community services and regular visits from her general practitioner. Then her daughter moved in with her, ostensibly to care for her. Her daughter cancelled all services and suggested to the GP that his regular visits were unnecessary. Three months later, one of Mrs Jones' neighbours contacted her GP. He was concerned that Mrs Jones appeared to have lost a lot of weight and was often seen in her backyard crying. The GP visited and was reluctantly admitted to the house by Mrs Jones' daughter. The GP noted that Mrs Jones had indeed lost weight, and she appeared unkempt and had facial bruising. Her mental state had markedly deteriorated. Arrangements were made for Mrs Jones to be admitted to hospital, where she was found to be malnourished, to have an untreated wrist fracture and to have bruising over her trunk and face. Back to text 3: Illustrative case of domestic violence involving Indigenous people "Eva" has been married for nearly 25 years and has been beaten many times and subjected to different forms of abuse by her husband. She has seven children, and prides herself on being a strong Aboriginal woman, a "survivor". She stays in the relationship because "all kids need a father". Calling the police has therefore never been an option when she is being assaulted. Nor would calling the police be of any help. They are already constantly involved in her life, and judge her as being "a bad mother", "a troublemaker" and "emotionally unstable". Her sons are all in trouble with the law for their public behaviour, which is often violent. They are either in jail or in juvenile detention centres, on remand or parole. On release from jail they go back into a family environment that provokes distress and anger. Her eldest son has just served his second jail term for assault, after stabbing a person who said something against his father. He unsuccessfully attempted suicide in jail. He grieves for the loss of relationship with his father and continually attempts to establish some nurturing communication. He says he wants to get married and have a happy life, but all his relationships with young women have ended because of his violence. His mother, whom he has seen bashed many times, is angry at the juvenile justice system, Corrective Services and other state agencies because they just lock her children up without helping them to stop their offending behaviours. She is more involved with her own day-to-day survival than being able to think through how she can help them "break their cycle".33 Back to text 4: Illustrative case of domestic violence involving a woman of non-English-speaking background presenting in general practice "Ruziye" is a Turkish migrant sponsored by her Turkish-Australian husband, to whom she has been married for 18 months. She presents to a general practitioner with a complaint of rectal bleeding and extreme pain. Her husband enters the surgery with her. Background Ruziye's file indicates that she has seen the doctor for vaginal bleeding on several prior occasions. Consultation GP: Mr Amir, I would prefer to see your wife alone. Husband: Her English is not good. I can do translating. GP: That's OK. I have learned to talk to patients from non-English-speaking backgrounds and require that the consultation takes place between Ruziye and myself. [Husband reluctantly leaves the office] GP: When did the bleeding and soreness begin? Ruziye: A few days ago. GP: How did it start? Ruziye: My husband he likes to, you know, that part of me. This is hard to say. Where I come from, we do not talk about these things. GP: I understand that it is not easy for you. To help you though I do need to have an understanding of what has happened. Ruziye: Yes, I see. He does push hard and it hurts. GP: Do you ask him to stop? Ruziye: I tried once but he said it is my duty as his wife. GP: Well, Ruziye, in Australia, it is actually not your duty. In fact, we have laws that say you can say "no" to your husband and if he still does it, he is breaking the law. Ruziye: I did not know this. But in my family, you have to stay married and I have nowhere to go anyway. GP: There is help for you, Ruziye. If you decide that he is hurting you and that you want to leave, I can give you a pamphlet that lists places and people that will help you. Ruziye: Thank you doctor. Ruziye returned to the doctor several times over the next year with similar problems. Each time, the doctor gently talked to her about marital rape and other types of violence. Back to text

Jill Astbury · Judy Atkinson · Janet E Duke · Patricia L Easteal · Susan E Kurrle · Paul R Tait · Jane Turner

New Drugs, Old Drugs COX-2 inhibitors Peter M Brooks and Richard O Day MJA 2000; 173: 433-436 Abstract - Adverse gastrointestinal events - Coxibs - The future of COX-2 - Practical issues - References - Authors' details - - More articles on General medicine Abstract Cyclooxygenase-2 (COX-2) inhibitors constitute a new group of non-steroidal anti-inflammatory drugs (NSAIDs) which, at recommended doses, block prostaglandin production by cyclooxygenase-2, but not by cyclooxygenase-1. Two COX-2 inhibitors are currently available in Australia -- celecoxib, which is taken twice daily, and rofecoxib, which is taken once daily. Both drugs act rapidly in providing pain relief and their anti-inflammatory analgesic effect in osteoarthritis and rheumatoid arthritis is equivalent to standard doses of non-selective NSAIDs. Celecoxib and rofecoxib show significantly lower incidences of gastrotoxicity (as measured by endoscopic studies and gastrointestinal ulcers and bleeds) than non-selective NSAIDs. There is Level 2 evidence that COX-2 inhibitors: reduce pain in classic pain models -- third-molar extraction, dysmenorrhoea and after orthopaedic surgery; reduce pain and disability in osteoarthritis of the hip and knee; and reduce pain and disability in rheumatoid arthritis. Other adverse effects, such as interference with antihypertensive agents and the potential to produce renal dysfunction in patients with compromised renal function by COX-2 inhibitors, seem similar to those of non-selective NSAIDs. Traditional non-steroidal anti-inflammatory drugs (NSAIDs) constitute one of the largest groups of pharmaceuticals, with a world market in excess of $13 billion per annum.1 Although primarily used to treat pain and inflammation in musculoskeletal disease, NSAIDs may also have a role in the management of such widely differing conditions as chronic pain associated with conditions other than musculoskeletal disorders, Alzheimer disease and colorectal cancer.2 Although NSAIDs have been extraordinarily useful in controlling signs and symptoms of musculoskeletal disease, it is now appreciated that their use is associated with significant morbidity, primarily because of gastrointestinal toxicity,3 but also because of renal dysfunction4 and cardiac failure.5Until 10 years ago, it was accepted that NSAIDs acted by reducing prostaglandin synthesis through inhibition of cyclooxygenase (COX). Over the last decade the finding that cyclooxygenase activity increases in inflammation led to the identification of a new COX isoform, and the elucidation of its molecular structure.6 Recognition that cyclooxygenase consisted of two isoforms, COX-1 and COX-2, spawned an active, molecular-based drug development program for specific inhibitors of COX-2. The isoforms differ in that glucocorticoids inhibit synthesis of COX-2, but not COX-1, and COX-2 has a larger active site and a side pocket into which the new specific inhibitors fit.7 Inhibition by traditional NSAIDs and the selective COX-2 inhibitors (now classified as a separate class of NSAIDs -- the coxibs) is compared in Box 1. Coxibs should have the same efficacy as a traditional NSAID, but without the effects on haemostasis and gut mucosa. Adverse gastrointestinal events and NSAID therapy Indigestion, mucosal erosion, ulceration, bleeding and perforation of the stomach are all associated with NSAID use, and serious side effects can be asymptomatic. The risk of adverse gastrointestinal events increases with age and dose. Other risk factors for gastrointestinal adverse effects include the simultaneous use of two or more NSAIDs, a history of peptic ulcer or gastrointestinal bleeding, comorbid conditions such as cardiac and renal dysfunction, and concomitant use of corticosteroids or anticoagulants.8 Up to 2% of patients who take an NSAID for 12 months develop an ulcer or a significant gastrointestinal bleed, and this imposes a significant burden on individuals and the community.3 Coxibs Two COX-2 inhibitors are currently available in Australia, and their drug profiles are given in Box 2. Rofecoxib has a longer half-life than celecoxib and is suitable for once-daily dosing, while celecoxib usually needs to be given twice daily. These two drugs also have significantly different effects on the cytochrome P450 (CP450) enzyme system, which is important in the metabolism of drugs. Celecoxib inhibits CP450 (CYP2C9) enzymes and thus may cause elevation of plasma concentrations of any drug metabolised by this isoenzyme, such as some β-blockers, antidepressants and antipsychotics. Rofecoxib does not inhibit this enzyme system and has fewer potential metabolic interactions. Like conventional NSAIDs, both rofecoxib and celecoxib may diminish antihypertensive effects of angiotensin-converting enzyme (ACE) inhibitors and diuretic effects of frusemide and thiazides. Both coxibs have the potential to increase plasma lithium levels. Warfarin levels and, more importantly, prothrombin times can be increased by both drugs. Plasma concentrations of methotrexate were increased by just over 20% when coadministered with rofecoxib, while celecoxib did not significantly increase methotrexate levels.9 The clinical significance of this interaction is unclear, but increased care with methotrexate monitoring is appropriate after introducing a coxib. Efficacy Pain relief: Rofecoxib (50 mg) has been shown to be superior to placebo and equivalent to naproxen sodium (550 mg) in the 12 hours after being taken for orthopaedic surgical pain relief (E2) (see Box 3 for an explanation of level-of-evidence codes) and for dysmenorrhoea (E2), and equivalent to ibuprofen (400 mg) after third-molar tooth extraction (E2). Celecoxib in a dose of 100 mg or 200 mg was significantly better than placebo for pain after third-molar extraction, and no different than ibuprofen 400 mg or naproxen sodium 550 mg (E2).10 Osteoarthritis of hip and knee: In a 12-week trial of more than 1000 patients comparing 50 mg, 100 mg and 200 mg celecoxib twice daily with 500 mg naproxen twice daily or placebo, the 100 mg and 200 mg doses of celecoxib were as effective as the naproxen. Although 50 mg celecoxib twice daily was better than placebo, it was not as effective as the higher doses.11 Rofecoxib in doses of 12.5 mg and 25 mg once daily has been shown to be significantly better than placebo, as effective as 2.4 g of ibuprofen daily (over six weeks)12 and as effective as 150 mg of diclofenac daily (over one year) for osteoarthritis of the knee (E2).13 Rheumatoid arthritis: A three-month, double-blind, placebo-controlled study comparing naproxen 500 mg twice daily, placebo and celecoxib in doses of 100 mg, 200 mg or 400 mg twice daily in more than 1100 patients with rheumatoid arthritis showed that all celecoxib doses and naproxen were effective for pain and inflammation throughout the 12 weeks (E2).14 Interestingly, only 60% of patients completed this study. The reasons for failure to complete were not different between the active treatment groups, although those taking placebo showed a higher treatment failure rate. These patients also underwent endoscopy within a week of commencing treatment and at the end of the three months. The peptic ulceration rate (defined as any break in the mucosa at least 3 mm in diameter with unequivocal depth) was 4% for those taking placebo, and 6%, 4% and 6% for those taking 100 mg, 200 mg and 400 mg celecoxib, respectively; these incidences were not significantly different. However, the rate was significantly higher (26%) for those taking 500 mg naproxen (E2).14 A six-month study comparing 200 mg celecoxib twice daily with 75 mg diclofenac twice daily in 655 patients with adult-onset rheumatoid arthritis showed that celecoxib had similar efficacy to diclofenac, with a significantly lower incidence of gastrointestinal side effects. In this study 430 patients underwent endoscopy within seven days of the last treatment, and gastroduodenal ulcers (defined as any break in the mucosa of at least 3 mm in diameter with unequivocal depth) were found in 33 patients (15%) treated with diclofenac and eight (4%) in the celecoxib group. In this study, the rate of withdrawal for any gastrointestinal-related adverse event (most commonly abdominal pain, diarrhoea and dyspepsia) was nearly three times higher in the diclofenac-treated group than in the celecoxib group, and this was significant at P < 0.001 (E2).15 In an eight-week study, 648 patients with rheumatoid arthritis were randomly assigned to groups receiving either placebo or 5 mg, 25 mg or 50 mg of rofecoxib once daily. In this study the 5 mg dose was no different to placebo, while both larger doses were significantly better than placebo. No clinically significant oedema, hypertension or serious gastrointestinal effects were reported.16 Adverse events Gastrointestinal: Carefully conducted endoscopy studies show a significantly lower incidence of endoscopically proven ulcers with up to 12 months of treatment with COX-2-specific agents. In patients with rheumatoid arthritis, celecoxib is associated with significantly less gastroduodenal ulceration than naproxen14 or diclofenac (E2).15 In a combined analysis of eight trials in patients with osteoarthritis, treatment with rofecoxib was associated with a significantly lower incidence of perforations, ulcers or bleeds than treatment with ibuprofen, diclofenac or nabumetone (E1).17 An endoscopic study in osteoarthritis showed an ulcer incidence at 12 weeks for rofecoxib equivalent to that for placebo and significantly lower than for ibuprofen.18 Large studies of gastrointestinal outcomes with both celecoxib and rofecoxib are currently in progress, and these data should be available in the next few months. There are also data suggesting that small bowel permeability is not affected by COX-2-specific agents, whereas it is increased with non-selective NSAIDs. Renal: Although it was initially felt that COX-2-specific agents might be renal-sparing, there is COX-2 in the kidney19 and it can be induced in circumstances such as sodium depletion or in patients taking ACE inhibitors. COX-2-specific inhibitors may affect renal function in much the same way as traditional NSAIDs, and particular care should be taken in prescribing these drugs to patients with renal dysfunction or in those taking diuretics or antihypertensive agents, particularly ACE inhibitors. Cardiovascular: The inhibitory effect on platelet function by traditional non-selective NSAIDs may play a contributory role in gastric bleeding. However, prostacyclin (PGI2) is also thought to play an important role as an antithrombotic and vasodilator, and COX-2 is thought to play a role in the biosynthesis of both systemic and renal prostaglandin (PGE2),20 thus influencing PGI2 synthesis. This may have important connotations in vascular disease. The implications of specific COX-2 inhibition on thrombosis are not known, although there have been several case reports of thromboses in patients with the antiphospholipid syndrome treated with celecoxib.21 As the COX-2 story unfolds it will be important to explore the effect of combinations of low-dose aspirin and specific COX-2 inhibitors in a wide range of patients. Reproduction COX-1 and COX-2 are both involved in various aspects of ovulation, implantation and parturition.22 COX-2-deficient mice are infertile and COX-2-specific inhibitors should not be taken by women wishing to become pregnant. The future of COX-2 inhibitors Large studies of gastrointestinal outcomes are currently in progress with both these agents to further examine clinical gastrointestinal events. Patients with a previous history of peptic ulceration (although not in the previous six months) and patients up to and over the age of 90 years have been included in outcome studies so far completed. As COX-2 is involved in ulcer healing, it is important to know whether use of these agents will retard this process. It will also be important to see, in large clinical trials, whether coxibs will have any effect on the incidence of vascular disease. With the knowledge that COX-2 is overexpressed in bowel cancer and in Alzheimer disease and that non-selective NSAIDs retard both of these conditions comes the tantalising prospect that coxibs may have potential for wider use in the future.1,7 Celecoxib has been approved in the US for patients with familial polyposis coli after a randomised placebo-controlled trial showed a 28% reduction in the number of polyps in patients who took 400 mg celecoxib twice daily.23 Practical issues An algorithm for prescribing specific COX-2 inhibitors is shown in Box 4, and important messages for patients are shown in Box 5. Cost-effectiveness studies (which are dependent on the local price of the drug), based on current US prices, suggest that use of COX-2 inhibitors would be cost effective in high risk patients -- those with a history of peptic ulceration, those taking high doses of NSAIDs or corticosteroids, and those aged over 65.24The release of COX-2 inhibitors in Australia appears to be good news for sufferers of musculoskeletal conditions.25 As with the introduction of any new drug, doctors should assess patients carefully, asking whether there are specific reasons for changing therapy (such as ineffectiveness or adverse events), and review patients taking the new drug at frequent intervals. In this way these drugs can be introduced cost effectively and benefit the maximum number of patients. Disclaimer: Peter Brooks serves on Advisory Boards for Merck Sharp and Dohme for rofecoxib, and in the past has consulted and been a member of Advisory Boards for Pfizer and Searle. Richard Day serves on Advisory Boards on rofecoxib for Merck Sharp and Dohme and on Advisory Boards for celecoxib for Pfizer and Searle. References Brooks PM. COX-2 inhibitors. Aust Prescriber 2000; 23: 30-32. Dubois RN, Abramson SB, Crofford L, et al. Cyclooxygenase in biology and disease. FASEB J 1998; 12: 1063-1073. Fries JF. NSAID gastropathy: the second most deadly rheumatic disease? Epidemiology and risk appraisal. J Rheumatol 1991; 18 Suppl 28: 6-10. Henry D, Page J, Whyte I, Nanra R, Hall C. Consumption of non-steroidal anti-inflammatory drugs and the development of functional renal impairment in elderly subjects. Results of a case-control study. Br J Clin Pharmacology 1997; 44: 85-90. Heerdink ER, Leufkens HG, Herings RMC, et al. NSAIDs associated with increased risk of congestive heart failure in elderly subjects taking diuretics. Arch Intern Med 1998; 158: 1108-1112. Luong C, Miller A, Barnett J, et al. The structure of human cyclooxygenase-2; conservation and flexibility of the NSAID binding site. Nat Struct Biol 1996; 3: 927-933. Hawkey CJ. Cox-2 inhibitors. Lancet 1999; 353: 307-314. Wolfe NM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of non steroidal antiinflammatory drugs. N Engl J Med 1999; 340: 1888-1899. Karim A, Tolbert DS, Hunt TL, et al. Celecoxib, a specific COX-2 inhibitor, has no significant effect on methotrexate pharmacokinetics in patients with rheumatoid arthritis. J Rheumatol 1999; 26: 2539-2543. Geis GS. Update on clinical developments with celecoxib, a new specific Cox-2 inhibitor: what can we expect? J Rheumatol 1999; 26 Suppl 56: 31-36. Bensen WG, Fiechther JJ, McMirren JI, et al. Treatment of osteoarthritis with celecoxib, a cyclooxygenase-2 inhibitor: a randomized controlled trial. Mayo Clin Proc 1999; 74: 1095-1105. Ehrich EW. Effect of specific Cox-2 inhibition in osteoarthritis of the knee: a 6 week double blind placebo controlled pilot study of rofecoxib. J Rheumatol 1999; 26: 2438-2447. Cannon GW, Caldwell JR, Holt P, et al. Rofecoxib, a specific inhibitor of cyclooxygenase 2, with clinical efficacy comparable with that of diclofenac sodium: results of a one-year, randomized, clinical trial in patients with osteoarthritis of the knee and hip. Rofecoxib Phase III Protocol O35 Study Group. Arthritis Rheum 2000; 43: 978-987. Simon LS, Weaver AL, Graham DY, et al. Anti-inflammatory and upper gastro-intestinal effects of celecoxib in rheumatoid arthritis. JAMA 1999; 282: 1921-1928. Emery P, Zeidler H, Kviem TK, et al. Celecoxib versus diclofenac in long term management of rheumatoid arthritis: randomised double blind comparison. Lancet 1999; 354: 2106-2111. Schnitzer T. The safety profile, tolerability and effective dose range of rofecoxib in the treatment of rheumatoid arthritis. Clin Ther 1999; 21: 1688-1702. Langman MJ, Jensen DM, Watson DJ, et al. Adverse upper gastrointestinal effects of rofecoxib compared to NSAIDs. JAMA 1999; 282: 1929-1933. Hawkey C, Laine L, Simon T, et al. Comparison of the effects of rofecoxib (a cyclooxygenase 2 inhibitor), ibuprofen and placeo on gastroduodenal mucosa of patients with osteoarthritis. Arthritis Rheum 2000; 43: 370-377. Komhoff M, Grone H-J, Klein T, et al. Localisation of cyclooxygenase-1 and -2 in adult and fetal human kidney: implications for renal function. Am J Physiol 1997; 272: 460-468. McAdam BFF, Catella-Lawson IA, Mardini A, et al. Systemic biosynthesis of prostacyclin by cyclo-oxygenase (Cox-2); the human pharmacology of a selective inhibitor of Cox-2. Proc Natl Acad Sci USA 1999; 96: 272-277. [Published erratum appears in Proc Natl Acad Sci USA 1999 May 11; 96: 5890.] Crofford LJ, Oates JC, McCune WJ, et al. Thrombosis in patients with connective tissue diseases treated with specific COX-2 inhibitors: a report of four cases. Arthritis Rheum 2000; 43: 1891-1896. Richards JS, Fitzpatrick SL, Clemens JW, et al. Ovarian cell differentiation: a cascade of multiple hormones, cellular signals and regulated genes. Rev Prog Hormone Res 1995; 50: 223-254. Steinbach G, Lynch PM, Phillips RKS. The effect of celecoxib, a cyclo oxygenase-2 inhibitor, in familial adenomatous polyposis. N Engl J Med 2000; 342: 1946-1952. Peterson WL, Cryer B. Cox-1 sparing NSAIDs -- is the enthusiasm justified? JAMA 1999; 282: 1961-1963. Schachna L, Ryan PFJ. Cox-2 inhibitors: the next generation of non-steroidal anti-inflammatory drugs. Med J Aust 1999; 171: 175-176. Authors' details University of Queensland, Royal Brisbane Hospital, Brisbane, QLD. Peter M Brooks, MD, FRACP, Executive Dean of Health Sciences. University of New South Wales, St Vincent's Hospital, Sydney, NSW. Richard O Day, MD, FRACP, Professor of Clinical Pharmacology. Reprints will not be available from the authors. Correspondence: Professor P M Brooks, Faculty of Health Sciences, University of Queensland, Edith Cavell Building, Royal Brisbane Hospital, Herston, QLD 4029. Make a comment 1: Action, regulation and inhibition of cyclooxygenase-2 Regulation: mainly constitutive, but increases 2-4 - fold with inflamatory stimuli. Expressed by most tissues, particularly platelets, stomach, intensive and kidney. Inhibition: by non-steroidal anti-inflammatory drugs. Regulation: mainly inducible (10-20-fold). Induced by inflammatory stimuli in macrophages, monocytes, synoviocytes, chondrocytes, fibroblasts and endothelial cells. Hormonally induced in ovaries and fetus. Constitutive in central nervous system, kidney, testes and trachea. Inhibition: by non-steroidal anti-inflammatory drugs and selective COX-2 inhibitors. Back to text 2: Drug profiles of celecoxib and rofecoxib Action At therapeutic plasma concentrations, coxibs block COX-2 but do not significantly interfere with COX-1. Onset of action Analgesia: 1 hour. Anti-inflammatory effect: less than 2 weeks after starting therapy. Dosing Celecoxib, 200-400 mg, orally, twice daily. Rofecoxib, 12.5-50 mg, orally, once daily. Metabolism Celecoxib: by cytochrome P450; half-life, 12 hours; protein binding, 97%. Rofecoxib: by metabolic reduction; half-life 17 hours; protein binding, 85%. Adverse effects Reduction in gastrointestinal events (ulcers, bleeds and erosions) compared with non-selective non-steroidal anti-inflammatory drugs (NSAIDs). Effects on renal function (potential for mild fluid retention, insufficiency in renally compromised patients and those taking ACE inhibitors) similar to those of non-selective NSAIDs. Drug interactions Celecoxib Rofecoxib Effect Clinically significant Warfarin Yes Yes Increased prothrombin time Yes Methotrexate No Yes Increased methotrexate levels Probably not Lithium Yes Yes Increased lithium levels Yes Angiotensin-converting enzyme inhibitors Yes Yes Reduced antihypertensive effects (potential for renal impairment) Yes Inhibitors of CYP2C9* Yes No Increased plasma concentrations of celecoxib Yes Substrates of CYP2D6† Yes No Increased plasma concentration of substrate Probably Frusemide and thiazides Yes Yes Reduced diuretic effect Yes Codeine and oxycodeine Yes No Potential for reduced pain efficacy of substrates Possibly Antacids Yes ? Reduced celecoxib plasma concentrations Probably *Amiodarone, cimetidine, fluoxetine, fluconazole, metronidazole, fluvastatin. †ß-Blockers, antidepressants (amitryptyline, desipramine, clomipramine, fluoxetine), antipsychotics (haloperidol, thioridazine), perhexiline. Back to text 3: Level-of-evidence codes Evidence for the statements made in this article is graded according to the NHMRC system7 for assessing the level of evidence: E1 Level I: Evidence obtained from a systematic review of all relevant randomised controlled trials. E2 Level II: Evidence obtained from at least one properly designed randomised controlled trial. E31 Level III-1: Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method). E32 Level III-2: Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case-control studies, or interrupted time series without a parallel control group. E33 Level III-3: Evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group. E4 Level IV: Evidence obtained from case-series, either post-test, or pre-test and post-test. Back to text 4: When to prescribe a COX-2 inhibitor Prescribe for patients with rheumatoid arthritis or osteoarthritis who are: Not responding to conventional non-steroidal anti-inflammatory drugs (NSAIDs) and/or At risk of gastrointestinal (GI) toxicity because they: have had previous NSAID-associated GI toxicity; are aged over 65 years; have severe arthritic disease; are taking a high dose of NSAIDs. Back to text 5: Important messages for patients COX-2 inhibitors produce many effects of non-steroidal anti-inflammatory drugs (NSAIDs) but with a reduced incidence of gastrotoxicity. COX-2 inhibitors are no better than NSAIDs in reducing musculoskeletal pain and inflammation but are safer. COX-2 inhibitors may interfere with antihypertensive or diuretic medication. Back to text

Peter M Brooks · Richard O Day

Editorial Alcohol and cardiovascular disease: still a research priority? MJA 2000; 173: 116-117 More precision in measuring drinking levels and patterns will give a firmer basis for advice about drinking The evidence amassed to date on the link between moderate alcohol intake and reduced risk of dying of cardiovascular disease might be thought already sufficient to bracket sceptics of alcohol's protective effect with doubters of manned lunar missions and members of the Flat Earth Society. Published studies demonstrating this link can now be counted in the hundreds, and no fewer than six plausible underlying biological mechanisms have been identified.1 In this issue of the Journal yet another study reports this link: Simons and colleagues show moderate alcohol intake to be associated with increased survival in elderly people.2 Their study is an elegant example of the genre and drawn from a highly respected prospective study of risk factors for death and illness in the population of Dubbo, New South Wales. The two fields of epidemiology and alcohol studies have much to learn from each other Alternative explanations for the protective effect of moderate alcohol intake, relying on ever more tenuous confounding effects, have been discredited one by one. The apparently protective effect of moderate alcohol consumption has so far survived the use of controls for sociodemographic status,3 for the "sick quitter hypothesis"4 (ie, the suggestion that many abstainers have stopped drinking because of serious illness), for the amount of cholesterol in the diet,5 and even for the degree of social isolation.6 As evidenced in the study by Simons et al,2 the protective effect is fairly specific to cardiovascular disease and does not operate for other major causes of death in older people such as cancer. While a handful of recent studies have failed to find a protective effect for moderate drinking,7,8 these are still heavily outnumbered by those with positive findings.1 In fact, the range of different countries and cultures in which the phenomenon has been documented is also testimony to its robustness, even if different levels of consumption appear to provide the benefit in different drinking cultures.1 So, does medical science need further research on this topic? My contention is that, while the basic protective properties of moderate alcohol consumption appear to have been identified, the precision of the measurement of drinking levels and patterns in these studies needs to be sharpened if we are to have a firmer basis for advising people how to drink to avoid ill-health. The recent major systematic review commissioned by the National Health and Medical Research Council to underpin revisions to Australia's national guidelines on low risk drinking found that nearly all epidemiological studies in this area only attempt to measure one of the important dimensions of alcohol consumption: total volume of drinking, usually expressed as average intake per day.1 Despite recent evidence that pattern of drinking plays a role independent of volume,9 large-scale epidemiological studies rarely include simple items in their questionnaires tapping this dimension, such as frequency of drinking five or more drinks in one day, or maximum amount consumed on one day. Simons et al make a rare contribution to our knowledge by providing an analysis of mortality risk, based not only on average volume of alcohol across all days, but also on usual amount consumed on a drinking day. Clearly, these can be very different measures (eg, seven drinks in a day once a week versus one drink every day of the week).2 While the power of the analyses in Simons et al is limited by sample size, usual consumption of five or more drinks for men and of three or four drinks in a day for women was not associated with a significantly reduced risk of death.2 It should be noted, however, that questions regarding "usual" consumption tend to suffer from a bias towards low-consumption occasions and against less frequent occasions of high intake.10 Forthcoming World Health Organization guidelines on measurement of alcohol consumption advise that a superior method is the "graduated quantity frequency", in which respondents are asked how often they drink at each of different levels of consumption, starting with the highest (eg, "How often do you drink 20 drinks on one day?").10 The same guidelines identify another problem bedevilling attempts to convert the results of alcohol studies into precise advice for drinkers: assumptions about the alcohol content of drinks reported vary between studies and are usually not empirically based. A number of studies from different countries have attempted to document usual-serve sizes employed by random samples of drinkers and found these to vary significantly from those usually assumed by researchers.11,12 One study found that the bias created towards under-reporting of consumption was massive in one particular population subgroup: Afro-American women.13 One striking consequence of a failure to measure pattern of alcohol consumption adequately can be the false identification of special benefits from one type of alcoholic beverage over another. Wine is often reported as being most associated with benefits, but being a wine drinker as opposed to a beer and spirits drinker is a marker for many other things, including a tendency towards a more consistent pattern of daily drinking rather than occasional "bingeing".14 A well known Danish study,3 often cited as evidence for a greater benefit of wine over other drinks, measured alcohol consumption by only asking about how much people usually drank if they drank every day. Because this is a less frequent pattern for heavy drinkers of beer and spirits, many of the latter will have been falsely categorised as light or moderate drinkers, thus significantly biasing against finding protective effects for these beverages. The two fields of epidemiology and alcohol studies have much to learn from each other. If epidemiological studies of risk factors for heart disease do not improve their measurement of patterns and levels of alcohol use, it will remain very hard to give precise advice to drinkers who wish to minimise harms and maximise benefits of alcohol consumption. In reality, despite hundreds of studies into the protective effects of alcohol in relation to heart disease, research into this area has only just begun. Timothy R Stockwell Director National Centre for Research into the Prevention of Drug Abuse Curtin University of Technology, Perth, WA Single E, Ashley MJ, Bondy S, et al. Evidence regarding the level of alcohol consumption considered to be low-risk for men and women. Final report. Canberra: National Health and Medical Research Council, 2000. URL: <http://www.nhmrc.health.gov.au/advice/alc-comp.htm> (accessed 29 June 2000). Simons LA, McCallumJ, Friedlander Y, et al. Moderate alcohol intake is associated with survival in the elderly: the Dubbo Study. Med J Aust 2000; 173: 121-124. Gronbaek M, Deis A, Sorensen TIA, et al. Mortality associated with moderate intakes of wine, beer or spirits. BMJ 1995; 310: 1165-1169. Rehm J, Sempos CT. Alcohol consumption and all-cause mortality: questions about causality, confounding and methodology. Addiction 1995; 90: 493-498. Rehm J, Sempos CT. Alcohol consumption and all-cause mortality. Addiction 1995; 90: 471-480. Murray RP, Rehm J, Shaten J, Connett JE. Does social integration confound the relation between alcohol consumption and mortality in the Multiple Risk Factor Intervention Trial (MRFIT)? J Stud Alcohol 1999; 60: 740-745. Leino EV, Romelsjo A, Shoemaker C, et al. Alcohol consumption and mortality. II. Studies of male populations. Addiction 1998; 93: 205-218. Hart CL, Smith GD, Hole DJ, Hawthorne VM. Alcohol consumption and mortality from all causes, coronary heart disease, and stroke: results from a prospective cohort study of Scottish men with 21 years follow up. BMJ 1999; 318: 1725-1729. Rehm J, Ashley KJ, Room R, et al. On the emerging paradigm of drinking patterns and their social and health consequences. Addiction 1996; 91: 1615-1621. World Health Organization (Substance Abuse Department). International guidelines for monitoring alcohol consumption and harm. Geneva: WHO. In press. Stockwell T. Information provided in Australia about the size of "standard drinks". Med J Aust 1992; 156, 295. Lemmens P. The alcohol content of self-report "standard drinks". Addiction 1994; 89: 593-602. Kaskutas L, Graves K. An alternative to standard drinks as a measure of alcohol consumption. Paper presented at International Conference on the Measurement of Drinking Patterns, Alcohol Problems and the Connection; 2000 April 2-7; University of Stockholm, Sweden. In press. Doll R. One for the heart. BMJ 1997; 315: 1664-1668. Make a comment

Timothy R Stockwell

Editorial Women in rural general practice: conflict and compromise The difficulties of practising in the country and of being a woman compound each other MJA 2000; 173: 119-120 Although women now make up almost 50% of Australian medical graduates,1 they are under-represented in the rural medical workforce. In 1998, only 19% of female general practitioners (GPs) worked in rural areas, compared with 23% of male GPs, while 27% of Australia's population lived in these areas.2Recruitment and retention of women in rural general practice is increasingly important. In rural areas, GPs provide a large proportion of medical services but are in short supply. More women than men are now entering general practice -- 57% of GP registrars who enrolled in the training program of the Royal Australian College of General Practitioners (RACGP) this year were women.3 If rural communities are to have equitable access to health services, then more women must be attracted to and retained in rural practice. In addition, there is evidence that female GPs practise in a style that differs from that of male GPs: they treat different conditions, provide longer consultations and perform fewer procedures.4 The smaller number of female doctors in the rural medical workforce limits the access of rural populations to female practitioners; this is of particular concern to young women in rural areas.5 Until recently, research on factors that affect recruitment and retention of rural GPs has not focused on possible sex differences,6-10 and little has been published on this topic in peer-reviewed journals. In 1997, we undertook a pilot study of factors that affect recruitment and retention of female GPs in rural practice, particularly their social support needs.11 This study involved six focus groups of six to 10 women GPs, followed by a postal survey of 155 female GPs in rural Western Australia and New South Wales. The survey questionnaire was returned by 117; the concerns they identified are shown in the Box. In addition, a number of other reports on this topic have been funded or commissioned by the Federal Government.1,12-14 Recently, the National Rural General Practice Study (NRGPS) identified sex differences in priorities and levels of satisfaction about quality-of-life issues, such as practice and social environments.12 Rural doctors usually work longer hours than urban doctors and provide more after-hours services.13 While both sexes are affected, the impact is compounded for female GPs because of their home and family commitments -- female medical practitioners commonly assume the main responsibility for childrearing and the home, whether or not they have full-time careers.14 Role conflict is thus likely to be a greater problem for female than male rural doctors, although it would also be a problem for male doctors who assume the main responsibility for childrearing and the home. Responsibilities for care of children, as well as remoteness, also limit female rural GPs' attendance at continuing medical education events.11 Involvement in after-hours work contributes to their concerns about personal safety.13 Our 1998 study of violence against rural GPs, which included a postal survey of 314 rural GPs (including 91 women), found that female rural GPs are more apprehensive about the possibility of violence during the course of their work than their male counterparts.15 Our 1997 pilot study also found that the small number of female professionals, particularly doctors, in rural areas compounded the problem of social isolation for female rural GPs.11 Although social isolation may also be a problem for some male rural GPs (eg, solo practitioners), the NRGPS identified "more peer support" as a higher priority for female than male rural GPs.12 Female and male doctors are also attracted to different aspects of rural practice.11,12,14,16For example, female rural doctors rate the opportunity to carry out inpatient care and access to hospital as less important than male doctors.12 A study in Victoria found that women made up 30% of doctors in towns without hospitals, but only 7% in towns with hospitals.16 We asked our focus groups for strategies to address the problems they had raised. Suggestions included: More flexible childcare services and financial subsidies for childcare; Childcare for continuing medical education programs; Support and email chat groups for female rural doctors; Discussion of gender issues in medical practice during undergraduate and postgraduate training; Involvement of Divisions of General Practice in improving the availability of health services for rural doctors; Adequate workplace security at a local and regional level, especially for after-hours services; Suitable continuing medical education programs for female rural doctors that reflect their practice content; and Retraining for rural female doctors returning to the workforce. A number of groups, including Monash University and the University of Newcastle, the NSW Rural Doctors Network, the RACGP and the Australian College of Rural and Remote Medicine, are already developing ways to better support female doctors in rural areas, including some of the suggestions from our pilot study. These include the development of curricula on gender issues in undergraduate medical programs and support groups for female rural GPs. The General Practice Partnership Advisory Council (which advises the Commonwealth Department of Health and Aged Care) is currently acting on recommendations of the 1998 General Practice Strategy Review to increase recruitment and retention of women in rural general practice.17 The recent numbers of women entering the rural training stream of the RACGP training program are encouraging (47% of entrants in 19993). However, to attract and retain more women in rural practice, it needs to be structured to reflect the ways in which women practise medicine. This may involve more flexible models of practice, which accommodate the doctor's home and family commitments, and in which the type of work performed by many female doctors is valued and given practical support. Helen M Tolhurst Senior Lecturer in Rural General Practice Jane M Talbot Senior Lecturer in Rural General Practice Faculty of Medicine and Health Sciences, University of Newcastle Newcastle, NSW Louise L T Baker Program Manager for Education and Workforce NSW Central West Division of General Practice, Cowra, NSW Australian Medical Workforce Advisory Committee and Australian Institute of Health and Welfare. Female participation in the Australian medical workforce. Sydney: AMWAC, 1996: 7. Data supplied by the Australian Institute of Health and Welfare. Unpublished data from the Royal Australian College of General Practitioners. Britt H, Bhasale A, Miles DA, et al. The sex of the general practitioner: a comparison of characteristics, patients and medical conditions managed. Med Care 1996; 34: 403-415. Bryson L, Warner-Smith P. Choice of GP: who do young rural women prefer? Aust J Rural Health 1998; 6: 144-149. Kamien M. Report of the ministerial inquiry into the recruitment and retention of country doctors in Western Australia. Claremont, WA: University of Western Australia Department of Community Practice, 1987. Strasser R. Rural general practice in Victoria: the report from a study of the attitudes of Victorian general practice to country practice and training. Melbourne: Monash University, 1992. Kamien M. Staying in or leaving rural practice: 1996 outcomes of rural doctors' 1986 intentions. Med J Aust 1998; 169: 318-321. Hays RB, Veitch PC, Cheers B, Crossland L. Why doctors leave rural practice. Aust J Rural Health 1997; 5: 198-203. Kamien M, Buttfield IH. Some solutions to the shortage of general practitioners in rural Australia. Part 4. Professional, social and economic satisfaction. Med J Aust 1990; 153: 168-171. Tolhurst H, Bell P, Baker L, et al. Educational and support needs of female rural general practitioners. Bathurst: School of Nursing and Health Administration, Charles Sturt University, 1997. Strasser R, Kamien M, Hays R, Carson D. National rural general practice study -- quality of life. Melbourne: Monash University Centre for Rural Health, 1997. Australian Medical Workforce Advisory Committee. The medical workforce in rural and remote Australia. Sydney: AMWAC, 1996: 8. Australian Medical Workforce Advisory Committee. Influences on participation in the Australian medical workforce. Sydney: AMWAC, 1998: 4. Tolhurst H, Talbot J, Baker L, et al. "An inkling of mayhem": violence against rural general practitioners. Report to the General Practice Evaluation Program, 1999. Campbell D, Strasser R, Kirkbright S. Survey of Victorian rural general practitioners in towns without a hospital. Traralgon (Vic): Monash University Centre for Rural Health, 1996. General practice. Changing the future through partnerships. Report of the General Practice Strategy Review Group. Canberra: Commonwealth Department of Health and Family Services, 1998. Make a comment Concerns of female rural general practitioners Professional experience Pressure to work longer hours than they wish (often full- rather than part-time) Large demand for their involvement in counselling services and women's health services so that other types of work are excluded Under-remuneration for their work, especially long consultations for mental health problems Perception that their work is undervalued by their colleaguesSocial support Limited availability of flexible childcare for after-hours and on-call work Lack of support from a peer groupRole conflict Conflict caused by competing professional and personal obligations Feelings of guilt because of inability to fulfil demands of competing role expectationsContinuing medical education Difficulty attending continuing medical education events because of personal commitments and need for childcarePersonal health and safety issues Concerns about personal safety, particularly while providing after-hours services Difficulty accessing health services for themselves, particularly gynaecological services. 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Helen M Tolhurst · Jane M Talbot

Caring For Older People Healthcare for older people in residential care -- who cares? Leon Flicker MJA 2000; 173: 77-79 Increasing needs should be met with improved organisation of services Recently in Melbourne, several older people in a high-level-care residential facility (nursing home) were reportedly found to have an infestation with the mite Sarcoptes scabiei. They were supposedly treated with a dilute topical application of a mixture of volatile hydrocarbons, commonly known as kerosene. Quite rightly, this practice was widely condemned,1 as it does not conform to accepted evidence-based guidelines, which recommend the topical application of compounds such as permethrin, which are safer and more effective.2 This incident has raised questions as to whether the standard of healthcare is adequate throughout the residential care industry. The residential care system has undergone major changes over the past 15 years. It is a system that has traditionally been divided into two tiers: high-level care (nursing home care) and low-level care (hostel care). This situation has been somewhat muddled by legislative changes enacted in October 1997 allowing residential care facilities to house residents of any degree of dependency, and in fact 18% of residents in hostels are classified as requiring "high-level" care (Commonwealth Department of Health and Aged Care, WA Branch, personal communication), a situation that should mean that nursing attention is available 24 hours a day.3 However, statistics analysed and reported by the Federal Government over the period 1985-1997 demonstrate a consistent trend towards fewer nursing home beds and slightly more hostel beds,3 a trend which has probably continued over the past three years. Despite a rapidly ageing population, there has been virtually no growth in the number of nursing home places. In Australia there were 71 503 nursing home beds in 1985 and 74 233 in 1997 -- a reduction in the ratio of beds per 1000 persons aged 70 years and over from 66.5 to 47.6. Over the same period, there has been real growth in the number of hostel places from 34 885 to 64 825 places, or an increase in the ratio from 32.5 to 41.6 beds per 1000 persons aged 70 years and over. These changes have produced predictable results, with a notable and sustained increase in levels of dependency of residents in nursing homes and hostels. In 1987, 30% of permanent nursing home residents were categorised as "high dependency" (Residential Classification Scale Index 1 or 2); in 1997, this proportion was 56%. In 1992, only 54% of hostel residents required assistance with personal care, whereas in 1997, 80% of residents required such assistance.3 Older people in residential care are the sickest and frailest subsection of an age group that manifests the highest rates of disability in the Australian population. For example, in 1998, only 5.2% of people aged 65-69 years required assistance with self-care activities (eg, bathing, dressing, grooming), while in the age group 80 years and over 31.4% of people required such assistance.3 As people age, they are not only more likely to have a severe or profound disability but are also more likely to be cared for in residential care. Approximately 15% of Australians aged over 65 years living in the community have a severe or profound disability, whereas 93% of people in residential care have such a disability. While one-third of older Australians aged 65 years and over with severe or profound disability live in non-private dwellings, the rates rise from only 13% of the 65-69-year-old group to over 50% of women over the age of 80 years. This increase is almost certainly due to two main factors: the decreased availability of informal carers for the oldest age group, and the increasing level of disability. What are the medical conditions underlying these dependency statistics? Unfortunately, although the Federal Government is responsible for both medical and residential care, few data are available on the common medical conditions of elderly people in residential care. Probably the commonest condition seen in these people is some form of dementia. In 1996, there were an estimated 134 809 people with dementia in Australia (this estimate does not include all people with mild disease).4 Approximately half of these individuals were housed in residential care.3 Estimates of the prevalence of dementia in people in hostels and nursing homes were 28% and 60%, respectively, although rates of cognitive impairment were even more alarming, at 54% and 90%, respectively.5 The main disabling conditions of the 707 600 people aged 65 years and over with a profound, severe or moderate disability (less than 20% of whom were housed in residential care) were arthritis, other musculoskeletal conditions, dementia, eye disease and stroke.3 It would appear that much of the disability suffered by people in residential care is related to chronic degenerative conditions. The pressure of caring for people with increasingly complex and disabling conditions within the residential care system may place other parts of the healthcare system under stress -- for example, the readmission of nursing home patients to the acute hospital system with acute complications of chronic medical problems. Such admissions (eg, the referral to an acute hospital of a nursing home resident with severe Alzheimer's disease complicated by hypostatic pneumonia) may be precipitated by avoidance of ethically difficult management decisions. Another part of the health and welfare system that may come under pressure is community care, despite substantial real increases in Commonwealth expenditure on Home and Community Care (HACC). This expenditure has increased, in inflation-adjusted terms, from $561 million in the financial year 1991-92 to $799 million in 1997-98.3 The pressure exerted by reduced availability of residential care has led to a waiting time of several weeks for community care in many parts of Australia, despite the necessity of providing care to patients discharged from a crowded acute hospital system. How should the provision of healthcare for people in nursing homes and hostels be organised? This issue has essentially not been addressed to date, and improvement in this area will require more than increased funding. Over the past 15 years, the focus of aged care services has been to prevent or delay the need for residential care by comprehensively assessing patients to identify those who might benefit from multidisciplinary rehabilitation and community services. The rationale for this approach is sound and clearly evidence based,6 and the policy has been very successful. While cynics may claim that the Federal Government has promoted the policy to halt the previous exponential growth in nursing home care, there is no doubt that older people themselves eschew the residential care option to remain in their own homes, if at all possible.7 However, the healthcare of people who go into residential care seems to be far less coordinated. Recent developments (part of the Enhanced Primary Health Care Initiative) that support medical practitioners in screening the over-75-years group and in care planning, exclude people in nursing homes. Furthermore, the organisation and proposed evaluation of this initiative do not appear ideal.8The very high prevalence of cognitive impairment among people in residential care limits the usefulness of surveying residents about their perceived needs and decreases their ability to be effective advocates for their own care. I believe several steps need to be taken to improve healthcare for people in residential facilities: We need to recognise that most older people do not choose residential care for "social" reasons. They do so because of chronic medical conditions resulting in permanent disability. Healthcare professionals need professional development involving training, peer review and transparency of operations, something that is apparent from the experience of acute care hospitals. (While accreditation of facilities may be a useful and long overdue stage in the development of residential care facilities, it is unlikely to improve the quality of healthcare provided.) Educational institutions, expert groups and professional organisations need to form strategic partnerships to establish what is currently accepted best practice in residential care and where investment should be made in targeted research. Health professionals working in the residential care environment should be trained in dealing with people who have major disabilities. This particularly applies to general practitioners, who should be encouraged to acquire specific qualifications and rewarded by increased remuneration. We need to develop a multidisciplinary team approach to healthcare delivery in residential facilities. Appropriate agencies, such as governments and private health insurers, need to provide sufficient funding to support the level of professional care required. Medical practitioners and some other health professionals may be able to get expert support from regional aged care teams; however, these services are currently under considerable stress because their funding has not kept pace with the increasing number of older people requiring care.3 A wider role for geriatricians and psychogeriatricians in supporting these developments is crucial.9 There is no need for the widespread nihilism that has pervaded the issue of healthcare in residential facilities -- indeed, it has been shown that legislative changes10 and educational initiatives11 can decrease the rate of inappropriate psychotropic drug use in nursing home residents. Healthcare for people in residential care is provided not only by medical practitioners, but also by other professionals. The largest group of professional carers are nurses, for whom professional and best practice guidelines are similarly underdeveloped. For example, there are no guidelines specifying which of the available care strategies for people with dementia (such as validation therapy,12 reality orientation13 or reminiscence therapy14) works best, and for whom. Similarly, other healthcare workers, such as dentists, pharmacists and allied health practitioners, all need to pay special attention to this vulnerable section of the population. A recent survey of Adelaide dentists15 revealed that their interest in and provision of services to people in residential care were low and that dentists provided little educational assistance for staff of nursing homes. A concurrent survey of the needs of the residents found a high level of standard dental treatment needs, with the severely cognitively impaired residents having the highest incidence of oral disease.15 Clearly, a diverse range of best practice guidelines for the care of residents of nursing homes and hostels is needed, together with appropriate resources to implement them. It is sometimes argued that these residents have "reached the end of the road" and that further attention to their needs is unjustified. This argument is usually rejected by the very many Australians whose relatives and friends are housed in residential care. Perhaps more telling is the realisation that entry into residential care is a common occurrence in our society, and in fact any individual who lives to the age of 65 years has a 33% chance of requiring a nursing home bed during their remaining life and a 20% chance of requiring a hostel bed.3 It is in the interests of all members of society to provide more adequate healthcare in this challenging environment. Disclosure statement: No conflict of interest. References Kerin J. Care for aged: a kerosene dip. The Australian Feb 25, 2000: 5. Walker GJA, Johnstone PW. Interventions for treating scabies. The Cochrane Library. Issue 1. Oxford: Update Software, 2000. Updated quarterly. Gibson D, Benham C, Racic L, editors. Older Australia at a glance. Canberra: Australian Institute of Health and Welfare, 1999. (Catalogue No. AGE 12.) Henderson AS, Jorm AF. Dementia in Australia. Canberra: AGPS, 1998. Rosewarne R, Opie J, Bruce A, et al. Care needs of people with dementia and challenging behaviour living in residential facilities. Canberra: AGPS, 1997. Stuck AE, Siu AL, Wieland GD, et al. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993; 342: 1032-1036. McAllister NL, Hollander MJ. Seniors' perceptions of and attitudes towards the British Columbia continuing care system. Health Rep 1993; 5: 409-418. Byles JE. A thorough going over: evidence for health assessments for older persons. Aust N Z J Public Health 2000; 24: 117-123. Draper BM. Medical care in aged-care facilities: new directions. Med J Aust 1999; 171: 94-96. Hughes CM, Lapane KL, Mor V. Impact of legislation on nursing home care in the United States: lessons for the United Kingdom. BMJ 1999; 319: 1060-1063. Snowdon J. Follow-up survey of psychotropic drug use in Sydney nursing homes. Med J Aust 1999; 170: 299-301. Neal M, Briggs M. Validation therapy for dementia. The Cochrane Library. Issue 1. Oxford: Update Software, 2000. Updated quarterly. Spector A, Orrell M, Davies S, Woods B. Reality orientation for dementia. The Cochrane Library. Issue 1. Oxford: Update Software, 2000. Updated quarterly. Spector A, Orrell M, Davies S, Woods RT. Reminiscence therapy for dementia. The Cochrane Library. Issue 1. Oxford: Update Software, 2000. Updated quarterly. Australian Institute of Health and Welfare Dental Statistics and Research Unit. The Adelaide dental study of nursing homes. Research report. [Adelaide]: AIHW, October 1999. (Catalogue No. DEN 50.) Make a comment

Leon Flicker

Fitness And Health Physical activity and cardiovascular risk factors: effect of advice from an exercise specialist in Australian general practice Julie A Halbert, Christopher A Silagy, Paul M Finucane, Robert T Withers and Phil A Hamdorf MJA 2000; 173: 84-87 Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on General practice and primary care Abstract Objective: To determine whether provision of individualised physical activity advice by an exercise specialist in general practice is effective in modifying physical activity and cardiovascular risk factors in older adults. Design: Randomised controlled trial of individualised physical activity advice, reinforced at three and six months (intervention) versus no advice (control). Setting: Two general practices in Adelaide, South Australia, 1996. Participants: 299 adults aged 60 years or more who were healthy, sedentary and living in the community. Main outcome measures: Changes to physical activity (frequency and duration of walking and vigorous exercise), selected cardiovascular risk factors (blood pressure, body weight, serum lipid levels) and quality of life over 12 months. Results: Self-reported physical activity increased over the 12 months in both groups (P < 0.001). The increase was greater for the intervention than the control group for all measures except time spent walking (P < 0.05). More intervention than control participants increased their intention to exercise (P < 0.001). Serum levels of total and low-density lipoprotein cholesterol and triglycerides fell significantly over the 12 months to a similar extent in the two groups. No other significant changes in cardiovascular risk factors were seen. Quality-of-life scores decreased over the 12 months. The decrease was significantly greater among intervention than control women, but not men, for emotional well-being (P = 0.02), physical well-being (P = 0.04) and social functioning (P = 0.04). Discussion: Provision of general practice-based physical activity advice reinforced three-monthly produced a sustained increase in self-reported physical activity. However, there were no associated changes in clinical measures of cardiovascular risk factors and minimal changes in quality-of-life measures. A large body of evidence shows that all-cause mortality and death and disability from cardiovascular disease decrease with regular physical activity1 and physical fitness.2 Leisure-time activity also reduces coronary risk factors,3 and the greatest decrease is achieved by moving individuals from the sedentary, low-fitness category.4,5Among Australians aged over 60 years, 55% of men and 61% of women are not sufficiently active to maintain general health.6 Encouragingly, a Western Australian survey found that 93% of general practitioners (GPs) reported asking about physical activity when a patient presented with a condition that might benefit from exercise, and 50% asked new patients about current physical activity patterns.7 However, GPs comment on a lack of skill in assessing and guiding activity and a lack of guidelines.8 Although many believe referral to a qualified fitness professional is desirable, fewer than 15% make these referrals.9 Previous studies of interventions to increase provision of advice and patients' physical activity in primary care have had mixed results and are of varying methodological quality.10 To reduce the demand on GPs, several groups have examined the effectiveness of advice from practice staff. Results of advice from a health visitor were initially favourable but were not sustained,11 while advice from practice nurses produced no increases in objectively measured12 or self-reported13 exercise levels in the short term. Therefore, we designed a properly powered study to determine the effectiveness of individualised advice from an exercise specialist in a general practice setting on changing physical activity levels and cardiovascular risk factors at 12-month follow-up. Methods The study was a randomised, controlled trial. Ethics approval was granted by the Committee on Clinical Investigation, Flinders Medical Centre, Adelaide. Recruitment and baseline measures Sedentary adults aged 60 years or over who lived in the community were recruited from two general practices in the southern region of Adelaide, South Australia, in 1996, as described previously.14 Briefly, 2878 people who met the above criteria were invited to a screening appointment; 913 attended and completed a questionnaire on demographic characteristics, medical history, medication use and physical activity levels. Exclusion criteria included a cerebrovascular or ischaemic cardiac event in the previous six months, malignancy or other life-threatening disease, inability to comply with the requirements of the study, a condition for which physical activity was contraindicated, use of β-blocker medication, and regular physical activity, leaving 351 people eligible. These 351 were invited to attend a baseline appointment at which they signed a consent form and were randomly allocated to the intervention or control groups using sealed opaque envelopes. They also answered a written questionnaire about current physical activity levels, intention-to-exercise,15 quality of life (assessed by the Short Form 3616) and demographic information. Blood pressure, body weight and height were measured, and a blood sample was taken for lipid studies. Interventions Both groups had a 20-minute session with an exercise specialist (with a master's degree in exercise physiology; J A H). Spouses were invited to attend these and follow-up sessions, which were held at the participants' usual GP surgeries. The intervention group received individualised advice about the benefits of physical activity and a pamphlet containing a plan for physical activity for the next three months. This plan, based on current position statements,17,18 involved aerobic activities at moderate intensity for a minimum of three sessions per week for at least 20 minutes per session, with self-monitoring of heart rate. The exercise plan, potential barriers to exercise and strategies to overcome these were discussed. The focus was on incorporating physical activity into the individual's usual activities and on increasing "self-efficacy" (belief in one's ability to perform the activity) by recommending a preferred, familiar activity and setting modest targets for the first three months. These targets were to be progressively increased, depending on progress, enthusiasm and health. The control group received a pamphlet promoting good nutrition for older adults, which was discussed for 20 minutes. Follow-up At three and six months, all participants were mailed a follow-up questionnaire to be returned in a postage paid envelope (control participants) or at an interview (intervention participants). This interview was arranged by telephone, and intervention participants were encouraged to attend whatever their adherence to the exercise plan. Participants were also asked to complete a seven-day physical activity log as a prompt for discussion, which included physical activity levels and benefits, reasons for success or failure, injuries, heart-rate monitoring and changes to the plan. At 12 months, all participants were invited to a follow-up interview, at which they completed a questionnaire, and clinical characteristics (except height) were remeasured. Energy expenditure was measured for 59 participants (31 intervention and 28 control participants) over four days (two weekends and two weekdays) using a Caltrac portable, vertical accelerometer.19 These 59 were recruited by telephoning randomly selected participants until six volunteers per week were obtained (a total of 88 were telephoned). Statistical analyses Sample size calculations indicated that 212 people were required to detect a 5 mm Hg difference in systolic blood pressure between the intervention and control group using a parallel group design (assuming a power of 0.9 and type I error rate of 0.05). Targeting 300 subjects allowed for a 40% dropout and non-compliance rate. Assumptions for parametric analysis were investigated. Repeated-measures analyses of variance were used to examine data for physical activity and five quality-of-life scores, using time as the within-subject variable, and time, intervention and sex as the between-subject variables. As data for three quality-of-life scales (roles physical and emotional and social functioning) were non-continuous and skewed, they were dichotomised (score of 100 = 0, score < 100 = 1) and then analysed with generalised estimating equations -- an extension of generalised linear models -- to examine time, intervention and sex interactions.20 Twelve-month changes in clinical characteristics, quality-of-life and accelerometer results were analysed with Student's t tests (independent samples). Intention-to-exercise data were analysed with χ2 statistics. All data were analysed on an intention-to-treat basis. In the event of missing responses, data were entered at the previous follow-up, thereby assuming no change. Results Participants Of the 351 people eligible for the study, 299 attended the baseline interview and were randomised (149 to the intervention group and 150 to the control group). Their characteristics have been reported previously.14 There were no statistically significant differences between the intervention and control groups in age (mean age, 67.3 years [SD, 7.9 years] versus 67.8 years [SD, 5.5 years]), sex distribution (48% versus 44% men), current and past medical history and current medication use or clinical parameters at baseline (Box 1). Three- and six-month follow-up questionnaires were returned by 274 (92%) and 269 (90%) participants, respectively, while 264 (88%) attended the 12-month follow-up interview (123 in the intervention and 141 in the control group). Of the 35 who did not attend, two had died, six were on holidays, seven were ill, and 20 were not interested. There were no statistically significant differences in baseline clinical and sociodemographic measures between participants who attended the 12-month follow-up interview and those who did not. Physical activity At all three follow-ups, all self-reported measures of physical activity had increased significantly from baseline levels in both the intervention and control groups (P < 0.05; Box 2). However, the intervention group reported significantly more physical activity than the control group for all measures except time spent walking (P < 0.05). Men reported significantly more minutes of walking per session (P = 0.02) and more frequent vigorous exercise (P = 0.02) than women at all follow-ups. In addition, the difference in frequency of vigorous exercise between the intervention and control groups was significantly greater for men than for women (P < 0.001). Energy expenditure data were available for 59 participants who wore an accelerometer (31 intervention and 28 control participants). The intervention and control groups did not differ significantly in any measured parameter of energy expenditure -- total per day, per day as a percentage of total energy expenditure, during activity per day, or during activity per kg body weight. At all follow-ups, there were significant differences between the intervention and control groups for change in intention to exercise (P < 0.001). At 12-month follow-up, more intervention than control participants increased their intention to exercise (Box 3). Cardiovascular risk factors Over the 12 months, there were no statistically significant changes in body weight, resting heart rate, blood pressure or serum high-density lipoprotein levels in either the control or intervention group (Box 1). However, there were significant decreases in serum levels of total and low-density lipoprotein cholesterol and triglycerides in both groups; the decreases did not differ significantly between the two. In addition, body weight decreased for all men and for control-group women, but increased for intervention-group women (P = 0.01). Quality of life Quality-of-life scores decreased between baseline and 12-month follow-up in both the intervention and control groups. These score decreases were significant in both groups for bodily pain (P = 0.001), general health (P < 0.001), physical functioning (P < 0.001), vitality (P = 0.04) and role physical (odds ratio [OR], 1.80; 95% CI, 1.33-2.43). Women in the intervention group had significantly greater score decreases than women in the control group for the scales role emotional (P = 0.02), role physical (P = 0.04) and social functioning (P = 0.04). In addition, women reported worse scores at 12-month follow-up than men for bodily pain (P = 0.02), mental health (P = 0.03), physical functioning (P = 0.04) and vitality (P = 0.01), and were 1.5 times more likely to report some difficulty with role physical (OR, 1.43; 95% CI, 1.03-1.99) and social functioning (OR 1.53; 95% CI, 1.06-2.21). Discussion This randomised controlled trial showed that provision of physical activity advice by an exercise specialist was effective in increasing the intention to exercise and self-reported physical activity among patients 60 years and over in two general practices. Other studies have also found increased intention to exercise14 and increased physical activity levels12,21 as a consequence of physical activity advice. However, our study differs from most others in that it had a large number of participants and high retention rate (88% at 12 months), and calculated results on an intention-to-treat basis. The high retention rate possibly resulted from participants' strong association with their GPs, who were aware and possibly encouraging of their participation, and the fact that all visits were conducted at the GPs' practices. The success of the intervention may be attributed to the enthusiastic volunteer population, who, while sedentary, were keen to start regular activity. Another possible contributor was the strong emphasis on walking as the preferred activity. The physical activity advice had the characteristics of successful physical activity interventions -- a home-based program, comprising unsupervised, informal exercise (generally walking), of moderate intensity and comparatively low frequency (which is associated with better maintenance), as well as frequent professional contact.22 The major limitation of this study was its reliance on self-report, as patients over 65 years tend to overestimate their physical activity.12 The number of participants and limited resources precluded general use of more objective measures of physical activity or fitness. Objective measurements of energy expenditure by accelerometer in 59 volunteers did not detect a difference between the control and intervention groups, possibly because of the small sample size. Other possible reasons are that people in each group who had established regular physical activity volunteered preferentially for accelerometer measurement, or that the self-reported increase in physical activity in the intervention group was not real. We were also unable to detect any differences between the intervention and control groups in cardiovascular risk factors after 12 months. This is consistent with results of others. For example, patients referred by their GPs to a local leisure centre had increased self-reported physical activity after 37 weeks, but no changes in systolic or diastolic blood pressures or body mass index.23 In our study, the increase in self-reported physical activity in the intervention group was possibly not large enough to increase physical fitness. Previous investigators have shown that cardiovascular risk factors are more strongly related to physical fitness than to physical activity,4,5and that, in individuals with low levels of fitness, increased physical activity without a change in fitness does not modify cardiovascular risk factors.24 Further, although the difference in physical activity between the intervention and control groups reached statistical significance, it was modest in absolute terms. Finally, all participants remained under the usual care of their GPs, who were free to initiate or cease prescribing medications that might modify cardiovascular risk factors. We found declines in quality of life from baseline to 12 months in both groups, with the greatest change in the first three months. We hypothesise that quality of life was more accurately reported at three months than at baseline, when scores were much higher than the Australian norms for the participants' age. It is possible that participants were initially keen to present themselves as healthy in all respects or that they were expressing high hopes for the study. In conclusion, this study showed that, for a specific population of general practice patients, providing physical activity advice three-monthly for six months resulted in increases to both self-reported physical activity and intention to exercise, which were maintained at 12-month follow-up. Further research in primary care is needed to determine whether these changes apply to other groups and whether they confer significant health benefits. Acknowledgements This project was funded by a Public Health Research and Development Project Grant from the National Health and Medical Research Council and Department of Health, Housing, Local Government and Community Services. We wish to thank the GPs and staff from Blackwood and Flinders Clinics, Adelaide, SA, for their assistance and Lynne Giles (Flinders University, Adelaide, SA) for statistical advice. Conflict of interest: None. References Paffenbarger RS, Hyde RT, Wing AL, et al. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. N Engl J Med 1993; 328: 538-545. Blair SN, Kohl HW, Paffenbarger RS, et al. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA 1989; 262: 2395-2401. Folsom AR, Caspersen CJ, Taylor HL, et al. Leisure time physical activity and its relationship to coronary risk factors in a population-based sample. Am J Epidemiol 1985; 121: 570-579. Eaton CB, Lapane KL, Garber CE, et al. Physical activity, physical fitness and coronary heart disease risk factors. Med Sci Sports Exerc 1995; 27: 340-346. Lochen M-L, Rasmussen K. The Tromso study: physical fitness, self-reported physical activity, and their relationship to other coronary risk factors. J Epidemiol Community Health 1992; 26: 103-107. Active Australia. Physical activity levels of Australians. Results of the Active Australia baseline survey 1997. Available at <www.ausport.gov.au/ partic/actozfr.html> Bull FCL, Schipper ECC, Jamrozik K, Blanksby BA. Beliefs and behaviour of general practitioners regarding promotion of physical activity. Aust J Public Health 1995; 19: 300-304. Murphy B, Ruth D. GPs role in CVD Prevention. A report on focus group discussions with general practitioners for the RISK study in general practice. Melbourne: Monash University, 1991. Bull FCL, Schipper ECC, Jamrozik K, Blanksby BA. How can and do Australian doctors promote physical activity? Prev Med 1997; 26: 866-873. Eaton CB, Menard LM. A systematic review of physical activity promotion in primary care settings. Br J Sports Med 1998; 32: 11-16. Harland J, White M, Drinkwater C, et al. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care. BMJ 1999; 319: 828-832. Sims J, Smith F, Duffy A, Hilton S. The vagaries of self-report of physical activity: a problem revisited and addressed in a study of exercise promotion in the over 65s in general practice. Fam Prac 1999; 16: 152-157. Simmonds GJ, Naylor P-J, Riddoch CJ, Velleman G. Stage-based counselling for exercise in primary care -- a controlled trial. Presented at the Scientific Basis of Health Services Conference. 1995 Oct; London. Halbert JA, Silagy CA, Finucane P, et al. Recruitment of older adults for a randomized, controlled trial of exercise advice in a general practice setting. J Am Geriat Soc 1999; 47: 477-481. Marcus BH, Banspach SW. Using the stages of change model to increase the adoption of physical activity among community participants. Am J Health Promot 1992; 6: 424-429. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 health survey manual and interpretation guide. Boston: New England Medical Center, 1993. National Institutes of Health Consensus Development Panel on Physical Activity and Cardiovascular Health. Physical activity and cardiovascular health. JAMA 1996; 276: 241-246. American College of Sports Medicine. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Position Stand. Med Sci Sports Exerc 1990; 22: 265-274. Jacobs DR, Ainsworth BE, Hartman TJ, Leon AS. A simultaneous evaluation of 10 commonly used physical activity questionnaires. Med Sci Sports Exerc 1993; 25: 81. Liang K-Y, Zeger S. Longitudinal data analysis using generalized linear models. Biometrika 1986; 73: 13-22. Stevens W, Hillsdon M, Thorogood M, McArdle D. Cost-effectiveness of a primary care based physical activity intervention in 45-74 year old men and women: a randomised controlled trial. Br J Sports Med 1998; 32: 236-241. Hillsdon M, Thorogood M, Anstiss T, Morris J. Randomized controlled trials of physical activity promotion in free living populations: a review. J Epidemiol Community Health 1995; 49: 448-453. Taylor AH, Doust J, Webborn N. Randomised controlled trial to examine the effects of a GP exercise referral programme in Halisham, East Sussex, on modifiable coronary heart disease risk factors. J Epidemiol Community Health 1998; 52: 595-601. McMurray RG, Ainsworth BE, Harrell JS, et al. Is physical activity or aerobic power more influential on reducing cardiovascular disease risk factors? Med Sci Sports Exerc 1998; 30: 1521-1529. (Received 4 Feb, accepted 4 May, 2000) Authors' details Department of Rehabilitation and Aged Care, Flinders University of South Australia, Adelaide, SA. Julie A Halbert, MSc, Research Manager; Paul M Finucane, FRCPI, FRACP, Head. Monash Medical Centre, Melbourne, VIC. Christopher A Silagy, PhD, FRACGP, FAFPHM, Head of Institute of Public Health and Health Services Research. School of Education, Flinders University of South Australia, Adelaide, SA. Robert T Withers, PhD, FASMF, FACSM, Senior Lecturer in Rehabilitation. Hampstead Centre, Royal Adelaide Hospital, Adelaide, SA. Phil A Hamdorf, PhD, Head of Centre for Physical Activity in Ageing. Reprints will not be available from the authors. Correspondence: Ms J A Halbert, Department of Rehabilitation and Aged Care, Repatriation General Hospital, Daw Park, SA 5041. julie.halbertATflinders.edu.au Make a comment 1: Clinical measures at baseline and 12-month follow-up (mean and 95% confidence interval) Control group (n=150) Intervention group (n=149) Baseline 12 months Baseline 12 months Body weight (kg) Height (cm) Resting heart rate (bpm) 74.0 (71.8-76.1) 165.8 (164.4-167.2) 71.3 (69.7-72.9) 73.6 (71.5-75.8) ND 71.6 (70.0-73.2) 75.9 (73.8-78.0) 166.9 (165.5-168.4) 70.9 (69.1-72.6) 76.0 (73.9-78.1) ND 71.1 (69.6-72.6) Blood pressure (mm Hg) Systolic Diastolic 148.1 (145.1-151.0) 85.7 (84.2-87.1) 146.6 (143.4-149.6) 86.3 (84.9-87.7) 148.6 (145.9-151.4) 85.6 (84.1-87.1) 147.4 (144.4-150.5) 86.1 (84.6-87.7) Serum levels (mmol/L) Total cholesterol Triglycerides HDL cholesterol LDL cholesterol 5.88 (5.73-6.03) 1.64 (1.50-1.78) 1.34 (1.27-1.40) 3.81 (3.67-3.95) 5.70 (5.55-5.85)* 1.57 (1.43-1.70)* 1.34 (1.28-1.41) 3.65 (3.52-3.80)* 5.85 (5.68-6.02) 1.70 (1.50-1.89) 1.30 (1.24-1.37) 3.78 (3.65-3.95) 5.63 (5.47-5.80)* 1.57 (1.42-1.73)* 1.29 (1.23-1.35) 3.64 (3.50-3.79)* *Significant decrease from baseline level (P<0.05). HDL=high-density lipoprotein. LDL=low-density lipoprotein. ND=measurement not done. Back to text 2: Self-reported physical activity at baseline and follow-up (median value and 25th-75th percentile) Control group (n=150) Intervention group (n=149) Baseline 3 months 6 months 12 months Walking Frequency (sessions/week) Time (mins/session) 0 (0-2) 0 (0-20) 2 (0-3)* 30 (0-49)* 2 (0-4)* 30 (0-60)* 2 (1-3)* 30 (10-60)* Vigorous exercise Frequency (sessions/week) Time (mins/sessions) 0 (0-0) 0 (0-0) 0 (0-1)* 0 (0-16)* 0 (0-2)* 0 (0-21)* 0 (0-1)* 0 (0-15)* Walking Frequency (sessions/week) Time (mins/session) 0 (0-1) 0 (0-25) 3 (1-4)*† 30 (19-50)* 3 (2-4)*† 30 (20-60)* 3 (1-4)*† 30 (10-60)* Vigorous exercise Frequency (sessions/week) Time (mins/sessions) 0 (0-0) 0 (0-0) 2 (0-3)*† 20 (0-35)*† 2 (0-3)*† 20 (0-40)*† 2 (0-3)*† 20 (0-35)*† *Statistically significant increase from baseline level (P<0.05). †Values significantly higher than for control group (P<0.05). Back to text Back to text

Julie A Halbert · Christopher A Silagy · Paul M Finucane · Robert T Withers · Phil A Hamdorf

Fitness And Health Healthy ageing: what role can physical activity play? Adrian E Bauman and Ben J Smith MJA 2000; 173: 88-90 Moderate activity is clearly beneficial for elderly people and should be actively promoted by general practitioners Epidemiological evidence - Strength, flexibility and prevention of falls in the elderly - Special needs of the frail elderly - Implications for practice - References - Authors' details - - More articles on General practice and primary care In an ageing Australia, important approaches to spiralling healthcare costs are primary and secondary prevention. The second most important area for risk factor reduction, after tobacco use, is physical inactivity, in terms of its contribution to the overall burden of disease for Australia.1 This applies equally to older patients and to the general community. Recent evidence, summarised in the 1996 United States Surgeon General's Report and elsewhere, has identified consistent epidemiological evidence for health benefits of physical activity at least as great as treating hypertension or cholesterol reduction.2,3Nonetheless, physical activity remains a poor relation in population disease prevention. In contrast to exponential increases in the volume of research in exercise science or broader disease prevention, research into physical activity in the elderly has remained quite static over recent decades.4 Our purpose was to review the available evidence for health benefits of physical activity among older adults. A summary of our key points is given in the Box. Epidemiological evidence The benefits of regular moderate physical activity are now acknowledged internationally.2,3 Health benefits for older adults are mostly similar to those for the general community: there is evidence of reduced risk of all-cause mortality and reduced rates of coronary heart disease among moderately active elderly men and women.2Population studies in diverse cohorts (such as 40 000 Iowan postmenopausal women and 472 elderly Dutch men) report similar findings -- a graded dose-response relationship between activity and all-cause mortality and coronary heart disease deaths.5,6 A South Australian study identified a mortality risk 74% greater in elderly people who were completely sedentary, compared with the (mostly moderately) active.7 Further, even those aged over 60 years who change from being sedentary to engaging in at least moderate levels of activity accrue a clear health benefit.8 New findings repeatedly confirm that aerobic or vigorous activities are not essential for these cardiovascular benefits. For those who are sedentary, accumulating half an hour of moderate activity on most days of the week seems sufficient. This finding is replicated across studies which adjust for other risk factors and for clinical comorbidity, and which measure physical activity in diverse ways. This notion is particularly important for older adults, where adherence to physical activity will be much more likely if they perceive they are capable of performing the activity, such as moderate walking.9 There is good evidence that regular moderate activity protects against the development of diabetes in populations quite independent of body weight.2,3,10 Up to half of people with diabetes are completely sedentary,11 presenting a further clinical opportunity for secondary prevention, as physical activity is part of optimal management. Moderate physical activity may also reduce the risk of ischaemic stroke in the elderly,12 and there is clear evidence, pooled across almost 30 studies, that physical activity reduces colon cancer risk, and may have a role in reducing breast cancer incidence in postmenopausal women.2,3 In addition, physical activity is recognised as being associated with improved mental health, and is a clinical approach to mild anxiety and depression.2 Cohort studies in the elderly show that more active people have a reduced risk of developing depression, and are more likely to maintain wellbeing.13 Clinical data suggest that moderate exercise regimens are anxiolytic, but that vigorous activity may have less effect, or even be counterproductive, among older adults. Finally, the quality and duration of sleep may be improved by activity, both for those living in the community14 and for nursing home residents.15 One important idea raised by the epidemiological literature is the notion of "compression of morbidity". Population studies suggest that the "disability-free years" can be increased in people who remain active,16 and that overall healthy lifestyles could postpone disability by up to five years.17 This has ramifications for improved functional status and quality of life. The concept of risks versus benefits of activity is worth exploring. The transient increases in the risk of acute cardiac events and sudden death following bouts of vigorous activity are not found for moderate activity, and overall, even for vigorous activity, the benefits outweigh the risks. This provides further support for encouraging moderate activity in middle-aged and older adults. Strength, flexibility and prevention of falls in the elderly Physical activity is commonly seen as a means of maintaining strength and vigour, and staving off the functional declines of ageing. Muscle strength is closely related to functional capacity, and has consistently been found to improve as a result of progressive resistance training.18 Resistance training techniques include using gymnasium equipment and elastic tubing, home-based exercise and even walking. Strength-building programs have additional benefits, such as improving mobility and balance and aiding in weight maintenance. Physical activity can help improve balance. This in turn helps older people by improving mobility and functional capacity, and reducing the risk of falls and injuries. Regular, gentle exercise classes, involving aerobic, strength, balance and coordination activities, improve balance when undertaken twice weekly over 12 months.19 Even a supervised program of gentle exercise such as tai chi may help to maintain balance.20 Flexibility is another domain of physical performance that is necessary for daily activities such as climbing stairs, rising from a chair or bed, or walking. The evidence is less clear here, but some studies have shown yoga and flexibility training, supervised aerobics classes and walking and upper-body training can benefit flexibility.21 Two key public health issues related to these areas of physical functioning are osteoporosis, and falls and injuries. Some studies indicate that older people who have stayed active have significantly lower losses of bone mineral density than their sedentary counterparts. However, as bone mineralisation is completed by late adolescence, strategies later in life may have less of a role in preventing osteoporosis. The American College of Sports Medicine concluded that functional loading through physical activity exerts a positive influence on bone mass, but that the types of program that may be most effective in producing beneficial results are still uncertain.21 Physical activity is a beneficial component of falls prevention, because of its effects on muscle strengthening and balance, and possibly on bone density. In the meta-analysis of the seven Frailty and Injuries Cooperative Studies Intervention Trials (FICSIT), participation in an exercise program was found to reduce the risk of falling, although some programs were supplemented by education and other interventions.22 The Cochrane review also found that activity had a beneficial role, particularly when supplemented by additional measures such as medications review and home modification among elderly people identified as at risk of falling.23 Many of these studies used supervised rather than at-home exercise interventions. Special needs of the frail elderly Initiating activity programs is more problematic in the frail elderly or in those with multiple comorbidities. This group may require medical screening and assessment before they begin. The frail elderly have typical problems that may make physical activity more difficult. Many may benefit from more moderate or even light activities; many of these can be carried out in residential settings and community centres. Apart from walking programs, other locally based interventions to improve mobility, increase strength and improve balance can be implemented and achieve improvements in this age group.15,21 In addition to strength training, working to reduce polypharmacy, and making residential environments more physical activity friendly are also important. A recent controlled trial has identified positive outcomes of intensive exercise and resistance training among 100 hostel residents with a mean age of 87 years -- even in this frail elderly group physical activity, gait velocity and muscle strength improved.24 Implications for practice There are two quite distinct forms of recommendation for physical activity. One is the opportunistic recommendation for regular walking and moderate activity for all adults to prevent chronic disease; the other focuses on strength, mobility and balance, and has quality-of-life and falls prevention benefits among older age groups, but may require more intensive program attendance. Recommending physical activity to people over 65 is cost effective,25 and a worthwhile part of many patient encounters in general practice. The counselling objectives are to identify achievable, moderate activities, increase confidence among patients that they can perform the activity, and highlight the importance of these activities in delaying disability. It is useful to know about local programs for referring patients to, and to encourage people to exercise with someone else. A New Zealand study identified general practice-based advice as being more effective if focused on written "exercise prescriptions" rather than verbal advice alone.26 However, it is not easy to train doctors to promote physical activity to the elderly,27 and other strategies may support this process. Given the time constraints of practice, allied health professionals may provide specialised counselling in this area. Another New Zealand study ascertained lower rates of falls among women aged over 80 years who were referred to a physiotherapist for an exercise intervention delivered through general practice.28 These improvements were maintained even at two years of follow-up. In a Victorian controlled trial, education of practitioners, extensive GP advice and home follow-up increased physical activity time per week among patients aged at least 65 years.29 Further, in this issue of the Journal, Halbert and colleagues show that having a qualified exercise scientist in the GP's surgery to provide detailed advice and exercise plans provided a sustained increase in self-reported physical activity.30 Thus, adjunctive methods like these may enhance the range of health outcomes, and achieve more than GP advice alone. It appears that many of the benefits of activity are reasonably acute, and it may be recent physical activity which confers many of the chronic disease and musculoskeletal benefits.21,31 Hence the advice "use it or lose it" should be as prevalent as antismoking messages. Given the credibility with which doctors' advice about exercise in older adults is perceived in the general community,32 each consultation presents an important -- and possibly overdue -- opportunity for promoting health to older adults. References Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. AIHW publication PHE 17. Canberra: Australian Institute of Health and Welfare, 1999. US Surgeon General's Report. Physical activity and health. Atlanta, Ga: US Department of Health and Human Services, Centers for Disease Control, 1996. Bauman A, Owen N. Physical activity of adult Australians: epidemiological evidence and potential strategies for health gain. J Sci Med Sport 1999; 2: 30-41. Lidor R, Miller U, Rotstein A. Is research on aging and physical activity really increasing? A bibliometric analysis. J Aging Physical Activity 1999; 7: 182-195. Bijnen FCH, Feskens EJM, Caspersen CJ, et al. Baseline and previous physical activity in relation to mortality in elderly men -- The Zutphen Elderly Study. Am J Epidemiol 1999; 150: 1289-1296. Kushi LH, Fee RM, Folsom AR, et al. Physical activity and mortality in post-menopausal women. JAMA 1997; 277: 1287-1292. Finucane P, Giles LC, Withers RT, et al. Exercise profile and subsequent mortality in an elderly Australian population. Aust N Z J Public Health 1997; 21: 155-158. Blair SN, Kohl HW, Barlow CE, et al. Changes in physical fitness and all cause mortality: a prospective study of healthy and unhealthy men. JAMA 1995; 273: 1093-1098. Kriska A. Physical activity and the prevention of type 2 diabetes mellitus. How much for how long? Sports Med 2000; 29: 147-151. Hu FB, Sigal RJ, Rich-Edwards JW, et al. Walking compared with vigorous physical activity and risk of type 2 diabetes in women. A prospective study. JAMA 1999; 282: 1433-1439. Hays LM, Clark DO. Correlates of physical activity in a sample of older adults with type 2 diabetes. Diabetes Care 1999; 22: 706-712. Wannamethee SG, Shaper AG. Physical activity and the prevention of stroke. J Cardiovasc Risk 1999; 6: 213-216. Morgan K, Bath PA. Customary physical activity and psychological wellbeing: a longitudinal study. Age Ageing 1998; 27 Suppl 3: S35-S40. King AC, Oman RF, Brassington GS, et al. Moderate intensity exercise and self rated quality of sleep in older adults. A randomised controlled trial. JAMA 1997; 277: 32-37. Alessi CA, Yoon EJ, Schnelle JF, et al. A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve? J Am Geriatr Soc 1999; 47: 784-791. Leveille SG, Guralnik JM, Ferrucci L, Langlois JA. Aging successfully until death in old age: opportunities for increasing active life expectancy. Am J Epidemiol 1999; 149: 654-664. Vita PJ, Terry RB, Hubert HB, Fries JF. Aging, health risks, and cumulative disability. N Engl J Med 1998; 338: 1035-1041. Healthy ageing and physical activity. State Health Publication No. (HP) 980195. Sydney: New South Wales Health Department,1999. Lord S, Ward J, Williams P, Strudwick M. The effect of a 12-month exercise trial on balance, strength, and falls in older women: a randomised controlled trial. J Am Geriatr Soc 1995; 43: 1198-1206. Wolfson L, Whipple R, Derby C, et al. Balance and strength training in older adults: intervention gains and Tai Chi maintenance. J Am Geriatr Soc 1996; 44: 498-506. American College of Sports Medicine. Position stand on exercise and physical activity for older adults. Med Sci Sports Exercise 1998; 30: 992-1008. Province M, Hadley E, Hornbrook M, Lipsitz L. The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials. JAMA 1995; 273: 13411-1347. Gillespie L, Gillespie W, Cumming R, et al. Interventions to reduce the incidence of falling in the elderly. Cochrane Database Systematic Reviews 1998; 3. Fiatarone MA, O'Neill EF, Ryan ND, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med 1994; 330: 1769-1775. Munro J, Brazier J, Davey R, Nicholl J. Physical activity for the over 65s: could it be a cost effective exercise for the NHS? J Public Health Medicine 1997; 19: 397-402. Swinburn B, Walter LG, Aroll B, et al. The green prescription study: a randomised controlled trial of written exercise advice provided by general practitioners. Am J Public Health 1997; 88: 288-291. Eckstrom E, Hickam DH, Lessler DS, Buchner DM. Changing physician practice of physical activity counselling. J Gen Intern Med 1999; 14: 376-278. Campbell AJ, Robertson CM, Gardner MM, et al. Falls prevention over two years: a randomised controlled trial in women aged over 80 years. Age Ageing 1999; 28: 513-518. Kerse NM, Flicker L, Jolley D, et al. Improving the health behaviours of elderly people: randomised controlled trial of a general practice education programme. BMJ 1999; 319: 683-687. Halbert JA, Silagy CA, Finucane PM, et al. Physical activity and cardiovascular risk factors: effects of advice from an exercise specialist in Australian general practice. Med J Aust 2000; 173; 85-87. Sherman SE, D'Agostino RB, Silbershatz H, Kannel WB. Comparison of past versus recent physical activity in the prevention of premature death and coronary artery disease. Am Heart J 1999; 138: 900-907. Booth M, Bauman A, Owen N, Gore C. Physical activity preferences and sources of assistance, and perceived barriers to increase activity among physically inactive Australians. Preventive Med 1997; 26: 131-137. Authors' details School of Community Medicine, University of New South Wales, Sydney, NSW. Adrian E Bauman, FAFPHM, PhD, Professor of Public Health and Epidemiology, School of Community Medicine, University of New South Wales. National Centre for Health Promotion, University of Sydney, NSW. Ben J Smith, MPH, Research Assistant. Reprints will not be available from the authors. Correspondence: Professor A E Bauman, Epidemiology Unit, Locked Bag 7017 Liverpool BC, NSW 1871. Make a comment Evidence for physical activity and exercise promotion in the elderly Evidence for: Level of evidence Comments Decreased incidence of and mortality from cardiovascular disease and diabetes with moderate activity Level III Replicated across many well designed population-based cohort studies Decreased incidence of falls in the elderly who engage in regular physical activity Level I and II Some systematic review data, several individual randomised controlled trials; needs resistance training, as well as training for balance and gait Improved functional status and quality of life in the elderly who engage in regular physical activity Level II and III Some randomised controlled trials for functional status; mostly observational (cohort) studies for quality of life Benefit of counselling and advice for moderate physical activity from general practitioners Level II Several randomised controlled trials but effects are modest; may be better if written advice is given, and if allied health professionals are involved Back to text

Adrian E Bauman · Ben J Smith

Changing Healthcare Complementary therapies: the appeal to general practitioners Heather L Eastwood MJA 2000; 173: 95-98 Abstract - Reasons for GPs' use of CAM - Clinical legitimacy - Ideological motivations - Postmodernisation - Postmodern values - References - Authors' details - - More articles on General practice and primary care Abstract Pragmatism -- among consumers seeking a cure and among general practitioners seeking clinical results and more patients -- is not a complete explanation for the burgeoning of complementary and alternative medicine (CAM) in Western societies. Instead, this growth is substantially a result of pervasive and rapid social change, alternatively termed 'globalisation' and 'postmodernisation'. Globalisation and postmodernisation are creating a new social reality, of which a prominent characteristic is the proliferation of consumer choice. GPs are enmeshed in this social change and subject to the trend to greater choice -- both their patients' and their own. On the one hand, GPs are reacting to social change as "economic pragmatists", responding to consumers' increasing demand for CAM. On the other hand, GPs themselves are acting as agents of social change by acknowledging the limitations of orthodox biomedical treatments and promoting CAM as part of their service delivery. Lack of scientific validation of CAM has not prevented GPs' use of such therapies. The phrase "clinical legitimacy" can be seen as a trump card that overrides "scientific legitimacy". It is the shibboleth of a postmodern movement among GPs towards healing and the "art" of medicine, as opposed to the "science" of medicine per se. Recent articles and editorials in the Journal1-3 have highlighted the increasing demand for complementary and alternative medicine (CAM) by Australians, and its provision by general practitioners (GPs). The findings of Pirotta et al that 1 in 5 Victorian GPs are using CAM in their practice1 support earlier data of the Royal Australian College of General Practitioners that 1 in 6 Australian GPs employed some form of CAM.4 A secondary analysis of Health Insurance Commission data indicates that about 1 in 7 GPs in Australia use acupuncture.5 CAM is a billion-dollar industry in Australia, and a multibillion-dollar industry globally.6-8 Pirotta and others have emphasised the need for further research into the reasons behind GPs' use of CAM. Reasons for GPs' use of CAM My research in this area -- a qualitative study involving GPs and alternative practitioners (see Box) -- produced two main explanations for the increasing use by GPs of CAM.9 The first is that GPs are responding to increasing consumer demand for these therapies because of their clinical success. The second and more contentious finding is that consumers are demanding, and GPs are using, these therapies because of factors beyond clinical success -- factors related to globalisation and the characteristics of the global market. These market characteristics include increased consumer choice,10 increased competition among providers, a resultant power shift from provider to consumer,11 and a return to and commercialisation of nature, history, and tradition.12The GPs I interviewed cited reasons for incorporating CAM into their practices that fall into three broad categories:13 Last resort: The use of or referral to practitioners of CAM to treat patients with chronic conditions unresponsive to orthodox medicine. Integrated approach: A considered choice to regularly incorporate CAM, in addition to orthodox biomedical therapies. Ideological conversion: The adoption of CAM as the main treatment practice. GPs who fall into this category also tend to use diagnostic techniques similar to those of alternative practitioners.13 The prevalence of the last two categories, at least among the GPs I have interviewed formally and conversed with informally, contradicts the conclusion by Bensoussan, in a Journal editorial,3 that simple pragmatism -- among both patients and doctors -- adequately accounts for the dramatic increase in the use of CAM. Clinical legitimacy Bensoussan, rightly and with apt humour, criticises recent articles that narrowly attribute patient demand for CAM to "postmodern" or "new age" values usurping scientific rationalism. He notes that a considerable segment of the medical profession has recognised this consumer demand, and that chronic sufferers and the elderly account for a large portion of the patients who request or accept CAM. He suggests that common sense indicates that medical practitioners, the elderly, and the chronically ill are not likely to embrace the naivety of "new age" thought or the jargonistic obscurity of postmodernism;3 instead, Bensoussan and others suggest that simple pragmatism among both doctors and patients provides a more satisfactory explanation for the dramatic increase in the use of CAM.3,14Other writers have coined the term "clinical legitimacy" (see Glossary) to explain the links among consumer demand, pragmatism, and increased GP provision of CAM. That is to say, CAM is effective, particularly in the treatment of chronic conditions, regardless of the lack of scientific explanation or validation. This clinical success, aside from gratifying both patient and doctor, ensures continuing consumer demand, and thereby increases the financial viability of GPs who incorporate CAM, whether directly or through referrals.14 Data from my research show that GPs acknowledge that, regardless of the deficit of scientific evidence for how or why, CAM does achieve clinical results. Ideological motivations GPs note that, in addition to being pragmatic, their patients want healthcare options, and some are indeed ideological in their increasing demand for "natural" therapies and their concomitant mistrust of pharmaceuticals and invasive surgery, a phenomenon described by one GP interviewed as the "greening of medicine".9GPs who offer CAM are keenly aware of this demand for "natural" therapy, and clearly do respond partly as pragmatists catering to consumer demand. However, my interviews reveal that GPs are not acting entirely as economic rationalists responding to market forces. GPs who resort to CAM, like their patients, are often ideological in their motivations. Many are genuinely disillusioned with their biomedical training and with the reality of general practice. They are genuinely seeking a more rewarding approach to primary healthcare, for themselves as well as their patients. For example, some GPs recommend CAM even to patients who prefer or expect synthetic drugs -- a practice described by one doctor interviewed as "good medicine", particularly in light of antibiotic overprescribing.13 Therefore, while my findings validate the roles of both therapeutic and market pragmatism in the increasing use of CAM by Australian GPs, these same findings suggest that this increase involves factors beyond simple pragmatism. The interview data support the sociological hypothesis that a broad cultural shift is occurring in late capitalist societies such as Australia, the United States, the United Kingdom and Western Europe, and GPs, like consumers, are not immune to this sweeping social change.15-17 Arguably, GPs who use CAM are not just influenced by this social change, they contribute to it. Postmodernisation Social scientists use the term postmodernisation -- which incorporates globalisation processes -- to designate fundamental changes occurring within Western societies, of which the inclusion of CAM into mainstream healthcare is a part. Bensoussan notes that factors in the globalisation processes include: increasing public access to information; increasing sensitivity towards traditional cultural practices; and increasing openness to traditional medicines, for example traditional Chinese medicine.3Another aspect of globalisation is concern about the ecological crisis, which has contributed to a "return to nature" within Western societies. Postmodernisation theorists point to this trend -- the return to nature -- as a key determinant in the historical shift from modernity to postmodernity. The return to "natural" medicines is a part of this trend and of globalisation processes generally.18 In Western societies, the effects of globalisation, along with the postmodernist movement, are creating a new social reality (ie, postmodernity), one that has created a greater awareness and, for some, greater appreciation of other cultures, which historically have used traditional medicines.12 Postmodernism has attacked the philosophical foundations that underpin the modernist worldview, including the belief that science, particularly medical science, holds the key to a utopian world "free of disease and inequality".19 All the GPs and alternative practitioners I interviewed advocated more scientific research into CAMs. However, the effects of globalisation processes and postmodernism are contributing to a new, relativistic, postmodernist worldview whereby both doctors and consumers see biomedicine as only one road to health and wellbeing -- not necessarily a dead-end road, but also not a freeway.9 Postmodern values Bensoussan rightly critiques facile resorts to postmodernism to portray increased consumer demand for CAM as a rejection of medical science in favour of individualist, "new age" values.3 Yet he and others fail to recognise adequately that the process of postmodernisation contributes to the rise of new values, values that are no longer an "alternative ideology" but are increasingly mainstream values. Moreover, CAM is being commercialised and aggressively marketed, an outcome predicted by globalisation and postmodernisation theory,12,18,20 and a far cry from a starry-eyed conversion to "new age" values.3 Benoussan notes that one does not have to adopt postmodern values to use CAM, but rather that we live in an age in which people shop around for healthcare services.3 No doubt this is true, but increased consumer choice -- the ability to shop around -- is itself a postmodern value. A fundamental premise of postmodernisation theory is that globalisation and the commercialisation of traditional culture, including healthcare, increases diversity in the market place and thereby increases consumer options.10,12,20 Market forces aside, a surprising number of the GPs interviewed were openly critical of their biomedical training and their perceived role in general practice as "technocrats" rather than "healers". As a result, GPs are seeking new avenues of specialisation and professional development. To reiterate, GPs who offer CAM are, like their patients, not only pragmatic but also ideological in their incorporation of CAM. Many of these GPs acknowledge the limitations of biomedical and synthetic pharmaceutical treatments. The lack of scientific evidence for CAM does not appear to have constrained these developments. In fact, my research revealed that GPs often legitimise their use of CAM -- in addition to citing clinical legitimacy -- by citing the history and tradition underlying these treatments.9 This return to tradition, history, and roots is a prominent aspect of postmodernisation.12,18 It is of considerable interest that the Australian Therapeutic Goods Administration has specified two major categories of evidence for complementary therapies: (1) scientific evidence, and (2) evidence based on traditional use of a substance or product.21 Despite the obvious weakness of much "postmodernist" literature on CAM, to dismiss postmodern theory outright is limiting and misleading. The following may serve to illustrate the effect of globalisation and postmodernisation upon Western health systems. Remarkably, these comments come from a GP who attended the Alternative Medicines Summit (organised by the Commonwealth Department of Health and Family Services) held in Canberra on 16 October 1996. This summit, the first of its kind, was attended by medical as well as alternative practitioners. In reporting events, the representative for the medical practitioners wrote: I felt the tone of the day's proceedings was one of "us versus them". Inasmuch as "natural and complementary practitioners" were seen as a distinct alternative to orthodox practitioners, particularly in cases of serious illnesses. Indeed, one speaker during the day indicated that as it was an Alternative Medicines Summit, orthodox doctors present should really be in only an observer capacity. There was no integration going on, rather the attitude was one of them seeking status as practitioners of the "new medicine", and control of their therapies.22 Note the dramatic contrast to the relationship between orthodox and alternative medical practice in modernity. Orthodox doctors are now concerned about being excluded from the "new medicine" practised by alternative practitioners rather than vice versa. The same doctor went on to conclude: There is a paradigm shift, occurring in health from within, that reflects a societal evolution, unstoppable by anyone. How to integrate all these practitioners, or even if it is desirable to, is a question that still perplexes me. There seems to be no one universal model, thus it becomes an exercise in lobbying for market share, and seeking, for example, inclusion in Medicare.22 With all due respect to common sense, simple pragmatism and clinical legitimacy, this type of sea change requires globally informed, forward-looking sophistication in the area of policy. For example, Duckett has noted that Australian health financing arrangements have not kept pace with a population that is embracing natural therapies. He opines that, as a society, "we may be over-investing in services for which there is a Medicare rebate and under-investing in other more effective or cost-effective services".23 Within the climate of evidence-based medicine, this observation invites the controversial question Based on evidence, who achieves the more cure-effective and cost-effective results: GPs who use exclusively orthodox treatments, GPs who incorporate CAM, or traditionally trained practitioners who use only CAM?. As things stand, any answer invites the truly urgent question Who regulates what, and how?. References Pirotta MV, Cohen MM, Kotsirilos V, Farish SJ. Complementary therapies: have they become accepted in general practice? Med J Aust 2000; 172: 105-109. Lewith G. Complementary and alternative medicine: an educational, attitudinal and research challenge [editorial]. Med J Aust 2000; 172: 102-103. Bensoussan A. Complementary medicine -- where lies its appeal? Med J Aust 1999; 170: 247-248. Services Division RACGP. Directory of RACGP Members and their Special Interests. Surry Hills: New Litho Pty Ltd. 1996. Easthope G, Beilby J, Gill G, Tranter B. Acupuncture in Australian general practice: practitioner characteristics. Med J Aust 1999; 169: 197-200. MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573. Eisenburg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997. JAMA 1998; 280: 1569-1575. Complementary medicine is booming worldwide [news]. BMJ 1996; 313: 131-133. Eastwood H. Why are Australian general practitioners using alternative medicine? Postmodernisation, consumerism, and the shift towards holistic health. J Sociol 2000; in press. Featherstone M. Consumer Culture and Postmodernism. London: Sage, 1991. Commonwealth Department of Health and Aged Care. Reforming the Australian Health Care System. The Role of Government. Occasional papers: New Series No. 1. Canberra: Publications Production Unit, 1999. Robertson R. Globalization: Social Theory and Culture. New York: Sage Publications, 1992. Eastwood H. General Medical Practice, Alternative Medicine and the Globalisation of Health [unpublished doctoral thesis]. Brisbane: University of Queensland, 1997. Willis E. Complementary healers. In: Illness and Social Relations. Sydney: Allen and Unwin, 1994; 54-74. Fisher P, Ward A. Complementary medicine in Europe. BMJ 1994; 309: 107-311. Pietroni P. Beyond the boundaries: relationship between general practice and complementary medicine. BMJ 1992; 305: 564-565. Goldszmidt M, Levitt C, Duarte-Franco F, Kacorowski J. Complementary health care services: a survey of general practitioners' views. CMAJ 1995; 153: 29-35. Crook S, Pakulski J, Waters M. Postmodernisation: Changes in Advanced Society. London: Sage Publications, 1992. Chan JJ, Chan JE. Medicine for the millennium: the challenge of postmodernism. Med J Aust 2000; 172: 332-334. Waters M. Globalization. New York: Routledge, 1996. Complementary Medicines Evaluation Committee's guide to levels and kinds of evidence to support claims. Canberra; Commonwealth Department of Health and Aged Care, 2000. Available at <http://www.health.gov.au/tga/docs/pdf/ tgaccevi.pdf>. Integrative Medicine Association. IMA Newsletter, Issue 6, December. 1996. Duckett S. Policy challenges for the Australian Health Care system. Aust Health Review 1999; 22: 130-147. Authors' details Department of Social and Preventive Medicine, University of Queensland, Brisbane, QLD. Heather L Eastwood, PhD, BA(Hons), Lecturer. Reprints will not be available from the author. Correspondence: Dr H L Eastwood, Department of Social and Preventive Medicine, Herston Medical School, University of Queensland, QLD 4072. h.eastwoodATspmed.uq.edu.au Make a comment Summary of the study of why general practitioners (GPs) use complementary and alternative medicine (CAM)9,13 Participants: GPs (n=27); alternative practitioners without a medical degree (n=17); GPs and alternative practitioners who represent key educational and political organisations (n=16). All practitioners were located in Brisbane, QLD. Methods: Qualitative, telephone and face-to-face in-depth interviews, observation, and primary document analysis. Findings: Increased resort by GPs to CAM is not entirely pragmatic. It is partly due to factors beyond consumer demand, clinical effectiveness and financial reward. GPs attribute consumer demand for CAM to increased consumer wariness of synthetic drugs and invasive surgery, greater consumer choice, and a more educated public. GPs' own reasons for their provision of CAM include competition in the healthcare market; personal dissatisfaction with general practice; personal satisfaction gained through the clinical effectiveness of CAM; resistance to becoming "technocrats" rather than "healers"; recognition of the limitations of orthodox biomedical treatments; and concern, genuinely shared with patients, about over-reliance on synthetic drugs and invasive surgery. Back to text Glossary Clinical legitimacy: Validation conferred by the clinical effectiveness of a given treatment with or without scientific evidence as to why or how it works. Globalisation: The "shrinking planet" phenomenon, caused by dramatic advances in transportation and communications and by increasing ecological and economic interdependence, encouraging the concept that the whole world is but a single, albeit very large and complex, community. Globalisation processes: The many and varied inputs to social change in Western societies (ie, postmodernisation), which include (1) a "return to nature" arising from ecological concerns; (2) a return to tradition, history and "roots"; and (3) greater awareness and appreciation of other cultures. Postmodernisation: A sociological term denoting the broad social change occurring in Western societies. The term refers to those processes that are changing modern Western society and its values, organisation, and institutions (modernity) to a new social reality (postmodernity). Postmodernism: A confusing term, referring to the ideological movement that attacks the philosophical foundations of modernity and the modernist worldview based on the assumption that science, technology and reason will create the optimal society. Postmodernism can also refer to the creation, via contemporary social change (ie, postmodernisation), of a new mainstream culture and concomitant "postmodern" values, such as consumer choice (eg, shopping around for health services), independence from scientific and technological products (eg, rejection of, or concern about, genetically modified foods and synthetic drugs), and increased public access to information (eg, the Internet). Back to text

Heather L Eastwood

Clinical Practice An approach to managing depression in general practice Ian B Hickie MJA 2000; 173: 106-110 Long term management of patients with depression: an essential skill for all general practitioners Abstract - Early detection - Diagnostic pragmatism - Risk assessment - Engaging and empowering - Choosing an antidepressant - Beyond drug therapy - Conclusion - Authors' details - - More articles on Allied health Abstract Detection of depression in primary care can be enhanced by use of self-report assessment forms. With the new classes of antidepressants, there is the opportunity to choose specific drug classes for different types of depressive disorders. Depression is frequently a relapsing illness. Treatment goals should include long term reduction of vulnerability factors. An active therapeutic partnership can be facilitated by providing accurate detailed information early in the course of the illness. Behavioural therapies, which focus on modification of the sleep-wake cycle, activity planning and reduction of substance abuse, are essential. Structured problem solving is the most accessible form of cognitive intervention that general practitioners can readily provide. More complex cognitive therapies are usually provided by mental health professionals or general practitioners with extensive training. Although major depression is common in primary care, general practitioners (GPs) may still find it difficult to detect and treat depression unless they have a high index of suspicion and additional mental health training.1-3 A range of patient, doctor and practice organisation factors contribute to this difficulty.1-4 Patient factors include comorbid medical disorders, presentation of somatic rather than psychological symptoms, poor understanding of mental health and fear of stigma. Examples of practitioner factors are inadequate training and reluctance to provide psychological treatments, whereas practice organisation factors include too little time, too little remuneration, too little mental health specialist support, lack of use of screening tools, and lack of access to independent educational materials. However, improvement in the quality of mental health care provided by GPs is now firmly on the national agenda.4High quality mental health care consists not only of informed prescribing, but also of early detection, provision of sound information, use of effective non-pharmacological techniques and reduction in factors which will lead to long term vulnerability to recurrent depression. A range of initiatives are under way nationally to improve mental health practice in primary care. In this article, elements derived from SPHERE: A National Depression Project are described to highlight one coordinated approach to the educational, training and practice support infrastructure needed to make such initiatives sustainable.5 Early detection in primary care GPs are ideally placed to detect depression early in its course. While patients frequently present with other urgent medical problems or unexplained physical symptoms,2,6 primary care contacts are ideal for mental health screening. Although much mental health training focuses on improving interview and assessment skills, simple screening instruments are time-efficient and engage patients actively in the therapeutic process. As with other screening procedures, such tests are not diagnostic. Instead, they highlight those patients who require specific assessment by the practitioner. Patients usually welcome the opportunity to reveal their difficulties in this way. Good examples of such instruments include the 12-item General Health Questionnaire (GHQ),7 the Prime-MD,8 and the 34-item Somatic and Psychological HEalth REport (SPHERE).5 SPHERE can be used to produce an output that compares the severity of the patient's physical and mental symptoms with a national practice sample. Currently, the SPHERE Project promotes a simple screening device (Box 1), which emphasises that depression is a syndrome with major effects on thoughts, feelings, behaviours and bodily function. Diagnostic pragmatism Formal psychiatric classification systems have become extremely complex and lack validity in primary care.3 However, for GPs to make use of the available evidence on treatment efficacy, certain grades of depression need to be recognised. British and European psychiatry has emphasised the importance of identifying "endogenous" or "melancholic" disorders, as they respond preferentially to antidepressant drugs. The depressed phase of bipolar disorder (manic depressive illness) also fits this category. Recent Australian research has re-emphasised this concept,9 highlighting the need to recognise observed (not patient-reported) psychomotor slowing, or agitation, as hallmarks of the disorder. Melancholia is relatively rare in primary care (as distinct from specialist and hospital-based practice). In primary care, non-melancholic depressive disorders (either primary, concurrent with anxiety or secondary to medical illness) are common and disabling.1,2,10,11 Key risk factors include premorbid anxiety, family history of anxiety, depression and substance abuse, medical ill-health, dysfunctional intimate relationships, and social adversity. Increasing sophistication of genetic,12 biochemical and psychosocial research has led to a new conceptualisation of these disorders, with greater emphasis on the interaction between long term (genetic and past experiential) vulnerabilities and current life stressors. That is, depression rarely occurs "out of the blue", and patients who have had major episodes are at high risk of relapse.13 Further, in this model, patients with non-melancholic disorders have their own individual biology (genetically determined arousability or nervousness) that may be treated pharmacologically or non-pharmacologically. Diagnostically, it is important to recognise not only the overt depressive disorder but also whether it is accompanied by a specific anxiety disorder (eg, panic attacks or agoraphobia) that requires additional attention. The recognition of premorbid anxiety, substance abuse and/or significant personality dysfunction completes this diagnostic phase. Risk assessment One of the most important tasks in primary care is the assessment of risk of various forms of self-harm. Prevention of suicide should not be seen as the primary goal; nevertheless, research has highlighted the high risks of self-harm in both younger and older men, with the latter frequently contacting family doctors before making serious suicide attempts.14 Other risk factors, such as social isolation, substance abuse and access to lethal means, need to be noted and appropriate risk-reduction strategies implemented (eg, involvement of family, frequent appointments, emergency contact procedures, reduction of alcohol, removal of lethal means). GPs can underrate the degree of both short- and longer-term risk,15 and may need to engage others (eg, family, other primary care practitioners, or mental health specialists) more actively in collaborative long term risk reduction. A necessary emphasis is the assessment of a range of risk-taking strategies (eg, deliberately driving fast or recklessly) and forms of self-harm other than overt suicide attempts (eg, prolonged substance abuse, neglect of other medical problems). Engaging and empowering the patient The community has little specific knowledge about depression, and patients hold generally negative views about antidepressant drug therapy.16 The key to overcoming these negative stereotypes is the provision of independent and sophisticated information. Most patients wish to make active choices about treatment and, increasingly, to receive alternative opinions, but few practitioners have the materials they need to facilitate such discussions. Furthermore, some are reluctant to provide detailed information that may apparently contradict their therapeutic choices. Provision of accurate information early in the course of illness facilitates active engagement and helps create the framework for long term treatment adherence.17 While these concepts are now routine for disorders such as diabetes and asthma, they are yet to become routine even among mental health specialists who treat severe and/or relapsing depression. Choosing an antidepressant The new classes of antidepressants differ substantially in their benefits and side-effects. Rather than prescribing the same antidepressant (or the same class) to every patient with depression, there is the chance to choose specific classes for different types of depressive disorders. Pharmacological therapy should be accompanied by appropriate means for recording benefits and side-effects and placing drug therapy within an overall treatment framework. One also needs a "road-map" for initiating rational prescribing (Box 2). Currently, there is a general paucity of comparative evidence to influence choices of antidepressant compounds (both within and across classes). Internationally, this has meant a reliance on panels of experts rather than systematic reviews of published studies. In the course of designing the SPHERE Project, we relied strongly on the clinical opinion of experts and a survey of practitioners.18,19 Subsequent studies20,21 and professional group recommendations22 are largely consistent with these views. Consequently, we still recommend some specific starting points for antidepressant therapy. These include: Selective serotonin reuptake inhibitors (SSRIs) are particularly helpful for those with moderately depressed mood, premorbid anxiety and/or panic disorder, agoraphobia and/or obsessive-compulsive disorder.23,24 They are also "first-line" agents for depression in the context of other medical illnesses, adolescents, and older patients.19,22 Generally, these drugs are very similar and good reasons for choosing one over another are limited. When selecting an SSRI, factors to consider are drug interactions (cytochrome P-450 enzyme systems), severity of withdrawal syndromes, and tendency to cause initial agitation. Patients with principal complaints of fatigue and/or sleep disturbance, without severe mood disturbance, may require different strategies. Fatigue without obvious mood disturbance responds poorly to SSRIs,25 and SSRIs may be associated with worsening sleep patterns in the first few weeks of therapy.26 Some of these patients may benefit from the use of other antidepressant classes. Preliminary evidence suggests the usefulness of moclobemide in patients with fatigue,27 and nefazodone in patients with fatigue and sleep disturbance.28 Patients who do not respond to a course of SSRIs may instead respond to serotonin and noradrenaline reuptake inhibitors (SNRIs).20 Whether to use SNRIs as first-line agents in primary care is debatable, but psychiatrists do not generally recommend them in this setting19 because of their side-effects and more complex dosing schedule. They are strongly favoured for use in specialist practice where patients have generally failed one or more courses of the first-line agents or have more severe illnesses. Patients with melancholia, psychotic depression, treatment-resistant depression and/or other very severe mood disorders may do less well with SSRIs and may benefit from commencing therapy with SNRIs20 or tricyclic antidepressants (TCAs).29 Some particular patient groups (eg, those with chronic pain) still respond preferentially to TCAs.19 Beyond drug therapy A great deal of educational effort has been invested (largely by the pharmaceutical industry) in increasing doctor recognition of major depression and provision of safer pharmacological therapy. Unfortunate consequences of this drive may be the perception that these agents are more efficacious than the older agents or that non-pharmacological strategies are no longer relevant.30 Although initial drug therapy can assist patients to get "out of the hole", ongoing maintenance therapy (Box 3) is also critical. Maintenance therapy needs to be thought of in terms of How long should this patient stay on the drug? and What other non-pharmacological strategies are necessary for this patient?. One of the clear (and somewhat unexpected) benefits of the SSRIs is their capacity to reduce ongoing "trait" anxiety in those who have been life-long worriers.23 That is, they appear to modify a personality style that is otherwise at high risk of recurrence of depression. In general, patients should continue effective drug therapy for at least 6 to 12 months after they recover from a major depressive episode. If patients have had several previous depressive episodes, and have responded to drug therapy, then they should consider longer periods (2 to 5 years) of prophylactic antidepressant therapy.22 The effective non-pharmacological therapies are generally lumped together as "cognitive-behavioural" approaches. This describes a range of potential interventions that commence with essential behavioural elements (eg, education, treatment adherence monitoring, sleep-wake cycle and activity planning, modification of substance use; see Box 4)31 and then move to more cognitive approaches (eg, structured problem solving, formal cognitive therapy). While debate continues as to the extent of benefit from these approaches,32 it is generally accepted that they form the basis of most non-pharmacological interventions.22,33 There is an ongoing issue of practitioner competency, as such treatments are not necessarily effective if provided by clinicians with limited training.34 For all patients, keeping a daily diary is an essential part of the behavioural approach. A very good analogy for patients with depression is that of diabetes. Whatever drug therapy may be required, major lifestyle modifications are also needed. The more effective the non-drug therapy, then the greater the chance that the patients will be able to withdraw drug therapy. Many doctors provide lifestyle advice, but fail to encapsulate it within other critical features of the behavioural approach, such as explaining the rationale, self-monitoring, reviewing the effects of modified behaviour, and identifying obstacles to implementation. Behavioural management of anxiety (eg, general stress, panic attacks, avoidant behaviour, social anxiety) needs to be considered in those with high premorbid anxiety or ongoing anxiety phenomena. This may include general stress management (including physical exercise), slow-breathing techniques, progressive muscle relaxation, and staged confrontation of feared situations (exposure therapy). In general, patients with significant anxiety disorders do best when they receive cognitive as well as behavioural approaches. Structured problem solving Many untrained professionals confuse effective psychological interventions (eg, structured problem solving, interpersonal therapy, cognitive therapy) with non-specific support and advice. Although the latter may help reduce the risk of self-harm, they do little to resolve major depression. The most accessible form of psychological intervention for primary care practitioners is structured problem solving.35 This creates a framework for the patient to re-engage with practical approaches to perceived problems and learn new cognitive skills (Box 5). The key factor is not whether the patient's preferred solution is ultimately successful (which tends to be the doctor's main preoccupation), but whether the patient learns a more general approach to coping with ongoing life stressors. By focusing initially on a style of behavioural analysis that describes specific rather than general problems, and then ranks them in terms of likely difficulty, the patient is forced to move from a position of general hopelessness (eg, "There's nothing I can do", "Everything fails in the end") to more specific problems (eg, "I don't have a job"). Identifying specific problems allows the generation of option lists (eg, "Ask family", "Register with Centrelink", "Change industries"). Once a reasonable option list has been generated, the patient then evaluates the potential interventions. That is, the patient is being forced to engage in the style of rational thinking that people without depression take for granted. By contrast, patients with depression tend to think in global terms, generate few solutions, fail to evaluate their actions, and avoid implementation of realistic options. This approach is well suited to general practice as it can be learnt quickly, requires little ongoing supervision, and can be broken down into manageable time frames (eg, three to six sessions of 15 to 30 minutes each). As with other cognitive approaches, it engages the patient as an active partner and formally prohibits practitioners from simply offering their own behavioural analyses and/or preferred solutions. It may also prove to be a useful means for recruiting additional input from other key people (eg, spouse or parent), as they may be encouraged to generate additional options or assist with implementation. As many depressed patients find themselves in dysfunctional intimate relationships,36 this change of focus may also assist to re-engage those who have found interactions with the depressed person non-rewarding or aversive. Cognitive and interpersonal therapies These more formal psychological therapies are suited to patients with repeated episodes of depression, chronic depression, or clear evidence of repeating patterns of self-defeating thoughts, avoidant behaviours, or dysfunctional intimate relationships.33,37 These treatments can be difficult to provide in primary care, as they require considerable therapist training, ongoing supervision and monitoring of clinical skills, and modification of the practice environment (typically 12 to 16 sessions of 45 minutes' duration). However, GPs have indicated a willingness to learn key aspects of these skills and implement them in their practice.38 Widespread provision of these treatments will require more radical training and financing. These may be in the form of more "shared" and better-structured care with secondary mental health specialists systems,39 or through the development of a large group of GPs with these specialised skills. Conclusion Most GPs can now provide reasonable antidepressant therapy for patients they identify as having depression. Improved quality of practice depends on greater identification (particularly in those with concurrent medical illness), better quality of initial psychoeducation and behavioural management, and initiation of psychological strategies designed to improve treatment adherence and reduce long term vulnerability. Acknowledgements: The assistance of Tracey Davenport and Joanne Gander with the preparation of this manuscript was greatly appreciated. Disclosure statement: SPHERE: A National Depression Project was supported in 1998 and 1999 by Bristol-Myers Squibb Pharmaceuticals, manufacturers of Serzone (nefazodone). Evaluation of the SPHERE Project is currently supported by the New South Wales Health and Mental Health Branch of the Commonwealth Department of Health and Aged Care. Australian Divisions of General Practice provide financial support for SPHERE training programs in local districts. A trial of Aurorix (moclobemide) in patients with chronic fatigue was supported by Roche Pharmaceuticals. Pfizer, manufacturers of Zoloft (sertraline), plan to support a SPHERE education module (Depression in the Medically Ill) in 2000. Representatives of the SPHERE Project have provided educational sessions for employees of Wyeth Pharmaceuticals, manufacturers of Efexor (venlafaxine). References Thompson C, Kinmonth AL, Stevens L, et al. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet 2000; 355: 185-191. Simon GE, Von Korff M, Piccinelli M, et al. An international study of the relation between somatic symptoms and depression. N Engl J Med 1999; 341: 1329-1335. Hickie I. Primary care psychiatry is not specialist psychiatry in general practice. Med J Aust 1999; 170: 171-173. Primary care psychiatry -- the last frontier. A report of the Joint Consultative Committee. Canberra: Royal Australian College of General Practitioners and Royal Australian and New Zealand College of Psychiatrists, 1997. Hickie I, Hadzi-Pavlovic D, Scott E, et al. SPHERE: A National Depression Project. Australas Psychiatry 1998; 6: 248-250. Simon G, Ormel J, Von Korff M, Barlow W. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry 1995; 152: 352-357. Goldberg D, Williams P. A user's guide to the General Health Questionnaire. Windsor, Berkshire: NFER-NELSON Publishing Company, 1988. Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 1994; 272: 1749-1756. Parker G, Hadzi-Pavlovic D, editors. Melancholia: a disorder of movement and mood. New York: Cambridge University Press, 1996. Ustun TB, Sartorius N, editors. Mental illness in general health care: an international study. Chichester: John Wiley and Sons, 1995. Katon W, Von Korff M, Lin E, et al. Population-based care of depression: effective disease management strategies to decrease prevalence. Gen Hosp Psychiatry 1997; 19: 169-178. Kendler KS, Neale MC, Kessler RC, et al. Major depression and generalised anxiety disorder: same genes, (partly) different environments? Arch Gen Psychiatry 1992; 49: 716-722. Frank E, Kupfer DJ, Perel JM, et al. Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 1990; 47: 1093-1099. Stoppe G, Sandholzer H, Huppertz C, et al. Family physicians and the risk of suicide in the depressed elderly. J Affect Disord 1999; 54: 193-198. Milton J, Ferguson B, Mills T. Risk assessment and suicide prevention in primary care. Crisis 1999; 20: 171-177. Jorm AF, Korten AE, Jacomb PA, et al. "Mental health literacy": a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med J Aust 1997; 166: 182-186. Kemp R, Kirov G, Everitt B, et al. Randomised controlled trial of compliance therapy: 18-month follow-up. Br J Psychiatry 1998; 172: 413-419. Hickie IB, Scott ES, Davenport TA. Enhancing the evidence base for clinical psychiatry: are practice surveys a useful tool? Med J Aust 1999; 171: 315-318. Hickie IB, Scott ES, Davenport TA. Are antidepressants all the same? Surveying the opinions of Australian psychiatrists. Aust N Z J Psychiatry 1999; 33: 642-649. Poirier M-F, Boyer P. Venlafaxine and paroxetine in treatment-resistant depression: double-blind, randomised comparison. Br J Psychiatry 1999; 175: 12-16. Boyd IW. Venlafaxine withdrawal reactions. Med J Aust 1998; 169: 91-92. American Psychiatric Association. Practice guideline for the treatment of patients with major depression. 2nd ed. Washington, DC: APA, 2000. Boerner RJ, Moller HJ. The importance of new antidepressants in the treatment of anxiety/depressive disorders. Pharmacopsychiatry 1999; 32: 119-126. Bakker A, van Dyck R, Spinhoven P, van Balkom AJ. Paroxetine, clomipramine, and cognitive therapy in the treatment of panic disorder. J Clin Psychiatry 1999; 60: 831-838. Vercoulen JHHM, Swanink CMA, Zitman FG, et al. Randomised, double-blind, placebo-controlled study of fluoxetine in chronic fatigue syndrome. Lancet 1996; 347: 858-861. Sharpley AL, Williamson DJ, Attenburrow MEJ, et al. The effect of paroxetine and nefazodone on sleep: a placebo controlled trial. Psychopharmacology 1996; 126: 50-54. Hickie I, Wilson A, Bennett B, et al. A double-blind placebo control trial of moclobemide in patients with chronic fatigue syndrome. J Clin Psychiatry 2000; in press. Hickie I. Nefazodone for patients with chronic fatigue syndrome. Aust N Z J Psychiatry 1999; 33: 278-280. Boyce P, Judd F. The place for the tricyclic antidepressants in the treatment of depression. Aust N Z J Psychiatry 1999; 33: 323-327. Boyce P, Hickie I. A brave new world in managing depression -- or is it? Aust Fam Physician 1994; 23: 627-632. Hickie I, Davenport T. A behavioral approach based on reconstructing the sleep-wake cycle. Cognitive Behav Pract 2000; in press. King R. Evidence-based practice: where is the evidence? The case of cognitive behaviour therapy and depression. Aust Psychol 1998; 33: 83-88. Scott J. Treatment of chronic depression. N Engl J Med 2000; 342: 1518-1520. Roth A, Fonagy P. What works for whom? A critical review of psychotherapy research. New York: Guilford Press, 1996. D'Zurilla TJ. Problem-solving therapy: a social competence approach to clinical intervention. 2nd ed. New York: Springer Publishing Company, 1999. Hickie I, Parker G, Wilhelm K, Tennant C. Perceived interpersonal risk factors of non-endogenous depression. Psychol Med 1991; 21: 399-412. Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 2000; 342: 1462-1470. Morgan H, Sumich H, Hickie I, et al. A cognitive-behavioural therapy training program for general practitioners to manage depression. Australas Psychiatry 1999; 7: 141-145. Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 1996; 53: 924-932. Authors' details School of Psychiatry, University of New South Wales, Sydney, NSW. Ian B Hickie, MD, FRANZCP, Professor of Community Psychiatry. Reprints: Professor I B Hickie, Academic Department of Psychiatry, 7 Chapel Street, Kogarah, NSW 2217. i.hickieATunsw.edu.au Make a comment 1: SPHERE checklist for depressive disorders. (From Hickie I, Scott E, Morgan H, et al. A brief guide to depression management. Melbourne: Educational Health Solutions, 2000. Used with permission.) Back to text 2: A "road map" for initiating antidepressant therapy. The times between treatment changes are a guide only. Actual washout periods will depend on the dose and duration of treatment and the current severity of depression. *For fluoxetine allow 14 days' washout. SSRI = selective serotonin reuptake inhibitor. 5HT2 antagonist=serotonin 2 receptor antagonist. RIMMA = reversible inhibitor of monoamine oxidase. SNRI = serotonin and noradrenaline reputake inhibitor. TCA = tricyclic antidepressant. ECT = tricyclic antidepressant. ECT = electroconvulsive therapy. (From Hickie I, Scott E, Morgan H, et al. Treating depression and anxiety in general practice: a training manual. Sydney: Educational Health Solutions, 1998. Used with permission.) Back to text 3: The course of depressive disorders. (From Hickie I, Scott E, Morgan H, et al. A brief guide to depression management. Melbourne: Educational Health Solutions, 2000. Used with permission.)Back to text Click in box for larger imageBack to text 5: A practical guide to structured problem solving. (From Hickie I, Scott E, Morgan h, et al. A brief guide to depression management. Melbourne: Educational Health Solutions, 2000. Used with permission.)Back to text

Ian B Hickie

Looking Forward The future of Medicare and health service financing Stephen R Leeder and Ian A McAuley MJA 2000; 173: 48-51 If we can afford to pay for healthcare, we can afford Medicare - - More articles on Administration and health services "Never make predictions, particularly about the future", was George Bernard Shaw's advice to futurologists. Shaw saw more of the future than most -- he died in 1950, aged 94, when the life expectancy of men in Britain was 67 years. Two years earlier, Aneurin Bevan,* Minister for Health in the Attlee Government,† had introduced the National Health Service (NHS) Act, the prototype for universal tax-funded healthcare like Australia's Medibank and Medicare. When the NHS was introduced, the prevailing view was that healthcare expenditure would stabilise once unmet need had been satisfied. But, from 1900 to 1950, the life expectancy of men in Britain had risen from 49 to 67 years, because of improved living standards and, latterly, cures for infections.1 Prescient indeed would have been the academic in 1950 who could have foreseen that lengthened life would result in a host of new healthcare needs, that technologies would be developed to meet those needs, and that Bevan's stability of expenditure on health would prove to be illusory. Speculating on the future of healthcare delivery is no less hazardous now than it was in 1948. Nevertheless, the major forces shaping the future generally are manifest in present trends. If we were developing scenarios about commodity prices we might well accept that, in a globalised world economy, the policies of national governments have, at most, a marginal effect. In the case of healthcare, however, this is no easy task. The experience of the past 25 years suggests we might expect at least four changes of government over the next 25 years. That would indicate an on/off sequence for Medicare, much as we have seen in the past 25 years, and this has not been totally related to which side of politics is in power. During Labor's time in office, the governments of Bob Hawke and Paul Keating reintroduced universal hospital care, but also brought in a much higher level of patient copayments in healthcare, particularly for pharmaceuticals. The present Liberal-National Coalition Government has reasserted a commitment to Medicare, and has tended to shy away from market forces in the private sector, encouraging community-rated insurance rather than self-reliance.2 Yet, at the same time, the present government suggests strongly that those who can afford to have private insurance should do so. A similar sentiment was evident in the proposals of the Labor Health Minister, Graham Richardson, in 1993. The vision of Medibank, and of Medicare, as defined by Neal Blewett when Minister for Health in the Hawke Government,‡ was as a universal shared system. During the 1990s, however, there was political pressure within both parties to redefine Medicare, in particular as regards access to public hospitals, as a charity system for the old and indigent. Because the basic principles of Medicare are not regularly articulated, Medicare becomes pliable to the fashions of government policy and subject to expedient interventions to solve real or perceived problems. Forty years ago, Charles Lindblom coined the term "muddling through" to describe a policy-making process which has no clear end or objective, but which lurches, reacting to one crisis after another.3 The Productivity Commission's modest proposal -- that the Commonwealth Government hold a broad public inquiry into Australia's healthcare system -- which might have led to a less muddled health policy, met with rejection.4 As an alternative to muddling, we can take account of probable changes in demand (especially ageing) and supply (especially technology) of healthcare and build a policy for the future. Demand -- an ageing population Box 1 shows population projections to 2025 for the 80 years and over age group. This age group will almost double in size over the next 25 years. Simple extrapolations of expenditure based on these projections are alarmist, for several reasons. For a start, many countries are already coping successfully with older populations (Box 2). The Scandinavian countries, especially, already have a population structure similar to that predicted for Australia in 2025, and are delivering healthcare for less than 10% of gross domestic product (GDP). These countries demonstrate the capacity of a single, national insurance scheme (similar to Medicare) to keep costs under control while providing quality care to an aged population. A further factor that may diminish demand for care among older people may be changes in lifestyle -- smoking, diet, and exercise are all major determinants of healthcare needs. Dr Wendy Everett, Director of the Robert Wood Johnson Foundation's health programs, suggests (as have many others) that behaviour contributes to 50% of our health status.7 These effects take decades to manifest. Thus, it is the "baby boomers", who grew up in the Golden Age of postwar prosperity and equality, whose lifestyle choices will become apparent when they are around the age of 70 to 80 in the year 2025. Another determinant is consumer attitudes to healthcare. Daniel Callahan, in his book False hopes, predicts the implosion of healthcare under the weight of grasping demand for perfect health unless all of us (in the case of the United States, especially older people) modulate our demands.8 He fears that the commercial imperatives that drive new pharmaceutical, biotechnological and bioengineering industries will further push demand for tinkering and spare parts to completely unsustainable levels. As an alternative, he posits education of the public that they cannot have it all, and this must begin now if a shred of equity in how healthcare is provided is to be retained. Thus, while the arithmetic of ageing is not complex, much depends on background economic capacity and the sociology of demand of the country concerned. Unless demand is disciplined, it is easy to see market forces overwhelming healthcare budgets. In that case, a scramble for care will occur, with only the rich doing well, further widening the already depressing gradients in health and healthcare between the rich and the poor.9,10 Presuming instead a more civilised society with a central health insurance agency such as Medicare, the omens are by no means bleak, as our Scandinavian colleagues demonstrate. Supply -- the role of technology Technological growth is blamed for much of the increase in health costs. Dr Joseph Newhouse, of Harvard University, told a National Health Summit in Sydney in 1991 that he attributed the increase in healthcare expenditure in the United States principally to technological change.11 He referred to the "march of science and the increased capabilities of medicine" as a large part of the cause, and cited renal (kidney) dialysis, transplantation, artificial joints and monoclonal antibodies (and other products of genetic engineering) as examples of this. However, the role of new technology is a mixed one, and, while there may be a Galbraithian "technological imperative", to suppose that it cannot be modified with time according to human design seems a defeatist position. Many technologies have revolutionised patient comfort, especially the replacement of old diagnostic procedures with new, far less invasive ones. The same can be said for many therapies that have enabled the massive movement away from prolonged inpatient care to ambulatory service. A step in the direction of the sane use of new technology is the development, in 1998, of processes of critical appraisal for services that might be supplied by Medicare. We have not yet seen what clinical care based on insights into the human genome may achieve, but not to consider this as a significant aspect of demand for future healthcare would be foolish. The other aspect of technology likely to have a profound effect is the Internet. It is shifting the locus of information in healthcare.12 Will it result in more shopping around, more time spent in argument, or will it result in more self-help displacing the need for formal care? Will it result in more mishaps through partial knowledge? How will it relate to Medicare? Can we afford Medicare? If we can afford to pay for healthcare, we can afford Medicare. That may sound glib, but, if we choose to share all or some of our healthcare costs, then Medicare is both the fairest and most efficient means of sharing. Community-rated private health insurance (a "privatised" tax) is a clumsy way to do what the taxation system does well. There is nothing that community-rated private health insurance does that Medicare and the taxation system cannot do better. The administrative expenses of private health insurance are $0.6 billion per annum, or 12.4% of premiums, compared with 3.7% for the Health Insurance Commission.13,14 The taxation system achieves community rating without the need for complex arrangements (such as apply with private health insurance), with "lifetime cover" and reinsurance, and because taxation is progressive it is fairer than private insurance. What would be the financial consequences of doing away with private insurance? Health insurance funds pay out $3.1 billion a year in hospital benefits.13 Of that, 30% is subsidised by the Commonwealth Government. Therefore, $2.2 billion of additional public funding could substitute for this funding. That could be met with a 0.75% increase in the Medicare levy. Its immediate effect would be to eliminate a large private bureaucracy. Its longer term effect would be to bring to the healthcare market the discipline of a single national insurer. Box 3 shows that countries with a larger proportion of healthcare funding passing through the public sector, through universal national health schemes like Medicare and Britain's NHS, tend to have much lower total healthcare costs. Would eliminating private insurance represent "socialised medicine"? No. It is quite possible to fund a private hospital system without private insurance. Medicare funds can just as easily go to private hospitals as to public hospitals. Would it be possible politically to raise taxes to pay for a universal Medicare? The evidence seems strongly to suggest it would. In both the 1993 and 1996 elections, healthcare was a major issue among voters. In 1993, the Coalition had promised private health insurance initiatives, while Labor did not, being more committed to Medicare. Polling researchers asked people which party was closest to their own views on various issues, including health policy. In response to that question, Labor had a 19% lead over the Coalition. In 1996 both parties promised support for private health insurance and the same polling found Labor's lead on healthcare had fallen to 5%.15 This year, in a multination poll, a small majority of Australians said they were in favour of higher taxes and higher public spending, with healthcare, at 75%, the second-highest priority (after education, at 78%).16 The last line of defence for private insurance is that, because it is "private", it is somehow superior to a "public" system -- a belief, known as "private sector primacy", which is grounded more in ideology than in economic rationality. The case does not rest on any economic analysis of whether a function is more efficiently carried out in the private or public sector; rather, it is a matter of faith that, if at all possible, it is always preferable for a function to be in the private sector. This argument has merit where private provision is accompanied by the discipline of price signals. But insurance, private or public, acts to suppress price signals, except for those of the premiums. At the point of use, there is no difference between the perception "Medicare will pay" and "private health insurance will pay". Insurers know this phenomenon by the quaint term "moral hazard". It applies whenever there is third-party funding. The real debate that we have to have If we dwell too long on the issues of private versus public insurance, we overlook more basic issues in health financing. We need now to address wider issues; the longer we defer this debate the harder it will be, as even uninformed views tend to become entrenched in a state of serious muddlement. This is especially so in a country with a large first- and second-generation migrant population, who have come from countries with a variety of contracts between citizen and government, from cradle-to-grave welfare through to a culture of laissez faire. We offer three issues for this debate. First, let us clarify the government's role in healthcare; is it charity or is it something we share? On that point we tend to the latter view. Even if we are generally inegalitarian, accepting the slings and arrows of life as a matter of private fortune, we may have a different attitude to healthcare. We may know our inheritances of material wealth and of physical and intellectual talent, but we do not know what lies around the corner when it comes to health. In the terminology of the Harvard philosopher John Rawls, when it comes to our healthcare needs we are in an "original position", and are more likely to choose to share our lot with others to the extent that we can.17 The second issue relates to the boundary between third-party funding and the market. The debate should not be between private and public insurance, but between insurance and the market. The final issue, after the first two have been settled, is how to rationalise the complex set of programs in healthcare. To those in the healthcare professions or who study healthcare from an academic perspective, it is complex. To the consumer it is bewilderingly unintelligible. Some programs have copayments, some do not. Simple procedures like ambulatory care usually require visits to several establishments, with different payment systems. Why, for example, is pharmacy separated from general practice? Why does a public hospital stay attract no copayment, while much less expensive procedures attract large patient contributions? Why is medical care separated from nursing care in private hospitals and nursing homes? Why does one have to wait days for test results which are generated instantly with new technology? Program divisions reflect ancient demarcations between crafts, and the complexities of Federal-State relations. Advances in medical technology have not been matched in structures and organisations providing healthcare. If Shaw had lived to 150, he would have found them surprisingly familiar. Will they be the same on his 175th birthday? Acknowledgements We extend our thanks to Professor John Deeble for helpful comments on drafts of this paper and to Amanda Dominello for assistance with editing. Footnotes * Aneurin Bevan, Minister for Health in the Labour Party (United Kingdom), 1945-1951. † Clement Attlee, Leader of the Labour Party (United Kingdom), 1935-1955. ‡ Bob Hawke, Labor Prime Minister, 1983-1991. References Organisation for Economic Co-operation and Development. Financing and delivering health care. Paris: OECD; 1987. McAuley I. Private health Insurance. Redefining the issues. Australian Rationalist 1988; 1 Spring: 47. Lindblom C. The science of muddling through. Public Admin Rev 1959; 19: 79-88. Industry Commission. Private health insurance. Canberra: Industry Commission, 1997. Australian Bureau of Statistics. Population projections. Canberra: ABS, April 2000. (Catalogue No. 3220.0.) Organisation for Economic Co-operation and Development. OECD health data 99 [on CD-ROM]. Paris: OECD, 1999. Stapleton S. New technology, smarter patients augur vast change. American Medical News 2000; March 13: 33. Callahan D. False hopes. New York: Simon and Schuster, 1997. Marmot M. Social determinants of health: from observation to policy. Med J Aust 2000; 172: 379-382. Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. Australian Institute of Health and Welfare. Canberra: AIHW, 1999. Newhouse JP. Keynote address: The costs of medical care and consumer willingness to pay for new medical technologies: how much should we be spending on health care? National Health Summit, Nov 15, Sydney 1991. Clarke RL. Hard times and great expectations. Healthcare Financial Management 2000; March: 16. Private Health Insurance Administration Council (PHIAC). Operations of the registered health benefits organisations. Canberra: PHIAC, 1999: 87. Health Insurance Commission (HIC). Annual report 1998-99. Canberra: HIC, 1999: 79. Bean C, McAllister I. Short-term influences on voting behaviour in the 1996 election. In: Bean C, Simms M, Bennett S, Warhurst J, editors. The politics of retribution -- The 1996 Federal Election. Sydney: Allen and Unwin, 1997: 198. Peering into 2010 -- a survey of the future of medicine. The Economist 1994; March 19: 63. Rawls JA. Theory of justice. Cambridge: Harvard University Press, 1971. Authors' details Stephen Leeder is Dean of the Faculty of Medicine and Professor of Public Health and Community Medicine at the University of Sydney. He was foundation professor of Community Medicine at the University of Newcastle (1977-1985), and Director of the Division of Public Health and Community Medicine at Westmead Hospital in the Western Sydney Area Health Service (1985-1997). He was the foundation chair of the Board of Censors of the Australasian Faculty of Public Health Medicine 1990-1994, and has served two terms as National President of the Public Health Association of Australia. He chaired the Health Advisory Committee of the National Health and Medical Research Council, 1997-1999. Ian McAuley has worked as an engineer, as a diplomat in the foreign service, and in the Commonwealth public service. He studied public administration at Harvard, and since 1987 has been at the University of Canberra, researching and teaching in public sector finance. Faculty of Medicine, University of Sydney, Sydney, NSW. Stephen R Leeder, PhD, FRACP, FFPHM, FAFPHM, Dean, and Professor of Public Health and Community Medicine. School of Management and Policy, University of Canberra, Canberra, ACT. Ian A McAuley, BE, DipBus, MPA, Lecturer. Reprints will not be available from the authors. Correspondence: Professor S R Leeder, Dean, Faculty of Medicine, Edward Ford Building, University of Sydney, NSW 2006. steveATmedicine.usyd.edu.au Make a comment Back to text Back to text Back to text

Stephen R Leeder · Ian A McAuley

Looking Foward Medicare: options for the next 25 years Richard B Scotton. MJA 2000; 173: 41-43 The best long-term option for healthcare in Australia would be a system of managed competition - - More articles on Administration and health services While it is difficult to predict the evolution of healthcare over as long a period as 25 years, we can be reasonably sure that some of the trends of the past 25 years will continue, and possibly accelerate. Thus, medical knowledge and the technology and techniques for its application will continue to advance and, on balance, this will increase costs. Two consequences will be that: equitable access, regardless of capacity to pay (ie, universality) will continue to be a basic component of living standards in an economically developed society, especially in the context of widening income disparities; and efficiency -- doing what is done at least cost (technical efficiency) and using scarce resources to maximise health outcomes (an aspect of allocative efficiency) -- will become an increasingly important component of health policy. Equity and efficiency Despite the theoretical trade-off between equity and efficiency, which applies in certain circumstances, these two objectives are not inconsistent. In fact, a universal national health insurance program gives the government a level of capacity to constrain total health expenditures, which is a necessary (but not sufficient) component of a strategy to increase efficiency. On the other hand, I am convinced that advocacy of improving efficiency by abandoning universal coverage is mistaken, and/or is the product of ideology or self-interest. Consequently, health policy options need to have as their goal the maximisation of efficiency within the framework of the overall equity goal. "Efficiency" in the economic sense means not only producing at minimum cost, but also managing the system so that it produces, at any given level of cost, that mix of outputs which contributes most to social goals and improved health outcomes. This will inevitably involve changes in industry structure. More complex technology and wider appreciation of the intricate interrelationships between epidemiological and social factors in health will call for an ever-increasing scale and more sophisticated interconnections between various parts of the healthcare sector. These factors impose increasing stresses on present structures for financing and delivering health services in all developed countries. The Australian scene In Australia, multiple program and funding streams, overlapping jurisdictions in the federal system of government and poorly articulated relationships between public and private sectors add layers of complexity to the problem. It is a tribute to the funders, managers and providers of health services that our system works as well as it does. On the whole, it provides universal and equitable access to most clinically effective health services, at an overall cost which compares well with those in most comparable countries, and is lower than some. The average citizen requiring health services would be as well treated in the Australian system as anywhere in the world. In other words, there is no "crisis" which constitutes a case for radical reform in the short term, but rather gradually increasing stresses -- organisational, financial and cultural -- flowing from changing patterns of morbidity and medical care. These stresses are largely or wholly unrelated to universality of access, to the present extent of public/private funding and service provision, or to the overall responsibility of public authorities for regulation of the system. A rational response to the current situation seems to justify a twofold strategy: first, implement some relatively straightforward measures to deal with specific difficulties, and second, work toward changes in management and funding arrangements to facilitate the evolution of delivery systems to achieve better health and related social outcomes from the available resources (the amount the community is prepared to allocate to these ends). Many of the options floated in recent years do not meet this specification. To my mind there are only two sensible directions for future reform: Limited reforms designed to ameliorate some systemic problem areas, while maintaining Medicare in more or less its present form; and More substantial reconfiguration of the legal and financial framework of the universal program in the direction of managed competition as a means of promoting increased efficiency of purchasing and service delivery. These options are not mutually exclusive. Rather, the first might stand alone, or could constitute a preliminary stage towards implementing the second. In fact, if one intended to move to managed care, solving some of the systemic problem areas would be a logical first step. The short term -- limited reforms There are several useful reforms which could be undertaken without amending the basic structure of Medicare. The most obvious and important deficiency of the present system relates to access to free hospital treatment, which is currently subject to widespread and lengthy waiting periods. This is largely due to the unsatisfactory nature of the financial arrangements, in which Commonwealth Government funding has never been tied to performance. The original Medibank cost-sharing arrangements allowed only limited control of total costs, and the subsequent method of block grants to the States, which have been in operation since 1981, have enabled some State governments to reduce their level of hospital funding to the point at which access to services has been significantly affected. This situation could be justified when there was no workable measure of hospital output, but since the development of casemix funding and the Australian national diagnosis-related groups (AN-DRGs) in the early 1990s this excuse no longer holds. The performance of the public hospital system, and the incentives for State governments to treat patients, could be greatly enhanced by replacing most or all Commonwealth Medicare grants to the States by DRG-adjusted case payments direct to hospitals. These payments could be calculated as a percentage of the cost per DRG episode, up to a volume of services determined by the Commonwealth Government. This payment system would have many benefits beyond the demonstrated increase in efficiency within hospitals. In particular, it would provide a basis for including hospital costs in the pooling of funds for coordinated care arrangements. It would also inhibit (but not eliminate) cost-shifting, and would facilitate detection of abuses, such as the partial diversion of public inpatients to private status. In the longer term, the substitution of case payments for Commonwealth grants would extend the options for more substantial structural reform of the universal program. The implementation of such payments lies well within the readily available powers of the Commonwealth Government. Other serious deficiencies of the present arrangements have been graphically described by a former State health administrator.1 They include the fragmentation of programs, poor articulation between public and private sector arrangements, and lack of comprehensive data on service utilisation at the individual patient level. The consequences include incapacity to control overservicing, receipt of benefits by ineligible persons, and barriers to developing coordinated care. The causes are partly the jurisdictional overlaps between Commonwealth and States, partly restrictions imposed by privacy legislation and its interpretation, and partly a general paralysis in policy development. A determined Commonwealth Government might be able to achieve a good deal in all the above respects within the framework of a totally public program, but there would be widespread reservation about the extent to which the Australian people would wish to concede to a government authority, however benign, the implied degree of control over their service use. The British National Health Service, whatever its virtues, is not a model for Australia in the 21st century. Perhaps, more importantly, a monolithic public program would lack incentives to increased allocative efficiency. In my view, increasing the efficiency with which scarce resources are used to produce health services is the most important determinant of our capacity to provide universal access to state-of-the-art healthcare in the long term. The standard means of achieving this is to increase the exposure of the participants to market incentives. For these reasons, I have become convinced that the best long-term option for Australia would be a system of managed competition. The longer term -- managed competition? In a managed competition system, private organisations would be free to compete with public provider(s) in the provision of services covered by public benefit programs such as Medicare, free public hospital care, pharmaceutical benefits, nursing home benefits and so on. The idea is a simple one. However, the formulation of a model in which a private market in healthcare would maximise efficiency in producing good health outcomes, free of risk shifting and other types of gaming, has been a more complex exercise. It has been said that there are lots of simple answers to complex questions, and that they are all wrong. All health systems are complex, and the Australian system, in several respects, is more complex than most. Any realistic solution is bound also to be complex, and, in the present context, it is possible to offer only the baldest outline of the managed competition model which I have developed progressively over the past decade (Box).2,3 In conclusion, the point has to be made that the rise in real costs of state-of-the-art healthcare will make it increasingly necessary to limit total expenditures on health. Raising the efficiency of resources used to produce services is the only way to minimise the consequent stresses. The managed competition model offers a framework within which higher efficiency can be pursued without sacrificing the principle of universal access, which remains as much as ever a core component of a humane society. References Paterson J. National healthcare reform: the last picture show. Melbourne: Department of Human Services (Victoria), 1996. Scotton R. Managed competition. In: Mooney G, Scotton R, editors. Economics and Australian health policy. Sydney: Allen & Unwin, 1998: 214-231. Scotton R. Managed competition: the policy context. Aust Health Rev 1999; 22(9): 103-121. Authors' details Richard Scotton is a health economist. He and John Deeble, as Research Fellows at the Institute of Applied Economic Research, University of Melbourne, between 1965 and 1970, formulated the program that became Medibank. From 1972 to 1979, Scotton was centrally involved in implementing Medibank, as Special Adviser to Minister for Social Security Bill Hayden and first Chairman of the Health Insurance Commission. Later appointments were Director (Planning) and Commissioner, Health Commission of Victoria; member of the Medicare Planning Committee appointed by Minister for Health Neal Blewett; General Manager (Policy and Planning), Victorian Accident Compensation Commission; and board member, Australian Institute of Health. Health Economics Unit, Centre for Health Program Evaluation, Monash University, Melbourne, VIC. Richard B Scotton, AO, BA, BEc, PhD, Honorary Professorial Fellow Make a comment Essential features of a managed competition model2,3 All current publicly supported programs - Medicare, free public hospital care, pharmaceutical/nursing home benefits, etc - to be rolled into one, so that all services and benefits for each individual would be paid from the same budget, thus eliminating much cost shifting and encouraging efficient service use. Defined roles for Commonwealth and State governments: the Commonwealth responsibilities limited to financing and the legislative/regulatory framework, and the States to public service provision and overseeing public budget holders. Organisation and management of health service delivery deputed to organisations entitled budget holders, which would be paid (by the Commonwealth Government) a risk-rated capitation for each person enrolled with them, and which would be required to meet all program costs incurred by their enrollees. Risk rating at the individual level is essential to minimise "cream skimming" and other forms of risk selection by budget holders. All persons not opting to be covered by a private budget holder would be covered automatically by a regional budget holder or, as a last resort, by the Health Insurance Commission. Private budget holders would be required to cover all services included in the public program, plus a minimum private hospital entitlement. They would be free to provide wider entitlements to private care, at unsubsidised additional cost. All providers (public and private) would depend for their incomes on payments from budget holders, under contracts or other arrangements (ie, there would be no government benefits or subsidies payable directly to service providers). It could be expected that basic tables (ie, those offering a minimum package of services) would involve some exposure to managed care (ie, medically directed restriction of choice) as incentives to efficient resource use become effective. Another outcome would be that services would be increasingly geared to the needs of people with greater health problems, since they would carry larger capitations. Over time, managed competition could be expected to result in profound structural changes in service provision. Back to text

Richard B Scotton