Mental health

Objective: To investigate whether the observed elevated levels of psychological distress in cancer survivors relate specifically to aspects of cancer diagnosis, to treatment or to disability.Design, participants and setting: Self-reported questionnaire data on demographic, health and lifestyle factors and mental health from 89 574 Australian men and women aged 45 years or older, sampled from the Medicare database for the 45 and Up Study from 1 February 2006 to 30 April 2008. Logistic regression was used to examine the risk of high levels of psychological distress in relation to cancer diagnosis and disability, adjusting for age, sex, income and education.Main outcome measure: High psychological distress (Kessler Psychological Distress Scale score ≥22).Results: Overall, 7.5% of participants had high levels of psychological distress. Among cancer survivors, the median time since diagnosis was 7.3 years. Compared with people without cancer, the odds ratios (95% CIs) for psychological distress were: 1.17 (1.09–1.26) in people reporting having had any cancer apart from non-melanoma skin cancer; 1.34 (1.08–1.67) in those with cancer diagnosed in the previous year; 1.53 (1.33–1.76) for those reporting treatment for cancer in the previous month and 1.11 (1.03–1.19) for those with cancer but without recent treatment. Using individuals with neither cancer nor disability as the reference group, the adjusted odds ratio (95% CI) for psychological distress was 6.51 (5.95–7.12) in those reporting significant disability but no cancer, 1.14 (1.04–1.24) in those without disability but with cancer and 5.81(4.88–6.91) in those with both cancer and disability.Conclusion: The risk of psychological distress in individuals with cancer relates much more strongly to their level of disability than it does to the cancer diagnosis itself.

Emily Banks MBBS, PhD, FAFPHM · Julie E Byles PhD · Richard E Gibson BSc · Bryan Rodgers MSc, PhD · Isabel K Latz MSc · Ian A Robinson BSc · Anna B Williamson PhD · Louisa R Jorm BVSc, MSc, PhD

Objective: To evaluate the efficacy of an interactive self-help workbook in reducing distress, and improving quality of life (QOL) and coping for women recently diagnosed with breast cancer.Design: Randomised controlled trial comparing the use of the workbook and that of an information booklet.Participants and setting: 49 women with Stage 0 to II breast cancer diagnosed in the previous month and recruited from 1 February 2007 to 1 February 2008, in two urban Australian public hospitals.Main outcome measures: The primary outcome measures were depression, anxiety, and posttraumatic stress. Secondary outcomes included QOL, body image, and the coping styles helplessness/hopelessness, cognitive avoidance and anxious preoccupation.Results: After controlling for baseline levels, interactions at 3-month follow-up showed that participants in the workbook group had significantly lower levels of posttraumatic stress (F [1,89] = 7.01; P = 0.01), helplessness/hopelessness (F [1,89] = 4.75; P = 0.03), and cognitive avoidance (F [1,89] = 4.95; P = 0.03) than those in the control (information booklet) group. However, women in the workbook group had significantly poorer body image than those in the control group (F [1,89] = 6.43; P = 0.01). At 6 months, only the body image interaction remained significant (F [1,93] = 7.44; P = 0.01).Conclusion: These results suggest that a self-help workbook can be an effective, short-term intervention for improving posttraumatic stress, cognitive avoidance, and certain depressive symptoms in women recently diagnosed with breast cancer. However, issues related to body image need to be dealt with differently.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12609000934246.

Lisa J Beatty · Bogda Koczwara · Janet Rice · Tracey D Wade

Objective: To describe the outcomes and clinical experience of a 12-week pilot study of routine distress screening of newly admitted patients to an acute haematology and oncology ward.Design, patients and setting: Bedside measurement of psychological distress, and collection of demographic and clinical data for 115 newly admitted patients in an acute haematology and oncology ward of The Alfred hospital in Melbourne between 5 June and 25 August 2006.Main outcome measures: Psychosocial distress as measured by the Distress Thermometer and Problem Checklist, and 18-item Brief Symptom Inventory; rate of referral to psychology and social work services in the 12 weeks before and 12 weeks during the pilot study; ward staff feedback on the benefits and challenges associated with routine distress screening.Results: 51% of patients were identified as being significantly distressed, of whom 47% had not received psychosocial support before screening. A significantly higher number of emotional and physical problems were reported by significantly distressed patients. Referrals to psychology and social work services during the pilot study increased, highlighting that screening directed more patients into care. Staff were generally positive about the ability of routine screening to help them care for their patients, and most agreed that some form of routine screening should continue.Conclusion: The use of routine distress screening by inpatient cancer services can significantly improve their capacity to offer psychosocial care.

Stuart J Lee BA(Hons), DPsych · Lynda J Katona BA(Hons), MPsych · Sue E De Bono BA, BSW · Katrina L Lewis RN

Objective: To assess the impact of an 8-week structured mindfulness-based cognitive therapy (MBCT) program on individuals experiencing distress as a consequence of cancer.Design, setting and participants: Prospective study of 16 participants with a history of cancer and five carers of people with cancer recruited from August 2008 to February 2009 through calls to the Cancer Council South Australia Helpline. Participants were assessed for anxiety and depression before and after undergoing a course in MBCT between 30 September and18 November 2008 and 20 February and 10 April 2009.Main outcome measures: Depression, anxiety and mindfulness as measured by the Beck Depression Inventory-II (BDI-II), State–Trait Anxiety Inventory (STAI), and Freiburg Mindfulness Inventory (FMI), respectively, and a consumer-centred evaluation.Results: There were significant reductions in depression (F [1,24] = 6.37; P = 0.012; partial-η 2 = 0.27) and anxiety (F [2,34] = 9.43; P = 0.001, partial-η 2 = 0.36) and mindfulness (F [2,32] = 8.36; P = 0.001; partial-η 2 = 0.34) following the intervention, and these effects were sustained at the 3-month follow-up. Reliable change indices further support these findings. Participants’ scores on measures of depression and anxiety decreased as a function of increased mindfulness, as reflected by significant (P < 0.05) negative correlations between FMI scores and BDI-II scores (ranging from r = − 0.46 to r = − 0.79) and STAI scores (ranging from r = − 0.46 to r = − 0.50) scores at all time points.Conclusion: The MBCT program appears to be an efficacious intervention for use among people affected by cancer who also experience symptoms of depression and anxiety.

Greg R Sharplin BHSc(Hons), BSc · Simeon B W Jones BHSc(Hons), BA · Barbara Hancock DipNurs, DipCouns · Vikki E Knott BA(Hons), PhD · Jacqueline A Bowden MPH, BA(Hons) · Hayley S Whitford PhD

Objective: To test the feasibility and acceptability of a telephone-based program to screen survivors of colorectal cancer (CRC) for distress, and to refer distressed patients to their treating health service.Design, setting and participants: A prospective, multicentre study involving 59 patients with CRC recruited from six public and private health services in Melbourne, Victoria, from 15 June 2008 to 22 September 2009. Patients who had completed adjuvant chemotherapy for CRC were contacted (7–10 days after recruitment [outcall one] and again 4 weeks later [outcall two]) by the Cancer Council Victoria’s helpline nurse, and screened for distress with the Distress and Impact Thermometer (DIT); participants were given tailored information and support and those with distress scores of ≥ 5, and impact scores of ≥ 4, were referred for follow-up. Telephone interviews were conducted 4 weeks after outcall two. Participating helpline and health service staff were surveyed on the feasibility and acceptability of the service.Main outcome measure: Anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS).Results: Of the 59 patients (87%) who agreed to participate, 63% were men; their mean age was 59 years (SD, 9.5 years). HADS depression decreased significantly from baseline (mean score, 4.93; SD, 4.22) to follow-up (mean score, 3.84; SD, 4.10; Z = − 2.375; P = 0.02). However, there was no significant difference in HADS anxiety between baseline (mean score, 5.29; SD, 4.11) and follow-up (mean score, 4.78; SD, 3.65). Outcall one generated two referrals (4% of participants) and outcall two generated four referrals (8%); five of these six participants took up the referrals. Satisfaction with the program among participants was high; 82% found outcall one “quite or very helpful” and 79% found outcall two “quite or very helpful”. Helpline and health service staff reported a straightforward process that did not adversely affect workloads. Conclusion: This model of care carries the potential to meet ongoing psychosocial needs of survivors of CRC.

Patricia M Livingston PhD · Melinda J Craike PhD · Victoria M White PhD · Amanda J Hordern PhD · Michael Jefford MPH, PhD, FRACP · Mari A Botti PhD · Carrie Lethborg PhD · John C Oldroyd PhD

To the Editor: The recent MJA supplement provides an excellent summary of internet interventions for a range of psychiatric conditions, including anxiety, depression and substance misuse.1 However, in highlighting the positive uses of the internet, it is important to remember other aspects of online engagement that can have a negative impact on patients’ mental health. It is useful to ask patients specifically about their internet activities, as they will not necessarily volunteer this information. For example, people can spend a large amount of time accessing pornography online. Negative effects of this may include the impact on existing real-world relationships, the cost, and the risks associated with participation in illegal activities. Some patients may go further, arranging to meet people they have encountered on the internet in person, which entails a risk of physical or sexual assault. The internet provides an opportunity for discreet gambling and, as with other forms of gambling, the effects can be destructive. Excessive participation in online games such as World of Warcraft, to the extent that people spend virtually all their waking hours engrossed in playing games, can also be a problem. Bullying and socially destructive behaviour occurring on widely used social networking sites such as Facebook can cause considerable distress to the victim. Such sites can be used to deliver unwelcome information (eg, ending a relationship by changing one’s Facebook status to “single” and “de-friending” the partner). Privacy can also be an issue, and Facebook provides much information to potential stalkers if users fail to adequately protect their data. Some medical practitioners have allowed patients to become their “friends” on Facebook, which can involve inappropriate access to the doctor’s personal life and a risk of blurring professional boundaries.2 Finally, the internet is increasingly being incorporated into delusions expressed by people with psychotic disorders.3 For example, patients with schizophrenia may have paranoid beliefs that derogatory material about them is being distributed via the internet. Enquiring about patients’ internet activities is therefore a useful addition to the standard mental health assessment.

Cherrie A Galletly

Bipolar disorders are cyclical mood disorders with clinical features including distinct sustained periods of mood elevation. Briefer (4 days or more), mild episodes of mood elevation define bipolar II disorder; lengthier (7 days or more), more severe episodes (or those requiring hospitalisation), with or without psychotic features, define bipolar I disorder. Depressive periods are more common and lengthier than manic or hypomanic states, and are the main cause of disability. Bipolar depression may respond poorly to antidepressants and these medications may destabilise the illness. The diagnosis of bipolar disorder should be considered when a patient with depression is treatment resistant. Irritability is a common symptom in bipolar disorder, particularly during mixed states (during which patients have features of mood elevation and depression concurrently) or when there is rapid cycling of mood (more than four episodes of mood disorder per year). Alcohol misuse and use of illicit drugs may simulate mood changes in bipolar disorder. Accurate diagnosis and assessment of bipolar disorder is essential for clinical decision making and determining prognosis and treatments.

John W G Tiller MD, FRACP, FRANZCP · Isaac Schweitzer MD, DPM, FRANZCP

General practitioners are often consulted for first presentations of bipolar disorder and are well placed to coordinate patient care. They can assist with early identification of bipolar disorder and monitoring for manic and depressive episodes. Delayed and incorrect diagnoses are common in bipolar disorder, and unipolar depression is a frequent misdiagnosis. Characteristics that can be used to distinguish bipolar I depression from unipolar depression (when no clear prior manic episodes are evident) include the course of illness, symptoms, mental state signs and family history. Manic episodes can be caused by poor adherence to medication, substance misuse, antidepressants and stressful events, and are often preceded by early warning signs. Early warning signs are less commonly observed for depressive episodes. Daily mood charts are useful for providing an overview of patient progress and for identifying and managing early warning signs. Families and carers can also play an active role in supporting patients with bipolar disorder.

Philip B Mitchell AM, MB BS, MD, FRANZCP, FRCPsych · Colleen K Loo MB BS, MD, FRANZCP · Bronwyn M Gould AM, MB BS, DipPaed, MPsycholMed

General practitioners are involved in the continuing care and shared care of patients with chronic mental illness, including bipolar disorder. Psychiatrists are particularly reliant on GPs to monitor and treat comorbidities as well as the psychiatric condition itself. Management of chronic mental illness is compromised by a number of factors, including problems with diagnosis, physical comorbidity, erratic attendance and poor compliance with treatment. Diagnosis of bipolar disorder is often delayed, and differential diagnoses to be considered include unipolar depression, anxiety disorder, drug and alcohol dependence, personality disorder, attention deficit hyperactivity disorder, and general medical and central nervous system diseases. New Medicare items have been introduced under the Better Access to Mental Health Care initiative. However, uptake for patients with chronic psychiatric illness, including bipolar disorder, is low. Patients with bipolar disorder may be prone to a range of comorbid psychological, social and physical problems, and GPs need to be vigilant to detect and manage comorbidity and social problems as part of the overall plan. This includes assistance with certification for sickness and unemployment benefits. GPs may become involved during crises affecting patients and this may pose significant problems for GPs who need to provide ongoing care following patient discharge from hospital. Despite these difficulties, opportunities exist for GPs to play a vital and ongoing role in the management of patients with bipolar disorder.

Leon Piterman MD, MMed, FRACGP · Kay M Jones BSW, MT+D, PhD · David J Castle MD, FRANZCP, FRCPsych

Rates of conditions comorbid with bipolar disorder are very high, with anxiety disorders, impulse-control disorders, and drug and alcohol problems being the most distinctly over-represented conditions. Although the high rates of comorbid conditions may be overestimates — owing to measurement distortions in community surveys, and because definitions of comorbidity generally include antecedent and consequential conditions (not merely coterminous ones) — they are clinically distinctive. Clinical comorbidity can be explained by at least four different models, which each have clinical management implications. If the bipolar disorder and the comorbid conditions are deemed to be interdependent, two broad approaches are appropriate: hierarchical management strategies and sequential management strategies. Successful management of bipolar disorder often involves the development of a wellbeing plan that addresses comorbid issues iterative to the bipolar disorder.

Gordon B Parker MD, PhD, FRANZCP

Bipolar affective disorders carry significant risks to the patient and sometimes others. The form of the illness relapse needs to be determined, and high-risk features such as psychosis and suicide considered. Gathering collateral information from others is invaluable. Mania brings particular risks of disinhibition, poor judgement, risk taking and sometimes aggression. Depression carries notable risks of suicidal behaviour, poor self-care and homicide. Both mania and depression bring risks of substance misuse and disrupted relationships. Management requires an optimal therapeutic alliance with good communication, appropriate treatment and sometimes compulsory care during crises. Preventive strategies are invaluable.

Darryl L Bassett MB BS, FRANZCP, DipPsychother

Objective: To provide a practical overview of the pharmacological management of adults with bipolar disorder in primary care and the role of general practitioners in the pharmacotherapy of this complex disorder.Data sources: Published guidelines for the treatment of bipolar disorder, plus Cochrane reviews, meta-analyses, review articles and reports from randomised controlled trials that were published up to May 2009.Study selection: Over 500 articles on the treatment of bipolar disorder were reviewed, with an emphasis on meta-analyses and systematic reviews of randomised controlled trials. Where evidence was more limited, open trials and non-controlled data were also reviewed.Data extraction: Key recommendations relevant to GPs were synthesised and rated according to National Health and Medical Research Council levels of evidence.Data synthesis: Lithium, valproate and atypical antipsychotics are first-line treatment options for acute mania, and monotherapy is ideal if it produces an adequate response. For depressive episodes, recommendations are less definitive and the use of antidepressants is controversial. Most patients require maintenance treatment, during which pharmacotherapy should be used to prevent relapse, and psychological and social interventions should be considered.Conclusions: Bipolar disorder is a lifelong episodic illness that affects 1%–2% of the population, many of whom are principally managed by their GPs. Pharmacological treatment with mood-stabilising agents is the primary form of management, although this is ideally provided in conjunction with psychosocial interventions.

Gin S Malhi FRCPsych, FRANZCP, MD · Danielle Adams BSc(Psych)(Hons), MPsych(Clin) · Michael Berk MB BCh, FRANZCP, PhD

Adjunctive psychosocial interventions for bipolar disorder target many of the issues that are not addressed by medication alone, including non-adherence, efficacy–effectiveness gap and functionality. Psychosocial interventions have been found to reduce relapse, particularly for the depressive pole, and improve functionality. Approaches such as psychoeducation, cognitive behaviour therapy, interpersonal and social rhythm therapy, and family therapy have shown benefits as adjunctive treatments. Each of the various psychosocial interventions has a unique emphasis, but they share common elements. These include: providing information and education; developing a personal understanding of the illness, such as triggers and early warning signs; having prepared strategies in place for early intervention, should symptoms of illness develop; and promoting a collaborative approach. Evidence to date supports the use of adjunctive psychosocial interventions in the management of bipolar disorder.

Sue D Lauder MPsych(Clinical) · Michael Berk MB BCh, FRANZCP, PhD · David J Castle MD, FRANZCP, FRCPsych · Seetal Dodd BSc, MSc, PhD · Lesley Berk MA(ClinPsych)

Inside chronic pain. An intimate and critical account . Lous Heshusius. New York: Cornell University Press, 2009 (xvii + 167 pp). ISBN 978 0 8014 4796 9. The lessons contained in this concise, personal narrative of an articulate patient crippled by chronic pain present a number of challenges to all who read it. There is a brief, scholarly foreword by David Morris, Professor of English at the University of Virginia, that sets the scene — conceptually, all chronic illness must be constructed at the crossroads of biology and culture. And there is an excellent coda by Scott Fishman, Professor of Anesthesiology and Pain Medicine at the University of California, Davis, which emphasises that the story you’ve just read is not unique. We have to ask ourselves, how can we consistently access all the options to put it together for these patients? How often do we even say, “I will go through this journey with you, and be your consultant”? More often than we care to admit, we neglect the social, spiritual and cultural dimensions of our patients’ experience in favour of a medical model of disease. The patients bear the largest burden on the journey towards recovery. How does one competently advocate for oneself when emotion and dysfunctional cognitions unduly influence the processes? Support systems are needed to negotiate a maze of clinicians, contradictory information and advice, and adversarial bureaucracies, yet time has to be spent alone in the present — not in the past or future — practising individualised coping strategies. This book will make you annoyed and frustrated — with the writer, her health care professionals, yourself, and with the system. Perhaps, you may also reflect on your management of chronic pain, and open new communication channels with your patients and your colleagues. Even undergraduates can learn from this little book, but I think it would be best read and digested by experienced clinicians. The only real downside is its North American setting. However, I can assure readers it all happens here too.

Robert D Helme

A primer of clinical psychiatry. David Castle, Darryl Bassett. Sydney: Churchill Livingstone, 2010 (xv + 311 pp). ISBN 9780729539036. Clinical Psychiatry is a rich and often challenging discipline. Clearly and concisely describing, in book form, the myriad presentations, tools of assessment and methods of treatment is no easy task. Yet Professor David Castle from Melbourne and Darryl Bassett from Perth, assisted by fellow Australian psychiatrists in some of the chapters, have achieved this with their “primer”. Medical students, in particular, and students of other health disciplines as well, will find this book very useful, but it will also appeal to general practitioners wanting a quick refresher or ready resource. As one might expect, the book covers the psychiatric interview, common investigations, major syndromes, biological and psychological treatments, and issues pertaining to special patient groups (eg, child and adolescent, old age, forensic, “dual disability”). A problem frequently encountered with introductory texts of this type is that, in attempting to provide a broad overview in limited space, they become “remote”, are reduced to checklists, fail to convey the essence of a field, and lack soul. Such criticisms cannot be levelled reasonably at Castle and Bassett’s book. For instance, the numerous case examples, advocacy for a hierarchical classification, and boxes and tables of practical information (such as “A safe restraint method” in the chapter on psychiatric emergencies) infuse the text with relevance and life. The book is not without quirks. For example, the only appendix, “Objective Structured Clinical Examinations (OSCEs) in psychiatry” sits oddly, if confirming the book’s utility for students. And the reason for including substance-use disorders among “special patient groups” rather than “psychiatric syndromes” is elusive, given the prevalence of such disorders. Finally, the authors eschew discussion of the ethical dimension of psychiatric practice, which I think is necessary even in the briefest and most basic of primers. Despite these limitations, this is an excellent text, bound to enhance the psychiatric knowledge and skills of the reader and, thus, render psychiatry less daunting.

Garry Walter

Incorrect statement of risk: In “Factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors” in the 2 August 2010 issue of the Journal (Med J Aust 2010; 193: 161-166), there was an error in the last paragraph of the Results section (page 163). The wording of the last sentence of the paragraph should be: “Doctors were at less risk of hazardous alcohol use if they: trained overseas rather than in Australia (OR, 0.56 [95% CI, 0.39–0.81); worked more than 60 hours a week compared with less than 40 hours a week (OR, 0.67 [95% CI, 0.45–0.99]); and had not taken a holiday in more than a year (OR, 0.63 [95% CI, 0.43–0.93]).”

Louise M Nash · Michele G Daly · Patrick J Kelly · Elizabeth H van Ekert · Garry Walter · Merrilyn Walton · Simon M Willcock · Chris C Tennant

New guidelines are timely but miss an opportunity to emphasise early intervention for all young people There are few mental health issues of greater concern to the wider community than the management of young people with depressive disorders. Consequently, the new draft clinical practice guidelines from beyondblue: the national depression initiative1 are timely. The previous National Health and Medical Research Council Clinical practice guidelines: depression in young people were produced in 1997 and rescinded in 2004, and a variety of other international perspectives are now available.2,3 Internationally, the limitations of the clinical trial database, such as small and non-representative or restricted trial samples, and exclusion of more severe cases or patients with suicidal ideation, are widely recognised. Hence, the authors rely very heavily on “good practice points” that are said to be “based on lower quality evidence, expert opinion and current good practice”. Importantly, the new draft guidelines recognise that appropriate services are still not provided to about 75% of Australian young people with depression. They suggest there is a lack of clear evidence for primary (or universal) prevention and give qualified support for pre-emptive psychological strategies for those at high risk. Recent systematic reviews of school-based prevention and early intervention programs for anxiety and depression, however, support a more optimistic view (reporting effect sizes of 0.11–1.37 for anxiety, using data from 20 programs;4 and 0.21–1.40 for indicated depression interventions, based on 28 programs5). These effect sizes were often clinically important and support the notion that school-based programs should be pursued more assertively. Other key issues covered by the guidelines include the challenges associated with engaging young people with our health care systems, the lack of focus on improving long-term outcomes, and the fact that more severe bipolar and psychotic disorders emerge against the background of earlier depressive disorders. In Australia, surveys of young people have highlighted attitudinal and knowledge barriers6 and the clinical reality that under-recognition of and lack of access to evidence-based psychological therapies are still common.7 Unfortunately, the guidelines overemphasise and reinforce stereotypes of young people who are reluctant to seek care, parents who are unaware of the nature of the disorder, the complexity of clinical assessment and lack of access to specialist mental health services. These are artefacts of the current failure to respond to youth mental health as a salient public health issue. We would encourage the authors to take full advantage of the opportunity to add depth to the emerging field of youth psychiatry and to support the development of enhanced models of empowering, collaborative and youth-focused clinical practice.8 The most novel outcome in the new draft guidelines is the Expert Working Committee’s decision to focus on the age range of 13–24 years, rather than a more restricted focus on 12–18 years. This is consistent with current understanding of the continuities in brain and social development,9 the pattern of incidence of mental disorders and the changing sociology of adolescent and early adult development.10 There is clear evidence of multiple transitions in both the genetic and environmental determinants of depressive disorders from the onset of puberty right through to the early adult period.11 The key developmental processes in the brain — synaptic pruning and maturation of the white matter tracts — are continuous throughout these years.9 However, in key areas, the guidelines fall back on the traditional divide between adolescents (13–18 years) and young people (19–24 years). While this reflects the reality that most treatment studies have used a 13–18-years age range, it ignores the fact that the division at 18 years is based on legal and educational boundaries rather than clinical, developmental, neurobiological or cultural considerations, and thus is not soundly based. What is desperately needed in both clinical research and service development12 is a shift away from this artificial divide to the more inclusive age range of 12–25 years. Short-term treatment recommendations are spelt out in the guidelines, at least for those under 18 years of age. Specific psychological therapies are the preferred first-line intervention for most patients, while new antidepressant drugs are reserved for those with more severe disorders or those who fail to respond to psychological interventions. The small risk of increased suicidal ideation in young people commencing newer antidepressant drugs (4% for active treatments versus 2% for placebo13) is appropriately re-emphasised. Previously, wide media coverage of United States Food and Drug Administration warnings about antidepressant drugs resulted in major changes in clinical practice in the US.14 Clearly, the authors expect a similar outcome in Australia, suggesting that these new guidelines may even lead to “a net saving in the area of pharmacotherapy”. This is inconsistent with the more serious emphasis that the rest of the document puts on providing evidence-based care for many more young people. Importantly, it has been suggested that the fall in antidepressant use in the US was associated with an increase in suicides in young people.14 Previous population-based data have indicated a positive relationship between exposure to antidepressants and reduction in suicides. In those under the age of 18 years, most suicide attempts occur in the month before treatment and then decline sharply once treatment has commenced.15 We need to move beyond endless debate about the appropriate threshold for providing active care — the real treatment issue is one of appropriate sequencing of treatments. Wherever possible, clinical care should start with engagement of the young person and his or her family and then be linked with active provision of relevant information and evidence-based psychological therapies. A clinical staging model16 combined with appropriate stepped care may therefore offer a useful clinical approach. In a basic stepped-care model, those presenting with early or less severe forms of illness are initially offered appropriate non-pharmacological interventions. If the condition is more severe, the clinical situation worsens or the young person fails to respond to psychological therapies, then antidepressant therapy may well have a crucial role to play. The guidelines fail to emphasise the emerging importance of early intervention services. What is really required in Australia is a fundamental commitment to increase access to evidence-based care systems for young people from 12 to 25 years of age. While various state and national planning documents and the recent Council of Australian Governments decisions on health reform point the way for future service reforms, we still lack the real investment and commitment to turn these treatment guidelines into accessible and responsive clinical services systems.

Ian B Hickie AM, MD, FRANZCP · Patrick D McGorry PhD, FRCP, FRANZCP

Objective: To identify factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors.Design, setting and participants: Cross-sectional postal survey of 2999 doctors (including all major specialty groups, trainees and general practitioners) insured with an Australian medical insurance company. The potential for psychiatric morbidity was measured by the General Health Questionnaire (GHQ), and the potential for hazardous alcohol use by the Alcohol Use Disorders Identification Test (AUDIT). The survey was conducted in 2007.Main outcome measures: Demographic, work-related and personality factors associated with a GHQ score > 4 and an AUDIT score ≥ 8.Results: Factors significantly associated with psychiatric morbidity in doctors were: having a current medicolegal matter, not taking a holiday in the previous year, working long hours, type of specialty, and having personality traits of neuroticism and introversion. Factors significantly associated with potentially hazardous alcohol use were being male, being Australian-trained, being between 40 and 49 years of age, having personality traits of neuroticism and extroversion, failing to meet Continuing Medical Education requirements, and being a solo practitioner.Conclusions: The mental health of medical practitioners is crucial to the quality of care their patients receive. Doctors should reflect on their hours of work and need for holidays. Involvement with medicolegal processes, such as lawsuits, complaints and inquiries, is a stressful part of medical practice today. Doctors need to be educated about these processes and understand how the experience may affect their health, work and loved ones.

Louise M Nash MB BS(Hons), BA, FRANZCP · Michele G Daly BSc(Hons), MSc · Patrick J Kelly BMath(Hons), PhD · Elizabeth H van Ekert BADipEd, MMedHum · Garry Walter MB BS, PhD, FRANZCP · Merrilyn Walton BA, MSW, PhD · Simon M Willcock MB BS, PhD, FRACGP · Chris C Tennant MD, MPH, FRANZCP

Charles Bonnet syndrome (CBS) is a disorder in which psychologically normal people, often with vision impairment, experience complex visual hallucinations. The hallucinations are purely visual and do not occur in any other sensory modality, and people with CBS have full insight into the unreal nature of the hallucinations. This report describes the case of a CBS sufferer who experienced a distressing change in the nature of her visual hallucinations following a stressful event — the Black Saturday bushfires of February 2009. Clinical recordA healthy and alert 80-year-old woman presented for an orthoptic consultation in September 2009. The patient was legally blind (ie, her best corrected visual acuity was less than 6/60), with diagnosed age-related macular degeneration and closed-angle glaucoma. She had a known 4-year history of Charles Bonnet syndrome (CBS), a condition that caused her to have complex visual hallucinations, usually triggered when she was in unfamiliar surroundings. She reported that the nature of her hallucinations had changed significantly. Previously, the patient had experienced images such as “an elephant walking down the street with a child on its back” and intricate blue designs when looking at white plates or coloured carpets. While the patient was aware that the images were not real, occasionally her insight was delayed if the hallucination fit into the surrounding environment. For example, she would see a truck while travelling as a passenger in a car and, upon alerting the driver that they were about to collide with the truck, would be informed that it was a letterbox by the side of the road. When the hallucinations had first appeared, the patient had thought “there is something going on in my head” and reported her symptoms to her husband and then to her ophthalmologist, who explained the benign nature of the disorder. Since that time, she had not been troubled by the hallucinations, explaining “usually I can laugh at it”. Initially, the patient’s experience with CBS followed the typical pattern — she experienced hallucinations weekly that usually lasted only for several seconds. The patient’s hallucinations became atypical on “Black Saturday”, 7 February 2009, a day of intense heat and bushfires in the southern Australian state of Victoria. Bushfires raged in 14 regions across the state, resulting in 173 deaths.1 The patient lives in an area affected by the fires and was evacuated from her home on Black Saturday. That day and subsequently, she experienced hallucinations that were horrific in nature to her, such as seeing a prickly coat on her short-haired dog, spiral wire-like hair protruding from the heads of bald family members, and their faces beginning to melt, “like wax dripping”. She saw people’s legs covered with curly, black, wiry hair. Despite her visual impairment, the patient is a talented artist and has drawn her disturbing hallucinations (Box 1). The hallucinations that commenced on Black Saturday persisted for days, rather than seconds, and the images frightened the patient for the several days during which she experienced them. She reported experiencing great stress during the bushfires and also recalled earlier distressing episodes with significant fires as a child, while living in London: a chimney caught fire in her home; she witnessed the burning of the Crystal Palace in 1936; and she was present during the “Blitz” between September 1940 and May 1941, when London was subjected to intense aerial firebombing. She reported that these stressful episodes relating to fire increased her fear on Black Saturday and explained that “fire has a particularly bad effect on me”. Following discussion about CBS and her experiences, a review was not considered necessary from an orthoptic point of view, but she was encouraged to make contact as necessary if symptoms changed. She was also instructed to continue seeing her ophthalmologist and her psychologist. DiscussionThis case demonstrates that a stressful life event can change the nature of hallucinations experienced in CBS, with an accompanying change in emotional experience (from non-distressing to distressing). In general, hallucinations can result from false sensory input to the brain and occur in the absence of external stimuli. When a person presents with visual hallucinations, an underlying psychiatric disorder, neurological abnormality or drug intake can be suspected.2 Visual hallucinations can also occur as a result of lesions in the visual system, from the cornea to the cortex. The occurrence of complex visual hallucinations, as reported in this case, was first described by Swiss philosopher, naturalist and lawyer Charles Bonnet in 1760, after whom the disorder was later named. CBS is characterised by vivid, elaborate and recurrent visual hallucinations in psychologically normal people, who have full insight into the unreal nature of the hallucinations.3,4 The hallucinations are purely visual and do not occur in any other sensory modality. Images of complex patterns and people are most common, and the hallucinations often fit into the surrounding situation. They can appear for several minutes every week, and can continue to occur for 12 months or more. Often CBS occurs upon waking, but not exclusively so.5 Key features of CBS are listed in Box 2. Two theories have been proposed to explain CBS: the “release” and “sensory deprivation” theories. The release theory postulates that a lesion at any level of the visual pathway leads to the release of defective electrochemical impulses, thereby causing visual hallucinations. The sensory deprivation theory proposes a similar mechanism, except that it is reduced sensory input to the brain as a result of an ocular lesion that causes spontaneous discharge of neurones at the level of the retina or cortex.6,7 Triggers for the onset of CBS have not been clearly identified, and the circumstances the person finds themselves in at the onset of an episode can vary. It is possible that this patient suffered with acute stress disorder, as she had a past history of exposure to fire-related trauma and reported distressing recollection of the bushfires, but she did not report other symptoms of acute stress disorder.8 The change in nature of her hallucinations may represent interplay between CBS and an acute or post-traumatic stress disorder. The number of cases of CBS in Australia is not known. Reticence to discuss symptoms of CBS out of fear of being labelled insane is common. Most people only tell a family member about their symptoms and very few discuss the problem with a medical professional.5 Further, the symptoms of CBS are probably not always recognised and therefore correctly identified. As in this patient, CBS is usually associated with vision impairment, and it is important for clinicians to be aware that these types of hallucinations may occur in patients with advancing age and early vision impairment. The prevalence of CBS in people with impaired vision has been reported to be between 10% and 40%, with a much lower prevalence in Asian populations (< 1%).9-13 It is estimated that almost half a million Australians have vision impairment,14 and the prevalence of CBS hallucinations among these patients has been found to be 17.5%,5 suggesting that about 85 000 people in Australia may have CBS. However, while there is an association between CBS and loss of vision, it can also occur in individuals with no obvious ocular abnormality. There is no treatment of proven effectiveness for CBS, but the use of selective serotonin reuptake inhibitors has been associated with a reduction in hallucinations.15 Sporadic reports of effective medications can be found in the literature, but no controlled clinical trials have been published. Some sufferers indicate that closing their eyes or blinking may make the hallucinations stop.5 This case report highlights the limited knowledge about the underlying causes and triggers of CBS and the need for further investigation into this disorder. 1 Patient’s drawings of her disturbing hallucinations following the Black Saturday bushfires Family members with melted faces and spiral wire-like hair on their heads and legs, and a prickly coat on the patient’s short-haired dog. 2 Key features of Charles Bonnet syndrome Vivid, elaborate and recurrent visual hallucinations3 Experienced by psychologically normal people who have insight into the unreal nature of the hallucinations3 Risk factors include vision impairment, old age, hearing impairment, living alone, and female sex5 Reported prevalence is 10%–40% of the vision-impaired population; prevalence is skewed by non-reporting of the hallucinations for fear of being labelled with a psychiatric disorder5 Hallucinations typically last for several minutes and commonly occur upon waking5 There is no treatment of proven effectiveness6

Meri Vukicevic BOrth, PGDiplHlthResMthds, PhD

To the Editor: The medical view, which is repeatedly stated in the literature,1-3 is that up to 100% of those who complete suicide are suffering from a mental disorder. This leaves many doctors feeling they can be held responsible for all those who suicide, including those for whom there is no evidence of mental disorder. A recent High Court of Australia judgment, Stuart v Kirkland-Veenstra,4 illustrates that the medical and legal views of the relationship between suicide and mental disorder are different. In this case, a wife alleged that police officers had failed to provide a duty of care towards her husband, who had been found by the officers in a car with a hose leading from the exhaust pipe into a rear window, but with the driver’s window down and the car engine cold. The officers talked to the husband, who claimed marital problems but that he had changed his mind about suicide and was planning to go home and discuss matters with his wife. The officers felt the husband was rational, cooperative and responsible, with no evidence of alcohol or drug misuse; they offered him assistance (which he declined) and allowed him to leave. Later that day, the husband completed the suicide. He had not told the officers that he was expecting to be served with papers relating to fraud charges that afternoon. The Stuart v Kirkland-Veenstra judgment,4 in favour of the police officers, includes the following statements: Suicide and attempted suicide are seen as reflective of psychological or psychiatric issues which may or may not involve ‘mental illness’ according to established diagnostic conventions . . . Given the complexity and variety of factors which may lead to suicidal behavior, it would be a bold legislative step indeed to sweep it all under the rubric of mental illness, however widely defined. Word limits prevent me from giving more detail about the case, but interested readers will find this accessible judgment valuable. Clinicians dealing with “difficult” (but not mentally disordered) people in difficult circumstances often feel themselves to be in a perilous legal position, able to be held responsible for the actions of all those who choose to end their lives. The Stuart v Kirkland-Veenstra judgment clarifies the legal perspective, that suicide does not necessarily indicate the presence of a mental disorder, and that where mental disorder does not exist, human services personnel will not necessarily be held responsible for the actions of others.

Saxby Pridmore

To the Editor: The recent review by Hayes and colleagues1 does not sufficiently emphasise practical approaches to managing the later stages of Parkinson disease (PD). Nazem and colleagues2 reported active suicidal or death ideation in 30% of patients with PD of mild-to-moderate severity, and an overall rate of major depression of 27.6%. They found that psychiatric symptoms and disorders, especially major depression, rather than PD-related variables, predicted suicidal or death ideation. Only half of the depressed patients were being treated with an antidepressant. Screening for psychiatric disorders should occur on assessment. Skilled counselling is required, and carers need to be well supported, particularly if the patient has intermittent suicidal ideation and a strong wish for the end of life. Clozapine is the only antipsychotic shown to be effective for treating psychosis in patients with PD.3 If the psychosis is schizophrenia-like, with persistent bizarre delusions and florid hallucinations causing agitation, clozapine can be prescribed in Australia by a registered psychiatrist and the patient can be registered with the clozapine monitoring service. If the patient is started on a very low dose (6.25 mg daily) that is only very gradually increased, side effects can be minimised. Successful use of clozapine enables remission of the psychosis and optimal treatment of motor symptoms. Mild hallucinations may be tolerated without specific treatment while the patient retains insight. In an open-label study of patients with mild hallucinations comparing no treatment with quetiapine therapy (or clozapine therapy in a minority of cases),4 the rate of progression to hallucinations without insight, or delusional psychosis, was significantly slowed. Hely and colleagues5 have argued that pathological processes in addition to Lewy body disease may have a role in the appearance of dementia, as age is a better correlate than PD duration. If it is clear that the dementia is a PD dementia, or dementia with Lewy bodies, a cholinesterase inhibitor such as rivastigmine could be prescribed. As rivastigmine is not subsidised on the Pharmaceutical Benefits Scheme in Australia for this indication, a private prescription could be provided in the first instance, and if there was a likelihood of significant Alzheimer disease associated with PD, an authority prescription would be justified. Hely and colleagues pointed out that, in the later disease stages of PD (at 20 years), less than 50% of patients still see their neurologist. However, the quality of life for PD patients in nursing-home care could still be significantly improved by specialist review by members of a multidisciplinary team on an inpatient, outpatient or outreach basis.

David S Tofler

To the Editor: A recent article by O’Donnell and colleagues1 claimed contradictory results to a previous study which found that compensation was associated with worse health and return-to-work outcomes after injury.2 Their findings were similar to those of the previous study until they excluded a group of non-compensable patients because they had accessed private health insurance. The authors argued that “private health insurance was similar to other compensation agencies in that patients in this group had their health care costs met”. Using this argument, all patients would be compensable, as Australia has a universal health care system in which all Australians have their health care costs met. There is no precedent in the literature for such an exclusion. Compensation bodies provide additional payments beyond health costs, including payment for pain and suffering and income replacement. They also involve patients in a complex process with many features thought to influence outcomes (eg, the adversarial nature of making compensation claims and delays in receiving payments). We believe that the exclusion of private patients from the non-compensable group in the study by O’Donnell et al was incorrect and reduced the already small study sample, limiting the capacity to identify differences across groups. Furthermore, O’Donnell and colleagues found that compensable patients had higher anxiety levels at 24 months, until a supplementary analysis showed that, after controlling for stressful interactions with compensation agencies, compensation itself became non-significant. Surely stressful interactions are one of the mechanisms by which any compensation effect might be mediated. To say that an association is not significant once the mechanism of the effect is allowed for is akin to stating that smoking is not carcinogenic once the carcinogens are allowed for. O’Donnell and colleagues appear to be stating that simple access to compensation is not harmful, with which we agree, but fail to consider the complexities of compensation involvement. Both studies1,2 share a common limitation — that of comparing victims of transport-related injury with victims of other injury types. A recent study confirmed compensation and lawyer involvement as predictors of worse outcomes in a study of compensable and non-compensable transport-related trauma.3 A true understanding of the effect of compensation requires comparison of patients of comparable injury circumstances (eg, road trauma) and different compensation systems. Studies are clearly needed to establish a better understanding of the complexities of compensation delivery and the impact on outcomes. O’Donnell and colleagues’ conclusions have the potential to mislead compensation authorities and other stakeholders who should be focused on addressing this issue.

Belinda J Gabbe · Ian A Harris · Alex Collie · Peter A Cameron

To the Editor: In their recent study, O’Donnell and associates1 examined the effect of compensation, and the clinically vexing problem of interaction with insurance companies, on recovery after hospitalisation for trauma in Victoria. They concluded that access to compensation might not be associated with a poor outcome per se. We agree that the relationship between compensation and health outcomes is complex, but believe there are a number of conceptual and methodological issues that undermine their findings. First, as they note, this sample of injured people might not be representative of those making an insurance claim. In an earlier study of motor vehicle accidents in New South Wales,2 less seriously injured victims who only attended their general practitioner or spent less than a day in hospital comprised as much as 70% of those seeking compensation. Furthermore, the article by O’Donnell and colleagues provides no description of any differential attrition with respect to factors that may be associated with poorer psychosocial outcomes (such as previous psychiatric disorders), other than sex and acute hospital factors. The outcome measurement characteristics change in the course of the analyses, potentially undermining power to detect any differences. For example, the quality-of-life and disability measures become dichotomised using norms in the population for the modelling, rather than as scores in the baseline characteristics as in Boxes 2 and 3. This approach has the potential to conceal true differences between the groups because of regression to the mean and baseline differences in both groups. The main problem relates to the possibly post-hoc exclusion of privately insured subjects from one group. We do not believe that private health insurance can reasonably be considered to be “compensation”. It can provide money to cover the cost of inpatient treatment and very limited outpatient services, but provides no more recompense and retribution for injury than Medicare. Older and wealthier Australians disproportionately hold private health insurance. This group is likely to differ on a number of factors, many of which are associated with better psychosocial outcomes. Although the authors have evaluated some demographic factors, this is likely to have introduced some potentially significant confounding. Thus there is little justification for the removal of this group from the non-compensable group alone. We would be interested to see an analysis after the removal of subjects with private health insurance from both groups. This would allow a more rigorous examination of the effect of one factor — actual insurance compensation — on recovery outcomes.

Nicholas S Glozier · Matthew Large

To the Editor: O’Donnell and colleagues seek to extend and improve on previous research into the relationship between compensation status of injuries and medium-term health outcomes.1 Improvements are needed because much of the empirical analysis in this area has had major methodological limitations.2 Their analysis uses an impressive array of mental health measures to probe the “compensation effects”. However, several aspects of the study design raise questions. First, with very few exceptions, the transport accident compensation scheme in Victoria covers all injuries arising from transport accidents. It is therefore unclear how a quarter of patients in the non-compensable group could have suffered injuries due to motor vehicle accidents (MVAs) yet have fallen outside the scheme. Second, the purpose of control variables in a multivariate model is to address potential confounders of the relationship between the predictor of interest (MVA compensability) and the outcomes (measures of health status at 24 months). Using significant univariate differences between the predictor of interest and other covariates as the basis for selecting control variables is statistically inappropriate, and this approach may have affected the results of the regression analyses. Third, a key study finding is that significant differences in health outcomes were detected between MVA-compensable and non-compensable patients at 24 months after injury. These then “all but disappeared” when the non-compensable group was altered by shifting three patients who had accessed Transport Accident Commission compensation over to the MVA-compensable group and dropping 54 patients who had accessed “other forms of compensation”. The result casts the spotlight on the removed group. It suggests that their mean health status at 24 months was relatively high. But who were they? Little information is provided, other than that nearly two-thirds (36/57) had private health insurance and were dropped for this reason. (In our view, private health insurance should not be construed as compensation, because policies tend to be highly selective about services covered and generally do not provide payment for lost income or non-economic losses.) Another possible explanation, not addressed, is that with only 88 patients left in the non-compensable group, the multivariate analyses lacked power to find differences. The relationship between compensation availability and injury recovery is complex. Policy interest in the relationship looks set to increase in the next few years, as the federal government explores the merits of a national disability scheme.3,4 In this environment, the need for rigorous research and reliable findings will be greater than ever. O’Donnell and colleagues’ welcome contribution to the evidence base should stimulate further debate about how best to disentangle the effects of injury compensation systems on the health outcomes of Australians who call upon them.

David M Studdert · Harold Luntz · Genevieve Grant

To the Editor: As noted by O’Donnell and colleagues,1 there is a growing body of evidence suggesting that provision of compensation is associated with poor recovery after injury. Most of this evidence arises from international workers compensation jurisdictions. However, two recent Victorian studies have examined health and work outcomes in compensable and matched non-compensable groups after transport injury.1,2 Despite examining broadly similar patient groups and using broadly similar outcome measures, the two articles reach very different conclusions. There has been substantial community reaction to these findings. Gabbe and colleagues’ suggestion that compensation is associated with poor recovery2 provoked public criticism of its methodology from the Law Institute of Victoria, and a prominent plaintiff legal firm released a public statement3 3 days after publication of the study by O’Donnell et al. There is a disconnection in conceptualisation of this issue between the research community and those involved in compensation regulation and policy. Researchers are focusing on the question “Does compensation lead to poor health outcomes?”, while the more nuanced policy question attracting the attention of many injury compensation regulators is “Which, if any, aspects of the compensation scheme have a positive or negative impact on health, vocational and social outcomes?”. Close inspection of the published literature suggests that there are individual components of compensation systems that may have a negative impact on outcome, including the provision of payments for pain and suffering4 and the provision of income benefits.5 There are also examples of compensation organisations acting to improve outcomes via their broader remit as government regulators. For example, the Transport Accident Commission was a major driver of the reorganisation of the Victorian state trauma system, which has resulted in a significant reduction in mortality after road trauma.6 O’Donnell and colleagues1 note the complex relationship between compensation and health outcomes, with particular reference to patient characteristics. The compensation schemes themselves are also highly complex. However, there has been very little research effort directed towards identifying the impact of specific scheme components on patient outcome. In Victoria, the two major injury compensation regulators have funded the Institute for Safety, Compensation and Recovery Research to address this issue. This level of interaction between policymakers and researchers is needed to improve outcomes for those injured in transport- and work-related accidents.

Alex Collie · Niki Ellis