Mental health

In reply: We thank the authors of the above letters for their comments. Our response will focus only on the major themes raised. We note the concerns about excluding people with private health insurance. The issue here is not whether having health care costs met by private health insurance is the same as having motor vehicle accident (MVA) compensation entitlements. Rather, it is whether access to private insurance payments for health care is the same as not having any compensation at all. We argue that injury patients with private insurance have access to a broader range of health care services and providers than those in the public system, and can access these services more quickly because they avoid long public sector waiting lists. The suggestion that patients who are dependent on public health care in the 2 years following injury (non-compensable patients) receive the same health care as those who have private insurance is unjustified. Most studies to date have not considered other schemes such as private insurance, ignoring the potential impact they may have on health outcomes. We recognise that there may be demographic differences between patients who are involved with other schemes such as private health insurance, and these factors may contribute to outcomes. In noting the inherent limitation in this approach, we nonetheless argue that there are also limitations to including these patients, and therefore an analysis that excludes privately insured patients is a valid addition to the literature on compensation. In response to the point raised by Gabbe and colleagues, we note that our analysis showing that “stressful interaction with the compensation agency” accounted for variance in anxiety scores was designed to investigate potential mechanisms that may explain why anxiety was higher in the MVA-compensable group. We did not conduct the analysis to argue that this group was not more anxious than the non-compensable group. They were more anxious. Glozier and Large were concerned that differential attrition may affect comparisons between the two groups. To clarify, there were no significant baseline differences between completers and non-completers on any measure. Their second issue relates to the removal of patients with private health insurance from the analyses. To clarify, we removed anyone who indicated at 24 months that they had accessed private or other forms of compensation, regardless of their original compensation classification. Studdert and colleagues were concerned that we used univariate differences to identify control variables. We adopted this process to replicate the statistical methodology used by Gabbe et al,1 in an attempt to replicate their findings. In conclusion, our study illustrates the complexity of compensation research and the importance of carefully defining populations — a point that has not yet been adequately addressed. Indeed, a recent review of the literature argues that most compensation research is methodologically limited.2 We agree that there are limitations to our methodology, as there are in previous studies, and recognise that conducting this kind of research is inherently difficult. We welcome the establishment of the Institute for Safety, Compensation and Recovery Research, noted by Collie and Ellis, and its support of this challenging and complex research.

Meaghan L O’Donnell · Mark C Creamer · Richard A Bryant · Alexander C McFarlane · Derrick Silove

To the Editor: I would like to clarify some of the statements made about the National Coroners Information System (NCIS) in the article by De Leo and colleagues.1 The article cites a study conducted by the NCIS concerning the presence of intentional self-harm determinations in coronial findings. Unfortunately, De Leo and colleagues did not note that this study was an internal and informal review of a small random sample of findings conducted by the NCIS that examined disparities between codes assigned on the NCIS and coronial findings. On the basis of this limited study, I would not endorse the statement (which was attributed to me) that “nationally, 29% of coroners omit reference to intent”. Further, it is important to note that NCIS staff do not assign intent codes on entries in the NCIS, and that this coding is performed by clerks in each of the coroners’ offices. The statement in the article that “the NCIS judged 111 (39%) as involving intentional self-harm” is therefore misleading, and should instead have indicated that the coding on the NCIS showed 111 deaths (39%) as involving intentional self-harm. I acknowledge that De Leo and colleagues did not intend to mislead readers as to the work of the NCIS.

Jessica D Pearse

Mental health across cultures. A practical guide for health professionals. Jill Benson, Jill Thistlethwaite. Oxford: Radcliffe Medical Press, 2008 (xiii + 208 pp). ISBN 9781846192197. In an increasingly multicultural Australia, a medical practitioner is called upon, on a daily basis, to treat patients from diverse cultural backgrounds: migrants, refugees, students from other cultures and Indigenous people. This cultural diversity extends to differences in social status, age, religion, sexual orientation and many other sociodemographic aspects. A medical consultation across the cultural divide is fraught with the risk of miscommunication. Jill Benson and Jill Thistlethwaite, in this small information-packed volume, provide an antidote to such a predicament. Both authors are doctors who have worked in diverse settings in Australia and overseas, have treated patients from many different cultural backgrounds, are knowledgeable about diverse cultures and sensitive to differences, recognise the importance of mental health consultations in general practice, and take a keen interest in their patients’ stories. The first call they make in the book is for physicians to become aware of cultural differences. They then present a model for working across the cultural divide, beginning with self-reflection, developing an understanding of another culture through networking and mentoring and, most importantly, listening to the patient’s story. The primary care physician is first and foremost a healer, and this book presents a succinct view of the issues that come up when psychotherapy, behaviour therapy or narrative therapy must bridge a cultural divide. Even pharmacotherapy is not immune to transcultural challenges as miscommunication can affect adherence and appropriate use of drugs, and ethnic or racial differences can influence drug kinetics and dynamics. The strength of this book lies in the distilled wisdom of two practitioners who teach through real-life examples and present practical solutions. It can therefore be recommended to all physicians and medical students. If you are an international medical graduate practising in Australia or an Australian graduate wishing to work overseas, you will find the case studies particularly appealing. The book fills a gap in the cross-cultural health literature.

Perminder S Sachdev

Innovative web services can overcome the barriers that block access to mental health care A range of factors have come together rapidly over the past decade to create a health services environment in which web-based technologies now offer one of the most promising opportunities for earlier and better management of common mental health problems. These factors include international recognition of the health burden attributable to anxiety, depression and substance misuse;1 epidemiological evidence that mental disorders largely commence before the age of 25 years;2,3 the development of highly interactive web-based technologies, and their widespread use in Australia (particularly among young people); and rapidly changing community attitudes towards help seeking for mental health problems.4-6 Sadly, the proportion of Australian adults with current mental health problems using traditional health care services has not increased (38% in 1997 v 35% in 2007).7 This is despite the apparent success of public awareness campaigns that have promoted help seeking4-6 and some substantial changes in primary care-based approaches to the provision of medical and psychological treatments.8,9 In reality, the structures, distribution and costs that currently underpin our primary and secondary care services make them relatively unavailable to many of those in need.10 Despite the strong arguments in favour of early intervention in youth mental health, it is this group who are most neglected by the current arrangements.11,12 By contrast, young people with difficulties are increasingly seeking informal and formal help online (see Burns et al). Recent work supported by the Australian Primary Health Care Research Institute has identified six successful models of e-health services.13 These include: stand-alone systems offering prevention, self-help and self-care approaches through websites; consumer-assisted care, offering early intervention and facilitated self-help delivered online through peer support from volunteers with lived experience of a mental disorder — these organisations are directed by individuals who have both lived experience and mental health professional qualifications; virtual clinics, providing early intervention and treatment using assisted professional care through the web, with telephone or email support; general practice models, where professionals offer e-treatment under various primary health care arrangements, including collaborative care approaches; and stepped care, which offers a range of integrated services from prevention, self-help and self-care through to assisted and professional care, and hospitalisation if required. The sixth model, common in the United States, is the development of packages of care that are offered in managed care environments by private organisations. Web-based mental health services have the capacity to not only overcome traditional geographical, attitudinal and financial barriers to access to care, but also to lower overall delivery costs and reduce demands on the clinical workforce. The 2006 Council of Australian Governments mental health reform package allocated $57 million for development of telephone counselling, self-help and web-based support programs.14 The new Fourth National Mental Health Plan15 suggests that better use should now be made of innovative web and telephone services. Very recently, a 10-year plan for the e-mental health sector in Australia has been drafted.16 It proposes a national e-health stepped-care service, a national access portal to all mental health services (see Christensen and Hickie), the establishment of consumer e-health records, and the development of a National Research and Development Collaborative Centre for Innovation in e-health. Australia has been a leader in the development of internet-based early treatment packages and prevention tools. At this critical stage, the articles in this Supplement present evidence concerning a number of key strategies and experiences to date. Several articles review the evidence for the effectiveness of internet interventions for anxiety and depression (Griffiths et al), adolescent alcohol use (Tait and Christensen), and management of high-prevalence disorders in young people (Calear and Christensen). The experiences of a range of online health service delivery models are also presented, including a stand-alone health promotion and social networking site for young people (Burns et al); self-help and prevention services (Bennett et al); an example of a virtual clinic (Andrews and Titov); and the use of an adjunctive e-health application delivering cognitive behaviour therapy for managing depression in primary care (Hickie et al). One report provides insights into the workings of a stepped-care program for e-mental health in the Netherlands (van Straten et al). Finally, a new health web portal — Beacon — is launched “in print” (Christensen et al). This web portal compiles all e-health intervention sites for anxiety and depression worldwide and rates them according to the quality of the scientific evidence of their effectiveness. Genuine health reform in Australia is slow and is likely to continue to neglect people with mental health problems.17,18 A significant national investment in e-mental health would not only give a real boost to prevention and early intervention, it would also address the fundamental lack of access to mental health services in this country. In doing this, we would finally orientate our efforts towards the long-term development of a more sustainable, equitable and patient-centric system that responds sensitively to the needs of those with difficulties.

Helen Christensen PhD, FASSA · Ian B Hickie AM, MD, FRANZCP, FASSA

Objective: To review the outcomes, nature and quality of published randomised controlled trials of preventive and treatment internet interventions for depression and anxiety disorders, and to document the availability of effective interventions.Data sources: Previous reviews of internet interventions for mental health and related conditions were updated using an extension of the original methodology. All studies included in the original reviews and more recent eligible trials (published before June 2009) were included, together with any trials identified from a search of the health intervention web portal Beacon and the Journal of Medical Internet Research.Study selection: A total of 29 reports describing 26 trials satisfied the inclusion criteria.Data synthesis: All trials employed a cognitive behaviour therapy intervention program. Of the 26 trials, 23 demonstrated some evidence of effectiveness relative to controls. Effect size differences ranged from 0.42 to 0.65 for depression interventions involving participants with clinically significant symptoms of depression, and 0.29 to 1.74 for anxiety interventions involving participants with a diagnosed anxiety disorder. Of the five effective English-language programs, three are available to the public without charge and two can be accessed at a small cost through health practitioner referral.Conclusion: Internet interventions for depression and anxiety disorders offer promise for use as self-help applications for consumers or as an adjunct to usual care.

Kathleen M Griffiths PhD · Louise Farrer BPsych(Hons) · Helen Christensen PhD

Objective: To identify and describe current internet-based prevention and treatment programs for anxiety and depression in children and adolescents.Data sources: Systematic search of the Cochrane Library, PsycINFO and PubMed databases conducted in June 2009.Study selection: Studies of internet-based programs that addressed anxiety or depression in children and adolescents. No restrictions were placed on study quality.Data synthesis: Eight studies of four intervention programs were identified. Programs were delivered via schools, in primary care, through mental health clinics or open access websites. Two were treatment programs, three offered universal prevention, two were indicated prevention programs, and one was a selective prevention program. Study quality was mixed, with three randomised controlled trials in which participants were randomly allocated to the intervention or control condition, one randomised uncontrolled trial, two controlled trials in which participants were not randomly assigned to conditions, and two uncontrolled pre–post evaluations. Two studies targeted anxiety in children, while the remainder addressed depression, or anxiety and depression, in adolescents. All the interventions were based on cognitive behaviour therapy, and six of the eight studies reported post-intervention reductions in symptoms of anxiety and/or depression or improvements in diagnostic ratings. Three of these studies also reported improvements at follow-up.Conclusion: Our findings provide early support for the effectiveness of internet-based programs for child and adolescent anxiety and depression. More extensive and rigorous research is needed to further establish the conditions through which effectiveness is enhanced, as well as to develop additional programs to address gaps in the field.

Alison L Calear PhD · Helen Christensen PhD

Objective: To explore patterns of internet use by young people in Australia and assess the usefulness of online resources for mental health problems, exploring functionality that may be relevant in the development of online mental health services.Design and participants: Cross-sectional survey of a nationally representative sample of young people (2000 randomly selected participants aged 12–25 years), via telephone interview, conducted in January–March 2008.Main outcome measures: Patterns of internet use including type of use, social networking, sources of information about mental health, alcohol or other substance use problems and levels of satisfaction with the information, and type of information accessed via websites.Results: Young people reported using the internet to connect with other young people (76.9%; 1464/1905) and to seek information about a mental health problem, regardless of whether they had a problem themselves (38.8%; 735/1894). Twenty per cent of young people (398/1990) had personally experienced a mental health problem in the previous 5 years; when these people were asked about sources of information used for this problem, 30.8% (70/227) reported searching the internet. Patterns of internet use and types of resources used differed by age and sex.Conclusion: Our findings suggest that technology is important in the everyday lives of young people, and online mental health services that encompass promotion and prevention activities should include a variety of resources that appeal to all ages and both sexes, such as “question and answer” forums and email.

Jane M Burns PhD · Tracey A Davenport BA(Hons), eMBA · Lauren A Durkin PhD · Georgina M Luscombe Bsc(Hons), PhD · Ian B Hickie AM, MD, FRANZCP, FASSA

Reach Out Central (ROC) is a serious game drawing on the principles of cognitive behaviour theory that has been designed to improve the mental health and wellbeing of young people, particularly men. ROC was developed over a 3-year period from 2003 to 2006, in consultation with young people aged 16–25 years who use the Reach Out mental health website (http://www.reachout.com). ROC was launched online in September 2007. A traditional and viral awareness campaign was designed to engage young men, particularly “gamers”. In the first month after launch, ROC had 76 045 unique website visits, with 10 542 new members (52% male) joining Reach Out. An independent online evaluation involving 266 young people aged 18–25 years was conducted between August 2007 and February 2008 to examine psychological wellbeing, stigma and help seeking in ROC players. Overall results indicated that ROC was successful in attracting, engaging and educating young people. Young women reported reduced psychological distress and improved life satisfaction, problem solving and help seeking; however, no significant changes were observed for young men. Although ROC was successful in attracting young men, demonstrating that the concept resonates with them, the service failed to keep them engaged. Further research is needed to explore how (or what changes need to be made) to sustain young men’s engagement in the game.

Jane M Burns PhD · Marianne Webb BA · Lauren A Durkin PhD · Ian B Hickie AM, MD, FRANZCP, FASSA

Objective: To determine the feasibility of conducting a cluster randomised trial in Australia of the effectiveness of general practitioner-supported delivery of internet-based cognitive behaviour therapy (CBT) and enhanced psychological care.Design, setting and participants: Cluster randomised trial involving patients attending general practices in Australia. Participating practices were randomly allocated to interventions. The study was conducted between January 2004 and January 2007.Interventions: Enhanced GP care was delivered by doctors who had completed specific mental health training; the experimental condition consisted of enhanced GP care plus MoodGYM, an internet-based CBT intervention.Main outcome measures: Demographic and behavioural characteristics of patients, and demographic and practice characteristics of GPs; time to resolution of psychological symptoms for patients involved in the longitudinal phase of the trial.Results: 1571 patients attending 90 GPs from 84 general practices were identified as potentially suitable for recruitment. These patients had a mean age of 35 years, 76% were female, 84% had access to the internet for personal use, and 22% reported high or very high levels of psychological distress on the Kessler Psychological Distress Scale. The 90 GPs had a mean age of 49 years, 53% were female and 25% had completed formal mental health training. Of the 1571 screened patients, 340 reported high levels of psychological distress, but only 140 of these could be further assessed for eligibility in the trial. Of these 140, 83 patients with depression (attending 10 GPs in eight general practices) proceeded to randomisation. For these patients, the experimental intervention (enhanced GP care plus MoodGYM) tended to result in prompt and more sustained resolution of depressive symptoms.Conclusion: Our capacity to conduct a definitive trial was limited by available resources. Preliminary data suggest that primary care patients with depression may derive additional benefits from an internet-based CBT program delivered in conjunction with enhanced psychological care from GPs.

Ian B Hickie AM, MD, FRANZCP, FASSA · Tracey A Davenport BA(Hons), eMBA · Georgina M Luscombe BSc(Hons), PhD · Michael Moore MB BS, FRACGP, GradDipPH · Kathleen M Griffiths PhD · Helen Christensen PhD, FASSA

Stepped-care approaches may offer a solution to delivering accessible, effective and efficient services for individuals with depression. In stepped care, all patients commence with a low-intensity, low-cost treatment. Treatment results are monitored systematically, and patients move to a higher-intensity treatment only if necessary. We deliver a stepped-care model targeting patients with depression. The first step consists of “watchful waiting”, as half of all patients with a depressive episode recover spontaneously within 3 months. The second step, guided self-help, is the key element of the stepped-care model. Guided self-help, especially when offered through the internet, is effective and cost-efficient. The third step consists of brief face-to-face psychotherapy. Finally, in the fourth step, longer-term face-to-face psychotherapy and antidepressant medication might be considered. Patients are monitored by one person, a care manager, who is responsible for the decision to step up to the next treatment and for continuity of care. The different treatments within the stepped-care model are evidence-based. Data on cost-effectiveness of the full model are still scarce, but we recently demonstrated that the incidence of new cases of depression and anxiety could be halved by introducing stepped care. Effects of web-based guided self-help could be enhanced by incorporating them in a stepped-care model.

Annemieke van Straten PhD · Wike Seekles MSc · Nelleke J van ‘t Veer-Tazelaar MA · Aartjan T F Beekman MD, PhD · Pim Cuijpers PhD

Objective: To describe the Beacon web portal, which lists and rates quality health websites, collects user characteristics and publishes user feedback; and to report summary data on Beacon’s highest-rated (best evidence-based) sites for mental health.Data sources: A systematic search was undertaken in February 2009 for potentially relevant websites through a review of research papers and a recently published book, an internet search of Open Directory Project medical categories, a review of material on a high-profile mental health portal, and a survey of international researchers.Selection criteria: All sites were ranked on a 7-point scale from − 1 to 5, with negative scores indicating evidence of no effect and scores of 2 or more indicating evidence of efficacy based on reports in the scientific literature.Results: By March 2010, 183 sites had been identified, of which 122 focused on physical health or wellbeing, 40 targeted anxiety, and 23 targeted depression. Of the eight generalised anxiety disorder sites identified, four achieved ratings of 2 or above. Two social anxiety disorder sites achieved scores higher than 2. Ten panic disorder sites were identified, with three achieving ratings of 2 or above; and five post-traumatic stress disorder sites were identified, with two achieving ratings of 2 or above. Of the 23 identified depression sites, four achieved a rating of 2 or above.Conclusions: There are a number of high-quality mental health websites on the internet, and Beacon provides a portal to enable the wide dissemination of these resources.

Helen Christensen PhD · Kristen Murray BA, BSc(Hons) · Alison L Calear PhD · Kylie Bennett BA(Hons) · Anthony Bennett BAppSc · Kathleen M Griffiths PhD

Internet treatment programs for anxiety and depressive disorders are becoming available and offer cost-effective alternatives to face-to-face treatment with medication or cognitive behaviour therapy. The Clinical Research Unit for Anxiety and Depression at St Vincent’s Hospital, Sydney, offers internet treatment courses at the VirtualClinic (http://www.virtualclinic.org.au) for people who meet diagnostic criteria for major depression, social phobia, panic disorder and generalised anxiety disorder. These courses are free to people recruited for research. The results of VirtualClinic trials show a high level of patient adherence and strong reductions in symptoms, and that very little clinician time is required. The four treatment programs that have been successfully evaluated in the VirtualClinic have been made available on a not-for-profit basis ($5 service fee) at the CRUfADclinic (http://www.crufadclinic.org) for general practitioners and other clinicians to use with their patients. These programs could be the first level of treatment in a stepped-care environment, where patients who do not benefit sufficiently could then receive face-to-face treatment from their clinician or be referred for specialist treatment.

Gavin Andrews AO, MD · Nickolai Titov PhD

Self-help delivered through online websites has been found to be beneficial for people with mental health problems, and consumers find internet support groups helpful. The Australian National University e-hub group delivers automated web interventions (BluePages, MoodGYM, e-couch) and an online bulletin board (BlueBoard) to the public for mental health self-help. The evidence-based web interventions require no direct therapist or other human involvement, while the bulletin board is moderated by trained consumers under the supervision of a clinical psychologist. Users may contact the e-hub service by email. These web services are used by a large number of users, with and without clinical mental disorders, often over a long period of time. These services provide programs for prevention and early intervention and are particularly suited to people who prefer anonymous services, live in rural and remote areas, or have a preference for self-help methods, as well as for use in school and workplace settings. A range of best-practice measures have been developed and put in place to ensure high-quality service delivery. Evaluation and quality control are enabled by a database and associated software.

Kylie Bennett BA(Hons) · Julia Reynolds MPsych(Clin) · Helen Christensen PhD · Kathleen M Griffiths PhD

Traditional clinic-based service delivery systems remain inaccessible to many Australians with mental health problems. If we are to substantially reduce the burden of mental illness, we need to develop more accessible, empowering and sustainable models of mental health care. E-health technologies have specific efficiencies and advantages in the domains of health promotion, prevention, early intervention and prolonged treatment. It is timely to use the best features of these technologies to start to build a more responsive and efficient mental health care system.

Helen Christensen PhD, FASSA · Ian B Hickie AM, MD, FRANZCP, FASSA

To the Editor: In your recent column, you drew attention to the “limitations of psychiatry’s scientific foundations for disorders of the mind”.1 This was despite psychiatry’s recent high profile, and the very large sums of money being thrown at the problem. The limiting factor for a scientific psychiatry is that there isn’t one. Extensive research has shown that orthodox psychiatry does not yet have a formal, articulated model of mental disorder to guide its practice, its teaching and its research.2,3 Moreover, not one of the models used today, including the biological approach, can be developed to the point where it would meet the minimum criteria for a scientific model. Confections such as the “biopsychosocial model” do nothing but conceal the problem under yet another layer of jargon. Releasing another Diagnostic and statistical manual of mental disorders (DSM) will achieve nothing because it does not address mental disorder within the framework of an agreed model. In the absence of science, there is scope for non-scientific pressures (such as politics and finance) to have an inordinate influence on the many DSM committees. Needless to say, this conclusion is most unpopular among many in the psychiatric establishment but, sooner or later, they will have to come to grips with the problem; otherwise, psychiatry as a profession will cease to exist.4

Niall McLaren

To the Editor: Cardiovascular disease (CVD) and mental disorders are the top two contributors to the total burden of disease in Indigenous Australians and make a substantial contribution to the excess morbidity and mortality in this group.1 There is increasing evidence that mental disorders are risk factors for, or consequences of, CVD.2 Awareness and better understanding of the intertwined relationship between mental disorders and CVD in Indigenous populations can provide opportunities for coordinated and seamless management of these conditions in health care systems. We investigated the association between mental disorders due to substance use and CVD in a remote Indigenous community in the Northern Territory. A cohort of 897 Aboriginal adults aged 20–74 years (85% of the community’s total adult population) was established through a population-based renal disease screening program in the community between 1992 and 1995.3 We followed up 784 participants, who were free of CVD at baseline, to 31 May 2005, using hospital and death records. The study was approved by the Behavioural and Social Sciences Ethical Review Committee of the University of Queensland. Substance use-related mental disorders were determined from participants’ hospital records, using International Classification of Diseases, ninth revision (ICD-9) codes 192, 291 and 303–305; and 10th revision (ICD-10) codes F10–F19. Cases of CVD were identified by the first CVD event recorded in participants’ hospital and death records, using ICD-9 codes 390–459 and ICD-10 codes I00–I99. We used the Kaplan–Meier method to calculate cumulative CVD incidence rates for those with and without substance use-related mental disorders. CVD hazard ratios were estimated using Cox proportional hazards models. During a median follow-up period of 10 years, 177 of the 784 participants (23%) had clinically diagnosed mental disorders due to substance use (mainly alcohol: 140 participants), and 243 (31%) developed CVD. Incidence rates of CVD were 71 (95% CI, 58–87) and 27 (95% CI, 23–32) per 1000 person-years for those with and without substance use-related mental disorders, respectively (Box). Participants with substance use-related mental disorders were 2.6 (95% CI, 2.0–3.3) times more likely to develop CVD than those without. After adjusting for CVD risk factors measured at baseline (age, sex, body mass index, smoking status, alcohol use, blood pressure, serum cholesterol level, diabetes and albuminuria status), the association remained statistically significant, with an adjusted hazard ratio of 2.6 (95% CI, 1.9–3.5). Our findings confirm an association between substance use-related mental disorders and CVD in an Indigenous population, after adjusting for potential confounders. Traditional health care systems tend to separate services and treatment for mental disorders from those for physical health problems such as CVD.4 This separation is even more evident in remote Indigenous settings, where primary health care practitioners are already overwhelmed in providing general medical care to community members, with mental health services being delivered infrequently by visiting psychiatrists.5 The observed intertwined relationship between these two common conditions calls for integration of mental health services into routine primary health care, and enhanced collaboration between primary care practitioners, cardiologists and psychiatrists, in an effort to curb the huge burden imposed by these diseases. The emerging Aboriginal mental health worker program in the NT has the potential to be an effective service model to bridge the gap between mental health care and day-to-day primary health care.5 Dedicated financial resources and ongoing support for recruitment, training and retention of Aboriginal mental health workers will be required for sustained integration of mental health care with primary care in Indigenous communities. Kaplan–Meier estimates of cardiovascular disease (CVD) incidence among Aboriginal adults with and without substance use-related mental disorders

Zhiqiang Wang · Damin Si · Wendy E Hoy

Objective: To explore emerging themes related to the mental health of Aboriginal children and adolescents (“young people”) arising from focus groups conducted in Sydney, New South Wales.Design, setting and participants: A qualitative study was conducted between April 2008 and September 2009 in three Aboriginal community-controlled health organisations in Sydney. A semi-structured approach was used in focus groups and small group interviews to elicit the views of 15 Aboriginal parents and 32 Aboriginal workers from a variety of health and social work backgrounds on important factors surrounding the mental health of Aboriginal young people.Results: Major themes identified were the centrality of family and kinship relationships, the importance of identity, confounding factors in the mental health of Aboriginal young people, and issues related to service access and implementation.Conclusion: Clinicians working with Aboriginal young people should be mindful of the critical importance of family and identity issues and should assess possible physical health or social factors that may complicate a diagnosis. Improvements in access to mental health services for Aboriginal families and a more holistic approach to mental health treatment are urgently required.

Anna B Williamson BPsych(Hons), PhD · Beverley Raphael AM, MB BS, MD, FRANZCP · Sally Redman BPsych(Hons), PhD · John Daniels MB BS, FACRRM · Sandra J Eades BMed, PhD · Naomi Mayers

Objective: To compare rates of visits to a general practitioner between users and non-users of mental health services (MHS).Design, participants and setting: Population-based retrospective cohort study of 204 727 users and 294 076 matched non-users of MHS in Western Australia from 1 January 1990 to 30 June 2006, based on linked records of the use of MHS, hospital admissions, Medicare claims for GP and specialist services, electoral roll registration and deaths.Main outcome measures: Adjusted rate ratios (ARRs) for the number of visits to GPs by users of MHS relative to non-users, and for different categories of mental disorders.Results: Relative to non-users of MHS, the ARR of visits to GPs by users of MHS was 1.622 (95% CI, 1.613–1.631) overall, and was elevated in each separate category of mental illness. ARRs were highest for alcohol/drug disorders, schizophrenia and affective psychoses (2.404, 1.834 and 1.798, respectively). The results were not changed by location (metropolitan, rural or remote addresses). However, the 4% of MHS users with no fixed address had a very low ARR of visits to GPs (0.058; 95% CI, 0.057–0.060).Conclusions: Users of MHS visit GPs substantially more often than non-users, with the exception of those with no fixed address who seldom see a GP at all.

Qun Mai MB BS, MPH · C D’Arcy J Holman MPH, PhD, FAFPHM · Frank M Sanfilippo BPharm, PGradDipPharm, PhD · Jonathan D Emery MB BCh, DPhil, FRACGP · Louise M Stewart BSc(Hons), GradDipPublicHealth

Objective: To examine the changes in rates of methods of suicide in Australian states and territories between 1988 and 2007.Design and setting: Meta-analysis of suicide mortality rates and suicide methods (hanging, shooting, gassing, poisoning, jumping from a height, drowning, use of a sharp implement) for males and females in Australian states and territories in the decades 1988–1997 and 1998–2007.Main outcome measures: Changes in use of suicide methods from 1988 to 2007; changes in the overall suicide rates and in rates for each method of suicide in Australian states and territories between 1988–1997 and 1998–2007.Results: There was a decline in rates of shooting, gassing, poisoning and drowning in males and a decline in shooting, gassing, jumping from a heiight and drowning among females, but an increase in hanging by both males and females in the decade 1998–2007 when the compared to 1988–1997. There was significant variation in the rates of and trends in methods of suicide between the states and territories of Australia between 1988–1997 and 1998–2007.Conclusions: The decline in rates of suicide in most parts of Australia coincides with a reduction in the availability of lethal methods. Consideration should be given to further measures to limit the availability of lethal methods of suicide.

Matthew M Large MB BS, FRANZCP · Olav B Nielssen MB BS, FRANZCP

Suicide and intentional self-harm are issues of major importance in public health and public policy, with rates widely used as progress indicators in these areas. Accurate statistics are vital for appropriately targeted prevention strategies and research, costing of suicide and to combat associated stigma. Underreporting of Australian suicide rates probably grew from 2002 to 2006; Australian Bureau of Statistics (ABS) suicide data were at least 11% or 16% undercounted (depending on case definitions) in 2004. In coronial cases with undetermined intent for 2005 to 2007, intentional self-harm was found in 39%. Systemic reasons for undercounting include: (i) absence of a central authority for producing mortality data; (ii) inconsistent coronial processes for determining intent, as a result of inadequate information inputs, suicide stigma, and high standards of proof; (iii) collection and coding methods that are problematic for data stakeholders; and (iv) lack of systemic resourcing, training and shared expertise. Revision of data after coronial case closure, beginning with ABS deaths registered in 2007, is planned and will reduce undercounting. Other reasons for undercounting, such as missing or ambiguous information (eg, single-vehicle road crashes, drowning), differential ascertainment (eg, between jurisdictions), or lack of recorded information on groups such as Indigenous people and gay, lesbian, bisexual and transgender people require separate responses. A systemic coordinated program should address current inaccuracies, and social stigma about suicide and self-harm must be tackled if widespread underreporting is to stop.

Diego De Leo MD, PhD, FRANZCP · Michael J Dudley MB BS, FRANZCP · Caroline J Aebersold BA(Hons) · John A Mendoza DipTeaching, BEd, GradDipHealthSci · Michael A Barnes BA, LLB, LLM · James E Harrison MB BS, MPH, FAFPHM · David L Ranson BM BS, LLB FRCPA

Objective: To examine the comparative prevalence and distribution of obesity and psychological disturbance in the asthma and non-asthma populations, and to determine how these comorbidities are associated with physical functioning.Design, setting and participants: A South Australian population-representative study of 3175 adults who provided data on asthma, psychological morbidity, physical functioning, and body mass index. Bivariate and multivariate analyses identified how these comorbidities were distributed in asthma and non-asthma subpopulations, and the variance in physical functioning that they explained.Main outcome measures: Rates of obesity and psychological morbidity, and physical functioning scores in asthma and non-asthma populations.Results: Men and women in the asthma population had similar prevalences of obesity (35.3% v 33.6%) and psychological morbidity (29.5% v 29.4%). When compared with non-asthma controls, both comorbidities were significantly higher only in men with asthma. The prevalence of psychological morbidity within different weight categories in the asthma population compared with non-asthma weight-category controls varied by sex. Physical functioning was lower in the asthma population than the non-asthma population (46.6 [95% CI, 45.9–47.3] v 48.8 [95% CI, 47.8–50.0]; P < 0.001), and psychological morbidity explained 22% of this variance.Conclusions: Psychological morbidity and obesity are common in people with asthma. The sex-specific variation in psychological morbidity across weight categories suggests that future studies of psychological morbidity in groups with asthma should adopt designs that consider sex-specific controls rather than comparisons between the sexes.

David H Wilson PhD, MPH, BEd · Sarah L Appleton BA · Anne W Taylor PhD, MPH, BA · Graeme Tucker BSc · Richard E Ruffin AM, MD, BSc(Hons), FRACP · Gary Wittert MB BCh, MD, FRACP · Graeme Hugo PhD, BA(Hons), MA · Robert D Goldney MB BS, MD · Christopher Findlay PhD, MEc · Robert J Adams MB BS, MD, FRACP

Objective: To conduct a descriptive study investigating the effect of access to motor vehicle accident (MVA) compensation on recovery outcomes at 24 months after injury.Design and setting: Longitudinal cohort study conducted in two Level 1 trauma hospitals in Victoria, Australia. Participants were 391 randomly selected injury patients with moderate-to-severe injuries. Compensable and non-compensable patients were compared at 24 months after injury on a number of health outcomes.Main outcome measures: Health outcomes at 24 months, including anxiety and depression severity, quality of life and disability.Results: Medical records identified two groups of compensation patients: MVA-compensable and non-compensable patients. After controlling for baseline variables, the MVA-compensable patients, at 24 months, had higher levels of post-traumatic stress disorder, anxiety and depression, and were less likely to have returned to their pre-injury number of work hours. However, some patients in the non-compensable group had accessed other forms of compensation (eg, private health care or compensation for victims of crime). When these were removed from the non-compensable group, the differences between MVA-compensable and non-compensable groups all but disappeared.Conclusion: Our findings do not support previous research showing that access to compensation is associated with poor recovery outcomes. The relationship between access to compensation and health outcomes is complex, and more high-level research is required.

Meaghan L O’Donnell BSc(Hons), MA(Clin), PhD · Mark C Creamer BA(Hons), MA(Clin), PhD · Alexander C McFarlane MMed(Psych), FRANZCP · Derrick Silove MMed(Psych), FRANZCP · Richard A Bryant BA(Hons), MA(Clin), PhD

New findings highlight that child sexual abuse is a major risk factor for future illness Child sexual abuse is a social issue but, because of its association with psychological and other problems, it is of special concern to the medical profession.1 An article by Cutajar and colleagues in this issue of the Journal (page 184) shows a greatly increased risk of suicide among people who have experienced sexual abuse in childhood.2 The findings are somewhat stunning: compared with the general population, those with a record of experiencing child sexual abuse had a relative risk of suicide of 18.09 (14.20 for males and 40.38 for females). The relative risk of accidental fatal drug overdose was 88.42 for females and 38.46 for males. Such relative risks are high and of the same order of magnitude as those that link cigarette smoking to lung cancer and chronic obstructive airways disease.3 The study by Cutajar et al, from the School of Psychology, Psychiatry and Psychological Medicine at Monash University, was made possible by the authors’ use of established but underutilised resources, including the Victorian Psychiatric Case Register, the National Coroners Information System, the Victorian Coronial Information Database and records of the Victorian Institute of Forensic Medicine. Although such databases underestimate the prevalence of child sexual abuse and adverse outcomes, they provide a means of extracting data on mental health status and rates of suicide and death from drug overdose for a population in which child sexual abuse had been notified. Increased suicide rates in people who have experienced child sexual abuse are not due to the abuse alone, and suicide is not an inevitable, or even a common, outcome. Just as the great majority of people who smoke cigarettes do not develop cancer of the lung, the great majority of people with a history of child sexual abuse do not commit suicide. Much work needs to be done in examining the intermediary variables in development for victims of child sexual abuse who develop psychological problems in adolescence and young adulthood. Although child sexual abuse is a marker for later psychosocial problems, it may not be the critical formative experience — many patients who become disturbed in adolescence and young adulthood report child sexual abuse but also have a history of other disruptive factors during childhood which centre on such issues as rejection, abandonment, problems regarding trust and an inner sense of chaos often associated with dissociation.1 It is also fascinating that Cutajar et al found that the most common background psychiatric disorder recorded for patients who experienced child sexual abuse and died from self-harm was anxiety rather than depression, which is usually perceived as the background psychopathological experience for those who ultimately commit suicide.4 This needs further research and explication. In clinical practice, it is common to meet women aged in their 50s and 60s who will tell you about a child sexual abuse experience. Despite this, many appear to have led otherwise “normal” lives. Some identify experiences that surround the circumstances of child sexual abuse, such as failure to feel protected, and say that they have always been sensitive about personal safety and trust, lack of order, and unpredictability. On the other hand, psychiatrists see many women during their 30s who have had childhoods that were disorganised and damaging on multiple levels (eg, involving physical and verbal abuse, a pervasive feeling of being unprotected, and chaotic parental relationships) and have included child sexual abuse, and who describe themselves as “complete ratbags in their teens and 20s who got their act together in their early 30s”. None whom I have seen can satisfactorily explain this transformation. One of the findings in the article by Cutajar et al was that the average age at time of suicide for those who experienced child sexual abuse (about 31 years) was similar to the average ages at time of suicide and accidental fatal overdose for the population as a whole. Many doctors and nurses recognise this as the age at which the worst excesses of personality disorder and borderline personality disorder begin to abate. This area of developmental research has been neglected. Patients with borderline personality disorder often report child sexual abuse among myriad insults during childhood development.5,6 These patients often begin to “settle” during their late 20s and late 30s. At my institution, the Emergency Mental Health team has developed modestly successful programs for patients with borderline personality disorder. In general, such programs do not include an extensive or in-depth investigation of the details of child sexual abuse, which many of our patients would be reluctant to discuss but are grateful to have acknowledged. Most of the time is spent discussing their pressing need to feel safe and their feelings of rejection and abandonment. I regularly see patients in a state of crisis and decompensation, apparently because their therapist feels that it is important that the details of their sexual abuse are fully revealed. However, it is not at all convincing that talking through the actual details of the abuse helps. Recently, dialectical behaviour therapy has been shown to be promising for patients with borderline personality disorder.5,7 This therapy does not emphasise revelation of past events related to child sexual abuse as part of the therapeutic exercise. Our understanding of the role and importance of child sexual abuse in disorders of adolescence and early adulthood is incomplete, and our present approach for treating patients with a history of such abuse is therapeutically eclectic. Research is lacking on whether our present approach will reduce the incidence of suicide and fatal overdose among people in their 30s. The moral and cultural complexities of child sexual abuse are appreciated and shared throughout the medical profession, and we are in a good position to provide special leadership. The complex psychopathological conditions that are associated with disorders of adolescence and young adulthood need more investigation, and their association with child sexual abuse needs explanation. The study by Cutajar and colleagues reveals important findings from a study in a complex area. These point to the need for a great deal of work in dissecting issues involved in the pathways to suicide in child sexual abuse victims, including why some patients are vulnerable and others are resilient. Additionally, preventing ongoing child sexual abuse requires improving resources for child protection services and a massive public health response.

Ross S Kalucy FRANZCP, FRACP, FRCPsych

Objective: To determine the rate and risk of suicide and accidental fatal drug overdose (ie, overdose deemed not to have been suicide) in individuals who had been medically ascertained as having been sexually abused during childhood.Design: A historical cohort linkage study of suicide and accidental drug-induced death among victims of child sexual abuse (CSA).Setting and patients: Forensic medical records of 2759 victims of CSA who were assessed between 1964 and 1995 were obtained from the Victorian Institute of Forensic Medicine and linked with coronial data representing a follow-up period of up to 44 years.Main outcome measures: Rates of suicide and accidental fatal drug overdose recorded in coronial databases between 1991 and 2008, and rates of psychiatric disorders and substance use recorded in public mental health databases.Results: Twenty-one cases of fatal self-harm were recorded. Relative risks for suicide and accidental fatal overdose among CSA victims, compared with age-limited national data for the general population, were 18.09 (95% CI, 10.96–29.85; population-attributable risk, 0.37%), and 49.22 (95% CI, 36.11–67.09; population-attributable risk, 0.01%) respectively. Relative risks were higher for female victims. Similar to the general population, CSA victims who died as a result of self-harm were predominantly aged in their 30s at time of death. Most had contact with the public mental health system and half were recorded as being diagnosed with an anxiety disorder.Conclusion: Our data highlight that CSA victims are at increased risk of suicide and accidental fatal drug overdose. CSA is a risk factor that mediates suicide and fatal overdose.

Margaret C Cutajar BA(Hons), DPsych(Clin) · Paul E Mullen MB BS, DSc · James R P Ogloff MA(ClinPsych), JD, PhD · Stuart D Thomas LLM, MSc, PhD · David L Wells MB BS, MA, DMJ · Josie Spataro PhD

Living with bipolar. A guide to understanding and managing the disorder. Lesley Berk, Michael Berk, David Castle, Sue Lauder. Sydney: Allen and Unwin, 2008 (xiv + 298 pp). ISBN 978 1 74175 425 4. Over the past decade there has been a palpable surge of fascination with bipolar disorder in this country, generated at least in part by the moving testimonies of high-profile patients, and a resurgence of academic and pharmaceutical interest in the condition. This increasingly transparent public discourse has been a boon to those who have suffered in silence for so many years, and who now demand and expect quality information and guidance on understanding and living with the highly disabling illness. Consequently, there is now a healthy, growing market for well written, informative self-help books targeting bipolar disorder, for sufferers, their families and the lay community. Living with bipolar, written by an impressive team of Australian researchers and psychologists, is an excellent addition to the genre, complementing an Australian canon of quality books. Others include Sarah Russell’s A lifelong journey: staying well with manic depression/bipolar disorder (a self-help manual written by a researcher who has experienced bipolar disorder), Penelope and Jessica Rowe’s The best of times, the worst of times (a frank account of a family’s struggles dealing with bipolar), and Mastering bipolar disorder, a compilation of individuals’ accounts of managing their mood swings, edited by Kerrie Eyers and Gordon Parker. Living with bipolar, unlike the others, is both a highly palatable mini-monograph on bipolar disorder for the layperson, and rich, common-sense advice for managing the condition. I particularly enjoyed the chapters on modern psychological strategies that patients can use to manage symptoms, including specific guidance on “catching symptoms early” and “managing your triggers”. This is no anti-medical treatise, finishing rather with advice encouraging patients to establish a collaborative relationship with their medical practitioner. A highly recommended book for your bipolar patients.

Philip B Mitchell