Mental health

Incorrect and misleading use of tense: In the Chistmas Offerings article “Cough disorder: an allegory on DSM-IV” in the 7/21 December 2009 issue of the Journal (Med J Aust 2009; 191: 674-676), in the second paragraph under the heading, “The problem with the DSM”, “is overdiagnosed” was incorrectly used in place of “was overdiagnosed”, thus giving the impression that schizophrenia continues to be overdiagnosed in the United States. Schizophrenia is no longer overdiagnosed in the US relative to Europe and Australasia.

Peter I Parry

To the Editor: A timely article by Yelland and colleagues in the 7 September 2009 issue of the Journal1 correctly identifies postnatal depression as a significant public health issue. However, as members of the consortium that developed the 2008 beyondblue National Action Plan for Perinatal Mental Health (NAP),2 we are concerned that the National Perinatal Depression Initiative is being considered by Yelland and colleagues without reference to the NAP, the document on which the federal government based its funding allocation. The NAP recommended not only identifying current depressive symptoms, but also — equally importantly — using a structured method to assess the broader psychosocial risk factors known to affect maternal and infant mental health.2 The NAP also clearly recommended that any psychosocial assessment be accompanied by adequate workforce training and supervision and integrated pathways to care, complemented by community awareness programs. Although Yelland and colleagues1 raise concerns about the potential harm of routine screening for depression in women during pregnancy, none of the participants in a recent Australian study of antenatal screening for depression reported feeling stigmatised, labelled or distressed after using the Edinburgh Postnatal Depression Scale (EPDS).3 Indeed, many reported feeling relieved and supported that additional care was offered. This reinforces the assertion made in the NAP that a well trained workforce is essential for conveying the purpose of routine assessment — that such assessment is not an endpoint nor a substitute for full diagnosis, but the beginning of an ongoing process that helps professionals to be aware of women who may need support and treatment. Multiple studies evaluating the EPDS against structured diagnostic interviews for detecting major depression have shown that the EPDS has very good psychometric properties for scores of 13 or more (indicative of possible depression) in English-speaking populations.4 Yelland and colleagues also express concern that a limited number of interventions will be recommended to help depressed women. In fact, the NAP recommended that the full range of treatment options be offered within an integrated framework of community, primary care and specialist services.2 A first step in a national approach to perinatal mental health is to develop evidence-based clinical practice guidelines for perinatal depression and related disorders. This task is now underway, a clear indication that we are well placed to begin translating knowledge into practice. Research across Australia continues to examine the efficacy of a range of psychosocial risk assessment models,5 barriers to the uptake of referral and treatment options, and the impact of psychosocial assessment on maternal outcomes. This work will help ensure that a national approach to perinatal mental health is embedded in an evidence-based and evaluative framework.

Marie-Paule Austin · Nicole Reilly · Jeannette Milgrom · Bryanne Barnett

High-functioning pervasive developmental disorders (PDDs) have only recently been widely recognised; they are diagnosed mainly in children. Key features are impaired social cognition and communication; obsessive interests, routines or activities; and social or occupational dysfunction. There are scant data about the prevalence of high-functioning PDDs in adults, and it is possible that many Australian adults with these conditions are undiagnosed. A specialist multidisciplinary approach is used for both children with PDDs and adults with other neuropsychiatric disabilities, and has the potential to help adults with high-functioning PDDs. Increased awareness and diagnosis of these conditions should not limit career or personal goals of individuals with PDDs but should aid them in finding happy and productive careers and lives.

Sarah J Abrahamson MB ChB, FAFRM, GradDipClinEpi · Peter G Enticott BAppSci(Hons), PhD · Bruce J Tonge MD, MRCPsyc, FRANZCP

To the Editor: There has been considerable debate about whether selective serotonin reuptake inhibitors (SSRIs) can induce suicidal thoughts and behaviour. Using data from the 2007 National Survey of Mental Health and Wellbeing (NSMHWB),1,2 we examined the relationship between SSRI use and suicidality. The NSMHWB was a nationally representative household survey of 8841 individuals aged 16–85 years. Respondents were interviewed face-to-face and they provided information to assess whether they met International Classification of Diseases (10th revision) criteria for a lifetime affective disorder, and had symptoms in the previous year; had experienced suicidality in the previous year; and had used SSRIs (and/or other psychotropic medications) in the previous fortnight (and, if so, whether they had been taking them for < 1, 1–2, 3–5 or > 5 months). We restricted our analyses to the 555 individuals with symptoms of an affective disorder in the previous year, and examined their suicidality over that year. In our first analysis, we compared those who had used SSRIs in the previous 2 weeks and had been taking them for any duration (n = 109) with those who had not used SSRIs in the previous 2 weeks (n = 446 [respondents in this group were not asked whether they had taken SSRIs at any other time]). Secondly, we compared the subgroup who had been taking SSRIs for more than 5 months (n = 80) with the same non-user group we used in the first analysis. In both analyses, SSRI users were no more likely than non-users to have seriously thought about suicide, made a suicide plan or made a suicide attempt (Box). These findings are consistent with two recent systematic reviews of studies of SSRI use and attempted or completed suicide.3,4 Our study results add to their findings because we considered a fuller range of suicidal thoughts and behaviour. Although the reviews concurred with our findings with respect to adults, they found some evidence for SSRI use increasing the risk of suicidality among children and adolescents. The NSMHWB had limitations, including a potential for recall and misclassification bias, and its inability to account for all possible confounders. Importantly, its cross-sectional nature precluded determining whether an individual’s SSRI use preceded or followed his or her suicidality. By restricting our second analysis to SSRI users who had used SSRIs for more than 5 months, we increased the likelihood that SSRI use occurred first, but we could not determine this conclusively. This would have been a problem had we found an association, because we could not infer the direction of causality. However, with no association demonstrated causality becomes a moot point. Our findings support the contention that SSRI use in adults with affective disorders is not associated with suicide risk. Nonetheless, clinical judgement is required in prescribing SSRIs. Suicidality in the previous year among SSRI users and non-users All users* (n = 109) Non-users† (n = 446) χ2 P Long-term users‡ (n = 80) Non-users† (n = 446) χ2 P Seriously thought about suicide 23% 15% 3.20 0.27 20% 15% 0.83 0.58 Planned suicide 9% 5% 1.76 0.31 4% 5% 0.45 0.41 Attempted suicide 8% 3% 5.23 0.10 2% 3% 0.52 0.52 SSRI = selective serotonin reuptake inhibitor. * SSRI use in previous 2 weeks and for any duration. † No SSRI use in previous 2 weeks (use at other times unknown). ‡ SSRI use in previous 2 weeks and for > 5 months.

Jane E Pirkis · Philip M Burgess · Amy K Johnston · Harvey A Whiteford

To the Editor: Robertson and Kerridge1 criticised our article “Patient privacy versus protecting the patient and the health system from harm”2 based on an interpretation that we were advocating notification for all patients with somatisation disorders, but our recommendation for a confidential notification system pertained specifically to factitious disorder. We agree that “ignoring or failing to integrate mental health care in future health planning is to invite a higher burden of morbidity, mortality and cost”.1 Indeed, we do not wish to “[constrain] the patient’s interaction with the health system”, but rather believe that a more complete, accurate and easily available patient history would allow doctors to optimise such patients’ care within the system. Clinically appropriate resource allocation would substitute appropriate psychiatric/psychological and primary care for more costly and inappropriate (potentially harmful) emergency and procedural care, such as numerous cardiac catheterisations. The case described in our article illustrates well the higher burden of morbidity and cost that the patient, and the system, had to endure because of the failure of multiple health providers across a range of acute settings to diagnose and treat the patient’s primary illness.2 Avoidance of truthful disclosure on the part of the patient contributes to this diagnostic failure. An electronic medical record (EMR) notification in this kind of case would allow any given doctor to overcome the otherwise almost insurmountable barriers to collating such a patient’s history, and thus to be aware of, to balance and to manage the factitious disorder diagnosis — a notoriously difficult task.3 Robertson and Kerridge argue there is a lack of evidence for “costly” EMR systems. However, it has been found that “Hospitals with automated notes and records [have] fewer complications, lower mortality rates, and lower costs”.4 A truly private portable EMR should help all patients obtain more appropriate and cost-effective care, by reducing duplication of costly investigations and doctors’ time spent chasing records. Conversely, patients might reasonably abhor a privacy system that inadvertently results in duplicate computed tomography scans — the prior records being “private” and unavailable — when radiation exposure increases the risk of cancer.5 We would be the first to acknowledge the risk of “stigmatisation” and agree with safeguards to mitigate potential consequences, as mentioned in our article.2 However, in the case of this patient and others in a similar situation, we still believe that he, the doctors struggling to provide appropriate care, and the system deserve better, which certainly won’t happen with the status quo.

Dawn E DeWitt · Ravi Bhat · Stephanie Ward

Knowing is not enough; we must apply. Willing is not enough; we must do. Goethe The most rewarding aspect of a career in mental health is that you get to spend time with truly inspiring people. My clinical work has focused on people whose lives have been affected by depression, bipolar disorder or schizophrenia. For any doctor who wants to connect with the most fundamental aspects of what it is to be human, nothing beats a career in mental health. However, the big frustration that I face on a daily basis is the impoverished mental health system in which we provide services. Too often have I run up against the comment, “That’s all true, Ian, but we won’t see any real change in our lifetime”. Brain & Mind Research Institute, University of Sydney, Sydney, NSW. Ian B Hickie AM, MD, FRANZCP, FASSA, Professor of Psychiatry and Executive Director ianhATmed.usyd.edu.au Getting into medicineI was fortunate to grow up in a large, academically oriented family. A rather strong Irish cultural legacy on one side and a printers’ union background on the other left me (and each of my siblings) at odds with the status quo. My early exposure to multiple perspectives, endless rounds of negotiation, and the need to come up with a collective rather than personal solution proved more valuable later in life than much of my professional training. Given my father’s distinguished career in academic medicine, my own journey down that same path may seem to have been rather predictable. Indeed, it now appears that there are strong transgenerational elements at work (Box 1).1,2 Unfortunately, like other rather glib narratives that are common in psychiatry, it’s an interpretation that doesn’t really fit the data. Having a father in academic medicine actually seemed to result in a household with an oversupply of lawyers! Perhaps we all do share a common sense of social justice. However, from my parents’ perspective, having only one of their seven university-educated children pursue a medical career always seemed a rather poor return on investment. While I enjoyed my early medical training at St Vincent’s Hospital in Sydney, the time I spent working for a bookmaker gave me a much better introduction to the more colourful aspects of everyday life. The real highlight of my undergraduate years was the time I spent in the Philippines during the later years of the Marcos regime. Not often can one so clearly experience the direct relationship between the impoverished state of a nation and the grossly inadequate health care that its citizens receive. The time spent with health professionals who took direct social actions to improve the lives of others also left a lasting impression on me. Pursuing psychiatryOn graduating, I jumped at the opportunity to be a resident medical officer at the still rather new and often chaotic Westmead Hospital. Here was a medical centre that was critical to the future of the community in which it was based. While working there, it became very clear to me that, although the rewards of procedural medicine were great and the challenges of internal medicine considerable, only psychiatry was really challenging from a personal and intellectual perspective. At that time, one training program stood out in terms of its academic rigour and breadth of teachers. Consequently, I moved to Prince of Wales and Prince Henry Hospitals to pursue my specialist training. Promoting medical paradigms in psychiatry researchOne of the difficulties that young psychiatrists face is the apparent drift away from conventional measures of pathophysiology. In the absence of clear laboratory markers, there is a recurring tendency to invoke more narrative accounts or other pseudo-sophisticated illness models. Fortunately, I was spared these distractions through my early research collaboration with two great physicians; namely, Andrew Lloyd and Denis Wakefield. Although our shared interest in post-infective fatigue syndromes has always aroused great controversy, it allowed us to work with a robust model for the onset of neurocognitive disturbance following a discrete medical event.3 Twenty years later, this work is now firmly based in more respectable models of cytokine-induced cognitive and mood disturbance.4 More importantly, very few psychiatrists ever receive the collegiate support that I have had from Andrew and Denis over the past two decades, and this collaboration put me in contact with a collection of international experts in medicine and psychiatry who share a much broader world view. Mood Disorders Unit at Prince Henry HospitalTowards the end of my registrar training, I was fortunate to work with the newly established Mood Disorders Unit at Prince Henry Hospital. The concentration of clinical researchers assembled under the leadership of Gordon Parker and Henry Brodaty was crucial to its success. While the work borrowed heavily from Leslie Kiloh’s earlier focus on the subclassification of depression, it used a range of neuroendocrine, neuropsychological and brain imaging technologies to develop a more specific fronto-subcortical model of severe mood disorders.5 During this period, I was lucky enough to lead projects that used magnetic resonance imaging. Although our neurological colleagues were aghast at our “waste” of such expensive tools, conveniently, the Professor of Radiology did not share their narrow view. Consequently, in partnership with Dr Liz Scott at Prince Henry Hospital, we were among the first groups internationally to demonstrate the clinical utility of these new techniques in people with severe depression.6,7 It kick-started a line of work that moved rapidly from detection of an underlying vascular abnormality in late-life depression to the development of large-scale preventive and early intervention programs.8,9 Growing more politicalWe should be active and loud advocates of the mentally ill and be in the forefront of their battle to realise their rights. This might require that we relinquish some of our professional role and add some political activism to our daily chores. Norman Sartorius, 199810 By its nature, the discipline of psychiatry is both philosophical and political. While many prefer the former path, I’ve always thought that Norman Sartorius was on the right track. In the early 1990s, I was very fortunate to win a Harkness Fellowship to pursue both my sociological and brain imaging interests at Duke University in North Carolina. Packing up a family with four young children and shifting continents proved to be quite an adventure. The Fellowship provided me with fundamental insights into the way in which communities could act collectively across a whole range of health and social issues. The emphasis on community action rather than government-based initiatives is central to social progress in the United States. Throughout this period, I had the good fortune of being assisted by an eminent clinician and Dean of Medical Education at Duke University School of Medicine, Dan Blazer. Dan is not only an international leader in depression research but, more importantly, he is gentle, educated, spiritual and community-oriented. His ongoing contributions are thoughtful and particularly relevant to those of us who work at the interface of society and biological medicine.11 Too few medical schools promote role models of this calibre. Joining forces with health administrationSoon after returning to Australia in 1995, I joined Dr Margaret Tobin at Sydney’s St George Hospital. She was determined to drag mental health services into the late 20th century. Margaret and I shared an ongoing joke over who would sustain this charm-free campaign after we had both moved on. Although the facilities were limited, the services were stretched, and the whole process appeared unnecessarily disruptive, it was a great learning experience. Margaret’s tragic death some years later robbed Australia of a person who was truly committed to changing the system. During my 5-year stay in southern Sydney, I learnt what it was possible to achieve with a small group of people who shared a common view of a better future. The deeply personal and broader collegiate relationships that I formed during this period continue to sustain me through tough times. Around this time, my own interests moved rapidly to the substantive issue of the lack of adequate management of depression in primary care settings.12 Working with Liz Scott, Tracey Davenport and a team of young psychologists, we were able to roll out SPHERE: a major national educational and service evaluation program.13 We conducted an audit of over 46 000 consultations in primary care settings. The study emphasised the low rate of detection and active treatment of common mental disorders, highlighted the lack of access to skilled non-pharmacological therapies, and set in place an enduring national general practitioner training program. Over a decade later, that program alone has provided various forms of general practice-based mental health training to more than 10 000 primary care practitioners. This work, in combination with my later advocacy work with beyondblue,14 provided the impetus to correct one of the major flaws in our Medicare funding system; namely, the lack of financial support for psychological services. By 2001, we had convinced the Australian Government of the need to provide specific payments for well trained GPs and clinical psychologists who provided psychological services.15 From my perspective, this was the first in a series of “not in our lifetime” predictions to be defeated. beyondblue and the Kennett eraIn the late 1990s, the Kennett Government in Victoria had moved to confront major health and social problems such as mental illness and drug misuse. In 1999, Kennett’s proposal to establish a national depression research institute appeared to have died with his election loss. However, immediately after that election, the federal Health Minister, Michael Wooldridge, set about resurrecting the plan. In 2000, beyondblue: the national depression initiative was born and Jeff Kennett was appointed as the chairman. It was a credit to the Victorians involved that they were able to put together this very smart deal. I jumped at the opportunity to become the inaugural chief executive officer of beyondblue (Box 2). Sadly, through a bizarre combination of state-based and professional rivalries, my home state of New South Wales refused to join. Despite the resistance, we set an ambitious agenda not only for improved community awareness of depression, but also for significant reform of primary care services, establishment of large-scale postnatal depression and secondary school-based preventive research, and investments in smaller-scale community-based and translational research programs. Importantly, we achieved major changes in other key industries such as life insurance and income protection.16 In the longer term, beyondblue has proven to be the major national driver of increased community awareness of depression and other common mental health problems.17 The wider significance of this to the field of mental health, and specifically the lives of those who live with depression, cannot be underestimated — we have seen major changes in community attitudes in our lifetime. Some have described my relationship with Mr Kennett as a rather odd example of a very odd couple. I always preferred the description provided by a Victorian taxi driver — he thought we could easily double for the comedians Roy and HG! In truth, Mr Kennett has many skills that are invaluable to our field. He also respected the fact that those with technical or clinical skills needed to take the lead on illness-related issues. If not for the offer of a lifetime from Max Bennett and the University of Sydney, I would have been happy to have spent a much longer period in Melbourne. Establishing the Brain & Mind Research InstituteThere is no doubt that the lack of a solid evidence base, and the long periods between genuine breakthroughs in clinical therapeutics, discourages some young doctors from pursuing a career in mental health. By the end of the 20th century, it had become clear that a fundamental change in direction for psychiatry was possible. The opportunity to forge real links with other clinical and basic neurosciences was emerging. Thanks to the foresight of Gavin Brown, then Vice-Chancellor of the University of Sydney, and the unrelenting drive of Professor Max Bennett, the Brain & Mind Research Institute (BMRI) was created (Box 3).18 In 2003, I left Melbourne rather prematurely to become its inaugural executive director. The BMRI is a unique campus, now combining over 20 major research teams that span key disciplines and technologies. I am proud that at least one major Australian educational institution has chosen to value mental health research so highly. The federal and state governments have responded positively to this movement, and we can now boast that the facilities provided for both patients and researchers are as good as any that one would expect for the management of cancer, infection or heart disease. This has been the third major “not in our lifetime” moment that I have experienced. Our ongoing focus on discovering how dysfunctional glial cell–neuronal networks give rise to the major mental disorders will keep us busy for some time to come. The BMRI is now the home of my own interdisciplinary and clinical research program. From 2007, this has been supported by a National Health and Medical Research Council (NHMRC) Australia Fellowship for health and medical research. Some of those close to me suggested that the NHMRC would be unlikely to back a clinical and health services-oriented psychiatrist under this scheme — just another “not in our lifetime” prediction that proved erroneous. It has enabled my talented team of clinicians and scientists to pursue large-scale national and international collaborative research. In partnership with Pat McGorry and his team in Melbourne, and led by Liz Scott and Sharon Naismith at the BMRI, we are rapidly developing a world-leading program of youth services19 and clinical research.20,21 This is complemented by our academic (with Helen Christensen at the Australian National University) and community (with the Inspire Foundation) partnerships in developing relevant e-health services. Achieving real political and social changeTwice in the space of a recent month I had senior political people say to me, “I know that needed to be said, but did you have to be the person who said it?!” One of the more obvious responsibilities associated with working in mental health is to speak out on behalf of those who are marginalised, neglected or abused. Fortunately, my peer relationships have grown to include a wider group of community and political leaders. Collectively, we have tried to push the political and social agenda. While the world of mental illness is no longer characterised by the more obvious abuses of human rights, it is still plagued by systematic failures in access to basic health care (only 35% of those with a common disorder receive treatment, and this has not improved in the past decade22), a lack of focus on early intervention for young people,23 too much reliance on the old restrictive ways,24 and disconnection from essential social, economic, employment, education and housing supports.25 As recently emphasised by the National Health and Hospitals Reform Commission,26 mental health continues to be an area of great inequity. Traditionally, politicians, health and educational institutions or philanthropists do not rush to identify with this form of suffering. At times, however, there have been notable exceptions. In 1993, the Keating Government responded positively to the findings of the Burdekin Royal Commission into mental health services and backed the first National Mental Health Strategy (1993–1998). This was continued as a second 5-year strategy (1998–2003) by the Howard Government. Sadly, leadership of that reform process was left under the control of a state-based committee that had little stomach for real change. By 2002, the community’s frustration with the lack of progress was palpable, and my colleagues and I decided it was time to revisit the community’s experiences. Working through the Mental Health Council of Australia, and with the assistance of the Human Rights Commissioner, Sev Ozdowski, we were able to complete a national evaluation that once again highlighted the disastrous consequences of our fundamental lack of investment in key mental health services and related social supports.27 The launch of the resulting report, Not for service: experiences of injustice and despair in mental health care in Australia,28 at the BMRI in 2005 indicated that our new academic home was not only committed to fundamental scientific advances but would also continue to engage in the issues that affected the daily lives of those with severe mental disorders. Although the Health Minister of the day sought to lay the blame at the feet of the states, a few days later, Prime Minister John Howard made it clear that mental heath reform was indeed a major social and economic issue that demanded a serious response. This rhetoric was matched by real action in mid 2006 when Prime Minister Howard and NSW Premier Morris Iemma enacted the Council of Australian Governments’ new National Action Plan on Mental Health 2006–2011.29 This national political action was a direct result of our 4 years of sustained campaigning. It was accompanied by over $4 billion in new investments and led directly to key structural changes. The most important of these was the introduction of new Medicare rebates for psychological treatments. Once again, this was a genuine “not in our lifetime” breakthrough. Prime Minister Howard went on to support the development of a new stream of youth services under the headspace initiative,23 while Premier Iemma backed substantial new infrastructure investments in youth mental health (Box 4) and research into the biological basis of psychotic disorders. Since its election in 2007, the Rudd Government has promoted much discussion about the future of our health system and, importantly for mental health, the development of the concept of social inclusion. At this stage, we are still waiting to see whether the rhetoric will be backed by decisive action.30 Although I have been appointed to the Health Minister’s new National Advisory Council on Mental Health, it is clear we need a government that genuinely prioritises improved access to mental health care, as well as linking health with other key areas of social services and disability support. The struggle to achieve another “not in our lifetime” moment is ongoing. Trying to find new ways to achieve real changeMost of my own community and advocacy work has sought to develop new styles of social and political partnerships. The key roles that the media, the business world, industries, community organisations and other professionals can play in improving the lives of those with mental illness have been obvious. I’m now deeply suspicious of those who seek either a largely government-delivered solution or, on the other hand, promote a simplistic, laissez faire approach. As in other areas of health care, developing services that respond personally to the particular needs of those we serve remains the biggest challenge. Staying in the businessA sustaining influence for much of my academic and social advocacy work has been the intellectual prowess of my professional colleagues. When asked why I chose to pursue psychiatry, I remark that the most interesting people I met throughout my medical training were psychiatrists. Real characters and genuine thinkers like Neil McConaghy, Gavin Andrews, Issy Pilowsky and Scott Henderson stand out. While leaders in other areas of medicine are identified by their technical skill or their lifetime dedication to patient care, psychiatry thrives on the daily contest of ideas. Although too few senior psychiatrists have engaged in the broader struggle to overcome the fundamental inequities that people with mental illness face, I have immensely enjoyed my work with the leadership of the Mental Health Council of Australia (and, specifically, the late Dr Grace Groom and then Mr John Mendoza). These days, I have the pleasure of the company of a new generation of Australian-based but international leaders in mental health such as Pat McGorry, Chris Pantelis, Helen Christensen and Nick Martin. Looking to the futureFor my colleagues and me, the past two decades have really been about working with the wider community to set a clear reform agenda in mental health. While our collective minds remain firmly focused on key issues of health equity, promotion of early intervention and youth-specific services, protection of human rights, access to evidence-based health services, and provision of appropriate social, employment and housing supports, real progress will remain dependent on our capacity to engage genuine community and political support. From a personal perspective, there are many more challenges ahead. 1 Three generations of medical research Ian Hickie (standing), with daughter Megan Hickie (left), partner Elizabeth Scott (right), and father Professor John Hickie AO (seated). 2 Launch of the beyondblue Victorian Centre of Excellence in Depression and Related Disorders, July 2002 L–R: The Hon Bronwyn Pike (Victorian Minister for Community Services), The Hon Jeff Kennett (Chairman, beyondblue), Ian Hickie (Chief Executive Officer, beyondblue), Professor Bruce Singh (University of Melbourne). 3 Opening of the Brain & Mind Research Institute research laboratories, 2006 Ian Hickie and Prime Minister John Howard. 4 Opening of the clinical and translational research facilities at the Brain & Mind Research Institute, 2007 L–R: Premier Morris Iemma, Professor Max Bennett AO, Ian Hickie.

Ian B Hickie

The yipping tiger and other tales from the neuropsychiatric clinic. Perminder Sachdev. Sydney: UNSW Press, 2009 (x + 289 pp). ISBN 978 1742 230849. With the opening phrase “The golf swing is an act of grace and supreme poise,” I felt I was about to read another Harvey Pennick (teaching golf pro) publication. Rather, this is a compilation of case studies the author gathered over 20 years. Perminder Sachdev, Professor of Neuropsychiatry at the University of New South Wales and Director of the Neuropsychiatric Institute at Sydney’s Prince of Wales Hospital, considers 10 disorders and their underlying brain mechanisms. “The yipping tiger” examines golfer’s cramps, “Shaking hands with Dr Strangelove”, the alien hand syndrome, and “Swearing like a Spanish sailor”, coprolalia in Tourette syndrome. Other chapters cover brain enhancement, anorexia nervosa, frontal lobe dysfunction, major depression, obsessive compulsive disorder, phantom limb and mild cognitive impairment. The inclusion of depression and obsessive compulsive disorder as topics was a little surprising — knowing the immense range of material referred to neuropsychiatrists I was expecting to find other topics (such as Lewy body dementia, Huntington disease, stroke and depression, epilepsy and psychosis and demyelinating disease) selected for discussion of the overlapping neurological and psychological/psychiatric aspects of brain disease. While well referenced with good notes accompanying each chapter, Sachdev might have shortened each chapter by a few pages in order to include other examples of neuropsychiatric disorders. Books of this format demand the difficult balancing of clinical vignettes with more detailed discussion of underlying systems and constructs (as demonstrated by Oliver Sacks and Harold Klawans). Some of Sachdev’s detours and digressions are distracting to the reader, particularly if this book is intended for the lay audience rather than the medical fraternity. Yet this book is interesting and informative, with the audience lying midway between the interested layperson and the professional. It is very reasonably priced.

John H Lloyd

The DSM-IV is more a reliable descriptive nomenclature than a valid classification of diseases The Diagnostic and statistical manual of mental disorders, third edition (DSM-III), published by the American Psychiatric Association in 1980, sought to define psychiatric syndromes in a way that increased the reliability of psychiatric terminology and diagnoses between practitioners and nations. The DSM-III’s introduction cautioned that, with regard to aetiology, it was a “generally atheoretical” document. The subsequent edition, the DSM-IV, published in 1994, went further, and cautioned specifically against diagnoses being applied in a “cookbook” fashion. Despite these warnings, conversion of the description of psychiatric disorders to discrete disease entities has not only occurred but, I believe, has also become problematic. Here, I present an allegory of a boy with “cough disorder” to illustrate. It was time for the annual post-prandial Christmas dinner nap. A niece was coughing on inhaled lemonade. Dreams are often allegorical; it had been a busy year, and I started to dream. “Cough disorder” — a dreamA mother came into my consulting room with her son. “He’s got cough disorder”, she declared. She’d read the symptoms on the internet: “a short, repetitive noise coming from the throat associated with the expulsion of air from the lungs”. This was, indeed, true. The website had quoted the DSM-IV. That is, the fourth edition of the Diagnostic and statistical manual of human noises published by the American Phoniatric Association. “He’s clearly got cough disorder, and he needs Suppressalin cough suppressant”, the lad’s mother said. Suppressalin had been advertised via a link on the “Help for Parents of Kids with Cough Disorder” website. The young chap himself broke into a succession of hacking coughs as if to emphasise the problem, at which point his mother widened her eyes and slowly and firmly nodded, to emphasise the obviousness of the diagnosis. One that, presumably, was now even more clearly in need of the advertised pharmacotherapy. I sighed. That is, I “exhaled in concert with slight laryngeal constriction, following a deep diaphragmatic inhalation”, making a “soft, rather low-pitched noise”, and this occurred “in a situation of frustration, tension, tiredness or boredom”. (I noticed my noise, recognised I was in a situation of frustration, and recalled research showing I’d just stimulated my vagus nerve to maintain autonomic nervous system equilibrium.) I coughed, but it was the “ah hem” subtype; the “short, sharp, double noise emanating mainly from the larynx without significant pulmonary air expulsion”. This is not normally considered a pathological cough, although I noted the lad’s mother raised an eyebrow. I knew my “ah hem” cough was the prelude to my well worn (and weary) noise-educative spiel to parents of coughing kids. “Well yes, he does cough; I totally agree with you there”, I said, to get mum on side, and noticed a slight easing of her wary defensiveness. “But you see ‘cough disorder’ doesn’t tell us very much. It is not really a diagnosis but a description of behaviour.” She was starting to resume the wary defensive posture; the boy uttered a quick succession of coughs. I decided to look grave and said how concerning his coughing was, and that it was very important we thoroughly investigated it. She said the parents’ help website had indicated that Suppressalin was exactly what was needed, but I noticed she was now less certain, and I made a “hmmm” sound in a particular way, to indicate understanding and empathy, but also that I knew more. I was, after all, the doctor. I sensed she seemed willing to listen to the spiel. “Cough disorder is simply a description, a starting point”, I said. “We have to find out why your young man here is coughing. Cough disorder can have many causes, and, for some children, several causes can combine.” I went on to describe inhaled objects, drinks down the wrong way, asthma, croup, bronchitis, pneumonia, pharyngitis (the tickly throat cough), postnasal discharge, and rarer, more serious causes, such as throat and lung cancer, pneumothorax, bronchiectasis, silicosis and congestive cardiac failure. It could be a reaction to dust or cold dry air; there is always an environmental context. And, it could even be something as mild as a frequent habitual “ah hem” cough to try to gain attention. I had the lad’s mother’s attention now, and the lad himself had also stopped coughing and was listening. I said that his cough may not need Suppressalin (although I acknowledged that, for some kids, Suppressalin is very beneficial, and they may need it for many years). We went on to look collaboratively for what was causing the cough. Even dad came to the next consultation. I also had an informative telephone discussion with the child’s teacher, who told me how the boy generally stopped coughing by morning recess. The problem with the DSMThe astute reader may by now have guessed that my “dream” is an allegory about attention deficit hyperactivity disorder (ADHD), and that, by corollary, the “DSM of human noises” is the Diagnostic and statistical manual of mental disorders published by the American Psychiatric Association, currently in its fourth edition.1 The DSM is sometimes referred to as psychiatry’s bible. However, like the Bible, it should be mainly read as descriptive, not literal, truth. The problem dates primarily from 1980 and the publication of the DSM-III. At the time, psychiatric terminology suffered from a different problem — psychiatrists using the same labels for different conditions; in particular, schizophrenia, which was overdiagnosed in the United States compared with Europe (and Australasia).2 The DSM-III devised “operationalised criteria” — lists of symptoms to define descriptive “disorders”, so that everyone would at least know what behaviour was being described when a term like “schizophrenia” was used. Reliability is a necessary step on the road to validity. The DSM-III brought about a more reliable nomenclature and a more robust definition of syndromes, a vital prerequisite for psychiatric nosology (the branch of medical science dealing with the classification of diseases) to advance. However, the DSM-III was not meant to be read as a valid classification of diseases, even though it aspired towards that goal. Diagnoses in other areas of medicine also vary in levels of understanding of aetiology (eg, migraine is still a syndromal diagnosis, and hypertension is a diagnosis based on deviance from normative dimensions); however, the level of scientific knowledge is more advanced in many other areas, and many disease states are well understood. Psychiatry is not so far advanced. A further complicating factor in psychiatry is the, as yet, unresolved mind–brain problem,3 and that for such a social species as Homo sapiens, the psychosocial and intersubjective domains, including narrative and meaning, are not easily accessed by symptom checklists. The DSM-III and DSM-IV attempt to address this with their multi-axial approach to a range of factors, such as personality, concomitant medical disorders, psychosocial stressors and level of functional impairment, as well as the “V-code” diagnoses — codes used to indicate problems that aren’t clinical disorders — such as “parent–child relational problem”. Further complicating nosology is the issue of multicausality and equifinality — syndromal end states may comprise a clustering of individuals with quite different aetiologies for similar presenting symptoms. This is implied in the DSM introductions, with the DSM-III purporting to take a “generally atheoretical stance” with respect to aetiology, and the advice in the DSM-IV that it is “not to be used in a cookbook fashion”. Despite these warnings, all too often, collections of symptoms classified as disorders tend, in practice, to be thought of as disease entities in their own right. This is less problematic for severe psychotic disorders such as schizophrenia and manic-depressive psychosis (now called bipolar-I disorder in the DSM-IV), which likely represent underlying brain disease. However, I do think that it is problematic with what used to be called “neuroses”, and symptoms that overlap with temperament, personality and responses to stress and trauma, where the interactions of brain, mind, body, relationships and environment are multidirectional. So the problem is not so much with the DSM itself, but with the way it is often used pre-emptively. My allegory on ADHD could apply to “conduct disorder”, “oppositional defiant disorder”, “school refusal”, “autism spectrum disorder” or, particularly in the US, the controversial “paediatric bipolar disorder”4 which, although it is not defined in DSM-IV, can be argued reflects an overly reductionist “neo-Kraepelinian” approach5 that common use of the DSM tends to foster. A similar problem occurs with anxiety, depression and adult “bipolar spectrum disorders”. The problem of seeing all depressive states as homogeneous, differing only in severity, has been raised previously.6 In his 2005 presidential address to the Royal Australian and New Zealand College of Psychiatrists (RANZCP), Boyce referred to a “dumbing down” of psychiatry by using the DSM for simplistic “cookbook” diagnoses. He also referred to the pharmaceutical industry’s pervasive influence in medical research and medical education.7,8 In psychiatry, this influence often supports a reductionist biomedical model of human emotional and behavioural problems, rather than the systemic biopsychosocial model upheld by the RANZCP. A simplistic cookbook approach to the DSM would, indeed, seem to be in industry’s interests, as behavioural symptom clusters get reified to disease states, and marketing to both the medical profession and the public can support a “pill for every ill” approach.9 Such marketing finds fertile ground — in a busy world, the siren call of such simplicity in diagnosis and treatment is appealing to both the public and the medical profession. Such misapplication of psychiatric nosology was predicted two decades ago as the rise of “biologism”,10 and eloquently expressed by Lipowski in his 1988 presidential address to the Canadian Psychiatric Association as the rise of “mindless psychiatry”.11 (Lipowski also noted the perils of the other extreme — “brainless psychiatry” — in which all psychopathology is seen in only psychosocial terms, something this essay is not advocating.) DSM-associated biomedical reductionism has been noted by many American psychiatrists.12 In contrast, an alternative approach to psychiatric nosology proposes the “four perspectives of psychiatry” (“disease, dimension, behaviour, life story”),3 which is a more radical multi-axial approach than the DSM axes and seeks to balance the neo-Kraepelinian disease approach with the “neo-Meyerian” focus on biopsychosocial case formulation.13 It was described in a course at the recent American Psychiatric Association annual meeting titled “Going from the bio-bio-bio model forward to bio-psycho-social reasoning”.14 Where disorders most likely fit the disease model, as with the psychoses, there are promising proposals to refashion the upcoming fifth incarnation of the DSM — the DSM-V — to move beyond the descriptive approach and attempt to base psychiatric classification on underlying causes.15 Further changes proposed include greater emphasis on dimensional measures (eg, to look at subsyndromal risk factors for depression and possible prodromal psychotic symptoms, like suspiciousness, that may aid early detection), rather than categorical measures (such as currently, when meeting sufficient criteria indicates disorder, and below that implies no disorder) to better reflect clinical reality. On the other hand, the head of the former DSM-IV taskforce has expressed strong concern that such moves are premature, would “flood the world with . . . false-positive patients” who “would pay a high price” in stigma and by being overmedicated and, with respect to problems like excessive Internet use, that expansion of criteria in the DSM-V would further “inappropriately medicalise behavioural problems”.16 Despite, or even because of, this problematic nosology, psychiatry remains a complex but compelling and rewarding profession that requires time, and experience, patience and wisdom acquired through clinical and life experience in helping those who come for help. There are no short cuts, DSM or no DSM. Return to our allegorical dream of cough disorderThe dream ended happily. The lad and his parents came to understand that cough disorder was not a diagnosis but a description, and that his real problem — mild asthma — required a different medication, and then no medication at all when his parents stopped smoking in his presence. We had tried Suppressalin at one point, but it gave only short-term relief. The parents and I even had a more philosophical discussion about how the third edition of the DSM of human noises focused on defining human noises descriptively, at a time when some doctors talked about “cough” when they really meant “sneeze”, “burp” or “hiccup”, and how that was a good development back in 1980. But we also discussed how, as an atheoretical descriptive system, it generally gives no information about underlying causes, and how important the search for real causes is; this is something the family now appreciates. During my last session with this family, there were several repetitions of “ah yes” and “hmmm” (shorter, higher pitched subtype, usually indicative of agreement) — all, in my opinion, completely non-pathological noises, although I understand some do think them overused and claim to have medications for them. . . . I awoke. My niece was playing happily with her Christmas presents. The cause of her coughing — inhaled lemonade — had cleared.

Peter I Parry MB BS, FRANZCP, CertChild

Objective: The belief that the full moon and disturbed behaviour are closely linked is alive and well, despite studies to the contrary. We investigated the possibility that there is an association between only extreme behavioural disturbance and the full moon.Design, setting and participants: We undertook an observational study of patients with violent and acute behavioural disturbance who presented to the emergency department of Calvary Mater Newcastle and patients with less severe behaviour for whom hospital security calls were made.Main outcome measure: Proportion of patients for whom presentation or security call occurred in each lunar phase, modelled as a Poisson process.Results: Of 91 patients with violent and acute behavioural disturbance, 21 (23%) presented during the full moon — double the number for other lunar phases (P = 0.002). Sixty (66%) had either alcohol intoxication or psychostimulant toxicity, and five attacked staff (biting [2], spitting [1], kicking [1] and scratching [1]). In contrast, 512 hospital security calls for patients with less severe behaviour were evenly distributed throughout the lunar cycle.Conclusion: Violent and acute behavioural disturbance manifested more commonly during the full moon.

Leonie A Calver · Barrie J Stokes BSc, MSc · Geoffrey K Isbister BSc, FACEM, MD

How far has our understanding of chronobiology come in the past 40 years? An MJA editorial on circadian rhythms published nearly 40 years ago lamented the “neglect ... in part engendered by the air of mysticism which surrounded much of the earlier work in this field” that had obscured recognition of their importance to health.1 Since that time, basic research has explored various aspects, including the intracellular generation of circadian oscillations, their intercellular synchronisation, the entrainment of the circadian “system” by environmental time cues or “zeitgebers” such as light, and circadian variation in biological functioning. Further, clinical research has focused on the consequences of circadian disruption, circadian rhythm sleep disorders (CRSDs), circadian abnormalities in affective disorders, and chronotherapy. Here, we summarise some of these key advances. In 1970, it was known that circadian rhythms are generated endogenously,1 but little was known about the mechanisms involved. The discovery of the first circadian clock gene, in the fruit fly Drosophila melanogaster, was reported the following year.2 A number of mammalian clock genes have now been identified, and there is considerable understanding of the transcription–translation feedback loops that generate circadian oscillations at the cellular level.3 In 1972, the importance to circadian pacing of the suprachiasmatic nuclei (SCN) in the anterior hypothalamus was established. The SCN comprise the “master” circadian clock, which plays a key role in synchronising peripheral (“slave”) oscillators and in the entrainment of the circadian system by light.3 Light information from melanopsin-containing retinal ganglion cells is transferred directly to the SCN via the retino-hypothalamic tract and indirectly via the retino-geniculo-hypothalamic tract. The SCN interpret and transfer this information to the pineal gland, which secretes melatonin accordingly. In the future, further understanding of normal circadian regulation will help to clarify abnormalities that occur in circadian disruption and disorders and hopefully indicate effective strategies for circadian “resetting”. In industrialised societies, 15%–20% of workers are involved in shift work or unusual work hours, and it has been reported that prolonged circadian disruption, especially from rotating night-shift work, increases the risk of cardiovascular disease,4 metabolic syndrome,5 and prostate, breast and colorectal cancer.6 Although important, questions remain about the evidence and explanation for these findings. For example, a recent systematic review concluded that there is limited evidence for the suggested link with breast cancer and insufficient evidence for a causal link with cancer overall.7 There is experimental evidence that circadian disruption can independently produce adverse metabolic and cardiovascular effects,8 but uncertainty remains about the extent to which other factors associated with shift work, particularly sleep disturbance,9 have contributed to reported findings from clinical studies. It is recognised that shift workers are more liable to injuries at work and road accidents when driving home from work, but circadian disruption is probably not solely responsible for this. Despite the need for further clarification, there appears to be sufficient evidence of the ill effects associated with rotating shift work to justify simple precautionary measures: identifying, educating and monitoring shift workers; improving rosters by including shorter shifts; avoiding rotation; scheduling rest or nap periods; and perhaps even favouring chronotype “owls” for night-shift work.10 The relationship between sleep and circadian regulation is complex and not well understood. It is known that the “sleep homeostat”, which monitors the need for sleep based on a person’s prior sleep history, can operate independently of the circadian clock. There is nevertheless an interaction between sleep and circadian regulation, as evidenced by CRSDs and the effects of orexins, which are functionally linked to the SCN and involved in mediating circadian suppression of rapid eye movement (REM) sleep. The clinical relevance of these complexities is that sleep disorders may arise from different combinations of sleep and circadian abnormalities. CRSDs are mainly abnormalities in the timing of sleep and are classified broadly as “extrinsic” or “intrinsic”. Extrinsic disorders include jet lag and shift work sleep disorder. Intrinsic disorders include advanced and delayed sleep phase syndromes, free running disorder, and irregular sleep–wake disorder. Intrinsic CRSDs are of interest, not least because a better understanding of the relationship between circadian and sleep regulation may lead to more effective treatment of insomnia — a frequent complaint in primary health care. Most serious mental illnesses are associated with sleep disturbance, and some, especially affective disorders, are also associated with circadian abnormalities. It remains to be seen whether circadian abnormalities are a primary or secondary manifestation in affective disorders, but there is evidently a relationship between mood and circadian regulation. Mood disorders are associated with a disturbance of circadian rhythms, and disruption of circadian rhythms is associated with a disturbance of mood.11 Under these circumstances, effective circadian resetting to a normal sleep–wake cycle, using methods such as artificial light, chronobiotic medication (antidepressants, melatonin agonists) and sleep deprivation, may be useful in the treatment of mood disorders. Chronotherapy considers the impact of circadian variation on diseases and treatment side effects. Applied to pharmacotherapy, it recognises that optimal treatment depends not only on the dose but also on the time of day that medication is given. Medications for asthma, allergies, cardiovascular disease, pain and cancer can produce better results with fewer side effects when given at particular times.12 The kinetics of antihypertensive medication vary with circadian rhythms in gastrointestinal pH, emptying and motility, and blood flow (“chronokinetics”). So-called “chronodynamic” effects can be seen with the use of non-steroidal anti-inflammatory drugs (NSAIDs) to treat arthritis. NSAIDs are more effective for osteoarthritis (symptoms worse at night) when taken around noon, but are more effective for rheumatoid arthritis (symptoms worse in the morning) when taken after the evening meal. Although recognised since antiquity, the scientific study of circadian and other biological rhythms, now referred to as “chronobiology”, did not become firmly established until the second half of the 20th century. There is now a burgeoning literature in the field and, specifically with regard to circadian rhythms, an expectation of useful clinical applications from further progress in understanding. Research conducted in the past 40 years has not only dispelled any remaining mysticism but has also provided a clear justification for teaching on chronobiology and chronotherapy to be included in medical curricula.

Hans G Stampfer MB BS, FRANZCP · Sean D Hood MB BS, MSc, FRANZCP

To the Editor: A recent article in the Journal describes, again, barriers to implementation of cardiometabolic monitoring among patients prescribed antipsychotic drugs.1 The cardiac health of patients with psychosis is not routinely assessed at first presentation for mental health services, adverse side effects of antipsychotic drugs are not systematically monitored, and patients with treatable risk factors for heart disease are not identified.2 We propose a practical solution to the seemingly intractable problem of implementing guidelines for cardiometabolic monitoring — change the delivery system. We have employed a general nurse to conduct cardiometabolic monitoring in a pilot study at the Recovery And Prevention of Psychosis Service (RAPPS), a first-episode psychosis service in Melbourne. All 15 eligible patients had their height, weight, blood pressure, waist circumference, fasting total cholesterol, high- and low-density lipoprotein cholesterol, triglycerides and glucose assessed according to national guidelines3 within 1 month of entry to the service, in the hospital, as an outpatient, or in the patient’s home; 14/15 blood samples were taken while the patient was fasting. Very early monitoring (within 7 days of first exposure to antipsychotics) was not implemented for four patients because they were inpatients and judged by ward staff as too unwell to be approached by a general nurse. Future follow-ups will be conducted at 3, 6, 12 and 18 months. Abnormal findings are referred to the treating psychiatrist, who is responsible for ensuring the patient receives appropriate follow-up. A general nurse can implement clinical guidelines, but this initiative requires substantial planning and ongoing management. Systematic identification of all patients eligible for monitoring requires identification of all pathways into the relevant mental health service, so as to begin monitoring at, or very close to, the point of first exposure to antipsychotics; management tools to track patients over time; and a clinical pathway to track test results and ensure appropriate medical interventions occur when required. Failure to implement prescribed monitoring guidelines is important because individuals with schizophrenia have a 20% shorter life expectancy than individuals in the general community.4 Side effects of antipsychotic drugs may include dramatic weight gain and elevations in serum cholesterol and glucose levels, which exacerbate the risk for cardiovascular disease. Most early deaths among individuals with schizophrenia are due to cardiovascular disease.5 Failure to monitor cardiovascular health and the adverse side effects of antipsychotic drugs is an important, life-shortening, failure of care. A simple solution to a complex problem exists if an effective delivery system is used.

Debra L Foley · Katherine I Morley · Karyn E Carroll · John Moran · Patrick D McGorry · Brendan P Murphy

In reply: Foley and colleagues rightly point out that a way to improve the cardiometabolic health of patients with psychosis is to change the way that mental health services are delivered. Although barriers to monitoring exist at the level of the patient, the illness, and the service,1 by focusing too narrowly on the barriers presented by patients, a blaming culture can be perpetuated. If blame is to be attributed, it should be directed towards inflexible services with a medieval belief in separating mental and physical health care. A number of centres in Australia have started to innovate in service delivery, with structured physical health clinics running in parallel to, and integrated with, mental health clinical programs. Our own centre, the Concord Centre for Cardiometabolic Health in Psychosis (ccCHIP), has been developed to take the notion of integrated care a step further — to actually treat the cardiometabolic abnormalities present. Our model involves a multidisciplinary team comprising psychiatrists, endocrinologists, and dietitians. However, we believe the potential for broader multidisciplinary input exists, including nurses, pharmacists, psychologists, occupational therapists, social workers and the patient’s general practitioner. It is our philosophy that although detection is the first step to improving the parlous outcomes for our patients, without active intervention, these poor outcomes are unlikely to improve. Recently, we received funding from the New South Wales Department of Health to develop a more comprehensive plan for education and training, including the production of a manual, to help psychiatric services in NSW develop their own monitoring and intervention services, using ccCHIP as their resource base. This initiative points to the need for government involvement to support these initiatives. Finally, it is apposite that Foley and colleagues write from the perspective of an early psychosis service — we believe that early detection and intervention for psychosis should be for physical as well as mental health issues.2

Timothy J R Lambert

To the Editor: We thank Page and colleagues for their important article considering the sociodemographic correlates of antidepressant utilisation in Australia.1 We note that fewer than 15% of the young people in the study were prescribed fluoxetine, and almost 40% were prescribed sertraline. These rates of antidepressant use contrast with the available evidence on treating young people diagnosed with depression. A recent review examining the effectiveness of selective serotonin reuptake inhibitors (SSRIs) for depression among children and adolescents demonstrated that fluoxetine is the only SSRI with at least some evidence for effectiveness.2 Current clinical guidelines recommend that a young person diagnosed with a major depressive disorder who is to be prescribed an antidepressant should be given fluoxetine in the first instance.3,4 Reasons for the apparent lack of concordance with the guidelines might include treatment of disorders other than depression, or prescriptions for those who have already had an unsuccessful trial of fluoxetine. It would thus be of great interest to learn what proportion of young people are prescribed an antidepressant other than fluoxetine, and what proportion of young people prescribed an antidepressant are concurrently undergoing guideline-concordant psychological treatments, such as cognitive behaviour therapy. The data presented by Page et al draw attention to challenges faced by doctors providing treatment for young people experiencing depression, which include a lack of good evidence about the effectiveness of newer antidepressants for this age group. However, there is an opportunity to support better use of evidence in decisions made about treatment options for young people. The provision of high-quality, evidence-based information for patients and their carers to enable informed decisions is essential, and shared decision making offers a way to enable this.5 By improving the knowledge transfer between doctor and patient, antidepressant prescription can be more judicious.

Magenta B Simmons · Michaela R Willet · Sarah E Hetrick

Perinatal depression is an important public health issue, with major consequences for the mother, child and family. Perinatal depression is often associated with anxiety and other mental health and psychosocial issues. The National Perinatal Depression Plan (NPDP) proposes routine screening during pregnancy and after birth, follow-up support for women assessed to be at risk of or experiencing depression, and training for health professionals. Identifying women at risk of or experiencing perinatal depression is difficult, and there is no standard tool used by all hospitals to assess women’s emotional health and psychosocial comorbidities. The NPDP provides an opportunity to develop and evaluate new approaches to assessing perinatal depression and a range of psychosocial issues, and to test strategies for supporting women and their families before and after birth.

Jane S Yelland BAppSc, PhD · Georgina A Sutherland BAppSci(Hons), PhD · Jan L Wiebe BHlthEd, MWomHlth · Stephanie J Brown BA(Hons), PhD

To the Editor: We applaud the attempt by Boyes and colleagues to ascertain the level of psychological distress experienced by patients over the years following diagnosis with cancer, through a retrospective, cross-sectional survey of New South Wales cancer registrants.1 However, we believe several methodological limitations ought to reduce the confidence with which the authors drew their conclusions. The authors’ comment that “life after cancer is not all doom and gloom” was, perhaps, intended to be a little facetious. From a scientific point of view, however, such a statement is also very difficult to ever disprove — of course it isn’t all doom and gloom. Further, the authors’ assertion that psychosocial wellbeing several years after cancer diagnosis is comparable with that of the general population cannot be substantiated by studies conducted by this method. As the survey was cross-sectional, we have no information about the level of distress experienced during the years since diagnosis. A longitudinal design is now de rigueur in this field for this reason. Certainly, clinical experience shows us that many patients actually do experience “doom and gloom” often, indeed, arising from “insidious and relentless disease” — this group may not, however, be well represented by a cancer registry survey sampling 5 years after diagnosis. Selection bias is a major problem. Of the sample of 2029 eligible, randomly selected people, 655 (32%) were deemed ineligible, with one of the exclusion criteria being not “mentally capable of participating”. Could this sizable subgroup have included those who were distressed? Also, of the eligible sample of 1374, 366 (27%) declined to participate. What were the reasons for refusal? Were some too distressed to participate? In summary, how were the 37% who did not participate in the study faring 5 years after diagnosis? The Hospital Anxiety and Depression Scale (HADS), used by Boyes et al to detect psychological distress in early-stage breast cancer, under-reports distress when recommended cut-off scores are used, compared with a structured clinical interview validated to provide Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV2) diagnoses.3 In other words, the HADS is known to lack sensitivity and positive predictive power in the cancer setting. Other cancer researchers found the same.4,5 Further, measuring distress only in terms of anxiety and depression 5 years into the adjustment process fails to capture the quality of continuing distress and the degree to which traumatic growth and other forms of meaning-based adjustment have been achieved. The limitations of the HADS should have been better acknowledged.

Jeremy W Couper · Anthony W Love · Annabel C Pollard · Sidney Bloch

In reply: We thank Couper and colleagues for their interest in our article,1 but reiterate that we focused on anxiety and depression experienced by long-term cancer survivors, specifically at 5–6 years after diagnosis. We agree that longitudinal studies are vital for understanding the level of psychological distress experienced during the years since diagnosis, and as discussed in our article, we are currently undertaking a longitudinal study with a diversity of cancer patients to assess a comprehensive range of physical, psychological, social and lifestyle effects of cancer. Although opinions on the performance of the Hospital Anxiety and Depression Scale (HADS) vary, it is one of the most popular measures of psychological distress, and has been used extensively across the cancer continuum.2 A recent review of the validity of the HADS concluded that it performs well in screening for caseness of anxiety disorders and depression in a range of patient populations, including patients with cancer, and in the general population.3 We acknowledge that our study had the strengths and limitations normally associated with recruiting through a population-based cancer registry.4 Nevertheless, our results are consistent with a growing body of evidence indicating that most cancer survivors are doing well 5 or more years after diagnosis.5 We believe our conclusions are justified.

Allison W Boyes · Afaf Girgis · Alison C Zucca · Christophe Lecathelinais

A 71-year-old man who presented to hospital with chest pain and a history of cardiovascular disease was repeatedly hospitalised over the course of a month for care that included multiple investigations, intensive care, transfer to and from a metropolitan hospital, discharge, and readmissions for collapse, hemiparesis, and vision change. The medical team excluded underlying disease related to his initial chest pain and subsequent neurological symptoms. A search for (undisclosed) prior hospitalisations revealed multiple previous admissions and invasive investigations at hospitals across Australia, resulting in a diagnosis of Munchausen syndrome. Assuming that, despite interventions, patients with Munchausen syndrome or somatoform disorders often continue to seek care at other hospitals, we discuss the implications of this patient’s behaviour for the health care system, society, and the risk to his own health. In our view, this case highlights conflicts between privacy legislation and doctors’ mandates to protect the patient from harm, as well as their duty to attend to the financial viability of health services by communicating with other potential health care providers. The health care system and similar patients may benefit from efforts to educate doctors about this spectrum of disorders and from considering the implementation of a highly confidential, structured notification system.

Dawn E DeWitt MD, FACP, FRACP · Stephanie A Ward MB BS · Sandeep Prabhu MB BS(Hons), LLB(Hons) · Bruce Warton MB BS, GradDipHealth

Younger onset dementia. A practical guide. John R Hodges, Carol Gregory, Colleen McKinnon, et al. Sydney: Alzheimer’s Australia, 2009 (38 pp). Alzheimer’s Australia has been producing the Quality Dementia Care series of useful fact sheets and booklets for people with dementia and their carers but, until recently, had neglected the area of dementia with early onset. This booklet, together with a few others released during the past couple of years, helps rectify the situation. John Hodges, one of the world’s leading authorities on younger onset dementia, gathered a competent group of collaborators to produce this document, which can be freely downloaded from: http://www.alzheimers.org.au/content.cfm?infopageid=5484. The booklet is divided into five sections covering key features of the clinical presentation of younger people with dementia, practical approaches to manage cognitive deficits and behavioural disturbances, issues that are of relevance to carers, preparing for the future (including legal issues), and further resources. The document has a smart layout that will make it easy for readers to find the information they are after; and although information has been maintained at a basic level (basic, but up to date), carers will certainly appreciate the helpful hints on issues related to management, services and how to access other relevant resources. If you work with people with dementia, I would encourage you to keep a few copies of this booklet at hand in your office. I certainly will.

Osvaldo P Almeida

Lessons from the past for today’s researchers in general practice In January 1971, a randomised controlled trial of management of depression by general practitioners was published in the British Medical Journal by Tim Blashki (T G B) and his colleagues Robert Mowbray and Brian Davies (Box 1).1 Although there had been two earlier trials of antidepressants conducted in general practice (one British and one American), this was the first in the world to have extractable data in general-practice-only patients that could be used in a meta-analysis. It is therefore the earliest study included in this year’s published Cochrane Reviews that examines antidepressants versus placebo for depression in primary care; the review’s authors were Bruce Arroll (B A), Grant Blashki (G A B) and colleagues.2 Tim Blashki, the first author of this historically important article, was a Melbourne psychiatrist who had been a GP before he commenced the study. Tim Blashki’s son, Grant (G A B), has continued the family tradition of researching the management of mental illness by GPs,3 and he recently took up Bruce Arroll’s suggestion to interview Tim to document some of his experiences from this early clinical trial. This interview took place by phone on 8 January 2009. The interviewCould you say something about your medical training?I graduated from medical school in Sydney in 1964, having had only about 12 lectures in psychiatry in total. My first real contact with psychiatry was as a second-year resident at Royal Melbourne Hospital, where I worked as a medical officer under Professor Brian Davies. Psychiatry interested me and came easily to me, and this sparked an interest which has continued for the rest of my life. As a result of this experience, I went to a typical psychiatric hospital of the time. There were some very good and dedicated people working there, but, for the most part, treatments at that time were only partially effective, and there was a large custodial component in the function of the institution. My first job was unsupervised, and involved looking after a ward for young women (adolescents and those in their early 20s), many of whom had psychosis with poorly controlled symptoms. I left after 6 months and began working in general practice, as I wanted to help people experiencing mental illnesses in the community. The general practice I joined practised in a traditional manner for that time. The focus was on patients’ somatic symptoms and on somatic treatments. Patients had great faith in the doctors, whom they had known for many years in what was a rather tight-knit community. Psychological problems were generally ignored or ascribed to some somatic problem or social difficulty. Treatment consisted of support, advice, and a variety of what were essentially placebo treatments, ranging from rose-coloured water (dill water), vitamins, Waterbury’s compound, the pharmacist’s special concoction (often a bromide-containing medication), and night sedation with drugs such as chloral hydrate and barbiturates. The use of tricyclic antidepressants, monoamine oxidase inhibitors and minor tranquilisers, often in minute doses, was just beginning. Depression was just starting to be acknowledged as an illness; most depressions were perceived as reactions to events or a failure of will. Anxiety more or less went with the depression, with the exception of phobias and “panic” states. It became clear to me that much of what I was seeing in general practice — I thought about 70% — was psychologically based, and so I returned to psychiatry at Royal Melbourne Hospital, where I again worked under Professor Brian Davies. It was in this dual setting of psychiatry and of general practice that I began to think about psychological disorder in the community, and depression and anxiety in particular. How did the idea of a randomised, placebo controlled trial of antidepressants in general practice come about?In the late 1960s, I decided to do a doctorate in medicine. I chose to do this with a focus on general practice for a number of reasons. First, as I’ve already mentioned, many of the problems that I’d seen in general practice were of a psychological nature. Second, while most mental health problems were being seen in general practice, most of the research was done in hospitals on inpatients and the results were being extrapolated to general practice patients. The assumption was that these patients were part of the same cohort, but, having worked in both places, I believed this to be incorrect. Third, I was interested in the notion of placebo as an effective treatment, and I had wondered whether some of the “antidepressant effect” seen in patients treated in general practice for depression was possibly the result of such a placebo effect. Fourth, I thought that some of the response to antidepressants in this mildly to moderately affected group might be occurring because of reduced anxiety, rather than to a specific antidepressant effect. Finally, I could find very little published research on what was essentially a large group of people in the community who had some type of mental disorder. What was involved in getting the study off the ground?Initially, I had two problems. The first was that GPs were said to be not particularly interested in psychiatry.4 However, I felt that given half a chance, many GPs would respond to an offer of some help and of an opportunity to be involved in a research project. This indeed proved to be the case. It involved me visiting GPs in their practices and talking about the sorts of issues that they faced, which facilitated the study and was central to its successful completion over 9 months in late 1969 and early 1970. The Research Committee of the Victorian branch of the Royal Australian College of General Practitioners were well acquainted with the project and approved it. The second problem was that of constructing a study that had the same scientific rigour as previous studies that had been conducted in institutions, and to apply this rigour in a general practice setting. To accomplish this, it was necessary to ensure randomisation, placebo control, double blinding, and for the patients to be rated both subjectively and objectively with the use of rating scales such as the Hamilton Rating Scale for Depression5 and the Taylor Manifest Anxiety Scale.6 To confirm whether the patients did actually take the tablets that were prescribed, riboflavine was included in the formulation, and patients’ urine was tested for compliance with treatment. The coauthors of the study, Robert Mowbray and Brian Davies, made important contributions to the planning of the study. What did the study find?For me, the most fascinating and important finding was that clinical improvements occurred in 55% of patients who had received placebo after 7 days, and in 61% at 28 days. Indeed, there was a handful of patients who wanted to continue taking the placebo even after they were told it was a placebo, and we managed to obtain more placebo from the pharmaceutical company, so that they might continue taking their “medication”. With respect to the specific treatments, I was not surprised that the higher dose of amitriptyline (150 mg per day) was the most effective in relieving depression and anxiety. Anecdotally, I thought that the smaller dose of 75 mg might also be effective in relieving symptoms, but this proved not to be the case. I was interested to read a recent study by Furukawa et al, published in the British Medical Journal in 2002, in which they found a good response to low-dose tricyclic antidepressants.7 With respect to side effects, there was no difference between the groups. This was very surprising, but I think it might be attributed to a problem in the study design. Participants were given a list of possible side effects before starting the medication — something I thought to be important because some might well have been troubled with the higher doses — and this may have created a bias that was reflected in the side-effect profile across all groups. What was the social context in which the study was conducted?I have already alluded to the apparent lack of interest in psychiatry among GPs in those days, to the stigma associated with psychiatric illness, to the notion that depression was induced by life circumstances or was a failure of will; certainly, “madness” was something to be avoided at all costs. While there was some acknowledgement of a biological tendency or disposition often reflected in a family history, when this was discerned, patients were generally sent off to the psychiatrist and the case considered exceptional. The other social factor was that while women came to their doctors for treatment, men generally did not. Men saw it as a weakness, unmanly, and indicative of failure; their way of expressing their distress was often through aggression, excessive alcohol consumption or, at worst, carefully planned or violent suicide. So, I saw mainly depressed women who seemed more ready to say something about how they felt and express something of their vulnerability. Hence, the idea of studying only women in this project came to mind. What is your view of mental health management in general practice today?The management of mental health in general practice is far removed from that of 40 years ago. GPs are more educated in mental illness, and mental illness is less stigmatised. Research has provided a greater understanding of mental disorders and the treatments available, whether they be biological, social or psychological, and much therapy is now evidence-based. It is important that mental health research continue in the setting of general practice, and there are at least three important lessons for future researchers that I’d like to share (Box 2). Fortunately, mental health is now seen as a community responsibility, and there is commensurate financial commitment. Powerful support structures now exist — community, psychiatric, psychological and social. GPs have rightly become an integral part of this process. 1 About one of the world’s first randomised controlled trials of management of depression by general practitioners1 The study was a double-blind randomised controlled trial of amitriptyline (two different doses: 75 mg and 150 mg per day), amylobarbitone (150 mg/day), and placebo, for 4 weeks. It was conducted between 1969 and 1970, and involved 82 women with depressive illness, recruited from 21 general practices in Melbourne, who were randomly allocated into the four groups (61 women completed the study). Improvement at 7 and 28 days was noted on several measures of depression and anxiety in all treatment groups. Of the treatments, amitriptyline at 150 mg/day was the most consistent in relieving depression and anxiety. Troublesome side effects were equally distributed among the four groups. 2 Lessons for researchers undertaking mental health studies in the general practice setting The success or failure of research in general practice will usually depend on the trust established between GPs and their patients. All modes of treatment should be assessed in the setting in which they are to be used, and this is especially true in general practice. Research needs to be scientifically rigorous and objective, while remaining sensitive to the subjective experience of patients.

Bruce Arroll PhD, FRNZCGP, FAFPHM · Timothy G Blashki MD, MRCPsych, FRANZCP · Grant A Blashki MD, MB BS, FRACGP

Incorrect name of author: In the Supplement article “Are common childhood or adolescent infections risk factors for schizophrenia and other psychotic disorders?” in the 16 February 2009 issue of the Journal (Med J Aust 2009; 190 [4 Suppl]: S17-S21), an incorrect author name was printed. The third author’s name was provided as Catherine H Stewart. It should have been Claire H Stewart.

Ian B Hickie · Richard Banati · Claire H Stewart · Andrew R Lloyd

Textbook of disaster psychiatry. Robert J Ursano, Carol S Fullerton, Lars Weisaeth, Beverley Raphael, editors. Cambridge: Cambridge University Press, 2007 (xii + 346 pp). ISBN 978 0 521 85235 7. Disasters, by their nature, are unexpected and often occur when services are least able to respond, such as the tsunami on Boxing Day in 2004. Therefore, the ready availability of resource material is particularly important in disaster management. Due to recognition of the importance of well coordinated and planned recovery programs, there is also growing interest in providing structured academic courses in the disaster field. For these activities, the Textbook of disaster psychiatry is a high-quality, welcomed edition to an already competitive stable. The editors are doyens of the field and bring together a richness of experience, knowledge, and anecdote that combine to provide a text of unusual depth. They focus not only on the challenges facing clinicians, but also on the obstacles the broader systems confront in the face of disasters. A text providing an integrative methodology for a broader public health approach is a valuable tool to ensure optimal long-term outcomes. This is not simply a disguised textbook on post-traumatic stress disorder; it has relevance beyond mental health practitioners. Despite the fact that individuals’ adaptive behaviour determines the success or otherwise of physical disaster relief programs, mental health programs are often seen as a low priority in disaster management. As a consequence, this text will be valuable to coordinators of medical services and those involved in community and social reconstruction. While the editors are truly an international group, the authors of the text are all, bar one, from the United States. Nevertheless, this does not detract from the international applicability of the content and approaches that it espouses. This is a book to have on the shelf for the day when the sky falls in.

Alexander C McFarlane

For many thousands of years it has been recognised that disasters have significant physical and psychological effects on human society. Some of the earliest written records from Sumeria comment on the destruction of Nippur in 2000 bc and report on the anguish and suffering of the population.1 More recently, research has provided ample evidence of psychiatric morbidity in the wake of natural and human-caused disasters.2 Much of the research has focused on post-traumatic stress disorder (PTSD), but other conditions such as depression and anxiety disorder have also been reported. Initial high rates of distress usually diminish over the ensuing months, except for the people most intensely exposed to disaster stressors such as threat to life, loss of loved ones and loss of home. Earthquakes have been associated with enduring rates of PTSD as high as 25% in the affected population, highlighting the need for mental health interventions.3 Children are particularly vulnerable in such circumstances.4 These issues were again brought to prominence with the Sichuan earthquake that occurred on 12 May 2008: 69 000 people were left dead, 374 000 injured and 4.6 million homeless. Many Chinese psychiatrists, psychologists and volunteers gave up their normal duties to help the affected people, who were experiencing a high level of psychological morbidity. They faced overwhelming levels of distress in the affected population and were keen for further detailed information to carry out their roles more effectively. A strong partnership established over the past 4 years between Peking University Institute of Mental Health and Asia–Australia Mental Health provided the basis for developing a collaborative program to support China’s response to mental health problems in the immediate aftermath of the Sichuan earthquake. Asia–Australia Mental Health is a consortium of St Vincent’s Health and the University of Melbourne’s Department of Psychiatry and Asialink, of which two of us (C N and J F) are directors. This partnership had focused on models of community mental health care more broadly, and before the earthquake had already established guidelines for supporting children in disaster situations.5 These were disseminated to affected regions in China and across the country. Soon after the earthquake occurred, a group of experts with experience in the field of mental health in disasters and psychosocial response was formed in Australia to plan and develop an education program. The group consisted of core members of Australia’s national disaster mental health coordinating process, the National Mental Health Disaster Response Taskforce. They were invited to develop the program in partnership with senior members of the ongoing collaboration from China. The Australian training team dealt with concepts such as “psychological first aid” and personal support; planning, organisation and implementation strategies; resilience building; the needs of children and other vulnerable populations; evidence-based intervention strategies for trauma, grief and other stressors (such as dislocation, loss of home, and injuries); and multiple consequences linked to what was known about the impact of the disaster. The Australian training team developed resources and presentation material in Australia, which were sent to the Chinese organisers through the leader of the process in China, Professor Ma Hong, of the National Centre for Mental Health, China Center for Disease Control and Prevention/Peking University Institute of Mental Health. The material was translated, shaped to suit local need, and prepared for an education and training program that took place in Chengdu in Sichuan Province in early July, 2 months after the earthquake. Three of us (B R, an expert on mental health response to trauma; A C, a senior manager leading emergency management for the Australian Red Cross; and R M P, who played a significant role in mental health recovery of Australians affected by the second Bali bombing6) were invited to conduct the training in association with senior faculty members of the Peking University Institute of Mental Health, with representatives from the provinces and from volunteer organisations such as Hope China. The training program was funded by AusAID and supported at a very high level in the Chinese Government, with Bai Huan, Deputy Director-General of the Bureau of Diseases Prevention and Control and Yang Gonghuan, Executive Director of the China Center for Disease Control and Prevention attending the opening ceremony. In his speech, Yang Gonghuan emphasised that mental health is an essential component of disease control in China. Those attending the workshop had volunteered or been sent to provide assistance to the affected population, and most had been working intensively in the region from the earliest time after the earthquake. Apart from these workers, senior mental health professionals from every province in China attended the workshop, to make up a total of 280 participants. The stories of their experience movingly portrayed the huge extent of the disaster and the human distress engendered: families who had lost their only children; seriously injured children being cared for in hospital; and the multitudes who had lost their homes, their way of living, their communities, and their capacity to work. At the same time, there were many stories reflecting the enormous courage and resilience of the people affected, and the compassion and dedication of those who had dropped everything to help them. Workers themselves were stressed by the extent of suffering they had witnessed. There were also stories of the ongoing aftershocks, re-awakening the trauma experience and adding to the difficulties of managing the consequences. Many Chinese speakers as well as visitors contributed to the presentation at the workshop, reinforcing the value of the partnership approach. Before the workshop, the Australian delegation was involved in preparatory work with teams of translators in the delivery of the lectures. This was a delicate and difficult task, with each line of text from 200 or more slides having to be worked through by the presenters and their allocated translator. The workshop was jointly conducted over 4 days and consisted of lectures with simultaneous English and Chinese PowerPoint (Microsoft Corporation, Redmond, Wash, USA) presentations on a range of topics. The lectures were conducted in a spirit of equal partnership with Chinese faculty members, with shared responsibility for material (Box). It became quickly apparent to the training team that participants wanted more engagement with the training process than could be simply developed through a “lecture program”. As a result, the Australian training team developed role plays around specific aspects of psychological first aid as well as responding to participants’ “questions from the floor”. In the evening, the Chinese faculty members provided supervision to the groups of volunteers and mental health professionals, helping them deal with their own emotional issues relating to working with the affected people. The effect of the earthquake on ordinary Chinese people was apparent in conversations such as those with the people of Pengzhou, a town destroyed by the earthquake, during a visit by the Australian team to the reconstruction village there. One of our team (C N) summed up the thoughts of the Australian delegation when he stated: The devastation of the earthquake that shook this province on 12 May will always be remembered. But the horror also brought a rare opportunity for all of us to rethink what really matters, to reach out to other humans who are suffering. People across China have responded with “one heart”. And people overseas, as far [away] as Australia, are moved to make a contribution. The workshop concluded with a banquet, providing a wonderful, warm and joyous opportunity for the visitors to share their experiences and express their respect for and recognition of the achievements of their Chinese colleagues in responding to this catastrophe. The ongoing effect of the training from the workshop was also evidenced by the further work done after the earthquake by Professor Xin Fang, a Chinese faculty member. Professor Xin, who has specific training in the psychotherapy of trauma, had given up her regular work to volunteer to help people affected by the earthquake. After participation in the workshop, she was travelling to Mongolia and Guangzhou to pass on the information she had learned to senior education officials and police, to help their organisations cope better with the psychological consequences of trauma. Asia–Australia Mental Health and the Peking University Institute of Mental Health agreed to build on the success of the workshop by conducting further training, including consolidating the training of the participants in the initial workshop. Both groups have looked to the development of further research to evaluate the effect of the training as well as mentoring of senior Chinese academics and policymakers to continue the progress of the initiative. Concluding comments at the workshop expressed the view that this model of partnership had been invaluable. It brought the strengths of mutual respect, and a recognition of the importance of continuing to develop new understanding that would be helpful, not only to China and Australia, but also for many other countries facing such disasters in the future. The education program A systemic approach of psychosocial response to disasters* Assessment of physical injury and first aid† Team leadership* Disaster worker recruitment* Maintaining a functioning team* Information and communication* Psychological first aid* Personal support* Clinical programs and early intervention* Assessment and treatment of clinical disorders* Medication* Children and adolescent mental health issues* General population mental health issues* Medical ethics† Supporting people affected by the earthquake* Rebuilding communities* Assisting cultural minority groups† Multidisciplinary cooperation† * Australia. † China.

Robert M Parker BMed, AFACHSE, FRANZP · Chee Ng MMed, FRANZCP, MD · Andrew Coghlan BA(SocSc) · Julia Fraser BEd, DipEdAdmin · Beverley Raphael MD, DPM, FRANZCP

Suicide prevention. Robert D Goldney. New York: Oxford University Press, 2008 (xi +105 pp). ISBN 978 0 19 953325 1. It is only in the past 15 years that suicide has been acknowledged as a potentially preventable public health concern, requiring broad national policies. Of course, much has been known about suicide for centuries, and this historical context is well described in Suicide prevention, Robert Goldney’s concise, well written overview. Professor of Psychiatry at the University of Adelaide, and an internationally acclaimed suicidologist and past president of the International Association for Suicide Prevention, his inexpensive pocketbook is very topical, given the current climate of global economic downturn. Despite the brevity of the text, Goldney clearly outlines the major issues relevant to suicide prevention from policy to practice. Perhaps the chapters on individual and clinical factors are stronger than those related to broader society and policy, a reflection, possibly, of Goldney’s clinical academic background, but it is a minor point. The clinical chapters provide the clinician with lucid, broad guidelines to aid assessment and management of the suicidal patient without being at all prescriptive. The recognition that the suicidal patient can be a challenge for many clinicians is crucial and timely. Pharmacological and non-pharmacological strategies are adequately covered. Key messages are helpfully summarised at the beginning of each chapter, and throughout there are boxes and tables outlining important issues. While there are references for each chapter, these seem to be more of a bibliography without any attempt to identify those that are more important. A brief list of useful website links is also provided. Although there are many books about suicide on the market, Suicide prevention fills a niche for students of various health disciplines, policymakers, and clinicians, by virtue of the relatively comprehensive yet succinct coverage of the topic.

Brian M Draper

A national study of eating disorders highlights potential underdiagnosis and high rates of complications in 5–13-year-olds In this issue of the Journal, Madden and colleagues report their prospective investigation of eating disorders in children across Australia (Madden et al).1 This study is an important “first” and investigates the putative increasing problem of early-onset eating disorders (EOEDs) in children aged 5–13 years. Over 3 years, detailed data were collected by the Australian Paediatric Surveillance Unit for 101 children who were managed either as outpatients or in hospital for EOEDs — mainly from paediatricians, but also from child psychiatrists. Most children were hospitalised for treatment. The study raises interesting issues and unanswered questions about eating disorders. Although there are no earlier data for comparison (ie, conclusions cannot be drawn about whether or not the incidence of eating disorders in younger children is increasing), the annual incidence rate for EOEDs of 1.4 per 100 000 children aged 5–13 years accords with international figures. This is especially true of the even higher incidence rate in New South Wales, where there may have been more comprehensive reporting. Of particular concern were the high rates of severe, life-threatening medical complications (hypothermia, hypotension and bradycardia) in inpatients, suggesting under-referral or under-recognition of the problem, and thus delays in active specialist care. Further, most of the children received nasogastric feeding, and a third received psychotropic medication — treatments that may not have been required with earlier, more active intervention. Turning to specific issues, there was a relatively high proportion of boys in this study — a quarter of the total. In contrast, men account for about one in 10 adult cases of anorexia nervosa and bulimia nervosa. When broader diagnostic groups, such as binge eating disorder, are considered, rates are higher, particularly in community samples,2 albeit men account for a minority (around 30%) of patients.3 However, the types of eating disorder reported in higher numbers in men (such as binge eating disorder) differ from the EOEDs reported in Madden and colleagues’ study. EOED was characterised by “determined food avoidance plus weight loss or a failure to gain weight during a period of growth, in the absence of any identifiable organic cause”1 — a variant of anorexia nervosa, if not full-spectrum anorexia nervosa. Nevertheless, the finding that one in four EOED cases affected boys is consistent with results of other studies. For example, a Danish study found males to be younger than females at first presentation and more likely to re-present with psychotic disorder.4 In addition, a large recent study of United States high school students found that binge-eating symptoms were reported by 11.0% of girls and 3.3% of boys, and that recurrent serious purging behaviour (eg, vomiting, laxative use or excessive exercise) was reported by 9.4% of girls and 13.5% of boys.5 How EOEDs in children relate to the eating disorders that emerge later, in adolescence and adult years, is unknown. A 10-year follow-up of a community cohort of 1943 Australian 14–15-year-old adolescents found that partial anorexia nervosa and bulimia nervosa occurred in nearly one in 10 girls aged 15–17 years, and that these girls appeared to be psychologically vulnerable, with poorer functional outcomes and psychiatric morbidity. However, there was little evidence of progression to full anorexia nervosa or bulimia nervosa.6 In contrast, prepubertal children with eating disorders are thought to have a particularly poor prognosis, with high levels of physical and psychiatric morbidity.7 Madden and colleagues’ data support a hypothesis that EOEDs may differ in important ways — including sex distribution and course — from eating disorders with onset in adolescence and adulthood. Whether they have a differing outcome is unknown, and follow-up is imperative. It is also important that an evidence base for treatments for prepubertal children is developed, despite the well known challenges of conducting controlled trials in an uncommon disorder in children. Notwithstanding this, the high (71%) rate of response to treatment reported by Madden and colleagues accords with other research that has demonstrated more positive treatment outcomes in older children and adolescents when compared with adults, particularly for anorexia nervosa.7 Madden and colleagues report that comorbidities, particularly anxiety disorders and depression, were common in the patients with EOEDs; they also found that around one in five patients were prescribed antidepressants, and one in 10 were prescribed antipsychotics. Given the concerns about the effects of these medications on the developing brain and the risks of antidepressant prescribing in youth, this level of use seems high. It is likely to reflect the severity of illness (especially anorexia nervosa), and the small evidence base supporting use of second-generation antipsychotics, such as olanzapine, in adults with anorexia nervosa.8 Lastly, these results highlight the dilemma of how to address concerns about the epidemic of obesity, while also avoiding contributing to the problems of the much smaller number of children with EOEDs that involve severe dietary restriction and weight loss. Although there is no similar “epidemic of eating disorders”,9 a recent South Australian study indicated that disordered eating in adults is increasing, mostly in the overweight population.10 This supports closer integration of prevention strategies and treatments for disordered eating and obesity, such as the promotion of healthy eating patterns and foods, rather than severe dietary restriction. Extreme weight control behaviour and weight disorders are both important health problems in young people, and Hippocrates’ aphorism that “a diet brought to the extreme point of attenuation is dangerous; and repletion, when in the extreme, is also dangerous”11 remains relevant today. In conclusion, Madden and colleagues address an important and potentially increasing problem in prepubertal children. It is imperative that research attention is now directed towards understanding why such young children are developing severe eating disorders and how effective identification and treatment can be targeted earlier.

Phillipa J Hay MD, DPhil, FRANZCP

Objective: To collect nationally representative epidemiological data on early-onset eating disorders (EOEDs) in children.Design: Prospective, active surveillance using the Australian Paediatric Surveillance Unit with key informant design.Setting: Child health specialists in Australia (July 2002 to June 2005).Patients: Incident cases of EOEDs in children aged 5–13 years.Main outcome measures: Disease rates, demographic characteristics, clinical features and complications, hospitalisation, psychological comorbidity, and concordance of clinical features with Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) criteria.Results: We identified 101 children aged 5–13 years with EOEDs (median age, 12.2 years; range, 5.5–13.9 years), of whom one in four were boys. Most were hospitalised (78%), and the mean duration of hospitalisation was 24.7 days (range, 1–75 days). More than 70% of inpatients were admitted to specialised eating disorder units in paediatric teaching hospitals. Among inpatients, 37% met DSM-IV diagnostic criteria for anorexia nervosa; although 61% had life-threatening complications of malnutrition, only 51% met weight criteria. Psychological symptoms were similar to those in adults with anorexia nervosa: 67% of inpatients met both psychological diagnostic criteria for anorexia nervosa (fear of weight gain/fatness and misperception of body shape). Of 19 postmenarchal girls, 18 had secondary amenorrhoea. Nasogastric feeding was used in 58% of inpatients, and 34% received psychotropic medications.Conclusions: This is the first prospective national study of EOEDs. It demonstrates the limitations of applying DSM-IV diagnostic criteria for anorexia nervosa to young children; the high proportion of boys affected by EOEDs; and the significant psychological comorbidity and high frequency of hospitalisation associated with EOEDs. Potentially life-threatening medical complications are common at presentation, suggesting possible missed diagnoses and a need for education of health professionals. The study underlines the severity of EOEDs and the need for joint medical and psychiatric specialist management.

Sloane Madden MB BS(Hons), FRANZCP, CAPCert · Anne Morris MB BS, MPH, FRACP · Yvonne A Zurynski BAppSc, MAppSc, PhD · Michael Kohn MB BS, FRACP · Elizabeth J Elliot MD, FRACP, FRCPCH