Mental health

To the Editor: Parker and Wilkinson raised the issue of medical students who behave inappropriately.1 It is likely that the major way medical students cause distress to others is through deliberate, inappropriate behaviour, representing a deficiency in empathy, rather than through laziness or other mental or social problems. In identifying the problem in these individuals, we need to consider whether the impairment is to the cognitive aspects of empathy — knowing how to behave — or to the emotional aspects — caring about the feelings of other people.2 Inappropriate behaviour can result from differing degrees of impairment in either of these domains, and different courses of action need to be considered for those at the extremes of either type of impairment. An extreme lack of the cognitive components of empathy might be seen in those with developmental disabilities, such as autism spectrum disorders. In these cases, intensive tutoring in professional skills and appropriate career guidance can produce competent and sympathetic doctors.3 At the other extreme, a severe deficiency in the emotional aspects of empathy — not caring about other people’s feelings — may be difficult to correct. Individuals with these psychopathic traits are thought to exist at high levels in many organisations.4 They — especially those with Machiavellian and narcissistic tendencies — may alter their behaviour to become competent medical students. However, their true lack of empathy may become apparent when their careers are secure, and they are in positions of real power. At that stage, they might put patient health and the psychological state of their colleagues at much greater risk. It is likely that some of the most dangerous doctors, such as Harold Shipman in the United Kingdom, represent extreme examples of this pattern. Medical schools need to be certain that any behaviour problems are truly correctable, and consider a thorough personality and cognitive assessment for students who present with inappropriate behaviour, to determine a course of action that will ensure the safety of future patients and colleagues of these students.

Sarah J Abrahamson

Depression alone is debilitating, and this effect is multiplied in people with physical illness

David M Clarke PhD, FRACGP, FRANZCP

Objective: To review the evidence for an association between depression and anxiety and the National Health Priority Area conditions — heart disease, stroke, diabetes mellitus, asthma, cancer, arthritis and osteoporosis — and for the effectiveness of treatments for depression and anxiety in these settings.Data sources: Systematic literature search of systematic reviews, meta-analyses and evidence-based clinical practice guidelines published between 1995 and 2007, inclusive.Data extraction: Each review was examined and summarised by two people before compilation.Data synthesis: Depression is more common in all disease groups than in the general population; anxiety is more common in people with heart disease, stroke and cancer than in the general population. Heterogeneity of studies makes determination of risk and the direction of causal relationships difficult to determine, but there is consistent evidence that depression is a risk factor for heart disease, stroke and diabetes mellitus. Antidepressants appear to be effective for treating depression and/or anxiety in patients with heart disease, stroke, cancer and arthritis, although the number of studies in this area is small. A range of psychological and behavioural treatments are also effective in improving mood in patients with cancer and arthritis but, again, the number of studies is small.Conclusion: The evidence for the association of physical illness and depression and anxiety, and their effects on outcome, is very strong. Further research to establish the effectiveness of interventions is required. Despite the limits of current research, policy and practice still lags significantly behind best evidence-based practice. Models of integrated care need to be developed and trialled.

David M Clarke PhD, FRACGP, FRANZCP · Kay C Currie GradDipAppPsych, BA, MPH

Objective: To compare the mental health and vitality of people caring for a family member with a disability with those of the general population. Second, to identify factors experienced by carers that put them at risk of poor mental health and vitality.Design: Cross-sectional design where logistic and multiple regression analyses were used to compare rates of mental health problems and vitality between carers and the general population while controlling for demographic characteristics. In addition, logistic and multiple regression using data from the survey of carers were used to identify risk factors for poor mental health and vitality that were particular to caregiving.Participants and setting: A randomly selected representative survey of 1002 carers from the Australian Centrelink administrative database (June 2006) who received government payments to care for a person with a disability or severe medical condition, or a person who was frail aged. A sample of 10 223 non-carers was drawn from the fourth wave of the Household, Income and Labour Dynamics in Australia Survey, a nationally representative household panel survey (August 2004 to February 2005).Main outcome measures: Mental health and vitality as measured by the Medical Outcomes Study 36-item Short-Form Health Survey.Results: Compared with the general population, carers were at significantly greater risk of having a mental health problem and lower levels of vitality, even after controlling for demographic characteristics. For carers, the risk factors for poor mental health and lower levels of vitality were caring for a person with a disability with higher care needs, experiencing greater levels of financial stress, lower levels of support and worse family functioning.Conclusion: Carers are at greater risk of mental health problems and lower energy levels than the general population.

Benjamin Edwards BA(Hons), PhD · Daryl J Higgins BA(Hons), PhD, MAPS

Objective: To determine the nature of depressive symptoms in a sample of patients with chronic pain, and to examine the relationship between depressive symptoms and physical disability due to pain.Design, participants and setting: Cross-sectional study of 812 patients with complete datasets from a total of 2419 patients with pain who were referred to the Pain Management Research Institute at Royal North Shore Hospital, Sydney, between January 2000 and December 2007.Main outcome measures: Pain severity and distress, physical disability, depressive symptoms, pain self-efficacy, catastrophising, fear of movement/(re)injury, use of unhelpful self-management strategies, sense of control over life, and perceived support from significant others, assessed by the West Haven–Yale Multidimensional Pain Inventory, modified version of the Roland Morris Disability Questionnaire, the depression subscale of the Depression Anxiety Stress Scales, Pain Self-Efficacy Questionnaire, Pain-Related Self-Statements Scale, Tampa Scale of Kinesiophobia, and Pain Self-Management Checklist.Results: After controlling for the effects of age, sex and duration of pain, depressive symptoms were most strongly correlated with a combination of catastrophising, sense of control over life, physical disability, pain self-efficacy beliefs, higher use of unhelpful self-management strategies and lower perceived social support. Depressive symptoms also correlated with physical disability, but to a lesser extent than other variables, including fear of re-injury, low self-efficacy for activity and pain severity. The depressive symptoms that were rated as most frequently experienced reflected sadness, lack of initiative and lack of ability to experience pleasure.Conclusions: In patients with chronic pain, depressive symptoms are correlated more strongly with cognitive variables than pain severity and pain distress, while physical disability is correlated more strongly with cognitive, behavioural and pain variables than depressive symptoms. Furthermore, depressive symptoms are characterised predominantly by mood-related symptoms, which suggests differences in the experience of depression in patients with chronic pain compared with those presenting with mental disorders.

Michael K Nicholas MPsychol(Clinical), PhD · Carissa M Coulston BSc(Hons), MPsychol(Clinical), PhD · Ali Asghari PhD · Gin Singh Malhi MD, FRANZCP, FRCPsych

Objectives: To examine the relationship between psychological response to injury at 1 week and 3 months, and disability at 12 months.Design: Multisite, longitudinal study.Participants and setting: 802 adult patients admitted to trauma services at four Australian hospitals from 13 March 2004 to 21 February 2006 were assessed before discharge and followed up at 3 and 12 months.Main outcome measure: Disability, measured with the 12-item version of the World Health Organization Disability Assessment Schedule II.Results: Logistic regression identified the degree to which high levels of depression and post-traumatic stress disorder (PTSD) at 1 week and at 3 months predicted disability at 12 months. After controlling for demographic variables and characteristics of the injury, patients with PTSD or subsyndromal PTSD at 1 week were 2.4 times more likely, and those with depression at 1 week were 1.9 times more likely to have high disability levels at 12 months. PTSD at 3 months was associated with 3.7 times, and depression at 3 months with 3.4 times the risk of high disability at 12 months.Conclusions: PTSD and depression at 1 week and at 3 months after injury significantly increased the risk of disability at 12 months. Routine assessment of symptoms of depression and PTSD in patients who have been physically injured may facilitate triage to evidence-based treatments, leading to improvement in both physical and psychological outcomes.

Meaghan L O’Donnell BSc (Hons), MA(Clin), PhD · Alexander C Holmes MMed(Psych), FRANZCP, PhD · Mark C Creamer BA(Hons), MA(Clin), PhD · Steven Ellen MB BS, MD, FRANZCP · Rodney Judson MB BS, FRCS, FRACS · Alexander C McFarlane MB BS(Hons), MD, FRANZCP · Derrick M Silove MD, FRANZCP · Richard A Bryant BA(Hons), MA(Clin), PhD

Objectives: To conduct initial analyses and examine ways in which depression and anxiety are associated with outcomes after participation in the Healthy Living Course (HLC), an early-intervention diabetes prevention program for adults with prediabetes.Design: Randomised controlled study using pre-intervention and postintervention measures to examine relationships between depression, anxiety and diabetes-related program outcomes.Participants and setting: 185 adults from urban and rural Victoria with prediabetes who had completed the HLC program and for whom postintervention measure data were available. Data were collected between 15 June 2006 and 15 June 2008.Main outcome measures: Baseline and postintervention scores on mood (anxiety, depression), biochemical (fasting plasma glucose, oral glucose tolerance), anthropometric (body mass index [BMI], waist circumference), cognitive (self-efficacy, diabetes knowledge) and behavioural (healthy eating, physical activity) measures; correlations between these measures.Results: The intervention alleviated depression, and improved eating patterns and scores on cognitive, anthropometric and biochemical measures. Cultural group and sex did not influence most results. Baseline mood was not associated with anthropometric or biochemical outcomes; however, more positive baseline mood factors were associated with activity changes, and with greater subsequent activity rates, self-efficacy and diabetes knowledge. In turn, baseline self-efficacy was associated with postintervention healthy eating. Changes towards healthier eating correlated with anthropometric and biochemical changes, while baseline cognitive measures were also associated with physiological outcomes. As expected, reductions in BMI and waist circumference were related to biochemical changes.Conclusion: Our findings highlight the importance of assessing mood factors in prediabetes, and the need to develop theoretical models of change mechanisms for mood in health outcomes.

Michael Kyrios BA, MPsych, PhD · Susan M Moore BSc(Hons), MEd, PhD · Naomi Hackworth BSc, BA(Hons), DPsych(HealthPsych) · Simone A Buzwell BA(Hons), PhD · Naomi Crafti BBSc(Hons), DPsych(Counselling) · Christine Critchley BA(Hons), PhD · Elizabeth Hardie BA(Hons), PhD

Objective: To assess the psychological impact of the different treatments for localised prostate cancer (PCA).Design, participants and setting: Observational, prospective study of consecutive patients with PCA attending clinics in public hospitals and private practices in metropolitan Melbourne between 1 April 2001 and 30 December 2005. Data were collected at initial diagnosis of histologically confirmed localised PCA, and close to the commencement of definitive treatment (Time 1), and 12 months later (Time 2). Patients were stratified according to treatment type (radical prostatectomy [RP], hormone therapy [HT] or other early treatment including radiation therapies [OET]). Patients who elected to undergo active surveillance/watchful waiting (WW) rather than active treatment were treated as a naturalistic control group.Main outcome measures: Levels of depression and anxiety were assessed by the Brief Symptom Inventory, and physical and psychosocial aspects of health-related quality of life (HRQOL) were assessed by the 36-item Short-Form Health Survey.Results: 211 patients with PCA were recruited; 193 completed the Time 1 questionnaires (38 RP, 56 HT, 38 OET and 61 WW); and 172 completed the Time 2 questionnaires (33 RP, 51 HT, 33 OET and 55 WW). At Time 1, the three active treatment groups all reported greater dysfunction in work role and daily activities compared with the WW group. The RP group also reported worse social and emotional role functioning, while the HT and OET groups reported poorer vitality levels. The HT group reported significantly higher depression scores. At Time 2, the RP and OET groups did not differ from the WW group on either HRQOL or psychological status. By contrast, the HT group reported significantly worse HRQOL (physical functioning, role-physical and vitality domains) and greater psychological distress compared with the WW group.Conclusions: Compared with the other active treatments for localised PCA, HT appears to be associated with poorer HRQOL and greater psychological distress 12 months after commencing treatment.

Jeremy W Couper MB BS, MMed(Psych), MD · Anthony W Love MA(Clin Psych), PhD · Judith V Dunai MPsych(Clin), PhD · Gillian M Duchesne BSc(Hons), MB ChB, MD · Sidney Bloch MB ChB, PhD · Anthony J Costello MB BS, MD · David W Kissane MB BS, MPM, MD

Assessing and managing depression and other forms of psychological distress in patients with advanced physical illness (such as advanced cancer) can be complex clinical tasks. Assessment of distress is complicated by the contribution of the physical disease and side effects of its treatment to symptoms. Clinical evidence has indentified factors that increase vulnerability to experiencing distress and interventions that can improve wellbeing in patients with serious physical illness, yet there are significant gaps in current practice and challenges for health professionals in addressing the core emotional concerns of patients with advanced physical illness. The 2003 publication Clinical practice guidelines for the psychosocial care of adults with cancer provides evidence-based recommendations for providing psychosocial care. Implementing existing guidelines, including systematic assessment of risk and adapting interventions to reflect the precise needs of patients, requires strategies to help clinicians in the emotional dimensions of this caring role.

Brian J Kelly BMed, FRANZCP, PhD · Jane Turner MB BS, FRANZCP

Objective: To assess the prevalence and predictors of anxiety and depression among a heterogeneous sample of long-term adult cancer survivors.Design and participants: Cross-sectional survey of 863 adults diagnosed with a new histologically confirmed cancer (local or metastatic) between 1 April and 30 November 1997 and still alive in 2002, living in NSW, able to read and understand English adequately, physically and mentally capable of participating, and aware of their cancer diagnosis, who were randomly selected from the New South Wales Central Cancer Registry.Main outcome measures: Prevalence of anxiety and depression assessed by the Hospital Anxiety and Depression Scale; and factors (patient, disease, and treatment characteristics; coping style; social support) predicting clinical or borderline levels of anxiety and depression.Results: Levels of anxiety and depression were low; only 9% of participants reported clinically important levels of anxiety and 4% reported depression. The strongest predictive factors of borderline or clinical anxiety were previous treatment for psychological illness, maladaptive coping styles (helplessness–hopelessness, anxious preoccupation) and poor social support. Borderline or clinical depression was most strongly predicted by previous treatment for psychological illness, being an invalid pensioner, maladaptive coping style (helplessness–hopelessness) and poor positive social interaction.Conclusions: By 5 years after diagnosis, most survivors had adjusted well to their cancer experience, with levels of anxiety and depression similar to those of the general population. Nevertheless, a small and important group of long-term survivors continue to experience adverse psychological effects and need assistance. Monitoring of psychological wellbeing and referring patients when appropriate need to be integrated into routine care for cancer survivors.

Allison W Boyes BA(Psych), MPH · Afaf Girgis BSc(Hons), PhD · Alison C Zucca BA(Psych)(Hons) · Christophe Lecathelinais DESS de Mathématiques Appliquées

Objectives: To assess the prevalence, severity and distress from physical symptoms and the prevalence of anxiety and depression in patients about to undergo chemotherapy for potentially curable cancers; and to explore the presence of symptom clusters and investigate their relationships with anxiety and depression.Design, participants and setting: Cross-sectional survey of 192 patients with breast or gastrointestinal cancers or lymphoma before first ever chemotherapy treatment with curative intent.Main outcome measures: Hospital Anxiety and Depression Scale to assess anxiety and depression and the Chemotherapy Symptom Assessment Scale to measure physical symptom prevalence, severity and distress (“bother”).Results: Prevalence of anxiety was 45% and depression 25%. The most prevalent physical symptoms were pain (48%), feeling unusually tired (45%) and difficulty sleeping (45%). Physical symptoms rated as most severe were pain (28%), difficulty sleeping (26%) and feeling unusually tired (19%). Physical symptoms causing the most distress were pain (39%), constipation (18%) and nausea (16%). Factor analysis of symptom distress scores indicated that five factors explained 36.7% of the variance and included: gastrointestinal (nausea, vomiting, pain), general malaise (tiredness, feeling weak, headaches), emotional (feeling depressed, feeling anxious), nutritional (changes to appetite, weight loss or gain) and general physical (mouth/throat problems, shortness of breath). Regression analysis indicated that symptom distress for the malaise (β = 1.46; P < 0.001), nutritional (β = 0.70; P < 0.05) and gastrointestinal (β = 0.73; P < 0.05) factors were independent predictors of depression.Conclusions: Before commencing chemotherapy, patients are already experiencing distressing symptoms and have high scores for anxiety and depression, partially explained by physical symptom distress. Patients should be routinely screened for both emotional and physical needs and appropriate interventions should be developed.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN012606000178549.

Sibilah J Breen BSc(Hons), PhD · Carl M Baravelli BBSc(Hons) · Penelope E Schofield BSc(Hons), PhD · Michael Jefford MPH, PhD, FRACP · Patsy M Yates RN, MSocSci, PhD · Sanchia K Aranda BApplSci(AdvNurs), MN, PhD

Victims of previous disasters have helped us learn much that can help those suffering now The horror and tragedy of the recent Victorian bushfires have affected all Australians, evoking both compassionate response and practical support. Alongside other members of their communities, doctors, nurses and other health professionals have all been directly affected, experiencing horrendous threats to life, loss, grief, and dislocation from their homes and way of life. General practitioners, community nurses, social workers and others will be called upon to provide care and to deal with the extensive mental health issues that arise in the aftermath of such incidents. It is important that any response is informed by the most up-to-date research findings in shaping the care provided. Studies, mainly by Australian researchers, have shown that the most important early responses involve protecting and comforting those most directly affected, linking them to loved ones and sources of support, and ensuring assessment and follow-up. A crucial issue is the central role of the GP in the provision of post-disaster services, as shown in a study of all the registered victims of the 1983 Ash Wednesday bushfires in South Australia.1 Local communities have a preference for their GP’s services in the post-disaster period, but they are also likely to need access to community recovery services for practical assistance and resources. Where possible, such services provided after the fires in Victoria should be linked to local clinics to facilitate access to health care. For the GP, assessing patients in terms of the nature of their experience of the disaster will be important — for instance, whether they were directly exposed to the fire, and whether they have lost family members or others close to them, or their home, property or other physical resources. A brief physical health check is important, alongside assessing levels of distress,2 providing guidance about health and wellbeing strategies, and assuring contact and outreach. Formal counselling is most effective after the early weeks, particularly for those with ongoing levels of acute distress related to the horror and life-threatening nature of the experience. Skilled management of bereavement in the early stages requires allowing patients to talk of their loved ones, and assisting them through any disaster victim identification and other formal processes. Follow-up over the months ahead is important for both physical and mental health needs in the post-disaster period. It is important to remember that the affected communities already carry a level of existing morbidity, which needs to be encompassed in planning a response. The magnitude of this problem is reflected in the 2007 National Survey of Mental Health and Wellbeing, which showed that 20% of Australian adults had a psychiatric disorder in the previous 12 months. Post-traumatic stress disorder (PTSD) was the most common disorder, with a 12-month prevalence of 6.4%.3 These findings suggest that the prevalence of traumatic events is much greater than is generally recognised in our community. Those already suffering are particularly at risk, but a further significant proportion may develop problems such as complicated grief, depression and PTSD as a direct consequence of the bushfire disaster.4 A lesson from the Ash Wednesday fires is that victims often delay seeking care for at least 18 months, despite experiencing considerable suffering.5 When they do present to GPs, it is often with physical symptoms,6 and the significance of these is missed. A recent treatment study after the London terrorist bombings that provided help by directly screening the high-risk victims found that many had presented to and requested help from GPs, who had discouraged them from seeking care, underestimating their distress.7 In the aftermath of the Victorian bushfires, one approach that should be considered is the use of screening for depression, PTSD and alcohol misuse in all GP presentations in affected areas. Clinical guidelines demonstrate that this approach leads to better outcomes if the screening is linked to adequate clinical services.8 However, GPs tend to prematurely terminate treatment, with subsequent loss of the demonstrated treatment gains, highlighting a need in fire-affected regions for continuing education programs that address the issues of diagnosis and treatment.9 Members of the emergency services also deserve particular attention because of the prolonged intensity of their exposure, particularly in light of the high number of fatalities.10 The community owes them a special duty of care. Active screening programs linked to occupational health services that are expert in managing traumatic reactions and grief should be instituted, as currently occurs in the Australian Defence Force. The willingness of victims of previous Australian disasters to participate in disaster research has resulted in the capture of many lessons and should be acknowledged. This knowledge needs to be used in the coming months so that the lessons already learned do not have to be rediscovered, as is too often the case after disasters. Future studies should build on what we already know, rather than simply replicating what has been studied before. Research that makes demands on people who are suffering has no role if it is not innovative. Image courtesy: Inspector Ben Shepherd, Rural Fire Service, NSW.

Alexander C McFarlane MB BS(Hons), MD, FRANZCP · Beverley Raphael AM, MB BS, MD, FRANZCP

To the Editor: Critics of the proposal to legalise trade in kidneys have pointed out the low rates of renal transplantation in Australia compared with the United States,1 where the trade in organs is also illegal. However, it is unclear if the lower rate of renal transplantation in Australia is a result of a shortfall in transplants from living or deceased donors. First, I ranked renal transplantation rates in 2005 in US states and from Australia using the numbers of transplants from deceased and living donors from the United States Renal Data System (Beth Forrest, Coordinating Center, US Renal Data System, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md, personal communication), the Australia and New Zealand Dialysis and Transplant Registry,2 and populations from the US Census Bureau.3 In 2005, there were 12.1 per million population renal transplants from living donors in Australia. All of the states of the US except Oklahoma had higher rates of renal transplantation from the living, and the rate in Minnesota was four times higher. In contrast, the rate of renal transplantation from deceased donors in Australia was 18.6 per million population, which was higher than 24 American states and lower that 26 states and the District of Columbia. Some US states had twice the Australian rate of kidney donation from the deceased. I then used multiple linear regression to examine associations between rates of renal transplants from the deceased and rates of homicide, suicide and motor vehicle accident deaths in US states.4 Rates of renal transplantation from living donors were included as a covariable to control for differing degrees of development in US state transplant services. Homicide rates were associated with rates of transplants from the deceased (R = 0.607, R2 = 0.386; Box), but deaths from suicide and motor vehicle accidents were not. Hence, the higher rate of renal transplantation from deceased donors in the US appears to be the result of greater availability of organs from homicide victims. The high mortality and morbidity associated with endstage renal failure, despite renal dialysis treatment, suggests a need for new approaches to increasing the availability of donor kidneys. Assumed consent for organ donation might increase donation rates from the deceased, but this has been resisted in both Australia and the US on the grounds that failure to opt out might only indicate lack of forethought and not consent. While Australia continues with an opt-in system for deceased donation, measures to encourage live donation might have more realistic prospects of success than attempts to increase the rate of renal transplantation from the deceased.

Matthew M Large

Biting anorexia. A first-hand account of an internal war. Lucy Howard-Taylor. Sydney: Finch Publishing, 2008 (ix + 214 pp). ISBN 9781876 451929. I undertook reviewing this book with some trepidation. I presumed it would be yet another distant “tortured” account of anorexia. I found it quite the opposite. Lucy is an 18-year-old Australian university student. Her depiction of her mental state in anorexia is quite extraordinary. I know that anorexia affects the brain negatively, as a result of both malnutrition and the pervasive thinking disorder. It isn’t until the later chapters that you realise the extreme blunting of her intellect that has occurred. Lucy’s diary is an extraordinarily honest, most intelligent account detailing the process of her illness and pathway towards recovery. I was particularly struck by the difficulties she experienced at all times, and by the depth and sophistication of her thoughts and the enormity of the struggle she went through in attempting to overcome her illness. This book really is the most lucid document and one I have started to recommend to colleagues and to patients. It gave me an insight I had not expected to gain into the extent of the damage done by this illness and the extreme difficulties endured to overcome it.

Simon D Clarke

To the Editor: Between 1997 and 2006, suicide rates fell in all mainland Australian states and territories.1 Despite a rise in the small-population jurisdictions of Tasmania (1997–2006)1 and an earlier rise in the Northern Territory (1981–2002),2 the overall unadjusted national suicide rate has fallen steadily, from 14.7 per 100 000 in 1997 to 9.06 per 100 000 in 2006, the year for which the most recent statistics are available. Trends in suicide occurrence are usually examined with reference to suicide rates. However, because there has been population growth in all parts of Australia, examination of the actual number of suicide deaths in each region is also useful to ascertain whether the demographic changes accompanying population growth can alter unadjusted suicide rates. Annual suicide mortality statistics by state and territory from 1975 to 20061,3,4 show that the number of suicides peaked in every mainland state in 1997 or 1998. Since then, the number of suicides has fallen in New South Wales by 46.5%, in Victoria by 33.5% and in Queensland by 36.4% (Box). There has been larger variation in the number of suicides over time in NSW than in other states. Suicides in NSW rose from under 600 per year (approximately 11 per 100 000 population) in the early 1980s to a peak of 935 suicides in 1997 (14.9 per 100 000) and then fell to 504 suicides (7.4 per 100 000) in 2006. Data available to 2002 indicate that the decline in suicides occurred in almost every NSW health service area and was mainly due to a reduction in the number of suicide deaths in males, including young males.5 By 2006, NSW had the lowest suicide rate in Australia of 7.69 per 100 000 compared with 9.73 per 100 000 for other states and territories. The reasons for the steeper rise and subsequent fall in suicide in NSW compared with other states are unclear, but warrant further investigation with a combined clinical and epidemiological approach. The decline in suicide in NSW coincided with a change to the Mental Health Act 1990 in 1997 that broadened criteria for involuntary care and allowed more people to be treated. However, this factor alone would not explain the extent of the decrease nor the continued decline over a decade. It is possible that programs to prevent suicide or measures to improve access to psychiatric care in NSW have been more successful than those in other parts of Australia. Annual number of suicides in Australian states and territories, 1975–2006* * Data are from the Australian Bureau of Statistics.1,3,4

Matthew M Large · Olav B Nielssen · Steven M Lackersteen

To the Editor: The randomised controlled trial recently reported by Blashki and colleagues does not support their hypothesis.1 The drop-out rates in both arms of the trial were very high — only 62% of general practitioners in the intervention group and 54% in the control group completed the trial. One cannot have any confidence in their conclusion that a short training course can improve GP skills in the provision of cognitive behavioural strategies (CBS). For example, what if the 38% of GPs in the intervention group who dropped out actually deteriorated in their CBS skills and therefore declined to be videotaped? Furthermore, only 56 of 1021 GPs in Victoria were willing to enrol in the trial. The authors concluded that their findings could only be applied to GPs who have a special interest in mental health. Perhaps the low participation rate indicates another more relevant idea — that GPs have had enough of “training models” being imposed on their lives. A recent systematic review has confirmed the low impact that educational training programs have on GPs for the management of mental health problems.2

Marjan Kljakovic

In reply: Our words in conclusion to our article were carefully chosen as: “Competency in CBS [cognitive behavioural strategies] in highly motivated GPs [general practitioners] can be improved by a brief training intervention”1 (italics added) — not that all such interventions will lead to improvements for all GPs, but that well designed and conducted training for selected GPs can do so. Research so far leaves open the possibility of large enough effect sizes for GP mental health training to be relevant to policy.2 The review cited by Kljakovic was limited in scope and noted the poor quality of studies included.3 A drop-out bias in our study, as proposed, seems most unlikely to us. Rather than being imposed, this training model was developed with GPs, by GPs and for GPs, and so might achieve better results than previous interventions studied. Funding for GP participation such as that more commonly available in drug studies might have increased participation. It is true that a great deal of training has been offered to GPs, and we hold that our study shows that such training can lead to GPs significantly improving their skills in this area. GP training should be considered within multifaceted interventions to improve primary mental health care.4

Grant A Blashki · Leon Piterman · Graham N Meadows · David M Clarke · Vasuki Prabaharan · Jane M Gunn · Fiona K Judd

Fight your dark shadow: managing depression with cognitive behaviour therapy. Therrie Rosenvald, Tian P S Oei. Brisbane: Depressionmanaged.com, 2007 (136 pp). ISBN 978 0 646 47032 0. Cognitive behaviour therapy (CBT) has been demonstrated to be a highly effective treatment for depression, both as a stand-alone treatment for mild cases, and in combination with medication for moderate and severe cases. Fight your dark shadow provides a basic introduction to the fundamental components of CBT, using clear, simple language and brightly coloured illustrations to convey its message. There are several CBT-based self-help books currently on the market, but Fight your dark shadow is unique. Firstly, it was co-written by professional and patient, resulting in accurate and relevant information presented in a very colloquial style. Secondly, it is brief, with introductory information only. Many self-help books contain case studies, questionnaires and worksheets that, while undoubtedly adding value for those who use them, may overwhelm and deter those looking for a very simple introduction. Fight your dark shadow would be useful for friends and family of sufferers as well as those experiencing depression directly. Co-author Tian Oei is a professor of clinical psychology at the University of Queensland, and the director of the CBT unit of Toowong Private Hospital. Professor Oei has published widely in the area of CBT, and this text reflects his expertise. As well as an introduction to CBT, the book provides information about diagnosis, depressive symptoms and medication. While there is emphasis on the cognitive component of CBT (identifying and challenging unhelpful beliefs), and some mention of behavioural strategies towards the end of the book, it would be enhanced by an earlier chapter addressing the importance of behavioural activation. Overall, this is a good resource, particularly for patients who are considering engaging in CBT for the first time.

Sarah Perini

New approaches to schizophrenia research and policy can provide a substantive basis for early intervention and better care

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

New primary data and systematic reviews have prompted the review of some long-held views about the epidemiology of schizophrenia. The incidence and prevalence of schizophrenia show prominent variation between locations. Males are more likely to develop schizophrenia than females (1.4 : 1). Migrant status, urban birth or residence, and advanced paternal age are associated with an increased risk of developing schizophrenia. Prenatal infection and nutrition are associated with an increased risk of schizophrenia. Individuals with schizophrenia have a 2–3-fold increased mortality risk compared with the general population. This differential mortality gap may have worsened in recent decades. Epidemiology is good for generating candidate exposures but poor at proving them. Cross-disciplinary projects between epidemiology and neuroscience may help us understand the pathways leading to schizophrenia.

John J McGrath MD, PhD, FRANZCP · Ezra S Susser MD, MPH, DrPH

Neuroimaging studies of individuals at risk of psychosis have the potential to identify markers predictive of illness onset and features that progress with transition. To date, reduced brain volumes have shown weak predictive value for onset of psychotic illness. All published longitudinal studies of the transition to psychosis show progressive brain changes that are not seen in at-risk individuals who do not develop the disorder. Although the cause of these changes is unclear, they challenge the conventional neurodevelopmental model of schizophrenia.

Stephen J Wood PhD · Christos Pantelis MD, FRANZCP · Alison R Yung PhD, FRANZCP · Dennis Velakoulis FRANZCP · Patrick D McGorry MD, FRCP, FRANZCP

Early detection and prevention applies to medical comorbidity as well as psychiatric symptoms Having a psychotic illness has been and remains a barrier to all forms of effective medical care. All serious mental illness is associated with undue medical morbidity and mortality.1,2 Such morbidity stems from a complex web of interactions between the illness itself, various aspects of the patient’s environment, the nature of the antipsychotic medication and, most worryingly, barriers to the acceptance within the wider medical profession of adequate screening and treatment for comorbidity.3 As 70% of patients with persistent psychoses receive some or all of their treatment from non-psychiatric physicians,4 this is an important issue for the broader profession. Severe mental illness is chronic, typically involves progressive neuropsychiatric impairment, and reduces the ability of individuals to independently manage their own care, both medically and socioeconomically. Psychosis lies at the centre of the illness, and its management depends on the use of antipsychotic drugs. These medications are the bedrock on which psychosocial interventions can then be brought into play to aid recovery. Yet, despite the centrality of antipsychotics in treatment, their therapeutic and non-therapeutic effects on the individual patient are by no means predictable. The adage that therapy must be individualised is as true today as it was in the 1950s, when these agents were first introduced. Reported efficacy is moderated by adverse effects, as well as patient-specific factors that influence adherence. These include patients’ own consideration of their susceptibility to the illness, their judgement of its severity, and their personal evaluation of the benefits and risks of treatment.5 The antipsychotic agent clozapine best illustrates the medication issues. Clozapine remains unique in its ability to alleviate the symptoms of patients with refractory illness (30%–40% of patients appear to be “resistant” to other antipsychotics). However, potential toxic side effects of clozapine include agranulocytosis; metabolic disorder (particularly hyperglycaemia, hyperlipidaemia and obesity); seizures; potent sedation; hypotension; hypersialorrhoea; central and peripheral anticholinergia; life-threatening gastric hypomotility; sudden death in elderly patients; and, of recent interest, cardiac complications such as myocarditis, cardiomyopathy and pericarditis.6 Articles by Layland et al 7 and Borovik et al 8 in this issue of the Journal discuss critical adverse effects of clozapine treatment. These reports are timely, as they serve to remind us that uncommon side effects may lead to considerable morbidity and mortality and that vigilance for all potential adverse events is critical in people with mental illness. The metabolic syndrome, along with other cardiometabolic risks such as smoking and inadequate exercise, is more prevalent in people with schizophrenia than in population controls and is a predictor of early coronary heart disease and mortality (with up to 25 years of life lost prematurely).3 Indeed, as the study by John et al 9 demonstrates, the metabolic syndrome appears highly prevalent in several other groups with serious mental illness such as bipolar disorder or schizoaffective disorder. Waterreus and Laugharne 10 propose a data entry form for metabolic risks, based on an earlier algorithm developed as a follow-on to a consensus document on diabetes and antipsychotics.11,12 The items on which their system is based are the five criteria proposed by the International Diabetes Federation to diagnose the metabolic syndrome. However, other factors that contribute to overall cardiometabolic risk should also be considered when monitoring and reviewing patients with enduring psychotic disorders.13 Ageing, family history, ethnicity, obesity, current smoking status, diet, and exercise/lifestyle are all currently being tested for significance in a study being conducted through the Concord Centre for Cardiometabolic Health in Psychosis in Sydney.14 Schizophrenia and bipolar illnesses are also independent risk factors for developing metabolic dysregulation.15 Finally, the issue of non-adherence cannot be ignored. Side effects in general may be important factors leading patients to less than full compliance with medication schedules. When this occurs, the bedrock of their treatment is lost. Thus the causes of the metabolic syndrome, while often laid at the feet of antipsychotic and other orexigenic agents, are more complex. These agents may be seen as forming the tip of the risk iceberg, while a plethora of independent factors associated with psychotic illness form the often unrecognised body of the problem.16 The alarming rates of premature death in this population confirm the need to closely monitor cardiometabolic risks for all patients with psychosis. In particular, although in the short term there may be differences in the incidence of metabolic risk associated with different antipsychotics, limits should not be imposed based on the specific antipsychotic the patient is receiving at any particular time.11 Clearly, the mantra of first-episode psychosis services (“early detection and prevention”) applies to comorbid physical health as well as psychosis itself. The paucity of long-term data in the global literature provided the impetus for a multicentre study currently underway in Australia to examine cardiometabolic risks in first-episode psychosis patients. The study exploits the strong signal of obesity and hyperlipidaemia often seen in clinical settings. Its aim is to determine the time to the development of key cardiometabolic risks from onset of treatment. The relationship between psychotic illness and metabolic illness is not a new one. Maudsley noted in 1895 that “diabetes is a disease which often shows itself in families in which insanity prevails”,17 and Hippocrates observed over two millennia ago that “persons who are naturally fat are apt to die earlier than those who are slender”. Although clinicians acknowledge the need for improved monitoring and management of comorbid and iatrogenic conditions, much needs to be done before outcomes are improved. A clearer understanding of medication side effects, of the metabolic syndrome and of compliance issues is needed. In addition, barriers to screening and management need to be identified and removed.3

Timothy J R Lambert MB BS, FRANZCP, PhD

During adolescence, about 30% of the synapses formed during childhood in the dorsolateral prefrontal cortex (DLPC) are lost; in patients with schizophrenia, the synapse loss is about 60%. Studies of synapse loss in the neuromuscular junction have provided insights into the molecular basis of synapse formation and regression, thereby providing a paradigm for investigations of synapse loss in the DLPC. Research into some of these molecules in the DLPC has shown that they are crucial to synapse formation and regression. Further research in this field could examine when synapse loss in the DLPC of patients with schizophrenia occurs, and further elucidate how these molecules are involved in the development of schizophrenia.

Maxwell R Bennett BEng, DSc, FAA

Postnatal infection may represent a preventable risk factor for onset of psychotic disorders in adolescence and early adulthood. The mechanism of action is likely to involve site-directed triggering of the brain’s innate immune system, mediated principally through localised activation of microglial cells. This triggering may occur in response to systemic inflammatory stimuli, without direct involvement of the central nervous system. Microglial activation can represent a primary response or a secondary phenomenon at sites made vulnerable by prior injury; that is, areas containing previously activated microglia will respond more strongly to a new stimulus. The presence of activated microglia is indicative of a recent insult or active disease. It is not characteristic of long-established neurodevelopmental abnormalities. Activated microglia, acting through a variety of cytokine and other signal systems, have the capacity to significantly interfere with synaptic turnover and thus, over time, alter synaptic architecture and function. This pathophysiological path should be investigated more systematically as it may explain a novel “neuroprotective” mode of action for some existing antipsychotic compounds.

Ian B Hickie MD, FRANZCP · Richard Banati MD, PhD · Claire H Stewart PhD · Andrew R Lloyd MD, FRACP

The aetiology of schizophrenia remains complex, although proposed models have identified genetic markers and environmental pathogens as important risk factors. Researchers have found no large-effect or unique genetic elements, and only a small number of putative environmental agents have been identified. Use of amphetamine-type stimulants (ATSs) is an exemplar environmental pathogen, as it is known to trigger schizophrenia-like illness and other psychotic and manic episodes. To date, the ATS model of illness onset has been under-utilised. It has the potential to reveal key neurobiological elements of schizophrenia and related psychoses. The model proposed here has the capacity to inform detection of those at risk of ATS-related psychoses, and therefore help develop early intervention strategies. It is possible that the same approach may be used in young people known to be at risk of schizophrenia and related disorders, by informing models that involve other environmental or genetic risks.

Daniel F Hermens BSc, GDipSci, PhD · Dan I Lubman PhD, FRANZCP, FAChAM · Philip B Ward BMedSc, PhD · Sharon L Naismith BA, DPsych, CCN · Ian B Hickie MD, FRANZCP, AM