Mental health

Objective: To assess the prevalence of metabolic syndrome and its association with sociodemographic, clinical and lifestyle variables among Australian patients with a variety of psychiatric disorders.Design and setting: Cross-sectional study of patients attending a public mental health service in Western Australia between July 2005 and September 2006.Participants: Patients who were aged 18–65 years; diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder with psychotic symptoms, drug-induced psychosis or borderline personality disorder; and currently taking at least one antipsychotic drug for a minimum of 2 weeks.Main outcome measures: Prevalence of metabolic syndrome diagnosed with International Diabetes Federation criteria; fasting blood glucose and lipid levels; sociodemographic and lifestyle characteristics.Results: Of 219 patients invited to participate, 203 agreed and had complete data. Prevalence of metabolic syndrome was 54% overall, and highest among patients with bipolar disorder or schizoaffective disorder (both 67%), followed by schizophrenia (51%). Sociodemographic variables, including age and ethnic background, were not significantly associated with metabolic syndrome, but a strong association was seen with mean body mass index. Other cardiovascular risk factors, such as smoking and substance misuse, were common among participants.Conclusions: Prevalence of metabolic syndrome in this population was almost double that in the general Australian population, and patients with schizophrenia had a prevalence among the highest in the developed world. Prevalence was also high in patients with a variety of other psychiatric disorders.

Alexander P John MB BS, MD, FRANZCP · Radhakrishnan Koloth MB BS, DPM · Milan Dragovic PhD · Stephen C B Lim PhD

We propose that various measures of brain structure or function, gene expression and proteomic technologies can be used to guide better treatment of schizophrenia and other psychotic disorders. These measures are not used to establish a specific diagnosis. Their purpose is to predict variations in underlying illness activity that predict severity, course of clinical illness, or other morbidity. We propose a new instrument that uses a composite scoring system of systemic biomarkers of illness-related changes in health status: the Brain and Mind Research Institute Biomarker Index. This may permit comparison of biological dysfunction among patients who are at similar points in their illness or have similar clinical features. A specific example of the use of a novel positron emission tomography marker of progressive brain disease in patients with schizophrenia is described.

Richard Banati MD, PhD · Ian B Hickie MD, FRANZCP, AM

A fundamental shift in the design of clinical trials for psychotic disorders is desirable and feasible. Priority should be placed on evaluation of the efficacy of interventions targeting different phases of illness. A range of traditional therapeutic approaches needs to be augmented by an increased emphasis on the potential benefits of informational, e-health, behavioural and neuroprotective strategies. A new national clinical trials platform, based on headspace, the National Youth Mental Health Foundation, is outlined. It provides the opportunity for conducting large multisite clinical trials in young people with emerging major mental disorders.

Patrick D McGorry MD, FRCP, FRANZCP · Alison R Yung MB BS, MPM, FRANZCP · Christos Pantelis MD, FRANZCP · Ian B Hickie MD, FRANZCP, AM

The metabolic syndrome (MetS) is a well described cluster of interrelated risk factors for developing cardiovascular disease and type 2 diabetes. The key components of MetS are central obesity, hypertension, hyperglycaemia and dyslipidaemia. The 2005 International Diabetes Federation (IDF) consensus definition of MetS aimed to reduce confusion over criteria for MetS and to provide a simple diagnostic and clinical tool. There is considerable evidence to show that patients prescribed antipsychotic drugs are at increased risk of developing MetS. Existing clinical guidelines for metabolic screening of patients taking antipsychotics focus on diabetes rather than on the broader syndrome of MetS and are not consistent with the IDF definition of MetS. Monitoring for MetS in patients taking antipsychotics (both inpatients and outpatients) is generally poor. We present a user-friendly clinical algorithm and monitoring form, based on current evidence and using the IDF definition of MetS, to help clinicians in primary care or specialist settings to effectively monitor for MetS in these patients.

Anna J Waterreus NZRN, DipNursStud, GradDipClinEpid · Jonathan D E Laugharne MB BS, MRCPsych

The oestrogen protection hypothesis proposes that oestrogen has a protective effect against onset of schizophrenia. In support of this: Epidemiological studies have shown that young women are less likely to develop schizophrenia than men of the same age, and women are more likely to develop late-onset schizophrenia after menopause. Clinical studies have shown higher psychotic symptoms in perimenopausal women, and women at the low oestrogen phase of the menstrual cycle. Animal studies provide further evidence in support of the oestrogen protection hypothesis. Three randomised double-blind placebo-controlled trials and an open-label study showed that adding oestradiol to women’s usual antipsychotic medications was associated with significant abatement of schizophrenia symptoms. A small study of men with schizophrenia who received oral oestradiol valerate also showed a significant abatement in psychotic symptoms. Although oestrogen appears to be a useful treatment for schizophrenia, further research is required to determine the correct dose and duration of use of oestradiol. New types of oestrogen compounds may provide a safer, non-feminising approach for the treatment of schizophrenia.

Jayashri Kulkarni MB BS, FRANZCP, PhD

Patients with schizophrenia have a wide range of risk factors for cardiometabolic disease, at rates 1.5–5 times greater than the general population. Despite the provision of many sets of guidelines and protocols for screening and monitoring of cardiometabolic risks, morbidity and mortality rates for those with psychotic illnesses remain excessive and premature. Surveys of mental health practitioners reveal a clear acknowledgement of the importance of managing cardiometabolic risks and subsequent comorbidity. However, inadequate screening rates of patients with antipsychotic-treated mental illnesses suggest “knowing is not doing”. Surmountable barriers (at service, patient and illness levels) to adequate integrated health care are not being adequately challenged for this population. Recommendations to improve the situation include service reorganisation, communication enhancement, improved training and education, better incentives, accreditation rigour, and government leadership.

Tim J R Lambert MB BS, PhD, FRANZCP · John W Newcomer MD

The Council of Australian Governments revitalised national mental health reform in 2006. Unfortunately, evidence-based models of collaborative care have not yet been supported. Previous attempts at national reform have lacked a strategic vision. We continue to rely on arrangements that are fragmented between different levels of government, poorly resourced community services, and an embattled public hospital sector. Our persisting unwillingness to record or publicly report key measures of health, social or economic outcomes undermines community confidence in the mental health system. Six priority areas for urgent national action are proposed and linked to key measures of improved health system performance. In Australia, we recognise special groups (such as war veterans) and organise and fund services to meet their specific health needs. Such systems could be readily adapted to meet the needs of people with psychosis.

Sebastian Rosenberg MPAdmin, BA · Ian B Hickie MD, FRANZCP · John Mendoza BEd, GradDipHlthEd

Over the past 15 years, governments have agreed to a series of National Mental Health Plans. These national strategies and plans have set goals and discussed the importance of monitoring and evaluation. Despite this ongoing national collaborative framework, Australia’s mental health policy lacks real accountability and relies largely on limited mental health service systems data. The lack of outcome data represents a critical gap in knowledge for mental health policy, planning and practice. Resistance from current stakeholders and a lack of investment in research and monitoring capacity are preventing more rigorous ongoing monitoring of mental health policy. The new Rudd Government appears to be shifting the emphasis towards measuring the outcomes of national policy in health, housing and employment. Measuring such outcomes will guide government decision making and ultimately improve mental health services.

David W Crosbie BA, DipEd, GradDipSpecEd

Mastering bipolar disorder. An insider’s guide to managing mood swings and finding balance. Kerrie Eyers, Gordon Parker, editors. Sydney: Allen & Unwin, 2008 (xiv + 272 pp). ISBN 978 1 74175 546 6. Bipolar disorder has seen an expansion of clinical, media and research interest, driven largely by the availability of new treatments. Although there are many quality books on bipolar disorder aimed at consumers, they generally share a theoretical derivation (psychoeducation, cognitive therapy, family therapy), tailored to a general readership. Almost all are written by health professionals. Mastering bipolar disorder differs from the herd because it is an edited collection of extracts from essays submitted to the Black Dog Institute essay competition, tasked with describing “The getting of wisdom — managing the ‘highs’ of bipolar disorder”. This collection of anecdotes, experiences and hints from people who have learned from their experiences, successes and difficulties provides a unique perspective. It has the credibility of being the learned experience of survivors, and is a useful counterpoint to evidence and theoretically based books. It is highly readable, creatively using metaphor and image. Its focus on mania captures a range of issues, including dealing with mania, acceptance of illness, medication, detecting and managing early warning signs, and the impact on the family, but does not attempt to cover all areas, lacking sections on key issues such as depression. As a collage of edits, Mastering bipolar disorder does not aim to be comprehensive or definitive, and is likely to be used in conjunction with more systematic books.

Michael Berk

Henry Handel Richardson’s 1929 novel Ultima Thule, the third volume of The fortunes of Richard Mahony, portrays the final years of Mahony’s failed 19th century colonial venture and the psychological challenges he faced. The novel graphically describes the onset and evolution of younger onset dementia, modelled on the author’s own experiences with her father, who died of general paresis of the insane. The issues on which Richardson focuses, including Mahony’s depression and suicidal despair, the difficulties of understanding behavioural change without a diagnosis, the impact of parental dementia on young children and the spouse, and the importance of person-centred care in dementia, remain relevant today.

Brian M Draper MB BS, MD, FRANZCP

To the Editor: A 50-year-old man presented with gynaecomastia and galactorrhoea, reporting diminished libido and energy over 12 months. Previous medical and psychiatric histories were unremarkable. The patient had a tender increase of the right breast tissue. His testes appeared normal. He had markedly elevated prolactin levels (410 μg/L; reference range [RR], < 15 μg/L) and decreased testosterone levels (5.6 nmol/L; RR, 10–33 nmol/L); results of other biochemical tests were unremarkable. Pituitary magnetic resonance imaging (MRI) showed a microadenoma. Cabergoline 0.5 mg twice weekly was commenced. One year later, the patient had normal prolactin (8 μg/L) and testosterone (14 nmol/L) levels. His libido and sexual function had improved — he claimed his “mates are envious”. MRI demonstrated no changes to the tumour. He was lost to follow-up. Five years after his last review, the patient re-presented with his estranged wife, who was concerned about changes to his behaviour after starting cabergoline. He had engaged in excessive casino and horse-racing gambling, resulting in financial losses (> $100 000), and excessive libido had led to hypersexual activities and divorce proceedings. His prolactin levels were normal (10 μg/L), but testosterone levels were low (8 nmol/L). Cabergoline was ceased. On review 3 months later, the patient’s change in behaviour was dramatic. All gambling and hypersexuality issues had ceased, and divorce proceedings were on hold. His prolactin levels had increased (78 μg/L); testosterone levels were unchanged (8 nmol/L). No changes were seen on MRI. Pathological gambling has been reported in patients with Parkinson’s disease who take dopamine agonists — particularly pramipexole but also cabergoline (4.5% of published cases).1 Most were also prescribed levodopa.1 A minority had concomitant hypersexuality.1 The prevalence of pathological gambling in patients with Parkinson’s disease has been estimated at 6.1%, compared with 0.25% in age- and sex-matched controls.2 There has been one published case report of pathological gambling (but not hypersexuality) following use of a dopamine agonist (cabergoline 0.25 mg weekly) for prolactinoma.3 However, the dose of cabergoline normally used in Parkinson’s disease is higher (0.5–6 mg/day).4 Normalising prolactin levels usually leads to increased libido and vitality, but not pathological gambling and hypersexuality. Our patient had not engaged in these activities before commencing cabergoline, and there was no personal or family history of psychiatric illness. Moreover, his testosterone concentrations during treatment ranged from low to low–normal, never high. His Naranjo score was 6, indicating a “probable” adverse drug reaction.5 No reduction in tumour size was seen, raising the question of a partial non-functioning pituitary adenoma. Cabergoline-induced pathological gambling and hypersexuality are probably under-reported, and physicians should consider screening for these in patients treated with dopamine agonists.

Henrik Falhammar · Jennifer Y Yarker

Objective: To examine the circumstances of homicides of children in New South Wales from 1991 to 2005.Design and setting: Retrospective analysis of all identified child homicides in NSW from 1991 to 2005, based on data on offenders and victims obtained from crime statistics, documents located by systematic searches of legal databases and media reports, and medicolegal reports of offenders who committed child homicides during psychotic illness.Main outcome measures: Demographic characteristics of homicides and a history of prior psychiatric treatment among offenders with psychosis.Results: We located documents describing 165 homicides by 157 offenders. Fifty-nine deaths were a consequence of child abuse, including those of five children who died from methadone overdoses. Both the offenders and the victims in fatal child abuse were significantly younger than in other forms of child homicide. The courts found that 27 child homicides had been committed by 26 offenders during the acute phase of psychotic illness, and 15 of these offenders had never been treated with antipsychotic medication.Conclusions: Earlier identification and treatment of psychotic illness in mothers, and changes in the way methadone is provided to opiate-dependent parents, might result in a small overall reduction in the number of child deaths. More lives could be saved by measures that reduce the incidence of child abuse, including the prohibition of corporal punishment of children.

Olav B Nielssen MB BS, MCrim, FRANZCP · Matthew M Large BSc(Med), MB BS, FRANZCP · Bruce D Westmore MB BS, MCrim, FRANZCP · Steven M Lackersteen BPsych(Hons)

Case management is inferior to a multidisciplinary team approach, where people can operate and be accountable within their specific areas of expertise Child and adolescent mental health has been identified as an area of critical concern for the future wellbeing of our society.1,2 However, it remains questionable whether mentally ill patients and their families are receiving high-quality medical care consistent with modern practice standards and published guidelines. Throughout Australia, the current public model of mental health care for children and adolescents uses generic mental health workers (case managers) who learn “on the job” rather than being required to receive specific psychiatric training and certification before they are employed. This case-management model permits young graduates from various courses (social work, occupational therapy, a bachelor of arts with a psychology major) to enter the mental health workforce and assume the role of an independent mental health professional. While such an approach may work in major metropolitan areas where sufficiently experienced senior allied health staff can provide supervision and on-the-job training to new graduates, it does not necessarily work in rural and regional areas where there may be few or no senior staff. Under the current model, allied health professionals are expected to make diagnoses and to provide counselling and other therapies for which they may not have had any specific academic training. Such an approach is a far cry from holistic scientific psychiatric treatment based on a specialised skill set, and is superficial at best and potentially harmful at worst. Given the lack of prevocational training in specific child and youth diagnoses and treatments, supervision by a qualified child and adolescent psychiatrist is essential. However, under the child and adolescent/youth mental health service model in use, all case managers are expected to work independently and interchangeably with each other, including doctors, whose only unique role would appear to be writing prescriptions, ordering investigations, and excluding organic causes. Not all clients will be seen by a doctor, and not all recommendations made by a case manager to a general practitioner or patient will have originated from or be known to the psychiatrist. Yet it is the doctor (for example, the GP who writes the prescription) who bears the overall medicolegal responsibility. Task transfer and substitutionA brief survey of the literature will indicate that doctors are not opposed to delegating to others tasks that were previously only carried out by medical staff.3-6 It is a practice that has been evolving over decades and centuries as skills and knowledge increase, and it will inevitably continue. However, “Poor economic outcomes arise when scarce resources are misallocated. To push the envelope on task substitution is to invite poor resource allocation. It is not a good use of resources to use health professionals in roles for which they are not trained and not expert.”3 Training and competenceCase management has been accepted in mental health service delivery in Australia now for over 20 years, although there is still no requirement to hold (or be training for) a postgraduate mental health qualification at the time of employment as a generic mental health worker. Instead, training is provided “on the job” (although without an apprenticeship), where knowledge and aptitude is never tested in any examination or formal assessment process. However, such an experiential approach to learning does not expose all workers to a set curriculum that ensures that all aspects of psychiatry will be considered in any one given case. No diagnosis can be accurate or trusted if the full range of differential diagnoses has not been considered, and no differential diagnoses can be considered without a comprehensive history taking and mental state examination. Without appropriate training, many aspects of a patient’s case history may not be recognised as important (or even elicited), and thus not be presented (or considered) at case conference. If the diagnosis is not correct, then any treatment plans based on it are useless. “The tragedy is that as our knowledge grows, our approaches to treatment seem to become simplistic, with psychiatric practice sadly becoming dumbed down . . . with a tendency to adopt a cookbook approach to our treatments and a lack of sophistication in the way we understand patient problems.”7 Workers operating beyond their level of competence will be appropriately anxious, but propped up by systemic reassurance. They will be unaware of what they do not know, ultimately lulled into a state of false overconfidence (a denial of the overwhelming reality of anxiety). “People tend to hold overly favourable views of their abilities . . . this overestimation occurs, in part, because people who are unskilled in these domains suffer a dual burden: not only do these people reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the metacognitive ability to realize it”.8 ConclusionThe case management model currently in use in mental health is now widely used and accepted throughout Australia. In some parts of the country, an attitude that all “mental health workers” are equivalent and interchangeable has developed, particularly among mental health administrative managers, but clearly this is not so in the eyes of the law and the public. I would argue that a multidisciplinary team approach provides a much safer and more efficient method of service delivery. Such an approach optimises the collection of information necessary for an accurate diagnosis, from which a high-quality integrated treatment plan can then be formulated. In reality, the current case management model tends to devalue the expertise of individual team members by forcing them into generic skills that do not necessarily utilise their specialist skills. However, individual team members have much to contribute from their own specialties. A well functioning multidisciplinary team will provide comprehensive assessment and consultation, together with a forum for learning more about the strategies, resources, and approaches used by other disciplines, without the need for a case manager to play all of these roles. I believe we need less of a managerial approach in teams, with a greater focus on individual clinical input and accountability, through integration and coordination (rather than management) of expertise.

Vicki A Degotardi MB BS, FRANZCP

Clinical record A man in his 70s was prescribed DuoTrav eye drops (Alcon Inc; combined prostaglandin analogue [travoprost] and β-blocker [timolol]) for worsening glaucoma. (He had previously been treated with latanoprost.) Within 2–3 days, he felt depressed and described “a black cloud descending over [him]”. His symptoms included tiredness, poor concentration, sleep disturbance, and loss of libido and appetite. Normally fit and active, with a zest for life and a good sense of humour, he struggled to get up in the mornings and lost interest in socialising. His general practitioner prescribed venlafaxine (75 mg, then 150 mg) for the depression. Subsequently, DuoTrav therapy was stopped and a combination of travoprost, brimonidine tartrate and brinzolamide started. A month later, his sleep and appetite were considerably improved and he rated himself as 70% better. Eleven years previously, he had suffered an episode of major depression with melancholic features after his initial diagnosis of glaucoma, for which he was prescribed the β-blocker betaxolol.1 At that time, his symptoms had been worse and of longer standing, requiring hospitalisation and electroconvulsive therapy (ECT). He had recovered slowly, while continuing to experience lethargy and a heavy head. Only several months later, when the episode of depression was linked to the initiation of betaxolol and the β-blocker was stopped, did he fully recover. Within 48 hours of ceasing betaxolol therapy, he felt more energetic, alert and alive. The patient had been treated once before with ECT when he experienced his first depressive episode, at the age of 50 years, associated with severe work-related stress. Both subsequent episodes of depression were seemingly unrelated to stressors or life events. The most common medical treatments for glaucoma in Australia are prostaglandin analogues. However, β-blockers still comprise a substantial proportion of all prescriptions, either alone or in combination. Despite their topical administration, β-blockers are absorbed from the eye through the conjunctival epithelium, lacrimal channels, nasal mucosa and gastrointestinal tract into the systemic circulation. Although only small amounts are absorbed, concentrations may be sufficient to cause systemic β-adrenergic receptor-mediated effects, including slowing of heart rate, lowering of blood pressure and non-response to bronchodilators. Central effects such as depression have also been reported. Lessons from practice Ophthalmic β-blockers are absorbed systemically and may cause central side effects. Depression is an occasional adverse effect of β-blockers, including those used for glaucoma. Ophthalmic β-blockers should be avoided in patients who have a history of clinical depression. When depression evolves soon after commencing β-blocker treatment, serious consideration should be given to changing the medication, as the β-blocker may be the causative agent. The literature investigating a causal relationship between β-blockers and depression is controversial. An evidence-based review concluded that depression was an uncommon side effect of treatment with β-blockers and usually occurred only in the presence of a pre-existing condition.2 Randomised controlled studies of β-blockers in cardiovascular disease found the incidence of depressive symptoms was similar in β-blocker- and placebo-treated groups.3 However, a review of 24 case reports4 showed a temporal relationship between the use of β-blockers and depression in more than half the cases. If there is a close temporal relationship between the commencement of a new treatment and the development of symptoms, the symptoms are considered likely to have been caused by the medication. In the initial case that we reported on this patient,1 depressive symptoms began within days after the diagnosis of glaucoma and commencement of betaxolol treatment. The patient’s symptoms only fully remitted when the drug was stopped, providing further evidence of a causative relationship. The case we report here describes recurrence of depression after the introduction of another β-blocker, timolol, and again cessation of symptoms when treatment was stopped. The recurrence of the syndrome following a re-challenge further strengthens the argument for a causal relationship. (The travoprost component of the medication was unlikely to have been the cause of the depression.) It is possible that the onset of the disorder occurred coincidentally with the introduction of the medication (though such an event is unlikely to have occurred twice) or was caused by the underlying illness for which the new medication was prescribed. In the only study we could find of ophthalmological patients with depression with and without glaucoma, no association was shown between depression and glaucoma.5 Glaucoma is mostly a disease of older people, a group prone to developing depressive illness. Depression is often dismissed in older people as a normal reaction to ageing, loss or chronic illness. However, it is treatable, with a very good prognosis. Older patients are frequently taking multiple medicines and may develop depressive symptoms as a side effect. The purpose of this case presentation is to emphasise that even a drug that is administered topically, such as antiglaucoma eye drops, is absorbed systemically and can potentially cause adverse effects elsewhere, including centrally. There are credible theoretical reasons why β-blockers may cause depression: the number of β1 receptors is increased in the brains of suicide victims and chronically stressed animals, and antidepressants cause down-regulation of β1 receptors. The fact that only a few patients develop depression after taking β-blockers may be due to genetic differences. It is possible that poor metabolisers of the enzyme cytochrome P450 2D6 will be exposed to higher systemic concentrations of β-blockers than those who are normal or fast metabolisers.6,7 To our knowledge, there have been no studies of depression in relation to β-adrenergic receptor gene polymorphisms, although associations have been found between these polymorphisms and haemodynamic effects after administration of betaxolol and timolol.8 Variability between individuals in the time course, affinity and extent of receptor occupation may also be relevant. Vuori and Kaila9 found substantial β1 and β2 blockade in plasma for up to 12 hours after administration of topical timolol. Thus, 12-hour dosage intervals could lead to substantial systemic blockade and could explain the reported systemic side effects. Our report adds to the evidence that depression is an occasional adverse consequence of treatment with β-blockers, including topical antiglaucoma agents. Development of depression is a serious consequence. Discontinuation of a β-blocker may relieve symptoms, but specific antidepressant treatment may also be needed. As there are alternative antiglaucoma medications, it is prudent not to prescribe β-blockers for patients who have a history of depressive illness. If depression develops after commencement of a β-blocker antiglaucoma agent, an alternative medication should be substituted if possible.

Isaac Schweitzer DPM, FRANZCP, MD · Kay Maguire BSc(Hons), MSc, PhD · Chee H Ng MMed, FRANZCP, MD

Journeys with the black dog. Inspirational stories of bringing depression to heel. Tessa Wigney, Kerrie Eyers, Gordon Parker, editors. Sydney: Allen & Unwin, 2007 (x + 280 pp). ISBN 978 1 74175 264 9. This is an inspirational book, useful to people who experience chronic depression. It holds the stories of over 600 people who entered a writing competition, challenged to write about their mood disorder — the black dog. Divided into logical sections, the text moves the reader from the experience of depression through to stories of healing and recovery. Innovatively, friends and family are also included in one section of the book, providing their insights into the difficulties people experience when they have a loved one with depression. I was pleased to see the “Staying on course” section, about adjuncts to medical treatment. My experience as a general practitioner and depression researcher is that many people find these things ofs equal, if not more, benefit than medication, particularly for those with moderate depression. Themes of having someone to talk to and really being listened to are prominent throughout the book. The tips for maintaining wellbeing at the end of the book are great and revolve around having a passion in life, being kind to oneself, living in the moment and savouring happiness when it does occur. The only limitation of the book is that it is weighted to the moderate to severe end of the spectrum of mood disorders, with many of the contributors having bipolar and long-term severe depression. Many of them are on medication and have been hospitalised. I would recommend Journeys with the black dog to my patients and to all people who live with or are touched by the black dog — it will provide inspiration to endure, survive and hopefully even thrive.

Kelsey L Hegarty

Primary care has the lead role in reducing the burden of common mental disorders in Australia. This supplement adds to the evidence base needed to achieve it

Harvey A Whiteford MPH, FRANZCP, FAFPHM

Objective: To identify reports in the “grey literature” of programs conducted in Australian primary care to improve depression and anxiety outcomes, and to examine these reports for evidence of effectiveness.Methods: A systematic search was undertaken for grey literature reports using primary health care research databases, community and professional websites, clearinghouse sources, government reports, and reports from the Australian General Practice Network. Reports were included if they related to programs targeting depression or anxiety, contained qualitative or quantitative effectiveness data, and were published during 1995–2006.Results: In total, 642 reports were identified, of which 43 met inclusion criteria. Of the 43 programs described, 30 were delivered in general practice, five in the community or residential care, three in schools, and five were Internet or computer based. Nine programs were also reported in the formal “black” literature, but most, including the Better Outcomes in Mental Health Care initiative, were not. Limited data on effectiveness or patient outcomes were available in the grey literature.Conclusions: There is currently no single service that identifies, describes and catalogues the range and effectiveness of mental health initiatives in Australia. There may be a role for a mental health information “clearinghouse” to facilitate dissemination and education, and to promote collaboration among researchers, practitioners, consumers and policymakers. Innovative schemes to disseminate evidence-based models and to encourage the collection of data on patient outcomes in such programs are needed.

Helen Christensen PhD, MPsychol(Hons) · Kathleen M Griffiths PhD · Amelia Gulliver BScPsych(Hons), BA

Objective: To examine whether there was a reduction in demand for psychological services provided through the Access to Allied Psychological Services (ATAPS) projects after the introduction of the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) program, and whether any such reduction was greater in urban than rural areas.Design and setting: A Division-level correlation analysis examining the relationship between the monthly number of sessions provided by allied health professionals through the ATAPS projects run by Divisions of General Practice, and allied health professional services reimbursed by Medicare Australia under the Better Access program, between 1 November 2006 and 31 March 2007.Main outcome measures: Uptake of each program, assessed by the number of sessions provided.Results: Overall, despite dramatic uptake of the Better Access program in the first 5 months after its introduction, the demand for ATAPS services was not reduced. The correlations between the numbers of sessions provided by both programs overall (r = − 0.078; P = 0.074) and in rural Divisions (r = 0.024; P = 0.703) were not significant. However, there was a significant negative correlation between the numbers of sessions provided by both programs in urban Divisions (r = − 0.142; P = 0.019).Conclusions: For the first 5 months of the Better Access program, the two programs seemed to operate relatively independently of each other in terms of service provision, but in urban Divisions there was a move towards services provided through the Better Access program. Early indications are that the two programs are providing complementary services and are working together to address a previously unmet need for mental health care.

Justine R Fletcher BPsych, MPsych · Bridget Bassilios BSc, GradDipPsych, DPsych · Fay Kohn DEd, MA, GradDipTESOL · Lucio Naccarella BSc(Hons), GradDipMHS, PhD · Grant A Blashki MB BS, MD, FRACGP · Philip M Burgess MA, PhD, FAPS · Jane E Pirkis MPsych, MAppEpid, PhD

Objective: To create a taxonomy of distress and depression for use in primary care, that mirrors the thinking and practice of experienced general practitioners.Design: Qualitative study, using an ethnomethodological approach, with observation of videotaped routine GP–patient consultations and in-depth interviews with GPs.Setting and participants: The study was conducted in metropolitan Melbourne in 2005. Fourteen GPs conducted 36 patient consultations where depression was a focus; nine GPs participated in in-depth interviews to elicit details of how they recognised and diagnosed depression in their patients.Results: GPs consider distress and depression in three steps. In the first step, a change in a group of symptoms and signs is observed (eg, facial expression, loss of drive). The second step categorises the syndrome according to whether or not there is an identifiable environmental cause (reactive or “endogenous”), with the final step categorising the reactive syndromes according to their most prominent symptoms: either anxiety and worry, or helplessness and hopelessness. The resulting taxonomy includes: endogenous depression (a chronic and perhaps characterological depression characterised by a lack of interest and motivation); anxious depressive reaction (stress or worry); and hopeless depressive reaction (demoralisation).Conclusion: This simple and parsimonious taxonomy has validity based on its derivation from within the primary care setting.

David M Clarke PhD, FRACGP, FRANZCP · Kay Cook MSc, PhD · Graeme C Smith MB BS, MD, FRANZCP · Leon Piterman MMed, MEdSt, FRACGP

Objectives: To assess the characteristics of people with common mental health problems who are recognised by their general practitioner, and those who are not.Design: Two different case-finding techniques (brief self-report and structured diagnostic interview) were compared with GPs’ independent assessments of patients’ presentations as psychological and/or medical.Setting and participants: 371 patients in general practices in metropolitan Sydney and rural New South Wales, with follow-up telephone interview as soon as possible after the GP visit. The study was conducted from 2001 to 2003.Main outcome measures: Overall rates of disorder, measured by the 12-item Somatic and Psychological HEalth REport (SPHERE-12), and anxiety, depression and somatisation diagnostic categories of the Composite International Diagnostic Interview – Auto; rates of disability, assessed by the 12-item Short-Form (SF-12) General Health Survey’s mental (MCS) and physical component scales; GP ratings of patients’ psychological problems, and intended treatments.Results: The SPHERE-12 showed the highest rate of case detection and greater agreement with GP assessments of psychological reasons for presentation. Patients who presented with somatic symptoms alone were most likely to be overlooked by GPs: none of the 57 patients identified by SPHERE-12 with a somatic disorder were identified by GPs as psychological presentations. Specificity for the SPHERE-12 psychological scale changed from 72% to 93%, and from 84% to 96% for the combined psychological and somatic scale, when the criterion of an SF-12 MCS score ≤ 40 was added.Conclusion: Low rates of recognition of psychological problems by GPs, and infrequent treatment for those presenting with somatic symptoms, indicate a need for building GPs skills in the assessment and management of somatisation. The SPHERE-12 may be a useful screening tool for primary care if followed by further questioning and other methods to assess diagnosis and severity to target appropriate treatment.

Kay A Wilhelm MD, FRANZCP · Adam W Finch MPsychol · Tracey A Davenport BA(Hons), eMBA · Ian B Hickie MD, FRANZCP

The Mood Assessment Program (MAP) is a computerised assessment and diagnostic program developed at the Black Dog Institute, Sydney, to assist with diagnostic subtyping and management of mood disorders. MAP decision rules capture the applied research, informed by clinical expertise, that has been undertaken over the past two decades. Preliminary validation studies suggest the MAP possesses acceptable validity for key diagnostic decisions, including determination of polarity and depressive subtype, and the presence or absence of the principal anxiety disorders. The MAP provides a rich set of information to help the practitioner derive a broad formulation and so shape a management plan in conjunction with broad treatment guidelines. The program will be rolled out over the next 6 months as a formal evaluative tool for wide assessment and application by general practitioners, and subsequently to assist a broader range of health practitioners.

Gordon B Parker PhD, DSc, FRANZCP · Kathryn Fletcher BSc(PsychHons) · Matthew P Hyett BSc, PGDipPsych

Objective: To evaluate the impact of an educational intervention on general practitioners’ skills in cognitive behavioural strategies (CBS).Design: Randomised controlled trial, with baseline and post-training measurement of GP competency in CBS using standardised simulated patient consultations, conducted between January 2005 and December 2006.Participants and setting: 55 GPs in Victoria with a special interest in mental health issues.Intervention: A 20-hour multifaceted educational program facilitated by mental health experts, incorporating rehearsal of CBS and provision of resources such as patient education material and worksheets.Main outcome measures: Objective ratings of videotaped consultations of a standardised simulated patient using the Cognitive Therapy Scale.Results: 32 doctors completed all phases of the intervention and the evaluation protocol. The intervention group showed greater improvements than the control group in both general therapeutic and specific CBS skills after the training.Conclusion: Competency in CBS in highly motivated GPs can be improved by a brief training intervention.Trial registration: International Standard Randomised Controlled Trial Number ISRCTN62481969.

Grant A Blashki MB BS, MD, FRACGP · Leon Piterman MMed, MEdSt, FRACGP · Graham N Meadows MD, MRCPsych, FRANZCP · David M Clarke PhD, FRACGP, FRANZCP · Vasuki Prabaharan PhD, MSc(Applied Statistics), GradDip(Applied Statistics) · Jane M Gunn PhD, FRACGP, MB BS · Fiona K Judd MD, DPM, FRANZCP

Objective: To evaluate the diagnosis of patients with somatisation disorders in primary care, and the effectiveness of coordinated care and evidence-based care planning on psychiatric symptoms and quality of life for these patients.Design, setting and participants: This was a project of the SA HealthPlus Coordinated Care Trial, comprising a randomised controlled trial of 124 subjects recruited by general practitioners in southern Adelaide. Eligible patients had a GP diagnosis of somatisation, including unexplained physical symptoms as part of anxiety, chronic pain or somatoform disorders. Diagnoses were checked using the Composite International Diagnostic Interview (CIDI). The study was conducted from December 1997 to December 1999.Intervention: A care plan including treatment for depression and anxiety disorders, a containment strategy for somatisation, and service coordinator-assisted self-management. Control patients received standard treatment.Main outcome measures: Psychiatric symptoms; quality of life; medication use; and depression, anxiety and hostility scores.Results: Compared with CIDI diagnoses, mood disorders in patients were underdiagnosed by GPs (64 v 31), particularly major depression (46 v 1). At 12 months, the intervention group showed reductions in depression (P = 0.002), guilt (P = 0.006) and anxiety (state, P = 0.043; trait, P = 0.001). Compared with the control group, physical role functioning improved for the intervention group (P = 0.006), and their medication use decreased by 8.9%.Conclusions: Conservative management, treatment of depression, and case management by service coordinators is effective in managing somatising patients in primary care. GPs require training in the diagnosis of depression and how to say “no” to patients with unexplained physical symptoms who request further unnecessary investigations or referrals.

Rene G Pols FRANZCP, FAFPHM, FFPMANZCA · Malcolm W Battersby PhD, FRANZCP, FAChAM

Objectives: To determine the effectiveness of “Keeping the blues away” (KBA), a manualised depression relapse prevention program for general practice, in reducing the relapse of depression compared with usual care (with the aim of halving the relapse rate), and in reducing depression severity and improving the process of care.Design and setting: A cluster randomised controlled trial conducted in 2004–2005 in South Australian general practices.Participants: 43 general practitioners from 23 urban and rural practices recruited 110 patients with depression (age range, 18–75 years).Intervention: GP training manual or patient manual and relaxation CD; 20 hours of training on depression, the study protocol, assessment tools and skills.Main outcome measures: Relative risk (RR) of depression relapse; depression severity and quality of life scores.Results: There were no significant differences in relapse rates between the groups (χ21 = 1.51; P = 0.23), although there was a non-significant tendency for relapse to be reduced in the KBA group (RR = 0.77; 95% CI, 0.50–2.05). Older patients (≥ 50 years) in the KBA group showed a significantly lower probability of relapse than those in the control group (P = 0.018). There was a decrease in depression scores in both groups. KBA participants had more severe depression at baseline, and the reduction in severity in those with symptoms for > 6 months was nearly significant (P = 0.06). KBA was positively received by GPs and patients.Conclusions: Although this pilot study of a small sample did not achieve its primary outcome of reducing depression relapse by 50%, KBA was found to be a promising program for older patients and for those with more severe or persistent symptoms.

Catherine A Howell BM BS, FRACGP, MHSM · Deborah A Turnbull BA(Hons), MPsych(Clin), PhD · Justin J Beilby MB BS, MD, FRACGP · Charlotte A Marshall BA(Hons), MPsych(Clin), MAPS · Nancy Briggs BSc, MA(Psych), PhD · Wendy L Newbury RN

Objective: To identify the health and mental health information needs of people with coronary heart disease (CHD), with and without comorbid depression.Design and setting: A qualitative study conducted in Melbourne in 2006, using thematic analysis of semi-structured interviews on the types of health information that patients with CHD considered useful to assist with the management of their illness. Structured clinical interviews were used to assess current and prior depressive episodes in these patients.Participants: 14 general practice patients (eight with current or prior history of major depression) who had experienced myocardial infarction, coronary artery bypass graft surgery, angioplasty or angina (confirmed via testing).Results: Four themes relating to information on how patients could manage their cardiovascular health and improve their psychosocial wellbeing emerged: psychosocial; physical activity; medical; and information for family. The most prominent information needs included identification and management of risk-related physical symptoms, and psychosocial information, most notably to enhance patients’ social support. Patients considered this information important for alleviating health anxiety and negative affect.Conclusion: This small patient sample endorsed the need for health and mental health information on a range of psychosocial and physical health topics. Participants desired specific types of information to assist with the self-management of their health and to assuage their health concerns.

Ciaran Pier PhD, BA(Hons)(Psych) · Kerrie A Shandley MPsych(Health), GradDip(Psych), BSc · Julie L Fisher PhD, MBusInfoSys, GradDipComputersInEducation · Frada Burstein MSc(ApplMath), PhD · Mark R Nelson PhD, FRACGP · Leon Piterman MMed, MEdSt, FRACGP