Mental health

To the Editor: There are two fundamental flaws in the case for reform of youth mental health services outlined recently by McGorry and colleagues.1,2 They argued that 18 years is an unnatural and inappropriate transition point between adolescent and adult services, and that Child and Adolescent Mental Health Services (CAMHSs) are somehow inherently ill equipped to deal with serious mental illness. McGorry has long advocated a “youth model” catering for adolescents and young adults together. I believe this would be a disaster, particularly for adolescents. Adolescents and young adults need very different models of care, because of the differing degrees of responsibility and autonomy they can handle, the legal and moral responsibilities of families, carers, schools and health professionals, and the effectiveness of treatments. McGorry’s well deserved reputation and influence mean there is a real risk his opinions will be accepted as fact, especially as the opposing view is seldom heard. People aged under 18 years (on average) are not expected, or permitted, to take full responsibility for their lives or their mistakes. Legally, they cannot vote, drink or buy cigarettes. They are generally still at school and living in the family home. Those aged under 16 years are not automatically entitled to grant or withhold consent to treatment. Families thus have a central role in the management of illness in adolescents, in a way that is neither possible nor appropriate for adult patients. Adolescent inpatient units need to be highly structured environments where adults would be out of place, with school-like rules, and careful control of group process and peer interactions. Otherwise, there is bullying, sexual exploitation, epidemics of self-harm, and the kind of competitive rebelliousness that leads to riots and fires. In adult units, adolescents are unacceptably vulnerable, not only from exploitative older patients, but from a lack of boundaries to their own behaviour. McGorry made several perplexingly dismissive comments about CAMHSs. Two cannot go unanswered: that CAMHSs “struggle operationally and clinically with . . . mood, psychotic, substance use, and borderline personality disorders”;1 and that “the capacity to skilfully and safely manage highly disturbed behaviour, and the more sophisticated psychopharmacological skills, are often lacking in . . . CAMHSs”.1 The disorders described are, in fact, “bread-and-butter” work for CAMHSs. Further, there is powerful anecdotal evidence that CAMHSs manage them better, not worse, than others. Examination of data held by the Victorian Department of Human Services and the Office of the Chief Psychiatrist on seclusion (sole confinement) rates, consumer satisfaction and suicide rates will bear this out. Child psychiatrists all train as adult psychiatrists first and, in my experience, do not lack psychopharmaceutical sophistication. It is hard to see what adolescents and their families have to gain from being incorporated into young adult services, nor why 30-year-olds should be excluded from specialist early psychosis services. We need greater integration between the current tiers of service, and a more flexible approach to transition between them, not another separate tier of service.

David A Sholl

In reply: Sholl asserts that our case for reform of youth mental health services is based largely on personal opinion. In fact, as detailed in the Journal supplement,1 it is based on hard epidemiological facts, the latest developmental perspectives and a growing evidence base. Consequently, it has been widely supported by young people, families, governments and the community. The youth model ensures that developmental approaches appropriate to all stages of the process of transition from childhood to adulthood continue until the young person is genuinely independent. To design a health system around the transition age of 18 years, based on legal and educational precedents, is outmoded. Many more young people now pursue postsecondary education and are financially and socially dependent on their families well into young adulthood.2 The youth mental health paradigm involves families in a developmentally appropriate way from puberty to the mid-20s, and also recognises the increasing value of peer relationships. The key difference is that young people have increasing choice about the level and pattern of family engagement. Similarly, brain development continues actively up until the mid-20s. We believe Sholl has misunderstood the fundamental issue of youth mental health reform. It is not a binary choice between current child–adolescent and adult service models. A new stream of care is required to respond to these “transition age youth” or “emerging adults”, as they were recently termed.2 This stream borrows many of the features of adolescent psychiatry and extends these to around 25 years of age, complementing them with new evidence-based approaches, which have been difficult to create and nurture within a constrained and under-resourced Child and Adolescent Mental Health Services system. This step is crucial for the “graduates” of state care, who have appalling outcomes when care is withdrawn at 18 years (even though they can vote).3 We have successfully developed and provided such an adolescent–young adult service to a quarter of Melbourne for over a decade. Recently, we extended this to Sydney. The real-world impact of this approach has helped greatly to convince the community, including federal and state government leaders, of its wider value. We want to see genuine reform, restructure and substantial investment in a new stream of care. How well this links, not only with existing child and adult specialist systems, but equally importantly with other key systems — notably education and employment, primary care, housing, justice and drug and alcohol services — will be critical to its success.

Patrick D McGorry · Ian B Hickie · Anthony F Jorm · Rosemary Purcell

To the Editor: Singh and Castle recently commented on the assumptions made in relation to the National Mental Health Policy.1 One such assumption was that the cost of the community care service model could be constrained by limiting services to the “severely” mentally ill. The authors went on to describe the realities associated with making this and other assumptions on current mental health care delivery. Many public wards have become the province of treatment-resistant consumers with limited insight who do not welcome the interventions provided by mental health workers. It may be that this type of inpatient population is influencing medical students’ views of psychiatry and contributing to low numbers in psychiatry training across the country. Students’ perceptions that psychiatry is a difficult and pressured work environment have been reported.2 Public services for consumers who have mental illnesses that do not involve psychosis are under severe pressure in the current paradigm. Despite the availability of effective treatments, anxiety and depressive disorders remain the principal cause of the disability produced by mental disorders, and half the people with such a disorder do not seek help, not realising how well they can become.3 However, the public system appears to be retreating from providing services for such patients. There seems to be a view that all Australians with anxiety and depression can be treated in private practice or by general practitioners. Does targeting low-prevalence disorders for treatment represent an acknowledgement by those in government of the power of mental health stigma? Is there misguided thinking that spending money on patients with psychotic disorders will keep mental illness and violence off the streets? Doctors have an obligation to inform those in power that effective treatments need to be made available to the broadest range of Australians, not just those who are obviously mentally ill. The difficulty of retaining psychiatrists in the public sector has been noted in many countries.4 Health services need to provide variety in the work of clinicians to keep them within the public sector — a diet of chronic psychosis tends not to attract or sustain staff. I believe fostering specialist units dealing with high-prevalence disorders like anxiety and depression, and high-morbidity conditions like eating disorders, would encourage the training of new staff, contribute to research, and strengthen the future of psychiatry. Revitalising public treatment services for high-prevalence psychiatric disorders could provide both symptom relief and a return to productivity for many thousands of Australians, and a more sustaining work environment for mental health clinicians. It is time for our governments to hear the call to provide mental health care for the many, not just the few.

James D Hundertmark

Objective: To review the evidence for the effectiveness of complementary and self-help treatments for anxiety disorders and situational anxiety in children and adolescents.Data sources: Systematic literature search using PubMed, PsycINFO and the Cochrane Library for 111 treatments up to February 2006.Study selection: There were 11 treatments for which intervention studies had been undertaken and reported.Data extraction: Studies on each treatment were reviewed by one author and checked by a second. A consensus was reached for level of evidence.Data synthesis: Relevant evidence was available for bibliotherapy, dance and movement therapy, distraction techniques, humour, massage, melatonin, relaxation training, autogenic training, avoiding marijuana, a mineral–vitamin supplement (EMPower +) and music therapy. Findings from case–control studies, individual cohort studies or low quality randomised controlled trials indicated that several treatments may have potential to reduce anxiety, including bibliotherapy, massage, melatonin, and relaxation training.Conclusions: Although some complementary and self-help treatments might be useful for children and adolescents with anxiety, they need to be tested adequately through randomised controlled trials before they could be recommended.

Ruth Parslow PhD · Amy J Morgan BASc, BAppSci(Psychol)(Hons) · Nicholas B Allen BSc(Hons), MSc, PhD · Anthony F Jorm PhD, DSc · Colin P O’Donnell MB BCh, BAO, MRCPsych · Rosemary Purcell PhD

Autism spectrum disorders (ASDs) are severe developmental conditions that require specialised intervention and lifelong support. Recent increases in ASD prevalence have prompted new initiatives in Western Australia to improve the consistency of assessments and to more accurately monitor diagnostic trends within the population. WA has implemented statewide guidelines for the assessment of ASDs, has developed an open forum for clinicians to discuss issues relating to the assessment process, and supports a statewide register of newly diagnosed cases. These initiatives have led to improved consistency across assessments, allowed analysis of diagnoses over time, and promoted cohesiveness among autism assessors. These strategies potentially provide an alternative model for other states and territories that wish to strengthen and assimilate ASD assessments.

Emma J Glasson BPsych, BSc(Hons), PhD · Sarah MacDermott BAppSc, MA · Glenys Dixon BPsych, MPsych(Clin) · Hugh Cook AM, MB BS, FRANZCP · Peter Chauvel MPH, FAFRM, FRACP · Alana Maley-Berg BPsych · John Wray MB BS, FRACP

Foundations of clinical psychiatry. 3rd ed. Sidney Bloch, Bruce S Singh, editors. Melbourne: Melbourne University Press, 2007 (xii + 642 pp). ISBN 978 0 522 85320 9. A good textbook of psychiatry is hard to find. Not only does such a book have to be well written, but its editors need to think carefully about what information is of relevance and vital to today’s trainee. Mindful of these issues, the editors of the latest edition of Foundations of clinical psychiatry have worked to bring the material up to date and have broadened the text, adding a chapter on intellectual and developmental disability. At the same time, they have retained the previous edition’s clinical focus and kept the book to a realistic length. The text is divided into four sections. The first presents a unifying biopsychosocial approach that trainees need to adopt when dealing with psychiatric patients. Important interviewing, synthesising and framework skills for formulating psychological problems are discussed. The second section deals with the range of basic psychiatric disorders such as trauma, anxiety, mood disorders and schizophrenia, while the third concerns special clinical areas such as children, older people, Indigenous peoples, and suicide. The final section deals with mental health service provision, including biological and psychological treatments. Importantly, Bloch and Singh recognise the calls that both science and the science of understanding people make on clinical practice by including a chapter on understanding and explaining psychiatric illness. To the best of my knowledge, this is unique in psychiatric textbooks and the key to successfully traversing a complex field. So much so that I would recommend all students read this chapter both at the beginning and again at the end of their training, to assist them in making sense of what they have learned. The second edition of Foundations was good; the third, however, is better. It is a readable, comprehensive textbook of psychiatry that easily meets its key task of educating medical students and interested health professionals.

Christopher J Pollock

The need for stimulant treatment must be assessed regularly In a United States legal action in 2000 about educational neglect, Albany County judge G E Maney ordered the parents to resume administering methylphenidate to 7-year-old Kyle Carroll.1 At the time, this controversial ruling was understandable, because controlled trials of stimulant treatment (dexamphetamine and methylphenidate) for attention deficit hyperactivity disorder (ADHD) had consistently shown that stimulants reduce ADHD symptoms. The catch is that trials have examined short-term effectiveness (usually over less than 6 months), while ADHD is a chronic condition. In 1992, the US National Institute of Mental Health funded the Multimodal Treatment Study of Children with ADHD (MTA) to examine the long-term effects of routine community management versus carefully delivered treatments. Children with ADHD, combined type (that is, showing symptoms of inattention, impulsivity and hyperactivity), were randomly allocated to medication, psychosocial treatment, a combination of both, or standard community care. The medication group received treatment with methylphenidate in which an optimal dose was titrated, with blinding, to achieve maximum benefit. The psychosocial group received a variety of interventions that consisted of parent training, a summer treatment camp and classroom management. Those in the routine care group were given information about services and left to their own devices. In total, 579 children with a mean age of 8.5 years were randomly allocated to the four groups, about 145 in each. After 14 months, children in both the medication groups showed greater improvement than those in the behavioural treatment and community care groups, leading the authors to conclude that “carefully crafted medication management was superior to the behavioral treatment and to routine clinical care that included medication”.2 The results were influential in treatment guidelines3 and clinical practice. Participants were naturalistically followed up 1 and 2 years after the end of the trial. The results of the last follow-up (3 years from the onset of treatment), of 84% of the original sample of children (then aged 10–13 years), showed that none of the treatment groups differed on any of the five clinical and functional outcomes (parent- and teacher-rated ADHD and oppositional symptoms, reading achievement scores, social skills, and functional impairment).4 Also, there were no differences in substance use or delinquency, with the exception of a slightly lower rate of substance use among those in the psychosocial treatment group.5 While improvement had been steepest during the first 14 months (mostly in the methylphenidate group), this levelled off, and at 3 years, all groups showed a similar improvement; the methylphenidate group had not deteriorated but the other groups had caught up.4 Speculation is bound to follow these results, which have many ambiguities and nuances. For example, this follow-up was not part of the controlled trial and, as happens in practice, children switched on and off their medication over time in the various groups, with consequent difficulties for analysis and interpretation. The results highlight several issues. First, it suggests the Rolls-Royce model (medication plus psychosocial treatment involving the child, family, and school) is not more effective in the long run than any of the other treatments, including the often maligned community care. The combined treatment is seen as the ideal, but is rarely delivered in practice, because of high cost and the burden for parents and schools.6 Second, there seems to be a “growing out of” or developmental factor at work. Epidemiological7 and follow-up8 data have consistently reported a reduction in ADHD symptoms with increasing age — although some individuals continue to show problems. This is also consistent with findings that brains of children with ADHD, rather than developing abnormally (as in autism), mature later.9 The MTA did not include a placebo group, which might have led to the conclusion that regression to the mean or maturation itself were the reasons for improvement. If that was the case, it is possible that helping families and schools contain children’s ADHD behaviour during the middle and late primary school years with minimal interventions (eg, parent management training) may be enough for a proportion — but not all — of these children to get better, or for medication to be required mostly during this developmental period. Finally, the MTA confirmed that medication can cause retardation of growth, including weight, particularly during the first year of treatment.10 While results of one study rarely justify drastic changes of practice, the findings underscore the complexity of ADHD, show that stimulant drugs are far from being a silver bullet, and that there is much that we do not yet know. This does not mean that stimulants no longer have a place in the treatment of ADHD. However, that place has shrunk, and clinicians should be circumspect when assessing the need for ongoing treatment (eg, through medication breaks). Much needs to be done to clarify who benefits the most from medication, at what developmental point stimulants are most useful, and for how long they should be taken. It is also not known whether these results apply to the slow-release formulations (which may enhance adherence) and to atomoxetine (a non-stimulant drug with antidepressant activity, which is thought to act by inhibition of the presynaptic noradrenalin transporter). Parents, often caught in the bind of concerns about their children taking medication and fear of the consequences of not treating them, might be comforted by these findings. One wonders whether Judge Maney would have issued the same order to Kyle Carroll’s parents had he been aware of this information.

Joseph M Rey MB BS, PhD, FRANZCP

Objective: To describe the incidence and risk of suicide in cancer patients in Western Australia from 1981 to 2002.Design, setting and patients: Retrospective cohort study of patients diagnosed with cancer in WA from 1981 to 2002, using data from the WA Linked Database.Main outcome measure: Age-standardised mortality ratios (SMRs).Results: A total of 121 533 patients were diagnosed with cancer, corresponding to a total of 543 696 person-years at risk. There were 129 suicides in this group (108 in men). The SMR for suicide in cancer patients was 1.61 (95% CI, 1.36–1.92). An initial period of peak risk was seen in the first 3 months after cancer diagnosis (SMR, 5.75; 95% CI, 3.89–8.51), mainly in patients with a poor prognosis. A second peak period of risk was found to occur 12–14 months after diagnosis (SMR, 2.33; 95% CI, 1.11–4.89) in those with a good or moderate prognosis.Conclusion: The rate of suicide in cancer patients in WA is low and represents an excess of two to three suicides per year, or 0.3% of all cancer deaths, comparable to studies in other Western countries. The risk is highest in the first 3 months after diagnosis, and a second period of increased risk 12–14 months after diagnosis may occur in response to cancer recurrence or treatment failure.

Nigel R C Dormer MB BS, MRCGP, DRCOG · Kieran A McCaul MPH · Linda J Kristjanson RN, BN, PhD

To the Editor: Senna is widely used in laxatives, but the results of its misuse are not inconsequential. We describe a 36-year-old woman admitted with hypercalcaemia and renal failure. She had a 6-year history of anorexia nervosa and ingestion of 50–100 senna tablets daily for weight loss. Examination revealed clubbing of the fingers and toes, a body mass index (BMI) of 17.7 kg/m2 and postural hypotension. Laboratory findings on admission are shown in Box 1. Results of autoimmune studies and protein electrophoresis, and the serum angiotensin-converting enzyme level were normal. Parathyroid hormone-related peptide was absent. She had a bland urinary sediment, trace proteinuria (150 mg/24 h; reference range, < 150 mg/24 h) and a urine pH of 5.0 (physiological range, 4.5–8.0). Computed tomography scans did not detect malignancy or infection, but showed bilateral medullary renal calcifications. Renal biopsy confirmed extensive nephrocalcinosis and the absence of primary glomerular disease. A skeletal survey showed prominent periosteal reaction and new bone formation at the ends of long bones (Box 2, A). A bone scan revealed increased tracer uptake in a pattern consistent with hypertrophic osteoarthropathy (HOA; Box 2, B). Interestingly, bone mineral density (BMD) scans showed increased lumbar and femoral T scores (1.2 and 1.3, respectively). Four years later, the renal failure, clubbing and HOA persisted despite a reduction in senna intake. Low urine volume is a prerequisite for urolithiasis, but hypercalcaemia is the key requirement for nephrocalcinosis.3 The suppressed parathyroid hormone level and elevated serum calcium level excludes primary hyperparathyroidism and made familial hypocalciuric hypercalcaemia unlikely. The serum and urine biochemistry was inconsistent with thiazide diuretic use or renal tubular acidosis. Hence, exogenous calcium is the likely cause of hypercalcaemia. Each of the senna (calcium sennosides) tablets the patient ingested contained 12.5 mg of calcium. Chronic ingestion, in addition to dehydration (with low calcium excretion) and a low BMI may contribute to a vicious circle of calcium phosphate retention, renal failure and nephrocalcinosis. Indeed, hydration increased her calcium excretion to 6.23 mmol/day and normalised her serum calcium and phosphate levels after a week. The association between finger clubbing and senna misuse, and the reversibility of finger clubbing, were reported in 1975.4 Several reports have followed, but only one noted concurrent HOA on plain x-rays.5 We believe that our report is the first to show the extent and distribution of HOA related to this disorder. It remains unknown whether HOA is reversible with abstinence from senna. Patients with anorexia are also more likely to have a low BMD, and the increased BMD scores seen in our patient might be the result of metastatic calcification or periosteal new bone formation. Neither could be conclusively proven. The development of nephrocalcinosis in anorexic patients is more common than is generally appreciated. Clubbing and HOA are useful clues to senna misuse, and BMD measurements should be interpreted with caution in this setting. 1 Biochemical parameters on admission before treatment Parameter Patient value Reference range Serum concentrations of: Sodium (mmol/L) 139 135–145 Potassium (mmol/L) 3.2 3.5–5.0 Magnesium (mmol/L) 0.74 0.80–1.50 Chloride (mmol/L) 102 95–107 Bicarbonate (mmol/L) 24 21–30 Urea (mmol/L) 8.6 2.5–7.8 Creatinine (μmol/L) 166 40–120 Albumin (g/L) 28 35–45 Corrected calcium (mmol/L) 2.93 2.20–2.60 Ionised calcium — pH adjusted (mmol/L) 1.51 1.14–1.29 Phosphate (mmol/L) 2.58 0.80–1.20 25-hyroxyvitamin D (nmol/L) 23 55–108 Parathyroid hormone (pmol/L) 1.0 1.1–7.7 Rates of: Creatinine clearance (mL/min) 20 90–150 Urine sodium excretion (mmol/day) 28 40–100 Urine potassium excretion (mmol/day) 29 50–140 Urine calcium excretion (mmol/day) 1.56 2.0–7.5 2 Ankle x-ray and full bone scan

Andy K H Lim · David H Hooke · Peter G Kerr

Objective: To determine the intentions that young people have for seeking help if they were to develop a mental disorder.Design, participants and setting: National telephone survey of 3746 Australians aged 12–25 years and 2005 co-resident parents, which asked questions about vignettes portraying either depression, depression with alcohol misuse, social phobia or psychosis.Main outcome measures: Where participating young people or co-resident parents would seek help if they (or their child) had one of the problems portrayed in the vignettes; barriers to seeking help.Results: For adolescents, family was the main source of intended help, mentioned by 45%–60% (depending on the vignette), while general practitioners were mentioned by only a small minority (4%–13%). For young adults, family was relatively less important (21%–31%) and GPs relatively more so (19%–34%). By contrast, parents frequently mentioned GPs as an intended source of help for their children (by 40%–72% of parents of adolescents and 61%–76% of parents of young adults). For young people, the main barriers to seeking help were embarrassment or concern about what others might think, while the main barrier for parents was resistance from the child.Conclusions: Recent initiatives to extend the uptake of treatment for mental disorders have been centred around GPs as the initial point of help-seeking. Few young people see GPs as a preferred source of help, and action is needed to alter this perception or to reform mental health services to be more attractive to this age group.

Anthony F Jorm MPsychol, PhD, DSc · Annemarie Wright BAppSc(OT), MMedSc(HProm) · Amy J Morgan BASc, BAppSci(Psychol)(Hons)

A number of recent studies have allayed fears about antidepressants precipitating suicidal behaviour in young people. Indeed, antidepressants appear to be conspicuous by their absence of use in young people who die by suicide. Furthermore, there is concern that the reduced prescribing of antidepressants to young people may be associated with an increase in youth suicide in the United States. Although not first-line treatment, antidepressants should not be denied young people if psychosocial and cognitive behavioural therapies are not effective for major depression.

Robert D Goldney MD, FRANZCP, FRCPsych

To the Editor: Austin et al1 bring to our attention findings from the report on maternal deaths in Australia in which 26 suicides were reported, making it one of the leading causes of indirect maternal deaths in the perinatal period — a finding consistent with the Confidential Enquiries into Maternal Deaths report from the United Kingdom.2 These reports raise the issue of the importance and risk of maternal mental illness in the perinatal period. While this high rate of suicide is unacceptable, it needs to seen in context: this is a rare event overall, representing a standardised mortality ratio of 1.14 per 100 000 women. This is considerably lower than the suicide rate for women in general, which ranges from 3.6 per 100 000 in the 15–19-year age group to 6.4 per 100 000 in the 25–29-year age group.2,3 This comparison verifies the observation made by Appleby that suicide rates are low during the perinatal period.4 Austin et al recommend that psychosocial screening, in conjunction with ongoing mental health monitoring and clear referral pathways, should be made available to women in a maternity setting as part of the solution to preventing the “relatively high” rate of early maternal suicide. But to date, antenatal screening programs have proven costly to implement, can produce large numbers of false positives, are often poorly accepted by antenatal care providers (as they add to the administrative burden), and do not result in greater uptake of services by at-risk women.5 Remarkably, 40% of the suicides reported by Austin et al occurred in the first trimester, predominantly before women had attended an antenatal clinic and before any psychosocial screening. A number of the suicide cases were already under the care of mental health services, and screening may not have prevented the tragic outcomes. We believe the answer to this problem is for appropriately resourced, accessible and publicly funded specialised perinatal psychiatric services to be put in place (including dedicated mother and baby units) so that high-risk women can be appropriately treated. In providing such services, we would need to develop appropriate strategies to engage mothers who need support from psychiatric services. This concurs with the National Institute for Health and Clinical Excellence perinatal mental illness guidelines,6 which advocate for the identification of pertinent risk factors (such as personal and familial mental health history) and assessment of current distress (through targeted interviewing). Screening is recommended to monitor outcomes but not to dictate clinical decision making.

Phillip M Boyce · Jodi Barton

In reply: Boyce and Barton raise a number of points. Firstly, with respect to their critique of the 2006 beyondblue postnatal depression report,1 there are, to date, no studies assessing the cost of antenatal screening programs. Furthermore, while false positives are a feature of all screening programs, that, in itself, is not a deterrent to using antenatal screening if the rate of false positives is considered acceptable. While midwives have concerns about undertaking routine psychosocial assessment, uptake of such a program can be done through adequate training and support of staff, as now demonstrated in a number of sites around Australia.2 With respect to the inadequate uptake of services by “high-risk” women, these are generally poor in the psychiatric clinic setting3 and would not be expected to be different perinatally. Secondly, the authors report that “a number of the suicide cases were already under the care of mental health services, and screening may not have prevented the tragic outcomes”. This overlooks one of the key attributes of routine psychosocial assessment in the primary health care setting — that it encourages communication and monitoring across the primary (eg, midwifery) and mental health sectors. Thus, while some women may be lost to psychiatric follow-up during pregnancy, most will attend antenatal appointments, thus providing their health care network with an opportunity for ongoing psychosocial review. Thirdly, while we agree with Boyce and Barton that “targeted interviewing” (as described in the UK National Institute for Health and Clinical Excellence guidelines) is important, “psychosocial assessment”, as undertaken in some Australian maternity settings, aims to assess the broad number of psychosocial risk factors that may contribute to the mental health outcomes of a woman and her infant. This point has been identified as a key issue in the 2007 beyondblue national action plan for perinatal mental health briefing document.4

Marie-Paule Austin

The logic and plan for achieving early intervention in youth mental health in Australia

Patrick D McGorry MD, PhD, FRCP, FRANZCP · Rosemary Purcell MPsych, PhD · Ian B Hickie MD, FRANZCP · Anthony F Jorm PhD, DSc

The two main goals of early intervention in psychotic disorders are to reduce the period of time between the onset of psychosis and the commencement of effective treatment, and to provide consistent and comprehensive care during the critical early years of illness. Effective care during the critical early years involves proactive engagement and initiation of drug and psychosocial treatments, aiming for maximal symptomatic and functional recovery and the prevention of relapse. Over the past 15 years, an increasing number of specialised or streamed treatment delivery systems for early psychosis have been established around the world. There is now evidence that these services can reduce the duration of untreated psychosis and produce better symptomatic and functional recovery. In addition, they are more cost-effective than standard models of mental health care for these patients. Fully fledged, specialised early intervention services should be established, with full integration with local communities, as well as enhanced primary care systems focused on young people.

Patrick D McGorry MD, PhD, FRCP, FRANZCP · Eóin Killackey BSc(Hons), DPsych(Clin) · Alison R Yung MB BS, MPM, FRANZCP

The early phases of bipolar disorders are difficult to diagnose and have specific treatment issues. The initial polarity of the illness is more commonly depressive, yet in counterpoint, mania is required for diagnosis; consequently, there is often a substantial delay in the initiation of appropriate therapy. There is good evidence that lithium in particular is most effective early in the illness course, and that its efficacy declines after multiple episodes. The notion of neuroprotection reflects this, and furthermore suggests that appropriate therapy may prevent the neurostructural and neurocognitive changes seen in the disorder. Inappropriate therapy may worsen the course of the illness. Patients with a first episode have specific psychosocial needs, and adherence to medication is relatively poor. There is a need for early identification, and to develop treatments and services applicable to the specific needs of this population.

Michael Berk MMed(Psych), FF(Psych)SA, FRANZCP, PhD · Karen Hallam BBSc(Hons), PhD · Nellie Lucas BPsych(Hons), DPsych · Melissa Hasty BAppSc(Hons), DPsych · Craig A McNeil DPsych · Philippe Conus MD, FRANZCP · Linda Kader MD, FRANZCP · Patrick D McGorry MD, PhD, FRCP, FRANZCP

Young people experiencing their first onset of depression are a group at risk of relapse and recurrence to whom early intervention and prevention efforts should be targeted. Despite the argument for a significant research effort addressing these issues, the evidence regarding optimal intervention strategies for first episodes is lacking. Cognitive behaviour therapy is an effective approach to treatment and relapse prevention among depressed adolescents, and is likely to be an important component of any evidenced-based approach to early intervention. Antidepressants are not recommended as first-line treatment for most first episodes of depression. The role that they may play in patients with severe depression, or those who do not respond to psychological therapies, requires further evaluation. Given the high prevalence of depressive disorders, and the significant burden of disease they represent within our community, early intervention in depressive disorders is a critical research agenda for the future.

Nicholas B Allen PhD · Sarah E Hetrick MA, DPsych · Julian G Simmons BSc, PostGradDipPsych · Ian B Hickie MD, FRANZCP

Borderline personality disorder (BPD) is a severe mental disorder that is associated with substantial psychosocial impairment and morbidity, disproportionate use of health resources, a high suicide rate, and a reputation for being “untreatable”. A diagnosis of BPD in young people has similar reliability, validity and prevalence to BPD in adults, and almost certainly has serious and pervasive negative repercussions over subsequent decades. Current data are inadequate to inform specific universal or selective prevention programs for BPD. However, they do support including BPD prevention as an outcome when evaluating universal and/or selective interventions for a variety of mental health problems and adverse psychosocial outcomes. The strongest data support early intervention for the emerging BPD phenotype. Early intervention programs will need to be realistic in their aims, require change in clinician attitudes and service systems, and must be mindful of the risk of iatrogenic harm.

Andrew M Chanen MB BS, MPM, FRANZCP · Louise K McCutcheon DPsych, MAPS · Martina Jovev MA(ClinPsych), PhD · Henry J Jackson PhD, FAPS · Patrick D McGorry MD, PhD, FRCP, FRANZCP

Early-onset or frequent substance use during adolescence increases the risk of developing mental health problems, as well as a range of other adverse outcomes (eg, alcohol or drug dependence, educational underachievement, health problems, social difficulties) during late adolescence and early adulthood. Increases in rates of risky drinking among young people are particularly concerning, suggesting that an effective, evidence-based alcohol policy and preventive framework needs to be developed. Restricting the supply of licit and illicit substances to adolescents, delaying the age that licit substances can be legally purchased, reducing positive media portrayals of substance use, and banning targeted promotions, should be universal, public prevention priorities. Mass-media campaigns need to deliver coherent and credible evidence-based messages to young people, utilising a broad array of dissemination strategies. Clear policy and guidelines for parents regarding appropriate alcohol use for adolescents also need to be developed. Prevention programs should target children and adolescents in families with parents who use drugs, young people who have been suspended from school, or those with mental health problems. Preventive screening and targeted brief interventions can be effectively delivered in a variety of settings by a range of health professionals.

Dan I Lubman BSc(Hons), MB ChB, PhD, FRANZCP, FAChAM · Leanne Hides BBehSci(Hons), PhD(Clin) · Murat Yücel BA(Hons), ClinPhD(Npsych) · John W Toumbourou MA, PhD

Objective: To determine the risk of suicide and drug overdose death among recently released prisoners.Design, setting and participants: Retrospective cohort study of 85 203 adult offenders who had spent some time in full-time custody in prisons in New South Wales between 1 January 1988 and 31 December 2002.Main outcome measures: Association between time after release and risk of suicide and overdose death.Results: Of 844 suicides (795 men, 49 women), 724 (86%) occurred after release. Men had a higher rate of suicide than women both in prison (129 v 56 per 100 000 person-years) and after release (135 v 82 per 100 000 person-years). The suicide rate in men in the 2 weeks after release was 3.87 (95% CI, 2.26–6.65) times higher than the rate after 6 months. Male prisoners admitted to the prison psychiatric hospital had a threefold higher risk than non-admitted men both in prison and after release. No suicides among women were observed in the 2 weeks after release. No increased risk of suicide was observed among Aboriginal Australians in the first 2 weeks after release. Of 1674 deaths due to overdose, 1627 (97%) occurred after release. Drug-related mortality in men was 9.30 (95% CI, 7.80–11.10) times higher, and in women was 6.42 (95% CI, 3.88–10.62) times higher, in the 2 weeks after release than after 6 months.Conclusions: Prisoners are at a heightened risk of suicide and overdose death in the immediate post-release period. After 6 months post-release, the suicide rate approaches the rate observed in custody.

Azar Kariminia MSc · Matthew G Law PhD · Tony G Butler PhD · Michael H Levy MD · Simon P Corben MSc · John M Kaldor PhD · Luke Grant MSc

Good mental health literacy in young people and their key helpers may lead to better outcomes for those with mental disorders, either by facilitating early help-seeking by young people themselves, or by helping adults to identify early signs of mental disorders and seek help on their behalf. Few interventions to improve mental health literacy of young people and their helpers have been evaluated, and even fewer have been well evaluated. There are four categories of interventions to improve mental health literacy: whole-of-community campaigns; community campaigns aimed at a youth audience; school-based interventions teaching help-seeking skills, mental health literacy, or resilience; and programs training individuals to better intervene in a mental health crisis. The effectiveness of future interventions could be enhanced by using specific health promotion models to guide their development.

Claire M Kelly PhD, BA(Hons) · Anthony F Jorm DSc, PhD · Annemarie Wright DAppSc(OT), MMedSc(HProm)

With 75% of mental illness beginning before 25 years of age, it is essential that we improve young people’s capacity to manage adversity and increase their opportunities for accessing professional help. With its unique ability to connect people to information and to other people, the Internet offers opportunities to engage the 70% of young people with mental health problems who currently are not seeking professional help. Reach Out! is a national Internet-based mental health service for young people. It has been accessed by over 6 million users since its launch in 1998. Reach Out! plays a role in the prevention of mental health problems by: facilitating help-seeking and connecting young people with services, such as general practitioners, and allied and mental health professionals in their local communities; and providing opportunities for all young people to develop the skills and capacity to better understand mental health difficulties and manage adversity, thereby complementing traditional support.

Jane Burns PhD · Carolyn Morey MPH · Alexandra Lagelée MA · Anna Mackenzie MPH · Jonathan Nicholas BA(Hons)

Despite the high prevalence of mental health problems and disorders that develop in adolescence and early adulthood, young people tend to not seek professional help. Young men and young people from Indigenous and ethnic minority groups tend to be those most reluctant to seek help. Young people are more inclined to seek help for mental health problems if they: have some knowledge about mental health issues and sources of help; feel emotionally competent to express their feelings; and have established and trusted relationships with potential help providers. Young people are less likely to seek help if they: are experiencing suicidal thoughts and depressive symptoms; hold negative attitudes toward seeking help or have had negative past experiences with sources of help; or hold beliefs that they should be able to sort out their own mental health problems on their own. Young people may seek help through talking to their family and friends, with family being more important for younger adolescents, and friends and partners becoming more influential later on. The professionals most likely to act as gatekeepers to mental health services for young people are school counsellors, general practitioners, and youth workers. Increasingly, Internet-based information and interventions are being used to engage young people in the help-seeking process.

Debra J Rickwood PhD, MAPS · Frank P Deane DipClinPsych, PhD, MAPS · Coralie J Wilson BA(Hons), PhD, MAPS

Diagnosis in psychiatry continues to struggle to fulfil its key purposes, namely to guide treatment and to predict outcome. A clinical staging model, widely used in clinical medicine, could improve the utility of diagnosis in psychiatry, especially in young people with emerging disorders. Clinical staging has immediate potential to improve the logic and timing of interventions in psychiatry, as it does in many complex and potentially serious medical disorders. Interventions could be evaluated in terms of their ability to prevent or delay progression from earlier to later stages of a disorder, and selected by consumers and clinicians on the basis of clear-cut risk–benefit criteria. This would ensure that, as treatments are offered earlier, they remain safe, acceptable and affordable, and potentially more effective. Biological variables and a range of candidate risk and protective factors could be studied within and across stages, and their role, specificity and centrality in risk, onset and progression of disorders clarified. In this way, a clinicopathological framework could be progressively constructed. Clinical staging, with restructuring across and within diagnostic boundaries and explicit operational criteria for extent and progression of disorder, should be actively explored in psychiatry as a heuristic strategy for developing and evaluating earlier, safer, and more effective clinical interventions, and for clarifying the biological basis of psychiatric disorders. Young people with emerging mental and substance use disorders could be the main beneficiaries.

Patrick D McGorry MD, PhD, FRCP, FRANZCP · Rosemary Purcell MPsych, PhD · Ian B Hickie MD, FRANZCP · Alison R Yung MB BS, MPM, FRANZCP · Christos Pantelis MD, FRANZCP · Henry J Jackson BA, MA, MA(ClinPsych), PhD, FAPS

Intervention in the prodromal phase of schizophrenia and related psychotic disorders may prevent or delay the onset of these disorders, or reduce the severity of the psychosis. Identifying the schizophrenia prodrome is difficult, however, because of its non-specific symptoms and the wide symptom variability between individuals. Over the past 15 years, we have investigated the schizophrenia prodrome and developed criteria for detecting people suspected of experiencing a prodromal phase (ie, they are thought to be at imminent risk of onset of a psychotic disorder). About 35% of those meeting our criteria have developed a psychotic disorder within 12 months. We have established a clinical service, the PACE (Personal Assessment and Crisis Evaluation) Clinic, for people with suspected incipient psychosis, and trialled interventions aimed at preventing or delaying the onset of psychotic disorders. Our results and studies in other countries seem to indicate that psychological and psychosocial interventions, either alone or in combination with pharmacotherapy, may be effective in at least delaying, if not preventing, the onset of a psychotic disorder.

Alison R Yung MD, FRANZCP · Patrick D McGorry MD, PhD, FRCP, FRANZCP · Shona M Francey MPsych, PhD · Barnaby Nelson MPsych, PhD · Kathryn Baker BSc(Hons), DPsych · Lisa J Phillips MPsych, PhD · Gregor Berger MD, FMH Psych (CH), FRANZCP · G Paul Amminger MD, FRANZCP