Mental health

The development of evidence-based (“collaborative care”) mental health services in primary care for young people with anxiety, depression and alcohol or other substance misuse is a major challenge. Data from two clinical audits of selected Australian general practices (1998–1999 and 2000–2002) were analysed to explore actual experiences of care among people aged 16–25 years. Syndromal (1998–1999: 31.0% [n = 1849/5957]; 2000–2002: 37.8% [n = 148/392]) and subsyndromal (1998–1999: 27.4% [n = 1635/5957]; 2000–2002: 29.1% [114/392]) mental disorders are very common among young people presenting to general practitioners. However, a mental health diagnosis (1998–1999: 42.6% [n = 740/1736]; 2000–2002: 52.0% [n = 77/148]) or provision of formal treatment (1998–1999: 36.1% [n = 600/1661]; 2000–2002: 51.7% [n = 74/143]) occurs in only about half of the patients with syndromal conditions. While some active treatment was received by 19.4% (1998–1999 [n = 1018/5236]) and 35.9% (2000–2002 [n = 133/370]) of the young people, respectively, the most commonly reported interventions were non-pharmacological alone (1998–1999: 13.1% [n = 687/5236]; 2000–2002: 22.4% [n = 83/370]) or non-pharmacological and pharmacological combinations (1998–1999: 4.1% [n = 214/5236]; 2000–2002: 10.3% [n = 38/370]). Only rarely is pharmacological treatment alone provided (1998–1999: 2.2% [n = 117/5236]; 2000–2002: 3.2% [n = 12/370]). New systems of primary care for young people need to be based on proven collaborative care models and encourage presentations for care, increase detection rates, and promote access to information and effective e-health services. Improved access to specific psychological treatments should remain a priority.

Ian B Hickie MD, FRANZCP · Andrea S Fogarty BPsy(Hons), MIPH · Tracey A Davenport eMBA · Georgina M Luscombe PhD · Jane Burns PhD

Despite mental disorders being the dominant health issue confronting young people, youth mental health is yet to be recognised as a discrete, unified program area; responsibility for young people’s mental health is currently split across multiple levels of government. Public specialist mental health services have followed a paediatric–adult split in service delivery, mirroring general and acute health care. The pattern of peak onset and the burden of mental disorders in young people means that the maximum weakness and discontinuity in the system occurs just when it should be at its strongest. Young people need youth-friendly services that recognise and respond to their special cultural and developmental needs. At the primary and community level, headspace: the National Youth Mental Health Foundation, is a national response to this and aims to provide better access, engagement and enhanced multidisciplinary care for young people across Australia. The specialist mental health service level should be complemented by youth-specific specialist mental health services for young people, aged 12–25 years, which would strengthen the existing system with a better targeted stream of care, providing access to integrated mental health, substance use, and vocational-recovery services. Alternative approaches to creating this capacity should be urgently developed and evaluated, and sustained reform informed by evidence as well as values.

Patrick D McGorry MD, PhD, FRCP, FRANZCP

Since the National Mental Health Policy was implemented in 1992, dissonance between mental health professionals and the general public on the success of the deinstitutionalisation components of the strategy has grown. Many of the premises on which the deinstitutionalisation components were based are false, and this has led to many problems in the system. Community psychiatry is not fundamentally flawed, and what has been learned in the past 15 years can be used to build on the foundations that have been laid. Better cooperation between state and federal governments is needed to effect real change.

Bruce S Singh PhD, FRACP, FRANZCP · David J Castle MD, MRCPsych, FRANZCP

Young people with mental illness face many barriers in accessing care and often have different needs to those of adult consumers. Young people’s participation in mental health services is one way of addressing quality and access issues, through receiving feedback and implementing youth-driven and youth-friendly strategies. headspace, the National Youth Mental Health Foundation, established in July 2006, highlights the mental health care sector’s commitment to young people. Existing youth participation programs provide examples of what can be achieved at national and local levels and with varying levels of financial and other support. These include: Ybblue, the youth program of beyondblue; Reach Out!, a web-based service; Headroom, providing health promotion and a website; and Platform Team (ORYGEN Youth Health), comprising current and past clients who advise the service and provide peer support. Current practice in youth participation in mental health services involves a variety of methods, such as ensuring information and education is appropriate for a youth audience, and participating in peer-support programs and staff selection panels. Challenges in the future development of youth participation in mental health services include avoiding tokenism, acknowledging that young people are not a uniform group, translating national strategies into local improvements in services, and gaining the support and cooperation of health care workers in genuine participation.

Anthony M James BVSc, BBus

The impact on family members of mental illness in a young person is intensely distressing. Symptoms that they cannot understand, and the stigma surrounding mental illness may lead to families feeling isolated in their distress. Family carers are reassured by talking with other families who have experienced the same or similar situations. The “Families Helping Families” program at ORYGEN Youth Health trains family peer-support workers, who are employed to provide information and support to families new to the service. Medical practitioners need to appreciate the importance of ensuring that families receive information and emotional support to help them cope effectively. Difficulties in helping family carers, often around perceived confidentiality restraints, need to be overcome so that collateral damage — family breakdown, persistence of symptoms, and behavioural maladjustments — can be reduced. Families who are supported can become advocates for improvements to mental health services for young people.

Margaret S Leggatt PhD, BAppSc(OT)

Creating a collaborative doctor–patient relationship is the bedrock upon which effective treatments are delivered. The interaction between normal developmental changes and psychopathology can present particular challenges to clinicians attempting to assess and treat young people. Assuming an attitude in which young people are seen to be doing their best, rather than being deliberately difficult or manipulative, can help clinicians avoid a controlling or punitive relationship and can facilitate collaborative problem solving. Stigma, denial and avoidance, ambivalence, hopelessness and coercion are potential threats to engagement and must be addressed specifically. Challenging patients, such as the reluctant, resistant, aggressive, self-harming or intoxicated patient require specific management strategies that can be learned.

Louise K McCutcheon DPsych, MAPS · Andrew M Chanen MB BS, MPM, FRANZCP · Richard J Fraser MSc, MRCPsych(UK) · Lorelle Drew MB BS, FRANZCP · Warrick Brewer MA(ClinNeuropsychology), PhD

headspace, Australia’s national youth mental health initiative, was created in 2006 in response to the recognition that the existing health system needed to be much more accessible and effective for young people with mental and substance use disorders. With funding of more than $54 million from the Australian Government, a carefully constructed and selected system of 30 “communities of youth services”, or integrated service hubs and networks, across the nation is being established, supported by programs for community awareness, workforce training and evidence-based resource material. headspace aims to improve access, and service cohesion and quality, and ultimately health and social outcomes, for young people aged 12–25 years experiencing mental illness and related substance use problems. Within the Council of Australian Governments framework, this will require synergistic planning with, and co-investment on behalf of, state and territory governments, as well as the support and involvement of local communities and the wider Australian society.

Patrick D McGorry MD, PhD, FRCP, FRANZCP · Chris Tanti BA, BSW · Ryan Stokes · Ian B Hickie MD, FRANZCP · Kate Carnell BPharm, FAIM · Lyndel K Littlefield MPsych, PhD · John Moran GradDip(Community Development)

John Cone was born on 6 December 1925 in Hawthorn, Victoria. He matriculated from Camberwell Grammar School and entered the medical school of the University of Melbourne in 1944. Graduating in 1949, he joined a general practice in the then outer Melbourne suburb of Ringwood, while retaining a sessional appointment in the medical outpatients clinic at the Royal Melbourne Hospital (RMH). He obtained a clinical doctorate of medicine from the University of Melbourne in 1954. Years later, when recounting his experiences in general practice, he described how his curiosity had been aroused by those often-frustrating patients whose problems could not be neatly categorised as either mental or physical, and he was drawn to psychiatry. In the 1960s, the most prestigious centre for the clinical study of such patients was the Department of Psychiatry of the Strong Memorial Hospital at the University of Rochester in New York State. There, the psychiatrist John Romano and the psychoanalytically-trained Professor of Medicine, George Engel, had pioneered the discipline of consultation–liaison psychiatry, based on the application of psychoanalytical ideas to clinical medicine. In 1964, John took his young family to Rochester to pursue state-of-the-art training in psychiatry. Returning to Melbourne in 1967, John established a private practice in psychiatry and became the senior Honorary Psychiatrist at the RMH in 1971, a position he held for 15 years. He was a foundation member of the Royal Australian and New Zealand College of Psychiatrists, serving on committees at both state and federal levels. He was also a founding member and chairman of the Melbourne Clinic, the city’s largest private psychiatric hospital. John was a connoisseur of fine food and wines, and, together with his wife, Margaret, a generous and welcoming host. He had an encyclopaedic knowledge of Australian and foreign flora and was a passionate gardener. He was diagnosed with cancer in 1994. During the period of terminal illness, he conducted himself with the same quiet dignity, resolve and thoughtfulness that had made him such an excellent doctor and teacher. He died on 16 January 2007. He is survived by Margaret and daughters Andrea, Felicity and Gair Amina.

Edwin Harari

To the Editor: In an ironic clinician–academic dichotomy, in the same month that the Royal Australian and New Zealand College of Psychiatrists published a survey showing that 79% of Australian psychiatrists combine antidepressants and 75% of psychiatrists believe that general practitioners should be given information on this topic,1 Keks et al chose a non-psychiatric journal to “mandate that combinations be used as a last resort, and only in specialist settings”.2 Specialists have voted with their prescription pads. That a large majority of Australian psychiatrists feel ethically and clinically obliged to use combination antidepressants speaks volumes about the poor results from the suggestions outlined by Keks et al. The multiple clinical reports and reviews of the benefits of combination antidepressants,3 the suffering and death from depression, and the very low rate of complications reported to the Adverse Drug Reactions Advisory Committee from combination antidepressants do not allow the luxury of awaiting combination therapy research which may never happen. Many combinations of antihypertensives or anti-asthma medications similarly lack such rigorous proof, but are widely used. Isolated case reports of medication complications must be seen as such. Access to psychiatrists for combination antidepressant therapy is a well intentioned but currently impractical suggestion. Most psychiatrists have massive waiting lists, and research confirms treatment resistance and progressive cell death in the hippocampus of depressed patients while awaiting effective treatment. Australian GPs are just as capable of using combination antidepressant therapy as their international colleagues, if given the same simple information and training. Canadian GPs read in their journals advice about using combination antidepressants. Anecdotally, many Australian GPs combine antidepressants, but express the wish that the issue could be discussed openly, without them feeling intimidated. Even textbooks of psychiatry, drafted some years ago, teach about combination antidepressants. In the United States, the National Institute of Mental Health STAR*D study of 4000 patients approved combination antidepressants such as venlafaxine with mirtazapine years ago, with no safety concerns.4 Keks et al refer to treatments that today are unacceptable to many, ranging from electroconvulsive therapy to tricyclic antidepressants, despite GPs and psychiatry trainees having been warned for years by academics that tricyclics are outdated, “dirty” and dangerous. Informed consent requires that patients be informed of all therapies that are relevant to their care and survival, and 88% of psychiatrists believe patients should be informed of combination antidepressants.1 Recent results from the STAR*D study demonstrate the superiority of modern combination antidepressants, with no statistically based evidence that they should not be used.5

David P Horgan

To the Editor: Keks et al make a number of important points about the place of combination antidepressant strategies in the pharmacotherapy of depression.1 However, it is important for readers to note that the vigorous repudiation of combination treatments is a peculiarly Australian preoccupation. Our colleagues in Europe and North America are not nearly so troubled. Combination antidepressant treatments are widely used by specialists. A recent survey of Australian doctors working in psychiatry reported that 79% of respondents had used combination antidepressants and that 75% believed that general practitioners should be given information on their use.2 There is emerging evidence for the use of combination antidepressant strategies — from case series, open clinical trials, and randomised controlled trials (RCTs). The largest summation of the data is a meta-analysis which found that combination antidepressant treatment produced a 62% response rate when monotherapy had failed.3 Although this finding alone cannot be convincing because of the acknowledged lack of large sample RCTs, it is quite another matter to decry combination prescribing as clinically unsound based only on the history of augmentation treatments such as lithium and, to a lesser extent, thyroid hormone treatment when, anecdotally, they provide such clinically disappointing results. It is not unreasonable to assert the primacy of good clinical reasoning, including sensible prescribing of combination antidepressants, over rigid adherence to evidenced-based algorithms. This sort of thinking is allowable because the evidence base for the treatment of depression is poor. Meaningful guidelines cannot be produced while the evidence is predicated on the flawed proposition that depression is an “it” (a homogenous construct).4 GPs might well be puzzled by the zeal in academic psychiatry for monotherapy. They are advised to “optimise” monotherapy, but not told what this means. They are very familiar with models of staged polypharmacy for common chronic illnesses such as hypertension, epilepsy, diabetes, and asthma, but in psychiatric pharmacotherapy this is apparently unwise or too risky. The way such admonishments are usually framed is by reference to serious but rare adverse reactions (like the serotonin syndrome), without proper attention to the equally serious and probably more common problems with the current “simple” psychotropic drug options already used by GPs. Failure to contextualise these risks leads to a distortion of risk–benefit prescribing decisions and an unnecessary restriction of treatment choices. We must have a commonsense approach to the treatment of depression that recognises the proper context of our knowledge base. Combination antidepressant treatments may be “beyond the evidence”, but this alone is not a sufficient justification to stop using them.

Murray J Walters · Alston M Unwin · Sean B Gills

In reply: The letters by Horgan and Walters et al underline our motive for reviewing antidepressant combinations. The conclusions of the survey are at least questionable, given that the response rate was only 36%, 18% of respondents were not psychiatrists, and affirmative responders may have only used combination antidepressants once.1 In any case, should clinical popularity substitute for evidence? If so, once popular but now research-discredited treatments such as insulin coma therapy would still be used. Equating combination antidepressants to combination drugs for asthma and hypertension is misleading. How often are two β-blockers given together in maintenance treatment? Major depression causes severe suffering, but this does not justify the use of unproven treatments ahead of those supported by evidence. General practitioners should be informed about antidepressant combinations, but the information must be evidence-based. We described the process of dose optimisation, and stand by our advice that complex cases that require unproven treatment (such as combination antidepressants) be referred to a psychiatrist. Patients should also be informed about combination antidepressants, including the paucity of evidence concerning efficacy and safety, the absence of information about consequences of long-term treatment, and that some combinations are lethal and others frequently unsafe. Published data from the STAR*D study provide equivocal support for the combination of citalopram and bupropion, as we noted. Evidence of modest effectiveness (remission rate, 13.7%) for the combination of mirtazapine and venlafaxine has appeared.2 Our conclusion was that some antidepressant combinations could be used in certain clinical situations where evidence-based treatments have failed, with safeguards. Given that 17% of respondents to the survey1 observed serious complications with combination antidepressants, this is good advice.

Nicholas A Keks · Graham D Burrows · David L Copolov · Richard Newton · Nick Paoletti · Isaac Schweitzer · John W G Tiller

There is clear evidence that coordinated systems of medical and psychological care (“collaborative care”) are superior to single-provider-based treatment regimens. Although other general practice-based mental health schemes promoted collaborative care, the new Medicare Benefits Schedule payments revert largely to individual-provider service systems and fee-for-service rebates. Such systems have previously resulted in high out-of-pocket expenses, poor geographical and socioeconomic distribution of specialist services, and proliferation of individual-provider-based treatments rather than collaborative care. The new arrangements for broad access to psychological therapies should provide the financial basis for major structural reform. Unless this reform is closely monitored for equity of access, degree of out-of-pocket expenses, extent of development of evidence-based collaborative care structures, and impact on young people in the early phases of mental illness, we may waste this opportunity. The responsibility for achieving the best outcome does not lie only with governments. To date, the professions have not placed enough emphasis on systematically adopting evidence-based forms of collaborative care.

Ian B Hickie MD, FRANZCP · Patrick D McGorry MD BS, PhD, FRANZCP

General practitioners have an important role to play in helping patients after exposure to severe psychological trauma. In the immediate aftermath of trauma, GPs should offer “psychological first aid”, which includes monitoring of the patient’s mental state, providing general emotional support and information, and encouraging the active use of social support networks, and self-care strategies. Drug treatments should be avoided as a preventive intervention after traumatic exposure; they may be used cautiously in cases of extreme distress that persists. Adults with acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) should be provided with trauma-focused cognitive behaviour therapy (CBT). Eye movement desensitisation and reprocessing (EMDR) in addition to in-vivo exposure (confronting avoided situations, people or places in a graded and systematic manner) may also be provided for PTSD. Drug treatments should not normally replace trauma-focused psychological therapy as a first-line treatment for adults with PTSD. If medication is considered for treating PTSD in adults, selective serotonin reuptake inhibitor antidepressants are the first choice. Other new generation antidepressants and older tricyclic antidepressants should be considered as second-line pharmacological options. Monoamine oxidase inhibitors may be considered by mental health specialists for use in people with treatment-resistant symptoms.

David Forbes MClinPsychol, PhD · Mark C Creamer PhD · Andrea J Phelps MPsych · Anne-Laure Couineau MA · John A Cooper MPM · Richard A Bryant PhD · Alexander C McFarlane MD · Grant J Devilly PhD · Lynda R Matthews PhD · Beverley Raphael MD

General practice psychiatry Grant Blashki, Fiona Judd, Leon Piterman, editors. Sydney: McGraw-Hill, 2006 (xii + 388 pp). ISBN 007471351 5. Who might have anticipated that a book dealing with psychiatry in general practice has, as its second chapter, “GP self-care”? Or that the first third of the text includes chapters on cross-cultural and Indigenous issues, consumers’ and carers’ views of general practice psychiatry, and mental health and the law, among others? What I like about this book is that it challenges conventional priorities and paradigms and offers new, unforeseen material, while retaining obligatory examination of the various psychiatric illnesses — depression, anxiety, substance misuse, psychoses, and others — encountered in general practice. The need for general practitioners to be skilled in the assessment and management of mental health problems is unarguable. Among other reasons, these problems are very common in the community (and far too common to be seen exclusively by mental health professionals), and many sufferers choose to seek help from a GP, certainly in the first instance. In this book’s pages, the reader will find much practical advice: there is information about assessment techniques, useful rating scales, psychological treatments and pharmacotherapy (in some detail), and strategies for difficult behaviours (eg, for the persistently angry patient or for when a staff member is a target of anger). The style is engaging, with regular use of case studies (often revisited later in a chapter), “key facts”, other lists (oddly, referred to as figures) and tables. The editors and assembled authors have a strong reputation in this field. It is noteworthy that each chapter was co-developed by a GP, so the utility for general practice was always in the contributors’ minds. General practice psychiatry is an ambitious book — at once attempting to be thought-provoking and to provide the “good oil” — but the editors and authors appear to have pulled it off. It is very good value for money.

Garry J Walter

New Australian government funding for the Better Outcomes in Mental Health Care initiative is a significant step forward for mental health, with general practitioners now able to offer direct referrals to psychologists, social workers, occupational therapists and Aboriginal health workers. Incentives for better teamwork between GPs and other mental health professionals have been introduced, but may have unintended consequences, including an exacerbation of workforce shortages in rural and remote areas. Possible solutions to these shortages include rural scholarships for students in the mental health professions; recruitment and retention of students coordinated by university departments of rural health; better access to continuing professional development; and federally funded rural positions and additional financial incentives for rural mental health practitioners.

James A Dunbar MD, FRCPEdin, FRACGP · Ian B Hickie MD, FRANZCP · John Wakerman MB BS, FFAPHM · Prasuna Reddy PhD, MAPS

In the past 10–20 years there has been increasing interest in the relationship between spirituality and health. I interviewed six patients from community mental health centres, using a phenomenological approach to explore how concepts of spirituality, occupation and mental illness/mental health are related. One person’s story is presented to illustrate the issues. Four main themes were identified: Spirituality is a phenomenon that provides meaning to life. Spirituality can help a person cope with mental illness. Spiritual beliefs can make everyday occupations more meaningful and health-enhancing. Some people find it valuable to engage in shared occupations that focus on spirituality. Spirituality is an important and relevant issue to be discussed between patients and health practitioners, provided that practitioners can exercise sensitivity, caution, tolerance and acceptance of values that may differ from their own.

Clare Wilding BAppSc(OT), MAppSc(OT)

Objective: To examine trends in hospital separations related to “drug-induced” psychosis for cannabis and methamphetamine, in the context of patterns of cannabis and methamphetamine use in the Australian population.Design and setting: Analysis of prospectively collected data from the National Hospital Morbidity Database on hospital separations primarily attributed to drug-induced psychosis (July 1993 – June 2004), and specifically for cannabis and amphetamines (1999–2004). Calculation of Australian population-adjusted rates of drug-induced psychosis hospital separations using estimated resident population data from the Australian Bureau of Statistics (at 30 June each year) and data on cannabis and methamphetamine use from the 2004 National Drug Strategy Household Survey.Main outcome measures: Number of hospital separations due to drug-induced psychosis, and standardised (age-specific) rates per million population and per million users.Results: There have been notable increases in hospital separations due to drug-induced psychosis, which appear to have been driven by amphetamine-related rather than cannabis-related episodes. The rate of hospital separations was higher for amphetamine users than for cannabis users in all age groups, and the rate increased among older amphetamine users.Conclusions: The risk of hospitalisation for a drug-induced psychotic episode associated with amphetamine use appears to be greater than that for cannabis use in all age groups.

Louisa Degenhardt PhD, MPsych(Clinical) · Amanda Roxburgh BA(Hons)Psych, MCrim · Rebecca McKetin PhD

Maternal mortality associated with psychiatric illness in the perinatal period (pregnancy to the end of the first year postpartum) has until recently been under-reported in Australia due to limitations in the scope of the data collection and methods of detection. The recent United Kingdom report Why mothers die 2000–2002 identified psychiatric illness as the leading cause of maternal death in the UK. Findings from the last three reports on maternal deaths in Australia (covering the period 1994–2002) suggest that maternal psychiatric illness is one of the leading causes of maternal death, with the majority of suicides occurring by violent means. Such findings strengthen the case for routine perinatal psychosocial screening programs, with clear referral guidelines and assertive perinatal treatment of significant maternal psychiatric morbidity. Data linkage studies are needed to measure the full extent of maternal mortality associated with psychiatric illness in Australia.

Marie-Paule Austin MB BS, MD, FRANZCP · Susan Kildea RM, BHSc(Hons), PhD · Elizabeth Sullivan MB BS, MPH, MMed(Sexual Health)

Verbal medicine. Twenty-one contemporary clinician–poets of Australia and New Zealand Tim Metcalf, editor. Canberra: Ginninderra Press, 2006 (148 pp). ISBN 1 74027 369 9 When I sit on medical curriculum advisory committees, I hear that the subjects studied and examined to gain entry to medical courses, and the courses themselves, have become too focused, too narrow, too mechanistic, too concentrated on sciences and biology. I hear that our students lack sufficient exposure to literature and philosophy to cope with the intense emotional impact of the blessing and the curse that is the life of a doctor. I worry that so many colleagues are at risk of emotional burnout. It has been said that there is no greater tragedy than an unexamined life. This book of poems by 21 contemporary Australasian clinician–poets is a delight, but it is no light read. I could not read it all in one sitting as each poem is strong and powerful. Verbal medicine goes a long way towards examining what it means to be a doctor, and how it feels to deal with the joys and sorrows, frustrations and successes of practice. It does not stop there; painfully, ruthlessly, thoroughly, it examines the role of doctor as patient and mortal human being. I believe that more doctors should be encouraged to write poems as a way of examining their own lives, and this book is a great example. The MJA editor took a chance on asking me, as a poet, to review a book on poetry. So I cannot let the opportunity pass without a poem of my own. Why? Why do we write, why do we dare? Do we think that there’s someone there? Have we a message, have we a thought? On a piece of our lives that fortune brought? Why do we write? Do we want to be heard? Or just carve order from the great absurd? To tear a pain from our inside? Or see a terror that no more can hide? To release our anger and give it vent? Until our passion and frustration’s spent? Or play with words and toy with sound? And admire the pretty game we’ve found.

Christopher D Hogan

Careful attention to persecutory delusions of patients and to concerns of family members may help Any homicide is a tragedy, with devastating consequences for all involved, including perpetrators, their families and the community. People with a psychotic illness make a small, steady contribution to homicide figures. Strangers are rarely victims of such events, with family members and others known to the individual at much higher risk.1,2 Other than the impact of psychotic symptoms themselves, the risk factors for violence by people with psychotic illness are similar to those for the rest of the population, and include being young and male, having a background of crime and/or violence, substance misuse, personality disorder, brain injury, and socioeconomic deprivation.3 This issue of the Journal features a case series by Nielssen and colleagues of 10 years of homicides committed by people whose acute psychotic illnesses were considered by the authors to be largely responsible for their crimes (→ Homicide during psychotic illness in New South Wales between 1993 and 2002).4 The authors make two key observations. Firstly, they note that evolving persecutory symptoms in which the subject perceives an immediate threat were highly correlated with homicidal behaviour in their sample. While caution must be exercised in generalising the findings from an uncontrolled series of homicides, selected because their illness was felt to be responsible for their crime, persecutory psychotic symptoms have been repeatedly but not consistently implicated in severe violence in other more rigorous studies.5-7 At the same time, it is clear that most people who experience such symptoms do not act on them.5 It is likely to be a complex and largely unpredictable interaction of risk factors and circumstances that bring about the final tragic outcome. Secondly, in this series, 69% of all homicides occured during the first year of the perpetrator’s illness. The authors raise the possibility that this may reflect inadequate detection and treatment. Although highly plausible, it is not clear from their study how many patients were in treatment at the time of their crime, nor whether that treatment was considered adequate. Other explanations are possible. From a population perspective, the peak age at which people commit homicide and have their first psychotic episode largely overlap.8,9 Therefore, lower homicide rates would be expected in those who are older. Also, family members are likely to be most vulnerable to becoming victims of homicide during a first psychotic episode because they are less attuned to indicators of risk. Further research is needed to clarify the nature of the observed elevated early risk of homicide, but, as the authors conclude, those in the first year of illness are worthy of particular attention regarding risk of violence. Is it possible to predict or prevent homicide by people with a psychotic illness? The accurate prediction of rare events is inherently problematic, with unacceptably low specificity and sensitivity.10 Nielssen and colleagues suggest that: “. . . many of the deaths might have been prevented if the dangerous symptoms had been identified and there had been assertive intervention”.4 Such a statement may greatly overestimate the capacity of mental health services to predict and prevent homicide in the context of psychosis, described by one prominent author as just “part of the human condition”.10 In retrospect, it is often clear where opportunities for intervention have been missed, but this does not guarantee that prevention was possible. This need not, however, be seen as an excuse for nihilism. Careful monitoring and appropriate intervention remain important. As well as preventing homicide, it may be rewarding to focus on the reduction of violence. While accurately predicting violence by individuals is statistically almost impossible, with high rates of false positives, it is possible to identify groups of individuals at high risk of committing violence and by extension, homicide.11,12 Paul Mullen, Director of Forensic Mental Health Services for Victoria, believes that only by intervening intensively and assertively with this often very difficult-to-engage group, and addressing the many biopsychosocial factors that mediate violence in addition to acute symptoms, might it be possible to significantly reduce violence by people with schizophrenia.12 His approach would require intensive, multidisciplinary input and a change in attitude by mental health and other services towards this very challenging group. With luck, such a pathway might reduce violence and occasionally even prevent homicide, while also improving the quality of life of many highly vulnerable people and their families and associates along the way. How then should clinicians proceed when attempting to develop a management plan for a person with a psychotic illness? Clearly, risk assessment necessitates careful enquiry about persecutory symptoms, with an emphasis on the patient’s experience of fear, and consideration of any associated risk to others. Such symptoms need to be considered in the context of other risk factors for violence when predicting risk and developing a management plan. The burden of risk borne by family members and close associates reinforces the need for close and ongoing family consultation. Perceived risk by family members must be taken very seriously and be embedded in the ensuing management plan, which should include direct advice as to how they should respond to actual threat. Because threatening and violent behaviours are rare and complex, predicting and preventing serious violence and, by extension, homicide will always be problematic. Despite its limitations, the study by Nielssen and colleagues reminds us of the need to place grave emphasis on persecutory delusions in the mental state examination, particularly during the early stages of psychotic illness, and to listen carefully to the concerns of family, who remain most at risk of violence. Improved multidisciplinary community mental health services, as are advocated in the early intervention psychosis model, if applied uniformly and rigorously, might go some way to improving the chances of preventing homicide.

Megan J Kalucy BMedSci(Hons), BM BS, FRANZCP · Ross S Kalucy FRACP, FRANZCP, FRCPsych

Objective: To review homicides committed during psychotic illness in New South Wales over 10 years from 1993 to 2002.Design and setting: Case series of all known homicides committed during psychotic illness in NSW, taken from reports of psychiatrists submitted in proceedings in the Supreme Court of NSW.Main outcome measures: Demographic and clinical features of perpetrators; estimated frequency of homicide during psychotic illness.Results: In the 10 years from 1993 to 2002, there were at least 88 people charged with 93 homicide offences committed during the acute phase of mental illness. High rates of drug misuse, especially of drugs known to induce psychotic illness and brain injury, were reported. Evolving auditory hallucinations and delusional beliefs that led the person to believe they were in danger were the symptoms strongly associated with lethal assault. The victims were mostly family members or close associates. Only nine of the victims were strangers, including three fellow patients. Most lethal assaults (69%) occurred during the first year of illness, and the first episode of psychotic illness was found to carry the greatest risk of committing homicide.Conclusions: People in their first episodes of mental illness should be considered to be at greater risk of committing serious violence than those in subsequent episodes. Illicit drug use, a history of brain injury, auditory hallucinations and delusional beliefs of immediate danger were particularly associated with lethal assault.

Olav B Nielssen MB BS, MCrim, FRANZCP · Bruce D Westmore MCrim, FACLM, FRANZCP · Matthew M B Large BSc(Med), MB BS, FRANZCP · Robert A Hayes LLB, PhD

Objective: To establish the nature and efficacy of Australian school-based prevention and early intervention programs for anxiety and depression.Data sources: Cochrane, PsychInfo and PubMed databases, and the Primary Mental Health Care Australian Resource Centre database, were searched in June 2006. Additional materials were obtained from program websites, reference lists and authors.Study selection: Programs that were developed in Australia or trialled in Australia and addressed anxiety, depression, or resilience were included.Data synthesis: 24 efficacy or effectiveness trials of 9 intervention programs were identified. Most were based on cognitive behaviour therapy, interpersonal therapy or psychoeducation. Six were universal interventions, two were indicated programs and one was a treatment program. Most were associated with short-term improvements or symptom reduction at follow-up.Conclusions: A number of schools programs produce positive outcomes. However, even well established programs require further evaluation to establish readiness for broad dissemination as outlined in the standards of the Society for Prevention Research.

Alison L Neil BAppPsych(Hons) · Helen Christensen PhD

To the Editor: I read with great interest Ellard’s article “The adventures of an alienist” in the Journal’s recent Christmas issue.1 Few have equalled or surpassed Ellard’s contribution to Australian psychiatry. However, as the only member of the College Committee still living, I must take issue with his statement, “In the 1960s, David Maddison created the College virtually single-handedly”. He was, of course, referring to the Australian and New Zealand College of Psychiatrists (the “Royal” prefix not granted until 1978). In May 1962, Dr J D Russell, President of the Australian Association of Psychiatrists, moved at the Council meeting that “Council resolve to take the necessary action forthwith to convert the Association into a College”. The Council appointed a College Committee, consisting of Dr Russell, as Chairman, with Professor David Maddison, Dr Ian Simpson and myself to plan the “necessary action”. At the Council’s annual general meeting in September 1962, members approved the formation of a College and its memorandum and articles of association, and, after legal approval, the College was officially incorporated on 28 October 1963. David Maddison was able to attend only some of the many meetings of the College Committee, but he did make a major contribution to our deliberations. Nevertheless, it could hardly be said that he “created the College virtually single-handedly”.

Bruce H Peterson

In reply: I have no difficulty in accepting Peterson’s comment. My view of what happened at the genesis of the College arose from the fact that, at the time, Professor Maddison and I were close friends and had many conversations about academia and its institutions. This led me to greater awareness of his contribution and less of the contribution of others. I should have been more careful in reaching my opinion.

John H T Ellard

To the Editor: The recent editorial by White and Whiteford raises the important issue of the need to provide more extensive and more effective mental health services for the prison population.1 However, their discussion of the reasons for the increased level of need does not consider one important problem that often results in the inappropriate imprisonment of people with mental illness. This is the frequent refusal of acute psychiatric units to accept mentally ill people referred by the courts. I recently reviewed a series of 102 referrals for medicolegal assessment from Legal Aid New South Wales between February 1999 and March 2006. The results were presented at the 2006 meeting of the Forensic Section of the Australian and New Zealand College of Psychiatrists.2 Of the 55 patients meeting the criteria for mental illness under section 32 or 33 of the Mental Health (Criminal Procedure) Act 1990 (NSW), 27 (49%) were seen in custody. For 14 of these patients, their incarceration had resulted from the failure of the local area heath service to accept patients for admission if they had drug-related exacerbations of mental illness. Hospital registrars would return patients to court with a certificate saying that they had no mental illness, even though some of them were currently under a community treatment order recommended by other professionals from the same mental health service. To some extent, this may be because of the strict application of the guidelines for compulsory hospitalisation. These are more stringent than the criteria for defining mental illness under the Mental Health (Criminal Procedure) Act, but one is left with anomalous situations such as the one described above. Important issues leading to this situation appear to be the presence of dual diagnoses (10 of the patients reviewed had a combination of psychosis and substance misuse) and violent behaviour. The rejection of violent patients reflects both occupational health and safety considerations in the context of inadequate resources and an industrial stance (usually informal) taken by the nursing staff. It is therefore important that some of the additional resources recently committed by Australian governments to the reform of forensic mental health services be directed towards the provision of acute hospital inpatient services for disturbed patients, so that the incidence of imprisonment in the acutely disturbed psychiatric population is reduced. This is more humane and may be more cost-effective than simply applying all the resources within the prison system.

Gordon R W Davies