Mental health

Objective: To identify the prevalence of mental health problems, rates of suicidal ideation and behaviour, and use of professional mental health services among children and adolescents residing in home-based foster care, and to compare these rates with those reported for children and adolescents in the general Australian community.Design: Cross-sectional survey.Participants and setting: 326 children and adolescents (aged 6–17 years) residing in home-based foster care in the Adelaide metropolitan region between August 2004 and January 2006.Main outcome measures: Prevalence of emotional and behavioural problems, suicidal ideation and behaviour, and use of professional services to obtain help for emotional and behavioural problems.Results: 61.0% of children and adolescents living in home-based foster care scored above the recommended cut-off for behaviour problems on the Child Behavior Checklist and 35.2% of adolescents scored above the cut-off on the Youth Self Report. 6.7% of 13–17- year olds in home-based foster care reported a suicide attempt that required medical treatment during the previous year. Caregivers reported that 53.4% of children needed professional help for their mental health problems but only 26.9% had obtained help during the previous 6 months.Conclusion: Children in home-based foster care experience high rates of mental health problems but only a minority receive professional help for their problems.

Michael G Sawyer PhD, FRCPC, FRANZCP · Josephine A Carbone BA(Hons) · Amelia K Searle BPsych(Hons) · Philip Robinson PSM, DipAppPsych, MPsych

To the Editor: St John’s wort (SJW) (Hypericum perforatum) is a natural medicine commonly used for treating depression. We recently encountered a case of an overdose of SJW leading to serious manifestations in the patient. A 16-year-old girl presented to the emergency department with seizures and confusion. She was intubated and admitted to the intensive care unit. The only relevant history was of febrile convulsions at the age of 4 years. There had been no head trauma. Results of a computed tomography brain scan and cerebrospinal fluid examination were unremarkable. Electrolyte levels were normal, and standard drug toxicological screens were negative. An electroencephalogram (EEG) confirmed diffuse spike wave activity consistent with generalised epileptic activity. On further questioning, it was found that she had taken large quantities of SJW — up to fifteen 300 μg tablets a day in the 2 weeks leading up to admission and an additional 50 tablets just before presentation — for a recent “depressive episode”. Depression had not been formally diagnosed, and the tablets had been obtained “over the counter” from a local pharmacy. A provisional diagnosis of seizures due to an overdose of SJW was made. High performance liquid chromatography was not performed to quantify hypericum extract in serum and urine, as these tests are not available in our hospital. A repeat EEG at discharge on Day 6 was normal, and there were no further seizures in the following 6 months. Psychiatric assessment during the patient’s hospital stay revealed a likely suicide attempt following recent social stresses. There is some evidence for the efficacy of SJW in treating depression.1 In the United States and Australia it is available without prescription, but in Germany, where it is prescribed more frequently than fluoxetine for depression, it is available by prescription only. The reported incidence of adverse drug reactions to SJW is 0–5.7%.2 Although these are usually minor and transient, more serious adverse reactions (such as serotonin syndrome) have been reported.3 SJW was implicated as a likely, but unproven, cause of seizure-related events in a recent review,4 but our case appears to be the most severe reported so far. Adverse reactions are thought to be more common if SJW is taken in conjunction with selective serotonin reuptake inhibitors, but have also been described when SJW is taken alone.5

Dharshi C Karalapillai · Rinaldo Bellomo

Objective: To identify whether the rate and average daily dose of stimulant prescribed for attention deficit hyperactivity disorder (ADHD) in Western Australia differed according to the geographical remoteness and socioeconomic status of the patient.Design and data sources: Secondary analysis of population-based administrative pharmacy data from 2004, stratified by the Accessibility/Remoteness Index of Australia (ARIA+) categories and the Index of Relative Socio-Economic Disadvantage (IRSD) quintiles for WA (2001 Census).Outcome measures: Rate ratios of stimulant prescription and mean average daily dose (in dex-equivalents) stratified by age (2–17, 18+ years), sex, ARIA+ category and IRSD quintile.Results: The rate of stimulant prescription was 2.3 to 5.3 times greater in major cities in WA compared with remote and very remote parts of the state. The association between socioeconomic disadvantage and the rate of stimulant prescription was highly variable. Adults with the least socioeconomic disadvantage were significantly more likely to receive stimulants compared with their most disadvantaged counterparts; however, the reverse association was seen with children. The average daily dose of stimulant prescribed did not vary greatly across remoteness or socioeconomic categories.Conclusion: Remoteness and socioeconomic disadvantage are significantly associated with rate of stimulant prescription for ADHD in WA, but not associated with average daily dose of stimulant prescribed. Further research is needed to understand why considerable variation exists in the use of prescribed stimulants for ADHD.

Janine Calver PhD · David Preen PhD · Max Bulsara MSc · Frank Sanfilippo PhD

Up to 45% of patients with debilitating and potentially lethal depressive illness do not achieve remission with initial drug treatment. Using combinations of antidepressants as an early option for treatment-resistant depression has become increasingly common. Before trying combination therapy, it is essential first to ensure diagnosis is correct, and then to optimise antidepressant monotherapy, using an effective dose for an adequate period. Subsequently, augmentation of antidepressants with lithium and triiodothyronine should be considered, as these strategies are strongly supported by numerous clinical trials. Electroconvulsive therapy is the most effective treatment for severe depression. There is little evidence to support use of antidepressant combinations. Risk of toxicity and drug interactions mandate that combinations be used as a last resort, and only in specialist settings.

Nicholas A Keks MB, PhD, FRANZCP · Graham D Burrows BSc, MD, FRANZCP · David L Copolov MB, PhD, FRANZCP · Richard Newton MB, MRCPsych, FRANZCP · Nick Paoletti MB, MPH, FRANZCP · Isaac Schweitzer MD, DPM, FRANZCP · John Tiller MD, BSc, FRANZCP

Getting the message right will help the public reduce their risk of mental illness In the 2006–07 budget, the Australian Government announced expenditure of $21.6 million over 4 years to improve community awareness of the link between using illicit drugs and the development of mental disorders. Community awareness programs to reduce the prevalence of unhealthy behaviours are nothing new; they have been around for decades for cancer, heart disease and infectious diseases. While campaigns focusing on the negative effects of drug misuse have already been delivered, this initiative breaks new ground. It will be the first large-scale campaign in Australia to tell the public what actions they can take to reduce their risk of developing mental disorders. Australia is not alone in this area, with both France and the United States launching campaigns in 2005 to alert the public to the potential link.1,2 However, it is too early to know whether these campaigns have had any effect. Probably the main reason that there have not been earlier campaigns on how to reduce the risk of mental disorders is a lack of evidence for causal links. How good then is the evidence that illicit drugs cause mental disorders? First, there is substantial agreement that an association exists between early onset of cannabis use and later psychotic symptoms or disorder,3 but there is ongoing disagreement regarding the causal basis of this association.4 Clearly, cannabis use is “neither a sufficient nor necessary cause for psychosis”,3 but it may “unmask” psychotic disorders in individuals who are vulnerable. The timing of drug exposure may be particularly critical here, especially given recent evidence that a specific polymorphism of the COMT (catechol-O-methyltransferase) gene conveyed increased risk of later psychosis only if cannabis was consumed during adolescence.5 Second, a number of studies have reported a modest association between early onset of regular cannabis use and later depression, although further research is required to determine whether this relates to a direct causal role or common psychosocial factors.6 The evidence implicating other illicit drugs is more limited. Methamphetamine, which is rapidly growing in popularity in Australia, has been consistently associated with a transient psychotic state that is more common in people dependent on this drug.7 A growing body of literature suggests that a significant minority of those regularly using methamphetamine are also at risk of more entrenched patterns of psychosis.8 While there is currently limited evidence of a direct causal relationship between illicit drug use and mental disorders, the issue becomes whether we can afford to wait and see if increasing early use of illicit drugs actually does lead to a rise in the incidence of mental disorders. If a community awareness campaign is to be effective, it needs to be appropriately targeted. Initiation of illicit drug use typically starts in adolescence, and the evidence points to those with the earliest onset of drug use as being at greatest risk of subsequent mental disorders. A campaign targeting an early adolescent audience requires clear, coherent and credible evidence-based messages that are balanced and free from political dogma. The messages must also be delivered in a format that is appealing and meaningful to adolescents and informed by current trends in media and information technology. This might include web-based campaigns and the development of related Internet sites. Whether the campaign also focuses on providing information for parents will need to be determined, as this would require a complementary set of relevant information and materials. Mass media campaigns in other areas of health have typically had very little effect, including when drug misuse prevention has been the goal.9 In many cases, the weak effect has been due to campaigns being insufficient in intensity. Nevertheless, there are lessons that can be learned from earlier campaigns and these need to be applied (see Box). Given that the campaign discussed here will be the first to address risk of mental disorders, it needs to be well evaluated, either through a staggered roll-out in which some regions serve as controls, or through a time-series analysis in which there are repeated measurements over time — before, during, and after the campaign. As the first of its kind in Australia, it is important that this campaign is done well. A bad start could set back a field with considerable potential. Reducing the prevalence of risky behaviours, like illicit drug use, is not the only approach. It is also possible to promote positive actions that all individuals can take to reduce their risk of mental disorders.12 Campaigns that focus on educating the public about other effective preventive strategies (eg, exercise) should also be a clear priority, similar to other areas of health policy. Indeed, we have good evidence regarding psychosocial factors that increase risk for both substance misuse and mental disorders, and we need to communicate this information to the wider community. We envisage a future in which the public will know as much about how to reduce their risk of mental disorders as they currently do about how to reduce their risk of cancer and heart disease. Principles of effective mass media campaigns9 and possible applications to a campaign promoting awareness of illicit drugs as a risk factor for mental disorders Carry out preliminary research with the target audience Carry out qualitative research with young people to help design the campaign and to get feedback about the effectiveness of messages. Use a theory to give the campaign a conceptual foundation There are several relevant theories of behaviour change, including the transtheoretical model (which specifies how to communicate with people who are at various stages of readiness to change)10 and the theory of planned behaviour (which looks at how behaviour is influenced by a person’s attitudes and those of the people closest to them, and whether the person believes that the behaviour is under volitional control).11 Segment the audience into subgroups of people whose message preferences are similar to one another Potential audience subgroups might include: young people currently using illicit drugs, adolescents not using drugs, people with a personal or family history of mental disorders, and parents. Design messages that are targeted to the audience subgroups Messages need to appeal to each group. For example, messages for young people might need to avoid preaching, use suitable role models, and include features such as humour, novelty and a fast pace. Place messages through appropriate media that are widely used by the audience The appropriate media may be quite different for each group (eg, the Internet or youth radio might be more appropriate for young people than for parents). Conduct a process evaluation to see that the messages reach the audience Surveys should be conducted to ensure that the messages have reached the target audiences with a high frequency of exposure. The approach should be changed if an audience is not being reached. Evaluate outcomes to find out whether the campaign caused any changes in target audience behaviour Measure changes in attitudes towards the link between drug use and mental disorders, as well as changes in drug use. Evaluate the effects using a staggered roll-out, with some regions used as controls, or a time-series design, which involves multiple measures before, during, and after the campaign.

Anthony F Jorm MPsychol, PhD, DSc · Dan I Lubman PhD, FRANZCP, FAChAM

I have had a long and interesting life. I have been doubly fortunate in that most of the rewarding activities came into my life not through my own endeavours but by being presented to me, often quite unexpectedly. My first choice of a career came from seeking vocational guidance while in secondary school. I was advised to become a psychologist. Having no other aspirations, I set off in that direction and, in due course, gained admission to the Faculty of Arts at the University of Sydney, hoping to gain an honours degree in psychology. All went well until my second year — in 1942. By then, the Second World War had become pressing, and I found myself being interviewed by an army recruitment officer. He told me that, with my university background, if I were to join the infantry I might be rapidly promoted. The alternative was radar and coastal artillery. Radar sounded more interesting, and turned out to be very active as well. In 1942 and 1943, the Japanese I class submarines sank 175 000 tons of shipping and drowned some 350 sailors in the waters around Sydney. Our job was to locate the submarines. Things happened quickly. At one stage, Sydney had only one 10 cm radar station and I was for a time the most senior soldier running it. After some time the war moved north. On the wayIn the military, one learns to be a little devious. After 2 years, I manoeuvred myself into the Australian Army Psychology Service and, in time, achieved the rank of Warrant Officer 1st Class. I was doubly fortunate: my immediate senior officers were both learned and helpful — they became Professors of Psychology after the war. Wide experience and expert supervision achieved the curious result that, with no formal qualification, by the end of the war I was performing the duties of the Clinical Psychologist at 114 Australian General Hospital, the principal interservice psychiatric hospital. Here I saw my first battle casualties. To make amends for my training deficiencies, I was given the title “Psychometrist”. Consulting the Oxford dictionary, I discovered that psychometrists had the power of divining — from physical contact with an object — the qualities of any person or thing that had been in contact with it. Although this would indeed have been a very useful talent, I had to acknowledge that I did not possess it, but no one seemed to mind. Working as a psychologist showed me that doctors had most of the professional power. Therefore, I decided to do medicine and become a psychiatrist. On the way through, I discovered that many doctors believed that only those who were unable to make a living in any other branch of medicine, or who were hopelessly dependent on alcohol, became psychiatrists. At that time, the solution was to prove that one was a “real” doctor by acquiring the Membership of the Royal Australasian College of Physicians. For that reason, many psychiatrists in my generation have the hard-won FRACP after their names. The immediate postwar yearsLooking back now, it is interesting to reflect on the medical world in New South Wales 60 years ago. There was one university — the University of Sydney — and its Faculty of Medicine had one Professor of Medicine, one Professor of Surgery and one (part-time) Professor of Psychiatry. Consider their numbers now! There were many roles to be filled. Within a few years, I found myself a Lecturer in Psychiatry in the Faculty of Medicine and a Member of the Board of Studies, Lecturer and Examiner for the degree of Master of Arts in Clinical Psychology in the Faculty of Arts. Additionally, I had become a Member of the Advisory Board of the Institute of Criminology at the University of Sydney. In those days, to be on the teaching staff of three faculties at once was a little unusual. Getting aheadMy entrance into the Australian and New Zealand College of Psychiatrists was atypical. In the 1960s, David Maddison created the College virtually single-handedly. For some time, I had examined with him in clinical psychiatry for the University of Sydney’s Diploma of Psychological Medicine. David Maddison rang me one day and said he wanted me to be a Censor of the College. Having the psychopathology of the only child, it does not occur to me to join things, and I pointed out that I was not a member of the College. David said, “Yes you are”. The next day, I paid my subscription, and a few days later I was in the College, and a Censor. There were many committees to join, and each would have a story to tell if there were more space. Their titles will have to suffice (see Box). The essence of it was that there was much to be done and I did my best to be as active as possible. In 1997, I received the College’s Medal of Honour, an award rarely given. It was awarded not only for my services to the College but also for being an “ambassador” for the College. The Law FoundationIn 1960, David Maddison’s brother, John, was the NSW Attorney-General. He rang me one day and invited me to join the Law Foundation of NSW. It sounded interesting, so I joined, and, in time, I found myself chairing it. This meant chairing a group comprised of the Attorney-General, the Head of the Bar and of the Law Society and one or two other worthies of similar status. It was an interesting experience for a psychiatrist and taught me a lot during my 20-year membership of the Foundation. There was no shortage of problems to be dealt with. Representatives of the articled clerks came to see me, and complained that some of them were receiving little instruction and were instead being used as lowly paid messenger boys. The solution was to set up the College of Law in Sydney, which is still going strong. There were other problems. My experience as a witness had shown me that, while the great body of judicial officers were intelligent and committed to their duties, there were some unfortunate exceptions. For example, in the District Court of NSW, I found myself giving evidence before a judge who did not raise his head from the bench. When finally he lifted it he said, “Bloody bullshit”. The only possible answer was “May it please Your Honour”. He replied, “Thank you, doctor”, and put his head down again. The Chief Justice of the day was manifesting clear evidence of dementia, but no one was doing anything about these and other problems in an important system. I persuaded the Law Foundation to set up the Judicial Commission to deal with such problems, and, from 1997 onwards, gave occasional lectures to the Educational Division of the Commission. Back to the servicesOne Friday afternoon in 1964, Bill Deane-Butcher, from a nearby office, came to talk to me. I knew he was Head of Royal Australian Air Force (RAAF) Reserve Medicine. He said, “We’ll be at war with Indonesia over the weekend. The mirages have gone to Darwin. You have service experience, and we want you in the RAAF this weekend.” And I was. I was on the active Reserve for the next 17 years, with service in Malaya and Vietnam. I became Senior Consultant in Psychiatry to the Director General of Air Force Health Services, with the rank of Group Captain — certainly an improvement on my army career! Once more, I learned a lot about many things and about myself. Vietnam, with its jump mines, left me with an enduring hatred and contempt for those who advise war and bring it about. There is no shortage of such people now. Something newIn the early 1980s, I received another memorable phone call, this time with an unusual invitation. It was the NSW Minister for Corrective Services, asking me if I would like to be a part-time Commissioner of Corrective Services. There had been much trouble in NSW prisons, culminating in the 1978 Report of the Royal Commission into NSW Prisons,1 in which Justice Nagle recommended the creation of such a position. As my work at the RAAF had been settling down and my advancing years made it unwise to fly in very fast highly manoeuvrable aircraft, and as I had never been a Commissioner of Corrective Services before, I could not resist the invitation. It turned out that I had a particular advantage. The common language used in the lower ranks of the army was exactly the same as that spoken by the prisoners. This made my communication with them much easier, since I spoke it as a native. On one occasion, I was in what was then the maximum security wing at Long Bay Gaol, housing 90 prisoners. The prisoners told me that heroin was much cheaper there than it was on the street and that they were all using it. They shared one syringe and one needle, and I was aware that HIV was spreading rapidly in the outside world. I went to the Minister and suggested that we start a methadone program and distribute clean needles and syringes. He was appalled at my suggestion, and when my 1-year term was up, he told me he would not reappoint me. When my job was advertised, I applied for it, was interviewed by the appropriate committee and chosen by it. The Minister did not welcome me, but I stayed for another year to make my point, and then resigned. On another occasion, to achieve a necessary result, I broke the law. During a visit to the NSW female correctional centre at Mulawa, I encountered a woman sitting with her shirt hitched up and her trousers pulled down. She had a single-edged razor blade in her right hand and was cutting deeply into her abdomen, with considerable loss of blood. There was a brief conversation. “That’s not a good thing to be doing, why are you doing that?” “There’s a baby in there and I’m going to get it out.” “Is there any way that I can persuade you to stop?” “If you send me to Rydalmere Psychiatric Hospital, I’ll stop.” In those days it was necessary to get the services of two psychiatrists, each of whom signed a Schedule 3, before a person could be moved from a prison to a psychiatric hospital. Both the Minister for Corrective Services and the Minister for Health were involved. The median time for a transfer under these conditions was about 6 weeks. This seemed excessive in the circumstances, so — unlawfully — I signed a Schedule 2 and sent her off immediately, the bleeding having been staunched. (A Schedule 2 required the signature of only one psychiatrist, but could not legally be used for the transfer of prisoners to a psychiatric hospital.) Soon after this, my good friend, Bill Cramond, who was Head of Mental Health at the time, contacted me and said that the NSW Cabinet wanted to know exactly what I had to say about breaking the law in this way. Part of my reply was unprintable, and the rest was to say that I had the choice of standing before them with a dead woman and a dead baby, or signing the wrong piece of paper. I had chosen to do what I did, and, presented with the same dilemma in the future, I would do the same again. If they did not like it, we would have it out on talkback radio, television and the newspapers. I heard no more. The game went both ways. At one time, we had a former Chief Magistrate and a former Minister for Corrective Services in custodial care for breaking the law! One of the biggest problems with the prison system was that the officers and prisoners had each other stereotyped as villainous creatures, and there was something close to open warfare between the two populations. The 1978 Royal Commission into NSW Prisons noted that, in 1942, there had been a substantial upsurge in prisoner unrest in NSW, “leading to a dramatic increase in breaches of prison discipline. There were several serious assaults on officers.”1 As a result, between 1965 and 1976, prisoners regarded as intractable were sent to a special unit at Grafton. They were welcomed with a “reception biff”, which consisted of a beating about the back, buttocks, shoulders, legs and arms by two or three officers using rubber batons. In 1970, there was a systematic flogging of a large number, if not all, of the prisoners in Bathurst Gaol. In 1974, the prisoners rioted and burned the gaol down. The antipathy that resulted was strong, and our principal task was to break it down and help each side (prisoners and officers) to see the other more as they really were. We started a special unit in which the very “heavy” prisoners (those with power in the prison population social structure) and prison officers mixed freely and enjoyed some pastimes together. To that we added a psychologist and a female governor. In those days, that was something like appointing a woman to head the Anglican and Catholic churches. My greatest day in corrections occurred when, on one occasion, I was sitting in the office of the Governor of the special unit and two heavy prisoners came in and addressed her by her first name. “Isabel, Christmas is coming and we can’t get any boots for Santa Claus. Can you help us?” “You’ll be right, boys. I’ll make sure that you do.” “Thank you, Isabel”, and off they went. This was a long way from the Grafton “biff” to which heavy prisoners had been sent to teach them who was “boss”, as described in the Royal Commission report. More than once, when there was a fierce riot raging in a prison and I was there with my brother Commissioner, Frank Hayes, the heavies reassured us that they would make sure that nothing nasty happened to us — and, indeed, nothing ever did. They recognised that we were trying to be just to both sides. In the end, we had a 6-week strike, with no prison officers working at all. The heavies said there would be no trouble in the gaols, and there was none. This was a significant communication, as their cooperation meant that the administration could run on for many weeks without any prison officers present and that the officers’ strike did nothing but harm their own interests. Other thingsDuring the second half of the 20th century, I had observed that there were many excellent psychiatrists in private practice but that the field had shown little indication of becoming organised, as academic psychiatry and public psychiatry had done. This moved on when I met Paul Ramsay, who then owned a small private hospital I was using. We formed a close and comfortable working relationship that led to the building of the Northside Clinic, a sizeable private psychiatric hospital that was opened in 1973. The psychiatric services were managed by my practice, in which there were some 15 or more psychiatrists and associates. We taught students and were recognised by the University of Sydney as a teaching establishment. We also had registrars, which was of special interest to me, as I had held the first registrar position in psychiatry in Australia in 1956. It was called “psychological medicine” at the time. It all went well, but, by 1999, after one partner had behaved improperly, I decided to concentrate on other things. Protecting the publicThere was another problem that troubled me. In the 1980s, psychiatrist Harry Bailey was practising deep sleep therapy at Chelmsford Private Hospital, Sydney, with a completely unacceptable number of consequent deaths. There were other improprieties as well. I was hearing about this in my consulting room, for it was widely known. There was no sign of the statutory bodies — the coroners, the Health Department, the Medical Board — taking action, even though many of the patients were transferred from Chelmsford to public hospitals and died there. Disturbed by it, I obtained the details of the death of a particular patient, and — supported by a professor of pharmacology and a senior physician — had the relevant information laid before the prosecuting authorities of the day with a charge of manslaughter in mind. Before anything could happen, the patient’s body was shipped overseas, as she came from another country, and the case collapsed. I felt that I could do no more, but then Merrilyn Walton — now Professor Merrilyn Walton — turned up in Sydney to establish the Health Care Complaints Commission. We conferred, and identified 18 deaths that should never have occurred. Dr Bailey was asked for his responses to each of these — seriatim. He suicided and, in his suicide note, blamed me by name for his death. Subsequently, I was an expert attached to the Royal Commission into Deep Sleep Therapy conducted by Justice Slattery. Those who wish to learn more about these matters can consult the Report of the Royal Commission into Deep Sleep Therapy.2 As a consequence of this activity, I was asked to investigate the management of Ward 10B at Townsville Hospital. The ward had been run as a “therapeutic community”, a popular concept decades ago. The essence of it was that an institution of this kind should be run by those in it rather than by the ordinary management team, such as psychiatrists and the like. As might be imagined, chaos reigned, and there was an inquiry to which I became a part-time consultant. I have always done my best to ensure that patients are treated competently and sympathetically. This has led to an interest in euthanasia. The notion that someone dying in agony, unrelieved by palliative care, should be made to go the full distance when they beg for death is repugnant to me. Much more could be said about this. It led to my involvement with a poor fellow in Darwin seeking to terminate his life when no other psychiatrist could be persuaded to become involved in the matter. It was a very public situation. I received both an award and hate mail. And nowIn my eighties, I find myself sitting on the Mental Health Review Tribunal and enjoying it. I have been there since its establishment under the Mental Health Act 1990 (NSW). The only problems are the vagaries of the Act and the traffic encountered in getting to some venues. I have had a good time with excellent friends, family and people to help me. My occupation has been interesting and I am still going strong. Who could ask for more? Awards, appointments and publications Awards Service medals 1939/45 War Medal Australian Service Medal (Second World War) Vietnam Service Medal (Vietnam War) Member, Order of Australia, 1983 Medal of Honour, Royal Australian and New Zealand College of Psychiatrists, 1983 Honorary Life Member, Faculty of Medicine, University of Sydney, 1994 Reserve Forces Decoration, 1996 Gold Star Award, Voluntary Euthanasia Society of New South Wales, 1998 Part-time consultancies Royal Commission into the Use and Effects of Chemical Agents, 1985 On Australian Personnel in Vietnam, 1985 Carter Inquiry into Ward 10B at Townsville Hospital, Queensland, 1990 Royal Commission into Deep Sleep Therapy, NSW, 1990 Adviser to Commission of Inquiry into Workers Compensation Common Law Matters (NSW), 2001 Previous appointments Member, Psychologists’ Registration Board of NSW, 1989–1996 Chair, Board of Practice Standards, Royal Australian and New Zealand College of Psychiatrists, 1990–1997 Chair, Clinical Practice Advisory Committee, Royal Australian and New Zealand College of Psychiatrists, 1990–1997 Chair, Inquiry into Psychosurgery (NSW Government), 1996–1997 Chair, Medical Committee (Poisons Act 1996 [NSW]), 1973–1992 Member, Legal Representation Committee considering the rights and needs of the mentally ill, 1977–1987 Member, Ministerial Advisory Committee inquiring into mental health services in New South Wales, 1987 Consultant Psychiatrist to the Health Insurance Commission, 1989–2005 Visiting professorships and lectureships in Malaysia, New Zealand and all Australian states except the Northern Territory Publications Writing has been one of my pleasures. My first publication was in the school magazine of my intermediate high school — a satirical additional chapter for the book we were obliged to study for the Intermediate Certificate. I am still at it: I have 170 articles in the medical and legal literature, eight chapters in books, and three books to my name. In addition, I edited the journal Modern Medicine for 22 years.

John H T Ellard MB BS, MRACP, DipPsyMed, FRACP, FRANZCP, FRCPsych, MAPsS

Family, adoption and twin studies demonstrate that many adult psychiatric disorders, including schizophrenia, major depression and bipolar disorder, have a clear genetic component. The aetiology of psychiatric disorders is a complex combination of both genetic and environmental components. While potential susceptibility genes for psychiatric disorders have been identified, interaction with the environment is a crucial component in disease development. Pharmacogenetics and genetic testing have the potential to play key roles in the future of clinical psychiatry. At present, an increased risk of psychiatric disorders can be identified through a detailed family history. The empirical risk of developing a disorder has been determined for many psychiatric disorders and can be used as a general guide. Genetic counselling can extend and enhance patient care by providing information to patients about the complexities of inheriting psychiatric disorders and the associated risks of recurrence. The genetic counselling process can facilitate informed decision making, alleviate misconceptions and reduce stigma through an improved understanding of the genetic cause of psychiatric disorders, and offer support to patients and their families.

Melissa K Hill PhD · Margaret Sahhar BA, DipSocStuds

Objective: To assess the psychosocial impact of the diagnosis of either localised or metastatic prostate cancer (PCA) on patients and their female partners.Design: Observational, prospective study at Time 1 and 6 months later at Time 2 of two groups of couples facing PCA. Time 1 was when patients were first diagnosed with histologically confirmed localised (potentially curable) PCA or metastatic (incurable) PCA.Main outcome measures: Depression and anxiety disorders according to the Diagnostic and statistical manual of mental disorders 4th edition (DSM-IV); psychological distress; marital satisfaction.Results: At Time 1, partners had rates of DSM-IV major depression and generalised anxiety disorder twice those of women in the Australian community, and considerably higher than the patients’ rates. At Time 2, psychological distress in partners had lessened but that in patients had increased. On the other hand, at Time 2, partners’ marital satisfaction had deteriorated.Conclusions: To be fully effective, interventions aimed at reducing the psychosocial morbidity of PCA must involve both patient and partner, rather than the patient alone.

Jeremy W Couper MB BS, MMed(Psych) · Sidney Bloch MB ChB, PhD · Anthony Love PhD · Gillian Duchesne BSc(Hons), MB ChB, MD · Michelle Macvean PhD · David W Kissane MB BS, MPM, MD

It often falls to general practitioners to identify and manage service-related mental health problems It has long been recognised that veterans may experience mental health problems after military deployments, and that these can be overlooked in the context of concern about physical injuries. Primary care practitioners, both military and civilian, are often the first port of call for affected veterans, and are best positioned to assess these patients and commence care when necessary. As over 85% of Australia’s trained forces are male, these health problems are particularly relevant for men’s health. American research on veterans from recent Middle East deployments shows high rates of psychological problems.1 Interestingly, British research on the same conflict found that problems are limited to reservists, with no elevated rates of mental health problems among regular personnel.2 Although local data are unavailable, it is reasonable to assume that Australian veterans from Afghanistan and Iraq will not be exempt. We learned much from the experience of Vietnam veterans, with their initial difficulties closely resembling those of younger veterans presenting today. While much attention is paid to post-traumatic stress disorder, evidence suggests that other anxiety, depression, and substance-misuse disorders are equally common.3 Providing effective mental health care for veterans presents particular challenges. For many reasons (including personality, military culture, deployment experiences, and adjustment to civilian life), veterans may be reluctant to acknowledge or report psychological problems. They may have poor mental health literacy, may avoid treatment, and can be hard to engage when they do present. Many have developed unhelpful strategies for managing distressing emotions, often channelling them into anger and aggression or covering them with substance misuse. Such strategies may have been adaptive in combat, but in civilian life they alienate the veteran from key sources of support. Veterans often present to general practitioners with physical health complaints that mask concerns about psychological issues. Early detection and appropriate intervention often become the responsibility of GPs. Once it is determined that the patient is a veteran, a few simple questions about sleep, family relationships, mood, anger, and substance use can provide an opening for intervention. The information in the Box identifies strategies and resources available to assist the mental health and wellbeing of veterans. Resources for veterans and their doctors The Australian Defence Force (ADF) has improved post-deployment screening, increased emphasis on mental health literacy and self-care, and attempted to improve the accessibility, acceptability and quality of care. This may help military personnel to not minimise health problems for fear of career damage. http://www.defence.gov.au/dpe/dhs/mentalhealth An enhanced career transition assistance scheme has been introduced by the Department of Veterans’ Affairs (DVA) and ADF for personnel discharging for medical reasons, to facilitate transition back to civilian life. http://www.defence.gov.au/dpe/dpectap The relatively new Military Rehabilitation and Compensation Act 2004 (Cwlth) focuses on vocational and psychosocial rehabilitation. This follows the Veterans’ Vocational Rehabilitation Scheme, which is designed to support veterans’ efforts to retain or return to employment while ensuring no loss of compensation entitlements in the process. http://www.dva.gov.au/health/younger/younger.htm In June 2005, the DVA released alcohol practice guidelines for practitioners helping veterans with alcohol problems. These guidelines cover screening and assessment through to treatment of comorbid alcohol misuse and post-traumatic stress disorder (PTSD). http://therightmix.gov.au/professionals.asp The DVA has produced an excellent self-help website for veterans with alcohol problems. http://www.therightmix.gov.au The Vietnam Veterans’ Counselling Service (VVCS) provides individual and group-based interventions to all veterans (not just from Vietnam), as well as their partners and children. VVCS also offers programs such as anger management, lifestyle management, heart health, and retirement preparation courses. http://www.dva.gov.au/health/vvcs Veterans with an accepted mental health disability are eligible for treatment from specialist mental health providers in the community, including psychiatrists and clinical psychologists. In addition, the DVA continues to fund high-quality treatment programs for veterans with PTSD across Australia. These accredited, group-based programs have demonstrated outcomes which match or better international equivalents.4 http://www.acpmh.unimelb.edu.au/mentalhealth/treatmentPrograms.html Other useful websites include: the US National Center for PTSD http://www.ncptsd.org the UK National Institute for Clinical Excellence PTSD guidelines http://www.nice.org.uk/page.aspx?o=248114 the US Veterans Affairs PTSD treatment guidelines http://www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm the Australian Centre for Posttraumatic Mental Health http://www.acpmh.unimelb.edu.au

John A Cooper MB BS, FRANZCP · Mark C Creamer PhD · David Forbes MClinPsychol, PhD

Fathers may be unintentionally marginalised by perinatal health services and by the maternal focus of social practices surrounding new babies. There is increasing recognition that a father’s depression and anxiety in the perinatal period can have serious consequences for his family. Health services could better support new fathers by providing them with information on parenting from a father’s perspective, or by running father-specific sessions as part of routine antenatal care programs.

Richard J Fletcher MMedSci · Stephen Matthey PhD · Christopher G Marley MB BS, FRACGP

Objectives: To determine the impact of the Australian provisions for temporary rather than permanent protection for asylum seekers found to be genuine refugees.Design and setting: A comparison of the mental health of Persian-speaking refugees with temporary (n = 49) versus permanent (n = 67) protection visas attending an early intervention program in Sydney, New South Wales, 2002–03.Measures: Standard measures were used to assess past trauma, detention experiences, postmigration stresses, symptoms of post-traumatic stress disorder (PTSD), anxiety, depression and functional impairment.Results: The two groups had experienced similar levels of past trauma and persecution. Nevertheless, holders of temporary protection visas (TPVs) returned higher scores on three psychiatric symptom measures (P < 0.001). Multivariate analyses showed that TPV status was the strongest predictor of anxiety, depression and particularly PTSD. Further analyses suggested that, for TPV holders, experience of past stresses in detention in Australia and ongoing living difficulties after release contributed to adverse psychiatric outcomes.Conclusions: The sequence of postmigration stresses experienced by TPV holders appears to impact adversely on their mental health.

Shakeh Momartin PhD, BA(Hons) · Zachary Steel MPsych(Clinical), BA(Hons) · Marianio Coello MPsych(Clinical) · Jorge Aroche MPsych(Clinical) · Derrick M Silove MD, FRANZCP · Robert Brooks PhD, BA(Hons)

Objective: To review the evidence for the effectiveness of complementary and self-help treatments for depression in children and adolescents.Data sources: Systematic literature search using PubMed, PsycINFO and the Cochrane Library for 131 treatments up to February 2006.Study selection: There were 13 treatments that had been evaluated in intervention studies.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 glutamine, S-adenosylmethionine, St John’s wort, vitamin C, omega-3 fatty acids, light therapy, massage, art therapy, bibliotherapy, distraction techniques, exercise, relaxation therapy and sleep deprivation. However, the evidence was limited and generally of poor quality. The only treatment with reasonable supporting evidence was light therapy for winter depression.Conclusions: Given that antidepressant medication is not recommended as a first line treatment for children and adolescents with mild to moderate depression, and that the effects of psychological treatments are modest, there is a pressing need to extend the range of treatments available for this age group.

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

There is a desperate need for effective mental health services for prisoners and ex-prisoners Deinstitutionalisation in Australia has seen the number of public and private psychiatric hospital beds fall from 30 000 in the early 1960s to 8000 today. The population of Australia doubled during this time. There is no doubt that many people with serious mental illness are not being managed well in the community.1 Some mental health researchers,2-4 as well as the popular press, argue that there has been a recent related transmigration of people from psychiatric beds to remand centres (which house prisoners who have been charged with an offence but not yet convicted) and prisons. Australian remand centres often contain more seriously mentally ill people than general hospital mental health inpatient units. However, it is unclear whether the apparent rise in prevalence of mental illness among prisoners reflects a genuine increase or an improvement in detection rates. Statistical modelling of the effect of deinstitutionalisation on the number of prisoners with mental health problems is fraught with methodological challenges and the absence of longitudinal data.5 This debate has tended to overshadow other major areas of concern about mental illness among prisoners.6 As Herrman et al pointed out 15 years ago, whatever the cause, services for people with mental illness in Australian prisons are inadequate and in need of urgent reform.6 On 30 June 2005, there were 25 353 people in prisons in Australia. This represents an overall imprisonment rate of 163 per 100 000 adults, although there was considerable variation between states. The average age was 34.5 years (with 20.2% aged under 25 years); 6.8% were women; 22.2% were Indigenous people (the Indigenous imprisonment rate was 2021 per 100 000); and 60.4% had been in prison previously. In Queensland, the Department of Corrective Services estimates that the custodial population will increase by 90% over the next 10 years. Australian and New Zealand studies have shown that many people involved in the criminal justice system have had psychiatric contact before entering the system. Prevalence rates for all psychiatric morbidities in the prison population are markedly higher than rates in community samples.6-14 This is particularly evident for substance misuse, with up to 80% of remandees and prisoners dependent on alcohol, cannabis or amphetamines before entering prison.6,7,12,14 However, few published studies allow direct comparison with rates of psychiatric morbidity in community populations. Butler et al9 compared the 12-month prevalence rate for prisoners in their survey to the results of the National Survey of Mental Health and Well-Being, a community-based survey. Prevalences of psychiatric disorders in prisoners were more than double those among people living in the community (Box). Studies in remandees have found prevalences of psychotic illness, such as schizophrenia, ranging from 5.1% to 9.6%.10,13 By comparison, in the general community, the 1-month prevalence is 0.5% for psychosis and 0.3% for schizophrenia.15 Other Australian and New Zealand studies of prisoners have found prevalence rates of between 25% and 50% for non-psychotic disorders such as major depression, anxiety disorders and post-traumatic stress disorder.6,8-10,12 Ex-prisoners also have an increased relative risk of mortality. Death from all causes in some groups was found to be 17 times higher than in the general population in the 2 weeks following release.16 The main causes of excess death are associated with drug and alcohol misuse. These deaths have been cited as an indicator of the poor mental health of prisoners. The experience of release may present an additional challenge to prisoners’ mental health and wellbeing, particularly in the absence of ongoing support. Despite these high morbidity and mortality rates, treatment services for prisoners and ex-prisoners are very limited and often ineffectual. This makes little sense, even from a criminal justice perspective, as comprehensive services can delay or prevent recidivism in mentally ill offenders.17 In February 2006, the Council of Australian Governments (COAG) announced a major reform of mental health services in Australia.18 In April 2006, the Prime Minister announced the Australian Government would commit $1.8 billion over 5 years to this reform. In July 2006, COAG released a National Action Plan on Mental Health, to be supported by a total federal, state and territory government commitment of almost $4 billion over 5 years.19 While only some of the funding announced at COAG by the states and territories is new funding, there is a clear commitment by governments to improve the state of mental health services in Australia. As COAG reforms bind all government agencies, they bring with them the opportunity to improve services in all the relevant government departments in order to provide the range of health, housing and community services needed by people with mental illness. This must include improved and expanded prison mental health services, court diversion programs, and well resourced inpatient and community forensic services that link mental health, judicial and correctional services and provide specialist pre-release assessment, consultation and liaison for clinical managers. Diversion from the criminal justice system of mentally ill people who have committed minor offences is one of the few opportunities for community-based prevention. Access to stable housing and to appropriate vocational rehabilitation services is essential for functional recovery. All of these programs will need specially trained and supported mental health and custodial personnel, including psychologists, psychiatrists and specialist case managers. Adequate training of other personnel involved, such as court and police staff, is also necessary. Thus, crucial to the success of the COAG package will be necessary workforce reforms. Forensic and prison mental health services are target areas for the COAG National Action Plan. However, drafting and funding an action plan is one thing; turning good intentions and money into better services is another, much harder task. To know whether services are improving, we will need public reporting of specific performance indicators, which are currently being developed. In time, the data may be able to tell us whether the historical deficiencies in care for people disadvantaged by both mental illness and involvement in the criminal justice system are at last being addressed. Comparative prevalence of psychiatric disorders in prisoners and in people living in the community9 Prevalence Disorder In prisoners In community Any psychiatric disorder 80% 31% Psychosis 7% 0.7% Affective disorder 23% 9% Anxiety disorder 38% 11% Substance abuse disorder 66% 18% Personality disorder 43% 9%

Paul White MB BS, FRANZCP · Harvey Whiteford MB BS, MPH, FRANZCP

Current data are encouraging, but no reason for complacency Since 1997, when the number of Australians committing suicide peaked at 2720, there has been a sustained reduction in the number of suicides each year. The most recently available figure — 2098 suicides in 20041 — represents an age-standardised suicide rate of 10.4 per 100 000 population, 29% lower than the rate of 14.7 per 100 000 in 1997. The figures are even more striking for people aged 15–24 years, for whom there was a reduction in suicide rates of about 50% — from 19.3 to 9.6 per 100 000 between 1997 and 2004.1 These figures have not achieved the media publicity that they warrant. Although suicide accounts for only 1.6% of all deaths in Australia, it comprises more than 20% of deaths for men aged between 20 and 39 years, and men remain four times more likely than women to die by suicide, with overall age-standardised rates of 16.8 and 4.3 per 100 000, respectively.1 The reduction in male and female suicide rates has been similar: 28.8% for males and 30.6% for females between 1997 and 2004.1 Remarkably, there was a reduction in all 5-year age groups for men and women between 1997 and 2004, except for women in the 45–49-years age group, for whom the rates were 7.0 and 7.1 per 100 000, respectively.1 The highest suicide rates in 1997 were for men aged 15–34 years, and in 2004 the peak was in that same group of men, now aged 25–44 years. This is consistent with a “cohort effect”, with that group carrying forward their increased propensity to suicide, a phenomenon noted previously in Australia in 1983.2 Methods of suicide have changed between 1997 and 2004, with the proportion using firearms reducing from 12.1% to 8.1%. This has been a continuing trend over the past 25 years, although it appeared to accelerate following the enactment of stricter firearms legislation after the Port Arthur massacre in 1996.3 In contrast, hanging has increased from 36.3% to 47.6%. This is of particular concern, as legislating against hanging is difficult, and it probably requires an education program to bring the dangerousness of hanging to the attention of the community. Poisoning by drugs has remained relatively constant (11.4% of suicides in 1997 compared with 10.9% in 2004). This is reassuring and is consistent with recent data, which have allayed previous concerns that use of antidepressants could be associated with suicidal behaviour.4 Naturally, there are always reservations in interpreting data of this nature. The figures are for deaths registered in each calendar year rather than the year they occurred, and about 7% of suicides over the past decade have not been registered until the year after they occurred.1 It is also possible that coronial practices and medical certification of cause of death may have changed. Notwithstanding such caveats, these most recent figures are gratifying, particularly in view of Australia-wide initiatives in the past decade to reduce suicide.5 The question arises of what may have been the reason or reasons for this reduction. The problem in determining this is that there is no clear-cut cause of suicide. Furthermore, even though suicide may seem all too frequent when it occurs, and retrospective analysis may suggest a plausible precipitant, the low base rate of suicide and ethical constraints preclude randomised controlled trials to assess the effectiveness of any one prevention program.6 Nevertheless, it can reasonably be assumed that the causes are several: better community awareness of both the antecedents of suicide and the fact that suicide prevention is possible has probably played a role, along with the provision of more accessible services. More specifically, it is likely that programs promoting better recognition and treatment of depression (the mental disorder most commonly associated with suicide) are paying dividends. That this is so is suggested by the research of Hall et al,7 who found an inverse relationship between antidepressant prescribing and suicide, and concluded: The increase in antidepressant prescribing may be a proxy marker for improved overall management of depression. If so, increased prescribing of selective serotonin reuptake inhibitors in general practice may have produced a quantifiable benefit in population mental health.7 This observation is consistent with the recent report by Ludwig and Marcotte,8 who, after analysing antidepressant use and suicide rates in 27 different countries, calculated that the rate of suicide for those 27 countries would have been 17% higher in 1999 than in 1990, but for the introduction of newer antidepressants. Although these latest Australian Bureau of Statistics data are gratifying, they are no reason for complacency, as illustrated by the increase in suicide in the Northern Territory reported by Measey et al (page 315).9 Furthermore, the general reduction in suicide rates does not negate its tragedy for the individuals and families affected. Continuing vigilance is required, with ongoing acknowledgement and acceptance of the unique role and responsibility that medical professionals, particularly general practitioners, have in identifying and treating the mental disorders, particularly depression, that are associated with suicide.

Robert D Goldney MD, FRANZCP, FRCPsych

Objective: To examine trends in suicide in the Northern Territory between 1981 and 2002, and demographic and other characteristics of people completing suicide in the Top End region in 2000–2002.Design: Retrospective descriptive analysis of Australian Bureau of Statistics death registration data and data from the NT Coroner’s Office.Setting and participants: All residents of the NT who completed suicide between 1981 and 2002.Main outcome measures: Changes in the age-adjusted and age- and sex-specific rates of suicide in Indigenous and non-Indigenous NT residents over time; prior diagnosis of mental illness and use of alcohol or other drugs by those completing suicide.Results: The age-adjusted suicide rate in the NT increased significantly between 1981 and 2002 (P < 0.001). Over this period, the rates among the Indigenous and non-Indigenous male populations increased by 800% (P < 0.05) and 30% (P > 0.05), respectively. Indigenous males aged under 45 years and non-Indigenous males aged 65 years and over were most at risk. In the Top End, a history of diagnosed mental illness was present in 49% of suicide cases, and misuse of alcohol or other drugs around the time of death was associated with 72% of suicide cases.Conclusion: Our study highlights the rising rate of suicide in the NT and suggests that suicide prevention initiatives need to specifically target Indigenous and non-Indigenous males in the age groups most at risk.

Mary-Anne L Measey MPH · Shu Qin Li MPH · Robert Parker FRANZCP · Zhiqiang Wang PhD

To the Editor: We are delighted at the attention which the editorial by Hickie and Blashki1 has drawn to our clinical update on the management of bipolar disorder in general practice.2 However, we are bemused by a number of the sentiments, criticisms and statements of fact included in that robustly expressed editorial. We will focus only on a few of the major issues raised. Hickie and Blashki argue that there are too many “worthy” guidelines promulgated to general practitioners by “specialist colleagues” across the range of medical conditions, and that extrapolation from specialist centre studies “may particularly annoy GPs”. On the other hand, they bemoan the fact that “few [guidelines] have targeted general practice”. We are surprised by this insinuation that such issues pertain to our clinical update. Three of the authors of our article are GPs in either clinical or academic practice, and the document has been formally endorsed by the Royal Australian College of General Practitioners. Our article focuses on the practical issues concerning the role of the GP in the management of patients with bipolar disorder, and deals frankly with the respective contributions of the GP, psychiatrist, and psychologist. It is our experience that GPs are enthusiastic in enhancing their skills in the management of mental illnesses such as bipolar disorder in the primary care setting. Therefore, we have little doubt that updates such as ours will be viewed as helpful aids for GPs, who are often the main “port of call” for people with this condition. We strongly contend the statement that we ignore practice-based issues and thereby risk “an overall negative rating from the target audience”. Hickie and Blashki state that “the most useful mental health guidelines tackle the tough issues”, such as sources of self-help, self-monitoring, detailed illness descriptions, family education, quality e-health resources, and guidance when patients become a danger to themselves and others. We fail to understand the implication that our update does not address such issues, as these very practical matters are clearly highlighted in detail in our article. Finally, we are surprised at the negative tone concerning guidance for the management of mental illness in general practice by authors who have argued strongly for the value of evidence-based guidelines in specialist psychiatric practice.3 Although (as we clearly acknowledge) there is currently a limited evidence base for managing such conditions in primary care, there is still a major need for practical guidance for the practitioner in this setting.

Philip B Mitchell · James A Best · Bronwyn M Gould · Ian G Wilson

To the Editor: Hickie and Blashki are to be commended for their view that clinical practice guidelines in mental health should be relevant to a primary care setting.1 Unfortunately, such guidelines have little effect on clinical outcomes, as most general practitioners have not been taught how to use them to their best advantage.2 There is also little known about the best way to implement guidelines in mental health, let alone in primary care mental health settings.3 As a result, more guidelines, even those more attuned to the primary care environment, will be of little benefit to our community. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is actively promoting the use of clinical practice guidelines4 as a quality improvement tool that will allow mental health practitioners (including GPs) to assess their practice more carefully and measure and analyse variance. The next step is to fund research into how best to implement mental health guidelines at the coalface. It is only through practice-based research that the barriers to successful implementation of evidence-based practice can be identified and overcome. Such research could be funded via a National Health and Medical Research Council (NHMRC) or Australian Research Council (ARC) grant program and coordinated by groups such as the RANZCP or the National Mental Health Working Group Safety and Quality Partnership Group. Mental health has already been identified as a grant funding priority by the ARC.5 Once this has been achieved, then training and mentoring to help practitioners review their practice as part of a quality improvement framework is required, rather than more guidelines per se. Providing well researched, up-to-date and accessible information for GPs on “self-help, self-monitoring, [and] detailed illness descriptions”, as suggested by Hickie and Blashki, is commendable, but is not what is required for guidelines to truly improve the safety and quality of mental health care in Australia.

Andrew J Wilson · David Barton

To the Editor: There has been much public discussion recently about comorbidity between substance misuse and psychiatric disorders.1,2 Drug and alcohol misuse can precipitate, exacerbate and prolong psychiatric disorders, and is often accompanied by a range of social problems. Here we report on the prevalence of substance misuse in an unselected group of patients admitted to the 20-bed acute psychiatric facility at Lyell McEwin Health Service, situated in an underprivileged region of northern Adelaide. The facility has five closed beds and 15 open beds. In October 2005, 45 patients (23 men, 22 women; mean age, 39 years) were admitted to the unit, of whom 28 (62%) were detained involuntarily. Semi-structured interviews, clinical history taking and collateral information gathering revealed that 27 patients (60%) had a comorbid substance misuse disorder. The most common substance misused was cannabis (20 patients [44%]), followed by alcohol (16 patients [36%]), amphetamines (15 patients [33%]), opiates (6 patients [13%]) and benzodiazepines (5 patients [11%]). Misuse of more than one substance was common — for example, all 15 patients diagnosed with amphetamine misuse also misused cannabis. Patients who misused cannabis were younger (mean age, 33 years) than those who did not (mean age, 44 years) (t43 = 0.23; P = 0.023) and were more likely to be male (61% of male patients misused cannabis compared with 27% of female patients; χ2 = 5.14; P = 0.036). Of 19 patients with psychotic disorders, 11 misused cannabis. These results indicate high rates of substance misuse in patients admitted to a psychiatric facility. Cannabis misuse by young men is a particular concern. It is apparent that more than half of inpatients with acute psychiatric conditions could benefit from interventions to address their substance misuse. The extent of cooperation between drug and alcohol services and mental health services varies between different localities and between the private and public sectors. In states such as South Australia, where there is a historical separation between drug and alcohol services and mental health services, the treatment of these disorders is regarded as outside the role of mental health services. Patients considered to have a primary problem with substance misuse are treated by specialised drug and alcohol services. This service divide does not reflect clinical reality. Patients with comorbidity can “fall through the cracks”, each service regarding them as someone else’s responsibility. Postgraduate training in psychiatry includes both academic input and the submission of case logs describing 10 patients with addiction disorders, but this aspect of training may need to be expanded in response to changes in the pattern of disorders in the patient population. Mental health clinicians, along with general practitioners and doctors working in settings such as emergency departments, will increasingly need to be highly skilled in diagnosing and managing comorbid drug and alcohol and psychiatric disorders.

Cherrie Ann Galletly DPM, FRANZCP, PhD · Darryl P Watson MB BS, FRANZCP

Guidelines for GPs need to tackle the tough issues These are interesting times in Australian mental health. On a daily basis, the gap between best practice guidelines and the quality of services delivered widens. Rapid advances in clinical neurosciences give us real enthusiasm for new approaches to treatment. By contrast, national and state-based inquiries highlight fundamental failures in acute and ongoing care. Although major service redevelopments continue, we do not yet provide an integrated health services response. All our governments now concede that a new round of investment, innovation and coordinated reform is essential. Substantial new investments are justified and necessary if we are to see genuine innovation, improved access to care, and better health outcomes in the mental health service environment. The production of guidelines for bipolar disorder internationally reflects the therapeutic gains that should be available for people with this common and disabling illness.1,2 However, when guidelines target general practitioners, like the recommendations provided by Mitchell et al in this issue of the Journal (The management of bipolar disorder in general practice),3 some hard questions need to be asked. Are they relevant to general practice in Australia? Do they connect with the target audience? Are the recommendations achievable in our health care environment? In recent years, most GPs feel that they have received truck loads of worthy guidelines from their specialist colleagues. Although guidelines are critical to improving health care quality, in the end most fail to recommend strategies that lead to real impacts on clinical practice. The mental health field is no exception. It too is awash with new guidelines.4 Surprisingly, given that 75% of mental health consultations take place in the primary care environment, few have targeted general practice. A notable exception is the guidelines for the treatment of depression in general practice settings, commissioned by beyondblue: the national depression initiative.5 From a GP’s perspective, most mental health guidelines don’t concede basic service limitations. First, GPs are not an unlimited mental health resource. In fact, recent data indicate a major slowing in the rate of increase in the treatment of common mental disorders in primary care settings.6 Second, mental health guidelines compete with all other medical guidelines for attention. Simply producing more guidelines for more disorders doesn’t increase the likelihood that recommendations will be put into action. Producing more guidelines for closely related topics (eg, bipolar depression,3 major depression in specialist settings,7 major depression in primary care,5 youth depression8) also doesn’t help. Third, simply extrapolating evidence from studies conducted in patients with severe, chronic or complex disorders encountered in specialist treatment centres may not only be scientifically questionable, but may particularly annoy GPs.9 Most importantly, “GP guidelines” for mental disorders should deal explicitly with the key issues: identification of less severe forms of the disorder; management of medical comorbidity; overlap with alcohol and substance misuse; limited geographical and economic access to specialist psychological support; use of alternative treatments for less severe or less complex cases; and implications of poor access to specialist assessment during acute phases of illness. Providing a detailed list of reasons for specialist referral does not assist those GPs who struggle on a daily basis to connect with any specialist support in the private or public sector. Rather than addressing such issues, specialist psychiatry has a particular knack for creating more disorders, more subcategories and more complex treatment regimens.1-3 The self-explanatory nature of manic-depressive illness has been replaced by the more opaque terms “bipolar I”, “bipolar II”, “bipolar depression”, “mixed episodes”, “rapid cycling”, and “cyclothymia”. However, if such fine-grained differentiation is not associated with quite specific differences in treatment or prognosis, or is not based on a solid evidence base,10 then it holds little appeal. The medical, psychosocial and legal consequences of a GP making a diagnosis of bipolar disorder are potentially considerable. To suggest that these can be minimised by having all such decisions reviewed by a specialist is highly optimistic, especially given the decreasing availability and inequitable access to such resources. While recent improved access to psychological therapies through partnerships in general practice,11 and proposed direct referral mechanisms to clinical psychologists,12 are most welcome, it is not yet clear whether these developments will increase access for patients with bipolar disorder to the more intensive and targeted therapies they require. From a primary care perspective, the most useful mental health guidelines tackle the tough issues that cross a GP’s desk on a daily basis.9 Where are the best sources of self-help, self-monitoring, detailed illness descriptions, and family education to be found? Are there high quality e-health resources available?13 What options are available to a GP when patients become a danger to themselves or their reputations? How should a GP deal with poor compliance? What are the cost implications for patients of particular management plans (eg, costs of travel to specialist appointments)? What should the GP do when specialist services are not available? What are a GP’s responsibilities when the patient doesn’t return for follow-up appointments and/or medication monitoring? How should a GP document mental health consultations in their medical records? What other clinical or management resources are available? Is additional training required to deliver the therapies recommended in the guidelines? While the recommendations presented by Mitchell et al,3 and the related technical summaries, do provide useful clues, insufficient attention to these practice-based issues risks an overall negative rating from the target audience.

Ian B Hickie MD FRANZCP · Grant A Blashki MD, FRACGP

Accurate diagnosis of bipolar disorder is essential for effective treatment. The diagnosis of bipolar disorder is particularly complex, resulting in lengthy delays between first presentation and initiation of appropriate therapy. Inappropriate therapy destabilises the course and outcome of the disease. Although the defining features of bipolar disorder are manic or hypomanic episodes, patients typically present for treatment of depression and commonly deny symptoms of mood elevation. A correct diagnosis can easily be masked by comorbidities, personality issues and complex phenomenology. A diagnosis of bipolar disorder can be assisted by: asking about symptoms of mania or hypomania in every patient presenting with symptoms of depression. recognising mixed states in which manic and depressive symptoms occur simultaneously. identifying the features of bipolar depression that distinguish it from unipolar depression. There is a risk of over-diagnosis of bipolar disorder among patients who are histrionic, show abnormal illness behaviour and/or have issues of secondary gain.

Michael Berk MB BCh, FRANZCP, PhD · Lesley Berk MA · Kirsteen Moss BSc(Hons) · Seetal Dodd PhD · Gin S Malhi MB ChB

Objective: To determine the psychological wellbeing of sole mothers in Australia.Design: Cross-sectional analyses of survey data from The Australian Longitudinal Study on Women’s Health.Participants: 9689 younger women (aged 22–27 years) surveyed in 2000 and 12 338 mid-age women (aged 47–52 years) surveyed in 1998.Main outcome measures: Demographic characteristics and economic status; prevalence of suicidal thoughts, self-harm, and psychoactive medication use; depression (Center for Epidemiologic Studies Depression Scale) and psychological health (the Mental Health Component Score of the Medical Outcome Short Form Health Survey [SF-36]).Results: Among the younger women, sole mothers were more likely than other women to have experienced suicidal thoughts (odds ratio [OR], 2.18; 95% CI, 1.45–3.27) and self-harm (OR, 3.25; 95% CI, 1.97–5.38). Among the younger and mid-age women, sole mothers were the group most likely to have used medication for depression (ORs, 2.75 [95% CI, 1.76–4.30] and 2.29 [95% CI, 1.56–3.37], respectively). They were more than twice as likely to have experienced depression, and had significantly poorer psychological health (P < 0.001). After adjusting for economic status, only depression and psychological health remained significantly associated with sole motherhood, and the strength of these relationships was reduced.Conclusions: Economic status partly accounts for the relatively poorer psychological health of sole mothers. Sole mothers are more likely than other women to experience debilitating psychological health problems.

Deborah Loxton PhD, BPsych(Hons) · Rosemary Mooney BA(Hons) · Anne F Young PhD, AStat

Michael Guy Duke Psychiatrist, Family Counselling Service, Victorian Aboriginal Health Service, 279 High Street, Northcote, VIC 3070. mmgdukeATbigpond.net.au To the Editor: Rey seems to me to have struck upon the ideal solution for the 20% of Australians who suffer from the various mental illnesses.1 Daniel Defoe (The shortest way with dissenters) would doubtless have approved. There is ample European precedent in the idea of a “ship of fools”. The solution, as Rey says, is to ship everyone diagnosed with a mental illness to a Pacific island. This would solve many problems at a stroke. The population of Australia would be reduced by 20% (and this would be continually improved as more cases develop), thus freeing resources for proper healthy Australians. Thoroughly screened (for mental illnesses) refugees and asylum seekers would easily enter the depleted urban centres. General practices would have a reduction of more than 40% of patients, as we all know this is roughly the percentage of people presenting with primarily mental health problems. No more crisis with general practitioner numbers. Hospitals would have a similar reduction of cases. No more shortages of hospital beds. Single vehicle traffic fatalities would surely reduce, if alcohol and other drug-dependent people were to be included under the umbrella of one of the mental illnesses. I envisage a whole fleet of Tampas flowing back and forth to the Pacific nations, ferrying more than 4 million psychiatric emigrants to their proper places in the world.

Michael Guy Duke

Alan Jennings was a pioneer in the field of child psychiatry whose visions were realised in his own lifetime. He was born on 10 June 1923 in Hull, UK, and completed his schooling there. At the outbreak of war in 1939, his mother migrated to Sydney with her three children. Alan graduated in medicine from the University of Sydney in 1945. After working for a short period in the NSW Department of Health, he went to Manchester to do a Diploma in Psychological Medicine. Returning to Australia in 1950, Alan worked at Yasmar Child Guidance Clinic in Sydney until 1954, when he became Director of the Brisbane Street child guidance clinics. These were teaching and training clinics for students in psychiatry and social work linked to the University of Sydney’s Department of Psychiatry. Alan soon realised that some children needed treatment in a residential unit. He was awarded a travelling grant to study residential care for emotionally disturbed children in the United States and the United Kingdom. In 1959, he established Australia’s first unit for emotionally disturbed children at North Ryde Psychiatric Centre. In a twin ward, he opened the first demonstration unit for 20 mentally retarded boys to show the advantages of having a much higher than usual ratio of nursing staff to patients. He also opened a ward for severely to grossly mentally handicapped children aged under 2 years, many of whom were also physically handicapped. He imbued all staff with a positive, caring philosophy. Alan was the first Director for the Mentally Handicapped in the NSW Department of Health (1964–1973), during which time he persuaded the Department to buy Renwick Children’s Hospital in Summer Hill to establish the first diagnostic unit for retarded children. Alan was Director of Marsden Hospital, Westmead (the first purpose-built institution for mentally retarded children), from 1969 to 1978. The Department of Health also bought the old King’s School, Parramatta, as a hostel for mentally retarded young men and women transferred from the old “mental retardation hospitals”. Later, group homes were established for selected children and residents from Marsden Rehabilitation Unit. Alan travelled and studied many times overseas, notably in Denmark and The Netherlands. He lectured at the University of Sydney, Macquarie University, the University of NSW and the NSW Institute of Psychiatry. He was the first President of the Australian Group for the Scientific Study of Mental Deficiency and served on many committees, including the Minister of Health’s Committee in Regard to Mental Defectives and the World Health Organization’s Policy Committee on Mental Retardation. After retirement in 1979, Alan studied Italian and lectured in art and religion at Adelaide University. Despite being blind in his later years, he had a very focused, enquiring mind and continued to explore many avenues of intellectual learning, including religion, philosophy, ecology and neuropathology. He died in Adelaide on 19 April 2005 after emergency heart surgery. He is survived by his wife Roleena and children Ian and Susan.

Millie Mills DipSocStud, AAPSW

Philip L P Morris Psychiatrist, 16 Riverbank Court, Ashmore, QLD 4214. pmorrisATiprimus.com.au To the Editor: In their letter on “GP Psych Opinion”, Wong and Tiller highlighted the poor uptake by general practitioners of a psychiatric consultation service based in a private psychiatric hospital in Melbourne.1 They compared the results of their service to the similar poor uptake by GPs of the public hospital-based psychiatric consultation service in Brisbane.2 One explanation for this disappointing result may be that most psychiatric illness is chronic, and continuity of care and advice from a consistently available psychiatric colleague is of great importance to GPs — over and above having the patient assessed. This does not seem to have been a strong characteristic of the Melbourne service, given that the assessing psychiatrist was a psychiatric trainee registrar, who is usually either rotating between clinical placements as part of training, or waiting to move on to a more senior position. GPs’ referral practices to specialists are based on a multitude of influences, of which availability is only one. Personal contact, quality of service and continuity of assistance are highly relevant. Perhaps if the Melbourne and Brisbane consultation services can push on and attend to these issues, then utilisation by GPs will increase over time — as this is what happens in more conventional private practice referrals.

Philip L P Morris

Duncan A Howard,* Sue D Waygood,* Sharon L Desmond† * General Practitioner, † Registered Nurse and Practice Manager, Brunswick Community Medical Centre, St Vincents Health, 11 Glenlyon Road, Brunswick, VIC 3056. duncan.howardATsvhm.org.au To the Editor: It is well known that people with serious mental health problems are more likely to suffer substantial physical health problems, or die younger, than those in the general population.1,2 We would like to report some early results from a program that is aiming to improve primary health care for people with serious mental health problems. The Stewart Lodge program was developed through cooperation between the local Moreland Community Health Service, two general practitioners and one registered nurse from the medical clinic collocated with the Community Health Service, the local area mental health service, and the managers of the Victorian Government Supported Residential Services program. The Stewart Lodge program includes a regular non-appointment doctor’s session, complete health assessments for all residents, and regular case conferences involving all carers and clinicians. Initial establishment was funded through a Victorian Government Department of Human Services GPs in Community Health Services strategy grant, which focused on improving integration and service coordination. There are around 85 people living in this community, most of whom have chronic schizophrenia or another serious mental health problem. We plan to report the findings from our program in more detail when we have completed the assessments of most Stewart Lodge residents. However, we would like to report our interim findings on vitamin D levels, which are likely to be relevant to many others in similar circumstances. Of the 30 residents tested so far, three have had vitamin D levels in the normal range (> 50 nmol/L), 20 in the deficient range, (25–50 nmol/L) and seven in the severely depleted range (< 25 nmol/L). An increased risk of low vitamin D levels has been previously reported in populations of older institutionalised people,3 and a recent position statement in the Journal on accepted levels of 25-hydroxyvitamin D (25-OHD) warned of risks of vitamin D deficiencyfor various groups in the community.4 We suggest that people with serious mental illness are another group that should be included in those at risk. The people we work with are at risk because of decreased exposure to the sun through inactivity, and because of their illness and medication. Of note, the median age of our residents is 49 years. We aim to tackle this issue by giving Vitamin D supplementation (although this is currently problematic because there is no suitable vitamin D supplement supported by the Pharmaceutical Benefits Scheme). We will be encouraging more physical activity, particularly outdoors, as this is most likely to be of overall benefit to our residents’ general health.

Duncan A Howard · Sue D Waygood · Sharon L Desmond