Mental health

Tolkien II — a needs-based, costed stepped-care model for mental health services. Gavin Andrews and the Tolkien II Team, University of New South Wales at St Vincent’s Hospital. Sydney: World Health Organization Collaborating Centre for Classification in Mental Health, 2006 (vi + 376 pp). ISBN 0 9578073 4 1 Rarely does a book grab you by the shirt front and shake you in the way that this one does. It is an in-your-face call for reform in the way mental health services are configured and delivered, claiming “a plan in which a 30% increase in budget could treat 50% more people and produce a 90% increase in health gain”. Mental illness is one of the key contributors to burden of disease. Burden of disease studies, though, don’t give any indication of marginal benefits that would accrue from additional investment and so do not per se provide useful information for an investment strategy. This book does. It starts with an analysis of the cost-effectiveness of the contemporary allocation of resources for the various classes of mental illness, suggesting, for example, that the cost-effectiveness ratio for affective disorders is $20 for each year of disability averted, compared with schizophrenia at $196 for each year of disability averted. It proposes a new configuration of investments, with greater reliance on community-based accommodation, for instance, and estimates that its proposals would lead to improved cost-effectiveness across all of the major illness subgroups. In format, it has a very brief introduction followed by proposed treatment recommendations or intervention models for each of the main classes of psychiatric illness. The “stepped-care model” in the title is reflected throughout the book in investments in front-end primary care and community interventions, designed to filter patients so that the use of the high-cost inpatient end of the treatment continuum is minimised. These plans are designed from a societal point of view, with implementation impacting on both Commonwealth and state responsibilities. I am not a psychiatrist, so I cannot make any assessment of the validity of the proposed treatment plans, but an impressive range of expert consultants has been used in the development of the plans. The weakness of an expert-panel approach is acknowledged, and the lack of approaches based on higher levels of evidence is claimed to be because of the lack of such evidence. There are nine people in Australia who, without a doubt, must read this book, or at least the first few pages: the Directors-General/Secretaries of the state, territory and Commonwealth Health Departments. They should then request their Directors of Mental Health to evaluate the book and the recommendations therein, and to advise on why this should not be the approach adopted for future investments in mental health funding. Stephen J DuckettExecutive Director, Reform and Development Division, Queensland Health, Brisbane, QLD

Stephen J Duckett

A government report concluded that the cause of the recent cluster of illness affecting 57 people at Melbourne Airport was a “mystery”. On reviewing the evidence, I noted the appearance of a constellation of distinct psychogenic features (in the absence of an identifiable pathogenic agent or source), and non-specific symptoms not correlated with any particular illness, strongly suggesting a diagnosis of mass psychogenic illness. Given the time differential between the illness onset in the index case and the initiation of air sampling, and the added factor of the air-conditioning in the terminal being switched to exhaust mode, the possibility that a toxic agent was responsible for making some of the victims ill cannot be completely excluded. Future investigations of similar incidents should, in the absence of clinical or laboratory findings, consider the diagnosis of mass psychogenic illness. Failure to do so can engender avoidable confusion and unease among the Australian public. The issue of diagnosing collective psychogenic illness will continue to be a major public health challenge, exacerbated by widespread anxieties over the threat of chemical and biological weapons and fears of contamination.

Robert E Bartholomew PhD, MA

The public image of psychiatry could be better. Just three of the perceptions held by the community are that psychiatrists are loopy, that their treatments are ineffectual, and that the profession is too removed from mainstream medicine. Turning around such strong public opinion is no easy task, and possibly unachievable. Or so I thought until earlier this year. Saturday 21 May dawned a crisp and clear day, albeit a little breezy. A quick shower and breakfast, then I was out the door with my son Adam for his Under 8 soccer match. After a wind squall midway through the first half of a gripping encounter, one of Adam’s team mates, Brad, suddenly clutched his right eye and began to scream, then ran towards his mother on the sideline. The match was temporarily suspended, and parents from both sides formed a huddle around Brad and his distraught mum, the sense of helplessness profound. Little did anyone know that, over 20 years ago and before commencing psychiatry training, I had spent a term at Sydney Eye Hospital and that, despite limited opportunities since, I still fancied my skills in this area over the next person. I decided to intervene. Brad’s right eye was swollen and watering profusely. “Is the pain worse when you blink?” I enquired. Brad nodded, sobbing. Without further ado, I gently pulled his right upper eyelid towards me by its lashes and slowly everted it. The sight of the lid’s inflamed inner conjunctival surface caused some parents to step back, others to look away and many to wince, but my focus was now on a speck of dirt, trapped under the lid, that beckoned, seductively, “Garry, I’m yours”. Without averting my gaze, I requested a clean tissue and an onlooker obliged by inserting one into my free outstretched hand. A deft dab saw the foreign body gone and Brad once more a “happy camper”. For the hero, of course, the trick on such occasions is to give the impression that these actions are all in a day’s work by making no fuss, by politely shrugging off backslappers, and by quickly resuming one’s previous activities. Accordingly, when the game restarted, I was the first to recommence barracking: “In there, Adam!”, “Defence! Defence!”, “Nice tackle Kevin!”, and so on. At the same time, I was very mindful of the sorts of conversation taking place nearby: “They say he’s a psychiatrist.” “Surely not?” “Yep, a shrink.” “You don’t say . . . Wow!” Now a psychiatrist’s self-esteem and the public image of a profession should never hinge on a fortunate turn of events, as occurred during Round 7 of the 2005 Under 8 Ku-ring-gai District Soccer Competition. Nevertheless, while I do not pray that a gale blows during every soccer game in which my son plays, I confess to now following the weather forecast more closely and to not minding the occasional stiff breeze on match days. I even keep a box of tissues handy. I have also recently reminded myself how to reduce a dislocated shoulder. Just in case.

Garry J Walter PhD, FRANZCP

Joseph M Rey Professor of Child and Adolescent Psychiatry, University of Sydney, Sydney, NSW. jmreyATbigpond.net.au To the Editor: Yet another report has been published highlighting the parlous state of mental health services in Australia and the plight of the mentally ill and their families.1 In the words of Mr Keith Wilson, Chairman of the Mental Health Council of Australia, they are the “untouchable and untouched”,2 the pariahs of Australian society. Summarising the findings of the report is unnecessary, as the issues (poor access to services, lack of continuity of care, and a dwindling workforce among others) have been much in the public eye and are all too familiar to most medical practitioners. More important is whether this report will succeed in generating change for the better where scores of others have failed. The difference this time is that consideration has been given to a Commonwealth Solution:2 the Commonwealth government taking over the management and funding of these services across Australia. As state governments have made such a mess of mental health services and have repeatedly failed to sort out the well known problems, that seems an attractive option. This solution would stop passing the blame between the states and the Commonwealth, would reduce cost-shifting, may standardise (if not improve) care across Australian jurisdictions, and may result in more adequate funding. There might be light at the end of the tunnel after all. The counterbalance is that having the Commonwealth in charge of mental health services will pose new problems, least of which is the creation of a parallel health bureaucracy. One of the few achievements of the past 30 years has been the “mainstreaming” of mental illness; that is, bringing psychiatric disorders out of the asylums and into the general health services and hospitals. If the Commonwealth takes over, demarcation disputes between mental health and general health services are likely to flare up, especially in emergency departments and hospital wards. Because general health services are themselves stretched and under-funded, clinicians and administrators will be tempted or even forced to push mental health patients out of the general hospitals and try to unload anyone with psychiatric problems, whether physically ill or not, into the Commonwealth-run services. “Mental illness is no longer our responsibility”, many relieved administrators and clinicians will say. Endless arguments and meetings will ensue about where these Commonwealth-run services should be located and where patients with both mental and physical illness belong. The only way to avoid this retrograde leap would be for the Commonwealth to take over all health services — too simple and rational a solution to be adopted. As the report eloquently depicts,1 mentally ill people and their families are desperate. In that context, any change can be perceived as better than nothing, certainly better than the hopelessness that currently pervades these services. Such a solution may also be tempting to a stretched and demoralised mental health workforce.3 Can the Commonwealth be more effective or enlightened than the states? The Commonwealth’s track record of compassion, of emphasising individualism, the survival of the fittest, does not augur well for its ability to care for the mentally ill. By and large, psychiatric patients are neither the “fittest” nor the best equipped people to compete in a free marketplace. The Commonwealth does have a track record of expediency. In that context, it is not too far-fetched to imagine the now empty refugee detention centres being reconditioned into outback psychiatric facilities for the severely disturbed. “This is a provisional but necessary measure to meet the urgent need for more psychiatric beds” will undoubtedly be the words used by the incumbent health minister. We may even be blessed with a “Pacific Solution” to mental illness.

Joseph M Rey

A 25-year-old woman with clinical depression was referred with vague epigastric pain and early satiety after meals for 6 months. Abdominal examination revealed an indentable J-shaped mass in the epigastrium. A barium meal examination was subsequently carried out. The image shows a whorled, stippled mass occupying the stomach, forming a ‘J’ shape. The most likely diagnosis was a trichobezoar. Bezoars are of different kinds and commonly include hair (trichobezoar), vegetable fibres (phytobezoar) or medications (pharmacobezoar). About 90% of bezoars are encountered in women, and about 10% of these patients have a psychiatric disorder. The patient underwent exploratory laparotomy with gastrotomy and removal of a large hairball, which had an extension into the duodenum.

Guneesh Dadayal MB BS · Dipesh D Duttaroy MB BS, MS · Sashidhar Yeluri MB BS, MS

We evaluated an Internet-based psychological intervention supported by either general practitioners or psychologists (Panic Online), and a Primary-care Evidence-based Psychological-interventions (PEP) strategy which involves training GPs to deliver specific psychological interventions. Economic modelling suggests that Panic Online is cost-effective when supported by either GPs or psychologists. Threshold analysis of the psychological training of GPs suggests that a modest effect size for clinical benefit would be sufficient to provide an acceptable cost-effectiveness ratio. The sustainability of these approaches depends on a range of factors, including funding, workforce availability, and acceptability to consumers and health care providers.

Cathrine Mihalopoulos BBSc(Hons), GDECSt, PGDHlthEc · Sophy Ting-Fang Shih BSc, MPH, DrPH · Litza Kiropoulos BEd-Sc, BSc(Hons), MClinPsych, PhD · Grant Blashki MD, FRACGP · Graham Meadows MD, MRCP, FRANZCP · Jane Gunn FRACGP, DRANZCOG, PhD

An adolescent with autism and intellectual disability presented with severe depression related to menstruation. Because of the complex medical, psychiatric and ethical issues involved, her care was coordinated by a hospital-based adolescent medicine unit. After trials of other therapies over an extended period and interdisciplinary and intersectoral case conferencing, it was decided that hysterectomy was the most appropriate management. This case highlights the complexity of adolescent health care in a tertiary hospital, the importance of intersectoral cooperation between hospital and community, and the integral role of interdisciplinary care of adolescent patients with chronic conditions.

S Rachel Skinner PhD, FRACP · Cindy Ng MB BS(Hons), DCH · Ann McDonald MPaed, FRANZCP · Tamara Walters FRANZCOG

Graham D Hocking Child Psychiatrist, 25 High St South, Kew, VIC 3101. ghockinATiprimus.com.au To the Editor: Catto-Smith gives a very good account of the medical management of constipation and soiling in children,1 but fails to mention psychological, interpersonal and social factors in the main part of his article. He does mention “behavioural abnormalities” towards the end, in the section “When to refer”. I think it is generally accepted among paediatricians and child psychiatrists that the problem of constipation and soiling, or encopresis, often has multiple determinants and varied psychological effects on the child and the family. Certainly, the older the child is, the more likely these effects will be present.2 If this condition is to be managed in general practice over a period of “6–12 months”, general practitioners need to be aware of these factors so they can be addressed. Twelve months is a long time in the life of a 5 year old, and in that time pathological patterns can become well established and hard to shift. Most children over 5 years with soiling have developed secondary psychological problems as a result of the soiling.3 At this stage, assessment by a child psychiatrist will often reveal that the child has developed a pathological fantasy world around what they believe is happening inside them. The physical management of constipation and soiling is an essential part of the management no matter what the aetiology, but addressing the psychological interpersonal and social factors is equally important. If these factors are obvious to the GP and are not responding to intervention, the family should be referred to a child psychiatrist. With children over 5 years, the secondary effects have almost always become significant, and I believe that all these families should be referred for assessment. Catto-Smith quotes a 30%–50% relapse rate,1 and “there is evidence that they do not improve on reaching puberty”. This is not my experience with families that have the benefit of a multidisciplinary approach to the disorder.

Graham D Hocking

Anthony G Catto-Smith Director, Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Flemington Road, Parkville, VIC 3052. tony.cattosmithATrch.org.au In reply: Hocking emphasises secondary behavioural and emotional effects that occur in some children with longstanding faecal soiling. Fortunately, there is good evidence that these tend to resolve with effective multimodal treatment of the constipation.1 The relatively high long-term relapse rate of soiling among children who have been treated in tertiary centres has only recently been recognised,2 but the psychological features of this relapsing group are not well defined. My review was directed toward general practitioners and was as much as possible evidence-based. I am unaware of any good quality evidence to support Hocking’s assertion of the benefits of automatic referral to a child psychiatrist of all children over the age of 5 years with ongoing faecal soiling. Given the beliefs of both myself and Hocking, that constipation and soiling are likely to have multiple determinants and varying psychological effects, it would seem to be appropriate to triage “problem” patients through a general paediatrician, with referral for psychological assistance if deemed appropriate. This is best summed up in my article in the section that Hocking mentions, “When to refer”.3

Anthony G Catto-Smith

Robert D Goldney Professor of Psychiatry, University of Adelaide, The Adelaide Clinic, 33 Park Terrace, Gilberton, SA 5081. Robert.goldneyATadelaide.edu.au To the Editor: Two recent items in the Journal might potentially lead to misinterpretation of the evidence on managing depression in young people. The first was the book review entitled Darker side of “wonder drugs” by Jureidini1 in which there was no disclosure that the author of the review is president of Healthy Skepticism, a body which has been quite strident in its opposition to antidepressant therapy. The second was the unattributed comment in the editorial by Rey and Dudley describing “parents who believe their children killed themselves because they were taking SSRIs [selective serotonin reuptake inhibitors] . . .”,2 which may imply subtly that this has occurred frequently. In a review of the United Kingdom General Practice Research Database of more than three million people,3 there were no suicides among the 6976 aged 10–19 years who had been prescribed one of two SSRIs or two tricyclic antidepressants; however, 15 people in that age group who had not received an antidepressant drug died by suicide. Furthermore, in a review of 14 857 suicides in Sweden, of the 52 involving people under 15 years, no SSRIs were detected, and in the 15–19-years age group, those taking SSRIs had a lower relative risk of commiting suicide than those taking other antidepressants.4 Clinicians with responsibility for children and adolescents can be reassured by these data, and also by the fact that the American Food and Drug Administration “black box” warning (their most potent warning) about antidepressants has recently been modified.5 Furthermore, the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association have provided a new resource about the use of medication in treating childhood and adolescent depression,6 which has been endorsed by over a dozen United States organisations comprising a “national coalition of concerned parents, providers, and professional associations”. This should allay questions that have rightly been raised, but that have been answered in favour of the judicious use of antidepressants, along with other therapeutic measures for children and adolescents with severe depression. In view of the strong association between child and adolescent mood disorders and suicide,7 the above research findings and the recommendations of respected professional bodies raise the issue of potential legal action for not at least trialling antidepressant medication in young people with severe depression if non-pharmacological measures are ineffective.

Robert D Goldney

Peter R Mansfield,* Melissa K Raven,† Jon N Jureidini‡ * Research Fellow, University of Adelaide, SA; † Lecturer, Flinders University, Adelaide, SA; ‡ Head, Department of Psychological Medicine Women's and Children's Hospital, Adelaide, SA. peter.mansfieldATadelaide.edu.au To the Editor: Rey and Dudley cite clinical experience as the basis of their recommendation of selective serotonin reuptake inhibitors (SSRIs) — chiefly fluoxetine — for youth with severe depression plus severe impairment or failure of non-drug therapy.1 They do not discuss the evidence on efficacy because they claim that it is “ambiguous enough for scholars to be divided”. It is true that industry-funded scholars are continuing to suggest that SSRIs (chiefly fluoxetine) provide a worthwhile benefit.2 However, the evidence is unambiguous. The four published comparisons of fluoxetine versus placebo for children and adolescents have all been negative on their pre-specified primary endpoints.3,4 A tiny average benefit is likely, but the magnitude of this benefit is unlikely to exceed the magnitude of less frequent but more severe harms. Furthermore, the common clinical impression of worthwhile benefit is to be expected given the large average improvements seen in placebo groups. Rey and Dudley speculate that psychosocial treatments may be less effective with uncooperative teenagers.1 However, that group may also be at higher risk of the dangers of intermittent use of, and overdosing with, antidepressant drugs. Rey and Dudley cite Timimi’s critique of the concept of childhood depression5 as supporting “treating depression primarily as a moral or social problem”. However, Timimi did not even allude to depression as a moral problem, and advocated a multi-perspective approach that normalises emotional responses to adverse life experiences and includes interventions addressing biological factors, such as diet, exercise, and cognitive abilities. Rey and Dudley use a related straw-man argument in their final sentence when they suggest that the only alternatives to SSRIs are tricyclic antidepressants, victim blaming, and non-treatment. Rey and Dudley deny being influenced by the gifts and funding that they have received from drug companies. There is compelling evidence that gifts and funding are effective, on average, for influencing beliefs, especially among people who have an illusion of invulnerability.6 We are not aware of any way that any individual can know that he or she has not been influenced.

Peter R Mansfield · Melissa K Raven · Jon N Jureidini

Joseph M Rey,* Michael J Dudley† * Professor, Psychological Medicine, University of Sydney, PO Box 142, North Ryde, NSW 1670. † Senior Lecturer in Psychiatry, University of New South Wales, Randwick, NSW. jreyATmail.usyd.edu.au In reply: The data available are inconclusive, but suggest that treatment with selective serotonin reuptake inhibitors (SSRIs) may increase the short-term (less than 14 weeks) risk of suicidal thoughts or self-harm in children and adolescents slightly, by about 2%. However, SSRI treatment may actually decrease the number of completed suicides,1 as Goldney also highlights. To show whether SSRIs influence the risk of completed suicide, a rare event, requires a randomised trial including up to two million individuals.2 This will not happen. Hence, clinicians must rely on accumulated data from experimental, epidemiological, and observational studies. Disagreements about interpretation will doubtless continue. In response to Mansfield and colleagues, we personally know of media reports influencing some practitioners to revert to using tricyclic antidepressants, and child psychiatrists to avoid treating depressed adolescents. We do not shrink from our interpretation of the implications of Timimi’s reconceptualisation of “depression” as “unhappiness”. Regardless of how childhood depression is classified or named, we remain concerned that the impetus for clinicians to diagnose and treat it not be lost. Its social correlates include stigma and racism, which often involve seeing mental health problems as moral failures of character. Our view is that fluoxetine shows a favourable harm–benefit profile in moderate to severe depression. According to the Treatment for Adolescents with Depression study,3 which was not funded by drug companies, four children need to be treated with fluoxetine for one to show much or very much improvement attributable to medication. This compares with having to treat 21 children for one to display a widely defined harm-related event. The numbers improve further when fluoxetine is combined with cognitve behavioural therapy (3 and 50, respectively). Pending new studies, clinicians would be unwise to ignore these data when treating serious depression in young people, a recurring illness that produces much suffering, physical and psychosocial disability, and suicide (odds ratio estimates ranging from 11.0 to 27.0).4 Our opinions are consistent with those of the recently released joint clinical guidance by the colleges of psychiatrists, general practitioners, and physicians.5 Mansfield and colleagues suggest that our editorial’s content might have been influenced by drug company gifts. We provided the educated readers of the Journal with information to judge this for themselves.

Joseph M Rey · Michael J Dudley

Duncan Topliss Chairman, Adverse Drug Reactions Advisory Committee, Therapeutic Goods Administration, Department of Health and Ageing, Canberra, ACT 2601. adracAThealth.gov.au Comment: Three essentially independent reviews of the use of selective serotonin reuptake inhibitor (SSRI) antidepressants in children and adolescents have been undertaken in Australia in the past 9 months.1-3 The review by the Adverse Drug Reactions Advisory Committee1 had input from representatives of the Royal Australian and New Zealand College of Psychiatrists and the Division of Paediatric and Child Health, Royal Australasian College of Physicians (RACP). All three reviews noted the paucity of information to support the efficacy of these and other antidepressants in children and adolescents, and the frequent observation of increased suicidal thoughts and self-harm in clinical trials. The colleges’ review2 and the National Prescribing Service Rational Assessment of Drugs And Research (RADAR) review3 support the ADRAC advice that: Any use of SSRIs in children and adolescents with MDD [major depressive disorder] and other psychiatric conditions should be undertaken only within the context of comprehensive management of the patient. Management should include careful monitoring for the emergence of suicidal ideation and behaviour which may particularly develop early in therapy, or if therapy is interrupted or irregular because of poor compliance. Cognitive behaviour therapy, if it is available, may enhance the outcome in MDD. An SSRI should be chosen for a child or adolescent with MDD or other psychiatric condition only after taking into account the recent evaluations of clinical trial data and the Australian product information. Prescribers should be aware that the marketers of fluvoxamine and sertraline (indicated for obsessive compulsive disorder) advise against their use in children and adolescents with MDD, and the marketers of citalopram, escitalopram, paroxetine, venlafaxine and fluoxetine warn or caution against their use in patients aged less than 18 years for any indication. It is important to note that children and adolescents who are being treated for MDD with an SSRI should not have their medication ceased abruptly.

Duncan Topliss

Gordon R W Davies Psychiatrist, 33 Smith Street, Wollongong, NSW 2500. alienistATihug.com.au To the Editor: The recent editorial by Andrews1 quotes a report suggesting that the integration projects funded by the Australian Government produced substantial benefits to patient care at no extra cost. Working in an area in which one of these projects was funded, I suggest that such an inference is unwarranted, particularly as many patients report increased difficulty in accessing public mental health services. The Illawarra, being geographically circumscribed and with a relatively small medical population, has always had a high degree of interaction between services, although it is true to say that these have somewhat declined in recent years with larger bureaucracies and increased privacy concerns. In my early days in the area, there was a monthly meeting involving police, Youth and Community Services, the Housing Commission, school counsellors, and hospital and community social and mental health workers to coordinate the management of problem families. Sadly, this no longer occurs. Unfortunately, the major effect of the integration project was simply to add a management structure to the prior interaction, and not to significantly increase it. It seemed that the core issue was control and not service provision. Useful coordination projects, such as some commonality of core records, never seemed to happen, and with the passing of the project, things have, in fact, been worse, as fundamental community services such as the crisis team and chronic care components have been cut. I have always been a strong supporter of a more integrated approach to care, but one that does not grow primarily from the workers involved in day-to-day clinical care and that addresses their needs is unlikely to be lasting and successful.

Gordon R W Davies

Objective: To identify changes in mental health literacy in regard to depression between 1998 and 2004.Design and setting: Face-to-face interviews with a random and representative sample of the South Australian population in 2004, compared with a similarly conducted survey in 1998 that used the same vignette, questions and methodology.Participants: 3015 randomly selected participants, aged 15 years and over.Main outcome measures: Responses to both open-ended and direct questions about symptoms and treatment options for depression.Results: The 3015 interviews conducted represented a response rate of 65.9%. Compared with 1998, in 2004 there was a significant increase in the proportion of people recognising depression in the vignette, acknowledging personal experience of depression, and perceiving professional assistance to be more helpful and less harmful. However, although more people nominated psychiatrists or psychologists as therapists of choice, the difference between 1998 and 2004 was not significant.Conclusions: There has been a significant increase in mental health literacy, at least as regards depression, in the South Australian community between 1998 and 2004. The lack of significant change in psychiatrists and/or psychologists being perceived as therapists of choice is of concern and suggests that community education about their expertise may be appropriate.

Robert D Goldney MD, FRANZCP, FRCPsych · Laura J Fisher BA(Hons) · Eleonora Dal Grande MPH · Anne W Taylor MPH

Re: “Recognition of depression and psychosis by young Australians and their beliefs about treatment”, by Annemarie Wright, Meredith G Harris, John H Wiggers, Anthony F Jorm, Sue M Cotton, Susy M Harrigan, Rosalind E Hurworth and Patrick D McGorry, in the 4 July print issue of the Journal (Med J Aust 2005; 183: 18-23). There was an error in Box 3 (page 20) under the heading “Rural region A” “Proportion of population”. The population number given as n = 69 786 should have been n = 41 618. The html and pdf versions of the article published online were correct.

Annemarie Wright · Meredith G Harris · John H Wiggers · Anthony F Jorm · Sue M Cotton · Susy M Harrigan · Rosalind E Hurworth · Patrick D McGorry

Objectives: To assess young people’s ability to recognise clinically defined depression and psychosis, the types of help they thought appropriate for these problems, their knowledge of appropriate treatments, and their perceptions regarding prognosis.Design: A cross-sectional telephone survey using structured interviews. Vignettes of a person with either depression or psychosis were presented, followed by questions related to recognition of the disorder, best forms of treatment and the prognosis.Participants: A randomly selected sample of 1207 young people aged 12–25 years.Setting: Melbourne, Victoria, and surrounding regional and rural areas.Outcome measures: Responses to a mental health literacy questionnaire.Results: Almost half the respondents were able to identify depression correctly, whereas only a quarter identified psychosis correctly. Counsellors and family or friends were the most commonly cited forms of best help, with family or friends preferred by the younger age group for depression. General practitioners were considered more helpful for depression, and psychiatrists and psychologists more helpful for psychosis. Most respondents considered counselling and psychotherapy to be helpful. However, more than half the respondents expressed negative or equivocal views regarding the helpfulness of recommended pharmacological treatments.Conclusions: The limitations we identified in youth mental health literacy may contribute to the low rates of treatment and the long duration of untreated illness reported in other studies. There is a need for initiatives to enhance mental health literacy among young people, and those close to them, if benefits of early treatment are to be realised.

Annemarie Wright BAppSc(OT), MMedSc(HProm) · Meredith G Harris MPH, MPASR, BA(Hons) · Anthony F Jorm DSc · Sue M Cotton BBSc(Hons), GradDipAppSci (Statistics), MAppSci (Statistics) · Susy M Harrigan BA, GradDipAppSci, MSc · Patrick D McGorry MD, PhD, FRANZCP · John H Wiggers BA(Hons), PhD · Rosalind E Hurworth PhD, MEd, PostGradDipSoc

Objective: To conduct a systematic review of the evidence for the effectiveness of a range of possible treatments for depression in older people.Data sources: Literature search using the PubMed, PsycInfo and Cochrane Library databases.Data synthesis: Treatments that have been suggested to be effective for depression were grouped under three categories: medical treatments, psychological treatments, and lifestyle changes/alternative treatments. We describe each treatment, review the studies of its effectiveness in people aged ≥ 60 years, and give a rating of the level of evidence.Conclusions: The treatments with the best evidence of effectiveness are antidepressants, electroconvulsive therapy, cognitive behaviour therapy, psychodynamic psychotherapy, reminiscence therapy, problem-solving therapy, bibliotherapy (for mild to moderate depression) and exercise. There is limited evidence to support the effectiveness of transcranial magnetic stimulation, dialectical behaviour therapy, interpersonal therapy, light therapy (for people in nursing homes or hospitals), St John’s wort and folate in reducing depressive symptoms.

Cathy J Frazer PhD · Helen Christensen PhD · Kathleen M Griffiths PhD

Andrew Firestone Psychiatrist; and Honorary Senior Lecturer, Monash University, Clayton, VIC 3168. afireATtpg.com.au To the Editor: Emerging evidence suggests that the so-called second-generation antipsychotics (SGAs), especially olanzapine and clozapine, can cause abnormal weight gain and increase the risk of diabetes mellitus.1-3 In Australia, there are calls for a prospective multicentre trial to compare the rates of weight gain and diabetes between SGAs.4,5 The Australian data presented here underline the pressing need for such a study. Data were examined for the 10-year period January 1994 to December 2003 for: Total prescriptions dispensed by the Pharmaceutical Benefits Scheme (PBS) and the Repatriation Pharmaceutical Benefits Scheme for 12 antipsychotic drugs; and Reactions reported in the same period to the Adverse Drug Reactions Advisory Committee (ADRAC) for each of these drugs, involving excessive weight gain or obesity, and diabetes mellitus or hyperglycaemic reactions. Reports were included in the survey only when it was considered that no other drug could be responsible. As clozapine is dispensed and recorded differently from other SGAs in Australia, complete data on numbers of prescriptions dispensed were not available. However, total Australian expenditure was available for each tablet strength of clozapine for the full 10-year study period, along with number of prescriptions dispensed and costs for the private hospital sector for the 4 years July 2000 to June 2004. Therefore, I calculated the average script cost for each tablet strength, and extrapolated the script numbers for the 10-year period, as shown in Box 1. Box 2 shows the “report rate” for each SGA for the side effects of weight gain or obesity, and diabetes or hyperglycaemia. The report rate for side effects was greater for clozapine than for any other SGA. Unfortunately, the true situation may be still worse. Clozapine is usually prescribed a month at a time, while the other drugs are prescribed for up to 6 months. Adjusting for this would widen the gap further. Moreover, as ADRAC promotes reporting for new drugs, the report rates for the five drugs introduced during the study period are probably inflated. Clozapine is not one of them. The limitations of ADRAC data are well known.4 Nevertheless, these are currently our best Australian data and strongly suggest that SGAs, of which risperidone has the most favourable profile, cause weight gain and diabetes much more often than the older antipsychotic agents. These data accord with previously published studies1 and support the US advice to avoid olanzapine and clozapine if possible. Recent PBS approval in Australia for use of olanzapine in bipolar disorder further underlines the urgent need for a prospective multicentre study to compare weight gain and glucose metabolism in patients taking antipsychotic drugs. Meanwhile, I suggest that: Patients who have abnormal weight gain with an SGA might be treated with chlorpromazine, trifluoperazine or haloperidol. PBS regulation of clozapine might be amended, to discourage its prescription until after failure of a “first-generation” as well as a second-generation antipsychotic drug. 1 Estimation of the total number of clozapine scripts in Australia Tablet strength (mg) Private hospitals data (Jul 2000–Jun 2004) Total clozapine used (Jul 1994–Jun 2004) Total prescriptions Cost ($) Average cost/ prescription ($) Cost ($) Estimated total prescriptions 25 3 650 230 929 63.27 9 636 814 152 313 50 25 1 443 57.72 85 980 1 490 100 21 057 6 632 499 314.98 153 276 771 486 624 200 69 24 392 353.51 463 131 1 310 Total 24 801 6 889 263 – 163 462 696 641 737 2 Report rates for side effects of antipsychotic drugs No. of years* No. of prescriptions dispensed No. of ADRAC reports Report rate (per million prescriptions dispensed) Weight gain† Diabetes‡ Weight gain† Diabetes‡ Chlorpromazine 10 950 221 0 0 0 0 Fluphenazine 10 327 126 0 0 0 0 Trifluoperazine 10 937 605 1 0 1.07 0 Pericyazine 10 657 514 0 0 0 0 Thioridazine 10 1 983 915 1 3 0.50 1.51 Haloperidol 10 1 499 254 2 0 1.33 0 Flupenthixol 9 121 132 0 0 0 0 Zuclopenthixol 8 93 839 0 1 0 10.66 Olanzapine 6 2 786 334 47 19 16.87 6.82 Quetiapine 4 271 957 1 4 3.68 14.70 Risperidone 9 1 298 156 6 2 4.62 1.53 Clozapine 10 641 737§ 41 61 63.89 95.05 ADRAC = Adverse Drug Reactions Advisory Committee. * Number of years with data available (as some drugs were introduced only after the start of the 10-year period). † Weight gain or obesity. ‡ Diabetes mellitus or hyperglycaemia. § Estimated number (see Box 1).

Andrew Firestone

This year marks the 60th anniversary of the end of World War II. The following poem pays tribute to those who carry the legacy of that war. Thus we seeThe memories of war are embodied forever. I wrote this poem some months after a 65-year-old man consulted me in the mid-1980s complaining of a band of chest pain that two cardiologists had investigated without diagnosis. As a Polish prisoner-of-war in World War II, he had been enslaved in a German coalmine, starved and inadequately clothed. He described to me how, as winter progressed, he and his fellow prisoners would wire the decaying pieces of their clothes together. His shirt was reduced to a band of fabric around the middle of his chest. His current chest pain was in the same anatomical zone as that covered 45 years before by the remnants of his shirt. Thus we see and sew and save the triangular, square or without form, coloured bits of fabric that keep us warm. Thus we see the landscape under snow, “the infected winter of our condition”, and in seeing, know. Thus we sew, as freezing prisoners of war, the remnants of the clothes we wear, Dole. Too rough: thread of repair is not enough to make us whole. Thus we save, as lining for our trap, flotsam rescued from the wave, the storm, from life’s enthralling compromise — worn and wet rags to fill the gap — we have only man’s eyes.

Stephen Leeder AO

Colleen T Bruce,* Paul S Thomas,† Deborah H Yates‡ * Research Assistant, † Associate Professor, Department of Respiratory Medicine, Prince of Wales Hospital, Randwick, NSW 2033. ‡ Respiratory Physician, St Vincent’s Hospital, Sydney, NSW. Paul. ThomasATunsw.edu.au To the Editor: The recent article by Willcock and colleagues on the high psychological morbidity and level of burnout that interns experience during their first year in hospital highlights an important topic.1 Willcock et al point out that there is an increase in psychiatric morbidity over the intern period in first-year medical graduates. This corroborates the findings of a larger study we conducted among interns during their first year, in which we showed that psychiatric morbidity rises, particularly during the middle of this first year as a doctor, but then decreases by the end of the year.2 The point made by Willcock et al1 is that psychiatric morbidity is not limited to first year graduates — senior doctors are also susceptible to psychological morbidity and burnout.3 Their article highlights the continuing need for workplace reform and support for the medical profession. In addition to reducing working hours, other interventions need to be considered to prepare medical students for their profession, and to reduce the factors which contribute to morbidity (eg, workload, multiple tasking, incessant paging). It should be feasible to test the efficacy of such interventions with the same instruments (such as the General Health Questionnaire) in future generations of interns, and to compare these results with the above studies. Showing that such interventions are effective will provide a strong platform from which to implement wider change in the workplace.

Colleen T Bruce · Paul S Thomas · Deborah H Yates

Simon M Willcock Director, Academic General Practice Unit, Hornsby Hospital, Palmerston Rd, Hornsby, NSW 2077. simonwATmed.usyd.edu.au In reply: Bruce and colleagues are correct to call for ongoing workplace reform and support for the medical profession in general. Our study, which followed medical students to the end of their intern year, did not show a significant fall in psychiatric morbidity towards the end of the intern year as theirs did. Our review of the recent literature suggests that any “improvement” in psychological morbidity after the mid-year peak during internship is likely to be transient, with the early postgraduate period representing a period of transition from normative population values of burnout and morbidity to levels which remain high throughout a medical career, when compared with the general population. The traditional interpretation of the internship as a “baptism by fire”, which tests and ultimately strengthens the new medical graduate, does not hold up to scrutiny. A realistic assessment of this period suggests that it is one where stress and distress often reach unhealthy levels, and where dysfunctional coping strategies may be developed which persist throughout a medical career. The development of mature personal coping strategies along with systemic changes to promote engagement with work have been identified as the most likely means of limiting burnout and its sequelae among medical practitioners.1

Simon M Willcock

Better coordination costs no more and improves the lot of patients How is it that Australia’s mental health services are in disarray? A Senate inquiry is mooted, and the press run stories of concern almost every week. Most of the stories are about failures in public-sector acute-care services that are the responsibility of the state and territory governments. Christopher Pyne, the Australian Government’s Parliamentary Secretary for Health said that “Australia’s states and territories stand condemned for their failure to deliver adequate mental health services . . . perhaps it is time for them to cede their responsibility for mental health to the Commonwealth”.1 So, while more money might make things easier, lack of money is not the cause of the crisis. Part of this rhetoric should be viewed in the light of federal–state relationships. However, part does reflect the uncoordinated way we fund our health systems — Medicare and Pharmaceutical Benefits at the federal level, private health insurance, the state and territory provision of public-sector services, and rising out-of-pocket expenses at the individual level. A coordinated funding system would be preferable. There are six contributors to Australia’s mental health service — general practitioners, private psychiatrists, private psychologists, private hospitals, state inpatient and community services, and non-government charitable organisations. The work of these contributors is poorly coordinated. It is like a six-horse chariot with six horsemen who seldom communicate. Coordination of health care is vital. In Canada, when Saskatoon, Edmonton and Calgary realised that a wave of influenza was coming, they had GPs give antiviral injections in nursing homes, made room in hospital intensive care units and had ambulances check their oxygen units. The wave of influenza came, there was no crisis and there were no unnecessary deaths. In Toronto, there was no such coordination — nursing homes closed, emergency rooms and intensive care units became full, ambulances circled the block and many people died unnecessarily.2 Coordinating the elements of a health system is important. The chariot needs a single horseman. In this issue of the Journal (page 396), Whiteford and Buckingham detail the achievements of the Australian Health Ministers’ Advisory Council’s National Mental Health Strategy 1993–2003, an attempt at federal–state coordination to which they contributed.3 The achievements have been considerable,4 but there are some reservations: While expenditure on mental health has increased, it has only increased in line with expenditure on other health services. Acute public-sector inpatient beds are at a satisfactory 18 per 100 000, but hospitals often are unable to admit critically ill patients because the number of rehabilitation beds and beds in the community is one quarter of the 50 per 100 000 recommended.5 Services that can’t discharge can’t admit. Community mental health services have grown as the number of hospital places has decreased. However, the absence of rehabilitation and community beds means that staff are being asked to care for people in the community who should be in supervised residential places. There have been few area-wide attempts to integrate the work of GPs, private psychiatrists and psychologists with the work of state inpatient and community services. Also in this issue of the Journal (page 401), Hickie and colleagues provide a manifesto for change, asking for money to establish national targets for mental health outcomes, to promote early intervention in the young, provide effective treatment in primary care, maximise rehabilitation opportunities, and invest in sustainable innovation.6 These are good aims, but won’t necessarily solve the present crisis. They do not address the issue of governance, how to enable the six contributors to work together, and how to remedy the deficiency in supervised accommodation. How did this crisis come about? Australia’s burden of mental illness (anxiety, depression, substance misuse and psychosis) is similar to that of other developed countries. Our coverage (proportion of people with a current mental disorder who seek treatment) is better than in most such countries. Our trained workforce is good. We have a strong consumer and carer movement and a powerful lobby in the Mental Health Services Conference <http://www.themhs.org>. We have very good data and know who is treated in each care sector.7 We have calculated that optimal care at current coverage would cost no more, but would be twice as effective as current care.8 So, while more money might make things easier, lack of money is not the cause of the crisis. The current crisis is most evident in the inability of the acute-care units to admit emergency cases, but there is a much more worrying problem looming — psychiatrists and nurses do not want to work in public-sector inpatient and community services.3 Psychiatrists in training, who staff state hospital and community services, find it uncongenial and resolve to leave the public system; and nurses who are no longer trained within the system resolve not to enter it. Information from new brain-imaging strategies and from the human genome project is changing our understanding of mental disorders. One would think that this impending avalanche of information would produce clinicians eager to be involved. In much of medicine, any physician hoping for an appointment at a teaching hospital will be doing a research doctorate. This is not happening in psychiatry. Patients deserve better. What to do? Is there any evidence that integrating the elements can improve services? There is. Projects in three health areas were funded by the federal government in 1999 to improve linkages between disparate parts of the mental health system. In each area, patient care improved, there was no increase in expenditure, and provider collaboration continued after the trial was over.9 Is Christopher Pyne right? Would things be better if there was a single payer and a single source of governance? Tony Abbott, Minister for Health and Ageing said “speculation about structural change is likely to dominate this year’s health debate”,10 which at least suggests that the matter is still on the table. The Constitution probably precludes the federal government forcibly taking over the states’ responsibility for health, but a way around this impasse has been suggested, arguing for an “Australian Health Commission” that could take responsibility for all health services and provide a patient-focused health care system which would be to everyone’s benefit.11 If something like this happens, the chariot would have one horseman, and the recurring crises in mental health might gradually ease.

Gavin Andrews MD

No cause for panic, but an incentive to improve clinical practice The use of selective serotonin reuptake inhibitors (SSRIs) in depressed children and adolescents has received consider-able attention in the past year; this attention has included concerns about increased suicide risk, revised evidence about effectiveness, growing prescription numbers, and revelations of drug companies withholding data.1 The discovery of unforeseen risks in other drugs such as cyclooxygenase-2 inhibitors has intensified the climate of uncertainty and mistrust about drug treatment. Some argue that to diagnose major depression in children is to medicalise the unhappiness caused by affluence, permissiveness, a decaying family and society.2 By contrast, medical practitioners and governments have been told during the last quarter century that depression is a serious illness that can lead to suicide, poor physical health, and personal, professional and social difficulties. Thus, the Australian community has invested considerable resources in trying to tackle this scourge (eg, The National Depression Initiative3). If experts disagree, it is little wonder that the public and clinicians are confused, yet severely depressed teenagers continue to come to doctors for management. Do SSRIs increase the risk of suicide?Although SSRIs have been used “off label” in children and adolescents from the early 1990s, none is formally approved for paediatric depression in Australia. Evidence of benefit is ambiguous enough for scholars to be divided,1,4 and we do not discuss it here. Findings of the few epidemiological and ecological studies available conflict about suicide risk. First, SSRIs are less toxic than the older tricyclic antidepressants, particularly in overdose.5 Second, youth suicide rates, after rising for about 40 years, inexplicably declined in Australia and other Western countries in the late 1990s.6 While its cause is probably multifactorial in origin, the decline correlates with increasing SSRI use.7 More prescriptions did not result in higher suicide rates, as might have been expected if SSRIs induce suicide, although this might have been disguised within the general decline.8 Third, SSRIs are not found more often than expected in post mortem examinations of people who have committed suicide.9,10 Conversely, some studies suggest that deliberate self-harm (DSH) episodes are slightly increased in adults taking SSRIs.11,12 Another study reported elevated suicidal behaviour during the first month of tricyclic antidepressant or SSRI treatment13 (this was not replicated in the paediatric trial data14). Clinicians have long recognised an increased risk of suicide in patients starting antidepressant treatment. A recent review commissioned by the Food and Drug Administration (FDA) of 24 controlled trials with more than 4400 children and adolescents showed a higher incidence of suicidality (suicidal thoughts, attempts) in those receiving antidepressants (4%), mostly SSRIs, compared with placebo (2%).14 There were no known suicides. Despite methodological shortcomings (eg, post hoc analyses, varying trial methods, suboptimal assessment of suicidality, exclusion of suicidal youth), this effect seems robust, if small (2%). Thus, the FDA issued the latest in a series of advisories about suicidal behaviour in children and adolescents treated with antidepressants, recommending the strongest labelling warnings, but not contraindicating their use. The meaning and mechanisms underlying increased suicidality in those taking antidepressants are unclear. Suicidal behaviour results from complex interactions in which individual and psychosocial factors, as well as depression and other mental health problems, play a role. In the review commissioned by the FDA, SSRIs induced akathisia, agitation, and irritability more often than placebo.14,15 Patients with these symptoms, often described as “activation”, were up to seven times more likely to show suicidality than those without activation.14 Like other antidepressants, SSRIs can trigger manic switches, often with unstable mood and higher suicide risk. Sex, age, history of suicide attempt, and non-completion of the trial did not influence suicidality, but statistical power was weak because of low numbers.14 It is also possible that non-compliance, which may set off withdrawal symptoms,15 plays a part. Handle with careGrowing knowledge about the risks of antidepressants is an incentive to improve clinical practice for a disorder that, if left untreated, is associated with significant morbidity and mortality. Large increases in the use of SSRIs in adolescents and children suggest we have become casual about prescribing them. We may be giving SSRIs to mildly depressed adolescents and neglecting regular review, counselling, and cognitive behaviour therapy (CBT). The association between “activation” and suicidality highlighted above14 emphasises the importance of monitoring and managing side effects, which are dose-related.15 As in all medicine, practice should be guided by a careful appraisal of benefit and risk based on best external evidence and individual clinical experience. While the credibility of antidepressant medications has been undermined, evidence for CBT and related treatments has not received the same level of scrutiny, and is flimsy for moderate and severe depression,16 particularly in non-research settings. Besides, psychosocial treatments require more cooperation from depressed teenagers who are often hostile, unmotivated, demoralised, or lack insight. This could easily lead to therapeutic nihilism or a regression to treating depression primarily as a moral or social problem.2 There is no definite answer yet about whether to prescribe or not; clinicians must weigh the pros and cons for each patient. Children and families must be informed of the risks of medication — parents who believe their children killed themselves because they were taking SSRIs consistently complain they “were not told”. Until the ambiguities are resolved, based on our clinical experience, we believe that SSRIs (chiefly fluoxetine1) can be considered, but only for severe depression, when it produces serious impairment and fails to respond to psychosocial treatment over a few weeks. Combining SSRIs and CBT may be more effective, and might reduce suicide risk17 However, apprehension about SSRIs should not lead us back to using tricyclic antidepressants (which are more toxic), to blaming sufferers or their families, or to refusing to treat depressed adolescents at all.

Joseph M Rey PhD, FRANZCP · Michael J Dudley FRANZCP

We summarise the most recent data available on changes to the public and private mental health sectors from the commencement of the National Mental Health Strategy in 1993 to 2002. There has been substantial service system change in the directions agreed by governments under the Strategy, supported by a 65% growth in government spending on mental health. Despite this there is growing public and professional concern about deficiencies in the mental health service system. We review the current call for change in light of increased community expectations and growth in demand for services. Given broad national and international support for Australia’s policy directions, the problems lie with the pace and extent of change and ensuring better outcomes from the increased investment in mental health care.

Harvey A Whiteford MPH, FRANZCP · William J Buckingham BSc(Hons), DipClinPsych