Mental health

After 12 years of national mental health reform, major service gaps and poor experiences of care are common. The mental health community reports little progress in implementing its key priorities, such as expanded early-intervention programs, comanagement of people with mental health problems and related alcohol or substance misuse, and widening of the spectrum of acute care settings. We propose new national targets for reducing the social and economic costs of poor mental health; these include increased access to effective care, reduced suicide rates and improved rates of return to full social and economic participation. We detail specific service reforms designed to maximise the chance of achieving these targets, and prioritise youth health and integrated primary care programs. New independent and national reporting systems on the progress of mental health reform are urgently required.

Ian B Hickie MD, FRANZCP · Tracey A Davenport BA(Hons), GCM · Georgina M Luscombe BSc(Hons) · Grace L Groom DHSc · Patrick D McGorry FRANZCP

Essential psychopharmacology. The prescriber’s guide. Stephen M Stahl. Cambridge: Cambridge University Press, 2005 (xv + 571 pp). ISBN 0 521 01169 8. Psychotropic drugs are heavily marketed and widely prescribed in general practice and Stephen Stahl, an internationally recognised clinician and teacher in psychopharmacology, is tapping into the need for a practical prescriber’s guide to psychotropic drug use. He has skilfully condensed essential information on individual psychotropic drugs and presented it in an attractive, user-friendly format. Information on each drug is broken down into five colour-coded sections: therapeutics; side effects; dosage and use; special populations; and the art of psychopharmacology, including how to get the best use out of a drug. The author also uses a list of icons to alert the reader to the class of drug, mechanism of action and concerns with drug interactions or major side effects. The drugs are listed in alphabetical order by their generic name and are supplemented by an index with generic and trade names allowing quick and easy reference for the busy clinician. For the Australian reader, approved indications for each of the drugs may differ from those in the United States so you may need to access “the yellow book” (Schedule of Pharmaceutical Benefits) to obtain information on PBS listings. Also, some medications are available in the US but are not approved for marketing in Australia. For example, since the book was published, regulatory decisions have led to the withdrawal of nefazodone from the market due to safety issues. There is considerable duplication of information for drugs of a similar class, such as the selective serotonin reuptake inhibitors (SSRIs). However, the advantage is that the prescriber can readily obtain all the information required on a particular drug without needing to access other chapters of the book. While the author clearly states in his introduction that certain drugs and combinations of drugs may be for the expert only, this is not always highlighted in the text, such as combination antidepressants with mirtazapine, venlafaxine or SSRIs, colloquially known as “Californian rocket fuel”. There is much in this book to recommend it to general practitioners, medical students and experts, but it is a glossy production and at $120 for the paperback, the cost is on the high side. Gordon F S JohnsonProfessor of Psychological Medicine University of Sydney, NSW

Gordon F S Johnson

Objective: To evaluate the effect on depressive symptoms in cardiac patients of patient-specific advice to general practitioners regarding management of comorbid depression.Design and setting: A randomised controlled trial in four general hospitals in Adelaide, South Australia.Participants: Patients (n = 669) admitted to cardiology units for a range of cardiovascular conditions who were screened and assessed as being depressed according to the Center for Epidemiological Studies Depression Scale (CES-D).Intervention: Inpatient psychiatric review, followed by telephone case conferencing between specialist hospital staff and GPs to provide patient-specific information about the patient’s depression and its management, educational material, and ongoing clinical support.Main outcome measures: Level of depression severity at 12 months post-hospitalisation.Results: On the basis of intention to treat, intervention patients had lower rates of moderate to severe depression (CES-D ≥ 27) after 12 months (25% v 35%, relative risk, 0.72; 95% CI, 0.54–0.96, number needed to treat for benefit, 11). The intervention was most effective in preventing progression from mild depression to moderate to severe depression. The multidisciplinary telephone case conferencing was difficult to implement and, in a post hoc analysis, brief phone advice from a psychiatrist was found to be effective.Conclusions: Screening hospitalised cardiac patients for depression and providing targeted advice to their GPs reduces depression severity 12 months after hospitalisation.

Geoff Schrader PhD, FRANZCP · Frida Cheok PhD · Ann-Louise Hordacre PhD · Julie Marker GDPH · Victoria Wade FRANCGP, MPsych

Andrew Firestone Psychiatrist, 30 Burke Road, East Malvern, VIC 3145. afireATtpg.com.au To the Editor: The drug company-funded article Diabetes, psychotic disorders and antipsychotic therapy: a consensus statement by Lambert and Chapman1 tests some ethical boundaries. Firstly, although categorised as a position statement, it does not express the position of any professional body. The cumbersome title was probably inspired by a recent landmark review of the same topic.2 But there, the American Diabetes Association (ADA), with others, recommended that prescribers bear in mind the strong association of olanzapine and clozapine with diabetes when choosing an antipsychotic drug. The MJA article does not dispute the ADA data, which rate a brief mention. But — and here is the second, more serious, ethical issue — the key ADA recommendation, that the varying diabetogenic potential of antipsychotic drugs should be a factor to consider when choosing an antipsychotic drug, is not mentioned at all. Instead, the article appears to be trying to use the weight of an impressive consultation process to influence prescribers to ignore the present state of knowledge. One cannot take issue with the Australian recommendations, which echo those of an important North American 2002 conference.3 But the funding source means that the omission of the ADA recommendations is an ethical problem: one must question why they have been omitted. To end on a positive note, the Australian recommendation for a prospective comparison trial of antipsychotic drugs for weight gain and diabetes is certainly a good one. It is high time that a university took this up —and published the results without drug company assistance.

Andrew Firestone

Timothy J R Lambert,* Leon H Chapman† * Director, OPEN (Office for Psychiatric Evaluation and Educational NewMedia), Department of Psychiatry, University of Melbourne, 7th Floor, Charles Connibere Building, Royal Melbourne Hospital, Melbourne, VIC 3050; † Diabetologist, International Diabetes Institute, Melbourne, VIC. lamberttATunimelb.edu.au In reply: Our article did not ignore the relative diabetic potential of various antipsychotic drugs. We wrote “clozapine and olanzapine are associated with greater weight gain and a higher occurrence of diabetes and dyslipidaemia than risperidone and quetiapine”, and so on.1 However, the article was not aimed to influence prescribing habits, but rather to alert health professionals to the relative metabolic risks both inherent in people with psychosis and arising from treatment with antipsychotic drugs in general, and the consequent need for constant assessment. The article tried to emphasise the need to balance risk versus benefit. We also tried to underline the need to effectively treat the illness (ie, the psychosis) with the most appropriate agent. Ignoring this would be akin to not using corticosteroids in severe asthma for fear of metabolic consequences. Finally, the article is a pointer to the full consensus statement, which is available on the Internet at www.psychiatry.unimelb.edu.au/open/diabetes_consensus/ and may be downloaded without charge.

Timothy J R Lambert · Leon H Chapman

CorrectionRe: “Bilateral acute angle closure caused by supraciliary effusions associated with venlafaxine intake” by de Guzman M H P, Thiagalingam S, Ong P Y and Goldberg I in the 7 February 2005 issue of the Journal (Med J Aust 2005; 182: 121-123). In the second paragraph of the “Clinical record”, the number “3” appears, instead of a multiplication symbol, in two places. The second sentence should read “Spectacle correction revealed compound hypermetropic astigmatism (right eye, +1.00 + 1.50 × 75°; left eye, +1.75 + 2.25 × 110°).” In the same article, the initial capital letter (“V”) of the first paragraph after the clinical record box is missing: the first word should be “Venlafaxine”. Similarly, in the article by Ng C V T [page 120] in the same issue, the initial capital letter (“M”) is missing: the first word of the first paragraph should be “Myasthenia”. The html and pdf versions of these articles were correct when published online.

Maria Hannah Pia de Guzman MD, DPBO · Sureka Thiagalingam MPH, MB ChB · Poh Yan Ong MD, MS · Ivan Goldberg MB BS, FRANZCO, FRACS

Aim: To ascertain the incidence of autism spectrum disorders in Australian children.Setting: New South Wales (NSW) and Western Australia (WA), July 1999 to December 2000.Design: Data were obtained for WA from a prospective register and for NSW by active surveillance.Main outcome measures: Newly recognised cases of autism spectrum disorders (defined as autistic disorder, Asperger disorder and pervasive developmental disorder not otherwise specified [PDD-NOS]) in children aged 0–14 years; incidence was estimated in 5-year age bands (0–4 years, 5–9 years, 10–14 years).Results: In WA, 252 children aged 0–14 years were identified with autism spectrum disorder (169 with autistic disorder and 83 with Asperger disorder or PDD-NOS). Comparable figures in NSW were 532, 400 and 132, respectively. Most children were recognised with autistic disorder before school age (median age, 4 years in WA and 3 years in NSW). Incidence of autistic disorder in the 0–4-years age group was 5.5 per 10 000 in WA (95% CI, 4.5–6.7) and 4.3 per 10 000 in NSW (95% CI, 3.8–4.8). Incidence was lower in older age groups. The ratio of all autism spectrum disorders to autistic disorder alone was 1.5:1 in WA and 1.3:1 in NSW, and rose with age (1.8:1 and 2.9:1 in 10–14-year-olds in WA and NSW, respectively).Conclusions: These are the first reported incidence rates for autism for a large Australian population and are similar to rates reported from the United Kingdom. Ongoing information gathering in WA and repeat active surveillance in NSW will help to monitor any future changes.

Katrina Williams PhD, FRACP, FAFPHM · Megan Helmer MHlthSc(CDM) · Craig M Mellis MPH, MD, FRACP · Marshall Tuck MPH · Emma J Glasson PhD · Carol I Bower MSc, PhD, FAFPHM · John Wray FRACP

Clinical record A 35-year-old man presented to the emergency department complaining of right visual blurring and discomfort overnight. Over the previous 2 years, similar episodes had occurred, mostly at night or in dim lighting, affecting one eye at a time and resolving spontaneously each time. The patient was not using any type of medication at the time when the episodes began to occur. Although infrequent initially, these episodes had increased to two or three times a week after mirtazapine, a tetracyclic antidepressant, had been prescribed for depression and anxiety 5 months previously. Symptoms persisted despite treatment being changed to sertraline, a selective serotonin reuptake inhibitor (SSRI). Ten days before presentation, the sertraline was replaced by venlafaxine 75 mg once a day. Symptoms were occurring about every other day. There was no other significant ocular or family history. Spectacle correction revealed compound hypermetropic astigmatism (right eye, +1.00 + 1.50 × 75° left eye, +1.75 + 2.25 × 110°). On presentation, the patient’s visual acuity was 6/24, improving, with a pinhole before the eye, to 6/9 (right eye) and 6/6 (left eye). The right pupil was fixed and mid-dilated and the cornea was mildly oedematous. Both anterior chambers were axially shallow, with forward displacement of the iris–lens diaphragm (ie, the plane formed by the iris and the anterior surface of the lens at the pupil). Intraocular pressures were 69 mmHg (right eye) and 62 mmHg (left eye) (intraocular pressure > 21 mmHg is generally considered as being elevated). Gonioscopy revealed bilateral completely closed angles. The patient was given intravenous mannitol 100 g over 40 minutes, oral acetazolamide 500 mg, topical timolol 0.5%, apraclonidine 1% and pilocarpine 2%. Intraocular pressures fell to 13 mmHg and 5 mmHg in the right and left eyes, respectively. Gonioscopically, the angles could now be opened with indentation of the cornea; however, the anterior chambers remained shallow. Bilateral laser peripheral iridotomies were performed on the day of presentation (left eye) and on the next day (right eye) to eliminate pupil block. Post-iridotomy gonioscopy showed no change in the angle configuration or anterior chamber depth. The patient was sent home with instructions to take oral acetazolamide 250 mg three times a day, topical timolol 0.5% once a day, pilocarpine 2% four times a day, and brimonidine 2% twice a day. Venlafaxine was discontinued. The patient refused alternative antidepressant medication and requested referral to a psychiatrist or psychologist for counselling. On Day 4 after the patient presented with acute angle closure, ultrasound biomicroscopy showed bilateral supraciliary effusions and anterior chamber shallowing (Box 1). Manifest refraction (ie, manual subjective measurement of refractive error) at this time revealed a myopic shift of about 3 dioptres in each eye. Over several weeks, medications to lower intraocular pressure were withdrawn one by one. Follow-up ultrasound biomicroscopy showed gradual resolution of the supraciliary effusion, which was complete some 5 weeks after the acute attack. The anterior chambers deepened slightly and the patient’s usual hypermetropic refraction returned. Gonioscopy at this time still showed easily occludable angles. Bilateral laser peripheral iridoplasties were performed to reduce the risk of future angle closure. Venlafaxine is described as a safe and effective antidepressant that is chemically distinct from other antidepressants.1 It is a non-selective inhibitor of the reuptake of serotonin, norepinephrine and dopamine and has no anticholinergic activity in vitro. Because of their relative lack of anticholinergic effects, venlafaxine and similarly acting selective serotonin reuptake inhibitors (SSRIs) are preferred over tri- and tetracyclic antidepressants for patients who are at risk of angle closure. We report the case of a young patient taking venlafaxine who developed simultaneous bilateral acute angle closure secondary to supraciliary effusions. Angle closure and/or acute transient myopia possibly caused by supraciliary effusion has been reported for many drugs, including sulfonamides, tetracycline and some diuretics.2 Supraciliary effusions causing secondary angle closure in patients taking topiramate3-5 and sulfonamides6 have been documented by ultrasound biomicroscopy by various authors. The postulated mechanisms by which supraciliary effusions produce angle-closure glaucoma and transient myopia are illustrated in Box 2. There have been reports in the literature of angle closure or increased intraocular pressure in patients taking venlafaxine8,9 or SSRIs.5,10-15 We found one previous report of bilateral acute angle-closure glaucoma in a patient taking venlafaxine8 and one report of raised intraocular pressure in two known glaucoma patients with narrow angles taking venlafaxine.9 Eleven cases of raised intraocular pressure in patients taking SSRIs have been reported to the Australian Adverse Drug Reactions Advisory Committee.10 However, the mechanisms for the raised intraocular pressure in these cases are not mentioned. To our knowledge, ours is the first reported case of acute angle closure in a patient taking venlafaxine in which the presence of a supraciliary effusion precipitating the secondary angle closure has been identified by ultrasonography. Furthermore, our patient was taking only venlafaxine at the time of presentation. The patient in the abovementioned case of acute angle closure8 had taken four other medications immediately before starting or during treatment with venlafaxine. There is a case report of secondary angle closure due to supraciliary effusions in a patient taking topiramate who was also taking venlafaxine, but the authors attributed the effusions to the topiramate.4 It is possible that the mirtazapine and sertraline taken previously by our patient contributed to his condition, as did his underlying hypermetropic status. It may be that the weak anticholinergic or mydriatic effects of serotonergic drugs are sufficient to precipitate angle closure by a mechanism similar to that of the cyclic antidepressants.6,8 The serotonergic effects of these drugs may also have a role in angle closure.11,14,16 Serotonin and serotonin receptors have been found in the human ciliary body, and serotonin, its agonists and antagonists do affect intraocular pressure.17 The supraciliary effusions documented here are evidence of the serotonergic effects of venlafaxine causing angle closure, although the precise cause for the effusions is unknown. Lessons from practice Use venlafaxine (and antidepressants in general) with caution in patients who are at risk of angle-closure glaucoma. Patients at risk are those with hypermetropic refraction (ie, whose distance spectacles magnify objects) and those with symptoms of angle closure (intermittent blurring of vision associated with seeing coloured rings around lights, eye redness, or eye pain). Such symptoms should not be dismissed as “migrainous”. Patients at risk of angle closure should undergo ophthalmological screening, particularly gonioscopy, before starting antidepressant drugs. Because any patient could develop a supraciliary effusion in response to various drugs (especially antidepressants), it is prudent to include symptoms of angle closure when educating patients about possible side effects of these drugs. They should seek ophthalmological care if they experience symptoms of angle closure or a myopic shift in their vision. 1 Ultrasound biomicroscopy images, Day 4 after the patient presented with acute angle closure A: Supraciliary effusion, right eye (arrow). (C = cornea; CB = ciliary body; I = iris; S = sclera.) B: Shallow anterior chamber, left eye. The large area of iris–lens apposition indicates forward displacement of the lens. Pupil block has already been relieved by peripheral iridotomy (not shown). (AC = anterior chamber; C = cornea; I = iris; L = lens.) 2 Postulated mechanisms by which supraciliary effusions produce angle-closure glaucoma and transient myopia * Based on information from Craig et al.7

Maria Hannah Pia de Guzman MD, DPBO · Sureka Thiagalingam MPH, MB ChB · Poh Yan Ong MD, MS · Ivan Goldberg MB BS, FRANZCO, FRACS

Trevor Anderson was born in Camberwell, Victoria, on 20 July 1941. The son of an army officer, he attended Melbourne High School before studying medicine at the University of Melbourne (1961–1966). In 1964, he joined the army, and, after completing his residency, was assigned to the Royal Australian Regiment as a Medical Officer in 1968. On 21 July 1969, in South Vietnam, Captain Anderson flew in to assist with treatment and evacuation after a landmine had killed and injured members of a platoon. As this process ended, another mine exploded, killing a corporal and causing further casualties. Trevor was blinded and wounded in the legs and abdomen. After rehabilitation, Trevor trained in psychiatry at Royal Park Hospital, Melbourne, and the Parkville Psychiatric Unit, studying with the help of his wife Janice. In 1976, he became Psychiatrist in Charge at the Elizabeth Street Clinic, remaining for 28 years as the clinic moved to become first the Ellery Clinic, in Carlton, then the Waratah Clinic, in Moonee Ponds. There he developed community psychiatry, trained young psychiatrists and inspired medical students. He also pioneered psycho-oncology, starting a liaison service to the Peter McCallum Cancer Institute. Trevor had a profound respect for individual rights. He never lost sight of the fact that our services are there to serve patients. His opening gambit to patients, “How can I help you?”, represented the ethical core of his practice philosophy. He was described by one colleague as “magic with difficult people”. Trevor served on numerous Department of Veterans’ Affairs committees and won the 1991 Returned Servicemen’s League Anzac of the Year award. He was President of the Victorian Blinded Soldiers’ Association, served on the board of the Royal Victorian Institute for the Blind, and, as president from 1999, oversaw an amalgamation with Vision Australia and the Royal Blind Society of NSW. He was a member of the Victorian Psychological Council and an adviser to the telephone counselling service Lifeline. No portrait of Trevor would be complete without mention of his extraordinary family. Married in 1968 to Janice Biggs, the home shared with their four children was an epicentre of activity and love. Despite his blindness, he sailed, canoed, skied, and rode a tandem bicycle on numerous excursions. After facing pancreatic cancer with characteristic courage, Trevor died on 29 October 2004. He is survived by Janice and his children Penelope, Hamish, Virginia and Emily.

David Ames BA, MD, FRANZCP

To the Editor: A recent editorial in the British Medical Journal reported advice from the UK Committee on Safety of Medicines that most types of selective serotonin-reuptake inhibitors (SSRIs) should not be used in the treatment of major depression in children.1 The editorial sparked interest in the Australian media, resulting in articles in large metropolitan newspapers with titles such as “Army of kids on antidepressants”.2 General practitioners were targeted as the cause of reported “over-prescribing”. Unfortunately, while the media drew data from the national BEACH program (Bettering the Evaluation and Care of Health; a continuing study of general practice activity3), the data presented were inflated: a “child” was defined as someone aged under 20 years (while the UK advice related to children under 18 years), and national figures were extrapolated from the upper confidence limit. Reliable estimates of GP prescribing of antidepressants to children in Australia are needed. We derived age-specific rates of antidepressants prescribed per encounter in Australian general practice for the period April 2001 to March 2004 from the BEACH data (Box 1). The data showed that children were prescribed antidepressants far less often than adults. Those aged under 12 years were rarely prescribed antidepressants. Most of those prescribed were tricyclics, which are more commonly used in management of enuresis than of depression. The media’s inclusion of 18–19-year-olds as “children” greatly increased the reported rate.2 The prescribing rate of antidepressants in children aged under 18 years was 0.47 per 100 encounters (5 per 1000 encounters), but was six times higher for 18–19-year-olds (2.82 per 100 encounters). Most antidepressants prescribed for 12–17-year-olds were SSRIs. Fluoxetine is the only SSRI currently approved for use in children in the UK.4 In Australia, caution is advised when prescribing any antidepressant to children, but venlafaxine and the SSRI paroxetine are specifically advised against.5 Nevertheless, venlafaxine and paroxetine were more often prescribed (accounting for 10% and 8%, respectively, of total antidepressants for children) than fluoxetine (5%). However, GPs provided concomitant counselling at almost 20% of contacts with children aged under 12 years where an antidepressant was prescribed, and at 40% with 12–18-year-olds (Box 2). GPs were also more likely to refer the children to a specialist than when prescribing antidepressants for adults. We do not know how many of these children have been referred to a specialist at a previous encounter, nor how often antidepressant medication is initiated by a specialist. However, it will be interesting to see whether the new advice reduces the current level of prescribing of antidepressants (SSRIs in particular) in children. 1 Antidepressant prescribing in Australian general practice, April 2001 to March 2004 Age-specific rate per 100 encounters (95% CI) Variable (ATC group)† <12 years (n = 31 869) 12–17 years (n = 11 576) 18–19 years (n = 5823) ≥ 20 years (n = 247 231) All antidepressants 0.11 (0.07–0.14) 1.48 (1.18–1.77) 2.82 (2.35–3.28) 4.18 (4.05–4.31) SSRIs (N06AB) 0.03 (0.01–0.05) 1.08 (0.82–1.34) 1.84 (1.49–2.19) 2.38 (2.29–2.46) Fluoxetine (N06AB03) 0.003 (–)* 0.08 (0.00–0.13) 0.07 (0.00–0.14) 0.28 (0.25–0.30) Paroxetine (N06AB05) 0.003 (–)* 0.13 (0.06–0.20) 0.22 (0.10–0.34) 0.48 (0.45–0.52) Other SSRIs 0.02 (0.01–0.04) 0.87 (0.63–1.12) 1.55 (1.22–1.87) 1.62 (1.55–1.69) Tricyclics (N06AA) 0.07 (0.04–0.10) 0.14 (0.07–0.21) 0.22 (0.09–0.35) 0.92 (0.87–0.97) Other antidepressants 0.006 (–)* 0.26 (0.16–0.36) 0.76 (0.49–1.02) 0.89 (0.83–0.94) Venlafaxine (N06AX16) 0 0.17 (0.09–0.25) 0.52 (0.29–0.74) 0.47 (0.43–0.51) * Insufficient observations for calculating 95% confidence intervals. † Drug group according to the World Health Organization Anatomic Therapeutic Chemical (ATC) classification. SSRIs = selective serotonin reuptake inhibitors. 2 Concomitant management provided at encounters where an antidepressant was prescribed in Australian general practice, April 2001 to March 2004 Concomitant management (% of encounters where at least one antidepressant was prescribed [95% CI]) Management <12 years (n = 34) 12–17 years (n = 171) 18–19 years (n = 164) ≥ 20 years (n = 10 137) Counselling 17.6% (4.8%–30.5%) 40.4% (32.8%–47.9%) 44.1% (36.1%–52.1%) 30.4% (29.0%–31.8%) Referral to specialist 5.9% (–)* 6.4% (2.7%–10.2%) 6.8% (2.7%–10.9%) 2.7% (2.4%–3.1%) * Insufficient observations for calculating 95% confidence intervals.

Christopher M Harrison BPsych(Hons), MSocHlth · Helena C Britt BA, PhD

Re: “The hidden tragedy of offender deaths”, the editorial by Stuart Ross in the 1 November issue of the Journal (Med J Aust 2004; 181: 469-470). The reference numbering in the text is incorrect because of a computer error. In the first 3 paragraphs, references 12, 13, 14 and 15 should be references 1, 2, 3 and 4, respectively. All other references are correct, except for reference 13 in the last paragraph of the text, which, again, should be reference 2. The html and pdf versions of the article published in the eMJA were corrected on 17 December 2004.

Stuart Ross

Objective: To determine whether mental illness is associated with accessibility and remoteness.Design: A cross-sectional, population-based, computer-assisted telephone interview survey, stratified by Accessibility and Remoteness Index of Australia (ARIA) categories.Setting: Secondary analysis of data collected from 2545 South Australian adults in October and November 2000.Outcome measures: Psychological distress and depression as determined by the Kessler 10 Psychological Distress Scale, the SF-12 measure of health status, and self-reported mental illness diagnosed by a doctor in the previous 12 months.Results: Overall, mental illness prevalence estimates were similar using the three measures of psychological distress (10.5%), clinical depression (12.9%) and self-reported mental health problem (12.7%). For each measure, there was no statistically significant variation in prevalence across ARIA categories, except for a lower than expected prevalence of depression (7.7%) in the “accessible” category. There was no trend suggesting higher levels of mental illness among residents of rural and remote regions.Conclusions: The prevalence rates of psychological distress, depression and self-reported mental illness are high. However, we found no evidence that the prevalence of these conditions varies substantially across ARIA categories in South Australia. This finding may challenge existing stereotypes about higher levels of mental illness outside metropolitan Australia.

Kerena A Eckert MPH · Anne W Taylor BA, MPH · Graeme R Tucker BSc · David D Wilkinson MB ChB, DSc

Psychotic illness and its treatment are associated with an increased rate of diabetes and worsening blood sugar control. The newer, second-generation antipsychotic agents are more likely to produce this effect than the first-generation agents, but both contribute to the problem. The effect is usually related to insulin resistance through weight gain, but other mechanisms may exist. Diabetic ketoacidosis is rare. Management of psychosis takes priority over concerns about the potential metabolic sequelae of treatment, but the prevalence of the latter requires that all patients taking antipsychotic agents be actively screened and treated. Patients treated with antipsychotic agents need baseline and regular checks, including weight, blood glucose and lipid levels and blood pressure. Management of psychosis with its attendant medical problems requires a multidisciplinary approach, with primary health practitioners playing a central role. Mortality and medical morbidity is higher in those with psychosis than expected; preventive measures, combined with early detection and treatment of hyperglycaemia and other metabolic problems, is a key public health issue.

Tim J R Lambert BSc, FRANZCP · Leon H Chapman FRACP

The justice system could go further in supporting the needs of those it detains after they are returned to the community Nearly 20 years ago, public attention was drawn to the previously hidden tragedy of deaths in prison and police custody. Initially, attention was focused on deaths of Indigenous people. However, it quickly became apparent that the death rate for all people held in custody was much higher than that for the general population. The result was a detailed investigation into the causes of the problem, in the form of the Royal Commission into Aboriginal Deaths in Custody.1 The Royal Commission made over 300 recommendations on penal policy, cell design, custody management regimens, treatment programs, services to Indigenous offenders and a host of other topics. In addition, the Deaths in Custody Monitoring Program was established at the Australian Institute of Criminology (AIC) to scrutinise and report on deaths in prison or police custody.2 In parallel with the acknowledged problem of deaths in custody, there is an equally significant tragedy in the form of high death rates among released prisoners3-5 and offenders in the community.6,7 In the decade after the Royal Commission (1990 to 1999), the AIC monitoring program recorded 628 deaths in police or prison custody. Over the same period, in Victoria alone, 820 men and women who had been released from prison died unnatural deaths.4 The study by Coffey and colleagues in this issue of the Journal (page 473) shows that the problem is not confined to adult offenders but affects juveniles as well.8 The high rate of unnatural deaths among offenders living in the community is a major public health issue, but what can we do to reduce these rates? One of the groups at greatest risk is injecting drug users — over half of the unnatural deaths examined in the earlier Victorian study were heroin related,4 and drug-related offences were an indicator of high mortality risk in the study by Coffey et al.8 Drug treatment and maintenance (methadone) programs lower the risk of death by overdose.9 However, many of those at greatest risk are profoundly alienated from society, and we need to find ways to engage them. For example, heroin-dependent Indo-Chinese offenders frequently face rejection by their families and community, and are isolated from the mainstream community as well. Female offenders often come from backgrounds of extensive sexual and physical abuse, their heroin dependency is often supported by prostitution,5 and any interventions need to take account of their responsibilities as parents.10 Treatment and maintenance programs need to be delivered in ways that meet the material, social and cultural needs of those at risk. Overdose risk can be dramatically lowered by behaviour changes, like not using drugs by yourself, being aware of variations in the purity of heroin, and not taking heroin in conjunction with alcohol or benzodiazepines. Again, the problem is partly that those at greatest risk are also the most difficult to communicate with, and tend to be unrealistic in judging risks to themselves. Peer-based education and information dissemination programs have shown they can transmit the key messages about risk reduction to this group (eg, how to avoid overdose and recognise its signs),9 but, again, a range of approaches tailored to the needs of specific groups at risk is required. Such approaches could include maximising the effectiveness of needle and syringe program workers by having them provide standardised, evidence-based messages and materials on safe injecting, overdose prevention and support options.9 The importance of heroin as a cause of unnatural death should not obscure the other dangers that offenders face. Individuals who have the combination of mental disorder and drug and alcohol misuse experience much higher risks of both overdose and suicide and can find it difficult to obtain the kind of treatment and support services that might alleviate their problems. Older offenders are at increased risk of a variety of general health problems, such as diabetes, cancer and liver disease, and there need to be programs that link at-risk offenders with healthcare and support services.11 People who are released from custody are at greatly increased risk, in part because their tolerance for heroin is reduced, and also because return to the community can be a time of great emotional stress. Prisoner release support programs like the Victorian Bridging the Gap program have shown that the period before release can be an important “window of opportunity” when offenders are motivated to plan for their release.12 A key feature of this program is intensive, outreach-based support, with the support agency helping the releasee to identify his or her specific needs and brokering access to material support, healthcare and social services. Releasees who participated in Bridging the Gap had improved outcomes as measured by accommodation stability and engagement in drug-treatment programs, and these in turn translated into lower rates of reoffending.12 Finally, we need to attend to an important lesson from the Royal Commission. Despite real improvements in custodial management, the number of deaths of Indigenous people in custody has continued to increase because there are now more Indigenous people in custody.2 The high rate of unnatural deaths among offenders is a public health problem that requires changes in the way that healthcare services are delivered to this vulnerable population. However, we also need to recognise that the justice system has a key role to play in ensuring that its goals of punishing offenders and preventing crime are properly balanced by a consideration of the health and support needs of the people who are the subjects of its interventions.

Stuart Ross

Depression is now Australia’s most debilitating illness, accounting for 8% of all years lived with disability and over $3 billion annually in direct and indirect costs. 1 Other mood disorders, such as bipolar disorder, add significant additional costs. 2 Unfortunately, mood and anxiety disorders, which typically first become evident in adolescence, often go untreated or only come to attention later in adult life. Thus, people who present for care have recurrent or persistent disorders. 3 Moreover, depressive disorders are frequently complicated by alcohol or other substance misuse,4 as well as physical health problems. 5 Mental disorders in total now account for 60% of all disability costs in those aged 15–34 years. 1 In a caring society, such statistics should demand an urgent, national and coordinated response. One aspect of our national response was the establishment in 2000 of beyondblue: the national depression initiative by the Australian and Victorian governments. 6 Towards the end of its first phase (2001–2005), it is now time to assess our progress. To reduce the burden of depression, we need an effective combination of prevention and early intervention; expanded evidence-based treatments (particularly in primary care); a reduction of social and economic barriers to full participation, such as exclusion from life insurance or discrimination in the workplace; and promotion of research on related health services and suicide prevention. 7 Early achievements of beyondblue: the national depression initiative 27% of Australians in 2002 recognised “beyondblue” as the national depression initiative. 61% of Australians in 2002 reported that they or someone close to them had experienced depression. beyondblue generated 1762 unique media stories between 1 April 2001 and 30 June 2004. The beyondblue website recorded 644 999 visits between 1 April 2001 and 30 June 2004. Support for critical changes in primary mental healthcare, introduced under the $120 million Better Outcomes in Mental Health Care package. Establishment of blueVoices as a new national consumer and carer advocacy network. Production of new guidelines with the life insurance and income protection industries to ensure equitable access for people with depression. Support for large national trials of primary and secondary schools-based, antenatal and community depression prevention and early intervention strategies. 8-10 Support for health services research through allocation of large research grants, focusing on the interface of primary and secondary care. In this Supplement, evidence is presented either directly from beyondblue or from analyses of other available national data sets. Importantly, the early impact of beyondblue can be seen in impressive rates of national awareness of the organisation, the number of media contacts, the extent of website utilisation, changing social attitudes to reporting personal experiences of depression, and reduced barriers in access to life insurance and income protection (see Box). 7 However, the personal experiences of those who care for people with depression,11 and the treatment experiences of those with bipolar disorder,12 indicate that there is still a great deal of work to be done to reduce stigma and to improve the interaction with healthcare services of people with severe affective disorders. A novel method for drawing media attention to our national progress, or our progress within target groups of greatest concern (eg, young people, new mothers, Indigenous Australians, small rural communities), is the development of a National Index for Depression. 13 We intend to report this index frequently, so that the general public and the media become as familiar with it as they are with other national measures like the road toll or the annual suicide rate. Prioritisation of mental health within Australian general practice is critical. beyondblue played a key role in advocacy for the $120 million national program Better Outcomes in Mental Health Care (BOiMHC) 2001–2004. 14 Others have highlighted the cost-effective health outcomes that could be gained by this type of reform, in that it seeks a better balance of primary and secondary care as well as improved access to specific cognitive-behaviour strategies. 15 The initial impact of BOiMHC is apparent, with 15% of the general practice workforce now participating. 16 If the program continues to promote improved consumer and carer choices and better access to non-pharmacological treatments, then the goals of higher remission rates, prevention of recurrence and delivery of cost-effective treatments may be achieved. Accompanying the rapid expansion in management of depressive disorders in primary care is the inevitable rise in the level of prescribing of antidepressant medications. Although this increase is associated with clear benefits, most notably a decline in suicide rates in those who access care,17 the wider community has been quick to question whether this increase is appropriate. 18,19 Mant et al have examined the trends in general practice prescribing and conclude that there is evidence of appropriate restraint in the use of these new antidepressants. 20 Another aspect of primary care management of depression is the common link to life-threatening substance misuse. Burns et al explore what we know about the links between mental health, prescription drug use and heroin overdose. 21 The number of Pharmaceutical Benefits Scheme prescriptions provided has a very strong relationship with overdose, particularly for benzodiazepines, opioids, and tricyclics, but not for the newer antidepressant agents. Self-care strategies for depression and anxiety are an increasingly important part of the mix of treatments that need to be available to the wider community. Previously, Jorm et al detailed the evidence for such strategies for treating depression. 22 Here, they set out the current state of knowledge of self-care strategies for anxiety disorders. 23 Anxiety disorders are often either the precursor to depression or a major source of comorbidity. Although a great deal of concern is expressed about rates of mental disorders in rural and regional Australia, very few systematic data have been available for detailed analysis. Caldwell et al report a most important finding — that an underlying factor relating to increased suicide in young men in rural and regional settings is lower use of services rather than higher rates of mental disorder. 24 This now requires an urgent suicide prevention and health services response. To date, few countries in the developed world have attempted such a coordinated population health response to the burden of depression. The most recent British initiative achieved limited benefits. 25 Improvements of 5%–10% were reported in terms of more positive attitudes to depression, reported experiences of depression, attitudes to antidepressants and treatment from GPs. 25 Few GPs (11%) had definitely made changes in their management of depression as a result of the campaign. 26 At this early stage, the Australian experience appears to be achieving wider benefits and establishing a broader framework for more sustainable changes in community attitudes and health service reform.

Ian B Hickie MD, FRANZCP

Objective: To explore the experiences of carers and families of people with depression.Design and setting: Structured focus groups conducted in six Australian capital cities between February 2002 and July 2002. Thematic analyses were conducted using the QSR NUD*IST software package for qualitative data.Participants: Thirty-seven carers or family members.Results: Thematic analyses highlighted five key themes. Most notably, the carer’s role is made more difficult by the lack of community awareness about depression, and, in some instances, an unwillingness of other family and friends to provide ongoing support. Carers experience a resulting sense of isolation, often exacerbated by adverse experiences with healthcare providers. Carers and family members are frequently excluded when key decisions are made, and report that emergency services are relatively unresponsive to their concerns. By contrast, community support organisations usually provided a sense of inclusion and common purpose.Conclusions: The experiences of carers and families of people with depression highlight the urgent need for more extensive community education about the illness and more productive collaboration within the healthcare system.

Nicole J Highet DPsych · Bernard G McNair GradDip(Nursing Management) · Tracey A Davenport BA(Hons), GCM · Ian B Hickie MD, FRANZCP

Objectives: To compare the prevalence of mental health disorders and the use of professional help by area of residence, age and sex; and to determine whether the differences parallel differences in suicide rates.Design: Retrospective cross-sectional analysis of Australian national mortality data (1997–2000) and the National Survey of Mental Health and Wellbeing (1997), using broad area-of-residence classifications based on the Rural, Remote and Metropolitan Area (RRMA) index.Main outcome measures: (a) Suicide rates; (b) prevalence of depression, anxiety and substance-use disorders; and (c) use of health professionals for mental health problems — by age, sex and area of residence.Results: Higher suicide rates were evident for men, particularly young men in rural (40.4 per 100 000; z, 3.2) and remote (51.7 per 100 000; z, 7.2) populations compared with metropolitan (31.8 per 100 000) populations. Although the proportion of young men reporting mental health disorders did not differ significantly between rural (23.5%; z, –0.5) and remote (18.8%; z, –1.6) areas compared with metropolitan (25.6%) areas, young men with a mental health disorder from non-metropolitan areas were significantly less likely than those from metropolitan areas to seek professional help for a mental health disorder (11.4% v 25.2%; z, –2.2).Conclusions: There is a need to investigate why young men in non-metropolitan areas, the population with the greatest suicide risk, do and do not engage with mental health services.

Tanya M Caldwell PhD · Anthony F Jorm PhD, DSc · Keith B G Dear PhD

Stress in doctors is a product of the interaction between the demanding nature of their work and their often obsessive, conscientious and committed personalities. In the face of extremely demanding work, a subjective lack of control and insufficient rewards are powerful sources of stress in doctors. If demands continue to rise and adjustments are not made, then inevitably a “correction” will occur, which may take the form of “burnout” or physical and/or mental impairment. Doctors need to reclaim control of their work environment and employers need to recognise the need for doctors to participate in decisions affecting their working lives. All doctors should be aware of predictors of risk and signals of impairment, as well as available avenues of assistance. Relevant medical organisations (eg, the Colleges, hospital administrations, and medical defence organisations) need to develop and rehearse effective response pathways for assisting impaired doctors.

Geoffrey J Riley MRCPsych, FRACGP, FRANZCP

Objectives: To examine the uptake by general practitioners (GPs) of the five key components of the Better Outcomes in Mental Health Care (BOiMHC) initiative: education and training for GPs; the three-step mental health process; focussed psychological strategies; access to allied health services; and access to psychiatrist support.Setting: All Australian states and territories during the first 15 months of the initiative (1 July 2002 – 30 September 2003).Design: Retrospective survey of de-identified registration data held by the General Practice Mental Health Standards Collaboration (training uptake), de-identified Health Insurance Commission (HIC) billing data (provision of the three-step mental health process, focussed psychological strategies and case conferences with psychiatrists), and reports from “access to allied health services” projects to the Australian Department of Health and Ageing (project participation).Main outcome measures: Number and percentage of Australian GPs certified as eligible to participate in the initiative; provision of the three-step mental health process and focussed psychological strategies by GPs; participation in allied health pilot projects; and access to psychiatrist support.Results: Within 15 months of the BOiMHC initiative commencing, 3046 GPs (about 15% of Australian GPs) had been certified as eligible to participate, including 387 who had registered to provide focussed psychological strategies. GPs had completed 11 377 three-step mental health processes and 6472 sessions of focussed psychological strategies. Sixty-nine “access to allied health services” projects had been funded, with the original 15 pilot projects enabling 346 GPs to refer 1910 consumers to 134 individual allied health professionals and 10 agencies. In contrast, the “access to psychiatrist support” component was less successful, with the HIC billed for 62 case conferences at which a psychiatrist and a GP were present.Conclusion: The level of uptake of the main components of the BOiMHC initiative has expanded the national capacity to respond to the needs of people with common mental disorders, such as depression and anxiety.

Ian B Hickie MD, FRANZCP · Tracey A Davenport BA(Hons), GCM · Jane E Pirkis PM(Psych), PhD · Grant A Blashki MD, FRACGP · Grace L Groom DHSc

Objective: To examine trends in types of antidepressant medications prescribed in Australia between 1975 and 2002.Design: Sales data from the Australian pharmaceutical industry were used to examine trends in overall antidepressant prescribing and changes in the types of antidepressants prescribed between 1975 and 2002.Main outcome measures: Antidepressant sales were expressed as defined daily doses (DDDs) per 1000 people per day, using the estimated Australian population for each year obtained from the Australian Bureau of Statistics.Results: Average annual growth in the sales of antidepressants was 1.1% per year from 1975 to 1990, after which growth rose steeply to reach 29% in 1995. By 2002 the rate of growth had slowed to 6.6%. Eighty per cent of total sales were accounted for by four drugs in 1975, 1980 and 1985; five in 1990; seven drugs in 1995 and 2000; and six drugs in 2001 and 2002.Conclusions: The rapid growth in antidepressant prescribing that was characteristic of the early 1990s, and reflected the emergence of new classes of agents, did not continue into the late 1990s. Selective serotonin reuptake inhibitors now dominate antidepressant prescribing in Australia.

Andrea Mant MD, MA, FRACGP · Valerie A Rendle BSc, MSc, MPsychClin · Wayne D Hall BSc(Hons), PhD · Philip B Mitchell MD, FRANZCP, FRCPsych · William S Montgomery BPharm · Peter R McManus MMedSc, BPharm · Ian B Hickie MD, FRANZCP

Objective: To identify patterns of mental health, prescription drug use and personal circumstances associated with heroin overdose in young people.Design: Linkage of data on use of Pharmaceutical Benefits Scheme (PBS) prescription drugs with data from a self-report questionnaire.Setting: Inner metropolitan Melbourne, Australia.Subjects: 163 young people, 15–30 years, using heroin.Main outcome measures: Personal circumstances, mental health (as measured by various scales), and PBS-listed prescription drug use.Results: Young people using heroin reported high rates of feelings of hopelessness, depression, antisocial behaviour, self-harm and diagnosed mental illness. A prior history of overdose was associated with previous mental illness, which in turn was associated with being female, having poor social support, being dissatisfied with relationships, and living alone or in temporary accommodation. While feelings of hopelessness and antisocial behaviour were strongly associated with overdose history, the number of PBS prescription drugs used had a very strong relationship with overdose, particularly benzodiazepines, other opioids, tricyclic antidepressants and tranquillisers.Conclusions: Further research to explore causal relationships between prescription drugs and heroin overdose is warranted. Improved data linkage to PBS records for general practitioners may facilitate safer prescribing practices.

Jane M Burns BA (Hons), PhD · Raymond F Martyres MB BS, MMed, FRACGP · Danielle Clode BA(Hons), DPhil(Oxon) · Jennifer M Boldero MA, PhD

Objective: To determine the prevalence of psychiatric morbidity and burnout in final-year medical students, and changes in these measures during the intern year.Design: Prospective longitudinal cohort study over 18 months, with assessment of psychiatric morbidity and burnout on six occasions.Participants: All 117 students in the first graduating cohort of the University of Sydney Graduate Medical Program were invited to participate in the study; 110 consented.Outcome measures: Psychiatric morbidity assessed with the 28-item General Health Questionnaire and burnout assessed with the Maslach Burnout Inventory.Results: The point prevalence of participants meeting criteria for psychiatric morbidity and burnout rose steadily throughout the study period.Conclusions: Internship remains a stressful time for medical graduates, despite initiatives to better support them during this period. The implications for the doctors themselves and for the communities they serve warrant further attention, including programs specifically aimed at reducing the rate of psychological morbidity and burnout during internship.

Simon M Willcock MB BS(Hons), FRACGP · Michele G Daly BSc(Hons), MSc · Christopher C Tennant MD, MPH, FRANZCP · Benjamin J Allard BA, MB BS

Objectives: To review the evidence for the effectiveness of complementary and self-help treatments for anxiety disorders.Data sources: Systematic literature search using PubMed, PsycLit, and the Cochrane Library.Data synthesis: 108 treatments were identified and grouped under the categories of medicines and homoeopathic remedies, physical treatments, lifestyle, and dietary changes. We give a description of the 34 treatments (for which evidence was found in the literature searched), the rationale behind the treatments, a review of studies on effectiveness, and the level of evidence for the effectiveness studies.Conclusions: The treatments with the best evidence of effectiveness are kava (for generalised anxiety), exercise (for generalised anxiety), relaxation training (for generalised anxiety, panic disorder, dental phobia and test anxiety) and bibliotherapy (for specific phobias). There is more limited evidence to support the effectiveness of acupuncture, music, autogenic training and meditation for generalised anxiety; for inositol in the treatment of panic disorder and obsessive-compulsive disorder; and for alcohol avoidance by people with alcohol-use disorders to reduce a range of anxiety disorders.

Anthony F Jorm PhD, DSc · Helen Christensen PhD · Kathleen M Griffiths PhD · Ruth A Parslow PhD · Bryan Rodgers PhD · Kelly A Blewitt BAppPsych

Objective: To describe the experiences of people with bipolar disorder with primary care and specialist mental health services.Design and setting: Focus groups and indepth interviews were conducted in seven Australian capital cities between July 2002 and April 2003. Thematic analyses were conducted using the QSR NUD*IST software package for qualitative data.Participants: Forty-nine people with bipolar disorder participated in the focus groups and four participated in the interviews.Results: Thematic analyses highlighted eight key themes. Most notably, respondents identified a lack of awareness and understanding about bipolar disorder within the Australian community, which contributed to apparent delays in seeking medical assessment. The burden of illness was exacerbated by difficulties experienced with obtaining an accurate diagnosis and optimal treatment. The healthcare system responses were described as inadequate and included inappropriate crisis management, difficulties accessing hospital care, inappropriate exclusion of carers and families from management decisions, and frequent discontinuities of medical and psychological care.Conclusions: People with extensive experience of bipolar disorder report barriers to optimal care because of lack of community understanding and healthcare system shortcomings. These barriers exacerbate the social, interpersonal and economic costs of this illness.

Nicole J Highet DPsych · Bernard G McNair GradDip(Nursing Management) · Marie Thompson BSc(Hons) · Tracey A Davenport BA(Hons), GCM · Ian B Hickie MD, FRANZCP

Objective: To develop a National Depression Index for measuring the depression status of the Australian population.Design: Cross-sectional data were analysed from two random samples of the Australian adult population — the National Survey of Mental Health and Wellbeing (2000) and the National Health Survey (2001).Participants: The National Survey of Mental Health and Wellbeing (2000) — 10 641 participants; and the National Health Survey (2001) — 17 918 participants.Main outcome measures: Selected items from the Kessler Psychological Distress Scale (K10); and diagnoses of a major depressive episode according to DSM-IV criteria using a computerised interview.Results: Six items from the K10 that were most closely related to the DSM-IV diagnosis of “major depressive episode” were identified. Scores on an index calculated from these items were rescaled to form an index reflecting relative risk of depression and having a value of 100 for the Australian adult population. Taking into account sex, employment status and income, index values were higher in younger people, females, unemployed people and those socioeconomically disadvantaged. This pattern provides additional support for the validity of the index, as well as establishing benchmark levels to which index values from future surveys and in other groups may be compared.Conclusions: The proposed National Depression Index is a valid indicator of depression and level of depressive symptoms. It is suitable for monitoring depression at the population level. The scaling characteristics of the measure ensure that it can be interpreted by members of the general public.

Andrew Mackinnon PhD · Anthony F Jorm PhD, DSc · Ian B Hickie MD, FRANZCP