Mental health

The Victorian Doctors Health Program (VDHP) was established in November 2000 to provide a confidential and compassionate service for doctors and medical students with health concerns, including alcohol, other drug and mental health problems. Although funded by the Medical Practitioners Board of Victoria, the VDHP is completely independent of the Board. Its staff include a director with experience of North American Physician Health Programs and a case manager/psychologist. In its first 3 years of operation, the VDHP had 438 contacts: 218 requests for advice and information, and 220 contacts resulting in provision of services (to 92 doctors and students with alcohol or other drug problems, 82 with psychiatric problems, and 40 with stress-related or emotional problems). 99 participants received standard care (assessment, referral and up to two consultations with the program) and 56 extended care (three or more consultations with the program). 65 participants (most with substance use disorder) entered the more intensive Case Management, Aftercare and Monitoring Program (CAMP); 57 of these have had outcomes considered satisfactory, with 50 returned to work.

Naham (Jack) Warhaft MB BS, GradDipSustanceAbuse, FANZCA, FAChAM

Marital challenges are ubiquitous in the relationships of doctors. Common issues include overwork, a need for control, self-neglect, perceived and felt stigma, being a “wounded healer”, trouble with boundaries, chemical dependency, depression, and more. Knowing the hallmarks of a healthy relationship, recognising warning signals of trouble, and taking action through suggested strategies can be salutary. As a specialist in doctors’ health, I have noted that relationship concerns constitute one of the most common complaints in my practice. 1 Although there are no empirical data on the prevalence of marital problems in doctors, there are some data on divorce, albeit mixed. Doherty and Burge2 reported that divorce rates in doctors are lower than in other occupational groups. In contrast, Sotile and Sotile3 describe divorce rates among doctors as 10%–20% higher than those in the general population. Historically, the call of medicine has given short shrift to our personal and family lives. It is refreshing to observe today’s younger doctors giving much higher ascendancy to their relationships. 4 A healthy relationship is an alliance of two mature individuals who are developmentally ready to form a union that will meet their individual needs and ensure their personal growth in the years that lie ahead. 5 The texture of this “coming together” depends on many factors: love, affection, sexuality, companionship, communication, financial security, intimacy and commitment. When we feel intimate in a relationship, we are describing notions of connection, trust, mutuality, and a sense of being loved and honoured. 6 Given our humanness, our personal pasts, and the demands and responsibilities of a career in medicine, is it any wonder that all of us, in greater or lesser measure, struggle with our intimate relationships? Common problemsThe following are some common characteristics of doctors and their intimate relationships. Overwork as normative. The number of hours worked per week varies enormously from one doctor to another, and is influenced by the branch of medicine and the doctor’s sex and life stage. The bottom line, though, is that we work hard and this affects the quantity and quality of time left for our partners. It is hard to be relaxed, interested, energetic, creative and fun with loved ones if we are tired or preoccupied with the residue of our work day. And our intimates are masters at detecting this, despite our protests, denials and defensiveness. Overwork in doctors seems to be a result of both the doctor’s personality and the culture of medicine. Escape into work. Overwork is not always the cause of relationship difficulty, but may be the result. We may deliberately stay at work late or go in to work to avoid the painful awareness of tension or unhappiness at home. Medical work can be seductive — and there is usually plenty of it. Further, it may be easier to solve clinical dilemmas than domestic problems. A need to be in control. Our work requires being in control and taking charge if we are to be effective in our patient management skills. In greater or lesser measure, this attitude or personality trait may colour our intimate relationships. Other traits commonly seen in doctors are compulsiveness,7 perfectionism,8 and pessimism, passivity and self-doubt. 9 Most spouses do not appreciate feeling controlled by their doctor-partner or not respected as an equal. To quote one wife of a cardiologist: “My husband forgets that the kids and I are not always going to step to attention like his office assistant. Nor do we hold him in awe like his patients do. My philosophy is that we’re all equals in this family.” Self-neglect. Many other professionals take better care of themselves than we do. 10 If they are ailing, they consult their general practitioner. Many of the best doctors do not have their own GP, live lives that are desperately out of balance, diagnose and treat themselves (sometimes incorrectly), and do not recognise the pain and suffering of their partners. For example, a psychiatrist who came to me for a consultation began with these words: A month ago, when I concluded that I was depressed, I started myself on antidepressant A. I didn’t feel any better after about 10 days, but, instead of increasing the dose, I decided to try another sample, antidepressant B. Well, after 2 days, I was really anxious and my sleep was worse so I stopped it and put myself on antidepressant C. About a week later, when the anxiety hadn’t gone away and my sleep was even worse, I decided to double the dose. Then I got really sick. I didn’t know if it was the drug, the flu, or my depression getting worse. Then the pharmaceutical rep came by with some samples of antidepressant D. So I stopped what I was on and started it. I don’t like it though — I feel strange on it. But I feel strange these days anyway. I am so glad to be here. Relieved that I’ve got someone to look after me. I feel dreadful. Do you know how hard it is to treat yourself properly when your cognition is off and you’re worrying constantly and you can’t make proper decisions and you don’t know if you’re going to recover? I would never treat my own patients like this. Stigma. Most doctors admit to fearing judgement or disrespect if they admit to relationship problems or psychiatric symptoms in themselves. 11 Fear of stigma is why so many doctors refuse to seek help, or delay consulting others for a long time, or treat themselves. It is aligned with rugged self-determination, not wanting to bother others, a strong capacity for denial of trouble and problems, and mistrust of other caregivers. Sadly, these beliefs are too often reinforced by a culture of medicine that elevates us to “gods” and renounces our humanness. “Wounded healer” notion. 12 Many doctors are “wounded healers” who have themselves faced one or more of the following: poverty, hunger, war, forced migration, torture, family heartache, alcoholism, divorce, suicide deaths of loved ones, physical/emotional/sexual abuse, racial or ethnic discrimination, religious persecution, gay-bashing, life-threatening disease, or other traumas and losses. While these “sticks and stones” often strengthen us and enable us to practise better medicine, they also make us vulnerable and subject to the same problems as any other human being. Lack of firm boundaries between work and home. Despite the fact that medicine is rarely a “nine-to-five” job and, by its very nature, extends into our personal and family lives (especially when we’re on call or making weekend hospital rounds), we should strive for some demarcation. Here’s a quote from the 14-year-old son of a doctor-patient of mine: My dad and I have a pretty close relationship, but I don’t know why he wears his pager when he’s not on hospital call. It really bugs me. We often do sports together on Saturdays — I worry that our fun is going to get interrupted if his pager goes off with something that’s not an emergency. Unrecognised substance use disorders and/or mood disorders. The culture of medicine accords low priority to doctors’ mental health, despite evidence of untreated mood disorders and an increased burden of suicide. 13 Our proneness to alcoholism and other substance misuse is not diminishing. These maladies have pernicious effects on our intimate relationships, especially communication, sexuality, and trust. Listen to the plaintive words of one doctor’s wife: I’m really worried about my husband, a family physician. I think that he’s quite depressed and burned out. He’s drinking a lot. Our marriage is the pits. I’ve asked him to come in to see you and he refuses. He says he’s fine, that all doctors are burned out these days. His father was also a doctor — he had a nervous breakdown at this age. What should I do? Warning signs of a relationship in troubleDoctors need to ask themselves, and answer honestly, the following questions about their intimate relationships: Do you feel bored or lonely, especially when the two of you are alone? Does your partner complain that you don’t share enough of yourself? How does this criticism make you feel? Defensive? And do your reasons — “I’m tired” or “I don’t have anything new to tell you” or “I was born this way” — seem unsatisfactory or tend to fall short? Are you arguing without resolving the issues? Do you argue about the same matters over and over? Do your arguments leave you feeling exhausted, frustrated or demoralised? Are your arguments increasing in frequency or in intensity (eg, are they escalating to verbal or physical fights)? Are you not arguing at all but are silently seething, withdrawing into yourself, or using passive-aggressive manoeuvres (forgetting to meet requests, being stubborn, disappearing, coming home late, responding with sarcasm)? Or, if you aren’t doing this, is your partner? Do you make a beeline for the liquor cabinet when you get home, and not talk about your day at work — or present only a very abbreviated version once the alcohol takes effect? Are you working so hard that you can’t find the time to talk with your partner? Is it possible that immersing yourself in your medical work has become preferable to talking with your partner? That you find practising medicine more fun, rewarding, and ego-boosting than spending time alone with your partner? How is your sex life? Do you find that your sexual relationship doesn’t seem very intimate? That you “have sex” but don’t “make love” anymore? Strategies to create and maintain relationship intimacySafeguard time for communication in your busy life. Experiment with venues and situations in which you communicate in a more open and relaxed manner — kitchen or living room? at home or outside the home? while out for a walk or a bike ride together? morning or evening? sitting opposite each other or beside each other? with food/beverage or not? The vast majority of couples whom I see tell me that their best talks occur outside the home, away from distractions, interruptions and undone tasks. And if you go for a walk or ride, and you’re not on call, leave your pager, mobile phone, personal digital assistant, etcetera, at home! Read up on relationships. Visit your local bookshop or library and pick up one of the many manuals on improving communication techniques in relationships. Or browse the Internet for material. Try some of the exercises together for a month or two. Consider a marital enrichment weekend. Most faith communities offer these, as do community college continuing education programs and private corporations. What works in many of these endeavours is the basic message that you give to each other: “I care enough about us to go away with you and try to learn new ways of renewing our relationship”. Go for marital therapy if you feel that your personal efforts are not working, or are having limited success. It helps tremendously to have the expertise of a trained professional who can diagnose the problems, explain the “why”, appreciate the positions of both partners, relieve anxiety and sagging spirits, and offer guidance and hope. Take care of your health. If you don’t have a GP, get one today. Concluding wordsCaring for our relationships is good medicine. Having someone to love and nurture is an integral part of being human. Doctors with children find the challenges more manageable and the joys more intense when their primary relationship is happy. And doctors living with illness find the experience much less frightening and lonely when they are fortunate enough to have a loving partner at their side.

Michael F Myers MD, FRCPC

Despite suffering bouts of deep depression at certain times of her life, Helen Tolhurst has survived to tell the tale. With the help of close friends and a caring and supportive therapist, she is learning to find a balance between pursuing her medical career and taking time out to relax and experience life’s small pleasures My first memories of depression are of black periods as a child during which I hated myself and would hide under the blankets at night, thinking that if I held my breath for long enough maybe I would die. Having had many further episodes of depression since that first childhood experience, I often think how fortunate I am to have been born in the latter part of the 20th century rather than the earlier part, like my grandmother. Not for the reasons that you might at first think — such as the convenience and ease of so many aspects of modern life — but because of the wonders of modern psychiatry. My grandmother (see Box) had her first “nervous breakdown” at the age of 17, when her brother was killed at Gallipoli. From that time on, her life was punctuated by episodes of disabling depression for which she was admitted to hospital and often given electroconvulsive therapy. Her life was transformed by the advent of tricyclic antidepressants in the 1950s — at last there was an effective medication to treat her illness. Like me, several of my family members have inherited a vulnerability to depression, with which some of us have struggled for much of our lives. Different events have triggered each episode of depression. There was an episode of feeling desolate and losing a lot of weight because of problems in a relationship in my late teens, but mostly I just got on with life, studied medicine, married in 1973, and graduated in 1975. We moved to Alice Springs in 1978 and soon had two beautiful daughters. However, all was not well. After returning to work when I had a 2-year-old and a 6-week-old baby, I found the struggle to balance work and family overwhelming and, after a miscarriage, fell into a black hole of depression. Because of past severe hyperemesis gravidarum, I had not wanted another baby and felt guilty about what I saw as my failures as a mother. I can remember thinking, as I drove around the town, that deliberately crashing into a telegraph pole would be a way out of the blackness. I felt as if I was desperately hanging on to life only for the sake of my husband and children. It is difficult for a doctor to seek help for mental health problems in a remote community like Alice Springs. I felt ashamed of my inability to cope and unable to talk to my colleagues about the desperation I was feeling. My practice partners were totally overloaded with work, and I felt that to tell them how miserable I was would just sound like whingeing. So I struggled through my depression, trying to hide how I was really feeling from those around me. Looking back, I sometimes wonder how I survived. Recognising our need for family support, we moved closer to my parents in 1984. Again, just getting on with life, I bought a general practice, while my husband worked as a teacher and our girls started school. But, feeling torn between work and family, I slipped again into the black hole of depression. Help was now more readily available, and I saw a psychologist who suggested I take antidepressants. Too embarrassed to consult any colleagues, I committed the cardinal sin of self-medicating. By 1995, I realised that, although I had always loved general practice, I was completely “burnt out”. I sold my practice so I could pursue interests in research and teaching. However, there were now problems in my marriage and difficulties coping with the needs of my teenage daughters and the demands of a stressful situation at work. For 6 months I scarcely managed to sleep more than 3 or 4 hours a night, waking in the early hours of the morning, feeling completely alone in the darkness, tortured by black thoughts. I felt guilty about my inability to cope with work and family life and my failure to be the perfect doctor, perfect wife and perfect mother. There were also conflicts at work that recalled past unhappy times during my childhood. As I woke each morning, I felt like a wrung-out rag and it took enormous effort to get out of bed. By this time, I had admitted to myself that I needed professional help. I recovered from this episode of depression with the help of a psychologist and antidepressants prescribed by my general practitioner. The tremors, sweating and increased appetite caused by the antidepressants were a small price to pay for relief from the depression. For the first time, on the advice of my therapist, I took some time off work when the depression was at its most severe. Although I was relatively well by now, I realised that just wishing to remain so would not make the depression go away. I needed some long-term expert help. Finding a psychiatrist with whom I felt comfortable and confident was more difficult than I had anticipated. I was initially referred to a senior psychiatrist who had an angry and aggressive manner and, without taking a proper history, told me to stop taking the antidepressants, at a time when I was quite suicidal. I think it can be difficult for psychiatrists to find the right balance between empathy and professional objectivity, and I found some psychiatrists so distant that they made me feel as if I were carrying some sort of contagious disease. But at last I found a skilled, caring doctor, who treats me like an intelligent human being and is empathic and understanding about the pain I feel. Thanks to his help, I have recovered more rapidly from subsequent episodes of depression. Recently, after almost 30 years of marriage, my husband and I separated, and, grief-stricken, I plunged again into deep depression. As I worked my way through many past hurts, I wept and wept until I wondered why I wasn’t dehydrated. The wound inflicted by the end of my marriage is slowly healing and at last I am well, but I know now that staying well will take more than just medication. There are many things I need in my life to manage my depression: loving, supportive relationships; the right balance between work and other parts of my life; enjoyable work and leisure pursuits; regular exercise; meditation; and even the company of my cats. I am still learning how much work I can manage, having recently courted a relapse by working 7 days a week for 3 weeks. I need to anticipate stressful events in my life and think about ways to best cope with them. I am learning to be kinder to myself. I am coming to accept that for me there will be side effects with a therapeutic dose of medication. Hoping to reduce the stigma that members of the community and even the medical profession attach to depression, I am now more open and honest about my condition. The responses of my colleagues to this vary. Some who also have depressive illnesses welcome the opportunity to share their experiences with a fellow depression sufferer, while some offer support and sensible advice. But others react with awkward silence, or rapidly attempt to change the subject with looks that say “Don’t mention the war”. I wonder why they find open discussion with a colleague about her experience of a mental illness so difficult. Is it so different from diabetes or asthma? Do they think emotional difficulties are too private and personal to discuss with a colleague, or do they really see depression as a manifestation of weakness that I could overcome if I tried a bit harder to “pull myself together”? Still, I continue to hope that being more open about my illness will make life easier for my family members who also suffer from depression. If I had had some say in the matter I would never have chosen to have a depressive illness — yet, at the same time, I don’t regret it. There are two reasons for this. The experience of depression has given me some understanding of the pain my patients suffer when they descend into that black hole, and has made me more able to be empathic about their illness. And emerging from the blackness into normality, which sometimes seems like dazzling light, I have discovered joy in the smallest of life’s pleasures. So, how can a depressed doctor find much-needed help? For me, a supportive relationship with a therapist has been one of the most important factors in getting well. Sometimes you may know of a GP, psychiatrist or psychologist whom you like and trust, or about whom you have heard good things. Sometimes it requires enormous effort to take that first step in seeking help — but you can’t, and shouldn’t, treat yourself. If you think you need professional help, don’t hesitate to seek it. If you don’t know someone appropriate you may prefer to contact an organisation such as the NSW Doctors’ Health Advisory Service (tel: [02] 9437 6552; website: www.doctorshealth.org.au) that can refer you to an appropriate therapist. There are other helpful resources, such as the website (www.beyondblue.org.au) and the book Beating the blues, by Tanner and Ball. But paramount in recovering from depression is the help of a competent and caring therapist. A familial illness A: The author’s grandmother, who suffered crippling bouts of depression before the advent of tricyclic antidepressants. B: The author enjoying life, with the help of antidepressants and a supportive therapist.

Helen M Tolhurst MB BS, FACRRM

There have been major advances in clinical understanding and treatment of bipolar disorder over the past decade. Randomised controlled trials of pharmacological treatments and psychological interventions have shown that there are effective short-term and long-term treatments for the disorder. Despite advances in treatment, diagnosis is often delayed or mistaken, and many people who could benefit are not using the treatments available. Functional and symptomatic recovery from episodes of bipolar disorder is frequently less complete than previously considered, and disability is often profound. Although manic episodes are the distinguishing feature of bipolar disorder, it appears that depression is the predominant mood disturbance and that much of the functional impairment associated with bipolar disorder results from this. Comorbidity with anxiety disorders or substance misuse is common. Advances in genetics, brain imaging and basic pharmacology are starting to provide understanding of the complex causative processes.

Philip B Mitchell MD, FRANZCP, FRCPsych · Gin S Malhi MB ChB, FRANZCP, FRCPsych · Jillian R Ball BA, MA (ClinPsych), PhD

Objective: To determine the prevalence and types of deliberate self-harm (DSH) in adolescents, and associated factors.Design: A cross-sectional questionnaire study.Participants and setting: 3757 of 4097 Year 10 and Year 11 students (91.7%) from 14 high schools on the Gold Coast, Queensland, during September 2002.Main outcome measures: DSH behaviour, including descriptions of the last act, psychological symptoms, recent stressors, coping styles, help-seeking behaviour, lifestyle choices, and self-prescribing of medications.Results: 233 students (6.2%) met the criteria for DSH in the previous 12 months, with DSH more prevalent in females than males (OR, 7.5; 95% CI, 5.1–10.9). The main methods were self-cutting (138 respondents; 59.2%) and overdosing with medication (69 respondents; 29.6%). Factors associated with DSH included similar behaviours in friends or family, coping by self-blame, and self-prescribing of medications. Most self-harmers did not seek help before or after their most recent action, with those who did primarily consulting friends.Conclusions: DSH is common in Australian youth, especially in females. Preventive programs should encourage young people to consult health professionals in stressful situations.

Diego De Leo MD, PhD, FRANZCP · Travis S Heller BSc(Hons), BA

Objective: To evaluate whether a collaborative model of mental healthcare involving general practitioners and clinical psychologists benefits patients with common mental disorders in primary care.Design and participants: Cohort study of 276 general practice patients with mental health problems receiving collaborative treatment from clinical psychologists and GPs compared with a normative sample of 198 patients attending the same general practice surgeries.Setting: Nine general practices in three regional cities (Bathurst, Armidale and Ballarat) and two single-doctor practices in two rural and remote townships (Rylstone and Trundle). Data were collected in Bathurst, Rylstone and Trundle during 2001 and 2002 and in Ballarat and Armidale in 2002.Intervention: Full assessment, case formulation and “focussed psychological interventions” relevant to the patient’s condition.Main outcome measures: Level of psychological dysfunction assessed before and after the intervention, using the DASS (Depression, Anxiety and Stress Scales), GHQ (General Health Questionnaire) and GWBI (General Well Being Index) scales.Results: After the intervention, average scores in the treatment group decreased significantly (P < 0.001) on all DASS and GHQ measures and increased on the GWBI, indicating a positive change in the patients' mental health. The follow-up scores of the treatment and normative groups did not differ significantly on any of these measures.Conclusion: Preliminary findings suggest that collaborative care involving GPs and clinical psychologists provides significant gains in patients’ mental health.

Robyn F Vines MSc, FAPS · Don Thomson PhD, FAPS · Michelle Kluin BLMC · Louise Vesely · Jeffrey C Richards PhD, FAPS · Margaret Brechman-Toussaint PhD

A nasogastric feeding tube became acutely blocked in a young woman with anorexia nervosa. The ward staff tried unsuccessfully to remove the tube, and the patient complained of left cheek and nose pain. The knotted tube had impacted in the nose and was subsequently removed under anaesthesia. Whether the knotting was with fingers or tongue is unknown.

Desmond Wee MB BS · Jon P Clarke MBChB, FANZCA

Constructing RSI: Belief and desire. Yolande Lucire. Sydney: UNSW Press, 2003 (xvi + 216 pp). ISBN 0 86840 778 X. It is with some interest that this reviewer, a clinical and investigative rheumatologist who is too young to have experienced the height of the repetitive strain injury (RSI) epidemic, finds himself being asked by the Medical Journal of Australia to report on independent medical examiner and forensic psychiatrist Yolande Lucire’s popularisation of her 1996 PhD thesis. Dr Lucire was a significant critic during the 1980s epidemic and still believes that the Medical Journal of Australia should have withdrawn several of the articles it published, and through which it irresponsibly contributed to the epidemic. It is clear that attitudes remain acrimonious and polarised on these matters. Dr Lucire continues in her view, even in the “endemic” period of recent years, that RSI is entirely a psychogenic disorder due to somatisation of psychosocial distress. As evidence, she relates the results of her PhD. This was a retrospective case study review of 100 (out of 319) randomly selected RSI patients who had been referred to her for an opinion between 1984 and 1991. She used census statistics for controls, and found that virtually all the patients had one or more personal problems or disruptive life events close to the time of seeking compensation. She also impressively reviews the historical forces of the time, highlighting the lack of correlation between workload and symptoms, and the persistent absence of objective abnormalities. Hers may have indeed been the most robust investigation of the RSI phenomenon possible for the epidemic, but it is tragic that no serious follow-up study of RSI sufferers has ever been performed. Moreover, a diligent Medline search will reveal more recent contrary epidemiological data and growing evidence for peripheral and central neural changes, at least some of which might not be reversible. The jury remains out as to whether RSI is just somatisation. Richard A KwiatekRheumatologist Queen Elizabeth HospitalAdelaide, SA

Richard A Kwiatek

Fast facts: Bipolar disorder. Guy Goodwin and Gary Sachs. Oxford: Health Press, 2004 (99pp). ISBN 1 903734 50 9. At first blush, a book from a series called Fast facts does not evoke enthusiasm — suggesting, rather, an uninspired commercial opportunism. However, this small volume is pleasingly pithy, erudite and accessible, as well as being helpfully informative. Goodwin and Sachs are eminent in the field of bipolar disorder, representing research groups from both sides of the Atlantic (Oxford and Harvard, respectively). The dominant style, however, is that quintessentially English amalgam of droll understatement and incisive intellectual directness. The authors are unabashed apologists for the scientific method in clinical medicine, while at the same time compassionate clinicians: “We believe that the medical model is useful in diagnosing bipolar disorder — indeed, we cannot see a viable or reliable alternative.” The richness of their clinical experience is apparent in their accounts of the condition, referring, for example, to the “mischievous state of elation” that characterises milder presentations of mania. When discussing the somewhat dry issue of aetiology, they engagingly describe the interplay of genetic vulnerability and life-event precipitants: “Triggers have the same relationship to the real causes of severe bipolar disorder as a spark has to gunpowder.” It is the sharp observations and commentary that make this volume distinctive. One striking instance is their discussion of the controversial issue of childhood bipolar disorder, which is being diagnosed at alarmingly high rates in the US: “It represents another of the ways in which practice in North America is different from that in most other parts of the world …. It is still possible for the sceptic to say that this is diagnosis inflation.” Bipolar disorder is a condition that is tentatively emerging from the shadows of shame, misunderstanding and fear. Thoughtful volumes such as this are a critical component of the process of destigmatisation. Philip B MitchellProfessor and Head, School of Psychiatry University of NSW, Sydney, NSW

Philip B Mitchell

Mood disorders. Recognition and treatment. Peter R Joyce, Philip B Mitchell (editors). Sydney: UNSW Press, 2004 (xvi + 508 pp). ISBN 0 86840 447 0. This is a big book about a big topic. Anyone concerned with observing — or improving — the human condition must be informed about mood disorders. The book covers both depression, which is the most common disorder, and the various levels of mania, where depression usually presents intermittently. Medical practitioners, in particular, need to be up-to-date in their knowledge of mood disorders in order to improve and save lives. The editors begin wisely. Instead of starting their book with its subjects stretched out anatomised on dissecting room tables, they begin with descriptions of being depressed or being manic written by people who have experienced these conditions. Any reader who has escaped these painful and destructive disorders should read the descriptions carefully and reflect upon them. This book, of more than 500 pages, containing 40 essays by clinicians, covers everything from brain imaging and electroconvulsive therapy to psychotherapy. It is an encyclopaedia, worthy of its subject, and I used it like an encyclopaedia. I put it on my shelves and took it down when I wanted to expand my knowledge in a particular area, or to examine whether or not I was up-to-date on a topic. Professor Mulder’s contribution on the duration and natural course of depression is particularly important (it is often subdued but only occasionally totally vanquished). The book was both illuminating and helpful. Importantly, it is also very thoroughly referenced so that one can pursue a topic further if one wishes. I would like to make one personal observation. To my mind depression is, in some respects, like pain. All pains have a lot in common, but there are many different causes of pain and many different kinds of pain. In most cases the cause determines the management (eg, the pain of acute appendicitis is better dealt with by appendicectomy than by referral to a pain unit). So it is with depression, but some contributors (eg, in “Psychological therapies for depression”) could lead one to believe that there are some invariant aspects of depression which require psychotherapy of some complexity. Sometimes this is true and sometimes not. Many patients make a full recovery with appropriate medication, some commonsense support, and information and advice of the kind that we would give to patients with diabetes mellitus. Who should buy this book? Certainly all psychiatrists, but there are many other practitioners who have to deal with this common and lethal spectrum of disorders. For many it will not be their primary text, but it will be a very good resource when difficulties arise. John H T EllardPsychiatrist, Sydney, NSW

John H T Ellard

Medicines out of control? Antidepressants and the conspiracy of goodwill. Charles Medawar and Anita Hardon. Amsterdam: Aksant Academic Press, 2004 (x + 258 pp) ISBN 90 5260 134 8 When Charles Medawar, a professional consumer advocate in the UK specialising in medicines policy and drug safety issues, first made The antidepressant web available on his Social audit website in 1998, the kinds of concerns he was expressing about antidepressants were very much on the fringe. In 2004, with the publication of Medicines out of control?, the mainstream has moved significantly towards Medawar’s stance. Together with Ralph Nader, Medawar began his career as a consumer advocate in the United States some 30 years ago, and experience has taught him the need for persistence and assertiveness in challenging the prevailing view in psychiatry. Recent scientific publications have largely vindicated his claims that the newer antidepressant drugs cause dependence and suicidal behaviour, and have poor efficacy; that the pharmaceutical industry is in the business of disease promotion; and that much “expert opinion” is compromised. He and his coauthor, Anita Hardon, an anthropologist, begin with a historical overview of psychotropic medications. They describe a recurrent pattern of new “wonder drugs” first hailed as the answer to mental illness, or to addiction, and eventually discarded as ineffectual, habit-forming, or frankly dangerous. The focus then shifts to the newer antidepressants, and the authors discuss the problems of patients who become dependent on the medication; the manipulation by the pharmaceutical industry of the public perception of the need for antidepressants; and the way in which regulatory authorities have failed public health. Medawar was instrumental in drawing attention to the real and significant adverse effects of these newer antidepressants, paroxetine in particular, and for this he deserves praise. One quibble is that he does not always show the same level of healthy scepticism to some of the reports of the apparent side effects of these drugs as he does to their apparent benefits — their capacity to be a “nocebo” does not get as much attention as their placebo qualities. Jon N JureidiniHead, Department of Psychological Medicine Women’s and Children’s Hospital, Adelaide, SA

Children of parents with mental illness. Personal and clinical perspectives. Vicki Cowling (editor). Melbourne: ACER Press, 2004 (xix + 242 pp). ISBN 0 86431 473 6. It is difficult to believe that only a short time ago parents were routinely vilified when their children developed psychiatric illness. Obvious examples are “the schizophrenogenic mother” and the lack of maternal communication skills that were blamed for the development of autism. Since we have come to understand the biological basis of psychiatric disorders, such blaming concepts appear foolish. On the other hand, people who are or who will become parents may suffer from mental illness. The children of these parents may be affected through genetic inheritance, quality of parenting, family relationships, and psychosocial adversity. The editor, a social worker and psychologist, has estimated that, in 1995, 27 000 Australian children were affected by maternal psychosis alone. Many ill parents parent well, and not all children are affected, but up to two-thirds probably experience negative consequences. Amazingly, the needs of these children have been largely ignored. Cowling has brought together 20 contributors from various disciplines to produce a highly instructive book addressing “coalface” issues for children of mentally ill parents. Four of the contributors had experienced parents suffering from schizophrenia, depression, bipolar disorder and Huntington’s disease. These personal accounts are extraordinarily revealing and I regret that there were not more of them included. The first part of the book provides some vital background information on the genetics, behavioural and psychosocial effects of major psychiatric illnesses. An excellent chapter outlines the possible impact of different illnesses and their symptoms on infants and children of different ages. Different treatments for disorders, as well as preventive interventions, are also outlined. The role of the partner of the mentally ill parent and wider family ramifications are also considered. There is a chapter with advice on how to talk to children and another that examines the impact on adolescents. In a welcome departure from the political correctness of cognitive behaviour therapy, a chapter relates anecdotes from the psychoanalysis of an 11-year-old boy who had been adopted away from his mentally ill mother at the age of 2½. There are other chapters on placing children in out-of-home care and adoption. A highlight of the book is its description of peer-support activities — various ways of organising group therapy for children of parents with mental illness. Group peer support combats isolation, shame and despondency and the benefits of group therapy can be enormous, but are frequently underestimated. In summary, this is a book that provides irreplaceable insights about children whose parents have mental illness. I found most of the book easy to read, highly instructive and often deeply moving. Medical students and doctors should set aside some reading time for this wonderful book. Nicholas A KeksPsychiatrist Box Hill, VIC

Nicholas A Keks

Communicating with vulnerable children: A guide for practitioners. David P H Jones. London: Gaskell, 2003 ($72.00, xvi + 188 pp). ISBN 1 901242 91 9. David Jones is well recognised for his research into the reliability of child testimony. This text provides a primer on good professional practice for interviewing children, based on current scientific evidence. This is an essential area of competence for the ever-increasing range of professionals working with children who have experienced adversity or abuse. This book provides a comprehensive and well-organised summary of the area, and is relevant to all those who may communicate with vulnerable children, including professionals from health, education, welfare and the law. It describes the process of enabling children to communicate freely and honestly, and to impart reliable and accurate information. The book is based on relevant research and clinical experience. As well, it has been carefully edited by an advisory board from the Department of Health and the Family Division of the High Court of Justice in the United Kingdom, with the aim of improving practice and reducing the amount of malpractice in communication with children. The first section covers the knowledge base of influences on childhood communication and interviewing style. It includes developmental limitations and considerations, especially regarding memory and language, and the influence of social context, including disability and culture. Childhood reliability in providing information is a small, though important, part of the problem of “erroneous concerns” in the system of child protection and notification, and the chapter about these issues helps refocus on the practitioner’s responsibility for unreliability. The second section guides practice at the different stages of communication, including response to first concerns, initial assessment and in-depth interviews. It also contains helpful chapters on the problems of using communication aids such as anatomically correct dolls, and advice on coping for parents. Medicolegal sensitivity means that this book is not always light reading and more case examples and diagrams would help improve accessibility. While full of useful details for even the most experienced clinicians, problems of development and mental health require more knowledge and expertise than is provided here. On the whole, a wide range of detailed information and practical advice is clearly presented, and we would recommend this as a comprehensive and common sense introductory text for all those who understand children, and essential reading for those who don’t. Emma HartwellPsychologist David R DossetorDirector of Mental Health Children’s Hospital at Westmead, Sydney, NSW

Emma Hartwell

To the Editor: Mental health literacy of the general public is suboptimal, and knowledge and attitudes about some mental illnesses, such as schizophrenia and substance use disorders, are particularly poor.1 The media have been implicated in contributing to overall low levels of mental health literacy, with studies showing that mental illness is commonly portrayed negatively and linked with crime.2,3 However, few studies have considered whether particular mental illnesses are especially likely to be “framed” in the context of crime. In 2000, we undertook a survey of media reporting of mental illness and crime. We retrieved 13 389 Australian media items on mental health or illness from 515 sources during the year 2000 (all national metropolitan daily and Victorian suburban and regional newspapers and all national radio and television networks). We extracted detailed information from a random sample of 1126 items, identifying the mental illness that was the item’s predominant focus (co-morbidity is not typically reflected in reporting) and whether this was mentioned in the context of crime.4 Overall, only 71 of the 1126 items (6.3%) referred to mental illness in the context of crime. However, a substantial proportion of items on schizophrenia (9 of 57, 16%) and substance use disorders (13 of 117, 11%) did so, as did 33 of 311 items (11%) about mental illness in general. By contrast, only a small proportion of items on depression (7 of 218, 3%) and other disorders (9 of 146, 6%) referred to crime, while none of the items on eating disorders (29), dementia (133), or stress (115), did so. Examples of media references to mental illness in the context of crime included: A teenager accused of a fatal stabbing was described as “psychotic, mentally retarded, displaying signs of schizophrenia [and] hearing voices” (The Australian 2000; 15 Nov: 4). A man was referred to as a “paranoid schizophrenic” and “lunatic” in association with attempted murder (ABC Television World at Noon 2000; 16 Nov: 12:19 h). A woman charged with “a spate of armed robberies” was described as “fighting a drug addiction” (Radio 3AW News 2001; 8 Jan: 13:02 h). It was encouraging to find that relatively few items referred to mental illness in the context of crime, but confronting that those that did were disproportionately about schizophrenia and substance use. Studies that have considered the extent to which people with these disorders contribute to crime statistics suggest that public perceptions of them as criminally dangerous are exaggerated,5 and the media may have a role here.

Catherine Francis PhD · Jane E Pirkis PhD · David R Dunt PhD · R Warwick Blood PhD · Philip M Burgess PhD

Background: The numbers 4, 14 and 24 are associated with death for Cantonese-speaking Chinese people, as the words for these numbers sound like the words for “death”, “must die” and “easy to die”, respectively. A previous study in the United States investigating psychological stress engendered by fear of the number 4 found more cardiac deaths in Chinese and Japanese people, compared with white Americans, on the 4th day of the month.Objective: To determine whether more cardiac deaths occur in Hong Kong Chinese people on the days of the month with “deathly connotations” (4, 14 and 24).Design: Analysis of mortality data (1995–2000) of the Chinese population of Hong Kong from the Census and Statistics Department of the Hong Kong Government for these three days of the month, compared with the remaining days, according to both the Gregorian and Lunar calendars.Results: There were 17 346 cardiac deaths registered under ICD-9 codes 410–414 in 1995–2000. The mean (+ 1 SD) of the cumulative number of cardiac deaths on each day of the month was 587 (+ 30) for the Gregorian calendar or 573 (+ 24) for the Lunar calendar. The mean number of deaths on the 4th, 14th and 24th day of the month was not significantly different from the mean number of deaths on the remaining days of the month.Conclusion: Our study of Hong Kong Chinese people does not support the concept that more cardiac deaths occur in Cantonese people on the 4th, 14th and 24th day of the month.

Nirmal S Panesar BSc PhD · Noel C Y Chan · Shi N Li · Joyce K Y Lo · Vivien W Y Wong · Isaac B Yang · Emily K Y Yip

Objective: To test for the presence of sex-based differences in perception (the notion that men and women “think” differently, and that differences in perception are biologically based) among healthcare professionals.Design: Prospective survey.Setting and participants: 90 medical personnel at a tertiary care hospital in Newcastle, NSW.Intervention: Healthcare professionals were shown two pictures that could be interpreted as depicting either a young or an old person, and a word that could be seen as geometric shapes.Main outcome measures: The effects of sex, age, seniority, and specialisation in relation to the first impression of the image, the ability to change one’s perception, and the speed of perception.Results: Contrary to popular opinion, male physicians were more likely to perceive the older figures, and just as likely as women to be able to change their perception. Surgeons and junior staff were more likely to see, as well as being faster to form, an impression requiring abstract thought, and were more able to change their perceptions.Conclusions: Traditional sex stereotypes do not apply to medical personnel, but other age-based stereotypes, and professional rivalries (medical versus surgical) may have some empiric basis.

Balakrishnan (Kichu) R Nair FRACP, FRCP · Stephen R Mears DipIM · Karen I Hitchcock BA(Hons), BMed · John R Attia MD, PhD, FRCP(C) · Steven J Bowe MMedStat

Whiplash and other useful illnesses. Andrew Malleson. Montreal: McGill-Queen’s University Press, 2002 (viii + 527 pp). ISBN 0 773 52333 2. Andrew Malleson is a septuagenarian Canadian psychiatrist, recently retired from years of giving medicolegal opinions and reviewing sufferers of whiplash. His Herculean task was to complete this laboriously researched book — an eye opener, presented in a most readable and interesting manner. It is as unique in style and presentation as the subject is controversial. That Malleson has a view against the organicity of whiplash is manifestly clear throughout this excellent book, and his experiences and attitudes permeate chapter after chapter. He offers many well presented arguments towards his conviction that whiplash is a fabricated illness, propagated by the legal, and other, systems. We are left with little doubt that he is probably right. He does not acknowledge much evidence for whiplash (perhaps there is none); the little presented is refuted completely, with little respect. The book is organised into several parts, with eccentric title chapters such as: Whiplash: head injury or legal headache; Lawyers, junk science and chicanery; and Copycats and fashionable illnesses. The information presented does not always flow in a logical fashion. It is extensively referenced, and detailed annotated notes are provided in a separate chapter. This causes some difficulty in crosschecking. At the end of the day, these minor points make little difference to the appreciation of the powerful message he presents. Whiplash is highly topical and has many stakeholders in medical, legal and social frameworks. That makes this book of interest to professionals across a range of disciplines. It is highly relevant to every musculoskeletal practice. A number of Australian authors are quoted in this book, as much local research has contributed to the controversy. At $66.00, this book is good value for money. Phillip C VecchioRheumatologist Princess Alexandra Hospital Woolloongabba, QLD

Phillip C Vecchio

Family focused grief therapy. David W Kissane, Sidney Bloch. Buckingham: Open University Press, 2002 (xviii + 254 pp). ISBN 0 335 20349 3. The mental health consequences of bereavement have long been recognised. However, the family context of grief has been relatively under-addressed and there is a limited research base to guide clinical interventions. The authors of this text have internationally recognised expertise in psychotherapy (including family interventions) and palliative care. They both have substantial clinical and academic backgrounds in psychiatry, and have a substantial body of innovative research in Australia into the psychological and psychiatric aspects of oncology and palliative care, including bereavement. Family focused grief therapy provides a scholarly overview of the research and theoretical basis of our current understanding of the impact of bereavement on the family. This work is highly relevant to many areas of healthcare and is particularly innovative in applying preventive approaches involving careful clinical screening and assessment of a family’s functioning and coping. Kissane and Bloch’s work identifying high-risk patterns of family interaction is an important and an internationally recognised contribution to this field. The authors successfully link a research framework and a strong theoretical base with practical clinical interventions to address a problem that frequently challenges clinicians. The provision of detailed clinical vignettes deepens the scope of the book and encompasses the complexities of family life and the realities of clinical practice. The examples are relevant to the broad range of cultural issues for families in the Australian community. The vignettes appropriately and sensitively recognise the multiple problems that many families contend with, but, at the same time, utilise an approach that recognises family resources. By doing so the authors walk an appropriately balanced path between acknowledgment of the significant adverse consequences of grief for families and individuals, and the resilience of many families. Underpinning this is the philosophy that family functioning and coping can be enhanced to protect the individuals who comprise the family, and that there are patterns of family functioning that can hinder recovery from bereavement. As a whole, the book demonstrates the relevance and importance of mental health approaches to this very broad area of healthcare, and the contribution that can be made by bridging the fields of psychotherapy and palliative care. While the book would be of particular interest to professionals working in oncology and palliative care, the research methods, the nature of the intervention, and the understanding that this work brings to family work, are likely to be of interest to a very broad range of clinicians. By bringing research into clinical practice, the authors have made a major contribution to this field. Brian J KellyPsychiatrist, St Vincent’s Hospital Darlinghurst, NSW

Brian J Kelly

Treating substance misuse might not significantly reduce the number of offenders According to recent estimates, crime costs the community $32 billion annually. Of this, $1960 million is directly attributable to drugs, and, if indirect costs were included, the proportion attributable to drugs would be higher.1 Clearly, interventions that target potential risk factors for crime, such as drugs and mental health problems, will have significant payoffs for individuals and the wider community. However, the relationship between drugs and crime is complex. Policy development in this regard needs to take into account the multifaceted nature of the problem. In this issue of the Journal (page 408), Heffernan et al present the first Australian publication that seeks to clinically assess the level of substance-use disorders and psychological distress among police arrestees.2 This article makes a constructive contribution to the evidence base. The study highlights that the overwhelming majority of arrestees suffer from clinical substance-use disorders and psychological distress, and that they are a population who may be in need of treatment. Replication of these findings is important to furthering our understanding of the need for treatment among this group. In Australia, evidence is emerging (building on overseas research) that criminal behaviours among arrestee and prison populations vary widely, from minor disorderly conduct through to homicide, with different factors contributing to these behaviours. Illegal drug use is just one of many risk factors, but there is no doubt that it is significant in the behaviour of a subset of offenders. Recent analyses of police detainees and the incarcerated adult male population estimate that this is the case for between 34% and 52% of offenders.3,4 This clearly suggests that effective treatment interventions could significantly reduce crime rates. Criminological studies that track when people start, persist with and desist from drug use and offending demonstrate that most offenders become involved in minor crime before experimenting with and using illegal drugs.5,6 For example, the onset of crime preceded regular heroin use in 69% of one sample of offenders.5 Illegal drug use seems to compound a pre-existing problem, and so produces higher levels of offending.7 Thus, treating substance misuse among offenders, although an essential public health measure, might not necessarily result in significant reductions in the number of offenders. This is because crime and drug use may be caused more by factors external to the individual, such as early-childhood experiences and development, access to labour markets, access to local drug markets and their supply routes, the social and cultural environment, lifestyle choices, and other determinants that are not easily amenable to treatment.8 The links between drug use and crime and the policy implications that flow from this will be affected by the nature of the local drug market. The Australian Institute of Criminology’s Drug Use Monitoring in Australia project has conclusively shown that police detainees’ drug use patterns vary across the country. Higher rates of amphetamine use have been detected in Queensland, Western Australia and South Australian sites; while higher rates of heroin use have been detected in New South Wales sites.9 Furthermore, breakdowns by offence type indicate that users of amphetamines are arrested for a range of offences, not just violence, and similarly heroin users are arrested for a range of offences, not just property. The links between drugs and offending types appear more variable than is often thought. Changing human behaviour is difficult. Some people take drugs because they like the effects, some because they are risk takers, and some to self-medicate for past and current painful situations and events; others take them because they are addicted and simply cannot stop. Not everybody who is defined as dependent will want or seek treatment. In this complex environment, public policy responses, such as drug courts and court diversion systems, need to be cognizant of what drives behaviours and develop appropriate responsive systems (of which levels of dependency will be only one factor). Recent evaluations of the south-east Queensland and NSW drug courts10,11 have shown that, even with a 12-month, structured, supervised program, some people continue to be criminally active and use illegal drugs. Estimates from the early stages of the Queensland study suggest about a third of graduates reoffended within the follow-up period after graduating from the court. Similarly, police diversion schemes need careful targeting, as good longitudinal research shows that, after a “first” contact with the criminal justice system, many young offenders (upwards of 60%) do not come back into contact with the juvenile system again.12-15 Because of the intersection between illegal drug use and crime, the criminal justice systems in Australia have developed a range of policy innovations to divert offenders into treatment and other programs. These include early police diversion programs, court-based initiatives to divert offenders into treatment, and formal drug courts for serious offenders. There have also been attempts to provide treatment programs within prisons. However, opportunities for diversion could be strengthened in other areas. The first area is at the “end” of the criminal justice system, by providing postrelease support programs for prisoners leaving custody. Given that some 58% of prisoners have been imprisoned previously and 22% of police detainees have been imprisoned in the past 12 months, interventions to break the cycle of reoffending would have a significant beneficial effect on both the individual and the wider community — drug treatment is clearly one of those interventions. The second opportunity to improve diversion to treatment is in the gap between police diversion and the drug court: targeting people who are arrested and processed but whose offence is not sufficiently serious to meet the criteria for a formal drug court program. The study by Heffernan et al includes a significant number of these people, providing support for “arrest drug referral” schemes, as undertaken in the United Kingdom.16 However, there could be very large numbers of people suitable for such schemes. Policymakers first need to know how many of those people would avail themselves of treatment. In addition, treatment options must exist — at present, there is a range of effective treatments for heroin, but options for other illegal drugs are extremely limited. Reducing crime requires a multipronged approach that goes beyond criminal justice and treatment responses, to include a whole-of-government approach. Building the evidence base with valuable contributions such as that by Heffernan et al is vital to ensuring our interventions are successful.

Toni Makkai PhD

Objectives: To determine the 12-month prevalence of substance-use disorders and psychological morbidity in an Australian arrestee population.Design: Cross-sectional descriptive study.Participants and setting: 288 police arrestees at the Brisbane City Police Watch House in February and March 2001.Outcome measures: Prevalence of drug and alcohol disorders; psychological “caseness” according to the 28-item General Health Questionnaire; demographics and index offences.Results: 86% of the arrestees had at least one substance-use disorder; most had multiple disorders. More than 80% were substance dependent. The predominant substances used were amphetamines, marijuana, opioids and alcohol. 82% of the men and 94% of the women were suffering significant psychological distress.Conclusions: Development of services for detoxification and treatment of this population is a pressing need. The findings provide crucial information for the planning and implementation of drug courts and court diversion systems.

Edward B Heffernan BSc(Hons), FRANZCP · John B Saunders FRACP, FAFPHM, FRCP · Gerard Byrne PhD, FRANZCP · Joe Finn BN

A new model of depression with meaningful subtypes will avoid simplistic treatments When you hear the term “major depression”, you imagine a clinically meaningful entity. Think “pseudoentity”, know “paradigm failure”.1 If I took my tegument for dermatological inspection, a diagnosis of “major” or “minor” blotches would be uninformative. I would need more categorical information (eg, freckle, melanoma) to make rational treatment choices. However, non-specificity now rules in depression modelling and treatment. “Depression” is currently viewed as a single disorder, varying dimensionally. The World Health Organization’s international classification of diseases, 10th revision (ICD-10), specifies “mild”, “moderate” and “severe” episodes.2 The US Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV)3 categorises depression as “major depression” (episodes requiring at least five symptoms present for two weeks) and other (including “minor”) disorders. The Plimsoll line for “caseness” (ie, for diagnosis of a depressive disorder) has been further lowered, with two or more depressive symptoms held to define “new” (“subsyndromal” or “subclinical”) mood disorders.4 If the criteria for caseness are progressively loosened so as to capture most of the “blue” population, isn’t the meaning of a “depressive disorder” lost? The logical inconsistency of positing a “subclinical” disorder as a clinical disorder has not, however, discouraged efforts to prove high prevalence, functional impairment and need for treatment. The dominant Zeitgeist views depression as an “it”, a disease having nothing to do with the individual’s personality, and, because “it” is caused by chemical brain changes, requiring an antidepressant drug. However, for those with an antipathy to antidepressants, there are equally effective psychotherapies. Thus, all roads lead to Rome. Such “homogenising” has resulted in efficacy studies (the largest database in psychiatry) producing quite meaningless results.5 “Evidence-based psychiatry” is at risk of becoming an oxymoron. Mere polemic? Let’s consider some data. For “major depression”, efficacy studies quantify all antidepressants (old and new classes compared between and within classes) as equally efficacious,6 and the overall antidepressant drug response as comparable to that for St John’s wort, cognitive behaviour therapy (CBT), other psychotherapies and counselling.5 Why? Data from efficacy studies submitted by pharmaceutical companies for product licensing are problematic. One analysis of data for antidepressants submitted to the US Food and Drug Administration (FDA) showed that, of 47 trials for major depression, there was no drug effect in nine, and a drug–placebo difference of questionable significance for the remainder.7 In another analysis of 52 pivotal placebo-controlled FDA-submitted studies,8 half showed no advantage to the antidepressant drug. “Homogenising” depression and implying “universal” application for treatments leads to the inability to distinguish between differing effects according to differing depressive subtypes. Furthermore, trial selection of pristine subjects (eg, those without comorbidity, in whom melancholic depression is rare) ensures a high response rate in trials (to both active treatment and placebo) and thus their minimal separation. Yet these are the data on which current practice and treatment guidelines are based.9 So, everyone’s a winner — and a loser. Winners? All therapies can claim efficacy. Treatment then risks being determined more by the therapist’s discipline or interest — a Procrustean approach that fits the patient to the therapist’s preferred treatment. Losers? The pharmaceutical companies are challenged for “overselling” the properties of antidepressant drugs, patients feel demeaned in reading that antidepressant drugs are akin to placebos, and practitioner credibility is challenged. Moving along the “overselling” dimension, we are informed that the benefits of CBT have been scientifically proven and that it is the benchmark non-drug therapy. While CBT has credibility, a recent review10 of its efficacy returned the Scottish verdict of “not proven”, in that it lacked any superiority over other psychotherapies or “clinical management”. Despite CBT being held to be useful for multiple psychosocial problems, a recent Cochrane review11 of psychosocial interventions delivered in general practice found “good evidence that problem-solving treatment by general practitioners is effective for major depression”, but limited or conflicting evidence for CBT. As for antidepressant drugs, a potentially useful treatment may “fail” or appear weak if it is not tested on people with subtypes of depression who are likely to benefit. Let’s broaden the argument. Would we be sanguine about grouping all breast lumps (ranging from benign cysts to malignant cancers), testing myriad treatments as universal ones, interpreting the “homogenised” group data as indicative of comparable efficacy, and having an individual’s treatment determined largely by the treating practitioner’s discipline or enthusiasm? We would surely expect that a subtyping diagnosis would be made and that any treatment would be empirically based. Such a standard should also be demanded for diagnosing and managing the depressive disorders. While it is important that the mood disorders be destigmatised and that people be encouraged to seek assessment, it is equally important that they then receive appropriate diagnosis and treatment. Unpublished data from our clinics suggest that bipolar disorder is often missed or misdiagnosed, that the more biological (“black”) depressive disorders are undertreated, and that there is too much reliance on pharmacological treatments for managing non-melancholic disorders. We favour a model for identifying meaningful depressive subtypes that incorporates aetiology, development of a matrix linking subtypes to specific (and non-specific) treatments, testing the model’s utility in “real-world” clinical studies, and promoting broader education of professionals. The model is not intrinsically complex. The complexity lies in recognising and changing the Zeitgeist (see Box). While there is an argument for destigmatising depression with a simple message, there is no argument for doctors continuing to buy simplistic “one-size-fits-all” management recommendations for patients who present for assessment. Recommendations Treatment guidelines for managing the depressive disorders that rely on efficacy data should be regarded as providing tentative information at best. There is no “universal treatment” for depression. As it encompasses mood disturbances, syndromes, disorders and diseases, clinicians should expect heterogeneity, resist simplification, and reject the plausibility of any “universal treatment” model. Clinicians should seek to identify and address the causes of an individual’s disorder, allowing that causes may be biological, psychological and/or social. Assessing disorder “pattern” and aetiology (as against depression severity) allows clarification of the differential impact of various treatments on different disorder “types”. Clinical effectiveness data (assessing the full range of mood disorders and associated comorbidity in “real-world” conditions) should be given more airtime in developing a disorder–treatment matrix.

Gordon B Parker DSc MD PhD

A 6-year-old child, held in detention with his parents pending the outcome of their application for refugee status, manifested psychological distress by repeated episodes of refusing to eat or drink. This case presented clinical and ethical dilemmas for health professionals who were constrained from acting in the child’s best interests by government policy of mandatory detention. It is Australian government policy to detain asylum seekers who do not have a valid entry visa in one of six privately operated immigration detention centres while their refugee status is determined (Box 1). The detention environment has been implicated as a direct contributor to psychological distress, either de novo or as a “retraumatising influence”.1 This is reflected in the suicide rate in detention centres, which is conservatively estimated at 3–17 times that in the Australian community.2 Justice P N Bhagwati, Regional Advisor, United Nations High Commission for Human Rights, identified key human rights issues pertaining to immigration detention in Australia.3 These included the lack of independent monitoring mechanisms, restricted access by healthcare workers and lawyers, lack of protection of the family unit (exemplified in the Woomera Housing Project, whereby women and children were allowed to live in the community while their husbands remained in detention), the policy of detaining unaccompanied minors, and the prison-like conditions, which are not conducive to healthy childhood growth and development. In August 2001, Australasian paediatricians and psychiatrists issued a joint position statement calling for children and their families to be released from Australian detention centres, and highlighting concern for children’s “subsequent emotional development and for the effects of detention on the functioning of their families”. In June 2003, there were 315 children held in detention in Australia and Australia’s “excised offshore places” (such as Ashmore and Christmas islands),4 as well as on Manus Island (Papua New Guinea) and Nauru.5 The clinical and ethical dilemmas that arise when government policy restricts clinicians’ decision-making are illustrated by the clinical record of a 6-year-old boy in detention with his family, who had repeated episodes of refusal to eat or drink (Box 2). This case highlights issues applicable to many children in detention in Australia. DiscussionThis boy was in a state of distress, and preoccupied by imprisonment and the violence he had witnessed, as depicted in his drawings (Box 4). The form of his response may have been influenced by the behaviour of distressed adults (as role models) in Woomera and Villawood detention centres who staged hunger strikes. His improvement when away from the detention centre, and rapid deterioration on returning, communicated the impact of an aversive environment. Several authors have described high levels of depression, anxiety and post-traumatic stress disorder (PTSD) in adult asylum seekers detained in Australia. They have also observed that detention may profoundly undermine the parental role, leaving children with little protection or comfort.1,7,8 Considerable evidence exists that refugee children themselves are at significant risk of developing psychological disturbance (PTSD, depression, anxiety and sleep disorders),9 but they frequently present with mixed symptoms, not necessarily fulfilling a single diagnostic category.10 The likelihood of psychological disturbance increases with the synergistic impact of multiple risk factors, including observing parental helplessness, separation from parents, witnessing or experiencing traumatic events, and the time taken for immigration status to be determined.11 Psychological distress in the early years may have implications for long-term functioning12,13 and competence in adult life.14,15 Protective factors for children exposed to trauma include being with their parents,16 having a safe and predictable environment,17 and achieving a sense of mastery over the environment by becoming part of a school community.18,19 In May 2001, when this child first presented, public and professional criticism of the conditions in detention centres was beginning to be voiced. The treating team studiously avoided media attention, on the assumption that maintaining confidentiality and advocacy at the individual level was likely to produce the most favourable mental health outcome. The team was challenged by differing views on the extent to which healthcare workers should confront the systems issues contributing to this child’s distress. This child’s presentation highlighted both a hiatus in the evidence base for effective treatment options for such children, and the frustrations of health professionals at being unable to provide best-practice care. Although we offered play and art therapy, family and individual sessions, “therapy” made little sense, given the boy’s awareness of the constant threat of discharge back to the “camp” and the uncertain outcome of the family’s refugee claim. Clinical recommendations, such as maintaining family integrity or school attendance, could not be accommodated by the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) and the agency managing the detention centre (Australasian Correctional Management). Child protection, legal and ethical issues were extensively discussed in managing this case. The overarching constraint was the clash between the principle of acting in the child’s best interests and government policy on mandatory detention — often prolonged mandatory detention. t Under the Children and Young Persons (Care and Protection) Act 1998 (NSW), healthcare workers in New South Wales are mandated to report children at risk of harm to the NSW Department of Community Services, so that appropriate protective measures can be instituted.20 This child fulfilled the criteria for reporting, and various attempts to report him were made. Child protection is governed by state legislation and could not be activated, as detention centres are a federal responsibility. Furthermore, the Minister for Immigration has certain guardianship rights with respect to asylum-seeker children, creating difficulties for state welfare authorities. The ethical dilemma of returning a child to an aversive environment is not unusual for health professionals. When the environment is known to be abusive, healthcare workers can call on nominated child-centred agencies to assist in maintaining children’s wellbeing. However, this was not possible in this case, as detainee children are not subject to Australian child protection legislation, and their welfare is not systematically monitored. In 1990, Australia signed the United Nations Convention on the Rights of the Child. This convention embodies the principles of provision (of education, health and other services), protection (from torture, abuse and arbitrary detention) and participation by children in decisions affecting their lives. Article 22 proposes that refugee children should have the same rights as citizen children.21 In May 2002, an alliance of health professionals launched a submission to the Human Rights and Equal Opportunity Commission (HREOC) Inquiry into Children in Immigration Detention, and recommended that children should not be held in anything other than minimal detention for processing purposes only, and that all children and their parents should be released immediately.22 The child presented in this article was the subject of a complaint to the HREOC, which “recommended” that the Australian government pay $70 000 compensation to the child for harm suffered. The government rejected the Commission’s findings and recommendations.23 Under present government policy, children seeking protection in Australia are unlikely to receive services that fulfil their complex needs, and we remain concerned that their prolonged detention will impair their psychological well-being and their capacity to become integrated members of the community.1 1: Schematic representation of the process for asylum seekers without a valid entry visa for obtaining a Temporary Protection Visa* * Information from Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) website (www.immi.gov.au/facts/index.htm). †A Temporary Protection Visa entitles the holder to: temporary residence for 3 years; limited Welfare and resettlement assistance; access to Medicare benefits; no access to government English lessons; no family reunion; cannot leave and re-enter Australia (www.immi.gov.au/facts/64protection.htm). 2: Clinical record — a 6-year-old boy with recurrent refusal to eat or drink A 6-year-old boy presented to the Emergency Department of the Children’s Hospital at Westmead in May 2001. He was accompanied by his mother, infant sister and a uniformed officer from the Villawood Detention Centre. His mother reported, via an interpreter, that he had refused to talk or eat for the last 4 days, but that she had managed to coerce him to take small amounts of liquid. This episode began after the boy observed a man cutting his wrists (in the boy’s words “killing himself”) at the detention centre. The family was of Middle Eastern origin and belonged to a small religious group regarded as heretics in their country of origin. They had arrived in Australia by boat in March 2000, and then spent 11 months at Woomera Detention Centre and almost 3 months at Villawood Detention Centre. The younger child was born in detention. The family had been refused refugee status at all the initial stages of processing (Box 1), and were making a final-resort appeal to the Minister for Immigration and Multicultural and Indigenous Affairs for humanitarian consideration, a process seldom successful. The chronology of events is shown in Box 3. For 6 months before presentation, the boy had withdrawn from play with other children, and had been drawing similar repetitive images (Box 4). He became startled when he heard two-way radios used by detention centre officers. His mother described a chronic history of bedwetting and nightmares, which began after he witnessed riots and people setting themselves alight at the Woomera Detention Centre. Before this, he had been healthy, with normal development, although he had refused to eat and talk for half a day after one incident at Woomera. On examination, the boy was pale, listless and had clinical signs of mild dehydration. His height and weight were on the 75th and 50th percentiles, respectively. He was admitted to hospital for 6 days during which he gradually resumed talking and eating, although his bedwetting and nightmares persisted. Mental-state examination revealed a dull affect with slow, quiet speech and an anxious penetrating stare. He was unable to verbalise any wishes for the future, and said there was no point in making friends, because they all left while he remained in the “camp”. He described bad dreams about officers taking his father to gaol, and people cutting children with glass. The only drawing he produced in which the figures were not covered with bars was one of “the man who cut himself” (Box 5). He displayed extreme separation anxiety when his father departed after visits. He was assessed by the child psychiatry team as having acute on chronic post-traumatic stress disorder, fulfilling the Diagnostic and statistical manual of mental disorders (DSM-IV) criteria6 in that: (i) he was exposed to traumatic events; (ii) his response involved intense fear and helplessness; (iii) he had persistent re-experiencing of his trauma (through nightmares and with various triggers); (iv) he had a numbing of general responsiveness (with social withdrawal and refusal to speak or eat); and (v) he had symptoms of increased arousal (resulting in disturbed sleep). The differential diagnosis included depression, but this was considered less likely when many of his symptoms resolved within his short admission. He was discharged back to the detention centre after 6 days in hospital, with follow-up arranged with the centre psychologist and hospital team. The discharge summary, copied to the Centre Manager of Villawood Detention Centre, stated that he was at high risk of recurrence unless a more normal environment could be provided, that he should remain together with his family, and that access to a school with stable peer relationships would be important. In addition, it was asserted that the uncertainty about his family’s future was likely to be perpetuating his symptoms. Six days later, the boy re-presented to the hospital with refusal to eat or drink and mild dehydration. His readmission necessitated a series of complex interagency negotiations in an attempt to provide a reasonable standard of care. The negotiations involved Australasian Correctional Management (the agency managing the detention centres), Villawood Detention Centre management and health services teams, and various case managers assigned by the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA), and covered coordinating parental visits and family counselling sessions, interpreters, visitors, culturally appropriate food, and possible discharge arrangements. Other difficulties included the lack of a structured daily program (as an asylum seeker, he was not eligible to attend the hospital [Department of Education] school), the social alienation of the child and family within the ward, the emotional distress experienced by the interpreters encountering the family situation, and dealing with the dilemma of whether the hospital should be acting as a place of safety for the child. Since protection from trauma was the most important part of treatment, discharge to the detention centre was likely to re-traumatise him. During the 8-week hospital stay, the boy became increasingly frustrated and difficult to contain because of his limited access to recreational, educational and other stimulating activities. He resented that detention centre officers were in close proximity at all times. His separation anxiety was fuelled by unpredictable parental visits, and the alternating arrangement of one parent staying with him. Multiple case planning meetings involving Villawood and DIMIA representatives failed to produce a resolution to the dilemma of a discharge placement for the child. The municipal office of the Department of Community Services was unable to intervene. There was no alternative except to discharge him back to the detention centre. The child now entered a phase of repeated presentations to the emergency department every few days over a period of 4 weeks, with a pattern of food refusal and dehydration. On each occasion, he required nasogastric rehydration and stayed for 1–2 days. His mother described how he would become pale, quiet and sweaty when he saw the fences that featured in his drawings. After six such presentations, he was readmitted for nutritional review as he had lost 3 kg. Two weeks later, his parents agreed to DIMIA’s offer of discharge to foster carers, and DIMIA arranged Department of Community Services approval of the nominated carer. DIMIA declared the boy’s new home and school a “place of detention”, and engaged a private psychotherapist. He was reported to have frequent emotional outbursts, disrupted sleep and difficulty coping with separations from his family after weekend access. The foster carers were ill-prepared for dealing with his distress, and the placement was continuously under threat. With no placement alternative, DIMIA granted permission for the boy to live with his mother and sister in the community. Seven months later, his father joined them when the Federal Court allowed re-application to the Refugee Review Tribunal and Temporary Protection Visas were granted. Of interest is that no new evidence was presented, compared with the family’s original application. These visas are valid for 3 years, and the future thereafter is uncertain for the family. Although an eager learner at school, the boy currently has regular nightmares and is fearful that his family may be returned to the “camp”. At the time of publication, the family are being seen by therapists at a state-funded trauma counselling service. 3: Chronology of events related to the child March 2000 Arrived in Australia (age 5 years) March 2000 – February 2001 Woomera Detention Centre. Infant sister born March – May 2001 Villawood Detention Centre May 2001 Initial hospital presentation and admission (age 6 years) May 2001 Re-presented 6 days after discharge May 2001 First letter and fax to the Minister for Immigration from treating team at Children’s Hospital at Westmead May – July 2001 8-week hospital admission June 2001 Subsequent letter to the Minister for Immigration from treating team at Children’s Hospital at Westmead July – August 2001 Six emergency department presentations August 2001 Received reply from the Minister for Immigration September 2001 2-week hospital admission September 2001 Granted Bridging Visa.* Discharged into foster care January 2002 Mother and sister granted Bridging Visas, and child returned to mother’s care in the community (aged 7 years) August 2002 Family granted Temporary Protection Visas, allowing family to live together in the community *Used to allow an applicant for a substantive visa to remain in the country out of detention while their visa application is being processed. 4: The child’s drawings were dominated by the fence “They’re crying. They’re all scared. Scared of officers — all of them” (the child’s description of the people in the foreground). “It’s a stick. They bash up children with that wood” (the child’s description of the person in the background). 5: The child’s drawing after seeing a detainee cut his wrists “The man who cut himself”

Karen J Zwi FRACP · Brenda Herzberg FRANZCP · David Dossetor FRCPsych · Jyotsna Field MPsych

Clinical records Patient 1 An 88-year-old man gave a 12-month history of seeing insects attacking his legs and crawling along the floor of his house. He described these insects as 4 cm long, black and white bugs with beaks, which pecked at his legs, causing wounds. He often felt a sharp stinging sensation heralding their presence. He also had burning pain in both legs below the knees. He had had his house fumigated twice in the previous year and put various chemicals across his doorways and bed to ward off the bugs. He described no other hallucinations or delusions. He was not using any regular medications and had never been a consumer of alcohol. He lived alone and managed all activities of daily living independently. His home was clean, and he had no pets. Score on Folstein Mini Mental State Examination was 28/30. Neurological examination revealed signs of peripheral neuropathy of the lower limbs. His visual acuity was poor. During the examination, he pointed to several “bugs” on his legs, which were actually pieces of skin peeling from superficial ulcers. Nerve conduction studies confirmed peripheral neuropathy. Computed tomography and magnetic resonance imaging of the brain showed ischaemic changes. Magnetic resonance angiography showed severe stenosis of the left internal carotid artery. Septic screen and serological tests for syphilis gave negative results. The patient’s symptoms were thought to be due to neuropathic pain. He was prescribed carbamazepine (100 mg twice daily) to alleviate the sensory stimuli, and risperidone (0.5 mg in the morning, 1 mg at night). After 2 weeks, the pain and delusions had decreased substantially. Diagnosis: Delusional parasitosis associated with medical conditions — neuropathy and poor visual acuity. Patient 2 A 72-year-old woman had a 20-year history of the delusion of worms crawling throughout her body, especially around a scar on her hip. She was convinced that the scar should be surgically explored. Past medical history included type 2 diabetes mellitus, normal pressure hydrocephalus with shunt insertion, ischaemic heart disease and fractured right neck of femur. She lived in a hostel. Her cognition was normal, and clinical examination found no abnormalities. She was treated briefly with thioridazine (40 mg daily), which provided some benefit but caused drowsiness. She was then treated with pimozide (2 mg twice daily), which was changed to olanzapine (2.5 mg in the morning, 5 mg at night) because of continuing agitation, paranoid ideation about her neighbours and “intruders”, and aggression to neighbours and hostel staff. Her symptoms decreased but did not resolve, and compliance was poor. Diagnosis: Paranoid schizophrenia with major psychotic symptom related to infestation. Patient 3 An 81-year-old woman was referred with a persistent belief that she had scabies and lice infestation of her eyes, nose, arms and anus. This resulted in her persistently washing her clothes and herself and reporting the retirement village where she lived to the Health Department. She had received anti-scabies treatment empirically. She had a long history of severe depression after the death of her husband, for which she took doxepin. She had paranoid ideation about her neighbours and saw things crawling down the walls, and had moved residences several times to avoid these problems. Other medical problems included treated hyperthyroidism, oesophageal stricture and partial pneumonectomy. She did not drink alcohol. Score on Folstein Mini Mental State Examination was 28/30. She was prescribed haloperidol (0.5 mg twice daily) and continued taking doxepin. The delusions of scabies subsided. Four years later, she developed new thoughts that dirt was being deposited in her unit by builders working nearby. She had stopped taking haloperidol in the interim. She became agitated, covering her furniture and closing all gaps around doors and windows. She was prescribed olanzapine (2.5 mg at night). Diagnosis: Delusional parasitosis in conjunction with depressive illness. Patient 4 A 74-year-old woman was referred for assessment of tactile hallucinations. She had a 2-month history of presumed worm infestation and persistent complaints of anal and vaginal pruritus despite multiple courses of an anthelminthic. She had complained previously of feeling head and body lice. Her past medical history included chronic airways limitation, trigeminal neuralgia, which was treated with sodium valproate, and temporal arteritis, which had responded previously to corticosteroid therapy. She lived alone and was previously active, but had became depressed and isolated because of these delusions. No abnormalities were found on physical examination. Examination of a skin specimen, which the patient thought contained worms, showed cotton threads. Full blood count was normal, with no eosinophilia and normal erythrocyte sedimentation rate. Sigmoidoscopy found no abnormalities, while computed tomography of the head showed a previous left parietal infarct. She was prescribed pimozide (2 mg daily), with complete resolution of the worm sensation. Diagnosis: Isolated delusional parasitosis. An older person requesting treatment for an infestation may not seem unusual. However, when the complaint persists despite repeated treatments for lice, scabies and other parasites, and examination shows no evidence of an infestation, the differential diagnosis includes delusional parasitosis. Management of this condition is challenging but rewarding, as it may cause severe emotional, social and physical disability in both the afflicted individuals and those around them. We describe four patients with delusional parasitosis who were managed in our department of geriatric medicine (see Clinical records). Delusional parasitosis, named in 1946,1 is a chronic psychiatric disorder in which patients have a false and fixed belief that they are infested by parasites. It is not a phobia.2 The core of the disease is the delusion of infestation and, although it is a psychiatric disorder, patients usually seek help from dermatologists. Its onset is insidious, and the delusion is typically preceded by a primary tactile experience, such as pruritus or paraesthesia, or tactile hallucination, which precipitates the secondary delusion of infestation. The condition may occur as an isolated thought disorder in a person whose psyche is otherwise intact, as illustrated by Patient 4. This has also been termed monosymptomatic hypochondriacal psychosis3 and “primary” delusional parasitosis.4 When associated with a psychiatric condition, such as schizophrenia (Patient 2) or depression (Patient 3), delusional parasitosis has been termed “secondary functional”, and, when caused by a medical illness (eg, diabetes, malignancy or nutritional deficiency), medication or substance misuse, it has been termed “secondary organic”5 (Patient 1). In the classification system of the Diagnostic and statistical manual of mental disorders (DSM-IV), primary delusional parasitosis corresponds to “delusional disorder, somatic type”, while the secondary organic type corresponds to “psychotic disorder due to general medical condition”.6 The prevalence of delusional parasitosis is unknown, but our literature review identified several hundred cases reported by dermatologists and entomologists.2,3,5,7,8 It can occur at any age, the average being in the fifth decade. In the older age group, women are more often affected than men.2,7 Mean duration of symptoms before attending tertiary care was 1.3 years in one study.8 Patients with no precipitating medical problems or psychiatric illness often have a personality disorder and isolate themselves, but function well in other aspects of their day-to-day living.3 Patients provide incredibly detailed descriptions of the “bugs” and explanations about why they are not visible on examination. They often bring in “specimens” in a small container, which are actually pieces of skin, lint or hair (“the matchbox sign”), or may identify “bugs” during examination by probing into skin until they are able to pick up a small piece of tissue. This may produce traumatic ulcers of varying size, typically on areas the patient can reach, in an asymmetrical distribution corresponding to the dominant hand. Secondary dermatitis may develop as a result of repeated washing and application of chemical preparations.2 Management involves first excluding a real infestation and any underlying condition, including psychiatric disorders, medical conditions with altered sensation, use of drugs (prescribed and illicit) or withdrawal from alcohol or cocaine. Mental state, including cognition, needs to be assessed. Other investigations may include examination of skin scrapings and skin biopsies. In therapy, the most important step is to establish a trusting doctor–patient relationship. An empathic approach is required, acknowledging the reality of patients’ symptoms without challenging or confirming their views about the cause. Samples of any alleged parasites presented must be examined. Ideally, patients should be referred to a psychiatrist, but many resist this. Consequently, medication with an antipsychotic should be initiated by the doctor who makes the diagnosis. Treatments include pimozide2,3,5,7 and the newer atypical antipsychotics, such as risperidone.9 Medication compliance can be a problem. There have been some reports that tricyclic antidepressants and anxiolytic agents alleviate the reactive component of the condition without much effect on the delusions.2,7 Doxepin has strong antihistamine and anxiolytic effects, in addition to its antidepressant effect, and, based on its effectiveness in chronic neurotic excoriation,10 may be useful in patients who frequently experience intense pruritus, anxiety and agitation as well as depressive symptoms. Corticosteroid creams and lotions may be helpful adjuncts to alleviate skin symptoms. Lessons from practice Delusions of parasitosis may occur alone or in association with medical or psychiatric illness. Antipsychotic agents are the mainstay of medical management. Empathy and a good doctor–patient relationship are required to optimise outcome.

Linda Le BM BS, DCH · Peter N Gonski BMedSc, FRACP

Mai Maddisson General Practitioner, Mitcham North Clinic, 188 Mitcham Road, Mitcham, VIC 3132. mmaddisson.nmcATwdgp.com.au To the Editor: I read with interest McFarlane’s article on post-traumatic stress disorder and debriefing,1 which reminded me of a long-term patient. Over a decade ago, I discovered that this patient was a Vietnam veteran, and expressed concern that he had not told me previously. His reply came thus (although, of course, I no longer remember the exact words): “How would you know what it feels like to be, by sheer chance, the only man left alive in a group of soldiers?” I acknowledged that he was correct, that I had no idea. With that poignant remark in mind, I planned his care. He is doing OK. Can we really address an abstraction that we cannot conceptualise, or predict the resulting obstacles in a person’s journey through life? This is equally valid at the beginning of the journey or anywhere along its course. Perhaps the notion of debriefing at an appropriate time is not the problem; perhaps it is the formula we use.

Mai Maddisson

Provision of "Focussed Psychological Strategies" by general practitioners is one component of the recent Better Outcomes in Mental Health Care (BOiMHC) initiative. The BOiMHC initiative requires GPs to undertake minimum training requirements before they may provide services under the new Medicare Benefits Schedule item number. We argue that GPs need further training and ongoing clinical interaction with mental health specialists (beyond the minimum training requirements) for refinement of psychological skills. Research focusing on GP training and how GPs interact with specialist services in the provision of psychological treatments is urgently required.

Grant Blashki MD, FRACGP · Ian B Hickie MD, FRANZCP · Tracey A Davenport BA(Hons)