Mental health

Re: "Asthma symptoms associated with depression and lower quality of life: a population survey?", the Research article by Robert D Goldney, Richard Ruffin, Laura J Fisher and David H Wilson in the 5 May issue of the Journal (Med J Aust 2003; 178: 437-441), in which variables in Box 1 were incorrectly labelled. "Male sex" should have been "Female sex", and "Overseas born" should have been "Australian born". The corrected table is shown. The html and pdf versions of the article were corrected online on 30 June 2003. Predictors of asthma determined by logistic regression Variable Odds ratio (95% CI) P Female sex 1.55 (1.22–1.99) 0.003 Depression 1.40 (1.04–1.88) 0.026 Australian born 1.60 (1.18–2.18) 0.003

Robert D Goldney MD, FRANZCP · Richard Ruffin MD, FRACP · David H Wilson MPH, PhD · Laura J Fisher BA(Hons)

Work and mental health: an employer’s guide. Doreen M Miller, Maurice Lipsedge, Paul Litchfield (editors). London: Royal College of Psychiatrists, 2002 (176 pp). ISBN 1 901242 85 4. This useful book is a joint effort by the Royal College of Psychiatrists and the Faculty of Occupational Medicine, Royal College of Physicians to give practical advice on mental illness in the workplace. Contrary to the subtitle, however, it will be of more use to doctors than employers because of its clinical focus. Most chapters are written jointly by a psychiatrist and an occupational physician, which helps to maximise relevance to the workplace. There are a few chapters written by others such as a human resource manager and an organisational psychologist. The book falls roughly into two sections; one dealing with specific psychiatric conditions and the other with workplace stress. The former begins with a superb chapter “Assessing mental health problems in the workplace”. There are also chapters on anxiety, depression, substance abuse, critical incidents, chronic fatigue syndrome, schizophrenia and organic states. These combine a good resume of salient clinical points with a discussion of the issues in managing the employability of the patient. The high quality information on these difficult topics will be appreciated by many clinicians. On the other hand, the chapters dealing with workplace stress are disappointing and emphasise how little progress has been made in this area over many decades. Several case studies of stress programs in various organisations are presented, including pharmaceutical, electricity and telecommunications companies. Each is claimed to have been beneficial. However, there is a distinct lack of candour in the presentations, which lessens their credibility. It is highly unlikely that so many programs were successful without some setbacks, but none are reported. Also, there is no substantial statistical data presented to support the claims of benefit even though it is stated that surveys of “staff opinion” (or similar stress indices) were done periodically. The main advance appears to arise from major legal decisions under disability discrimination law which require employers to make reasonable adjustment for the employment of those affected by work stress or other mental illness. The book is a timely summary of mental illness in the workplace, showing both the strengths and weaknesses of current practice. It will be of much interest to those who provide medical care to workers and workplaces. Bruce HockingOccupational Physician Camberwell, VIC

Bruce Hocking

Healthy risk-taking is a normal part of adolescence. Young people who participate in multiple risk-taking increase the chance of damaging their health. There appears to be a growing range and prevalence of health-risk behaviours among young women, notably in their use of alcohol and marijuana. Research suggests that such health-risk behaviours may be related to psychological factors such as stress and depression. General practitioners have a central role in identifying and preventing health-risk behaviours and associated mental health problems in young people. Comprehensive assessment includes a series of screening questions about home, education (or employment), activities, drugs, sexuality and suicide for young people, known as the HEADSS technique.

Michael RC Carr-Gregg BA(Hons), MA, PhD, MAPS · Kate C Enderby BA, GradDipHealthPsych · Sonia R Grover MB BS, FRACOG

Many young women feel that body image and exercise are important for their self-esteem, want to lose weight, are afraid they might gain weight, and feel fat. Interventions that improve self-esteem, encourage communication and help adolescents to be supportive of each other may prevent some of these women from developing eating disorders. If an eating disorder is suspected, it may be useful for physicians to ask about fear of loss of control over the body, eating, weight and shape; and preoccupation with food, eating, nutrition, body weight and shape, as these issues may differentiate those at greater risk.

Suzanne F Abraham MSc, PhD

In this issue of the Journal, Priest and colleagues report a further study showing the lack of effectiveness of "debriefing" after a traumatic event in preventing psychological disorders — in this case, in women after childbirth.1 Their use of debriefing for this purpose indicates how widely the enthusiasm for this intervention has spread in the past decade. On superficial examination, early interventions are an appealing ...

Alexander C McFarlane MD, DipPsychother, FRANZCP

Objective: To test whether critical incident stress debriefing after childbirth reduces the incidence of postnatal psychological disorders.Design: Randomised single-blind controlled trial stratified for parity and delivery mode.Setting: Two large maternity hospitals in Perth.Participants: 1745 women who delivered healthy term infants between April 1996 and December 1997 (875 allocated to intervention and 870 to control group).Intervention: An individual, ...

Susan R Priest M Psych, PhD · Jenni Henderson BSc, MPH · Sharon F Evans MSc, PhD · Ronald Hagan MB BCh, MBA

Re: the 5 May 2003 supplement to the Journal, Comprehensive care for people with schizophrenia living in the community (Med J Aust 2003; 178: S41-S80). In some articles, authors referred, in the text or reference list, to other articles in the same supplement. In a few instances, the page numbers of the cited articles were omitted in the printed version. The web version published simultaneously ...

Surviving stalking. Michele T Pathe. Cambridge: Cambridge University Press, 2002 (vi+166 pp). ISBN 0 521 00964 2. To be stalked is an unhappy experience. The consequences range from a continuing disquiet to gross disruption of one’s life, thoughts of suicide, and the development of a range of psychiatric disorders. Since some victims keep quiet about being stalked its exact prevalence is not known, but one large survey in the United States found that 8% of women and 2% of men had been stalked at some time in their lives. Usually it goes on for months, but occasionally it continues for years. In spite of all this it is difficult to find a comprehensive, up-to-date and clearly written account of what happens, who does it and what one can do about it. This book does all that, and much more. Pathe is well qualified to write it, being a consultant forensic psychiatrist at the Victorian Institute of Forensic Mental Health in Melbourne, where she has been treating stalkers in the world’s first clinical outpatients program, since the early 1990s. She is co-director of the Stalking and Threat Management Centre and is co-author of the best-selling Stalkers and their victims, and winner of the American Psychiatric Association’s Guttmacher Award for an outstanding contribution to the literature on forensic psychiatry. The book is relevant both to our patients and to us. Many doctors receive continuing unwelcome attention from disgruntled patients. Read the book and you will find out what to do about it. Not only does Pathe cover the practical and clinical issues but, in addition, she has chapters on how to navigate the criminal justice systems in the United States, the United Kingdom and Australia. All this and more is covered in 135 pages of text. There is no jargon and nothing is left out. Doctors considering launching into authorship could use her book as a model. Its price is more than one might anticipate for a relatively short paperback but the contents are worth it. John EllardPsychiatrist Balmoral Beach, NSW

John Ellard

To the Editor: The beyondblue guidelines for treating depression in primary care by Ellis and Smith1 are intended to assist both healthcare professionals and consumers. While they provide several helpful indications, they also include some misleading suggestions. The authors state that drug treatment of depression should continue for at least one year for a first episode of depression, and at least two years for repeated episodes or when there are other risk factors for relapse. However, no background literature is cited in support of this statement, and indeed would be difficult to find. Maintenance pharmacotherapy has been advocated as an effective tool for reducing relapses and recurrences in major depression.2 A number of studies have shown the superiority of antidepressant drugs (mostly tricyclics) compared with placebo in protecting the patient from relapse. Duration of drug treatment, however, did not seem to affect long-term prognosis once treatment with the drug was discontinued. In clinical terms this means that, whether you treat a depressed patient for three months or three years, it does not matter when you stop therapy with the drug. In fact, after recovery from an index episode of major depression, risk of postdiscontinuation relapse was nearly significantly greater after longer treatment (ρ = 0.37; P = 0.052).3 Further, Ellis and Smith1 fail to mention a vexing clinical problem in maintenance antidepressant treatment: the return of depressive symptoms.3 Dose increase is likely to entail only a temporary solution to the problem, which may occur in up to 57% of patients. However, there is a promising alternative. Treatment of depression by pharmacological means is likely to leave substantial residual symptoms.4 Residual symptoms hinder lasting recovery and are one of the strongest risk factors for relapse. In randomised controlled trials, cognitive behavioural treatment of residual symptoms was found to significantly improve long-term outcome of recurrent depression and to allow discontinuation of drug therapy.4 Preventing recurrence in major depression cannot simply be based on prolonging ongoing pharmacological treatment. The belief that a longer course of treatment will result in a more favourable outcome after discontinuation of antidepressant drug therapy is not supported by research evidence.5 Active collaboration with the patient (in choosing a treatment option, in lifestyle modification, in seeking treatment again when needed) is a crucial, and yet neglected, variable. It can lead to a more rational use of antidepressant drugs and to therapeutic efforts of more enduring quality than those prevailing today.

Giovanni A Fava · Chiara Ruini · Eliana Tossani

In reply: Fava observes that duration of treatment with an antidepressant does not affect the subsequent rate of relapse. Indeed, it would be unexpected if it did; medication only works while it is being taken. He then states that the duration of antidepressant treatment is immaterial. However, Figure 1 of the reference he quotes1 indicates that, for at least 54 months after the index episode, continuing medication provides greater protection against relapse than early discontinuation. This argues strongly for the beneficial effects of continuing antidepressant therapy for a significant period after recovery. The duration of this period depends on the number of previous episodes of depression and is a compromise between the benefits of effective prophylaxis and the burden of treatment. He also refers to a study of "tolerance" to 20 mg fluoxetine.2 Of patients who responded to treatment, 31.4% relapsed while on maintenance treatment. Of these, 57% responded to an increase to 40 mg fluoxetine and remained well for six months. He appears to have interpreted these data differently. I agree that treating depression involves more than prescribing. The beyondblue guidelines promote active collaboration with the depressed person in addressing key issues in their lives and a focus on relapse prevention.3 Cognitive behavioural therapy is one strategy for achieving this.

Pete M Ellis

Cries unheard. A new look at attention deficit hyperactivity disorder. George Halasz, Gil Anaf, Peter Ellingsen, Anne Manne, Frances T Salo. Alton, VIC: Common Ground, 2002 (x+91pp). ISBN 1 86335 497 2. There have been controversies about the existence and nature of attention deficit hyperactivity disorder (ADHD) since George Still first described it in 1902. The “new look” presented here is the notion that the diagnosis is used as a quick fix to deal with complex situations, allowing one to write a prescription rather than attempt to understand a complex psychodynamic problem. There can be no objection to this approach as our profession has some expertise in producing epidemics which disappear as rapidly as they have appeared — consider the rise and fall of repetitive strain injury (RSI). This book argues that there are many pressures in modern society urging us to find a quick fix, ranging from the activities of the pharmaceutical companies, to the DSM-IV-driven push to confine human distress within categorical boundaries. This is true, however one must examine the total situation, and this is where the authors’ bias shows. Being psychodynamically oriented, they see it as likely that wisdom is to be found in that direction. So it may be, but it is not many years since their antecedents proclaimed that schizophrenia was due to the activities of “schizophrenic” mothers, autism to cold-hearted parents, and the “psychosomatic” disorders to psychodynamic mechanisms. For example, Alexander regarded ulcerative colitis as a regression to the anal stage of psychosexual development, while Szasz and Cushing emphasised the orality of the disease. There were descriptions of the “typical conflict situation” associated with peptic ulcer and asthma. No theoretical position has a mortgage on wisdom. There are some facts about ADHD which will not go away. They emerge most clearly when one deals with adults who are able to give a good account of themselves. It has a firm correlation with dyslexia and anomalies of motor dominance, such as being left-handed and right-footed. Recent work suggests that chromosome 6p may be involved. There are well-established neuroimaging anomalies and there is the paradox that the hyperactivity calms with stimulants instead of being exacerbated. By all means let us look carefully, but let us look in all possible directions. John H T EllardPsychiatrist Balmoral Beach, NSW

John H T Ellard

In Australia there continue to be significant barriers to care and gaps in service provision for people with schizophrenia. The extent of these shortcomings is echoed in the National Survey of Mental Health and Wellbeing study on low-prevalence (psychotic) disorders.1 Of the 998 people with psychotic disorders surveyed, 84% were single, separated, divorced or widowed; 85% were reliant on welfare benefits; 72% did not have a regular occupation; and 45% were living in some form of hostel or supported accommodation, or were homeless. These unacceptable psychosocial outcomes were evident despite the fact that 91% of the people surveyed were currently receiving psychotropic medication. Furthermore, only 19% of patients had used any form of rehabilitation service over the previous year. It was not that they did not want to access such services; indeed, 47% of the survey cohort perceived the need for a particular type of service that was not accessible to them, either because it was unavailable or they could not afford it. The service provider with whom the majority of survey respondents did have regular contact was their general practioner: 81% had seen their GP in the previous year, and the average number of visits was 12 per year.1 Clearly, not all of these contacts were for mental health reasons, but the extent and regularity of contact with GPs by people with schizophrenia highlights the potentially crucial role GPs can play in their overall health. GPs are likely to have increasing involvement with managing medical comorbidity in patients with schizophrenia, especially now that newer "atypical" antipsychotic drugs are available. Thus, this Supplement, highlighting the latest developments in managing schizophrenia and delivering comprehensive care, is particularly relevant for GPs. Hocking (page 47)2 underlines the place of the community in schizophrenia management — highly pertinent in these "post-institutionalisation" days, when the vast majority of people with schizophrenia are resident in the community. It is important that GPs understand the functioning of the modern mental healthcare system, know what resources are available to assist in managing patients with schizophrenia, and have the information required to negotiate potential barriers to accessing support services. These issues are detailed by Harvey and Fielding (page 49).3 A model for GP participation in managing people with schizophrenia is outlined by Meadows (page 53),4 in the hope that the principles can be adapted more broadly. There have been substantial recent developments in pharmacological treatments for schizophrenia. No longer are treatments for psychosis inevitably associated with unpleasant and potentially debilitating extrapyramidal side effects such as parkinsonism, akathisia and tardive dyskinesia. The newer "atypical" antipsychotics are much less likely to have these disabling side effects, and are now first-line treatment for schizophrenia. However, the atypicals have been associated with other medical problems, including weight gain,5 diabetes6 and hyperlipidaemia.7 The decision about which drug to use for any individual patient requires a careful weighing of the side effects against potential therapeutic effects. An overview of the atypical antipsychotics is provided by Lambert and Castle (page 57).8 Despite pharmacological advances, some patients remain "resistant" to conventional treatments. However, we are increasingly able to offer such patients newer treatments that more effectively reduce psychotic symptoms and enhance quality of life. Indeed, the newer agents can have benefits in a number of domains, including those of behaviour, depressive and suicidal thoughts, and cognitive functioning, as well as improving social and vocational outcomes. The management of "treatment resistance" in schizophrenia is reviewed by Pantelis and Lambert (page 62).9 The physical health of people with schizophrenia is often suboptimal, and general medical conditions may either be missed, through inadequate screening, or treated suboptimally. The GP has a crucial role to play here. Lambert et al (page 67)10 outline the main medical problems encountered in people with schizophrenia and the barriers to detection and treatment. Many of the interventions for general medical conditions such as obesity and hypertension require educating the patient about "healthy living", including regular exercise, attention to diet, and stopping smoking. A common problem among people with schizophrenia is the misuse of alcohol and illicit substances. Substance misuse impairs the overall health of the individual, resulting in more severe symptoms, greater chance of relapse and re-hospitalisation and, in some instances, increased risk of crime and violence. Again, the GP has an important role to play in detection and management of comorbid substance misuse. Lubman and Sundram (page 71)11 provide practical guidance for GPs in dealing with this complex issue. Finally, Crosse (page 76)12 suggests ways in which people with schizophrenia can be helped to participate fully in society so that each day is full and meaningful. This should be the aim of all of us involved in the care of people with schizophrenia.

David J Castle MD, MRCPsych, FRANZCP · Christos Pantelis MRCPsych, FRANZCP

The stigma associated with schizophrenia is pervasive, both in the community and among healthcare workers, and forms a real barrier to optimal recovery from the illness. The negative consequences of stigma include discrimination in housing, education and employment, and increased feelings of hopelessness in people with schizophrenia. Health professionals have a responsibility to improve their own attitudes and behaviour towards people with schizophrenia so they do not contribute to the stigma. Educational campaigns aimed at people in the community and media personnel could help to demystify mental illness and reduce the portrayal of offensive stereotypes of people with schizophrenia.

Barbara Hocking BSc(Hons), DipEd, DipHEd, GAICD

In Australia, the configuration of public mental health services varies between States and Territories, but, overall, community-based services are increasingly integrated and responsive to people with schizophrenia. Community-based services include mobile crisis teams, providing home-based acute treatment, and case-management services for ongoing treatment. Service improvements have been uneven across Australia. Some people with schizophrenia in psychiatric crisis have had difficulty accessing either home-based acute psychiatric treatment or acute psychiatric beds. Social isolation and lack of meaningful occupation continue to be a problem for people with schizophrenia. Psychosocial interventions can enhance reintegration into the community. However, the number of community-based psychosocial rehabilitation programs is still inadequate.

Carol A Harvey MRCPsych, FRANZCP · John M Fielding MD, FRANZCP

Many people with schizophrenia are in regular contact with their general practitioners. GPs commonly play a sentinel role in management, but may require support from Area Mental Health Services (AMHSs). The CLIPP (Consultation and Liaison in Primary-care Psychiatry) shared-care model of patient management combines a collocated consultation/liaison service for managing referrals from GPs to specialists with a carefully structured approach to long-term care of patients transferred from AMHS care to GPs. The CLIPP model uses the concept of a "relapse signature", involving recognition of early warning signs of relapse, to simplify clinical monitoring of patients with schizophrenia.

Graham N Meadows MBChB, MRCP, FRANZCP

Pharmacological treatment remains the mainstay of the management of schizophrenia. Older, "typical" antipsychotics carry a significant burden of side effects, notably extrapyramidal and neurocognitive side effects. Newer, "atypical" agents carry a lower risk of extrapyramidal side effects. They appear to have added benefit for treating negative and cognitive symptoms of schizophrenia, and hence can enhance the quality of life of some patients. The choice of particular agents for individual patients requires a balancing of efficacy and side effects. Medication is only one element of what should be an individualised comprehensive treatment plan for people with schizophrenia.

Timothy J R Lambert BSc, MB BS, FRANZCP · David J Castle MD, MRCPsych, FRANZCP

Patients who fail to respond adequately to pharmacological treatment present an ongoing therapeutic challenge. The term "incomplete recovery" (IR) is preferred to the current term "treatment resistance" to describe these patients. IR should be considered from a multidimensional perspective that includes a broad range of symptoms and functional disabilities that are relevant to schizophrenia. The approach to the incompletely recovered patient needs to be systematic, with consideration given to the factors that may hamper recovery. "Atypical" (second-generation) antipsychotic drugs target various domains of symptoms relevant to IR. Adjunctive treatment strategies (eg, mood stabilisers, antidepressants, combinations of antipsychotics) may be useful, but should be undertaken in specialist psychiatric settings. Although pharmacological treatment is a necessary first step in managing incompletely recovered patients, adjunctive psychosocial interventions are needed to optimise treatment success.

Christos Pantelis MB BS, MRCPsych, FRANZCP · Timothy J R Lambert BSc, MB BS, FRANZCP

Reforms to the management of schizophrenia in Australia have stalled A decade ago, the management of schizophrenia languished in medicine's backwaters. Treatment still occurred in asylums, using drug therapies serendipitously discovered decades earlier. Even these had proved ultimately disappointing and were used in excessive doses, with inevitable serious adverse effects, a great deal of suffering and only modest benefit. Psychosocial treatments were similarly obsolete or simplistic, with a weak evidence base. Therapeutic nihilism was pervasive and stigma profound. The public knew little about schizophrenia and gave little thought to it unless they happened to be directly touched by the disorder in their own lives. The Burdekin Report graphically captured this bleak scenario.1 The situation 10 years on is much more promising. Spurred on by the reintroduction of clozapine, a new wave of drug discovery has produced a second generation of antipsychotic drugs. Because of their better tolerability, and boosted by potent marketing campaigns, these "atypical" drugs have now become the first-line treatment in Australia and have engendered greater optimism in managing schizophrenia. Psychosocial treatments have undergone a similar renaissance,2 with the advent of evidence-based family interventions, cognitive behaviour therapy for persistent psychotic symptoms, and vocational rehabilitation models. The first National Mental Health Strategy catalysed an overdue reform process and created a real sense of progress. Early intervention strategies, not seriously attempted previously in schizophrenia, were effectively developed in Australia, evaluated and exported.3 The prospects for people with schizophrenia never seemed better. However, the potential for greatly improved outcomes has not been realised in Australia. The daily reality for most people with schizophrenia is that quality of treatment and quality of life are relatively poor.4 Many live in poverty in substandard housing, having little to occupy their time and trying their best to cope, often with the aid of harmful amounts of legal and illegal substances. The plight of family members is also serious and all too often leads to frustration and despair. Despite the early intervention reform, which is being taken up enthusiastically overseas,3 long delays in obtaining treatment for first episodes of schizophrenia are still common. Treatment is typically withheld until it can no longer be denied.5 In 2002, the Mental Health Council of Australia was contracted by the Federal Government to conduct a comprehensive review of the mental health system. The review concluded that, despite a decade of reform, Australia still does not have effective or accessible mental healthcare. Serious under-resourcing was identified as the fundamental cause. By the end of the 1990s, the devolved and mainstreamed mental healthcare system had developed a raft of problems. The reform process had stalled behind the complacent facade of a "mission accomplished". A recent review of Victoria's mental health services by the State's Auditor General found evidence of unmet need, poor access to and continuity of care, and low levels of satisfaction with services — problems attributed primarily to under-resourcing.6 Similar problems are likely to exist in other States. Furthermore, a substantial proportion of people with schizophrenia, whose management requires a team approach with specialist review, are being managed in minimalistic fashion by general practitioners with insufficient support from a beleaguered and reactive specialist system. As a result, despite significant advances in treatment efficacy, there is a vast gap between efficacy and effectiveness, which could be bridged if it were possible to implement optimal evidence-based treatment. The Royal Australian and New Zealand College of Psychiatrists is poised to release new clinical practice guidelines for the treatment of schizophrenia.7 The guidelines emphasise the need for an optimistic therapeutic approach to treating schizophrenia, and stress that the social environment of people with schizophrenia needs to be improved (eg, through housing support, vocational rehabilitation and family support). The guidelines also endorse atypical antipsychotics as the first-line treatment for schizophrenia because they are better tolerated in the short term by the vast majority of patients.11 Some have claimed that these outcomes could be achieved if the "typical" (first-generation) agents were used in lower doses,12 but there is increasing evidence that this is not the case, and in practical terms such low-dose use of typicals is unlikely to be achievable. Used over longer periods, the atypical agents are showing a significant advantage in relapse prevention13 and lower rates of tardive dyskinesia than the typical agents. However, this has to be balanced against the increased risk of adverse effects, such as weight gain and impaired glucose tolerance. Clozapine is clearly superior to other drugs for managing "treatment resistant" patients and reducing suicide risk.14 Despite practical difficulties relating to its use (notably the need for routine blood monitoring), clozapine should be more widely used in Australia. Psychosocial treatments2 are now solidly evidence-based, but are still only sparsely available in Australia.15 This reflects a major failure of public policy and practice. The failure to continue the reform process means that what is currently on offer is little more than acute-phase containment of risk in a reactive and rationed manner, with, at best, rapid disposal to minimal outpatient care. It has been claimed that much current funding for mental health services is not put to good use and that replacing some existing practice with evidence-based interventions is all that is required.13 This is clearly desirable but a manifestly inadequate response, which also ignores the costs that would be involved in achieving such global change in clinical practice. Despite the much-emphasised high direct cost of treating schizophrenia,14 treating it adequately, let alone optimally, will cost substantially more, and will require a much more professional and proactive approach, with widespread community support. For disorders that are treatable but not yet curable, achieving better outcomes is quite feasible but comes at a threshold price (my estimate of that threshold would be at least $24 000, but further research is needed). Current direct costs are about $18 000 per patient per year,14 a figure that has been labelled high, yet which is clearly below this threshold. Indirect costs (eg, costs of social security, costs involved in reduced working capacity of family members and the patient, and prison costs) are very substantial and could ultimately be diverted to proactive direct treatment. In fact, treatment in psychiatry is not intrinsically expensive in contrast to other complex medical disorders, yet Australia provides less funding per patient with schizophrenia than many other developed countries. Sartorius claims that "there is enough money around to help those with mental illness, but it is not available because of the attitude of most decision makers and a large part of the general public towards mental illness and all that surrounds it".15 People with schizophrenia are most affected by the lack of funding. Members of the public do not discover this until a friend or relative develops the disorder, by which time it is too late. Australians need to consider the following question: "Are you willing to pay to make optimal treatment freely available? — you or your family may need it.".

Patrick D McGorry MD FRANZCP

Schizophrenia has been described as a "life-shortening disease", and physical comorbidity accounts for 60% of premature deaths not related to suicide. People with schizophrenia and other mental illnesses have a higher rate of preventable risk factors such as smoking, high alcohol consumption, poor diet, and lack of exercise. Recognition and management of morbidity in people with mental illness are made more difficult by barriers related to the patient, the illness, the attitudes of medical practitioners, and the structure of healthcare delivery services. Improved detection and treatment of medical illness in people with schizophrenia will have significant benefits for their psychosocial functioning and overall quality of life.

Timothy J R Lambert BSc, MB BS, FRANZCP · Dennis Velakoulis MB BS, FRANZCP · Christos Pantelis MB BS, MRCPsych, FRANZCP

Smoking presents a substantial health and economic burden to people with schizophrenia. Comorbid use of other substances is common, under-recognised, and associated with a number of serious adverse consequences, such as psychotic relapse and poorer social outcomes. All patients with schizophrenia need to be screened for substance misuse. Effective interventions involve integrated, modified pharmacological and psychosocial strategies.

Dan I Lubman PhD, FRANZCP, FAChAM · Suresh Sundram PhD, FRANZCP

While many of the overt symptoms of schizophrenia may be controlled by medication, the associated psychiatric disability requires ongoing psychosocial rehabilitation and support in the community. The general practitioner can play a crucial role in this rehabilitative process, through

Caroline Crosse BA (Hons)

Objective: To identify any association between asthma and depression and quality of life.Design and setting: A face-to-face Health Omnibus Survey of a random and representative sample of the South Australian population in August 1998.Participants: 3010 randomly selected participants aged 15 years and over.Main outcome measures: Prevalence of doctor-diagnosed asthma, and scores for depression (measured by PRIME-MD instrument) and quality of life (measured by SF-36) in affected participants.Results: The prevalence of asthma was 9.9%. The prevalence of major depression was significantly higher for those who experienced dyspnoea, wakening at night with asthma, and morning symptoms of asthma. Quality-of-life scores were also lower for the same groups.Conclusions: Depression is a serious but potentially remediable comorbidity with asthma that may affect appropriate diagnosis and outcome.

Robert D Goldney MD, FRANZCP · Richard Ruffin MD, FRACP · David H Wilson MPH, PhD · Laura J Fisher BA(Hons)

To the Editor: At the Australasian Schizophrenia Conference in Sydney in October 2002, Professor Patrick McGorry of the Orygen Research Centre, University of Melbourne, presented draft guidelines on the management of schizophrenia and early psychoses.1 One of the recommendations was that atypical antipsychotic drugs should be used as the first-line pharmacological treatment in preference to typical antipsychotics and depot antipsychotics. With a shift in management of schizophrenia to community-based care, the number of patients with schizophrenia managed by general practitioners has increased over the past decade (from 36 per 10 000 encounters in 1990–91 to 45 per 10 000 in 2000–02).2 With the pending introduction of the guidelines, a baseline measure of GP prescribing rates of antipsychotics, both typical and atypical, will allow future measurement of the impact of the guidelines. We analysed the 1998–2002 data from the Bettering the Evaluation and Care of Health (BEACH) program, a continuous national cross-sectional survey of general practice.3 About 1000 GPs participate in this program every year, each providing details (on structured forms) about 100 consecutive patient encounters. Data collected include GP and patient characteristics, problems managed and treatment provided. We examined 401 300 encounters from 4013 GPs, with 431 537 medications recorded. Prescription rates were calculated and regression analyses performed using SAS software4 to adjust for the cluster effect of the study design. There were 1988 schizophrenia or psychosis problems managed in the four years of data collection (a rate of 49.5 per 10 000 encounters); 1883 medications were prescribed (94.7 per 100 contacts), of which 926 (49.2%) were typical antipsychotic drugs and 484 (25.7%) were atypical antipsychotic drugs. In 1998–99, the prescription rate of atypical antipsychotics was 15.7 per 100 contacts with patients with schizophrenia or psychosis (95% CI, 11.8–19.7). This rate increased to 31.1 per 100 contacts (95% CI, 26.3–36.0) in 2001–02. In the same period, the prescription rate for typical antipsychotics fell from 51.3 per 100 contacts (95% CI, 45.6–56.9) in 1998–99 to 40.6 per 100 contacts (95% CI, 35.4–45.8) in 2001–02. Linear regression showed that the prescription rate of atypical antipsychotics had increased by an average of 5.1 per 100 contacts per year over the four years (P < 0.0001), while the prescription rate of typical antipsychotics had decreased by an average of 3.8 per 100 per year (P < 0.005). Over the four-year period, there was no significant increase in the rate of overall prescriptions for people with schizophrenia (92.0 prescriptions per 100 contacts [95% CI, 83.4–100.7] in 1998–99 v 96.3 [95% CI, 89.4–103.3] in 2001–02). Between 1998 and 2002, the relative prescribing rate of atypical antipsychotics for schizophrenia and other psychoses in general practice nearly doubled. These results show that, even before the introduction of the guidelines, there has been a shift towards prescribing atypical antipsychotics in preference to typical antipsychotics. This change may reflect a change in specialist behaviour, as specialists have a direct effect on GP prescribing.5 The BEACH study will be able to assess the effect of the guidelines on the prescription rate of atypical antipsychotics by GPs.

Christopher M Harrison · Helena C Britt

An Expert Working Group of the National Heart Foundation of Australia undertook a review of systematic reviews of the evidence relating to major psychosocial risk factors to assess whether there are independent associations between any of the factors and the development and progression of coronary heart disease (CHD), or the occurrence of acute cardiac events. The expert group concluded that (i) there is strong and consistent evidence of an independent causal association between depression, social isolation and lack of quality social support and the causes and prognosis of CHD; and (ii) there is no strong or consistent evidence for a causal association between chronic life events, work-related stressors (job control, demands and strain), Type A behaviour patterns, hostility, anxiety disorders or panic disorders and CHD. The increased risk contributed by these psychosocial factors is of similar order to the more conventional CHD risk factors such as smoking, dyslipidaemia and hypertension. The identified psychosocial risk factors should be taken into account during individual CHD risk assessment and management, and have implications for public health policy and research.

Stephen J Bunker PhD, RN · David M Colquhoun MB BS, FRACP · Murray D Esler PhD, FRACP · Ian B Hickie MD, FRANZCP · David Hunt FRACP, FACC · V Michael Jelinek FRACP, FACC · Brian F Oldenburg PhD, MPsychol · Hedley G Peach PhD, FFPHM · Denise Ruth FRACGP, FAFPHM · Christopher C Tennant MRCPsych, FRANZCP · Andrew M Tonkin MD, FRACP

To the Editor: We would like to comment on a recent article by Chan et al on clinical practice guidelines for depression in young people.1 We disagree with their proposal to amend National Health and Medical Research Council (NHMRC) guidelines2 to include a statement that "SSRIs [selective serotonin reuptake inhibitors], particularly fluoxetine and paroxetine, should also be considered as a first-line treatment" for major depression in young people. We believe that there is insufficient evidence to assign a grade of "E1"2 to this statement. Chan et al1 quote three randomised controlled trials (RCTs) and one systematic review in support of their argument, but as yet the results of only two of the three RCTs have been published.3,4 Unfortunately, Chan et al do not include a critical appraisal of the significant methodological and analytical problems with each of the studies. Nor is any comment made about risk–benefit ratios, or the fact that even if the results were sound the clinical relevance of such small differences between active drug and placebo is questionable.5 The following brief commentary on the two studies highlights the dangers of carrying out sophisticated procedures such as meta-analysis without sufficient attention to the quality of the trials included in the analysis. The very high dropout rates (46% of 48 for placebo; 29% of 48 for fluoxetine) in the study by Emslie et al3 raise questions about the reliability of the results. Other interpretations of the findings are plausible. For example, in their study, significant advantage to fluoxetine over placebo on the Clinical Global Impressions improvement rating (a primary outcome measure) was lost when only patients completing the trial were counted (P = 0.2). More worrying is that Chan and colleagues do not seem to have noticed the dangerously distorted reporting in the study by Keller et al.4 On neither of the two designated primary outcome measures (change from baseline in Hamilton Rating Scale for Depression [HAM-D], and response, set as "fall in HAM-D to ≤ 8 or by ≥ 50%") did paroxetine differ significantly from placebo. But Keller and colleagues never report this negative finding. Instead, the criteria for response are covertly altered (to "fall in HAM-D to ≤ 8", which does achieve significance). The authors then erroneously claim significance on this (altered) primary outcome measure, ignoring the lack of significant change. Thus, a study that showed no significant improvement on either of two primary outcome measures is reported as demonstrating unqualified efficacy. Similar problems can be found in a more recent article by Emslie and colleagues6 (published after the review by Chan et al1), in which the authors openly acknowledge that the difference between fluoxetine and placebo on their prospectively defined primary outcome measure did not reach statistical significance, yet claim to have demonstrated the drug's efficacy. Another worry is that Chan and colleagues, in their list of proposed changes to NHMRC recommendations,1 suggest that the availability of SSRIs obviates the need for more expert and thoughtful assessment and management of depression. We are uncomfortable that the prescribing and management of psychotropic medication is portrayed as requiring relatively few skills and resources, to be carried out by those general practitioners who lack training in mental health and/or access to expert mental health services. We urge the NHMRC to maintain a conservative approach to the use of psychotropic drugs in children with depression unless more convincing evidence is forthcoming.

Jon N Jureidini · Anne L Tonkin