Mental health

In reply: We thank Jureidini and Tonkin for their comments. In relation to their criticism of the study by Emslie et al,1 intention-to-treat analysis is the accepted standard. In relation to the study by Keller et al,2 their criticism about the criteria for response has already been answered elsewhere. (Criteria were defined in the report as a final Hamilton Rating Scale for Depression [HAM-D] score that was ≤ 8 or a reduction from baseline of ≥ 50%. Dual criteria were selected because the scores at entry could range from a minimum of 12 [set by protocol] to a maximum of 53 [highest scores for the 17-item HAM-D]. Limiting response to either a 50% reduction or a specified cut-off point would impede patients at the lower end of the ranges from meeting the criterion.3) The concern about the absence of differences in change scores on the HAM-D cannot be resolved, as mean change in scores and standard errors of the means were not reported. However, 63.3% (57/90) of subjects taking paroxetine (P = 0.02 versus placebo) achieved a HAM-D total score of ≤ 8 at endpoint. With respect to the size of difference in response rate to active treatment versus placebo, the results of trials involving selective serotonin reuptake inhibitors (SSRIs) in children and adolescents are similar to those reported in adults (ie, SSRIs achieve a response in about 20% more participants than placebo,4 which is similar to the 26% difference between cognitive behavioural therapy and various control conditions5). Consistent with these results, the US Food and Drug Administration has recently approved fluoxetine to treat children and adolescents aged seven to 17 years for major depression. We believe that there are sufficient new treatment data (including a study,6 published since the submission of our article, showing fluoxetine's superiority over placebo in symptom improvement and in remission rates) to warrant revision of the 1997 guidelines. Depression affects one in 20 Australian teenagers, few of whom will access specialist mental health services.7 Contrary to the view of Jureidini and Tonkin, we believe general practitioners must provide treatment for young people suffering depression. A strength of the National Health and Medical Research Council guidelines is that they offer comprehensive advice to promote thoughtful assessment and management of depression in young people.

Raphael TW Chan · Joseph M Rey · Philip L Hazell

To the Editor: I do not believe that Dinnen's comments1 should be so easily dismissed as suggested by the academics proposing that general practitioners should do questionnaires,2,3 at least in New South Wales. I write this as barely a month has passed since a most damning report was released by a NSW Parliamentary Inquiry into Mental Health Delivery. A prime example of arrogance and loss of contact with the reality of clinical services by academia and administration is that, during the demise of mental health services in NSW, the services have been forced to complete a new 30-page admission process for every admission. Just what was needed by registrars spending hours trying to find beds for seriously mentally ill patients! The gulf between academia and administration on the one hand and real clinical services on the other is now huge in NSW, at least in mental health services. No one outside real clinical services has any credibility or right to demand doctors, let alone hard-pressed GPs, engage in dubious and very likely useless research projects without very special funding to support the project. I found the K10 questionnaire extraordinarily simplistic compared with a Mental State Examination (MSE). Surely, if there is concern, doctors should be encouraged to revise how the MSE is carried out, and not encouraged to adopt "cookbook" medicine.

Brian M Boettcher

To the Editor: As a general practitioner I was gratified to see Dinnen's letter1 in which he questioned the "urgent need" for GPs to use more questionnaires for depression management. Reading the professorial reply,2 I despair. As more and more specific health promotions are introduced (eg, Asthma 3-Step Plans, Diabetic Care protocols, Health Assessments, Care Plans) we have to consider not just our patient's problems, but which forms to fill out or numbers to put down to fulfil Health Insurance Commission requirements or be correctly remunerated. By the time a depressed patient is sitting in my room, he or she wants to be correctly diagnosed and treated, not to be given a form to fill out. In my opinion, to hand a form to a depressed patient who has tearfully told me his or her problems is an insult. We do not (yet) expect patients to fill out a checklist for heart failure. As to the suggestion that the form be filled out in the waiting room, how is this to be done? Should the patient be sent out again with form in hand? Privacy concerns do not allow reception staff to hand out such forms, and the waiting room is not the best place to fill them out if they are needed. In reality, the GP is likely to give the patient a form and then go have a coffee or make a telephone call. No psychiatrist will ever receive a referral from me based on a K10 score. I may, however, mention that my patient still has suicidal impulses, cries a lot, has trouble sleeping and cannot concentrate at work. That should be easy enough for anyone to understand.

Heidi Andersen-Dalheim

To the Editor: I read with great interest about your search in dictionaries for the word "pathography".1 Pathography2 originates from reflections on genius and its possible association with insanity, a question that has occupied experts in many fields since Socrates, Plato and Aristotle. The first psychiatric scientific treatise concerning this question was contributed by Moreau de Tours in 1859.3 Inspired by him, Cesare Lombroso, in 1863, coined the famous expression genio et follia, and contributed many, albeit somewhat uncritical, pathographies. The term pathography was first used about 1899 by the German psychiatrist Paul Julius Möbius, who contributed with several seminal pathographies, including Rousseau, Goethe, Schopenhauer and Nietzsche. Among other famous pathographers should be mentioned Freud, W Lange, Jaspers, Birnbaum and Kretschmer. Pathography can be defined4 as . . . historical biography from a medical, psychological and psychiatric viewpoint. It analyses a single individual's biological heredity, development, personality, life history, and mental and physical pathology, within the socio-cultural context of his/her time, in order to evaluate the impact of these factors upon his/her decision-making, performance and achievements. No preconceived format can be assumed as the method depends on the nature of the various available materials and on the specific inquiry. A prerequisite for plausible pathographical results is a thorough knowledge and understanding of psychopathology, and of the borderland between normal and abnormal mental life, combined with a capacity for [sober] historical judgement. . . . The pathographical method is applicable to any personality, sick or sound, provided that sufficient biographical sources are available. The pathographical result is a facet but often an indispensable one. Subjects of pathography have traditionally been famous people in all areas of human achievement. Pathography is also indispensable in assisting historians, political scientists and other groups in their quest for a better understanding of events where leaders or other "very important persons" have played a significant role, and where personality or illness, physical or mental, has been decisive, at times with far-reaching consequences for nations.5,6 History is replete with such examples.

Johan A Schioldann

People with dementia usually experience behavioural and psychological symptoms of dementia (BPSD) during the course of their illness. Currently, in Australia, there is a lack of comprehensive planning for managing and preventing BPSD, and the resources required for optimal care are inadequate and unevenly distributed. We propose a seven-tiered model of service delivery based on severity and prevalence of BPSD, ranging from no dementia through tiers of increasingly severe behavioural disturbance to the propensity for extreme violence in a small number of individuals. Each tier is associated with a different model of intervention. People with dementia may move up or down between tiers depending on their condition, their care and the intervention provided. Lower-level interventions may prevent the need for the more intensive interventions needed when disturbance becomes more severe.

Henry Brodaty AO, MD, FRACP, FRANZCP · Brian M Draper MB BS (Hons), MD, FRANZCP · Lee-Fay Low BSc (Hons) (Psych)

Certain social expectations of medicine combine with characteristics of subspecialised technological paediatrics to facilitate the form of child abuse labelled "Munchausen by proxy syndrome". Examining this form of child abuse highlights possible shortcomings of medical practice. The primary medical tasks of diagnosing and curing illness and of preventing suffering are sometimes overridden by other motivations of which doctors may not be fully aware. More open discussion of what motivates health professionals in their work may improve medical practice and lead to a reduced incidence of Munchausen by proxy syndrome.

Jon N Jureidini PhD, FRANZCP · Allan T Shafer MA (Clin Psych), D Litt et Phil · Terence G Donald MBBS FRACP

Much has been written about the motivation of perpetrators in Munchausen by proxy syndrome (MBPS), but little, as far as I know, about the motivation of doctors who "collude" with parents in these behaviours. In general, I have no quibble with the analysis by Jureidini and colleagues.1 It is interesting, as they have done, to put forward a theory as to why doctors who are motivated to make "the diagnosis" might fail to recognise invented illness; however, the motivation of the "relentless investigator" is not the only one that should be examined. Indeed, doctors do not practise in a vacuum and are subject to pressures, societal among others, which may change with the clinical setting, affecting their practice. As a result, we may make mistakes in aspects of the clinical encounter — whether in our assessment of the process, the history, the examination or our interpretation of tests. Thus, when dealing with children, persistent parents may force the hand of even-thinking doctors because of current medicolegal and societal pressures. I do agree that children are more at risk from doctors who are enthusiastic about making a medical diagnosis and who ignore the social aspects of the consultation. However, concentrating on the motivation of the parent in MBPS cases has not proven useful in practice because of the complex psychopathology underlying such behaviour,2-4 and I doubt that focusing on the motivation of doctors will improve practice for similar reasons. While the relentless investigator is a particular problem in these cases, factors such as being busy, stressed or forgetful may also account for failure to identify the problem sooner. My concern is that, for an understanding of motivation to be useful in preventing the phenomenon of MBPS, it would be necessary to both reliably identify doctors' motivations and intervene to change these, and I do not believe that either of these steps is feasible. As a practising paediatrician, I suggest that a more useful approach to this problem of paediatric diagnosis would be to establish guidelines for the problem of the unresolved clinical problem or "difficult diagnosis" (see Box). The unresolved clinical problem: a practical approach4 Always consider MBPS in the differential diagnosis when the pieces do not seem to fit. Pay attention to the process of the consultation (how does the patient present?), especially where there is a history of maternal psychological problems. If worried about missed disease, draw up a list of hypotheses that should be used to direct further testing. Include the process of consultation in these; consult a colleague. Do not order invasive tests to "reassure" parents. Consider the cost and harm of tests versus the benefits. Do not overinterpret test results in the clinically well child. Get corroboration of previous illness from independent sources. Do not accept at face value a history of severe illness in a well child. Consult with a colleague before doing invasive tests where there is a major and unexplained incongruity between the story and the assessment. This is particularly important in gastroenterology and neurology. If all appropriate treatments inexplicably fail, be very wary of invasive testing. Consult with a colleague.

Kieran T Moran FRACP

To the Editor: To achieve greater dissemination of mental health education to general practitioners, the Adelaide Central and Eastern Division of General Practice developed a program to be taken to GPs, based on individual need and using a medical expert/facilitator. The "GP Meets the Psychiatrist Project" is an initiative of the Division in collaboration with the Eastern Mental Health Service, and supported by the Lundbeck Institute — a Danish foundation with a special interest in psychiatric education and pharmaceuticals (www.luinst.org). The specific objective of the project is to facilitate access by GPs to psychiatrist support, in the form of education and advice. This takes the form of a psychiatrist visiting a practice for a one-hour "open tutorial", on a topic preselected by the GPs in the practice. Lundbeck funded the psychiatrist's time. GPs were not funded, and no Continuing Medical Education points were sought for these sessions. The project began in February 2001, and during the year 75 GPs from 22 practices were involved. Following the tutorial, both the GPs and the psychiatrist completed an evaluation questionnaire that covered issues such as the topics chosen by GPs, discussion of medications, referral for psychiatrist support, the need for further sessions and how they rated the sessions.1 The main topics raised by GPs were depression, medication issues, difficulties with access to psychiatry services, psychosis, and management of acute situations or angry patients. GPs felt the sessions were very useful, and 87% were interested in having meetings with other specialists. From October 2001, 23 GPs rated the usefulness of the tutorial using a Likert scale of 1 ("no use") to 5 ("very useful"). The value of the tutorials was clearly demonstrated by the mean rating of 4.6. Three psychiatrists participated and all found the experience of attending general practices and running the sessions very rewarding. They found their assumptions about the nature of family medicine were often wrong; for example, they were interested to find that practices were often focused towards particular areas of health. The project has demonstrated the usefulness of tailoring education packages to the specific needs of GPs and has shown that this would be a suitable avenue to improve links between GPs and specialists. With specialist support, a similar session involving an endocrinologist discussing diabetes is now being run through the Division, with no funding, which suggests this type of program may be sustainable in the long term.

Greg A Lovell · Phillipa J Hay

To the Editor: In advocating the use of questionnaire measures for outcomes for patients with depression or anxiety in clinical practice, Hickie, Andrews and Davenport advised that "for physicians who work predominantly in academic, specialist or administrative settings, the arguments for routine outcome measurement are obvious".1 The arguments are not at all obvious for clinicians. What is obvious is the divide between clinical practice and academia. The claim that there is now "an urgent need" to promote such questionnaires for general practitioners is difficult to understand. The historical and professional resistance to the use of such "instruments" is for good reason. They are unwieldy and unreliable. The oldest measure of outcome, known to clinicians but overlooked by academics, is to ask the patient "Are you feeling any better?", and to evaluate outcome using clinical skill and expertise. The key to understanding this peculiar proposition is to be found in the final sentence of the article, in its reference to the move for governments to "support major service innovations in primary mental healthcare". Those who produce, administer and measure such innovations will not, of course, see themselves unrewarded for their valued efforts to improve healthcare outcomes in the community. The poor GP will be burdened with yet another clinically irrelevant activity. Hickie and colleagues will no doubt press on regardless. There is a hint of insight, however, in the professorial obiter dictum that these measures would not be "the prime concern for the treating clinician". The "health services planning and other research benefits" of collating clinical data is a nice idea. It is hard to see its relevance to general practice based treatment of psychiatric disorder. If it is true that one out of three general practice consultations are driven by some psychiatric problem, then GPs will have a lot of forms to fill out, won't they?

Anthony Dinnen

In reply: It is pleasing to note that a senior psychiatrist is looking at the practicality of general practitioners (GPs) measuring the clinical outcome of patients with mental disorders. However, Dinnen's concerns may be groundless. For example, the Kessler Psychological Distress scale (K10) consists of 10 simple questions that patients can complete in two minutes in the waiting room and doctors can then score by summing 10 numbers between one and five.1 This takes less time than writing a progress note. The websites www.gpcare.org, www.beyondblue.org.au and www.mentalhealth.gov.au1-3 are the simplest places for doctors to familiarise themselves with the proposed outcome measures and with other new initiatives for better outcomes in mental healthcare. For the K10, the website1 advises GPs that if, after treatment, a patient's score remains above 25 the GP should review the patient and consider seeking a second opinion from a psychiatrist. In a specialist clinic (St Vincent's Hospital, Sydney) the average K10 score of a cohort of patients was 26.1 before treatment and 21.7 after treatment (indicating the effect of sound treatment). Nevertheless, the scores of a fifth of patients remained above 25 after treatment. Psychiatrists might therefore familiarise themselves with the measure so they understand when a GP refers a patient for a second opinion "with a K10 score above 25 after treatment".

Gavin Andrews · Ian B Hickie · Tracey A Davenport

On the Ides of March 2002, the "Magistrate 2" (M2) virus decimated my computer's hard drive. In one cruel fraction of a second, hundreds of files — not all backed up — representing countless hours of toil, were irreparably destroyed. My immediate sentiments were intense anger, directed at the faceless, malevolent inventor of M2, and despair over my loss. Unbeknown to me at the time, while it was neutering my computer M2 was simultaneously forwarding virus-laden Word files from my hard drive to persons listed in my email address book. Addressees included many parents and teachers of my children's preschool. Further, as luck had it, most of the transmitted files were publications arising from one of my areas of research, namely the use of electroconvulsive therapy (ECT) in children and adolescents. Thus, when they next checked their inbox, parents and teachers unexpectedly received one or more papers on the history of ECT in young people, an epidemiological study on ECT use in children and adolescents in New South Wales, studies on the opinions of teenage patients and parents regarding the treatment and, last but not least, a "user's guide" to how ECT should be administered to the young. Preschool parents and teachers had been oblivious to this particular interest of mine. Though I had nothing to be ashamed of — indeed, ECT can be a life-saving treatment for young people — it is still not an interest one advertises widely, nor mentions in the course of small talk at school meetings or social gatherings. Now, it is probably OK by parents of preschoolers for one of their number to be a child psychiatrist. Indeed, this sometimes comes in handy for the mums and dads ("Has Sarah got ADHD?"; "Is it normal for Trevor to be hitting his baby brother over the head with a cricket bat?", etc). It is, however, clearly another matter if the parent happens to be an expert on the use of "shock treatment" in kids. "Not nice, Dr Walter!", I imagined them saying when the secret was out, "Surely not Garry!". And yet there might have been cause for them to be grateful because, from that time on, classroom behaviour seemed to improve, particularly whenever I was around — dropping off or collecting kids, attending class concerts, etc. Was it possible that the children had been warned about the consequences of not behaving well at school, that they had been told what "Dr Volta" might do? Of course, the kids need not have worried. It was not as though I carried an ECT machine or set of electrodes on me. Must have been the spark(le) in my eyes.

Garry Walter PhD, FRANZCP

Current controversy about diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) reflects the divergence between developmental and non-developmental approaches. While there is growing evidence for biological vulnerabilities associated with ADHD, we believe that environmental factors, including early problems in parental attachment, are also important in determining the type and timing of deficit that a child develops, the risk to academic and social performance and eventual outcome. We warn against labelling children with ADHD simply because they fulfil the cross-sectional diagnostic symptom criteria of the Diagnostic and statistical manual of mental disorders — 4th edition (DSM-IV). We advocate an integrated biopsychosocial approach to diagnosis and management with a thorough developmental assessment to identify developmental factors, such as deficits in early attachment, contributing to the presentation.

George Halasz MRCPsych, FRANZCP · Alasdair L A Vance MD, FRANZCP

To the Editor: The working group responsible for the recent chronic fatigue syndrome (CFS) guidelines needs to be congratulated for producing a sensible and well balanced document in a most controversial area.1 Larkins and Molesworth have contributed a somewhat predictable response.2 Some sufferers of CFS can be characterised by their capacity to react strongly to the suggestion that psychological factors may be involved in the pathogenesis of their condition.3 From the perspective of the consultation-liaison psychiatrist, their response can be written with the comments on physical and psychological issues substituted for one another. Hence it can read (1) there is no current evidence that the syndrome has a specific physical origin, and (2) there is evidence that a range of psychological issues occur in people with CFS, although it remains unclear whether these changes are primary or secondary. The mental health movement has worked hard in recent times to reduce the stigma associated with psychiatric conditions. The sufferers of chronic physical illness now accept the importance of looking after their emotional health as well as their physical well-being. Enlightened CFS sufferers and support groups accept the links between physical and psychological morbidity and do not mindlessly exclude the latter. There is ample evidence that cognitive–behavioural strategies and graded exercise programs assist those with CFS, and psychiatrists are skilled in providing these treatments.4

James D Hundertmark

To the Editor: The process of destigmatising chronic fatigue syndrome (CFS) is not advanced by either limiting enquiry to "acceptable" sciences or increasing the stigma already experienced by people with other neuropsychiatric disorders. Contrary to its intent, and in contrast to the recently published Royal Australasian College of Physicians (RACP) guidelines,1 the recent statement by the immediate past president of the RACP and the Chairman of the ME/Chronic Fatigue Syndrome Association of Australia2 is in danger of increasing the stigma for both people with CFS and people with other common mental disorders. Unfortunately, key propositions in their letter ("There is no evidence that the illness is primarily psychological in origin") are clearly at variance with the tone of the guidelines (see Box 1.5, p. S31; Box 1.7, p. S32; and, "Management" summary, p. S38). Their letter reinforces the classical "dualistic" and rather simplistic "biological" approach (eg, "There is significant evidence of a range of biological abnormalities occurring in people with CFS"). Unwittingly, it colludes with community-based beliefs that mental health problems are "not health",3 and often imaginary or under the voluntary control of the patient.4 There is no doubt that people with CFS share many experiences with people with other neuropsychiatric disorders. They both have daily experiences where their credibility is challenged, their disability is minimised and their needs for appropriate medical management are not met. Australian research and best practice have been recognised internationally for emphasising the integration of psychological, psychiatric and biological factors and respect for the experiences of persons with these debilitating disorders.5 Unfortunately, the major advances captured in the guidelines may now be undermined if the RACP is perceived to be backing away from supporting appropriate psychological assessment and provision of effective "psychological" treatments (such as cognitive–behavioural therapy and physical rehabilitation approaches). Similar equivocation has left clinical guideline processes in the United Kingdom in disarray.6 As demonstrated recently, prolonged fatigue syndromes are common in the Australian community, and the vast majority of those who seek healthcare services have concurrent depression or anxiety.7 Real progress towards destigmatisation, meaningful research progress and improved health services for people with CFS will only occur when the field is mature enough to deal with the clear relevance of psychological factors. Instead of rejecting "psychological factors" and associated treatments, relevant professional and consumer bodies should now join with the broader community movement towards increased community awareness of common neuropsychiatric disorders, genuine understanding of their (genetic, "biological", psychosocial and personal) causes and provision of effective (pharmacological and psychological) treatments.8

Ian B Hickie

To the Editor: In the recent letter from Larkins and Molesworth1 various statements are made on which I would like to comment. From time to time everyone becomes physically or mentally exhausted, whether or not it is related to activity. For some people this exhaustion becomes disabling. They deserve understanding and sympathy. We must do everything we possibly can to assist them to recover and to try to find possible causes. Larkins and Molesworth acknowledge that chronic fatigue syndrome is a serious, disabling illness. When does ordinary exhaustion become disabling? I would agree that at this stage there is no clinical evidence that the condition is primarily psychological. Nor is there evidence that it is primarily physical. There may be a mixture. What is the "significant evidence" of a range of biological abnormalities occurring in people with CFS? What are these biological abnormalities and what physiological evidence is there for each one of these abnormalities to produce fatigue? Larkins and Molesworth state that treatment plans should be "within the capabilities of the patient": is there evidence to indicate that stimulating each patient to do just that little more each day will do harm? It was stated that scientific evidence of the aetiology, pathology and treatment is grossly deficient. It is in fact absent. There is no evidence at all. Research is certainly required. One of the problems is that, as soon as a medical advisor informs a patient that investigations have shown no serious abnormality, the patient often goes away and says to himself or herself or family that the "doctor said there is nothing the matter with me and that it is all in my head". Nothing could be further from the truth. Something is the matter and it is up to us to find it out.

Donald D Beard

In reply: We thank the writers for their comments on the CFS guidelines1 and our joint letter about these guidelines.2 Hundertmark remarks on the interplay between physical and psychological factors in morbidity associated with CFS. We trust that our letter in no way contradicts this. Similarly, the inferences that Hickie drew from our letter are not supported by the text of the letter. Far from undermining the guidelines, our letter had the full support of the convenor of the working party responsible for the guidelines. As clearly discussed in the guidelines, in the absence of specific diagnostic tests it is likely that a range of factors may contribute to the pathogenesis of CFS. Assumption of a primarily "psychological" pathogenesis is as unjustified as assumption of a primary "physical" basis. There are "abnormal" test results in many people with CFS, including abnormalities of the hypothalamic–pituitary–adrenal axis and some abnormalities of immune function. As stated, it is controversial whether such abnormalities are primary or secondary. While cognitive–behavioural therapy with graded exercise is effective in some patients, the guidelines outline the deficiencies of the evidence which "significantly limit the generalisability of the findings". As the guidelines indicate, and as is supported by our letter, treatment should be designed in partnership with the patient, and tailored according to the patient's capacity and response. Finally, as implied by Beard's letter, we restate the need for further research into the aetiology, pathology and treatment of CFS. We believe that effective progress in the management of this complex and mysterious illness will be best achieved by positive and cooperative rather than adversarial relationships between those suffering from the condition and the doctors and researchers attempting to help them.

Richard G Larkins · Simon R Molesworth

A case of public policy confusion In recent years, there has been an increasing focus on the mental health of children and adolescents.1 This is part of the broader process of reform of Australian mental health services, which now emphasises mental health promotion, the development of preventive approaches, early detection of mental disorders and early treatment interventions.2 At the same time, there is now clearer recognition that, in a country as culturally and linguistically diverse as Australia, specific attention must be paid to the cultural dimensions of mental disorder and mental health service design and the specific needs of Indigenous people, immigrants and refugees.3 Major national mental health policy statements now recognise these issues, and funding for State-based transcultural mental health units and centres for the treatment and support of torture and trauma survivors is one aspect of implementing this policy. This is consistent with increased attention being paid to the mental health of immigrants and refugees internationally.4 Of the 6.1 million refugees worldwide for whom demographic data are available, 45.6% are aged under 18 years, although the proportion of children and adolescents varies considerably by region (eg, 56% of refugees in Africa, 23% of refugees in Europe).5 In 2001 there were 900 000 asylum applications pending worldwide.5 The article by McKelvey and colleagues6 in this issue of the Journal (page 413) is important for several reasons. Firstly, research data on the mental health of immigrant and refugee children and adolescents are scarce. The study contributes to knowledge about one of the largest immigrant/refugee communities in Australia in a way that cannot be achieved even by large-scale and expensive studies that aim to be representative of the Australian population.1,7 The recent national survey of 4500 children and adolescents "provides only very limited information about the mental health of children and adolescents living in non-English speaking families".1 Secondly, the authors carefully avoided methodological pitfalls commonly seen in cross-cultural mental health research. They used appropriate translation methods for the questionnaire, worked in partnership with community leaders and Vietnamese-speaking mental health professionals, and conducted research interviews in either English or Vietnamese, using bilingual research staff who were trained and supervised in interview administration. Such attention to appropriate cross-cultural research methods is essential to ensure the validity of information obtained. Thirdly, the study is important because of the finding that the prevalence of psychiatric disorders in Vietnamese children and adolescents was not significantly different from that found in a general Western Australian sample8 and in a national sample,1 despite the fact that many of these children and adolescents had been affected by the stresses of migration to a vastly different cultural environment and that many came from families who had lived through the traumas of war. The data of McKelvey and colleagues relate to Vietnamese refugees settling in Western Australia at one point in time. The same rigorous research process is highly desirable when comparing other refugee populations, especially those experiencing different traumas before migration or different experiences of settlement within Australia. A clinical challenge is to identify subgroups who have suffered, or are at risk of developing, adverse psychiatric consequences. In the study by McKelvey et al, the low rates of mental health problems identified by parents highlights but one of the difficulties that young people from migrant families have in accessing mental health services. There may be a range of explanations for the relatively low rate of mental disorders identified in the study. However, if corroborated by studies of other ethnic groups and research in other settings, these data may reflect a feature of Australian society that has been a considerable success. That is, our capacity to accept immigrants and refugees from all over the world; to integrate new arrivals into a generally harmonious and well-functioning multicultural society; to create the conditions necessary for refugees to recover from trauma; and to provide an environment that is conducive to normal development, especially in children and adolescents. Underpinning this success have been legal and policy frameworks for multiculturalism, extensive services that have supported the successful permanent settlement of immigrants and refugees, and the general goodwill shown by the Australian population to immigrants and refugees. Unfortunately, recent years have seen a substantial bipartisan policy shift in Australia's treatment of asylum seekers, particularly of people arriving unauthorised by boat.9 The policy of mandatory detention of unauthorised "boat people" is now the subject of heated debate. One component of the debate has been the question of whether prolonged detention has harmful effects on the mental health of detainees in general,10 and on the mental health and development of children and adolescents in particular.11 On this latter issue, the subject of an inquiry by the Human Rights and Equal Opportunity Commission, there is remarkable unanimity of medical opinion: prolonged detention is causing harm to the mental health and development of children and adolescents.12 Also of concern is the plight of refugees who have been granted temporary protection visas and live within the community. In comparison with refugees who have obtained permanent residency visas, these people have substantially restricted rights, including the preclusion of family reunion and limited access to social services, English-language training and other services. There is concern that such restrictions may contribute to mental health problems in this group.13,14 Children's emotional and social development may be adversely affected if they are living with parents who are functionally impaired because of depression, anxiety or other mental health problems relating to the stresses and uncertainties of being a temporary visa holder. Current immigration policy, in the form of prolonged detention of asylum seekers and the move to temporary visas for some, is resulting in harm to the mental health of already vulnerable children, adolescents and adults. The mental health impact of this aspect of immigration policy appears at odds with national mental health policy and with the successful settlement policies that still apply to authorised immigrants and some refugees. The study by McKelvey and colleagues6 shows that we can do very much better than this.

I Harry Minas FRANZCP · Susan M Sawyer MD FRACP

Objective: To determine the prevalence of psychiatric disorders among Vietnamese children and adolescents living in Perth, Western Australia.Design, participants and setting: A list of Vietnamese households was drawn from Perth telephone directories. A computer program generated a systematic probability sample of households. All children and adolescents aged 9–17 in these households were invited to participate in the study. Children and their parents were interviewed in their home using the Diagnostic Interview Schedule for Children, version 2.3 (DISC-2.3). The child version (DISC-C) was used for children and the parent version (DISC-P) for adults. The study was conducted between July and December 1997.Main outcome measures: The prevalence of psychiatric disorders in children and adolescents, based on DISC-C and DISC-P data.Results: Results were based on the 519 children (89.2%) for whom complete data were available. Twenty-three parents (4.4%) reported that their child had one or more disorders on the DISC-P, 82 children (15.8%) reported one or more disorders on the DISC-C, and 18.3% of children were reported to have a disorder on either the DISC-C or the DISC-P. Parent–child concordance on specific diagnoses was very low (0.6%). The great majority of disorders reported were anxiety disorders, especially simple and social phobias.Conclusions: The combined prevalence of psychiatric disorders among Vietnamese children aged 9–17 was similar to that found among children in Western Australia's general population. Vietnamese children in our study were much more likely to report symptoms of a psychiatric disorder than were their parents.

Robert S McKelvey MD, FRANZCP · David L Sang PhD · Loretta Baldassar PhD · Lisa Davies PhD · Lynne Roberts PhD · Neil Cutler BA

The 1997 NHMRC clinical practice guidelines for depression in young people included recommendations for treatment that need to be modified in light of more recent research. Changes to the guidelines should include the findings that selective serotonin reuptake inhibitors and some forms of psychotherapy are effective in treating adolescent depression. It is increasingly recognised that depression in adolescents often recurs and that prevention of recurrences should be a priority for research and practice.

Raphael T W Chan MB BS, FRANZCP · Joseph M Rey PhD, FRANZCP · Philip L Hazell PhD, FRANZCP

Prevention is feasible by providing quality interventions at key moments Each year, more than 800 000 adults1 and 95 000 children and adolescents2 are affected by depression. Depression is already a leading cause of both disability and premature mortality,3 and is likely to be second only to cardiovascular disease within 20 years.4 Even if effective treatments were provided to all those affected, the overall burden of depression ...

Ian B Hickie MD, FRANZCP

The reduction of coercive or inadequate parenting is essential if the mental health status of Australian children and adolescents is to be improved. Of the available approaches that address parenting practices, behavioural family interventions have the strongest empirical support and are effective in reducing parenting practices that contribute to the development of behavioural and emotional problems in children. However, only ...

Matthew R Sanders MA, PhD

Cumulative adverse experiences, including negative life events and early childhood adversity, together with parental depression and/or non-supportive school or familial environments, place young people at risk for developing depression. Enhanced life skills and supportive school and family environments can mediate the effect of stressful life events. Programs that enhance the school environment are associated with improved behaviour ...

Jane M Burns PhD, BA(Hons) · Gavin Andrews MD, FRANZCP · Marianna Szabo PhD, BA(Hons)

The prevention of some mental disorders in young people appears to be possible. Several small and medium randomised controlled trials show that some anxiety, affective and substance-use disorders can be prevented. These trials show that the interventions are efficacious, but whether they will be effective in routine practice is not known. The evidence is ...

Gavin Andrews MD, FRANZCP · David D Wilkinson MB ChB, MD

Significant perinatal distress and depression affects 14% of women, producing short and long term consequences for the family. This suggests that measures for early detection are important, and non-identification of these women may exacerbate difficulties. Screening provides an opportunity to access large numbers of women and facilitate pathways to best-practice care. A valid, reliable, ...

Anne E Buist MD, FRANZCP · Jeannette Milgrom PhD, FAPS · Bryanne E W Barnett MD, FRANZCP · Sherryl Pope PhD · John T Condon MD, FRANZCP · David A Ellwood MA, DPhil, FRACOG, FRANZCOG · Phillip M Boyce MD, FRANZCP · Marie-Paule V Austin MD, FRANZCP · Barbara A Hayes DNSc, FRCNA

I knew something was very wrong during the last trimester of my first pregnancy. I had overwhelming anxiety; I cried continuously; I couldn't sleep; I had panic attacks; I experienced obsessive fears that I could harm my unborn child; I thought I was "going mad". I was frightened to tell anyone, certain that I must be suffering from some untreatable mental illness. I was trapped ...

Lara M Bishop BAppSci, BA