Mental health

Depression is one of the most common mental health disorders in older people. Sequelae include unnecessary suffering, excess physical and social disability, exacerbation of co-existing illness, earlier death, and overuse of services. There are currently no reported public health approaches to prevent late-life depression. Five risk factors appear susceptible to community-level prevention programs: recurrent ...

Michael J Bird PhD, MPsych · Ruth A Parslow MPH, PhD

Objective: To determine if screening in general practice and related medical settings improves management and clinical outcomes in people with depression.Data sources: The Medline (1966–2002), EMBASE (1980–2002) and PsycINFO (1966–2002) databases were searched. These were supplemented by searching the Cochrane databases (to 2002); performing additional specific searches on Medline, EMBASE and PsycINFO; scrutinising reference lists of selected articles; and querying experts.Study ...

Ian B Hickie MD, FRANZCP · Tracey A Davenport BA(Hons) · Cristina S Ricci BSc(Hons)

Community awareness and understanding of depression ("depression literacy") underpins successful implementation of prevention, early intervention and treatment programs. Improving depression literacy is a major goal of beyondblue: the national depression initiative. Although other countries have previously attempted to address this issue, there is little evidence to indicate that those attempts have achieved their aims. Work in other ...

Ruth A Parslow MPH, PhD · Anthony F Jorm PhD, DSc

Efficacy trials suggest that depression is preventable in children and adults. However, current depression prevention interventions are not deliverable to the community en masse. The Internet offers an opportunity to deliver tailored prevention interventions such as those based on cognitive behavioural therapy (CBT) to a large audience, cost-effectively, while preserving intervention fidelity and anonymity. The Internet offers ...

Helen Christensen MPsychol(Hons), PhD · Kathleen M Griffiths BSc(Hons), PhD

Trial: Hobbs M, Mayou R, Harrison B, Worlock P. A randomised controlled trial of psychological debriefing for victims of road traffic accidents. BMJ 1996; 313: 1438–1439. Mayou R, Ehlers A, Hobbs M. Psychological debriefing for victims of road traffic: three year follow-up of a randomised controlled trial. Br J Psychiatry 2000; 176: 589–593. QuestionHow effective is psychological debriefing for people subject to unpleasant psychological shock? Trial details Design: Randomised controlled trial of psychological debriefing. Setting: A British teaching hospital (the Radcliffe Hospital, Oxford). Patients: 66 men and 40 women, aged 17–69 years, admitted to hospital after a motor vehicle accident. Most had been the driver of a car. Median admission duration was four days for the 52 control patients and eight days for the 54 who underwent the intervention. Interventions: A debriefing of about one hour on Day 2 of admission, encouraging patients to describe the accident and express their emotions, followed by a cognitive appraisal which included describing common reactions to traumatic experiences and suggesting a range of people who might be able to assist in the future, including the patient's general practitioner. 91 patients were assessed at four months and 61 were assessed at three years. Control patients had no debriefing or counselling. Main outcome measures: Impact of Event Scale (IES, which focuses on intrusive thoughts and avoidance of similar situations to the event); Brief Symptom Inventory (BSI, a measure of 53 symptoms); and other questions related to physical pain and functional activities. Main results: At four months there was still considerable psychological morbidity among the patients who were followed up. There was a significant difference (P < 0.05) in changes of IES between the 42 who received the intervention, in whom it increased from 15 (standard deviation [SD], 15) to 16 (SD, 15), and the 49 controls, in whom it fell from 15 (SD, 12) to 13 (SD, 14). Similarly, two subscales of the BSI score changed significantly between the intervention group, among whom it deteriorated from 0.5 (SD, 0.5) to 0.6 (SD, 0.8), and the control s, in whom it hardly changed from 0.4 (SD, 0.3) to 0.4 (SD, 0.4). Among the 61 patients followed for three years, the 30 randomised to receive the intervention were significantly worse, by self-report, both psychologically and physically. Their mean IES score deteriorated from a baseline of 15 (SD, 14) to 16 (SD, 18). In comparison, scores for the 31 control patients improved from 16 (SD, 12) to 13 (SD, 17). The difference in change was significant (P < 0.05). Among all patients with high initial scores, these decreased among the controls but not among those receiving the intervention. Conclusion: Psychological counselling should only be used in the context of trials rather than routine care. CommentaryRationale for the trialVictims of psychological shock are vulnerable for many years after the incident to a cluster of symptoms (including intrusive thoughts, avoidance symptoms, functional problems extending to social problems, and pain and other physical symptoms), commonly called "post-traumatic stress" disorder. The response of society has been to try to deflect this.1 For example, after the Port Arthur tragedy, teams of counsellors were flown to the scene and made available for those who wanted to talk through the horrors of the incident. The trial under consideration was a clever way of testing such debriefing for people subject to a sudden, unexpected event in which some were physically hurt. Trial methodsThe methods appear to have been well constructed. However, despite random allocation by random number tables, the patients in the intervention group were worse affected (nearly double the hospital stay and higher IES scores). Presumably, this happened by chance, but it might explain some of the result. Also, the rate of follow-up at four months was higher among control patients (49 out of 52) than intervention patients (42 of 54), although both follow-up rates were equally poor at three years. It is reassuring that the different measures of severity were the same for those followed up and those not. New informationThe results are compelling. There was a very strong suggestion that the sort of counselling we expect should be effective was actually harmful. It might be that we have some sort of mechanism ("denial", or a method of dismissing disturbing memories from our minds) that protects us from further psychological effects that interfere with normal living. Moreover, this finding is supported by evidence from another trial in which women who had had operative childbirth were debriefed to defer postnatal depression. This intervention also failed to be effective, with a trend in the direction of causing more harm than good.2 Implications for clinical practiceThis trial's findings challenge an assumed and conventional approach to protecting people against post-traumatic stress disorder. It may be another case of the empirical informing the psychopathological process. We should reconsider the impulse to assist people who have undergone an unpleasant psychological event by counselling them and getting them to talk about it and relive the event. It may be harmful. Could it be that the unfashionable British "stiff upper lip" is the better approach after all? We should provide such psychological counselling only in the context of trials rather than routine care. The stroke of genius here was that the authors thought to challenge an intervention whose benefits seemed self-evident. From this we learn that we must continue to do so with many other interventions whose benefits we take for granted.

Christopher B Del Mar MD, FRACGP, FAFPHM

For most doctors, it would be inconceivable to manage common long term disorders (such as diabetes or asthma) or serious risk factors (like hypertension or hypercholesterolaemia) without using standard clinical, pathology or other investigative parameters. The data from standard clinical measures have underpinned the drive towards outcomes-based healthcare and have long been recognised as the optimal response to "uninformed patients, skeptical payers, frustrated physicians and besieged health care executives".1 Recent Commonwealth Department of Health and Ageing measures provide incentives for general practitioners to improve the management of patients with complex, chronic or relapsing disorders, including asthma, diabetes and mental disorders.2 Doctors do not need to be convinced of the need to monitor peak flow in asthma or blood glucose (or other metabolic parameters) in diabetes. These simple measures do not try to describe the aetiology of the disease, the breadth of clinical manifestations or the patient's experience of illness. However, as proxy measures of clinical status, they can be used reliably over time and be gauged by different care providers operating in different care settings. Furthermore, the significance of the results can be easily communicated to the patient. Such measures are also used to monitor the response to treatment over time or responses to different types of interventions. Hence, such outcome data, in combination with other clinical and patient factors, are a crucial part of high-quality clinical practice. By contrast, few patients treated for depressive or anxiety disorders by GPs or psychiatrists will have any systematic measure of their ongoing clinical status or outcome documented.3 This deficit is confined largely to doctors, as clinical psychologists consider repeated systematic measurement an essential clinical tool.4 This deficiency in clinical record keeping by medical professionals persists despite the availability of valid and reliable outcome measures. Depression and anxiety are relapsing or chronic conditions5 and are often comorbid with other medical conditions in primary care. Patients will be managed mainly by primary care providers6 and the time frame for such care is years (not weeks or months). Consequently, we propose that all medical providers need to incorporate standard outcome measures for depression or anxiety into the management plans of patients with depression or anxiety. The other, clinical reasons why such a practice should be pursued are detailed in Box 1. Although not the prime concern for the treating clinician, health services planning and other research benefits rely on the collation of clinical data in combination with other practitioner and organisational information. The evidence base for high-quality mental health practice in primary care is limited and urgently needs relevant longitudinal data.9 These non-clinical outcomes (Box 2) should also be of concern to the wider medical profession. What measures should be used in day-to-day practice?Although there are no specific laboratory-based diagnostic tests for depression or anxiety, clinical diagnoses can be made reliable by determining whether a sufficient number and type of clinical symptoms are present. The number of diagnostic categories that are relevant to primary care is limited and easily incorporated within standard checklist formats.9 There are specialised neuroimaging and neuropsychology strategies that may emerge as useful clinical markers of risk factors for illness, severity of illness, or predictors of course or response to treatment; however, none are yet suitable for application in everyday clinical practice. Consequently, our current focus is more on the use of appropriate outcome measures rather than diagnostic measures. We now have a wide range of instruments that rate relevant psychological symptoms or resultant disability. For people with depression or anxiety, it is necessary to recommend the measurement of symptoms and disability, because some people minimise their symptoms simply by avoiding stressful situations. For example, a housebound person with agoraphobia, or a socially withdrawn person with chronic depression, may show only mild elevations on current symptom measures but reveal severe disability on other measures. Similarly, while people with comorbid physical and mental disorders can show elevated symptom scores, inspection of the mental and physical scores on disability measures can be helpful in prioritising treatment. Importantly, the common general disability measures (eg, Short Form Health Survey [SF-12]14 and Brief Disability Questionnaire15) can be used across the broad spectrum of general medical practice. To encourage widespread application in general medical settings, measures need to have a number of key characteristics. These include brevity, low cost (preferably being in the public domain), self-report rather than clinician-administered format, results that are readily communicated to the patient, and demonstrated responsiveness to change in clinical status. Further, symptom-based instruments should be focused on the common symptoms of depression, anxiety or related somatic constructs.9 Such instruments also lend themselves to automation and electronic record keeping. While illness-specific measures are commonly used in specialist practice (eg, for major depression, panic disorder, social anxiety or obsessive compulsive disorder only), they are far less attractive in general medical settings. Given these considerations, we recommend a small series of instruments for use in general medical settings. For the assessment of common symptoms of depression and anxiety, we recommend the Kessler Psychological Distress Scale (K10),16 the Somatic and Psychological HEalth REport (SPHERE),8 or the Hospital Anxiety and Depression Scale (HADS).17 The K10 is a 10-item instrument that was developed internationally and has been used in the Australian National Survey of Mental Health and Wellbeing. Scores range from 10 to 50, with scores above 30 being highly predictive of a depressive or anxiety disorder. The sensitivity and specificity of the K10 (ie, its ability to predict diagnosis) is superior to that of the 30-item General Health Questionnaire (GHQ).18 In the national mental health survey, it correlated 0.5 with the GHQ, –0.6 with the SF-12 disability measure, and 0.3 with the number of consultations for a mental health problem in the previous year.19 It measures the relevant constructs, is simple to use and requires little expertise to score and interpret the results. The SPHERE has a 34-item version that was developed to rate the psychological and somatic symptoms reported by people with common mental disorders in primary and other medical care settings. The utility of the shorter 12-item version for use in primary care was demonstrated as part of SPHERE: a national depression project and was based on more than 46 000 consultations in Australian general practice.8 The instrument is best used to differentiate two levels (and three types) of common mental disorders (patients reporting both characteristic psychological and somatic symptoms [Level 1, Type 1], and patients reporting either psychological symptoms [Level 2, Type 2] or somatic symptoms [Level 2, Type 3]). These levels predict not only formal psychiatric diagnoses, but also disability and doctor- and patient-perceived need for mental healthcare.8 The HADS is a 14-item instrument that was developed to rate the severity of specific depressive and anxiety symptoms in patients with comorbid medical disorders. Hence, it avoids rating those common somatic symptoms that accompany many mental disorders. While this narrower focus is advantageous for assessing changes in depressive and anxiety symptoms, it may mean that it is less useful in patients with the more mixed psychological states that are commonly seen in primary care. For rating disability, we recommend the SF-12.14 The 36-item Medical Outcomes Study Short Form Health Survey (SF-36) was developed as a measure of disability or functioning and is applicable to people with any illness, physical or mental. It is now available as a 12-item version (SF-12) that correlates 0.95 with the results of the parent SF-36 instrument. It has three sections: a preliminary question about self-perceived health status; eight questions about the extent to which current health status limits activities; and three questions about feelings. Two scores are generated: a mental and a physical component score. The scoring method is complex and is arranged so that scores on the physical and mental components are independent. The SF-12 has excellent psychometric characteristics, is sensitive to change, and is probably the de facto world standard for measuring outcome of treatment for both physical and mental disorders. ConclusionsFor physicians who work predominantly in academic, specialist or administrative settings, the arguments for routine outcome measurement are obvious.3,20 In association with the move to manage the common psychological disorders like depression and anxiety more effectively in primary care, there is now an urgent need to promote the clinical utility of standard outcome measures to GPs. The historical and professional resistance to the use of such measures has hampered the delivery of standardised and effective treatment in primary care settings. As new treatments are developed and as governments move to support major service innovations in primary mental healthcare, we need to measure routinely whether "improved" treatments and services are actually changing the lives of the individual patients who present for treatment. 1: Clinical reasons for using standard outcome measures in individual patients with depression or anxiety A. The instruction of patients in the collection of standardised illness measures maximises their involvement in a long term partnership. The provision of accurate information and recruitment to take an active role are empowering and serve to reduce both stigma and a sense of helplessness. These approaches improve compliance with standard clinical treatments.7 B. Standard measures can be used to document a range of clinical outcomes, including: psychological and somatic symptom severity, key illness-related behaviours (eg, extent of avoidance behaviour or substance misuse), cognitive and interpersonal distortions, comorbid medical difficulties, and health-related disability.8 C. Patients with depression or anxiety who monitor their own symptom or disability state can recognise signs of early relapse and seek earlier intervention for subsequent episodes. D. Patients with more severe or more complex disorders are likely to be exposed to an ever-increasing number of pharmacological or psychological treatments. Standardised outcome measurement permits comparison of responses (within each individual) to different treatment approaches. E. Patients with depression or anxiety will often require assessment by specialist providers. Standardised measures permit the determination of the short and long term benefits achieved by such specialised interventions. F. Clinical record keeping is enhanced and can be linked (electronically or through disease management systems) with appropriate triggers to consider changes in management planning. For example, if a patient treated for depression fails to achieve a significant reduction in standard symptom severity or disability measures, then a change in treatment approach or referral to a specialist service would need to be considered. 2: Health services planning and other research outcomes A. Evaluation of clinical effectiveness of new pharmacological or psychological treatments in relevant primary care settings. Given the range of new treatments and the differing views of clinicians, such studies are an important aspect of the evidence base for mental health.10 B. Cost-effectiveness research focused on the long term benefits of new pharmacological or psychological treatments. C. Investigation of the patient, practitioner and organisational factors that predict variations in the quality of clinical practice11 or access to various types of mental health assessments and treatments.12 D. Evaluation of the impact of major health service innovations on a range of clinical outcomes (eg, Primary Mental Health Care Teams in Victoria, 2001). E. Evaluation of the impact of specific incentives (eg, Better Outcomes in Mental Health Care, 2001) or innovative education or disease management support processes on clinical practice (eg, mental health training and clinical audits).13

Ian B Hickie MD, FRANZCP · Tracey A Davenport BA(Hons) · Gavin Andrews MD, FRANZCP

Objectives: To examine the prevalence of psychotropic medication use by children with attention-deficit/hyperactivity disorder (ADHD) and children without ADHD. To identify factors associated with stimulant use by children in the community.Design: A representative, multistage probability sample of Australian households was conducted in 1998. Parents completed questionnaires assessing children's mental health problems and health-related quality of life. They also completed a structured interview to identify children's psychiatric disorders and their use of medications during the previous six months.Participants: Parent or main caregiver of 3597 children aged 6–17 years.Main outcome measures: Rates of use of stimulants (dexamphetamine and methylphenidate), antidepressants and clonidine by children.Results: Overall, 1.8% of children (95% CI, 1.5%–2.3%) were receiving stimulant medication. Of those with ADHD, 12.6% (95% CI, 9.8%–16.1%) were being treated with stimulants, 2.3% (95% CI, 1.3%–4.3%) with antidepressants, and 1.9% (95% CI, 1.0%–3.7%) with clonidine. Among children without ADHD, 0.5% (95% CI, 0.3%–0.8%) were receiving stimulant medication. This represented 22.9% (95% CI, 14.6%–34.0%) of all the children who were receiving stimulants. Variables significantly associated with stimulant use were being male, having ADHD, attending a paediatrician, and having higher scores on the Aggressive Behaviour and Attention Problems scales on the Child Behaviour Checklist.Conclusions: About 13% of Australian children with ADHD, and a substantial number of children without ADHD, are taking stimulants. The question of whether Australian children are being undertreated or overtreated with stimulant medication depends on the criteria used to assess the appropriateness of stimulant use. Additional information is needed to clarify when stimulants should be used to treat ADHD.

Michael G Sawyer MB BS, PhD · Brian W Graetz MPsych (Clin) · Jennifer J Clark BA(Hons), DipEd · Peter A Baghurst PhD · Joseph M Rey MB BS, PhD

Objective: To explore, among middle-aged women, the relationship between having ever had cosmetic surgery and the frequency of use of other health services.Design: Retrospective analysis of cross-sectional survey data from the Women's Health Australia (WHA) study.Setting and participants: A nationally representative sample of the "mid-aged" (45–50 years) cohort of women who participated in the 1996 WHA baseline postal survey. Responses were received from 14 100 women (a response rate of 54%).Results: Seven per cent of women reported ever having had cosmetic surgery. After adjusting for demographic variables, multivariate analysis confirmed that women who had had cosmetic surgery were significantly more likely to use health services more frequently (eg, surgical procedures, consultations with specialists and alternative healthcare providers). Cosmetic surgery was also associated with a greater number of chronic illnesses and use of medication for anxiety and sleep problems.Conclusion: Further research is needed to determine whether cosmetic surgery is directly related to health conditions or to attitudinal or psychosocial variables. Such research should examine whether alternative interventions may be more cost-effective in dealing with the issues that motivate women to seek cosmetic surgery.

Rafat Hussain MB BS, PhD · Margot Schofield MClinPsych, PhD · Deborah Loxton BPsych(Hons)

Both men and women are becoming increasingly concerned about their physical appearance and are seeking cosmetic enhancement. Most studies report that people are generally happy with the outcome of cosmetic procedures, but little rigorous evaluation has been done. More extensive ("type change") procedures (eg, rhinoplasty) appear to require greater psychological adjustment by the patient than "restorative" procedures (eg, face-lift). Patients who have unrealistic expectations of outcome are more likely to be dissatisfied with cosmetic procedures. Some people are never satisfied with cosmetic interventions, despite good procedural outcomes. Some of these have a psychiatric disorder called "body dysmorphic disorder".

David J Castle MSc, MD, FRANZCP · Roberta J Honigman BComm, BSocWork, Grad Dip Conflict Resolution · Katharine A Phillips MD

To the Editor: Comments made by Parker et al1 in response to Leeder and Rychetnik's article on evidence-based medicine (EBM)2 do not reflect the reality of the dilemmas clinicians face in practice — arguably, because of political misuse of the concept of EBM, which Leeder and Rychetnik warned against. Parker et al take issue with the "worry that EBM might be misused in public policy . . . where evidence is difficult to obtain", and argue that this is not the case. However, the previous Health Minister, Dr Wooldridge, was a great admirer of the Cochrane Collaboration, and, based on a perceived lack of evidence, he cut Medicare rebates in 1996 (by 50%) for patients needing long-term intensive psychiatric outpatient treatment. Although, after much protest, this decision was amended somewhat, Item 319 of the Medical Benefits Schedule remains today as a stark reminder of how some patients cannot access fully the treatment they desperately need. There is abundant evidence (international and local) as to the efficacy of this form of intensive treatment.3 There is also abundant and clear evidence that all who seek this treatment are traumatised by previous failed shorter treatments, often have comorbid disorders, and have established DSM-IV diagnoses of long standing.4 All this evidence was made available to the Minister — but Item 319 remains, with its exclusionary and discriminatory criteria to ration access, in my opinion due in large part to political misuse of the concept of EBM. Contrary to the assertion of Parker et al, there is a great deal to worry about. In addition, Parker and colleagues make the claim that mental health is attracting government attention and funding. Again, in reality, a great deal of money is being spent on promoting education and awareness — and certain kinds of treatment. There is no evidence that short-term treatments (which are heavily promoted) actually help the group excluded by Item 319 regulations. Yet public policy is being pushed along the lines of "one size fits all". It does not. All this is evidence of misuse of the idea of EBM reflected in public policy, and patients are suffering as a result. To make matters worse, cuts in one area are mindlessly used to push agendas that in clinical reality will be unworkable in other areas — all of which devalues professional expertise and judgement. Parker MH, Del Mar CB, Glasziou PP. Ethics and evidence-based medicine [letter]. Med J Aust 2001; 176: 138. <eMJA full text> Leeder SR, Rychetnik L. Ethics and evidence-based medicine. Med J Aust 2001; 175: 161-164. <PubMed> Doidge N. In: Cameron PM, Ennis J, Deadman JC, editors. Standards and guidelines for the psychotherapies. Toronto: University of Toronto Press, 1998. Doidge N, Simon B, Gillies LA, Ruskin R. Characteristics of psychoanalytic patients under a nationalised health plan: DSM-III-R diagnoses, previous treatment and childhood trauma. Am J Psych 1994; 151: 586-590. (Received 7 Feb 2002, accepted 25 Mar 2002)

Gil M Anaf

In reply: Anaf seems to have missed our point that the choice by Leeder and Rychetnik1 of mental health as an area relatively devoid of good quality evidence was a poor one — quality research has revealed mental health as an area of considerable need, and mental illness as a significant component of the global burden of disease. Despite the fact that evidence is often more difficult to obtain within the mental health area, much evidence exists — for example, the Cochrane Collaboration Depression, Anxiety and Neurosis Group has 11 500 controlled trials in its registry, and the Drugs and Alcohol Group has 3314. Anaf would agree with us here (on the basis of his assertions about the quality of the particular evidence he alludes to). On the narrower issue of the evidence base for long-term intensive psychiatric treatment, Anaf implies that this was ignored or distorted by the then Health Minister in deciding to amend the Medicare Benefits Schedule. We agree that EBM (and sound research) can be politically misused (as can any product of science), but that is no basis for rejecting EBM. Political misuse is a political mischief, not a failing in the particular instrument being misused. EBM itself is frequently blamed for all sorts of problems in health service, whereas, to use Anaf's example, the relative quality of the evidence for short or long term psychiatric treatment is a contingent matter for development and deliberation within and outside the psychiatric research community. Leeder SR, Rychetnik L. Ethics and evidence-based medicine. Med J Aust 2001; 175: 161-164. <PubMed> (Received 22 Mar 2002, accepted 25 Mar 2002)

Malcolm H Parker · Chris B Del Mar · Paul P Glasziou

As a result of the National Mental Health Strategy (1993–2003), the reform of Australian mental health services has come a long way.1 Specifically, issues highlighted by consumers and carers (increased access, commitment to equity, improved quality of services, promotion of choice and active participation by consumers and carers in national and local planning and decision-making) have been increasingly recognised. The time has now come to move from recognition of these issues to service changes that meet the identified needs, expectations, and standards of the wider community.2 The aim of consumer and carer participation is to improve the quality of service delivery and increase the level of consumer and carer satisfaction. The Mental Health Council of Australia, which is the peak, national, non-government organisation established to represent and promote the interests of the Australian mental health sector, has played a key role in the development of national policy on consumer and carer participation. Improved health outcomes are achieved when consumers and carers play an active role in decision-making and treatment programs and are given the opportunity to work in partnership with service providers in determining effective treatment options.3 It is no longer acceptable for healthcare professionals and policy makers to dismiss the input and deny the participation of consumers and carers in healthcare systems. Consumers and carers are entitled to access to equitable and quality healthcare services which offer choice and participation in selecting the most appropriate treatment options in the most empowering settings. The provision of effective and empowering healthcare services requires healthcare professionals to: foster an understanding of effective treatment options and treatment guidelines; be aware of how mental illness is perceived and experienced by the individual and the community; and ensure participation of, and provision of information to, people who experience mental illness and their carers. The material provided in this Supplement should assist practitioners in these tasks. Mental health services must aim to assist the individual back into active participation in community life by promoting independence and autonomy. Listening to what consumers and carers want from service delivery, taking account of what their needs are, and involving them in treatment and management plans is simply the starting point. If we are to move beyond "tokenism" to "a respected and affirmed role" for consumers and carers,2 then we need mental health service providers to be more informed, more engaged and more willing to enter active partnerships with people whose lives are affected daily by mental illness.

John F McGrath

General practitioners are usually the first point of contact for people with depressive illnesses. Their ongoing support, encouragement and, most importantly, provision of appropriate information is critical to the management of these illnesses. Patients generally respect and trust their doctor and will be guided by the GP's advice. Information is empowering. It allows people to make informed choices about their treatment and care. Initially, a patient suffering from a depressive illness may only need, or want, basic information about their illness. However, over time, the provision of more specific and detailed information for both the sufferer and his or her family is desired and appropriate. Unfortunately, doctors often assume that patients know more than they do about their illness. However, lack of knowledge about where to look, the stigma associated with depressive illnesses and the belief that they can somehow "pull themselves together" may dissuade many people with depression from directly asking the GP for information. Even the most proactive patients can become disheartened at the lack of general information about depressive illnesses available to the community. GPs have taken on the role of information providers, but now need to see this role in broader terms. Consumers and carers want information in the form of handouts, lists of appropriate books and articles, website addresses, support group details and other available resources. It is also important that the information presented to patients is relevant, easy to read, written for the target audience and not biased. The Internet is extremely useful for accessing relevant information, but it is also a source of inappropriate information. Anyone can be an author about depressive illnesses on the Internet, writing only from their own point of view. For example, in a search on antidepressants, I found a website condemning their use, based only on the experiences of the writer.1 This sort of (mis)information can be confusing to patients and their families. Therefore, gentle guidance of patients to appropriate websites, in addition to other sources of appropriate information, is crucial. The information in this supplement will help GPs and other healthcare professionals in this task.

Lara M Bishop

Depression is a major public health issue in Australia.1 Although more than 800 000 Australians experience depression each year, less than 40% of affected individuals present for care and fewer than one in six receive an evidence-based treatment.1 Most people with depression experience significant disability (reduced productivity on "seven of the past 28 days"2) and those who present for care are likely to have relapsing or chronic disorders.3 The current health burden of depression, and the projected future impact on our society, prompted the Federal and Victorian governments to develop beyondblue: the national depression initiative.4 The initiative has bipartisan political support and has grown to include active participation by other States and Territories and the development of partnerships with a range of non-government and community-based organisations.5 The aim of beyondblue is to promote effective population health-based strategies.6 Current projects focus on: increasing community awareness of key aspects of depression (such as characteristic symptoms, risk factors, pathways to care, preventive and effective treatment strategies); promoting destigmatisation of people with depression and related disorders; confronting barriers that discourage full social participation; and advocating for improved primary-care-based mental health services. With regard to secondary services, the initiative is focused on improved specialist support for the primary care sector. To meet the specific needs of people with depression and their carers, beyondblue has initiated a range of studies, some of which are outlined in this Supplement, and promoted the rapid dissemination of results to the medical profession. The review by Jorm et al7 (page S84) of complementary and self-help therapies used for treating depression represents a landmark study. It departs from the traditional debate about access to strategies that people say they want (such as access to counselling8) and evidence about what professional services people actually receive (eg, medication and non-specific psychological support9), and presents a scientific, dispassionate appraisal of treatments that people often use. Elsewhere, the same authors have noted that people not only use such complementary therapies,8 but also prioritise the use of harmful substances such as alcohol. The report by Jorm et al7 and the community survey on how Australians perceive depression10 (page S63) highlight that the community does not see doctors as a critical part of the public health response to depression. This is due to the persistent view that mental health is, at best, a marginal health issue, in combination with a lack of knowledge about available services and treatments.10 Unfortunately, the experiences of consumers and carers11 (page S69) indicate that interactions with different levels of the healthcare system reinforce the belief that depression is not a major concern of healthcare providers. Furthermore, the ongoing stigma within the community has major negative effects on people with depression and their carers. This results in overt and covert barriers to social participation that continue even when these people have recovered. The lack of leadership by both primary care and specialist doctors in promoting destigmatisation is clear to people with depression who use our healthcare system. For beyondblue, the promotion of the direct voice of consumers and carers is critical to the process of destigmatisation and ongoing medical education. Given the lack of detailed knowledge about depression in the community,10,12,13 beyondblue needs to find new ways of providing authoritative information to people who have not sought care and to those who have, because, all too often, access does not lead to the receipt of sufficient information to make treatment or personal choices. Advances in information technology are often seen as one solution. The review of Australian depression websites by Griffiths and Christensen14 (page S97) is intended to assist doctors and other healthcare professionals in recommending websites to patients and their carers. It is also intended to encourage healthcare professionals, particularly in primary care, to promote the use of high-quality Internet sites. Finally, if consumers are to make informed choices, they require access to the most up-to-date syntheses of professional knowledge. Evidence-based guidelines can assist consumers to avoid treatments that do not work (or do more harm than good), that do not justify the personal or wider social cost, or that delay access to more effective treatments. beyondblue felt that it was essential to commission recommendations for the management of depression in primary care and that the key recommendations be made directly available to doctors and other primary care professionals (page S77).15 Over the life of the beyondblue initiative, it will be critical to continue to evaluate community recognition of depression, the impact of this recognition, and the extent and persistence of personal and social barriers to full social participation. The results presented here10,11 provide baseline data and underpin an agenda for promoting the concerns of consumers and carers.11 In turn, beyondblue hopes that these articles will promote a variety of new methods (including novel instruments for measuring consumer- and carer-based concepts of recovery and other illness outcomes), and the development of quality monitoring and outcome systems within our healthcare environment.16,17 beyondblue looks forward to reporting the outcomes of such endeavours in the near future.

Ian B Hickie MD, FRANZCP

Objectives: To determine the degree of recognition and understanding of depression and its treatments in Australia in 2001, and detail factors and personal experiences that influence awareness of and attitudes to depression.Design and setting: Cross-sectional survey of a representative community sample (900 randomly selected respondents), via telephone interview, conducted 5–7 October 2001.Main outcome measures: Reports of community awareness, knowledge and attitudes to depression and its treatments in Australia.Results: The Australian community does not view mental health as a major general health issue. When asked specifically, depression was recognised as the most common mental health problem. Recognition of depression was greater among women and younger people. Most people (58%; 508/879) reported that they or a family member had experienced depression. People younger than 55 years and people with personal or family experiences of depression viewed depression as more disabling than other chronic medical conditions. Half the respondents differentiated depression from normal sadness. Awareness of common risk versus protective factors was limited. Most people endorsed a preference for self-help and non-pharmacological treatments, but community views of antidepressant drugs were less negative than expected. General practitioners were identified as the preferred point of first contact among healthcare professionals.Conclusions: Although mental health is still not highlighted as a major health issue, Australians do recognise depression as the major mental health problem. Women and younger people have more substantial knowledge about key aspects of depression and its treatments.

Nicole J Highet DPsych · Ian B Hickie MD, FRANZCP · Tracey A Davenport BA(Hons)

Objectives: To describe the experiences of people whose lives have been affected by depression.Design, setting and participants: Thematic review of data collected from 21 community meetings (1529 people, providing 911 evaluation forms) and nine focus groups (69 individuals) held nationally, and written feedback and website-based interactions with beyondblue: the national depression initiative between April and December 2001.Main outcome measures: Barriers to social participation experienced by people whose lives have been affected by depression, and their interactions with the healthcare system.Results: The key theme was the experience of stigma, which was evident in healthcare settings and in barriers to social participation, particularly regarding employment. Inadequacies of primary care and specialist treatment systems were highlighted. Particular emphasis was placed on limited access to high-quality primary care and non-pharmacological care. The stigmatising attitudes of many healthcare providers were notable. Within society, lack of access to knowledge and self-care or mutual support services was evident. Lack of support both from and for people in caring roles was also emphasised.Conclusions: People with depression are subject to many of the same attitudes, inadequate healthcare and social barriers reported by people with psychotic disorders. Consumers and carers prioritise certain notions of illness, recovery and quality of healthcare, and expect healthcare providers to respond to these concerns.

Bernard G McNair RN, GradDipNursingMgmt · Nicole J Highet DPsych · Ian B Hickie MD, FRANZCP

Objectives: To review the evidence for the effectiveness of complementary and self-help treatments for depression.Data sources: Systematic literature search using PubMed, PsycLit, the Cochrane Library and previous review papers.Data synthesis: Thirty-seven treatments were identified and grouped under the categories of medicines, physical treatments, lifestyle, and dietary changes. We give a description of each treatment, the rationale behind the treatment, a review of studies on effectiveness, and the level of evidence for the effectiveness studies.Results: The treatments with the best evidence of effectiveness are St John's wort, exercise, bibliotherapy involving cognitive behaviour therapy and light therapy (for winter depression). There is some limited evidence to support the effectiveness of acupuncture, light therapy (for non-seasonal depression), massage therapy, negative air ionisation (for winter depression), relaxation therapy, S-adenosylmethionine, folate and yoga breathing exercises.Conclusion: Although none of the treatments reviewed is as well supported by evidence as standard treatments such as antidepressants and cognitive behaviour therapy, many warrant further research.

Anthony F Jorm PhD, DSc · Helen Christensen MPsychol, PhD · Kathleen M Griffiths BSc, PhD · Bryan Rodgers MA, PhD

Objectives: To provide information about Australian depression sites and the quality of their content; to identify possible indicators of the quality of site content; and determine the accessibility of Australian depression web sites.Design: Cross-sectional survey of 15 Australian depression web sites.Main outcome measures: (i) Quality of treatment content (concordance of site information with evidence-based guidelines, number of evidence-based treatments recommended, discussion of other relevant issues, subjective rating of treatment content); (ii) potential quality indicators (conformity with DISCERN criteria, citation of scientific evidence); (iii) accessibility (search engine rank).Results: Mean content quality scores were not high and site accessibility was poor. There was a consistent association between the quality-of-content measures and the DISCERN and scientific accountability scores. Search engine rank was not associated with content quality.Conclusions: The quality of information about depression on Australian websites could be improved. DISCERN may be a useful indicator of website quality, as may scientific accountability. The sites that received the highest quality-of-content ratings were beyondblue, BluePages, CRUfAD and InfraPsych.

Kathleen M Griffiths BSc(Hons), PhD · Helen Christensen PhD, MPsychol(Hons)

There is persuasive anecdotal evidence that healthcare professionals have a heightened vulnerability to being stalked by their patients. This is supported by an overrepresentation of healthcare professionals in stalking-victim populations.1 Some stalking behaviours constitute little more than minor irritations, but more serious cases can ruin a clinician's career. Rarely, but tragically, stalking has cost some doctors their lives. Stalking refers to a constellation of behaviours encompassing repeated and persistent attempts to impose unwanted communications or contact upon another. While legal definitions of stalking do not specify time periods, it is increasingly apparent that harassing behaviours extending beyond two weeks constitute clinically significant stalking.2 The behaviours include telephone calls, letters, email, unsolicited gifts, following, maintaining surveillance, making complaints of professional misconduct or initiating spurious legal action against the victim, ordering or cancelling goods or services on the victim's behalf, property damage, threats, and physical or sexual violence. Stalking has emerged as a significant social problem3 and now constitutes a specific criminal offence in many jurisdictions. Although the past decade has seen a virtual explosion of interest in this phenomenon, only in recent years has stalking begun to pique the interest of the medical profession. This attention relates in part to the observation that stalking behaviours are becoming more prolific3 and may be amenable to clinical intervention.4 Although the extent of the problem has yet to be quantified, it is timely to highlight pertinent issues relating to the stalking of medical practitioners by their patients. We searched the Index Medicus/MEDLINE and PsycLIT databases for articles pertaining to stalking and related behaviours perpetrated against medical practitioners by their patients, and we review the literature in this article. We also present strategies that can be used to discourage a patient's intrusions and minimise the impact of these behaviours on clinicians' professional and personal lives. Because there is a lack of empirical data on the efficacy of specific interventions, these management strategies are based on our experience of assessing and treating stalkers and their healthcare practitioner victims during the past decade. Harassment and stalking in healthcare settingsWorkplaces can be risky environments, as burgeoning reports of violence, bullying and sexual harassment attest.5 Clinicians cannot claim immunity from these abuses.6-8 One survey of 850 forensic psychiatrists found that 42% of the 480 respondents had been harassed in some way by patients: 9 17% reported threats of physical harm, 13% reported non-violent threats (such as a lawsuit), and 3% had been physically assaulted. A study documenting the nature of threats to clinicians10 observed that intimidation could continue after the patient's discharge from inpatient care. Clinicians attending the 1994 annual meeting of the Oregon Psychiatric Society were surveyed about stalking.11 Twenty-six of the 90 respondents had been subjected to behaviours that met the authors' definition of stalking, and 37 reported other forms of distressing intrusions. In Australia, healthcare professionals were overrepresented in a sample of 100 self-referred stalking victims (nine general practitioners, three psychiatrists, two gynaecologists, one rheumatologist, a medical resident, a psychologist, a nurse and an occupational therapist).1 The vulnerability of medical practitioners to the unwanted intrusions of their patients is one legacy of a profession that comes into regular contact with lonely and disordered people. In some of these individuals, "sympathy and attention is easily reconstructed as romantic interest".12 Despite this, little systematic research has been conducted on the abnormal attachments of patients to their doctors, and it is likely many incidents of stalking remain unreported. This paucity of research relates in part to the nature of the profession. The authors of one study suggest that some staff may not have reported stalking behaviours because "denial and minimisation are common reactions to being the target of patients' aggressive behaviour".13 Denial enables clinicians to ignore threats and continue their work.10 Some doctors may fear that their victimisation will be equated with incompetence, or, in the current climate of sexual misconduct allegations, that their complaints of harassment will be met with scepticism. In popular depictions of doctor–patient liaisons, the emphasis is usually on the doctor exploiting the patient, with an implication that the imbalance in power precludes the patient from victimising the doctor.8 Resistance within the criminal justice system to prosecuting patients, especially when the patient is mentally ill,10 may also discourage reporting. Patients who stalkStalking behaviours are the product of a number of different motivations and states of mind.14 The two most common motivations for stalking clinicians are: Patients' developing romantic or child-like attachments that lead them to entertain hopes of a relationship. These hopes may arise on the basis of delusional beliefs (as in erotomania, a false conviction that one is loved by another), misplaced expectations in the lonely and desperate, or simply the unrealistic expectations of a would-be suitor. The last group is typically drawn from the socially incompetent or narcissistically self-absorbed. Patients' developing a resentment against the professional, usually connected to some supposed injury or dereliction. It has long been recognised that patients may transfer feelings of love or hate to their therapist as a consequence of the treatment situation and early experiences, a phenomenon known as transference.15 However, transferential explanations for patients' misplaced affections or anger foster in healthcare professionals an unhelpful sense of responsibility that can lead to feelings of guilt. They also foster the counterproductive assumption that the stalking and harassment can be managed within the doctor–patient interaction. The impact of stalking on healthcare professionalsIn one report, the authors noted that the harassing behaviours of their subjects had a disruptive impact on hospital staff, and consequently the functioning of the hospital.13 Staff became more vigilant and modified aspects of their work practices and lifestyle to ensure their safety. Some even changed their place of residence. Another study also highlighted the disruption created in the professional and personal lives of physicians who experienced threats.10 Examples included modifying their treatment style or refusing certain referrals, reducing their practice size, and placing restrictions on family activities. Some expressed guilt for the intense family stress that resulted. Many of the doctors who participated in the Australian survey1 said that nothing in their medical training had prepared them for this and they had emerged feeling frustrated, helpless and disenchanted with their profession. Management strategiesMany doctors have, or feel they are expected to have, a high tolerance for the criminal behaviour of patients, even when it induces fear and disrupts the lives of practitioners and their families. We believe such tolerance is misplaced, both in terms of the clinician's health and the patient's long term interests. The following strategies (summarised in the Box) can be used to discourage a patient's unwanted intrusions and to minimise their impact on all concerned. The first threat or declaration of loveStalking behaviours can emerge gradually out of apparently appropriate behaviours, such as attending more frequently at the doctor's rooms, phoning ostensibly for clarification of some aspect of treatment, or "chance" encounters outside of the work context. Alternatively, they may have a sudden onset, heralded, for example, by a declaration of love. Clinicians often respond awkwardly to these sudden declarations, giving polite disclaimers of interest on the basis of the professional nature of the relationship. All too often this results in patients' discharging themselves from the practice and returning, hopeful that now all obstacles have been removed. Worse still, the clinician may suggest an intimate relationship is precluded on the basis that they already have a partner. The patient might hear this as, say, "I would be interested but for my wife", with potentially dangerous repercussions. Stalking behaviours will be more readily recognised and their emergence may be subdued when clinicians set clear boundaries for appropriate behaviour in their patients.16 It is important to state that their relationship is, and will only ever be, a professional one. While this message should be firm and unequivocal, the clinician must endeavour to preserve the patient's dignity, lest they give the patient further reasons, particularly anger and resentment, to continue their harassment. The early stages of stalkingIt is reasonable to confront the patient and set limits by restricting the duration and frequency of appointments and any other behaviours that are aimed at maximising contact with the doctor. However, this approach has most chance of succeeding with the socially incompetent would-be suitor. Stalkers driven by morbid infatuation or resentment seldom respond to these measures alone. If a patient's intrusions continue despite the clinician's warnings, particularly when the behaviour persists beyond two weeks, there is a substantial risk of protracted harassment.2 In these circumstances, the clinician is ill-advised to continue the therapeutic relationship and should resist any temptation to engage in endless debates and negotiations. Ongoing communication will only reward the patient's efforts to maintain contact. However, transferring such patients can be difficult,11 both because of medicolegal abandonment implications and because prospective physicians may be understandably wary of accepting them. It is essential to document the termination process. In some instances it may be necessary to defuse the situation by hospitalising the patient. It is essential that the clinician carefully document each incident, noting the time and date, a synopsis of the behaviour and the names of any witnesses. These records should be kept in a secure place, as they can be invaluable in any future legal proceedings. The victim should also retain any concrete evidence of the stalking, such as answering machine messages, gifts and letters. Correspondence should not be returned, as this perpetuates contact between victim and stalker and vital evidence is lost. Affected professionals should not suffer in silence. They should inform a trusted colleague and discuss the case with a psychiatrist familiar with these issues. Other staff at the doctor's practice, particularly receptionists, must be apprised so that they do not inadvertently countenance the patient's pursuit and to enable them to adopt personal safety precautions. Spouses and other family members should be informed for similar reasons. Established stalkingStalking is a criminal offence and cases that do not respond to the above measures warrant a police report. This is particularly important when stalking involves threats or violence, or where there is a known history of sexual or physical aggression. Morbidly infatuated stalkers generally have a low incidence of threatening and violent behaviour, and, although resentful stalkers often issue threats, they seldom proceed to actual personal violence.14 Nevertheless, threats should never be disregarded, particularly in a stalking context, and the clinician must take precautions to ensure his or her personal safety and the safety of others who may be at risk. If the stalker threatens to initiate spurious legal action against the practitioner, or there is a likelihood of future action, the doctor's medical defence organisation should be alerted. Restraining orders or protective injunctions are frequently advised in stalking situations, but are not universally effective.12 Erotomanic patients are likely to be impervious to legal sanctions, although these are often useful in dissuading the socially incompetent and less entrenched resentful stalkers. Erotomanic stalking patterns will not subside without definitive treatment, and referral for psychiatric evaluation is a priority. It must be stressed that any escalation in stalking behaviours, particularly when it involves threats and overt hostility, should not be ignored or "worked through" in therapy. Threats are indications to seek advice. If a patient poses an immediate risk of harm to the therapist, he or she may require civil commitment or, for patients who are not mentally ill, prosecution under anti-stalking statutes.17 Anti-stalking strategies Don't disclose personal details to patients. Don't leave personal information where patients can access it. Don't give home contact details to professional organisations that allow public access to the information. Beware of confidentiality and privacy issues associated with electronic patient data. Consider security measures: obtain an unlisted home phone number and post office box address; install deadlocks, window locks, peepholes and exterior motion sensor lights; trim trees and shrubbery. Ensure patients understand your relationship is a professional one and will never be otherwise. If concerned about a patient's intrusions, set limits on proximity-seeking behaviours and ensure the patient is seen only when other people are nearby. Carefully document the patient's intrusions. Retain all evidence of stalking. Inform a colleague and other parties as appropriate, including medical defence organisation. If unwanted contact or communication persists, discontinue the patient's care and refer to another practitioner. If the patient poses an immediate risk to the practitioner or third parties, consider civil commitment (if mentally ill) or prosecution. Preventive strategiesIt is crucial that medical practitioners take steps to protect their privacy. They should be cautious about disclosing personal details to patients or leaving personal information where patients can access it, and avoid divulging home contact details to professional organisations or registries that appear in the public domain. With the introduction of electronic patient data, clinicians need to be familiar with the associated confidentiality and privacy issues.18 Office security is a priority in any medical rooms.9 Clinicians who practise in relative isolation without the support staff available in group practices or hospital outpatient departments are precariously placed to manage patients with a history of stalking or other threatening behaviours. It is wise to arrange a chaperone for physical examinations and, if the patient objects, to document this in the medical file. A doctor who is concerned about possible stalking behaviours by a patient should at the very least endeavour to see the patient when other staff are nearby.19 ConclusionsIn studying stalking, we are constantly seeking more effective ways of identifying and protecting the victims. At a time when healthcare resources are a widespread concern, phenomena with the potential to end medical careers cannot be ignored. Studies to date indicate that stalking of medical practitioners occurs with sufficient frequency to warrant systematic attention. Research is currently in progress to empirically measure the extent of the problem in the medical profession. Future research efforts should be directed to developing specific management strategies and formulating workplace policies. Greater emphasis must be placed on incorporating this knowledge into medical training curricula, so that doctors are less confused about their responsibilities, less inclined to ascribe these experiences to their own shortcomings, and more likely to obtain definitive help before their lives (and often those of their patients) are devastated. Because not just doctors but a range of healthcare professionals are at risk, these approaches will almost certainly have wide application.

Michele T Pathé MB BS(Hons), FRANZCP · Paul E Mullen MB BS, DSc · Rosemary Purcell BA, MPsych

Comprehensive management of pregnancy loss is enhanced by psychological support and follow-up counselling It is generally accepted that 12%–15% of confirmed pregnancies do not progress to term, with the risk of pregnancy loss increasing with maternal age. In particular, early pregnancy loss (< 20 weeks' gestation) is experienced by one in four women. In about half these women, a medical explanation can be found,1 although, in clinical practice, investigations to identify the cause are rarely pursued. Most women go on to have successful subsequent pregnancies, although there is a slightly increased risk of a second miscarriage that increases incrementally with each subsequent loss.1 Although early-pregnancy loss is relatively straightforward medically, the psychological outcome is more problematic and the grieving process is complicated.2 First, there is no tangible life or memory to grieve. Instead, the woman has to come to terms with grieving for a potential life with all its hopes and aspirations. Second, the grieving is often complicated by feelings of self-blame, particularly when there is no medical explanation for the loss or the woman has engaged in potentially hazardous behaviour (eg, alcohol consumption or smoking). Her partner may also harbour feelings of responsibility for the loss. Other factors which may influence the grieving process and the emotional outcome include miscarrying later in gestation (especially if the woman has felt the fetus move and formed an emotional attachment to it);2,3 the importance and meaning of the pregnancy (eg, a first, wanted pregnancy lost near the end of the reproductive lifespan); and the difficulty experienced in conceiving the pregnancy (eg, an assisted conception). Finally, psychosocial factors, such as a woman's support network (especially her intimate relationship) and her personality style and culture, will affect how she appraises her loss and her level of distress. The psychological sequelae after a late pregnancy loss and stillbirth are well described;3 those after an early pregnancy loss are similar but may not be as severe. There can be high levels of psychological distress characterised by anxiety, depression and somatisation, which can persist for at least six months4 and are only partly accounted for by grieving for the loss of a potential child. There is an increased risk of developing a depressive or anxiety disorder in the six months after a pregnancy loss, and any pre-existing psychotic disorders can be precipitated. The risk of developing depression is high, with studies reporting rates between 10%5 and 48%,6 depending on the study methods.7 One of the more rigorous controlled studies5 reported that 10.9% of women developed major depression after a miscarriage, compared with 4.3% of women (controls) from the same community who had not been pregnant in the previous year. Depression is more likely in women with a history of depression or past psychopathology, and in women who have had a previous pregnancy loss or have no other children. Other factors precipitating depression, such as poor social support or having a vulnerable personality style, are well recognised. The rates of anxiety disorder are lower than those for depression. Recently, exacerbation of obsessive–compulsive disorder after miscarriage has been reported.8 Finally, if the pregnancy loss has been traumatic (eg, an ectopic pregnancy or the woman's life was at risk), post-traumatic stress disorder can arise.9 The comprehensive management of pregnancy loss will be enhanced by psychological support and follow-up counselling.7,10 This can be provided by the woman's obstetrician, general practitioner or another health professional involved in her care, who can address medical as well as psychological issues.11 The purpose is to allow open discussion about the loss, monitor progress and counsel the woman about future pregnancies. In the initial stages, she will benefit from the opportunity to talk about her loss and have her grieving acknowledged. Providing information about the normal grief process may help a woman who is masking her grief or does not believe it is legitimate. The grief process will be facilitated by the opportunity to talk about feelings of guilt and self-blame, particularly when there is no medical explanation.12,13 In our opinion, there should also be an opportunity to discuss dissatisfaction with medical care, as the woman may feel angry and blame her medical practitioner for the loss. An open discussion about this will help her, and may reduce the possibility of litigation. Medical practitioners, particularly when the issue is pregnancy loss or stillbirth, are often reluctant to use the phrase "I'm sorry" because of fears that this equates with an acknowledgement of guilt and may have legal implications. Bereaved parents are often highly aware of this omission, angered by it, and may actually retaliate through litigation. Both obstetricians and insurance companies need to seriously look at the distinction between empathic expression of "sorrow" for the distress experienced as opposed to an apology for negligent action. Regular follow-up is recommended for the first six months. Distinguishing between feelings of grief (which may require grief counselling) and the onset of a depressive illness (which may require specific treatment) can be difficult. Depression is suggested by persistence of depressed mood, lack of enjoyment in pleasurable activities, low self-esteem or excessive guilt, and sleep or appetite disturbance or fatigue.14,15 A pathological grief reaction, characterised by excessive distress, guilt feelings or a preoccupation with the loss, may require more specific counselling. Sometimes a woman may have her depressed feelings dismissed as "grieving" and miss out on appropriate and effective treatment for a depressive disorder. Other family members may also need psychological support. The woman's partner may experience similar feelings of loss.16 In such situations, the father is often neglected ("men aren't expected to talk about their feelings"). He will also benefit from an opportunity to talk about his feelings of loss, as will other children in the family, especially as they may feel responsible if they had feelings of jealousy about the new sibling. The sense of loss may dissipate when the woman becomes pregnant again, and some studies suggest that the shorter the time between a pregnancy loss and a subsequent pregnancy the better the outcome for the woman.13 Such women usually feel anxious during the stage of pregnancy at which the previous loss occurred. Finally, women may benefit from the opportunity to talk to other women who have experienced a pregnancy loss through support groups such as SANDS <http://www.sands.org.au/>.

Philip M Boyce MD, FRANZCP · John T Condon MD, FRANZCP · David A Ellwood DPhil(Oxon), FRANZCOG

To the Editor: We are writing in response to the editorial of Ben-Tovim et al.1 Although we agree that more research into treatment efficacy in eating disorders is needed, we believe that the study to which reference is made2 is seriously flawed. The study should not be presumed to provide evidence about the effect of treatment on outcome, particularly as the majority of patients studied received no treatment. The high death rate (3/95 [3.2%] among patients with anorexia nervosa and 2/37 [5.4%] among patients with "eating disorders not otherwise specified") in such mildly ill patients (few of whom would have warranted hospitalisation on the basis of their weight) approximates that of seriously emaciated patients in longer-term studies of treatment outcome3,4 and could more properly be said to illustrate the results of having no treatment or inadequate treatment. Exactly what constituted specialised treatment is never actually described in the original article,2 in which "extended inpatient treatment" is defined as treatment lasting more than two weeks and "extended outpatient treatment" as three or more visits. Thus, the so-called "resource intensive treatment" the authors refer to would not necessarily represent even adequate management of these conditions. In our own 6–10-year outcome study5,6 cited by the authors, 61 emaciated patients with anorexia nervosa received, on average, 11 weeks of inpatient treatment consisting of nutritional rehabilitation and psychotherapy. Only one patient died (of suicide) and, of the patients fully assessed, 41/50 (82%) had a good or intermediate outcome. The degree of weight restoration achieved by the end of treatment correlated with the degree of osteoporosis 10 years later.7 In other studies, duration of illness and early intervention have been shown to significantly influence outcome.4 This contrasts with the findings of Ben-Tovim et al,2 which may have been skewed by an unusual level of chronicity in the study group. A recent study of 69 patients with eating disorders treated in our own multidisciplinary program showed that, on 12–18-month follow-up, 48/69 (70%) had improved and 34/69 (49%) no longer had an eating disorder diagnosis. Mean levels of all but one of the major behavioural and psychological features rated by the EEE-C (Eating and Exercise Examination by Computer) instrument8 were significantly reduced. The advice given by Ben-Tovim and colleagues to the parents of the hypothetical 15-year-old girl with anorexia nervosa is regrettably nihilistic and, if based on their Lancet study,2 not founded on sound or generalisable evidence. Parents should be referred to a program for which good outcomes have been demonstrated, treatment accords with published guidelines, the clinicians are suitably experienced, and in which early intervention is the aim.4

Janice D Russell MD FRACP FRANZCP · Suzanne F Abraham PhD

In reply: The commitment of Russell and Abraham to their own program has distracted them from accurate reporting and sound epidemiological principles. They say that the majority of patients that we studied received no treatment. Not so. We clearly stated that only 34 of the 220 patients studied received no treatment.1 They then draw a range of inferences from the fact that "3/95 (3.2%)" patients with anorexia nervosa died. In fact, only 2 of 95 patients with anorexia nervosa died as a consequence of that disorder during the five years of our study. At 2.1%, this is similar to the crude death rate of 1/61 (1.6%) that they describe in their own study. However, it is only acceptable to use a rare outcome as a measure of the efficacy of a treatment program if the clinical characteristics that put patients at risk for such an outcome are known and accounted for. We do not know the specific factors that put people at particular risk of dying from anorexia nervosa. Without such knowledge, small differences in crude death rates can not of themselves inform us whether treatment programs diminish or accentuate such risks. Unfortunately, there are no other studies against which to compare the outcomes of the patients with "eating disorders not otherwise specified" in our study. We have dealt with issues such as the representative nature of our study elsewhere.2 I stand by our work and the conclusions we draw from it.

David I Ben-Tovim PhD FRANZCP

To the Editor: The recent supplement by Hickie et al looking at the mental health of Australians attending general practice1 would have us believe that we are quite a mentally unwell nation indeed! The authors propose a broad concept of "mental disorder" which they found in 49% of general practice attenders based on 12 questionnaire items (the SPHERE-12). These 12 items include six relating to psychiatric symptoms (PSYCH-6) and six relating to somatic symptoms (SOMA-6).2 The SOMA-6 items are muscle pain after activity, needing to sleep longer, prolonged tiredness after activity, poor sleep, poor concentration, and tired muscles after activity. Patients with a total score of two or more in PSYCH-6 and/or three or more on SOMA-6 were classified as having a "mental disorder". Firstly, the SPHERE-12 is grossly oversensitive, as the six somatic items detect many medical conditions, glandular fever being just one example. Other validity issues include the two-week cut-off for symptoms (further adding to the overinclusiveness because of temporary distress and minor illnesses), and the lack of discussion regarding transcultural and inter-rater reliability, particularly with so many general practitioners involved. Secondly, the authors' interchangeable use of neurasthenia and chronic fatigue syndrome and somatisation needs discussion. Ten years ago, Hickie and several New South Wales physicians were dismissive of an article linking chronic fatigue syndrome and neurasthenia: "We have demonstrated immunological abnormalities in patients with chronic fatigue syndrome as compared with both normal controls and patients with major depression. Further, the demonstration of abnormal cytokine production in patients with chronic fatigue syndrome may underpin 'acquired neurasthenia'."3 All the SOMA-6 items are key symptoms of chronic fatigue syndrome. With the overwhelming amount of biological data now available, purely psychological theories about chronic fatigue syndrome (as opposed to chronic fatigue) are totally untenable, as is the use of the term neurasthenia, introduced into medicine in 1869 and discarded by the American Psychiatric Association's Diagnostic and statistical manual of mental disorders4 as invalid.5 A recent study from the Fatigue Clinic, King's College Hospital, UK,6 found that an astonishing 68% of patients had been inappropriately misdiagnosed with a psychiatric illness. This is surely a warning for overzealous psychiatrists. Thirdly, treatment implications are a concern. The authors comment that "only 27% of patients with Level 1 disorders received pharmacological interventions" (Level 1 implying positivity for PSYCH and SOMA items). They say that general practitioners mostly used "relatively ineffective non-pharmacological strategies", and that they had responded to missing all this "unmet need" by "criticising the oversensitivity of the screening instrument and inappropriateness of diagnostic systems used", implying an underprescribing of antidepressants. The recent National Survey of Mental Health and Well-being7 showed that somewhere between two-thirds and a half of the 23% of the population diagnosed with psychiatric disorders did not visit their general practitioner. How does this fit in with the 49% found by Hickie et al? In summary, the authors' broad and idiosyncratic conceptualisation of "mental disorder" and their use of a screening tool which labels many physically ill people with or without concurrent distress as cases of "mental disorder" implies that general practitioners need to prescribe more antidepressants — at what cost and for whose benefit?

Nicole Phillips MB ChB, FRANZCP · Michael J Oldmeadow MB BS, FRACP · Natalie Krapivensky MB BS, FRANZCP

In reply: It is with great pleasure that we resume our ongoing correspondence with Phillips concerning the medical and psychological status of patients who present with non-specific somatic complaints such as chronic fatigue.1 As we have reported previously,2 we have been strong advocates of both the need to develop appropriate instruments for measuring neuropsychiatric states characterised by non-specific somatic symptoms and to promote effective medical and psychological management of patients with these disabling conditions.3 In their letter, Phillips and colleagues fail to grasp the essential issue. To describe a condition as a neuropsychiatric state (or mental disorder) does not necessarily lead to simplistic and entirely unhelpful assumptions about "medical" versus "psychological" causes or treatments. Phillips et al attempt to promote once again the notion of "biological" (ie, acceptable) versus "psychological" (ie, unacceptable) theories of the causation of chronic fatigue syndrome. Such an approach is not only intellectually sterile and inconsistent with the past decade of intensive research by a wide range of medical and psychological research teams,4 but also profoundly unhelpful to people affected by these disabling disorders.3 In recent years, the very significant health burden of common mental disorders such as depression, anxiety, alcohol or other substance misuse, and neurasthenia (prolonged fatigue states lasting longer than three months) has been well documented in the Australian community5 and in the primary care setting.6 Phillips and colleagues appear to have no knowledge of the basic epidemiological fact that mental disorders are two to three times more common in primary and other medical care settings than in community studies (hence the total rate of disorder in our study is about twice that detected in the Australian National Survey of Mental Health and Well-being). Contrary to their implications, the total rates reported in our general practice study are entirely consistent with the largest multinational study of primary care ever conducted.7 That study indicated that a third of all primary care patients have mental disorders and another third have mental health difficulties (with or without concurrent medical disorders) requiring specific psychological assessment. The significance of our study is that it has brought the extent of common mental health needs (including depression, anxiety, alcohol or other substance-misuse and somatoform disorders) to the attention of the Australian medical profession. What is now required is a concerted and integrated response — not a return to dualistic notions of illness that have for so long hampered the provision of effective pharmacological and non-pharmacological treatments to patients with mental disorders who present for medical care.

Ian B Hickie MD, FRANZCP · Tracey A Davenport BA(Hons) · Elizabeth M Scott FRANZCP · Sharon L Naismith BA(Hons)

To the Editor: The letter "Prejudice against mental illness" in the 20 August issue of the Journal1 resonates with my own experiences when attempting to obtain income protection insurance. Many colleagues have a similar story. In 1994, I suffered an episode of major depression requiring hospitalisation. I was a first-year resident medical officer, had relocated to a different city, and had just moved out of home for the first time, at the age of 25. Subsequently, I have progressed well in my career, and will soon complete specialist training. I have dealt successfully with a number of substantial personal and career hurdles, including postgraduate examinations and training, difficult property transactions, engagement and subsequent break-up of the engagement, the death of a flatmate, and illness and personal difficulties within my family and close friends. I have invested considerable time and effort in cognitive–behavioural therapy, and changed many attitudes and behaviours contributing to the initial breakdown. Wary of the implications for insurance, I have been reluctant to have any contact with my psychiatrist. My last appointment was a courtesy visit two years ago, with another visit 12 months before that. I have continued to self-prescribe an antidepressant tablet in the belief that it is probably doing more good than harm. Without any reference to medical reports, an examination, or an appraisal of my achievements and performance, several experienced brokers have confirmed that my history prevents me from being able to obtain income protection insurance, even with an exclusion clause for mental health problems. The one insurer that will consider covering people with a history of depression, with such an exclusion clause, requires me to be off any treatment for 12 months. It is understandable that an income protection insurer would refuse cover for depression-related claims. However, I fail to see why I am denied the opportunity to purchase insurance against the myriad other accidents and illnesses that can befall anyone, irrespective of their history. It appears the underwriters' methods are based on actuarial data that are overly generalised, and undoubtedly many years out of date in terms of diagnosis and prognosis of mental illness. Ironically, private health insurers cannot refuse to cover any patient, regardless of pre-existing conditions. Such discrimination reflects endemic ignorance and prejudice about mental health and illness. It is time for a review of the criteria by which insurers may reject applications.

Name and address withheld