Mental health

To the Editor: The article by Sultan and O'Sullivan on detention of asylum seekers in Australia in the 3/17 December issue of the Journal1 contains several errors of fact and distortions that I believe you have an obligation to address. While I am not addressing medical issues, this nevertheless goes to the issue of credibility. The article made several claims that are factually wrong and would not have withstood even cursory examination had you sought verification. I will not attempt to deal with all distortions and factual errors, but your readers should be made aware of at least some elements. Detention is not arbitrary. It is humane and is not designed to be punitive. Staff are provided with cultural-awareness training and are expected to interact with detainees in an appropriate manner. Further, the level and range of medical services available to detainees exceed those available in many regional areas of Australia. It is true some people have been detained for some years. However, Sultan and O'Sullivan neglected to mention that these cases are ones where people have been found to have no lawful right to remain in Australia, but have been pursuing all legal avenues or have been refusing to cooperate with departure arrangements. Another distortion and half-truth relates to a hunger strike where "power and water supplies were cut to the cell block . . . affecting uninvolved women and children". Firstly, there are no cells at Villawood and the alleged cell block was actually a recreation room. The water supplies were cut when earth-moving equipment outside the centre accidentally cut the mains supply to the area, affecting surrounding homes and the centre. Water containers were provided for the detainees until the water supplies were restored. What Sultan and O'Sullivan do not tell you about the power supply was that it was cut when detainees ripped wires out of electrical equipment and threatened to use them to electrocute staff. This action obviously also posed a risk to the children who were moving in and out of the room. A small number of protesting detainees were denied access to the visitors' area because of the disruption their actions would cause to the majority of detainees who were not involved in the protest. Head counts have taken place at 2 am, but what you were not told was that these followed escapes and are not routine. The claim that there has been a dearth of educational and resource material is a factual error. It is disappointing that a publication of your standing did not make even cursory enquiries on simple factual issues.

Aamer Sultan MB ChB · Kevin O'Sullivan BSc, PhL, DipClinPsychol · Debra Graves MB BS, MHA, FRACMA

In reply: The Minister for Immigration and Multicultural and Indigenous Affairs, Mr Philip Ruddock, claims that our article contains several errors of fact and distortions. He does not comment on the substantive concerns of the article, but implies that the errors undermine the credibility of our finding — that prolonged detention of asylum seekers appears to cause serious psychological harm. In response, we will address the alleged errors of fact and then the credibility of the observations made in our article. The Minister states that we failed to identify the factors leading to long periods of detention for some asylum seekers. It is clearly stated in the article that "lengthier detention is particularly common for detainees who appeal against adverse decisions about their refugee status". The Minister's response adds nothing of substance to this and fails to identify the other major factor accounting for prolonged detention, namely the difficulties in removing individuals who are stateless or from countries such as Iraq and Afghanistan. The Minister states that nightly head counts at Villawood occur only after escapes. Unfortunately, the Minister has not been accurately briefed on this matter. Nightly head counts have been a regular practice at Villawood. One of us (A S) has documented proof from the minutes of both the Community Reference Committee and the Centre Manager's detainee meetings held at Villawood, which record the concerns of the detainees and the refusal of management to discontinue the practice. Moreover, this practice was openly acknowledged by the operators of Villawood to the Parliamentary Joint Standing Committee which visited the centre in February 2001.1 It is pleasing to note that, after the publication of our article, nightly head counts have been discontinued in the Stage Two section of Villawood. There are conflicting accounts between detainees and management regarding the events surrounding the hunger strike referred to by the Minister. One of us (A S) sent a complaint about this incident to the Commonwealth Ombudsman. In his reply, the Ombudsman quoted a letter from the Department of Immigration and Multicultural Affairs dated 27 October 2000, which states: "I can confirm that power to the recreation room was cut-off for a short period of time to ensure the safety of the detainees participating in the protest action who had been threatening self harm". There is no mention of attempts by detainees to electrocute staff, as suggested by the Minister, and one of us (A S) has spoken to some of the detainees involved in the protest, who have categorically denied this. Many detainees remain highly sceptical of the official explanation offered regarding the lack of water to the block where the hunger strikers were being held. The very existence of the mass hunger strike and the conflicting accounts of the incident all attest to the emotionally charged environment that has at times existed at Villawood, which was the major point of discussing this incident in our article. We made it quite clear that there have been recent improvements in recreational resources at Villawood. However, as stated in our article, there had been a long history of neglect of this issue. This was confirmed by the statement of the Human Rights and Equal Opportunity Commission in 1998 that "the recreation facilities at Villawood are inadequate for the number of detainees being held there".2 Moreover, despite recent improvements, our statement that detainees face long periods of unstructured time remains true. Although we did not discuss the issue of whether mandatory detention was arbitrary, it is worth noting in response to the Minister's claim that the Human Rights and Equal Opportunity Commission concluded that "In some instances, individuals . . . have been held for more than five years. This is arbitrary detention and cannot be justified on any grounds".2 The failure of the Minister to consider the substantive issues we raised, namely the negative psychological effects that long-term detention appears to be having on asylum seekers, was disappointing. As we stated, we attempted to report our observations in what we consider to be an objective and truthful manner. Nothing in the Minister's response suggests that we have failed to do this. Even if the findings in our report were to be entirely dismissed, Steel and Silove (in the same issue of the Journal)1 document compelling evidence of the serious psychological symptoms observed among long-term detainees. In conclusion, we can only offer a continued exhortation for the Minister to attend to the collective weight of evidence indicating a mental health crisis within Australian detention centres.

Philip Ruddock MP · Derrick M Silove · Zachary Steel · George Halasz MRCPsych, FRANZCP · Michael Block · Leon Petchkovsky · Howard Cooper · Martin B Van Der Weyden · Ruth M Armstrong · Helen M Randall

In reply: Several aspects of Mr Ruddock's letter concern us. The tendency to evade the substance of the message and instead to attack the messenger, in this case the MJA, is unwarranted. Fortunately, the Journal's reputation rests secure with its more usual, considered readership, but the accusation that the MJA has acted in a cursory manner is particularly jarring — the media response by the Minister to the publication of the relevant articles occurred within hours, hardly sufficient time to subject them to a considered analysis. The haste of the response is also evident in the substance of the letter, with its focus on largely irrelevant technical aspects rather than on the key issue — the legitimate concerns raised about the impact of detention on the mental health of inmates. Are we to assume from the Minister's silence on this core matter that he acknowledges that the majority of long-term detainees are suffering from severe depression and other disabling emotional disturbances, as described in the article by Sultan and O'Sullivan and supported by other data we cite? The rates of depression reported by Sultan and O'Sullivan represent a roughly eightfold greater prevalence than is found in the general Australian population — if correct, this reflects an epidemic of mental illness among long-term detainees. Until proven otherwise, there is every reason to assume that the mental disorders identified are a direct outgrowth of the conditions of detention. One of the key findings of research in this area is that asylum seekers in detention report similar patterns of abuse and trauma as their refugee counterparts authorised to resettle in Australia. It is paradoxical and contradictory that we provide authorised refugees some of the best rehabilitative services in the world through our national network of services for survivors of torture and trauma, while at the same time creating conditions in detention centres that exacerbate the effects of past trauma in their compatriots. The claim that detention is humane is extraordinary. From a medical perspective, the obvious test of such a claim is in the health outcomes. Instead of the steady improvement in psychosocial status witnessed in authorised refugee populations after resettlement, there appears to be a progressive deterioration in the mental health of similarly traumatised persons in detention. A policy that in its implementation directly undermines the capacity of displaced persons to recover from the effects of past stresses cannot, by any stretch of the imagination, be humane. If detention is not punishment, then what is it? We are told repeatedly that detention is a deterrent aimed at discouraging the arrival of asylum seekers. How then does detention act as a deterrent if not by punishing the few to deter the many? Interestingly, punishment, according to many criminologists, is not a good deterrent. This makes the situation even worse — punishing those whose only "crime" is to seek asylum from persecution for a presumed greater benefit that remains unattainable. The practical failure of the "punishment as deterrence" approach is evident in the recent, desperate policy shift to the costly and unsustainable "Pacific solution". What next? In short, detention is not humane — prolonged detention, in particular, exacts severe costs by undermining the mental health of detainees. The stark reality is that political policy is creating a preventable public health tragedy. If doubts remain about this conclusion, then we should turn to science as the final arbiter. It is now pressing that an independent group of researchers undertake a comprehensive survey of detention centres in Australia and the Pacific to establish once and for all the impact of current policies on the mental health of the detainees.

Philip Ruddock

To the Editor: We wish to acknowledge Dr Aamer Sultan's courage in carrying out his research as a "participant–observer" into the impact of long-term detention on psychological health of asylum seekers1 at the Villawood Detention Centre, Sydney. In response to the article, Dr Louise Newman, Fellow of the Royal Australian and New Zealand College of Psychiatrists, called for an urgent assessment of the mental and physical health of asylum seekers in detention. As well, The Australian2 reported that Dr Newman advised members of the College not to accept appointments in detention centres because of serious concerns about how they were run by Australasian Correctional Management. Dr Sultan inspires the medical profession, at considerable risk to himself, in order to fulfil the obligation of the first aphorism of Hippocrates: "The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate."

Philip Ruddock

To the Editor: I am writing as a member of the Australian Medical Association, and hence a subscriber to the MJA, to express my concern over the recent publication of the participant–observer account of psychological disturbances in asylum seekers,1 and the subsequent media reporting of the issue as a consequence of the publication. I would like to say at the outset my views are personal. Like most healthcare professionals, I consider access to basic medical care, including care for those with mental illness, is a human right. However, I do not support the use of a peer-reviewed journal such as the MJA for political purposes. The right of freedom of speech is fundamental in a democratic society; however, if the AMA wishes to push a political issue then such articles should be published not in the MJA but in Australian Medicine, with appropriate recognition that the issue is medicopolitical and not scientific. My concerns relate to the responsibility I consider peer-reviewed journals such as the MJA have in ensuring that articles, which include reports of alleged research, are scientifically valid. As can be seen by the media coverage on this issue, the fact that the "research study" was published in the MJA gave the impression to the general public that it was a valid scientific study and should be taken seriously. I have a number of specific issues of concern in relation to the article. Firstly, there is the fact that the principal author and researcher, in being a detainee with serious concerns over his treatment by the democratically elected government of this country, obviously has considerable potential bias in reporting observational research of this kind. Secondly, there is no attempt to assess the baseline mental health of the detainees before coming to Australia, but an assumption that all the symptoms observed are a result of detention. Thirdly, it would appear that there was no attempt to validate the observational research using more rigorous psychological testing. Finally, the methodology of the survey is not outlined, nor is the sample size discussed from the point of view of statistical validity. Admittedly, there was an acknowledgement of the survey's limitations; however, I do not consider that this article should have been published in the MJA. It does the Editorial Committee no credit and the Journal less so.

Philip Ruddock

In reply: The Hon. Philip Ruddock, the Minister for Immigration and Multicultural and Indigenous Affairs, believes that the article by Sultan and O'Sullivan1 makes "several claims that are factually wrong and would not have withstood even cursory examination". When assessing whether contributions are suitable for publication in the Journal, the editors of the MJA submit them to peer review, which has been defined as "independent assessment of the scientific merit of research by experts having knowledge of the research area equal to that of the performers of the work".2 The article referred to by the Minister posed a dilemma. Those with "equal knowledge of the research area" — representatives of the Department of Immigration and Multicultural Affairs or the Department's provider of security services (Australasian Correctional Management) — would have a patent conflict of interest. The Journal did, however, seek advice as to the accuracy of the article from a person with knowledge of the situation at Villawood, who did not advise as to "errors of fact and distortions", as alleged by the Minister. The discrepancy between the truth according to the Minister and according to Sultan and O'Sullivan may reflect differing interpretations and perceptions of information conveyed by intermediaries. Graves implies that detained asylum seekers' mental health and access to healthcare is a medicopolitical issue and that the forum for this debate should be the Australian Medical Association. So it should be! But the MJA has complete editorial independence from the AMA, and we believe that the mental health of asylum seekers transcends medicopolitics and goes to the very core of the ideals of medicine. Finally, it was very clear from the title of the article, and its authorship, that it represented the perspectives of a detained doctor (one of Graves' concerns) and a former visiting psychologist. However, we believe that our readership is sophisticated enough to interpret the content of such articles. We also believe, contrary to Ruddock and Graves, that the standing of the Journal remains solid, as does its policy of "providing a forum for . . . commentary and informed debate on standards of clinical practice, ethics, social, legal and other issues related to health care in Australia".3 To our knowledge, the information conveyed by Sultan and O'Sullivan's article is the best available data on the mental health of detained asylum seekers in Australia. We look forward to a more rigorous and independent assessment, hopefully initiated by the Minister. The opportunity is his.

Philip Ruddock

Re: "What people say about their general practitioners' treatment of anxiety and depression", by Andrews G, Carter GL, in the 16 July Supplement on the SPHERE National Depression Project (Med J Aust 2001; 175: S48–S51, not available online). On page S49, column 1, the last sentence under the heading "Assessment" should be replaced by "'Perceived health need' was based on questions derived from the work by Meadows et al.1 These questions were asked principally of people who had not sought treatment. Similar concepts were used by the UK Survey of Psychiatric Morbidity questions." The authors apologise for this omission and would like to draw readers' attention to another article by Meadows et al2 for a more complete discussion of the development of the perceived need for care questionnaire.

G Andrews · and G L Carter

The special healthcare needs of young people have long been recognised, but, before 1990, much of Australian adolescent medical practice was confined to small inpatient units in the major city paediatric hospitals. Other facets of adolescent healthcare — primary care, sexual and reproductive health, student health and mental health — operated independently. This was in stark contrast to North America, where the specialty of adolescent medicine had taken the lead in adolescent healthcare for three decades. Centres for Adolescent Health. Much has now changed. The establishment of Centres for Adolescent Health in Melbourne, Sydney and Auckland has signalled a broader role for adolescent medicine. Shifting disease patterns lie behind these developments. Cancer, cardiovascular disease and neuropsychiatric disorders have become health priorities in an ageing population, highlighting the need for preventive and early interventions in younger people. Adolescent disease patterns have also shifted. Infectious diseases, both blood-borne (hepatitis C, HIV) and sexually transmitted (HIV, herpes, chlamydia), pose new threats. Drug dependence, eating disorders and depression have become common. Longer survival in young people with chronic illnesses and disabilities (eg, spina bifida, cystic fibrosis) has introduced complicating psychosocial and behavioural problems. In response to these trends, adolescent medicine has embraced preventive models of care, incorporating new clinical skills and building working relationships across the spectrum of health and welfare practice. The role of specialist adolescent units has been questioned, but the number of young people admitted to hospital in the United Kingdom justifies regional adolescent inpatient units.1 In Australia, their popularity with young people (and clinical staff) and their families is a strong endorsement.2 Prevention and early intervention. The care of adolescents with chronic physical illness extends beyond the acute problems (that trigger inpatient admission) to previously undiagnosed morbidities with longer-term health implications. It is now usual to screen for psychosocial and behavioural problems affecting adherence with therapeutic regimens and, in the case of tobacco and substance misuse, possibly causing early complications. Advances in other fields of medical practice have extended the scope for prevention, with simple immunological screens for hepatitis B and C, and HIV, and vaccination for hepatitis B. So too has the introduction of clinical tools such as HEADSS, a psychosocial screen covering an adolescent's Home life, Education, recreational Activities, Drugs, Sexuality and Suicide risk/depression.3 Prevention, early diagnosis and intervention have come to dominate the care of marginalised groups, such as young offenders and homeless youth, in whom risks for blood-borne and sexually transmitted infectious diseases, substance dependence and major psychiatric disorders are very high. An emphasis on prevention and early intervention is also important in the common health problems of teenagers — depression, substance dependence, eating disorders and obesity. The greatest barrier to effective early intervention is engagement with young patients. General practitioners are the healthcare providers most commonly accessed, but most consultations are for acne, respiratory and musculoskeletal problems rather than the major causes of disease burden in this age group. Practitioner lack of confidence, skills and training in dealing with adolescent mental health and behavioural problems explains some of the unmet need. To enhance competencies in adolescent healthcare, practitioners need well-designed training based on an understanding of adolescent development, a full risk assessment, sound communication skills and a respect for confidentiality.4 With greater Medicare card ownership and the availability of longer GP consultations, adolescent access to healthcare, perhaps in the form of a "wellness" visit, would improve substantially.5 Diagnosis and intervention. New diagnostic concepts have also changed clinical practice and revealed previously under-recognised problems, such as adolescent depression and attention deficit hyperactivity disorder (ADHD) persisting beyond puberty. Prodromal and subsyndromal forms of less common disorders, such as schizophrenia and anorexia nervosa, have also been recognised. Interventions (pharmacological, educational and psychotherapeutic) used in other age groups have been adapted and shown to be efficacious in adolescents. Cognitive-behavioural treatments of depression and eating disorders, motivational interviewing for adolescent substance misuse, and pharmacotherapy for ADHD, depression or prodromal psychosis, have all shown promise in influencing short-term outcomes and even preventing the onset of fully-fledged disorders. Conclusion. Australian adolescent medicine practice has moved from being a narrow specialty to a flourishing generality, dealing with common health problems and providing a point of convergence for disciplines such as paediatrics, primary care, psychiatry, and internal medicine. The potential for an integrative approach, emphasising prevention and early intervention, is clear, but is currently constrained by a disconnection in health policies for mental health, acute care, substance misuse and services for high risk groups. The need for a coherent adolescent and youth health policy across government has never been greater.

George C Patton · Lena A Sanci · Susan M Sawyer

Three recent developments of outstanding international significance have occurred in psychiatry. First, The global burden of disease report,1 which showed that depression, bipolar disorder, alcoholism, schizophrenia and obsessive compulsive disorder were among the leading causes of worldwide disease disability and burden, has had major ramifications for government prioritisation of health services. Second, significant research in Alzheimer's disease has revealed the specific molecular defects underpinning the rare familial early-onset form of this condition. Third, major advances in pharmacotherapy have led to dramatic shifts in treatment, particularly for depression and schizophrenia, but also for dementia and bipolar disorder. Nationally, a major epidemiological study — the National Survey of Mental Health and Well-being of Adults2 — confirmed the high prevalence and disability of mental illnesses, with depression and anxiety accounting for considerable morbidity. These international and national findings prompted the Federal Government to establish the National Depression Initiative "beyondblue". Diagnosis. In psychiatry, diagnoses continue to be made on the grounds of pattern recognition (ie, by delineation of clinical syndromes). However, as the pathophysiological mechanisms underlying the various mental illnesses gradually become apparent, the prospect of diagnostic tests comes closer. Most noticeably, there is an air of excitement surrounding aetiological research into Alzheimer's disease. The abnormal degradation of amyloid precursor protein (present on all cells) releases the β protein fragment that polymerises to form amyloid, which, over some decades, results in the formation of plaques. In the past decade, the first animal model of Alzheimer's disease has been developed in mice; abnormal genes on chromosomes 1 (coding for presenilin 1), 14 (coding for presenilin 2) and 21 (coding for an altered amyloid precursor protein, APP) have been identified in families with early-onset Alzheimer's disease. It has also been recognised that some alleles of the gene for apolipoprotein E increase the risk of the late-onset form. These findings may lead to an understanding of the key events in the genesis of the disease, and possibly to prevention or cure. Interventions. For depression, the selective serotonin re-uptake inhibitors have become the most commonly prescribed antidepressants, probably reflecting their greater tolerability and safety. Meta-analyses suggest that the recently available agents that act on both noradrenaline and serotonin (ie, venlafaxine and mirtazapine) may have greater efficacy. Other antidepressants likely to become available in the next few years include the selective noradrenergic agent reboxetine, and antagonists of corticotropin-releasing factor. For bipolar disorder, the anticonvulsants valproate and carbamazepine have proven to be of similar efficacy to lithium. Newer anticonvulsants, such as lamotrigine and topiramate, are showing promise as future potential mood stabilisers. The second generation (atypical) antipsychotic drugs — clozapine, risperidone, olanzapine and quetiapine — are being prescribed for schizophrenia (and for bipolar disorder) at ever-increasing rates because of their beneficial side-effect profiles, and, in the case of clozapine, superior efficacy in treatment-resistant disease. In the next five years, newer antipsychotic drugs, such as ziprasidone, iloperidone and aripiprazole, are likely to be in routine clinical use. A further major advance is the advent of drug treatments for Alzheimer's disease.3 Currently, the only drugs approved are the cholinesterase inhibitors donepezil, rivastigmine and galantamine, which work by blocking the enzyme that destroys acetylcholine, the major neurotransmitter for memory. While their clinical effects are modest but significant, their major impact has been in stimulating earlier diagnosis and raising doctors' awareness. The cholinesterase inhibitors may improve or maintain cognition, as well as having positive effects on behaviour and function. Cholinesterase inhibitors provide symptomatic relief only. Increased attention is needed to the integration of psychosocial and pharmacological treatments. A major Australian contribution to management of mental illness has been the development of the concept of "mental health literacy" (community knowledge of mental disorders),4 which is now recognised as a major determinant of the effectiveness of any intervention. Prevention. This is a goal that is yet to be realised. Promising avenues include early intervention (secondary prevention) for schizophrenia, and the (more distant) possibility of vaccination as primary prevention for Alzheimer's disease. Studies in Melbourne of early intervention in schizophrenia have received considerable international attention.5 The focus on early detection and intervention in psychiatry is likely to grow stonger.

Philip B Mitchell MD, FRANZCP, FRCPsych · Henry Brodaty AO, MD, FRACP, FRANZCP · David L Copolov PhD, FRACP, FRANZCP

Asylum seekers and healthcare Psychological disturbances in asylum seekers held in long term detention: a participant-observer account Confinement in immigration detention centres for extended periods of time can have severe, psychologically disabling effects on asylum seekers. Aamer Sultan is a medical practitioner who fled persecution in Iraq after providing casualty medical care to Shiite Muslim rebels. He has been detained in the Villawood Detention Centre, Sydney, since May 1999, as his claim for protection under the United Nations Convention has not been endorsed by Australian authorities. He can not be returned to Iraq because Australia currently has no diplomatic ties with Iraq and no international flights go to Iraq. As a health professional and a bilingual Arabic/English speaker, he has acted as a confidant for many detainees. His observations are supplemented by those of clinical psychologist Kevin O'Sullivan, who provided psychological treatment for over 50 asylum seekers during a recent 12-month contract with the same detention centre. Aamer Sultan and Kevin O'Sullivan MJA 2001; 175: 593-596 For editorial comment, see Steel and Silove Abstract - The environment of detention - Refugee assessment process - Cumulative effects on the mental state of asylum seekers - Effect on children - Survey of detainees at Villawood - Conclusions - Authors' details - - More articles on Social issues Abstract The process of applying for refugee status in Australia is complex, lengthy and often poorly understood by asylum seekers. The psychological reaction patterns of detainees whose claims for asylum are unsuccessful are characterised by stages of increasing depression, punctuated by periods of protest, as feelings of injustice overwhelm them. These reactions have a marked secondary impact on their children in detention. The prolonged detention of asylum seekers appears to cause serious psychological harm. Even if many of those who spend long periods of time are not deemed to have proven their refugee claims, this administrative decision should not be grounds for inflicting grave ongoing psychological injury on the applicants. Most of the asylum seekers detained at Villawood Detention Centre come from developing countries ruled by oppressive regimes with poor human rights records. Many have been victims of State-organised violence, including torture and other forms of inhuman or degrading treatment or punishment, or have family members who have suffered such abuses. Thus, they are at high risk of the range of post-traumatic psychological reactions widely documented among victims of mass trauma and organised violence. These background issues are relevant to the understanding of the impact of detention on asylum seekers' psychological state. The environment of detention On arrival in Australia, most asylum seekers hold strongly to the belief that their applications for protection are legitimate and most are confident that a just society such as Australia will accept the veracity of their claims for refugee status. After transfer to a detention centre, several factors converge to undermine this faith and hence the psychological stability of the asylum seeker. The most threatening aspect is loss of liberty for an indeterminate period of time — detention without trial imposed on people fleeing injustice in a context where no crime has been committed. The average length of detention in Villawood in February 2001 was six months, although the duration varies from individual to individual and, for some, may extend for longer periods of time, with no maximum limit on the period of detention. Lengthier detention is particularly common for detainees who appeal against adverse decisions about their refugee status, or those who are unable to be deported from Australia (because they are stateless or from countries with no diplomatic ties with Australia, particularly Afghanistan and Iraq). The physical environment at Villawood is intimidating in a number of respects. Each compound is surrounded by multiple layers of high fencing topped and grounded by razor wire. All visitors must pass through high security checkpoints. Within the detention centre, there are multiple daily musters and nightly head counts, which may occur at 2 AM and 5.30 AM. The public address system, which operates almost continuously from 7 AM to 9 PM, is also disturbing. For most of the previous two years, there has been a general dearth of activities, resources, or educational materials, leaving detainees with long periods of unstructured time. Despite recent improvements, boredom, aimlessness and apathy are widespread, particularly among those who have been detained for longer periods of time. At times, we have observed harsh and uncompassionate handling of asylum seekers by staff. Detainees are routinely handcuffed during transportation to and from the facility for medical or legal appointments. Access to medical services sometimes has to be negotiated through correctional centre staff, especially after hours or during security incidents. Detainees may then perceive medical practitioners as being aligned with the detaining authorities and are concerned that this may hinder them in acting in their best interests. Concerns have been raised about doctors authorising sedative medication for containment and removal of detainees rather than for genuine medical reasons. Multiple complaints have been lodged by detainees with the Commonwealth Ombudsman, the Human Rights and Equal Opportunity Commission, and the NSW Health Care Complaints Commission about inadequacies in medical and dental care. Apart from official hearings and interviews, interpreter services are not generally available, leaving detainees with poor English isolated and unable to communicate. During crisis periods, such as when hunger strikes or breakouts occur, detainees have been confined for long periods in their rooms, and denied access to phones, faxes, postal services, and visitors. The rules governing daily life seem arbitrary, changing from time to time, and from one detention officer to another. Some detainees have suffered intimidation and reprisals after acts of advocacy, protest or revolt. Authorities have instituted room searches, confinement in solitary cells, restrictions in receiving visitors, and obstacles to accessing legal representation or medical care. During a hunger strike in July 2000, all electrical power and water supplies to the cell block where the hunger strikers were residing were cut-off, affecting uninvolved women and children. As a consequence of these inhumane actions, the atmosphere at Villawood leads to fear, despondency and frustration. It is within this context that the refugee determination process is undertaken. It is soon apparent to all detainees that their future depends on the procedures established to test their refugee claims, but the complex mechanisms and the legal processes applied are poorly understood by most asylum seekers. Given the context and conditions of their detention, asylum seekers find it difficult to distinguish between the authority of the company managing the detention centre (Australasian Correctional Management) and that of the Department of Immigration and Multicultural Affairs in reaching decisions about their refugee claims. It is a widely held belief by detainees that every action within the detention centre may be observed and may critically influence the outcome of refugee claims. This belief appears to be covertly encouraged by those operating the facility to increase their control over the detainees. Refugee assessment process In their testimonies and at interviews, asylum seekers have to recount in detail the most distressing moments of their lives, testimony that may be treated with doubt, suspicion and incredulity. It is little wonder that memories for details become blurred under such pressure, yet inconsistencies in accounts are often cited as the reason for rejecting a claim. Those people whose claims are rejected at this primary (Department of Immigration and Multicultural Affairs — DIMA) stage can appeal to the Refugee Review Tribunal (RRT). If the claim is rejected by the Tribunal, recent legislation has removed any right of judicial review. The final resort is to appeal to the Minister for Immigration and Multicultural Affairs for humanitarian consideration. Few of these appeals receive compassionate outcomes. (For a summary of the stages of application for protection visas, see Smith.) As the period of detention continues, life is increasingly punctuated by feelings of loss and grief arising from the release of compatriots who have been successful in their refugee claims or the forcible removal from Australia of those who have been unsuccessful. These stresses are combined with the ever-present anxiety about the wellbeing of family members left behind. Some may experience guilt for having left their family to secure their own survival and protection, for not yet being able to work and send money home to assist their family, and for not being able to sponsor them to the safety of Australia. Cumulative effects on the mental state of asylum seekers Our observations suggest that there may be some common themes in the psychological reaction patterns of detainees over time. Each successive stage is associated with increasing levels of distress and psychological disability. Non-symptomatic stage: During the early months of detention, before the primary refugee determination decision, the detainee is shocked and dismayed at being detained, but these feelings are mitigated by an unwavering hope that confinement will be short-lived and that their claim will be upheld. Primary depressive stage: This follows the receipt of a negative decision by DIMA and the realisation by detainees that they face a serious threat of forcible repatriation or detention for an indeterminate period, or both. The clinical presentation is consistent with a major depressive disorder, with the severity closely related to pre-existing risk factors, such as premigration exposure to trauma or personal predisposition to depression. There may also be a reactivation or exacerbation of any pre-existing post-traumatic stress reactions from past abuses (eg, torture, incarceration in political prisons and other forms of persecution). The sense of injustice overwhelms many detainees, who enter a "primary revolt stage" of non-compliance and non-conformity. The nature of the revolt varies: some become protesters (engaging in hunger strikes and other non-violent demonstrations); others become advocates (attempting to raise public awareness about the realities of detention); and some become aggressors (engaging in confrontations, riots, detainee-guard conflict and interdetainee violence). Secondary depressive stage: This typically follows the rejection of the asylum seeker's application by the Refugee Review Tribunal, the ultimate administrative level. The timing of this final rejection may vary, but generally occurs between six and 18 months after first being detained. This stage is associated with a more severe and debilitating depressive reaction, with a greater level of psychomotor retardation and/or agitation. There is a marked narrowing of focus to issues of self-preservation and survival and an overwhelming feeling of impending doom. Whereas before most asylum seekers confided in others about their personal lives and their concerns for family left behind, communication about these issues ceases almost entirely. Some asylum seekers will also enter into a secondary revolt stage that is less aggressive and largely associated with passive, non-compliant resistance and attempts to escape. Many asylum seekers will remain in this secondary depressive stage for the duration of their detention, but a significant number appear to progress to an even more serious state of debilitation. Tertiary depressive stage: At this stage the detainee's mental state is dominated by hopelessness, passive acceptance and an overwhelming fear of being targeted or punished by the managing authorities. Affected detainees become self-obsessed and trapped in their predicament. Ties to other detainees that were once strong become fragmentary and in some cases disintegrate. There is a significant and chronic impairment in concentration, with detainees being unable to perform even simple tasks. The detainee's life can become dominated by paranoid tendencies, leaving them in a chronic state of fear and apprehension and a feeling that no one, including other detainees, can be trusted. Long periods of time are spent alone and some develop frankly psychotic symptoms, such as delusions, ideas of reference and auditory hallucinations. Chronic rage and resentment are directed at the detaining country and the host government. The most disturbed engage in self-stimulatory, stereotypic behaviours, such as repetitive rocking or aimless wandering. Postures and facial expression are consistently downcast and affected detainees may appear to be disengaged or dissociated from their physical environment. Some engage in repeated acts of self-harm or self-mutilation leading to acute hospital admissions. Effect on children Between 10 and 50 children are held at Villawood at any one time. The detention environment, exposure to actions such as hunger strikes, demonstrations, episodes of self-harm and suicide attempts, and forcible-removal procedures, all impact on a child's sense of security and stability. A secondary effect is mediated via the parents, whose ability to provide a caring and nurturing environment is progressively undermined as they pass through the stages outlined above, with risk of neglect and physical abuse of dependent children increasing across the course of detention. Following allegations of child sexual abuse at the Woomera centre, detaining authorities have increased their monitoring of parents at Villawood for evidence of negligence and abuse, leading to parental fears of their children being removed, which has further increased family insecurity. At times, children have also become negotiating pawns in attempts to contain protests within the detention centre. For example, on a number of occasions, the authorities have separated children from their parents to pressure adults to cease their hunger strikes. A wide range of psychological disturbances are commonly observed among children in the detention centre, including separation anxiety, disruptive conduct, nocturnal enuresis, sleep disturbances, nightmares and night terrors, sleepwalking, and impaired cognitive development. At the most severe end of the spectrum, a number of children have displayed profound symptoms of psychological distress, including mutism, stereotypic behaviours, and refusal to eat or drink. Children of parents who reach the tertiary depressive stage appear to be particularly vulnerable to developing a range of psychological disorders. Survey of detainees at Villawood To support some of our participant-observer accounts, in August 2001 one of us (A S) conducted a survey of detainees who had been held for over nine months. Of the 37 people meeting this criterion, 33 agreed verbally to participate in the survey and to allow the results to be reported. The survey consisted of a semi-structured interview based on previous observations. As most of these detainees had been held in Villawood since their arrival in Australia, A S was able to corroborate much of the information from his own longitudinal observations of each participant. The detainees originated from 10 countries, with most being from Afghanistan, Iraq, Iran and the former Yugoslavia. The average period of continuous detention was two years, with the longest period being three years and 10 months. Most were men (85%), and over half were married (55%), with most of these being separated from their spouses on fleeing to Australia. Despite rejection of their refugee claims, over half reported being victims of gross human rights violations before arriving in Australia, enduring abuses such as physical torture (58%) and the murder or disappearance of immediate family members (30%). All but one of the detained asylum seekers displayed symptoms of psychological distress at some time. At the time of the survey, 85% acknowledged chronic depressive symptoms, with 65% having pronounced suicidal ideation. Close to half the group had reached the more severe tertiary depressive stage. Seven individuals exhibited signs of psychosis, including delusional beliefs of a persecutory nature, ideas of reference and auditory hallucinations. Due to the severity of their psychological symptoms, hospitalisation has been recommended for some of these people by the centre health staff, but authorities have not approved this, except in medical emergencies after incidents involving self-harm. A few have been deported without receiving any appropriate care. Conclusions In drawing conclusions, we acknowledge the limitations of our report. A S is faced with the same challenges that other detainees encounter and it might be claimed that he is motivated to advocate not only for others but also for himself. The only counterargument we can offer is our commitment to reporting our observations in what we consider to be as objective and truthful a manner as possible. The observations are broadly consistent with those of other health and mental health professionals who work with detainees, either within the detention environment or on their release from detention. It is therefore difficult to avoid the conclusion that the policy of mandatory detention of asylum seekers is leading to serious psychological harm. Even if many of those who spend long periods of time in detention are not deemed by the strict criteria enforced to have proven their refugee claims, this administrative decision should not be grounds for inflicting grave ongoing psychological injury on the applicants. Authors' details Aamer Sultan, MB ChB, Immigration Detainee, Villawood Detention Centre. Kevin O'Sullivan, BSc, PhL, DipClinPsychol, Former Visiting Clinical Psycologist, Villawood Detention Centre. Reprints will not be available from the authors. Correspondence: Dr A Sultan, Villawood Detention Centre, Villawood, NSW 2163. Make a comment Survey of 33 detainees at Villawood Detention Centre Questionnaire items No. of detainees Demographic Information Average period of detention in Australia, 2.1 years Males Females Married Single 28 5 18 15 Premigration trauma exposure History of physical torture Murder or disappearance of immediate family member(s) 19 9 Symptoms during first six months of detention Sleep problems Regular nightmares Loss of libido Anhedonia Feelings of intense bitterness Adoption of a non-conforming approach to detaining authorities Psychological symptoms, requiring psychotropic medication (primarily, antidepressants) 32 32 32 31 26 22 19 Current mental state Chronic feelings of helplessness Bitterness towards authorities Chronic depressive symptoms Chronic headache Impaired memory and concentration Suicidal ideation Stuttering Delusions of a paranoid nature Psychosis 31 30 28 27 25 23 13 13 7 Stage of observed functioning Not symptomatic Primary depressive stage Secondary depressive stage Tertiary depressive stage 1 4 12 16 Back to text

Aamer Sultan · Kevin O'Sullivan

Asylum seekers and healthcare The mental health implications of detaining asylum seekers In the year when we should be celebrating the 50th anniversary of the United Nations Refugee Convention, we appear instead to be ignoring the lessons of history Zachary Steel and Derrick M Silove MJA 2001; 175: 596-599 Abstract - Recent independent inquiries into detention - Research studies - Discussion - After September 11 - References - Authors' details - - More articles on Social issues - More articles on Psychiatry Abstract The possible mental health impact on asylum seekers of Australia's policy of mandatory detention is an issue of special relevance to health professionals and the public. Independent commissions of inquiry in Australia have found varying degrees of mental distress to be common in detained asylum seekers. Research studies in Australia and elsewhere suggest that detained asylum seekers may have suffered greater levels of past trauma than other refugees, and this may contribute to their mental health problems, with their detention providing a retraumatising environment. Studies are urgently required to examine the mental health consequences of detention, and to determine the effect of detention on acculturation and adaptation for asylum seekers subsequently released into the community. Australia is the only Western country that enforces a policy of mandatory detention for asylum seekers arriving without entry documents. This policy is noteworthy given the fact that Australia receives only a small number of asylum applications (12 700 in 1999-20001) compared with most European countries (Germany, 117 650; the Netherlands, 43 900; Belgium, 42 690; France, 39 780; Switzerland, 32 430 in 2000), the United Kingdom (75 680 in 2000), the United States (91 600 in 2000) and Canada (34 250 in 2000).2 On a per capita basis, Australia was ranked 17th out of 21 industrialised countries in terms of the absolute number of asylum applications received during 1999.3 Because of Australia's policy, the possible mental health impact of mandatory detention on asylum seekers is an issue of special relevance to Australian health professionals and the wider public. Sultan and O'Sullivan,4 provide a picture of the daily difficulties and mental reactions experienced by detained asylum seekers in Australia. Their documentation represents a unique convergence between the observations of an "insider" — a medical practitioner detained at Villawood Detention Centre, Sydney, since May 1999 — and those of a mental health professional who has worked in the same facility. We focus here on several key areas raised by Sultan and O'Sullivan: the mental health implications of detaining people who have previously been exposed to trauma including torture; the patterns of mental and behavioural responses manifested by detainees; and the possibility that conditions of detention may act to retraumatise those who are held for indeterminate periods. In assessing these issues, we will draw on the findings of recent inquiries into the policy of detention and also on the small number of empirical studies investigating the mental status of detainees. Recent independent inquiries into detention A comprehensive inquiry undertaken by the Human Rights and Equal Opportunity Commission5 found that mental distress in varying degrees is a common manifestation in detained asylum seekers, with "a large number of detainees experiencing mental health problems". Factors regarded as increasing the risk of mental distress included prior experiences of torture or other forms of persecution in the country of origin, the stresses created by the length and conditions of detention, and the feelings of anxiety and desperation in those whose refugee claims are rejected. The report noted that suicide attempts by asylum seekers are not infrequent, with "numerous examples of detainees attempting suicide or serious self-harm" being cited in incident reports. This inquiry also found "evidence of violence between detainees, especially within families, as well as between detainees and custodial officers", and concluded that there was "considerable tension created by the regime of control necessary to implement the policy of mandatory detention". The evidence suggested that the indeterminate nature of the detention made it considerably more difficult to endure. Of particular concern to the Commission was that there were no formal procedures to identify people who needed specialist care, such as survivors of torture and other forms of extreme trauma, or people at risk of suicide. In a subsequent report, the Commission concluded that the "balance between security and care is undermined by the contractual arrangements between DIMA [the Department of Immigration and Multicultural Affairs] and ACM [Australasian Correctional Management — the private contractor]", and the increasing emphasis on security ("multiple musters, night curfews") can be traced to this imbalance.6 An independent inquiry by the Commonwealth Ombudsman found evidence from credible witnesses about "the inappropriate use of force, unnecessary "trashing" of rooms for no apparent reason and the alleged harassment of detainees by some [ACM] staff".7 The report concluded that "long-term detention of immigration detainees is a source of frustration, despondency and depression often resulting in drastic action being taken by the detainees". Evidence of self-harm, damage to property, as well as fights and assaults, suggested "systematic deficiencies in the management of the detainees".7 A similar set of concerns emerged from a report by members of the Parliamentary Human Rights Sub-Committee.8 According to the report most committee members were shocked by what they saw during their visits to the centres: "the physical impact . . . the double fences, [the] barbed wire". Inside the centres, committee members were struck by the despair and depression of some of the detainees, and "their inability to understand why they were being kept in detention in isolated places, in harsh physical conditions with nothing to do". The Committee found that medical treatment was not always satisfactory, educational facilities were limited and the range of activities was inadequate for the number of detainees. The report also highlighted the negative psychological impact of prolonged detention, pointing out that "those who had been at Woomera [detention centre] for three or four weeks, for example, were notably less tense and depressed than those who had been at Curtin or Port Hedland [detention centres] for a year or more".8 Research studies Several clinical observations have been published about the general plight of asylum seekers in detention in Australia,9,10 with some focusing on specific issues such as hunger strikes.11 More systematic studies are relatively scant, largely because of problems of access to the centres by researchers. A survey in mid-1995 of 17 East Timorese held at the Curtin Detention Centre, in Victoria, for 1-3 months found substantial levels of premigration trauma, including random and unprovoked harassment, torture and physical assaults, and being arrested and/or detained under harsh conditions.12 All 17 East Timorese were found to be suffering from posttraumatic stress disorder (PTSD), 16 were depressed and 11 suffered from severe anxiety. Thompson and colleagues reported a survey of 25 detained Tamil asylum seekers held at Maribyrnong Detention Centre, Victoria, during 1997 and 1998.13 The results were compared with those of a parallel community-based study of Tamil asylum seekers, immigrants and resettled refugees living in New South Wales.14 Detained asylum seekers reported extensive trauma histories: 18 were victims of torture; 23 had witnessed the murder of family or friends; and 22 had been threatened with death at some time. Detained asylum seekers reported exposure to an average of 12.4 (of a possible 16) major trauma categories, compared with 4.8 for asylum-seeker compatriots residing in the community. Compared with the community group, the detainees were more depressed, suicidal, and suffered more extreme post-traumatic panic and physical symptoms. Levels of past trauma exposure did not account entirely for the symptomatic differences across comparison groups, suggesting, albeit indirectly, that the immediate conditions of detention might be contributing to the mental health problems of detainees. Although Australia is the only country that has adopted a policy of mandatory detention, a number of other countries, including the United States and the United Kingdom, detain asylum seekers considered at high risk of absconding or asylum seekers at various stages of the asylum-seeking process.15 In the United Kingdom, a group of 10 detained asylum seekers, six of whom had been tortured previously, were all found to be clinically depressed, manifesting appetite loss and multiple somatic complaints. Four were suicidal, with two having made suicide attempts while in detention.16 Another UK study found high levels of past trauma, including systematic torture, and ubiquitous depressive, posttraumatic stress, as well as suicidal symptoms, in 15 detained asylum seekers.17 The investigators observed that "a profound sense of injustice characterises detainees' views of their reception and treatment . . . detention is seen as punitive, hostile and unfair". Discussion In recording trauma histories, there is always a risk of retrospective bias, particularly when there is potential for gain, for example to advance a refugee claim. However, exposure to past trauma does not, in itself, provide grounds for claiming asylum. The key criterion is proving threat of future persecution. In addition, consistency in reports of trauma across various samples of asylum detainees, corroborated by the indepth investigations of successive commissions of inquiry, makes it difficult to avoid the conclusion that at least a portion of the detained population have been subjected to extreme forms of previous persecution, including incarceration in political prisons and torture. One study found that detainees may have suffered greater levels of threat and trauma than other refugees,13 suggesting that those under most threat tend to leave their home countries in haste, often without documents, thereby increasing the risk of being detained on arrival in Australia. (This conclusion is supported indirectly by statistics provided by the Department of Immigration and Multicultural Affairs which show that over 85% of recent detainees have been found to be genuine refugees fleeing from persecution, an endorsement rate that is higher than that for refugee applicants living in the community.18) Sultan and O'Sullivan's account of past trauma among detainees thus appears to be credible.4 Their observations need to be considered in the light of conclusive evidence that extreme trauma associated with human rights violations constitutes a potent risk factor for a variety of mental disturbances, including PTSD, depression and anxiety.19,20 A consistent dose-effect relationship has emerged from epidemiological studies of refugees, with greater levels of trauma exposure incrementally increasing the risk of mental disturbance.19 In refugees with comorbid disorders, particularly major depression and PTSD, the impact on psychosocial functioning is particularly severe.21 Furthermore, certain forms of trauma, particularly torture and incarceration in political prisons or concentration camps, appear to be particularly injurious to subsequent mental health.20,21 Yet, according to successive commissions of inquiry into detention in Australia, there is no policy in place to systematically assess the psychological needs of detainees who have suffered trauma or to offer them special consideration in relation to early release. The mental suffering of detainees identified by Sultan and O'Sullivan is not only consistent with the findings of recent research studies, but also paints a more complete picture of the way asylum seekers react at particular milestones in the asylum-seeking process.4 The close association between administrative procedures and psychological reactions is particularly worrisome, as it endorses the concern that these procedures, in themselves, act to undermine the psychological well-being of detainees. Although symptoms of depression and PTSD loom large in all recorded accounts, Sultan and O'Sullivan highlight additional features, such as extreme anger and resentment, self-destructive urges, profound social withdrawal, bitterness and alienation, and interpersonal conflict. These accounts of the wider adaptive difficulties triggered by conditions of threat, frustration, dehumanisation and confinement are reminiscent of those observed in survivors of concentration camps after World War II.22 A critical issue is therefore the extent to which the detention environment itself is a direct contributor to psychological distress, either de novo or as a retraumatising influence. There is growing evidence that refugees rendered psychologically vulnerable by past trauma are at greater risk of PTSD if they are exposed to further trauma or adverse conditions.23 For clinicians, there is little doubt that exacerbations of PTSD occur under stress, especially when people are exposed to salient triggers that remind them of the conditions of past trauma. Conversely, it is well accepted that the provision of a safe, supportive and predictable environment is instrumental to recovery for those suffering early psychological reactions to mass trauma.24 Early recovery is important, as there is some evidence that the longer PTSD symptoms persist, the less potential there is for remission.25 These more general observations in the field of traumatology support the contention raised by Sultan and O'Sullivan4 and others10 that environmental, procedural, and legal stressors associated with detention may converge to undermine the mental well-being of detainees, particularly those who have suffered past persecution and trauma. Longitudinal studies are urgently needed to examine more definitively the possible mental health consequences of detention, an imperative supported by a recent public statement by the Australian Medical Association (for a summary of the AMA's statement, see Smith). Of particular concern is the possibility that detention may leave long term psychological scars that may impede the process of acculturation and adaptation when asylum seekers are released into the community — the outcome for a majority of cases. After September 11 We have focused here on the mental health implications associated with the detention of asylum seekers. Elsewhere, we have considered some of the broader human rights concerns associated with detention, and the social and political implications of contemporary refugee policies.26,27 The paradox of contemporary refugee policies has been thrown into stark relief by the world crisis precipitated by the terrorist attack on September 11. On the one hand, there is bipartisan political support in Australia for an international war against terrorism. At the same time, those fleeing from terrorist States are treated as criminals when they reach our shores. Also, in supporting war, we should not forget that one of the most certain outcomes is a large flow of refugees seeking asylum. Yet, our leaders have gone to unprecedented lengths in recent times to deter asylum seekers by confining them in detention centres in economically poor island countries to our north, thereby incurring criticism from the United Nations and other international agencies. Australia is a signatory to the Refugee Convention, a landmark international instrument committing ratifying countries to providing humane protection to persons fleeing persecution worldwide. In the year when we should be celebrating the 50th anniversary of the Convention, we appear instead to be ignoring the lessons of history. In so doing, we risk travelling full circle to the pre-Holocaust era. At an international meeting on the refugee crisis in Europe in 1938, Australia expressed its vociferous opposition to resettling Jews and others fleeing the Nazi terror — all in the name of defending our racial homogeneity and our "way of life". The outcome was the most destructive genocide of all time. Socrates once proclaimed that an unexamined life is not worth living. Are we examining closely enough a national "way of life" that requires, as its cornerstone, the exclusion, punishment and confinement of those fleeing persecution? References Department of Immigration and Multicultural Affairs. Humanitarian Program http://www.immi.gov.au/statistics/publications/popflows/c2_4.pdf (accessed November 2001). United Nations High Commissioner for Refugees. 2000 global refugee trends: analysis of the 2000 provisional UNHCR population statistics. Geneva: UNHCR, 2001. United Nations High Commissioner for Refugees The state of the world's refugees: fifty years of humanitarian protection. New York, NY: Oxford University Press, 2000. Sultan A, O'Sullivan K. Psychological disturbances in asylum seekers held in long-term detention: a participant-observer account. Med J Aust 2001; 175: 593-596. Human Rights and Equal Opportunity Commission. Those who've come across the seas: The report of the Commission's Inquiry into the detention of unauthorised arrivals. Canberra: HREOC, 1998: 167, 153, 154, 218. Available at: http://www.hreoc.gov.au/pdf/human_rights/asylum_seekers/h5_2_2.pdf (accessed November 2001). Human Rights and Equal Opportunity Commission. 1998-99 Review of immigration detention centres. Canberra: HREOC, 1999: 12. Available at: http://www.hreoc.gov.au/pdf/human_rights/asylum_seekers/idc_review.pdf (accessed November 2001). Commonwealth Ombudsman. Report of an own motion investigation into the Department of Immigration and Multicultural Affairs' immigration detention centres. Canberra: Commonwealth Ombudsman, 2001: 26, 20, 2. Available at: http://www.comb.gov.au/publications_information/Special_Reports/IDCMarch.pdf (accessed November 2001). Joint Standing Committee on Foreign Affairs, Defence & Trade, Human Rights Sub-Committee. A report on visits to immigration detention centres. Canberra: Parliament of the Commonwealth of Australia: 2001: 65-67, 104. Silove D, McIntosh P, Becker R. Risk of retraumatisation of asylum-seekers in Australia. Aust N Z J Psychiatry 1993; 27: 606-612. Becker R, Silove D. Psychiatric and psychosocial effects of prolonged detention on asylum-seekers. In: Crock M, editor. Protection or punishment: the detention of asylum-seekers in Australia. Sydney: The Federation Press, 1993. Silove D, Curtis J, Mason C, et al. Ethical considerations in the management of asylum seekers on hunger strike. JAMA 1996; 276: 410-415. Victorian Foundation for Survivors of Torture. The East Timorese: clinical and social assessments of applicants for asylum. In: Silove D, Steel Z, editors. The mental health and well-being of on-shore asylum seekers in Australia. Sydney: University of New South Wales, Psychiatry Research & Teaching Unit, 1998: 23-27. Thompson M, McGorry P. Maribyrnong Detention Centre Tamil Survey. In: Silove D, Steel Z, editors. The mental health and well-being of on-shore asylum seekers in Australia. Sydney: University of New South Wales, Psychiatry Research & Teaching Unit, 1998: 27-31. Silove D, Steel Z, McGorry P, et al. Trauma exposure, postmigration stressors, and symptoms of anxiety, depression and posttraumatic stress in Tamil asylum seekers: comparisons with refugees and immigrants. Acta Psychiatr Scand 1998; 97: 175-181. Silove D, Steel Z, Watters C. Policies of deterrence and the mental health of asylum seekers in Western countries. JAMA 2000; 284: 604-611. Bracken P, Gorst-Unsworth C. The mental state of detained asylum seekers. Psychiatr Bull 1991; 15: 657-659. Pourgourides C, Sashidharan S, Bracken P. A second exile: the mental health implications of detention of asylum seekers in the United Kingdom. Birmingham, UK: North Birmingham Mental Health, NHS Trust, 1995: 96. Edmund Rice Centre. Just comment: debunking more myths about asylum seekers. Sydney: Edmund Rice Centre for Justice and Community Education. October 2000. Available at: http://www.erc.org.au/issues/text/se01.htm (accessed November 2001). Mollica R, Donelan K, Tor S, et al. The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps. JAMA 1993; 270: 581-586. Van Ommeren M, de Jong Joop T, Sharma B, et al. Psychiatric disorders among tortured Bhutanese refugees in Nepal. Arch Gen Psychiatry 2001; 58: 475-482. Mollica R, McInnes K, Pham T, et al. The dose-effect relationships between torture and psychiatric symptoms in Vietnamese ex-political detainees and a comparison group. J Nerv Ment Dis 1998; 186: 543-553. Bergmann M, Jucovy M. Prelude. In: Bergmann M, Jucovy M, editors. Generations of the Holocaust. New York: Basic Books, 1982: 3-29. Steel Z, Silove D, Bird K, et al. Pathways from war trauma to posttraumatic stress symptoms amongst Tamil asylum seekers, refugees and immigrants. J Traumatic Stress 1999; 12: 421-435. Silove D. The psychosocial effects of torture, mass human rights violations and refugee trauma: Towards an integrated conceptual framework. J Nerv Ment Dis 1999; 187: 200-207. Kessler R, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52: 1048-1060. Silove D, Steel Z, Watters C. Policies of deterrence and the mental health of asylum seekers in Western countries. JAMA 2000; 284: 604-611. Silove D, Steel Z, Mollica R. Detention of asylum seekers: assault on health, human rights and social development. Lancet 2001; 357: 1436-1437. Authors' details School of Psychiatry, University of New South Wales, Sydney, NSW. Zachary Steel, MPsychol, Adjunct Lecturer; Derrick M Silove, MD, Professor. Reprints will not be available from the authors. Correspondence: Mr Zachary Steel, Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, Level 4, Health Services Building, Liverpool Hospital, Sydney, NSW. z.steelATunsw.edu.au Make a comment

Zachary Steel · Derrick M Silove

Death and the Physician The intention to hasten death: a survey of attitudes and practices of surgeons in Australia Charles D Douglas, Ian H Kerridge, Katherine J Rainbird, John R McPhee, Lynne Hancock and Allan D Spigelman MJA 2001; 175: 511-515 For commentaries, see Hunt and Ashby See also: Survey instrument Abstract - Methods - Results - Discussion - Acknowledgements - Competing Interests - References - Authors' details - - - More articles on Ethics Abstract Objective: To determine attitudes among surgeons in Australia to assisted death, and the proportion of surgeons who have intentionally hastened death with or without an explicit request. Design: Anonymous, cross-sectional, mail-out survey between August and November 1999. Participants: 683 out of 992 eligible general surgeons (68.9% response rate). Main outcome measures: Proportion of respondents answering affirmatively to questions about administering excessive doses of medication with an intention to hasten death. Results: 247 respondents (36.2%; 95% CI, 32.6%-39.9%) reported that, for the purpose of relieving a patient's suffering, they have given drugs in doses that they perceived to be greater than those required to relieve symptoms with the intention of hastening death. More than half of these (139 respondents; 20.4% of all respondents; 95% CI, 17.4%-23.6%) reported that they had never received an unambiguous request for a lethal dose of medication. Of all respondents, only 36 (5.3%; 95% CI, 2.9%-6.1%) reported that they had given a bolus lethal injection, or had provided the means to commit suicide, in response to an unambiguous request. Conclusions: More than a third of surgeons surveyed reported giving drugs with an intention to hasten death, often in the absence of an explicit request. However, in many instances, this may involve the use of an infusion of analgesics or sedatives, and such actions may be difficult to distinguish from accepted palliative care, except on the basis of the doctor's self-reported intention. Legal and moral distinctions based solely on a doctor's intention are problematic. The use of drugs to intentionally hasten the death of a terminally ill patient is prohibited in most countries, including Australia. The only country that has openly allowed medically assisted deaths is the Netherlands, where 3.4% of all deaths are reported as (intentional) medically assisted deaths.1 Most of these are voluntary euthanasia or assisted suicide, but about a quarter are "life-terminating acts without explicit and persistent request".2 The most recent survey indicates that 53% of Dutch doctors have practised euthanasia or assisted suicide and 23% report that they have performed "life-terminating acts without explicit and persistent request".1 Medically assisted deaths also occur in countries where they are prohibited and the figures have been remarkably consistent — in the United States,3-6 Denmark,7 England8 and Australia,9 between 2.2% and 12.3% of doctors report that they have assisted death in response to an explicit request. Outside of the Netherlands, however, few studies have broadened the question of assisted death to include instances where there has been no explicit request. In a study comparing North American and Dutch physicians, 2% and 15%, respectively, reported "ending of life without an explicit request from the patient", but the numbers were small and the difference not statistically significant.10 In Australia, it has been claimed that 3.5% of all deaths are cases of "ending life without explicit request".11 A potentially confounding issue faced by all researchers of assisted deaths is that of intention. Doctors sometimes give large doses of potentially lethal drugs to terminally ill patients to treat symptoms, foreseeing but not necessarily intending a medically hastened death. This kind of action has been shown consistently to have the approval of more than 80% of doctors.1,5,7,12 However, there may be considerable ambiguity about a doctor's intention,13 and some studies have indeed noted partial or dual intentions (to relieve pain and to hasten death) when analgesic drugs are given.1 An intention to hasten death has been suggested as being best distinguished by the use of drugs in doses greater than those required for symptom control.14 Our study incorporates such a distinction. Our objective was to conduct a survey of attitudes to and practices regarding assisted death using questions that were absolutely explicit about the agent's intention. Methods Sample A list was obtained of all doctors with Australian mailing addresses registered as general surgeons with the Royal Australasian College of Surgeons (n = 1218). No attempt was made to exclude those who had recently retired or who had subspecialised. After excluding 200 surgeons who had been randomly selected for pretesting and those who had moved, were ill or deceased (26), a final eligible sample of 992 remained. Survey instrument The survey instrument was an anonymous, self-administered, mail-out questionnaire (available on the MJA website at <http://www.mja.com.au>. The questionnaire was developed from a review of the literature, discussion within a multidisciplinary research group and extensive pretesting, including 13 interviews and consistency checks on the responses to 200 mailed questionnaires. Advice was sought on specific questions from three independent ethicists with substantially different ethical backgrounds in ethics. All questions were closed (mostly "Yes/No"), but respondents were invited to make additional comments on the final page of the survey. The survey instrument included a clinical vignette (see Appendix), and some of the questions alluded to this vignette. Our main question on experience with assisted death (Question 1, Box 2) was presented alone under a separate heading and was prefaced by the comment "All further questions address general issues and are not specific to the scenario [clinical vignette] . . .". Key words in Question 1 ("greater" and "intention") were printed in bold and underlined. Further testing of the understanding of this question was undertaken by interview with 10 general physicians after they had completed the entire questionnaire. Administration of questionnaire The questionnaire and three subsequent reminder letters were sent according to a set protocol15 commencing in August 1999. Intention to participate was indicated by return of a labelled consent or refusal card separate from the unmarked questionnaire, and reminders were sent to those who had not returned a consent or refusal card. Statistical analysis Affirmative responses are reported as a proportion of all respondents (not just those answering the question), except where explicitly stated. The rate of missing data was less than 4.4% for all questions and less than 2.3% for questions reported here. The Wilson procedure with correction for continuity was used to calculate 95% confidence intervals (CI) for single proportions.16 To determine the influence of the five demographic variables (Box 1) on attitudes and practice, logistic regression analysis was performed using SAS for Windows.17 Variables which were significant at α = 0.2 (Pearson's χ2 or Fisher's exact test) were entered into the logistic regression model and then eliminated in a backward stepwise procedure until only those variables remained that were statistically significantly associated with an affirmative response. Ethical approval Ethical approval for our study was obtained from the Hunter Area Research Ethics Committee, from the Human Research Ethics Committee of the University of Newcastle, and from the Ethics Committee of the Royal Australasian College of Surgeons. Results Of the eligible sample of 992 surgeons, 683 returned questionnaires (response rate, 68.9%). This sample size was associated with a precision of ± 4% (95% CI). Six hundred and fifty-four surgeons (65.9%) returned a separate consent card or other communication indicating intention to participate; 166 (16.7%) indicated that they did not wish to participate and 172 (17.3%) did not respond. Of those who declined to participate, 25 volunteered reasons. Of the respondents, 210 (30.7%) volunteered additional comments. Demographic features of respondents are summarised in Box 1. Only age, sex and years in practice were available for non-respondents. There were no sex differences between respondents and non-respondents, but older surgeons and those who had been in practice for longer were slightly less likely to respond. Results for selected questions are given in Box 2, with wording and textual emphasis unchanged from that in the questionnaire. Use of drugs with the intention of ending life or hastening death Twenty-nine respondents (4.2%) reported having given a bolus lethal injection "in response to a sincere and unambiguous request", 13 (1.9%) reported assisting with suicide (Questions 3, 4, 5 and 6 in Box 2), and 36 respondents (5.3%; 95% CI, 3.8%-7.3%) had done one or both of these. Two hundred and forty-seven respondents (36.2%) reported that they had, for the purpose of relieving a patient's suffering, given drugs in doses greater than those required to relieve symptoms with the intention of hastening death (Question 1, Box 2). Of these, 139 indicated (in response to questions 3, 5 and 6, Box 2) that they had never received a sincere and unambiguous request for a lethal injection, and had never granted a request for assisted suicide. Thus, at least 20.4% of the entire sample (139/683; 95% CI, 17.4%-23.6%) have apparently given drugs with the intention of hastening death, but without the explicit request of the patient. Of the remaining 108 respondents who reported having given drugs with the intention of hastening death, it is unknown whether they have ever done so in the absence of a request. Effect of religion Religious affiliation was a significant predictor of response to questions on attitudes to and practice of intentionally assisted death. Roman Catholics were about 4-10 times more likely, and Protestants about 2-3 times more likely, to give a negative answer than colleagues who had no religious affiliation (Box 3). Discussion Our finding that very few doctors report having given a bolus lethal injection in response to a patient's request agrees with the findings of previous reports.3-9 Our study also reveals that many doctors report giving drugs in doses greater than those required to relieve symptoms, with the intention of hastening death, often in the absence of an explicit request. Outside the Netherlands, this has not been widely reported. Our main question on experience with assisted death was deliberately written to include the use of infusions of drugs, with or without a request. That some doctors are prepared to hasten death by infusion (but not by bolus) was confirmed by volunteered comments: "It is difficult to actually administer a lethal injection, but setting up a potentially lethal system allows a degree of psychological and physical separation from the actual event." "The giving of a single lethal injection would be unusual. Increasing infusion is a far preferable and controllable method." "I also appreciate the inconsistency between being prepared to 'up the dose', but not being prepared to give it as a bolus — but that's the way I feel . . ." "I have frequently used large doses of morphine (previously heroin!) to hasten death . . . I can't see the ethical difference between this and a bolus injection in a fully informed patient . . . but simply would not be capable of the deed myself." "Talk of bolus injections in fully competent patients is not the real-life situation. We help very ill patients to die by a combination of sustenance withdrawal, increasing analgesia and 'masterly inactivity'." Clearly, surveys that have limited their inquiry to the administration of a bolus lethal injection are likely to have underestimated doctors' involvement with assisted death. It may be that researchers have avoided addressing the use of infusions because of uncertainty about a doctor's intentions in such circumstances. However, it is possible to be unambiguous. Our question specified an intention to hasten death, and a dose of drug greater than that required to treat symptoms. Physician interviews confirmed that the question was indeed understood by most respondents, but there is also quantitative evidence of this from the survey itself. Firstly, there was internal consistency: 95% of those who answered affirmatively to Question 1 also answered affirmatively to a question on the morality of giving drugs by slow intravenous infusion with the intention of hastening death (Question 2, Box 3), although the questions were separated in the questionnaire. Secondly, there was a profound effect of religious affiliation on responses to both Questions 1 and 2, with odds ratios that were similar to those measured for questions relating to euthanasia by bolus lethal injection or assisted suicide (Box 3). The only plausible explanation for this strong association is that the respondents understood Questions 1 and 2 to be about the intentional hastening of a patient's death. In contrast, responses to a question about the use of an infusion of drugs that might incidentally hasten death (Question 7, Box 3) showed no effect of religion, with more than 90% of respondents supporting such action regardless of religious affiliation. Euthanasia and palliative care — same drugs, same doses? Our question specified a dose of drugs greater than that required to relieve symptoms, but it may be difficult to assess symptoms once consciousness has begun to deteriorate in a dying patient. Possibly the only way to be sure that a patient is not suffering at this point is to render him or her deeply unconscious by giving generous doses of opiates and/or sedatives. It would then be probable, but not certain, that the doses used were greater than those required to relieve symptoms. One respondent volunteered a comment to this effect: "Intravenous infusion may be used to induce an unconscious state at a rate equal or greater than that to relieve symptoms, whereby the practitioner and family are then guaranteed that all the patient's symptoms are relieved . . ." Whether the use of generous doses of analgesic or sedative drugs constitutes "good palliative care" or "non-voluntary euthanasia" depends, according to a widely held view, on the doctor's self-professed intention.14 Question 1 clearly specified an intention to hasten death. Doctors who responded affirmatively to this question have therefore crossed a legal threshold and, according to some, a moral threshold. However, it is not clear that they have acted differently from their colleagues other than by reporting their own mental state differently. Furthermore, it may be hard to distinguish many of their actions from those of Dutch doctors who have performed "life-terminating acts without explicit request". At least 20% of our entire sample appears to have given drugs with the intention of hastening death in the absence of an explicit request, similar to the 23% of Dutch doctors who report performing "life-terminating acts without explicit request".1 There is a discrepancy between the relatively large proportion (36.2%) of surgeons who report giving drugs with the intention of hastening death, and the small proportion (5.3%) who report giving a bolus lethal injection or assisted suicide in response to an explicit request. We believe that many of those who make up this difference have given generous doses of analgesics or sedatives by infusion to dying patients. The circumstances of these deaths, other than in the agent's reported intention, may not differ substantially from what is widely accepted as good palliative care. Acknowledgements We would like to thank Professor Miles Little for critical reviews of our questionnaire and methodology, and Professor Grant Gillett and Dr Bernadette Tobin for providing opinions on the wording of key questions. This research project was conducted with the assistance of a Royal Australasian College of Surgeons research scholarship. Competing Interests None declared. References van der Maas PJ, van der Wal G, Haverkate I, et al. Euthanasia, physician assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996; 335: 1699-1705. Pijnenborg L, van der Maas PJ, van Delden JJM, Looman CWN. Life-terminating acts without explicit request of patient. Lancet 1993; 341: 1196-1199. Meier DE, Emmons C, Wallenstein S, et al. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med 1998; 338: 1193-1201. Back AL, Wallace JI, Starks HE, Pearlman RA. Physician-assisted suicide and euthanasia in Washington State. JAMA 1996; 275: 919-925. Fried TR, Stein MD, O'Sullivan PS, et al. Limits of patient autonomy. Arch Intern Med 1993; 153: 722-728. Lee MA, Nelson HD, Tilden VP, et al. Legalizing assisted suicide - views of physicians in Oregon. N Engl J Med 1996; 334: 310-315. Folker AP, Holtug N, Jensen AB, et al. Experiences and attitudes towards end-of-life decisions amongst Danish physicians. Bioethics 1996; 10: 233-249. Ward BJ, Tate PA. Attitudes among NHS doctors to requests for euthanasia. BMJ 1994; 308: 1332-1334. Kuhse H, Singer P. Doctors' practices and attitudes regarding voluntary euthanasia. Med J Aust 1988; 148: 623-627. Willems DL, Daniels ER, van der Wal G, et al. Attitudes and practices concerning the end of life: a comparison between physicians from the United States and from The Netherlands. Arch Intern Med 2000; 160: 63-68. Kuhse H, Singer P, Baume P, et al. End-of-life decisions in Australian medical practice. Med J Aust 1997; 166: 191-196. Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician assisted suicide: attitudes and experiences of oncology patients, oncologists, and the public. Lancet 1996; 347: 1805-1810. Quill TE. The ambiguity of clinical intentions. N Engl J Med 1993; 329: 1039-1040. Gillon R. Foreseeing is not necessarily the same as intending. BMJ 1999; 318: 1431-1432. Dillman DA. Mail and telephone surveys: The total design method. New York: Wiley, 1978. Newcombe, Robert G. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 1998; 17: 857-872. SAS system for Windows [computer program], version 6.12. Cary, NC: SAS Institute Inc, 1998. (Received 28 May, accepted 3 Sep, 2001) Appendix: Abridged version of the clinical vignette Mrs S, a 60-year-old widow, presents to hospital with peritonitis and confusion and is found at operation to have a perforated carcinoma of the rectosigmoid junction which is unresectable, and is associated with peritoneal metastases. You perform a limited resection and end-colostomy. After 10 days she has recovered from her sepsis, but has persistent pain from her metastatic disease, and is devastated to find that she has a colostomy. She says she has "had enough" and she repeats this on several occasions over the next week. You organise consultations with a psychiatrist (who does not believe she is clinically depressed), a social worker, a stomal therapist and a palliative-care specialist who prescribes oral slow-release morphine and a co-analgesic and sees her daily to adjust doses. Five weeks after her operation, Mrs S remains in hospital because of general weakness, lack of a carer at home, and because of her pain, which is still not adequately controlled with oral analgesia. She says that she doesn't want to go on living, and that it is not just the severe pain. She complains of having lost her independence, that she is uncomfortable, and that she dislikes living with a stoma. She says that she has had a good life, but that she is "ready to go". Mrs S then asks if you will help her to die. Subsequent questions clarified explicitly what Mrs S meant by "help her to die". The complete vignette is included in the survey instrument which is available at <http://www.mja.com.au>. Authors' details Faculty of Medicine and Health Sciences, University of Newcastle, Newcastle, NSW. Charles D Douglas, BMed(Hons), BSc(Maths), Surgical Registrar, Discipline of Surgical Science, School of Medical Practice; Ian H Kerridge, FRACP, MPhil, Lecturer, Clinical Unit in Ethics and Health Law; John R McPhee, BCom(Hons) (LegStud), Consultant in Health Law, Clinical Unit in Ethics and Health Law; Lynne Hancock, BSc(Hons), PhD, Senior Lecturer, Discipline of Behavioural Science; and Program Manager, Hunter Centre for Health Advancement, Wallsend, NSW; Allan D Spigelman, FRACS, MD, Professor, Discipline of Surgical Science, School of Medical Practice. Hunter Centre for Health Advancement, Wallsend, NSW. Katherine J Rainbird, BA(Hons), PhD, Research Associate. Reprints will not be available from the authors. Correspondence: Dr C D Douglas, c/- Professor A D Spigelman, Discipline of Surgical Science, Faculty of Medicine and Health Sciences, University of Newcastle, Locked Bag No 1, Hunter Region Mail Centre, Newcastle, NSW 2310. cdouglasauATyahoo.com.au Make a comment 1: Demographic characteristics of general surgeons — respondents and non-respondents Frequency Demographic characteristic Respondents Non-respondents Age* n=680 n=342 35 or less 27 (4.0%) 5 (1.5%) 36-45 147 (21.6%) 71 (20.8%) 46-55 199 (29.3%) 72 (21.1%) 56-65 154 (22.6%) 90 (26.4%) More than 65 153 (22.5%) 104 (30.5%) Sex† n=680 n=341 Male 651 (95.7%) 330 (96.8%) Female 29 (4.3%) 11 (3.2%) Years in practice‡ n=680 n=342 Less than 10 12 (1.8%) 2 (0.6%) 11-20 150 (22.1%) 70 (20.5%) 21-30 205 (30.1%) 71 (20.8%) 31-40 162 (23.8%) 86 (25.2%) More than 40 151 (22.5%) 113 (33.1%) Practice setting n=674 Teaching hospital 368 (54.6%) Other urban hospital 167 (24.8%) Rural hospital 139 (20.6%) Religious group n=675 Roman Catholic 115 (17.0%) Protestant 225 (33.3%) Jewish 24 (3.6%) Other 25 (3.7%) No religion 286 (42.4%) *<0.01 (χ2=17.4). †=0.10. ‡<0.01 (χ2=20.5). Back to text 2: Frequency of affirmative responses to selected questions. Data are number of affirmative responses and percentage of entire sample, with 95% CIs in parentheses Question* Affirmative responses Administration of drugs with the intention to hasten death 1. Have you ever, for the purpose of relieving a patient's suffering, given drugs (orally or parenterally, by bolus or by infusion) in doses greater than those required to relieve symptoms, with the intention of hastening the patient's death? 247 36.2% (32.6%-39.9%) 2. Do you believe that there are any circumstances in which it is morally acceptable to give a terminally ill patient sedatives or analgesics by slow intravenous infusion, in doses greater than those required to relieve symptoms, with the intention of hastening the patient's death? 370 54.1% (50.4%-58.0%) Administration of lethal drugs by bolus injection on request* 3. Have you ever received a similar request (that is, a sincere and unambiguous request, from a competent patient, for you to administer a lethal dose of a drug)? 187 27.4% (24.1%-30.9%) 4. Have you ever granted such a request by giving a bolus lethal injection? 29 4.2% (2.9%-6.1%) Assisted suicide* 5. Have you ever received such a request (ie, an apparently sincere request, from a competent patient, to provide him or her with the means to commit suicide)? 70 10.2% (8.1%-12.8%) 6. Have you ever agreed to and carried out such an action? 13 1.9% (1.1%-3.3%) Treatment of pain by analgesic infusion* 7. Would you be prepared to commence an opioid analgesic infusion for Mrs S's pain, and to run this at whatever dose is necessary to keep Mrs S comfortable (even if this may, incidentally, hasten her death)? 641 93.9% (91.7%-95.5%) 8. Suppose Mrs S continues to complain of pain until the infusion has been increased to a rate at which she is drowsy but rousable. She is apparently comfortable, and the infusion is left at this rate overnight. The following morning, the nursing staff inform you that her respiratory rate has dropped to 6, that she is no longer rousable, and that her oxygen saturation is 82%. What would you do now? -Reduce the infusion rate to see if she is comfortable at a lower dose 318 46.6% (42.8%-50.4%) -Continue the infusion at the current rate 296 43.3% (39.6%-47.2%) -Increase the infusion rate 24 3.5% (2.3%-5.3%) *Questions 3, 4, 5, 6, 7, and 8 refer to the clinical vignette (see Appendix). All questions are "Yes/No" questions, except Question 7, which included "undecided" as an alternative, and Question 8, which offered the three alternatives indicated. The numbering and grouping of questions have been changed from the original questionnaire, but the wording and textual emphasis are identical. The headings used in this Box were not used in the original questionnaire. Back to text 3: Influence of religious affiliation on response to selected questions.* Results are proportions in each religious group responding affirmatively (odds ratios [OR] are relative to "No religion", with 95% CIs in parentheses). (The numbering of the questions coincides with that for Box 2.) 1. Have you ever, for the purpose of relieving a patient's suffering, given drugs (orally or parenterally, by bolus or by infusion) in doses greater than those required to relieve symptoms, with the intention of hastening a patient's death? Roman Catholic Protestant Jewish Other No religion 19.3% OR, 0.28 (0.16-0.47) P 33.9% OR, 0.59 (0.41-0.86) P 33.3% OR, 0.58 (0.24-1.4) P=0.22 36.0% OR, 0.65 (0.28-1.52) P=0.32 46.4% OR, 1.00 2. Do you believe that there are any circumstances in which it is morally acceptable to give a terminally ill patient sedatives or analgesics by slow intravenous infusion, in doses greater than those required to relieve symptoms, with the intention of hastening the patient's death? Roman Catholic Protestant Jewish Other No religion 31.0% OR, 0.19 (0.12-0.31) P 48.6% OR, 0.40 (0.28-0.59) P 62.5% OR, 0.71 (0.29-1.75) P=0.46 60.0% OR, 0.61 (0.26-1.44) P=0.49 70.0% OR, 1.00 7. Would you be prepared to commence an opioid analgesic infusion for Mrs S's pain, and to run this at whatever dose is necessary to keep Mrs S comfortable (even if this may, incidentally, hasten her death)? (see Appendix)† Roman Catholic Protestant Jewish Other No religion 93.0% 95.1% 100% 96.6% 92.7% *Question 7 refers to the clinical vignette (see Appendix). †Because of the small numbers of negative responses to this question, χ2 analysis was potentially invalid using the categories listed. Analysis was repeated with all religious groups combined. The results were: religious groups, 94.9%; no religion, 92.7% (P=0.22). Back to text

Charles D Douglas · Ian H Kerridge · Katherine J Rainbird · John R McPhee · Lynne Hancock · Allan D Spigelman

Medicine and the Community The physical, sexual and emotional violence history of middle-aged women: a community-based prevalence study Danielle Mazza, Lorraine Dennerstein, Corrine V Garamszegi and Emma C Dudley MJA 2001; 175: 199-201 Abstract - Methods - Questionnaire - Study participants - Statistical analysis - Results - Domestic violence - Unwanted sexual experiences with someone other than a husband or partner - Childhood abuse - Discussion - Acknowledgement - Reference - Authors' details - - More articles on Obstetrics & gynaecology and women's health - More articles on Social issues Abstract Objectives: To determine current and lifetime rates of the experience of partner abuse and sexual violence in a community-based sample of middle-aged women and compare these to figures obtained in a general practice setting. Design and methods: This research was part of the Melbourne Women's Midlife Health Project (MWMHP), an observational, longitudinal, population-based study of 438 Australian-born women conducted over nine years. In 1996, during the sixth year of the study, we asked the MWMHP participants to complete a self-administered "violence questionnaire", incorporating a modified Conflict Tactics Scale and questions on sexual abuse experienced during childhood and adult life. Results: Of the 395 women remaining in the sixth year of follow-up of the MWMHP, 362 (92%) completed the questionnaire. Overall, 28.5% (n = 101) of the women had experienced some form of domestic violence (physical, sexual or emotional) during their lifetime; 5.5% (n = 15) of women had experienced severe physical abuse in the past year at the hands of a partner; and 11.8% (n = 42) of the women had experienced rape or attempted rape between the age of 16 and the time of our survey. Regarding abuse in childhood, 8.9% (n = 32) of women had experienced physical abuse, 42.3% (n = 152) had experienced non-contact sexual abuse, and 35.7% (n = 128) contact sexual abuse. Compared with the general-practice-based study, rates of childhood physical abuse and penetrative sexual abuse were similar, but rates of less intrusive child sexual abuse were significantly higher in our study. Conclusions: Doctors in all areas of medicine who are dealing with middle-aged women need to be aware of the levels of violence sustained by women throughout their lives. Such experiences may have a substantial impact on women's physical and mental wellbeing. Over the past 20 years, the high prevalence of violence against women has been exposed by rigorous research. Women's Safety Australia,1 a large community-based survey of 6300 women undertaken by the Australian Bureau of Statistics, found that 2.6% of women who currently had partners had experienced an incident of physical violence in the previous 12-month period; 8.0% reported an incident of physical violence at some time during their current relationship; and 1.9% of women had experienced an incident of sexual violence during the 12 months prior to the survey. Mazza and colleagues2 examined the prevalence of physical, sexual and emotional violence experienced by women attending general practitioners in metropolitan Melbourne. Their study found that, of women aged 18 years and over who were in relationships, more than a quarter had been victims of physical or emotional abuse by a partner in the previous year, with one in 10 experiencing severe physical violence. In two Australian studies undertaken in hospital emergency departments,3,4 about 19% of female attendees disclosed histories of domestic violence. It is now recognised that domestic violence has an important influence on the morbidity and mortality of women. Increased utilisation of healthcare facilities,5 chronic pain (particularly pelvic pain),6,7 functional gastrointestinal disorders,8 drug and alcohol dependence or misuse,9-11 attempted suicide11 and psychopathology12-14 are all strongly associated with the experience of violence. The aims of our study were to determine current and lifetime rates of the experience of partner abuse and sexual violence in a community-based sample of middle-aged women and to compare these to figures obtained in a general practice setting in a previous study.2 Methods Questionnaire The "violence questionnaire" that was handed to participants for self-completion was the same as that used in a prevalence study of domestic violence experienced by women attending general practices in Melbourne,2 with which we wanted to compare our study data. The questionnaire incorporated the Conflict Tactics Scale,15 with the modification that respondents were asked whether the tactic had occurred never, once or more than once in the past year, and with the addition of questions on emotional abuse. Physical violence was classified as minor or severe.2 Questions about sexual abuse were derived from the studies of Wyatt16 and Russell,17 both of which used multiple screening questions to allow time for the respondent to become accustomed to the nature of the questions. Childhood sexual abuse was classified as "contact" abuse (involving physical contact) or "non-contact" abuse. (For the purposes of our study, a "child" was defined as a person under 16 years of age.) Study participants The subjects of our study were participants in the sixth year of the Melbourne Women's Midlife Health Project (MWMHP),18 a longitudinal study of a community-based cohort of Australian-born women aged 45-55 years at the beginning of the study. An initial cross-sectional study undertaken in 1991 of a randomly selected community-based sample of 2001 women gathered baseline information regarding women's health experiences and variables related to these experiences.19 The MWMHP study was approved by the Human Research Ethics Committee of the University of Melbourne. Eligibility for the longitudinal phase of the study included women who at baseline were premenopausal, were not taking the oral contraceptive pill or hormone therapy, and had an intact uterus. Of the 779 women eligible to enter the longitudinal study, 56% (n=438) chose to do so. Volunteers for the longitudinal study were more likely than non-participants to report better self-rated health, paid employment, more than 12 years of education, having ever had a Pap smear, exercising at least once a week, and having undergone dilatation and curettage.19 In the MWMHP study, women were interviewed annually face-to-face in their own homes by trained interviewers. Information was collected on a range of variables, including sociodemographic factors, health status, lifestyle behaviours, menopausal status and hormone therapy use. By 1996, when our study was conducted, the retention rate of MWMHP participants was 90% (n = 395). Of these women, 23 who had experienced surgical menopause were not given the violence questionnaire, and a further 10 women refused to complete the questionnaire, leaving 362 women who took part in our study. Statistical analysis The Statistical Package for the Social Sciences (SPSS)20 was used to analyse the sample and determine the prevalence of different forms of violence reported by the women. A statistical comparison was made between the results of our study and the data (previously unpublished) for the subset of women aged 50-69 years (n = 411) from an earlier, general-practice-based study of violence2(Box 1). Ninety-five per cent approximate confidence intervals were used. Results Of the 362 questionnaires available, there were missing data for eight women who did not answer questions on adult violence, four who did not complete the adult sexual abuse questions, and four who did not answer either one or more questions on childhood violence. At the time of completing the violence questionnaire the women were between 51 and 62 years of age (mean, 54.6; SD, 2.42). Sixty-six per cent (238/362) were in paid employment and 77% (277/362) were married or living with a partner. The median parity was 3 (range, 0-9), and 35% of the women had had more than 12 years' education. Domestic violence Overall, 28.5% (101/354) of the women in our study had experienced some form of physical or emotional violence over their lifetime (Box 2). A comparison between our sample and the general-practice-based sample with regard to prevalence of violence experienced in the past year is shown in Box 1. Unwanted sexual experiences with someone other than a husband or partner Overall, 40.8% (146/358) of respondents had, between the age of 16 years and the present, experienced either unwanted sexual advances or been in a situation in which the threat of sexual assault was associated with violence or threat of violence. This included one or more of the following: experiencing rape or attempted rape; encountering sexual advances from someone in authority; or narrowly missing being sexually assaulted. A comparison between the responses in our study and the general practice study is shown in Box 1. Childhood abuse Childhood physical abuse had been experienced by 8.9% (32/358) of the women in our study, and more than one in three women had experienced some form of childhood sexual abuse. Our study showed similar levels of physical abuse and penetrative sexual abuse in childhood, but significantly higher levels of less intrusive child sexual abuse, compared with the general practice sample (Box 1). Discussion Using a longitudinal cohort study such as the MWMHP provides many benefits in a prevalence study. Principal among these is that the women surveyed have been interacting with the research staff for over six years and have therefore built up a degree of trust and comfort with these people. This may facilitate disclosure of sensitive issues such as domestic violence and sexual abuse. A limitation of the study is that in order to obtain some comparative value with other work the questions were delivered by self-administered questionnaire, allowing no opportunity for clarification or exploration of the issues being recorded. Also, the additional questions about emotional abuse had not previously been validated. Of interest is the fact that, despite the participants being a self-selected group of relatively well-educated and health-conscious women, there is a considerable lifetime prevalence of domestic violence among them. The fact that our community-based survey results were similar to those of the general-practice-based survey2 confirms that violence affects the lives of all kinds of women and that it may be a very important contributor to concurrent morbidity occurring at the menopause. In the area of child abuse, our data show similar levels of physical abuse and penetrative abuse but significantly greater levels of less intrusive sexual abuse than those found in the general practice sample. This is surprising given that prevalence rates of most forms of abuse are usually lower in community-based settings than in general practice.2 The greater levels in our sample may reflect a cohort effect or may be owing to the long-term relationship developed over six years of follow-up that may have led to more disclosures. Many studies have demonstrated a relationship between experience of violence and long-term morbidity. Our findings of a high prevalence of violence experienced by women over their lifetime suggest that doctors practising in all areas of medicine need to recognise and explore violence issues when considering middle-aged women's reasons for presenting with ill health. Acknowledgement This study was funded by the National Health and Medical Research Council, the Victorian Health Promotion Foundation, and the Australasian Menopause Society. References Australian Bureau of Statistics. Women's Safety Australia 1996, Canberra: ABS, 1996. (Catalogue No. 4128.0.) Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence against women: a general practice-based prevalence study. Med J Aust 1996; 164: 14-17. de Vries Robbe M, March L, Vinen J, et al. Prevalence of domestic violence among patients attending a hospital emergency department. Aust N Z J Public Health 1996; 20(4): 364-368. Roberts GL, O'Toole BI, Lawrence JM, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1993; 159: 307-310. Stark E, Flitcraft A, Zuckerman D, et al. Wife abuse in the medical setting: an introduction for health personnel. Monograph No. 7. Rockville, Maryland: National Clearinghouse on Domestic Violence, 1981. Schei B. Psycho-social factors in pelvic pain. A controlled study of women living in physically abusive relationships. Acta Obstet Gynecol Scand 1990; 69(1): 67-71. Walling MK, Recter RC, O'Hara MW, et al. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstet Gynecol 1994; 84(2): 193-199. Drossman DA, Leserman J, Nachman G, et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med 1990; 113(11): 828-833. Burnam MA, Stein JA, Golding JM, et al. Sexual assault and mental disorders in a community population. J Consult Clin Psychol 1988; 56: 843-850. Winfield I, George LK, Swartz M, Blazer DG. Sexual assault and psychiatric disorders among a community sample of women. Am J Psychol 1990; 147: 335-341. McCauley J, Kern DE, Kolodner K, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995; 123(10): 737-746. Gleason WJ. Mental disorders in battered women: an empirical study. Violence Vict 1993; 8(1): 53-68. Mullen PE, Romans-Clarkson SE, Walton VA, Herbison GP. Impact of sexual and physical abuse on women's mental health. Lancet 1988; 1: 841-845. Beitchman JH, Zucker KJ, Hood JE, et al. A review of the long-term effects of child sexual abuse. Child Abuse Negl 1992; 16: 101-118. Straus MA. Measuring intrafamily conflict and violence: the conflict tactics (CT) scales. J Marriage Fam 1979; 41(1): 75-88. Wyatt GE. The sexual abuse of Afro-American and white-American women in childhood. Child Abuse Negl 1985; 9: 507-519. Russell DEH. The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse Negl 1983; 7: 133-146. Dennerstein L, Smith A, Morse C, et al. Menopausal symptoms in Australian women. Med J Aust 1993; 159: 232-236. Burger HG, Dudley EC, Hopper JL, et al. The endocrinology of the menopausal transition: a cross-sectional study of a population-based sample. J Clin Endocrinol Metab 1995; 80(12): 3537-3545. SPSS for Windows. Statistical package for social sciences. Version 9.0. Chicago, Ill: SPSS Inc, 1999. (Received 2 Mar 2000, accepted 29 Mar 2001) Authors' details Office for Gender and Health, Department of Psychiatry, University of Melbourne, VIC. Danielle Mazza, MD, FRACGP, Research Fellow; Lorraine Dennerstein, AO, PhD, FRANZCP, Director; Corrine V Garamszegi, MWH, SRN, Research Assistant; Emma C Dudley, BSc(Hons), GradDip Epidemiol, Research Fellow. Reprints will not be available from the authors. Correspondence: Professor L Dennerstein, Office for Gender and Health, Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Charles Connibere Building, Parkville, VIC 3050. ldennATunimelb.edu.au Make a comment 1: Number of women experiencing various types of violence among MWMHP* participants compared with the number of women aged 50-69 years reporting these experiences in a general practice setting† Type of abuse MWMHP study (%) General practice study (%) Difference in prevalence between the 2 studies (95% CI) P Adult experience of violence Overall physical and/or emotional abuse by partner in the past year 57 (20.9%) 80 (29.6%) -8.7% (-16.0%, -1.4%) Minor physical abuse by partner in the past year 46 (16.9%) 61 (22.8%) -5.9% (-12.6%, +0.8%) 0.088 Severe physical abuse by partner in the past year 15 (5.5%) 18 (6.7%) -1.2% (-5.2%, +2.8%) 0.550 Emotional abuse by partner in the past year 31 (11.3%) 54 (20.0%) -8.7% (-14.8%, -2.6%) All forms of sexual assault between 16 years of age and the present 146 (40.8%) 135 (33.3%) +7.5% (+0.6%, +14.4%) Unwanted sexual experience between 16 years of age and the present 85 (23.7%) 79 (19.8%) +3.9% (-2.0%, +9.8%) 0.189 Rape or attempted rape between 16 years of age and the present 42 (11.8%) 43 (10.7%) +1.1% (-3.4%, +5.6%) 0.640 Childhood experience of violence Physical abuse 32 (8.9%) 34 (8.6%) +0.3% (-3.7%, +4.3%) 0.856 Non-contact sexual abuse 152 (42.3%) 103 (25.5%) +16.8% (+10.2%, +23.4%) Contact sexual abuse 128 (35.7%) 110 (27.2%) +8.5% (+1.9%, +15.1%) Penetrative sexual abuse 24 (6.7%) 17 (4.2%) +2.5% (-0.8%, +5.8%) 0.129 * MWMHP = Melbourne Women's Midlife Health Project (our study was based on the cohort of women participating in the MWMHP study18 in its sixth year). † The group of women aged 50-69 years was a subset (previously unpublished data, n=411) of the 2181 women aged over 18 years who took part in a general-practice-based study of violence against women.2 ‡ Missing data from incomplete questionnaires were excluded when calculating prevalences. Back to text 2: Lifetime prevalence of domestic violence among middle-aged women (MWMHP* participants) Type of abuse Number of women Prevalence† (95% CI) Overall physical 101 28.5% and/or emotional (23.8%-33.2%) abuse Minor physical 79 22.4% abuse (18.4%-26.2%) Severe physical 31 8.8% abuse (5.9%-11.8%) Emotional abuse 60 17.0% (13.1%-20.9%) * MWMHP = Melbourne Women's Midlife Health Project (our study was based on the cohort of women participating in the MWMHP study18 in its sixth year). † Missing data from incomplete questionnaires were excluded when calculating prevalences. Back to text

Danielle Mazza · Lorraine Dennerstein

Abstract Objective: To examine the relationship between compensation claims for psychiatric injury after motor vehicle accidents and physical injuries sustained. Design: Audit of Compulsory Third Party (CTP) insurance claims. Subjects and setting: 559 consecutive CTP claims referred by NRMA Insurance Limited to its sole provider of CTP legal services during a three-month period in 1994 after the claimant had engaged legal representation. Main outcome measures: Claim for psychiatric injury (any psychiatric disorder excluding traumatic brain injury) supported by a medicolegal report from a psychiatrist, other medical practitioner or psychologist; pre-existing psychiatric disorders; Injury Severity Score; initial treatment setting; hospital stay; percentage of accidents involving loss of consciousness or a death. Results: 522 claims were eligible for the study; 19.5% (102/522) included a claim for psychiatric injury. A pre-existing depression or anxiety disorder was documented in 11 claims (2.1% of all claims and 3.9% of those claiming psychiatric injury). Only very severe injuries, particularly those involving loss of consciousness, were associated with an increased rate of claims for psychiatric injury. Conclusions: No association was found between claims for psychiatric injury and severity of physical injuries, except among those most severely injured. More than 25 000 people are injured in motor vehicle accidents in New South Wales each year.1 Data from the NSW Motor Accidents Authority from 1998 show that about 60% of people who made a claim after a motor vehicle accident obtained legal representation,2 and that the percentage of claims with a psychiatric component rose from 2.2% to 8% between 1990 and 1998.3 NSW Motor Accidents Authority data also show that minor physical injuries result in 54% of all claims, but 77% of claims for psychiatric injury.3Motor vehicle accidents are associated with post-traumatic stress disorder (PTSD), other anxiety disorders and depression,4,5 although most recent publications refer to PTSD rather than other syndromes.4-9 However, the true incidence of PTSD and other disorders after these accidents is unclear; most studies have sampling bias and other methodological problems.4 The extent to which motor vehicle accidents cause the observed psychiatric disorders is also uncertain. Factors associated with PTSD include those not directly related to the accident, such as past psychiatric history6-9 and involvement in litigation,6,7 and others that are difficult to assess objectively, such as victims' recollections of fear of death6-10 and self-reported loss of consciousness.6,7 The relationship between PTSD and severity of physical injuries has also been investigated,6-13 with one study finding a positive correlation.7 In this study, I examined the relationship between compensation claims for psychiatric injury after motor vehicle accidents and physical injuries sustained. Methods Sample The sample comprised 559 consecutive claims on Compulsory Third Party (CTP) insurance that were referred by NRMA Insurance Limited to its sole provider of CTP legal services in a three-month period in 1994 after the claimant had engaged legal representation. All claims arose from motor vehicle accidents that occurred in New South Wales between 1989 and 1994. In this period, 39.5% of NRMA CTP claimants had legal representation. Of the 559 claims, 37 were excluded from the study as files were missing (25), the claim was from bereaved relatives (10) or the claimant had died since the claim (2). A further 50 files had data missing on one or more of the following: injuries, demographic details, or setting of medical care. As these files did not to appear to include claims for psychiatric injuries, they were included in denominators for proportions with psychiatric injury but were excluded from further analysis. Data collection and analysis I collected de-identified data from the files on systematic forms. The dependent variable was a claim for psychiatric injury (defined as any psychiatric disorder, excluding traumatic brain injury) supported by a report from a psychiatrist, other medical practitioner or psychologist. I recorded the presence of one or more of these injuries or traumatic brain injury attributed to the accident by the claimant's experts, as well as any pre-existing psychiatric disorder noted by claimants' or defendants' experts. Independent variables recorded were age and sex, type of motor vehicle accident and whether fatal (ie, any person killed), Injury Severity Score (ISS)14(calculated from information in the injury summary document in each file), setting of initial medical care (most medically intensive setting in the week after the accident), length of hospital stay, loss of consciousness during or after the accident (self-reported or corroborated), and self-reported neck or back pain (irrespective of physical or radiological signs). Data were analysed using the computer program SPSS.15 Logistic regression was used to determine the influence of independent variables on the presence of a claim for psychiatric injury. Results Most claimants (380; 73%) were passengers or drivers, and the remainder were motorcyclists, cyclists or pedestrians (92; 18%). The status of another 50 (10%) was not known because of incomplete files. Mean age was 34 years (range, 2-82 years), and 49% were male. Claims for psychiatric injury Claims for psychiatric or traumatic brain injury are shown in Box 1. One hundred and two people (19.5%) claimed at least one psychiatric injury related to the accident, combined with traumatic brain injury in six cases (another 11 people claimed traumatic brain injury alone). Thirty-six people claimed more than one psychiatric injury. Pre-existing psychiatric disorders are also shown in Box 1. These were documented in 25 people (4.8%), and comprised a depressive or anxiety disorder in 11 (2.1% of all claimants, and 3.9% of those claiming psychiatric injury). The reports supporting the psychiatric injury claims came from psychiatrists (65), psychologists (28) and other medical practitioners (9); mean time between the accidents and report dates was over two years. Experts disagreed on many claims, with treating practitioners and claimants' experts using the diagnoses of PTSD and depression (15% of claimants) more often than defendants' experts (2.5% of claimants), as described elsewhere.16 Variables associated with psychiatric injury claims The group that claimed psychiatric or traumatic brain injury had significantly longer hospital stay and higher mean ISS and proportion of accidents involving loss of consciousness than the group who claimed neither type of injury (Box 2). The group that claimed psychiatric injury but not traumatic brain injury also had significantly more accidents involving loss of consciousness and fatal accidents compared with those who claimed neither type of injury. There were no significant differences between the groups in proportions with self-reported neck or back pain. For the 102 who claimed psychiatric injury, the most medically intensive treatment in the week after the accident was provided by a local medical officer (33), in an emergency department (35), as a general inpatient (25) or in an intensive care unit (9). Psychiatric injury claims and injury characteristics are shown in Box 3 by initial treatment setting. The percentage of people who claimed psychiatric injury was significantly higher in those treated initially in intensive care than in those treated elsewhere (χ2 = 6.74; df = 1; P = 0.009). The percentage who claimed for PTSD and traumatic brain injury was also higher in the intensive care group (PTSD: χ2 = 8.99; df = 1; P = 0.003; and traumatic brain injury: χ2 = 103; df = 1; P <0.001). Mean ISS, hospital stay and percentage who reported loss of consciousness were also greater in those treated in more medically intensive settings (inpatient and intensive care), supporting the use of initial treatment setting as an indicator of injury severity. However, claims for neck or back pain were lower in claimants who received inpatient or intensive care treatment (Box 3). The percentage of people who claimed for a psychiatric injury did not increase with increasing ISS over the first nine deciles (mean, 20%). However, the percentage was significantly higher (33%) in people in the tenth ISS decile (ie, the most severely injured 10%) compared with those in the lower nine deciles (χ2= 4.34; df = 1; P = 0.04). A logistic regression analysis was performed using variables found to be significantly related to claims for psychiatric or traumatic brain injury by previous analyses (Box 4). Loss of consciousness and a fatal accident were significant predictors of claims for psychiatric injury. Discussion A claim for psychiatric injury was made in 19.5% of the legally represented CTP claims in this study, which is higher than the 4.6% estimated by the NSW Motor Accidents Authority for all victims of motor vehicle accidents during the same period.3 This confirms the previously reported association between psychiatric injury and legal representation.6,7 PTSD and depression were reported more often in this sample than in a recent survey of the Australian population.17 Conversely, pre-existing psychiatric disorders were documented much less often than the estimated prevalence of all psychiatric conditions in Australia (4.7% v. 17.7%17). This suggests that medicolegal assessments may under-report pre-existing psychiatric disorders and may sometimes wrongly identify a motor vehicle accident as the cause of a depressive or anxiety disorder that was actually pre-existing. In contrast to findings of the NSW Motor Accidents Authority,3 my study found that minor injuries were no more likely to be associated with a psychiatric injury than more severe injuries. However, a third of psychiatric injury claims (33/102) were made by people with physical injuries that were not severe enough for them to attend an emergency department or be admitted to hospital at the time of the accident. The study did find a positive relationship between the severity of physical injuries and claims for psychiatric injury in people who were very seriously injured. The psychological trauma of being severely injured may cause PTSD.5,7 Severe physical injuries may also cause psychiatric symptoms because of disability, pain or financial loss.5 However, in my study, the higher rate of claims for psychiatric injury in severely injured claimants was associated with loss of consciousness and involvement in a fatal accident rather than with other measures of injury severity. Reported loss of consciousness may be difficult to distinguish from amnesia resulting from emotional stress,18 which may predispose to psychiatric injury.19 The use of insurance claimants as the sample in this study led to selection bias and may have influenced the psychiatric injuries diagnosed by experts. The incidence and prognosis of whiplash injury are influenced by the system of assessing eligibility for compensation,20 and psychiatric injury may be similarly affected. More severely injured claimants may under-report their psychiatric symptoms because they are more concerned about their physical injuries and because the grounds for compensation for physical injuries have been clearly established. Claimants who are not seriously injured but are hurt or upset and have received less initial medical care may report more psychiatric symptoms. The opinions of expert witnesses may, in turn, be influenced by their role in the adversarial legal system.16 Under the current NSW system, some claimants may exaggerate their disability or genuinely become disabled because "significant disability" is a requirement for compensation;21 claimants who have a psychiatric injury but are less disabled are not compensated. Reform of the rules on expert evidence designed to reduce bias22,23 and a move to more detailed assessment of the cause of psychiatric symptoms after motor vehicle accidents may reduce the pressure for the NSW government to further limit psychiatric injury claims. Acknowledgements I would like to acknowledge NRMA Insurance Limited and Mr Victor Kelly of Abbott Tout Solicitors, Sydney, NSW, for making claimants' files available; Dr Timothy Heath (Concord Repatriation and General Hospital, Sydney, NSW) for his help with data analysis; and Dr Olav Nielssen (Psychiatrist, Sydney, NSW) for his assistance with the manuscript. The study was not funded. References Motor Accidents Authority and Roads and Traffic Authority of New South Wales. Road safety statistics, 2000. Available at <http//www.maa.nsw.gov.au/proftest/statistics/injury/report05.htm> (last sighted Jul 2001). Motor Accidents Authority and Road Traffic Authority of New South Wales. Compulsory third party statistics, 1999. Available at <http//www.maa.nsw.gov. au/professionals/statistics/CTP_stats_98.htm> Suhood S. Claims involving psychological disturbance, September 2000. Sydney: Motor Accidents Authority and Road Traffic Authority of NSW, 2000. Blaszczynski A, Gordon K, Silove D, et al. Psychiatric morbidity following motor vehicle accidents: a review of methodological issues. Compr Psychiatry 1998; 39: 111-121. Mayou R. The psychiatry of road traffic accidents. In: Mitchell M, editor. The aftermath of road traffic accidents. London: Routledge Press, 1997: 33-48. Ehlers A, Mayou RA, Bryant B. Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. J Abnorm Psychol 1998; 107: 508-519. Blanchard EB, Hickling EJ, Taylor AE, et al. Who develops PTSD from motor vehicle accidents? Behav Res Ther 1996; 34: 1-10. Mayou R, Bryant B, Duthie R. Psychiatric consequences of road traffic accidents. BMJ 1993; 307: 647-651. Ursano RJ, Fullerton CS, Epstein RS, et al. Acute and chronic posttraumatic stress disorder in motor vehicle accident victims. Am J Psychiatry 1999; 156: 589-595. Green MM, McFarlane AC, Hunter CE, Griggs WM. Undiagnosed post-traumatic stress disorder following motor vehicle accidents. Med J Australia 1993; 159: 529-534. Feinstein A, Dolan R. Predictors of post traumatic stress disorder following physical trauma: an examination of the stressor criterion. Psychol Med 1991; 21: 85-91. Bryant RA, Harvey AG. Initial posttraumatic stress responses following motor vehicle accidents. J Trauma Stress 1996; 9: 223-234. Blanchard EB, Hickling EJ, Taylor AE, Loos W. Psychiatric morbidity associated with motor vehicle accidents. J Nerv Ment Dis 1995; 183: 495-503. Baker SP, O'Neill B, Haddon W, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14: 187-196. SPSS for Windows. Release 9.0.1. Chicago: SPSS Inc, 1999. Large M, Nielssen O. An audit of medico-legal reports prepared for claims of psychiatric injury following motor vehicle accidents. Aust N Z J Psychiatry. In press. Henderson S, Andrews G, Hall W. Australia's mental health: an overview of the general population survey. Aust N Z J Psychiatry 2000; 34: 197-205. Kopelman MD. Fear can interrupt the continuum of memory. J Neurol Neurosurg Psychiatry 2000; 69: 431-432. Mayou RA, Black J, Bryant B. Unconsciousness, amnesia and psychiatric symptoms following road traffic accident injury. Br J Psychiatry 2000; 177: 540-545. Cassidy JD, Carroll LJ, Cote P, et al. Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. N Engl J Med 2000; 342: 1179-1186. Motor Accidents Compensation Act (NSW) 1999. Friston M. New rules for expert witnesses: The last shots of the medico-legal hired gun. BMJ 1999; 318: 1365-1366. Federal Court of Australia. Practice direction: guidelines for expert witnesses. Canberra: Federal Court of Australia, 1998. Available at <http://www. fedcourt.gov.au/pracproc/practice_direct.html> last sighted Jul 2001. (Received 31 Jul 2000, accepted 3 May 2001) Authors' details Department of Psychiatry, Royal Prince Alfred Hospital, Sydney, NSW. Matthew M Large, FRANZCP, Staff Specialist Psychiatrist. Reprints will not be available from the author. Correspondence: Dr M M Large, Department of Psychiatry, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050. mlargeATozemail.com.au Make a comment 1: Number of people claiming psychiatric or traumatic brain injuries and pre-existing psychiatric disorders among 522 insurance claimants Injury or disorder Injury claim Pre-existing disorder Traumatic brain injury (TBI) 17 (3.3%) 0 Post-traumatic stress disorder 48 (9.2%) 0 Depressive disorders 46 (8.8%) 8 (1.5%) Anxiety disorders 15 (2.9%) 3 (0.6%) Somatoform disorders 8 (1.5%) 3 (0.6%) Adjustment disorders 12 (2.3%) 0 Substance abuse 3 (0.6%) 4 (0.8%) Dementia or low IQ 0 3 (0.6%) Schizophrenia 0 2 (0.4%) Other 6 (1.1%) 2 (0.4%) Total* Psychiatric injury 102 (19.5%) 25 (4.7%) Psychiatric injury or TBI 113 (21.6%) 25 (4.7%) *36 people claimed more than one psychiatric injury. Back to text 2: Demographic, injury and accident characteristics among 472 insurance claimants* (95% CI) Variable No psychiatric or traumatic brain injury (n=359) Psychiatric injury (n=102) Psychiatric or traumatic brain injury (n=113) Age in years (95% CI) 33.4 (31.8-35.1) 36.4 (35.5-39.1) 35.7 (33.0-38.3) % Male 49% (44%-54%) 46% (36%-56%) 49% (39%-58%) Hospital stay in days 4 (3-5) 8 (4-12) 11 (6-16) Injury Severity Score† 11.7 (11.0-12.5) 14.0 (12.1-15.9) 16.1 (13.1-18.4) % With loss of consciousness 9% (6%-12%) 25% (16%-33%) 31% (23%-39%) % In fatal accident 1% (0-3%) 8% (3%-13%) 7% (2%-12%) % With neck or back pain 62% (57%-67%) 68% (59%-77%) 64% (55%-73%) Values in bold are significantly different from values for group with no psychiatric injury or TBI, as defined by non-overlapping 95% CIs. * 50 claimants were excluded from this analysis as no information was available on one or more of the following: nature of physical injuries, demographic details, or setting of medical care. † Maximum possible score, 75. Back to text 3: Psychiatric injury claims and injury characteristics among 472 insurance claimants,* according to initial treatment setting† (95% CI) Local medical officer (n=177) Emergency department (n=146) General inpatient (n=129) Intensive care unit (n=20) % With psychiatric injury 19% (13%-24%) 24% (17%-31%) 19% (12%-26%) 45% (26%-63%) % With post-traumatic stress disorder 10% (6%-14%) 10% (5%-15%) 8% (3%-12%) 30% (10%-50%) % With traumatic brain injury 0.6% (0-1.7%) 0.7% (0-2.0%) 5% (1%-8%) 45% (23%-67%) Mean Injury Severity Score 8.0 (7.5-8.5) 10.3 (9.5-11.0) 18.5 (17.0-20.0) 36.7 (31.3-42.0) Mean hospital stay (days) 0 1 13 (9-17) 40 (24-56) % With loss of consciousness 2% (0-4%) 12% (6%-18%) 27% (19%-35%) 60% (38%-82%) % With neck or back pain 81% (75%-87%) 71% (64%-78%) 33% (24%-41%) 20% (2%-38%) PTSD=Post-traumatic stress disorder. TBI=Traumatic brain injury. * 50 claimants were excluded from this analysis as no information was available on one or more of the following: nature of physical injuries, demographic details, or setting of medical care. † Most medically intensive treatment setting in the week after the accident. Back to text 4: Multivariate logistic regression analysis of variables potentially associated with psychiatric injury claims Odds ratio (95% CI) P Injury severity score* 0.98 (0.95-1.02) 0.29 ICU treatment 1.86 (0.80-4.35) 0.15 Hospital stay (days)* 1.00 (0.98-1.02) 0.45 Loss of consciousness 1.82 (1.20-2.88) 0.006 Fatal accident 3.47 (1.52-7.92) 0.003 ICU=Treatment in intensive care unit during first week. *Continuous variables. Back to text

Matthew M Large

Editorial The mental health of young Australians Are we as a nation taking seriously enough the task of preventing and treating mental illness in the young? MJA 2001; 174: 380-381 The United States Surgeon General recently warned that "The burden of suffering experienced by children with mental health needs and their families has created a health crisis in this country [USA]. Growing numbers of children are suffering needlessly because their emotional, behavioural, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illnesses in youth."1 What is Australia's scorecard in the area of children's mental health? In 1995, as part of the National Mental Health Strategy, the Federal Government funded a national survey to establish the prevalence of mental disorders, disability and service use in the Australian population. The adult component (ie, people over 17 years) was conducted in 19972 and the child and adolescent survey (people aged 4-17 years) in 1998. Findings of the latter survey were released recently3 and are summarised in the Box. The strength of the child and adolescent survey was that it considered mental health problems in a variety of ways, including psychiatric diagnosis, service use, and the impact of mental disorders on quality of life. Limitations of the survey were that diagnoses were based solely on information from parents (some questionnaire data were obtained from adolescents but no information was sought from teachers), and only three conditions were examined. These shortcomings may explain, among others, the high rates of attention deficit hyperactivity disorder found — as many as 19.3% of boys aged 6-12 years were found to be suffering from this condition. Some findings are worth highlighting. First, the prevalence of mental health problems among the young (14%) is high and not much different from that found in adults (18%).2 That is, half a million Australians aged 4-17 years have serious emotional and behavioural problems.3 Second, these conditions impair their functioning and quality of life. Disturbed young people also behave in ways injurious to health much more often than their healthy counterparts. Third, only a quarter of those who need help receive it. Mental disorders impose a heavy burden on children, families and communities1,2,4 and often persist into adulthood. The cost to society in human and economic terms is great.1 There is broad agreement that we need to detect these problems early, provide effective treatment and attempt prevention.1,4 A four-pronged approach is necessary: Increase awareness that mental health problems are a major issue in child health and try to prevent them. This will help give children the chance for a healthy start in life.1 Improve the use of resources and access to services. For example, general practitioners could, with appropriate training, play a central role identifying and treating children with mental health problems. GPs (after schools, the second most common source of help) are well placed to take on this role, especially as disorders are often chronic, and contact with specialist services is likely to be only episodic.5 To do this, GPs will need better support — for example, rapid access to specialist telephone advice and to psychiatric assessment, and good liaison with child and adolescent community teams.5 Psychiatrists, psychologists and other mental health professionals need to be more accessible and responsive, particularly in crises.6 It is poignant that, while Australia prides itself on providing universal access to free healthcare, half of the parents needing help believe it is too expensive.3 Increase funding for mental health services for young people. In 1997-98, the last year for which data are available, State and Territory governments spent $1.4 billion on mental health services ($74 per capita).7 Of this sum, only $107 million (7%) was spent on the young, who make up a quarter of the Australian population — this amounts to an average of $23 per child, compared with $95 per adult.7 Increase the number of specialists in mental health and carry out more research. The shortage and maldistribution of specialists7,8 is well documented, and it is important to establish which treatments and service-delivery models work and which do not.1,4 We must ask ourselves whether we as a nation take seriously enough the task of preventing and treating mental illnesses in the young. The recent proliferation of programs8 promoting mental health suggests we are moving in the right direction, but it remains to be seen whether this is a measure of real commitment or just window dressing. The findings of the latest survey of mental disorders in young people3 will at least give us a baseline for comparison when the next national survey is conducted. Joseph M Rey Professor, Department of Psychological Medicine, University of Sydney Director, Child and Adolescent Mental Health Services Northern Sydney Health, Sydney, NSW Report of the Surgeon General's Conference on Children's Mental Health: a national action agenda. Washington, DC: US Public Health Service, 2000. Australian Bureau of Statistics. Mental health and wellbeing profile of adults, Australia 1997. Canberra: AGPS, 1998. Sawyer MG, Arney FM, Baghurst PA, et al. The mental health of young people in Australia. Canberra: AGPS, 2000. Raphael B. Promoting the mental health and wellbeing of children and young people. Discussion paper: key principles and directions. Canberra, AGPS, 2000. Garralda ME. Child and adolescent psychiatry in general practice. Aust N Z J Psychiatry (in press). Australian Medical Workforce Advisory Committee. The specialist psychiatry workforce in Australia. Sydney: AMWAC, 1999. (AMWAC Report 1999.7.) Commonwealth Department of Health and Aged Care. National mental health report 2000. Canberra, AGPS, 2000. National action plan for promotion, prevention and early intervention for mental health. Canberra: Commonwealth Department of Health and Aged Care, 2000. Make a comment Main findings of the 1998 Australian Federal Government survey on the mental health of young people3 From interviews with a representative sample of 4509 parents and questionnaires returned by 1490 adolescents aged 13-17 years, the following information was obtained: 14.1% of 4-17-year-olds had experienced mental health problems in the previous six months. The prevalence of three specific mental disorders during the previous year had been — Depressive disorder 3.7% — Conduct disorder 3.0% — ADHD 11.2% (Inattentive subtype, 5.8%; hyperactive-impulsive subtype, 2.0%; combined subtype, 3.3%) Young people living in sole-parent and low-income families had higher rates of problems. In adolescents, rates of suicidal ideation, suicide attempts, cigarette smoking, and alcohol and cannabis use increased steeply with increasing emotional and behavioural problems. Twenty-five per cent of children and adolescents with problems had used at least one service (broadly defined) in the previous six months. The three services attended most often were counselling at school or in a special class, GPs and paediatricians. Half of the parents reported that help was too expensive, and almost half did not know where to seek help. Only 6% reported that social stigma was a barrier to seeking help. Among the adolescents, 38% preferred to manage the problems themselves, 18% believed nothing could help, 17% did not know where to get help, and 14% were worried about the social stigma. ADHD = attention deficit hyperactivity disorder. Back to text

Joseph M Rey

Defining Moments In Medicine Psychiatry MJA 2001; 174: 18-19 Lithium: While Melbourne psychiatrist John Cade both discovered the antimanic effects of lithium and published his findings in the Journal in the 1940s, its distinctive impact on bipolar disorder management only crystallised in Australia in the 1970s after extensive developmental work, and with a mid-90s article in Science estimating that, since 1970, lithium therapy had saved the US economy alone US$145 billion in health costs. Chlorpromazine: The introduction of this "major tranquilliser" in 1952, described by David Healy (University of Wales College of Medicine) as "the single most important breakthrough in psychiatric treatment", had a dramatic impact on the management of schizophrenia: for the first time some patients became non-psychotic, and the acute management of schizophrenia improved markedly. Improving the practice of ECT: Electroconvulsive therapy is still psychiatry's most powerful treatment for depression. Despite major advances -- the introduction of anaesthetics and muscle relaxants, stimulus dosing and electroencephalographic monitoring -- the antipathy of patients (and the community) to ECT has regrettably only slightly lessened. Lessons from military psychiatry and refugee groups: Principles developed between World War II and the Vietnam War (ie, making psychiatric care immediately available "on the spot", and communicating an expectation that recovery would occur) were intrinsically important and diffused into other practice domains, such as community psychiatry, and the management of post-traumatic stress disorder. Deinstitutionalisation: This misnomer was used to describe the moving of patients in the 1960s from maxi-institutional lives in large psychiatric hospitals to mini-institutional existences in boarding houses and nursing homes, often to be even more forgotten and neglected. Yet, we progressively recognised an old principle -- that while risking "dying with one's rights on", people value personal freedom above institutional existence. Forced community assimilation also modified images of the "insane" to softer, disability images. Mainstreaming: Moving the care of psychiatric patients from the Dickensian, isolated psychiatric institutions to general hospitals helped bring Australian clinical psychiatry into general medicine, reducing stigma and resulting in superior lines of responsibility. Malfeasance responses: Disturbing revelations of the Royal Commission into Deep Sleep Therapy at the Chelmsford Private Hospital, and the Queensland Commission of Inquiry into assault and maltreatment of patients in the psychiatric ward of the Townsville General Hospital, reports of sexual misconduct and other boundary violations surfaced in the past 20 years. Grave community concerns resulted in impressively non-defensive responses by the profession and the monitoring authorities to redress such issues, including increased legal involvement (and procedures) now intertwined with public mental health services. Formalised professional markers: The establishment in 1964 of a Royal College (the RANZCP) linking Australian and New Zealand psychiatrists, and, in 1967, of a professional journal (The Australian and New Zealand Journal of Psychiatry), together with the development of an innovative membership examination, were markers of a move from a small network of individual psychiatrists to a formalised grouping -- now one of the largest professional medical specialties in the region. Growth in Australian academic psychiatry: Once a "home alone" model (eg, David Maddison, Professor of Psychiatry, Sydney University, and Foundation Dean of the Newcastle University Medical School being one of a small set of identifiable local produce) or "run away from home" expatriate model (eg, local Adelaide lad, Aubrey Lewis, dominating British academic psychiatry), now "home grown" dominance is evident, with a disproportionately successful Australian impact on international research publications, but also a decrease in "critical attitude" by academics and an overvaluation of quantitative research. Clozapine: This "atypical" neuroleptic drug was produced in 1962, but only taken up in Australia in the past decade (because of its side effect of agranulocytosis). Despite its monitoring requirements and its expense, its wide prescribing by Australian public mental health services is noteworthy. Its use gradually causes a considerable number of patients with schizophrenia to "normalise", and its capacity to restore suggested cognitive limitations has changed our understanding of a disorder once called "dementia praecox". Growth of biological psychiatry and psychiatry as a neuroscience: This movement has delivered striking results in understanding the determinants of many major psychiatric disorders, in establishing a dominant and successful research paradigm, and in integrating psychiatry with medical research. Caveats emerge from overly zealous or inappropriate application of the model -- "the sin of biologism". At risk is rejection of psychiatry's distinctive contribution to the practice of medicine -- a pluralistic model, respecting and integrating (in formulation and management) the multiple paradigms of sentient human beings. Detumescence of psychotherapy: Psychotherapy has been shrunk less by failure to produce an evidence base, ad hominem attacks and growth of alternative contenders (eg, cognitive behavioural therapy) than by a loss of significance and relevance as biological psychiatry has "Pac-Manned" the old Zeitgeist. Psychotherapy requires revisionism, repositioning and more pragmatic advocacy. Introduction of "new" antidepressants and "atypical" antipsychotic drugs: The selective serotonin reuptake inhibitors (SSRIs) are not merely antidepressants, but non-addictive "anti-worry" agents, with the potential to modify "neurosis", a feat once thought impossible. The "atypical" antipsychotic drugs may only be slightly more effective for treating schizophrenia, but their more benign side-effect profile improves quality of life and medication compliance. Formulation of clinical depression as an economic problem: The number of people with depression is not growing substantially, despite historical formulations of depression as a response, a disorder, an illness and a disease. Its recent reformulation as a major economic cost due to its disabling effects, endorsed by the World Bank, Harvard University and the World Health Organization, provided the spin, attracting public, media, health department and political attention. Consumerism: At last year's RANZCP Conference, psychiatrists danced in a congo line to music played by a band of consumers. As the Convenor, Bob Barrett, observed: "It was a delicious sight indeed to see psychiatrists dancing, for the first time, to the tune of the patients." Consumers and their advocates have had a more difficult row to hoe in psychiatry than in most other medical specialties, with their contribution and impact on professional attitudes humbling. On doctors and nurses: Once non-psychiatrist doctors married their hospitals and, on the rebound, the ward sister, who was ever able to undertake ward rounds at home ("Are all the children in bed, sister?"). Once psychiatrists were strange schizoid creatures (to wit, "alienists"). Now doctors no longer marry nurses (most are professors now) and psychiatrists are rugby-following, tie-wearing, non-intellectual conservatives. As biological psychiatry has reached its zenith, psychiatry is no longer as attractive or distinctive to those seeking "different" medical careers. The "magic" in the therapeutic process has gone -- magic that could lead to foolishness and invite ridicule or, alternatively, which imbued psychiatrists with a luminous sense of understanding. Recruitment is down and there is a lack of plurality in the air. Has psychiatry been mainstreamed away from its ineffable status? Has it not become stale to medical student and graduates seeking a specialty? How will it reconstitute itself above and beyond its procrustean biological bed? The January 2051 issue of The Medical Journal of Australia will detail the rollback. Gordon B Parker Professor and Head School of Psychiatry University of New South Wales Prince of Wales Hospital, Sydney, NSW John H Ellard Psychiatrist Bead Lane Specialist Centre, Sydney, NSW Above photograph. Ambulatory psychiatric patients, who have been put to bed in broad day-light, Callan Park Mental Hospital, Sydney, circa 1960. From the Report of the Royal Commission into Callan Park Mental Hospital, 1961. Crown copyright. Make a comment

Gordon B Parker · John Ellard

Editorial Media and young minds Despite the best efforts of J K Rowling, young Australians this Christmas will be more interested in video games and cyberspace MJA 2000; 173: 570-571 Whether linked with fictional suicides in 18th-century romantic literature or reports of real-world suicides in today's mass media, copycat suicides have generated suspicions that media images may undermine mental health and moral development.1 Suspicions have given way to uneasiness as a growing number of problems -- drug and alcohol abuse, sexual promiscuity, depression and eating disorders -- have been laid at the media's door. Young people's enthusiasm for new electronic media, where the pace of change outstrips current understandings of effects on health and development, has done little to diminish this sense of uneasiness. In this context, Bokey and colleagues2 have studied images of youth in the "old" media, focusing on "Notable Texts" recently recommended by the Children's Book Council of Australia. Suicide, mental disorder and failure were commonplace in portrayals of an insecure and pessimistic young generation. Psychiatrists were predatory or incompetent and offered no reprieve for the distressed. This genre has been termed "social realism" and its rise attributed to the social and economic changes that have aggravated the usual turmoil of adolescence. It is true that with these social changes familiar adult milestones such as stable employment, financial independence, parenthood and home ownership are delayed3 and rates of adolescent emotional and behavioural problems appear high.4 Even so, images of pervasive adversity, mental disorder and suicide are overly pessimistic and do little to destigmatise mental disorder in a group whose access to health services is already poor. Moreover, if these images are to be found in the familiar old media, how much more concerned should we be about the new? Hard answers are elusive. Academic research on the media and youth lags far behind that of marketing. Most work is North American, where the main focus has been on television violence. It is clear that childhood viewing of violence predicts later aggression and criminal behaviour.5 It is also clear that there are many powerful moderating influences. Parents, for example, have traditionally influenced not only what children watch but also the effect of those images on actual behaviour.6 The closer an image is to real-world scenarios, the greater the effect on behaviour.7 For this reason the virtual-reality experiences of the new media may prove particularly powerful. Trends in young people's media use are relevant. Only a third of today's Australian youth read for recreation.8 In contrast, electronic media have become pervasive and the convergence of telecommunication and computer technologies into the Internet has led to a dizzying growth in communication options. The new media offer individualised, two-way, synchronous interactions, and increasingly draw on sound and vision to offer sophisticated virtual environments. The effects are not all negative and the benefits from opportunities for social contact, education, publication and establishment of businesses, regardless of location, can not be dismissed lightly. The media's growing role in shaping youth lifestyles and cultures also deserves consideration. A longer period of full-time education, growing affluence and greater recreational time have made youth a distinct consumer group, with lifestyles shaped increasingly by the media. The new media offer myriad ways to market messages that affect self-concept, body image, sexuality, and drug and alcohol consumption. The tobacco industry has rightly been the main focus, but the health effects of marketing food, alcohol, fashion, pharmaceuticals and entertainment deserve greater attention. What options exist for action? One is to do little and allow the market forces behind the media to drive solutions. The success of the Harry Potter series is one example of market forces in action, as young readers turn away from a "social realism" they find boring.9 However, the dizzying pace of media change, and a mistrust of increasingly global marketing targeting the young, suggest that few will have confidence in this approach. One alternative is to rely on advisory bodies such as the Children's Book Council of Australia. However, with recommendations to librarians, teachers and parents based on artistic merit alone, a body such as the Book Council seems poorly placed to take on the role. It's a fair bet that, despite the best efforts of J K Rowling, young Australians this Christmas will be more interested in video games and cyberspace. Without better information from research, parents, media professionals and young people face difficult choices. For parents, media education may prove useful in overcoming their unfamiliarity with the new media, one reason for their diminishing monitoring role. For professionals working in competitive media and advertising industries, emerging ethical questions deserve expert advice. An encouraging step is the release by the Commonwealth Department of Health of a media resource kit as part of a mental health promotion strategy.10 It marks the beginning of a dialogue between the health professions and the media and one that should go further. Even with the best of parental and technical monitoring, today's young people will be exposed to a greater number and diversity of media images than any previous generation. For this and future generations, the role of media education in both interpreting images and dealing with virtually limitless information is likely to grow. Academic research may or may not tell us whether Harry Potter is a better companion than the cyberheroine Lara Croft, but should help us all make better-informed decisions about the presents we buy for our children in the years to come. George C Patton Professor Susan M Sawyer Associate Professor Centre for Adolescent Health William Buckland House, Melbourne, VIC Phillips DP. The influence of suggestion on suicide: Substantive and theoretical implications of the Werther effect. Am Sociol Rev 1974; 39: 340-354. Bokey KM, Walter G, Rey JM. From Karrawingi the emu to Care factor zero. Mental health issues in contemporary Australian adolescent literature. Med J Aust 2000; 173: 625-628. Furlong A, Cartmel F. Young people and social change: invidualisation and risk in late modernity. Buckingham, UK: Open University Press, 1997: 40-52. Rutter M, Smith D. Psychosocial disorders in young people: time trends and their causes. Chichester: Wiley & Sons, 1995. Cook DE, Kestenbaum C, Honaker LM, Anderson ER. Joint statement on the impact of entertainment violence on chikdren. Congressional Public Health Summit, American Academy of Pediatrics 2000. <http://www.aap.org/advocacy/releases/jstmtevc.htm> (accessed November 2000). Huesmann LR, Eron LD. Television and the aggressive child: a cross-national comparison. Hillsdale, NJ: Lawrence Erlbaum, 1986. Comstock G. Deceptive appearances: television violence and aggressive behaviour. J Adolesc Health Care 1990; 11: 31-44. Australian Bureau of Statistics. How Australians use their time. Canberra: ABS, 1998. (Catalogue No. 4153.0.) Waldren M. Return to Narnia. The Weekend Australian 2000 September 30: C6. Commonwealth Department of Health and Aged Care. Mental Health Promoting Media Strategy. Canberra: The Department, 1999. Make a comment

George C Patton · Susan M Sawyer

Mental health issues in contemporary Australian adolescent literature So it was the emus were left in peace for three long years, during which Karrawingi, from a mere stripling, grew into a fine adult bird. His head was held over five feet high on his long smooth blue skinned neck. His eyes were splendidly large and of clear liquid brown, with black pupils . . . And now that Karrawingi was fully grown and winter was striding in once more, he began to feel strange urges in the blood. He was drawn to show his prowess in the company of female emus . . . He would whoosh and drum and dance and balance on one leg and puff out his throat feathers. (Karrawingi the emu, 1946, pp. 19-21) 1 She heaved herself up onto the railing. "Stay away from me. I'll jump!" "I hear that every day," he smirked. "People owing me rent. Girls wanting to get out of the game. My game. I take care of them, don't I? Come here, Larceny Farino. I'm going to take care of you. You won't jump. But then you are your mother's daughter." He smiled. She looked at him and saw the cruelty in his eyes. There was no escape. All the countless numbers of shrinks, pills, injections weren't as bad as this. Her head spun, but her thoughts were chillingly clear. And sane. "You're my daughter. You won't jump, will you?" She did. (Care factor zero, 1997, p. 206)2 MJA 2000; 173: 625-628 For editorial comment, see Patton & Sawyer Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Psychiatry Abstract Objective: To examine the depiction of mental health issues in contemporary Australian adolescent literature. This material might influence teenagers' understanding of mental illness and their willingness to seek help, and may provide insights into societal attitudes towards adolescents and the psychiatric problems encountered in this age group. Design: Systematic examination of a sample of 94 books, the "Notable Texts" in the "Older Child" category of the Children's Book Council of Australia Awards for the years 1996, 1997 and 1998. Main outcome measures: Number of works referring to psychiatry; characters who experienced trauma, loss, psychiatric symptoms, qualified for a psychiatric diagnosis, exhibited suicidal behaviour or sought help; and the nature of treatments given. Results: There was reference to psychiatry in over two-thirds of the works. In these books the image of psychiatry was generally negative or mixed. Most adolescent characters suffered major losses. Two-fifths of characters met criteria for a psychiatric diagnosis. The outcome for characters who satisfied criteria for a psychiatric diagnosis was more negative than those without. Of the 10 characters in the sample who committed suicide, eight had a psychiatric disorder. Conclusions: Psychiatric themes are a major component of the Australian teenage novel. Young people in contemporary Australian teenage literature are beset with trauma, loss and psychiatric disorders. Even when help is obtained, the outcome is seldom positive. This nihilistic view may increase hopelessness and pose a barrier for teenagers seeking help. In the inaugural decade of the Children's Book Council of Australia Awards (1946-1955), honoured books carried titles such as Karrawingi the emu,1Bush cobbers3 and Good luck to the rider.4 The titles reveal a fascination with Australiana - the flora, fauna, Indigenous population and traditional images of the white Australian family in an idealised rural landscape. By the late 1980s these themes had vanished and "realism" had settled into the Australian teenage novel. Among honoured books were Pausacker's What are ya!,5 which describes a lesbian relationship, and Marsden's So much to tell you,6 which portrays emotional abuse, post-traumatic stress disorder, elective mutism and psychiatric institutions. The apparent maturing of the teenage novel has been controversial. At issue is the potential impact of the novel's content on the well-being of the reader. A grassroots revolt against what is perceived as an increasingly nihilistic form of realism is emerging. In Sydney's Child, an article describes a parent's horror at the content of a Marsden novel: "Can we trust John Marsden with our children's minds?".7 In The Australian Magazine, Kate Legge asks "is the nihilistic trend in children's literature out of control?".8 The foci of these critics' discontent are no longer books about sex and rule-breaking, but books which showcase severe psychiatric illness and suicide (eg, Shoovy Jed,9Care factor zero2 and Dear Miffy10). The complaint is that the vividness of the contemporary teenage novel has gone beyond the honest to the offensive: "Young adult fiction is carving up the literary nature strip and hanging wheelies on the hard-baked bitumen of realism and it is not just nostalgic fogies and Christian Fundamentalists wrinkling their noses at the smell of burnt rubber."8 At a time of growing alarm at the high youth suicide rate,11 increasing awareness of the psychiatric problems confronting our adolescents,12 and concern about the effects of television, movies and video games on young people,13 it is worth ascertaining what we can learn from teenage literature. What attitudes to mental health issues are expressed in this literature and what impact might this literature have on the well-being of its readers? We aimed to explore these issues by systematic examination of a sample of Australian teenage novels. Methods Sample The sample comprised 94 adolescent literary works which represented all "Notable Texts" in the "Older Child" category of the Children's Book Council of Australia Awards for the years 1996, 1997 and 1998. The purpose of the Council is to select and honour books of high literary and artistic quality written for children.14 The category "Book of the Year - Older Reader" aims to identify works of fiction, drama or poetry which are appropriate for high school or upper primary school children. From all entries to the category, the judges choose "Notable Texts". These texts provide librarians, teachers and book sellers with a guide to book selection. Tools We designed two instruments: a 13-item instrument applicable to the literary work as a whole and a 70-item instrument applicable to the characters (available from the authors on request). Data sought with the first instrument included information about the novel's setting, humour, references to psychiatry and ending. Information obtained with the second instrument (which examined the main characters) included character demographics, experience of loss, abuse and life stressors, attitudes to life's challenges, presence of psychiatric symptoms and DSM-IV diagnosis,15 suicidality, sexual activity, help-seeking behaviours, and treatments. Only characters about whom there was information to answer at least 25 of the 70 items in the second instrument were included in the description of characters. The 94 works were read and rated by K M B over 10 months. Statistical analysis Because this is mainly a descriptive study, little statistical analysis was applied to the data to minimise overinterpretation. The χ2 test was used when comparing subgroups. Statistical significance was defined as P < 0.05. Results The works as a whole The context of the books was very much in the "here and now": 78% were set principally in Australia, 71% were reality-based, 76% had a contemporary setting and 63% had an urban backdrop. Humour was rare; only 4% of works were judged to be "funny". Thirty-four per cent of books had a happy ending. There was reference to psychiatric illness, institutions, treatments or mental health professionals in 69% of the books. In 9% of those, the reference was "slight" (eg, a one-line reference to Freudian psychoanalysis). In 75%, the reference was "significant" (eg, a refugee child suffers a post-traumatic stress disorder which strongly influences the story line). In the remaining 15%, the reference was "major" (ie, the work was about a character with a severe psychiatric illness or a child's experience of a parent with major psychiatric illness). Among works which refer to psychiatry, there were very few positive portrayals (6%); the depiction of psychiatry was usually negative (51%) or mixed (43%). A typical "negative" portrayal is one in which the sufferer of psychiatric illness is stigmatised, or there is futility expressed about seeking help from mental health professionals and institutions, or the mental health professional is depicted as emotionally abusive and the endpoint of mental illness is suicide. The characters There were 269 characters for whom there were sufficient data to answer at least 25 of the items in the second study instrument. The typical character was a teenager (76%), single (93%), a student (70%) with two or fewer siblings (67%). In 17% of cases the character or character's immediate family were migrants or refugees; 4% of characters had an Indigenous background. Twenty-three per cent had a medical or surgical illness. Fifty-three per cent had a conventional two-parent family background. Thirty-two per cent were sexually active in their teenage years. Most were uncertain (59%) or despairing (22%) about life's challenges. A fifth had experienced some form of child abuse (physical, sexual or emotional abuse, or neglect). Sixty-four per cent of characters experienced a "severe" stressor (eg, rape, sustained physical abuse, a life-threatening motor vehicle accident, or becoming a refugee from war). Having suffered a major loss (eg, death of family member or close friend, loss of home or homeland) affected 78% of characters. Fifty-seven per cent were distressed in some way. Specific psychiatric symptoms were identified in most characters and 41% met DSM-IV diagnostic criteria for a psychiatric diagnosis (Box 1). Most of these (63%) had one diagnosis; 31% had two (31%) and 6% had more than two. Of the 180 characters who were distressed, experienced psychiatric symptoms and/or had a psychiatric diagnosis, 73% received help (Box 2). The attitude of the 180 characters to seeking help was ambivalent (48%), negative (22%) and positive (24%), with no clear attitude described for the remaining characters. The 38 characters who sought help from mental health professionals accessed cognitive behavioural therapy (45%), hospitalisation in a psychiatric unit (37%), psychotropic medication (31%), family therapy (16%), dynamic psychotherapy (1%) and treatment in a therapeutic community (0.5%). Treatment outcomes varied: in 55% there was no change in symptoms; in 32% there was clear benefit, while in the remaining 13% mental health intervention had a negative effect. Twenty-six characters (10%) had suicidal thoughts; 22 of these characters had a psychiatric disorder. Twenty-one manifested suicidal behaviour and 10 actually killed themselves, a very high rate of completion. The psychiatric profile and means of suicide are shown in Box 3. Comparison of characters with and without a psychiatric diagnosis Only 1% of the 111 characters with a psychiatric diagnosis experienced no stressor, compared with 14% of the 158 without a diagnosis. For 84% of the characters with a psychiatric disorder the stressor was "severe", compared with 51% for the well characters (P < 0.001). Major loss was experienced by 92% of characters with a psychiatric disorder versus 68% of the well characters (P < 0.001). Characters with a psychiatric disorder were more likely to have been abused in childhood. This association was significant for neglect (P < 0.01) and approached significance for emotional and physical abuse. Characters with a psychiatric condition were less competent than their well counterparts, except in artistic ability. They were poorer scholars (P < 0.05), less able to socialise (P < 0.001), less attractive physically (P < 0.05), less capable of intimacy (P < 0.001), more pessimistic (P < 0.001), and more likely to have suicidal thoughts (P < 0.001), manifest suicidal behaviour (P < 0.001) and complete suicide (P < 0.05). Characters who had a psychotic illness were conspicuous for their pessimistic outlook and poor outcome; 78% of these characters had a pessimistic outlook, and 55% completed suicide. Discussion The books examined in this study are works of fiction and do not necessarily reflect what happens in the "real world". For example, the rate of family separation in our sample was about twice that found in the community (47% versus 21%),16 and the proportion of teenage characters who met criteria for a psychiatric diagnosis (41%) was much greater that the rate of mental health problems found among adolescents in a recent national survey (13.4%).12A limitation of our study is that we have no data on the instruments' reliability and validity. For instance, we do not know whether the assessments of the rater (a senior trainee in child psychiatry) about issues such as "humour" would concur with those of a teenage reader. Despite these shortcomings, this report describes how contemporary writers (and those who selected the books) view growing up in Australia at the end of the 20th century. What image of the times do these books project? The past decade appears to have been a time of trauma and loss for youth, unrelieved by humour or hope. Young people in these books experienced high levels of mental distress, but professional help was seldom obtained for mental health problems (only 38 out of 111 characters with a psychiatric condition accessed mental health services) and few patients actually benefited from the contact (only 12 of the 38 youths). Characters who met criteria for a psychiatric diagnosis were more likely to have been abused, traumatised and to have suffered a loss. They were less attractive, worse academically, and social failures. And for characters with a psychotic illness the outlook was even more grim (over half killing themselves). Considering this image of our times we may well ponder whether the genre has crossed the threshold from realism into nihilism. Yet, in some respects, the depiction of mental illness in teenage fiction can be applauded. Acknowledging mental illness is a first step towards understanding and the removal of prejudice. Many of the portrayals are so authentic that the teenage novel can be used to educate both general readers and students of psychiatry. However, we have concerns about some aspects of psychiatry's representation in these novels. Detailed speculation about the effect of literature on young people's behaviour is outside the scope of this article. Nevertheless, many questions arise. How will books that are scathing of mental health professionals influence the preparedness of young people to seek or accept treatment? As soon as she'd revealed a weakness, the shrink had gone for the jugular. To reveal that you were weak, scared or confused gave them power. And once they had the power, they could manipulate you, control you -- Who the hell did they think they were anyway, trying to pry into your soul: God? (Care factor zero, p. 106).2 What is the impact of books which feature psychiatric illness on vulnerable teenagers or those who either suffer a psychiatric illness or have a family member affected? For example, how can one safely expose a teenager with a psychiatric illness to a book in which the principal character (who also has a psychiatric illness) is bad/mad, consummately devilish and incurable,17 or to a book in which a teenage boy with schizophrenia is hounded to his death by the ignorance and cruelty of his peers, the abject failure of psychiatric help and the urgings of his hallucinations?18 Both these books are wonderfully crafted and educative, but at whose expense are we "doing wheelies on the hard baked bitumen of realism"? Similarly, will a character's decision that suicide is the best or only option tip the scales for teenagers going through a rough patch? Although data are lacking on the effects of reading literature on psychopathology and suicide, there are suggestions that other media -- newspapers, television, music -- may have an adverse impact.13,19,20 Do medical professionals have a valid role in encouraging accurate and therapeutic content in teenage literature, without becoming "thought police" or encroaching upon "artistic freedom"? Do authors feel that responsibility for the well-being of their readers is compatible with the right to such freedom? If so, these two professions should enter into a dialogue and exchange perspectives. A recently published resource kit to assist various media professionals portray mental illness and suicide makes no mention about the possible responsibilities of authors in this matter.21 In any case, there seems to be a very wide gap between Karrawingi the emu and Care factor zero. Exploring the reasons for this and its consequences may prove just as helpful for the future of Australian society as many epidemiological and clinical studies. Acknowledgements We thank Associate Professor John Stevens, Ms Pam Hatfield, and the New South Wales Branch of the Children's Book Council of Australia. Book covers reproduced with permission. Clark, M. Care factor zero. Sydney, Random House, 1997. Harnett, S. The devil's latch. Melbourne, Penguin, 1998. Hilton, N. Hothouse flowers. Sydney, HarperCollins, 1997. Marsden J. Checkers. Sydney, Pan Macmillan, 1997. Orr, W. Peeling the onion. Sydney, Allen and Unwin, 1996. Saliba, S. Watching seagulls. Melbourne, Longman, 1997. Walters, C. The killing of mud-eye. Brisbane, UQP, 1997. Winton, T. Lockie Leonard legend. Sydney, Pan Macmillan, 1997. References Rees L. Karrawingi the emu. Sydney: John Sands, 1946. Clark M. Care factor zero, Sydney: Random House, 1997. Morell M. Bush cobbers. Sydney: Australasian Publishing, 1948. Phipps J. Good luck to the rider. Sydney: Angus and Robertson, 1953. Pausacker J. What are ya? Sydney: Angus and Robertson, 1987. Marsden J. So much to tell you. Melbourne: McVitty Books, 1987. Bolt A. Do you want your children influenced by the world of John Marsden? Sydney's Child, Dec 1999/Jan 2000: 52. Legge K. Life sucks, Timmy. Australian Magazine, March 8-9 1997: 10-18. Stewart M. Shoovy Jed. Sydney: Random House, 1997. Marsden J. Dear Miffy. Sydney: Pan Macmillan, 1997. Cantor CH, Neulinger K, De Leo D. Australian suicide trends 1964-1997: youth and beyond. Med J Aust 1999; 171: 137-141. Sawyer M, Arney M, Baghurst PA, et al. Child and adolescent component of the national survey of health and well-being. Canberra: AGPS, 2000. Centerwall BS. Television and violence. JAMA 1992; 267: 3059-3063. Children's Book Council of Australia. The Children's Book Council of Australia Awards Booklet. Brisbane: The Council, 1997. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). Washington, DC: American Psychiatric Association, 1994. Australian Bureau of Statistics. Children, Australia: a social report (1999). Catalogue no. 4119.0 <www.abs.gov.au> Accessed 28 August 2000. Hartnett S. The devil latch. Melbourne: Penguin Books, 1996. Walters C. The killing of Mud-Eye. Brisbane: University of Queensland Press, 1997. Hassan R. Effects of newspaper stories on the incidence of suicide in Australia: a research note. Aust N Z J Psychiatry 1995; 29: 480-483. Martin G, Clarke M, Pearce CM. Adolescent suicide: music preference as an indicator of vulnerability. J Am Acad Child Adolesc Psychiatry 1993; 32: 530-535. National Mental Health Strategy. Achieving the balance: a resource kit for Australian media professionals for the reporting and portrayal of suicide and mental illness. Canberra: Commonwealth Department of Health and Aged Care, 1999. (Received 4 Jul, accepted 12 Sep, 2000) Authors' details Rivendell Unit, Central Sydney Area Health Service, and New Children's Hospital, Sydney, NSW. Kathleen M Bokey, BA, FRANZCP, Fellow in Child Psychiatry; Garry Walter, MB BS, FRANZCP, Acting Director, Child and Adolescent Mental Health Services, Central Sydney Area Health Service, and Clinical Lecturer, Department of Psychological Medicine, University of Sydney. Department of Psychological Medicine, University of Sydney, Sydney, NSW. Joseph M Rey, PhD, FRANZCP, Professor of Child and Adolescent Psychiatry, and Director of Child and Adolescent Mental Health Services, Northern Sydney Health, Sydney. Reprints will not be available from the authors. Correspondence: Dr G Walter, Rivendell Unit, Hospital Road, Concord West, NSW 2138. gwalterATmail.usyd.edu.au Make a comment 1: Psychiatric symptoms and diagnoses in 269 characters* Symptoms Emotional (eg, anxiety) Behavioural (eg, conduct problems) Somatic (eg, conversion symptoms) Psychotic (eg, hallucinations) Cognitive (eg, memory loss) 151 (56%) 126 (47%) 18 (7%) 18 (7%) 16 (6%) Psychiatric diagnosis Adjustment disorder Post-traumatic stress disorder Mood disorder Substance abuse/dependency Personality disorder Psychotic illness Oppositional defiant disorder Delirium Eating disorder Conduct disorder Anxiety disorder Dissociative disorder Mental retardation Dementia Pre-menstrual dysphoric disorder 32 (12%) 22 (8%) 21 (8%) 14 (5%) 11 (4%) 9 (3%) 7 (2%) 6 (2%) 6 (2%) 5 (2%) 3 (1%) 3 (1%) 2 (1%) 2 (1%) 1 (1%) *From Children's Book Council of Australia "Notable Texts -- Older Child", 1996-1998. Eating disorder (from All of me, p. 68) "You said something yesterday about how to fool them. How?" she asked Sharon. "They check everything." "Oh, you can't do it here. When you get home you can. See, you just buy laxatives at the supermarket or the chemist. Then you take a handful before you eat. So you can eat, see, but the food just goes straight through you and you get gastric and you don't put on weight! It works just fine. "Obsessive compulsive disorder (from Checkers, p. 40) Daniel . . . actually laughs at the weird stuff he does, but he can't stop himself doing it. One of his obsessions is with cleanliness. He spends four, five, six hours a day in the shower . . . He spends so much time in the shower he gets all pink and wrinkly . . . He won't go into a new room until he's touched five different types of wood. . . . He gets dressed in a certain order . . . Like I say, I don't know how he survives. Mania (from Hothouse flowers, p. 157) Rose was listening . . . while the good doctor talked. "Manic is when your brain makes you feel fantastic. . . . It makes you want to try things and buy things . . . remember . . . ". He'd held up a box of baby rattles in gloriously bright colours that chimed and sang and chirruped when they were moved. Rose had bought two giant boxes of them and charged them to her father. "It's not really you when you behave like that". Schizophrenia (from The killing of mud-eye, p. 158-159) I waded upstream and downstream looking for transistors. . . . Now they have wired up the rocks and cliffs. Now the voices come from here and over there and here and over there again and in the running river and they tell me to die. They go on and on in a terrible jumble of things but most of all they tell me to die. Back to text 2: Sources of help for 132 characters* with mental health problems Peer Parents or other family member Adults (other than parent) Mental health professional General practitioner 86 (65%) 48 (36%) 39 (30%) 38 (29%) 15 (11%) *From Australian Children's Book Council "Notable Texts -- Older Child", 1996-1998. Back to text 3: Teenage characters who suicided* Character Psychiatric profile Means of suicide Jesse in The house on river Terrace Drug and alcohol abuse, personality disorder, depression Jumping over cliff while intoxicated Robyn in Third day, the frost Eating disorder, depression, post-traumatic stress disorder Explosive device, altruistic suicide(?) Michael in Bad behaviour Depression Firearm Bo in Green monkey dreams Psychotic illness, family history of "madness" Jumping in front of train William in Green monkey dreams Major mood/psychotic illness Self-immolation Ragmar in Green monkey dreams Psychotic illness Self-immolation Linton in The killing of mud-eye Schizophrenia Hanging Larceny in Care factor zero Psychotic illness, drug and alcohol abuse Jumping from balcony Ella in Shade's children No diagnosis Explosion (altruistic motive) Drum in Shade's children No diagnosis Explosion (altruistic motive) * From Children's Book Council of Australia "Notable Texts -- Older Child", 1996-1998. Back to text

Kathleen M Bokey · Garry Walter · Joseph M Rey

Medicine and the Community Healthcare on the Internet Buyers beware Peter M Yellowlees MJA 2000; 173: 629-630 The World Wide Web is becoming a new medium of medical practice. Access to misinformation - Internet addiction - The practice of skullduggery - References - Authors' details - - More articles on Psychiatry Around the world books and other media are focusing increasingly on aspects of healthcare on the Internet.1 A whole series of new jargon terms are evolving, such as "B2B" (Business to Business), "B2C" (Business to Consumer), "D2D" (Doctor to Doctor) and "D2C" (Doctor to Consumer/Patient). While these terms seems to derive more from the business world than the medical, the two worlds are becoming increasingly intertwined. Doctors are more familiar, through their training, with the derivation of other new terms such as "cyberchondria", "cybersex", "technophobia" and "Internet addiction disorders". As a clinician and researcher who is interested in the exciting possibilities of Internet healthcare, I have been encouraging patients to use the Internet to access health information for some years, and also to communicate with me, if they wish, by email. Several patients have effectively self-referred themselves to me, via their general practitioners, after reading my curriculum vitae, which is posted on a website at the University of Queensland (www.coh.uq.edu.au). I also encourage patients to download information about their disorders from the Internet to discuss with me or other doctors or healthcare professionals who might be treating them. I keep a list of what I consider to be good sites on the Web that I can hand out to patients who wish to do research themselves, and who at least want a reasonable start in finding good-quality information from reliable sites. In future, with the increasing prevalence of published e-books in particular, patients will be able to learn how to do structured searches that make it more likely that they will get good-quality health information from the Internet.2 I am confident that the Internet, and in particular the much faster Internet2 that will be with us within two or three years,3 will have a positive overall effect on the way we treat our patients and the way they manage themselves. It is, however, crucial to retain a critical view of any new approaches in healthcare, and to evaluate them carefully, as it is becoming clear that there are some quite marked "side effects" to the Internet. Access to misinformation Patients do need to understand the importance of finding both reliable and valid information,4 and I believe that doctors will increasingly need high level skills in information analysis as a core medical competence. Unfortunately, at present, patients too often gain health information from chat rooms and discussion groups, and this is frequently either wrong or inappropriate. Just as there have been well publicised cases of individuals altering stock market values on the NASDAQ (the American National Association of Security Dealers Automated Quotation system) by aggressively presenting themselves in discussion groups, so cases are arising of cults, religious or otherwise, and other unusual organisations, trying to influence people through misinformation. Patients may heed this information and buy the wrong products or services. Similarly, many health sites promote the sales of unproven treatments, or may in fact be entirely bogus, intended as satire or designed to steer people towards pornographic sales and marketing situations, or the like. Patients are increasingly sending emails to sites that offer medical advice, purported to be from licensed medical practitioners, or seeking consultations by email. It is obviously vitally important that patients know who exactly is the doctor that they are emailing, and I would personally strongly advise against any patients receiving information from an anonymous doctor. As a brief test of potential quality of health "advice" on the Internet, I recently asked a question at a major commercial American health site about the ideal treatment for depression. I received three single-sentence replies from an individual identified only by a number and which were completely contradictory, informing me I should (a) see a psychiatrist, (b) always engage in psychotherapy, and (c) consider medications, without any further details. I believe I would have received a better reply from a women's magazine agony aunt. Some clinically sensible and ethically focused Internet healthcare sites are beginning to emerge. Perhaps the most well known is NHS Direct,5 in the United Kingdom, where symptom-driven decision trees (effectively patient decision-support systems) are backed up by a nursing telephone service which allows symptomatic patients to be triaged and to select either self-care, general practice or hospital treatment options. In Australasia the most comprehensive email consultation site is doctorglobal.com,6 with which I am commercially involved. Patients who access Doctor Global consult a named doctor, whose photograph and biography appear on the site, whose work is audited by a clinical advisory board and who has gone through a formal accreditation process before being allowed to practise through the site. At the moment, mainly because of medicolegal fears and a more restrictive clinical culture, there is no equivalent broad healthcare website in the United States providing real electronic clinical consultations. Internet addiction The concept of Internet addiction disorder7,8 has been around for some years, but cases of patients so affected are becoming increasingly prevalent, and I have treated several (Case 1). Internet addiction disorder is so well described on the Internet that it is even possible to receive treatment online.9 This seems a bit like going to the pub for a few drinks to try to cure one's alcohol dependence, and isn't something that I would instantaneously recommend. Cyberchondria is a syndrome closely related to Internet addiction disorder that is also becoming increasingly common, and which occurs in anxious or hypochondriacal patients who start spending too much time chasing around the Web searching for information which may make them more anxious (Case 2).10 I can see no reason to define cyberchondria as a new form of psychiatric disorder, as it is simply a modern-day approach taken by those hypochondriacal patients who in the past have tended to read too many medical dictionaries. The practice of skullduggery Like it or not, our world will always contain some dreadful people who prey on others, and who will now use the Internet as their chosen access route to victims.11 At least one man has already been imprisoned for "stalking" his ex-girlfriend on the Internet by publicising her name and contact details as someone who prostituted herself for clients wishing to have sadomasochistic sex. There are examples of men who cross-dress on the Internet pretending to be women, and then having steamy cyber-relationships with other men (a seemingly fairly common danger of Internet love affairs), and many instances of paedophiles joining chat rooms to try to meet adolescents. As long as we are aware of these sorts of side effects, or dangers, we can make sure that patients are appropriately warned. Whatever we may think personally of the Internet -- and I am an obvious enthusiast -- it is inevitable that patients will increasingly use it both to find information about their disorders, and to communicate with doctors. There are now several publications that promote the sensible use of the Internet in healthcare and which propose guidelines for medical activities, in particular email use, on the Web.12,13 These should certainly be reviewed by all doctors who intend now, or in the future, to practise, at least in part, in this manner. References Slack W. Cybermedicine. San Francisco: Jossey-Bass; 1997. Yellowlees P. Your guide to e-health. Third millennium medicine on the Internet. Brisbane: University of Queensland Press, 2000 [eBook available from http://www.uqp.uq.edu.au]. Accessed 27 October 2000. About Internet2. <http://www.internet2.edu/html/about.html> Accessed 27 October 2000. Yellowlees PM, Brooks P. Health online: the future isn't what it used to be. Med J Aust 1999; 171: 522-525. NHS Direct. <http://www.nhsdirect.nhs.uk> Accessed 27 October 2000. Doctor Global. <http://www.doctorglobal.com> Accessed 27 October 2000. Young K. Caught in the net: how to recognise the signs of Internet addiction. New York: J Wiley & Sons; 1998. Yellowlees PM. E-therapy: a guide to mental health in cyberspace. [eBook available from http://www.mightywords.com]. Accessed 27 October 2000. Center for On-line Addiction. <http://www.netaddiction.com> Accessed 27 October 2000. Brosnan M. Technophobia: the psychological impact of information technology. London: Routledge, 1998. Gwinnell G. Online seductions: Falling in love with strangers on the Internet. New York: Kodansha Press; 1998. Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. J Am Med Inform Assoc 1998; 5: 104-111. Spielberg AR. On call and online: sociocultural, legal and ethical implications of email for the patient-physician relationship. JAMA 1998; 280: 1353-1359. Authors' details Department of Psychiatry, Faculty of Health Sciences, University of Queensland, Brisbane, QLD. Peter M Yellowlees, MD, FRANZCP, Head, and Director, Centre for Online Health. Reprints will not be available from the author. Correspondence: Professor P M Yellowlees, Department of Psychiatry, University of Queensland, K Floor, Mental Health Centre, Royal Brisbane Hospital, Herston, QLD 4029. P. YellowleesATmailbox.uq.edu.au Make a comment Case 1: Internet addiction disorder Mr A was a 25-year-old, highly intelligent university student undertaking a health sciences course. At the age of 22 he had his first bout of severe depression, and was soon diagnosed with a bipolar disorder after a manic episode. This young man also had a very obsessional personality style and started spending many hours every day searching the Internet for information about the biology and treatment of bipolar disorder, sitting up all night and sometimes spending as much as 16 to 18 hours a day on his searches. His inappropriate use of the Internet took over his life and made it impossible for him to continue with his studies, and eventually became a greater cause of disability than his original bipolar disorder. He was successfully "withdrawn" from the Internet by agreeing to move back home to live with his parents, who did not have an Internet connection, and discontinued his university studies for some months while he received treatment for his primary psychiatric disorder. Back to text Case 2: Cyberchondria Mr B was a 28-year-old single man with a five-year history of somatisation disorder. He became fascinated by the Internet, particularly by support groups for people with his type of disorder, and started to spend large amounts of time communicating with other sufferers on the Web. He became obsessed with the need to find a "biological cure" for his disorder and communicated regularly with researchers around the world involved in this area. Treatment consisted of the conventional treatment for his psychiatric disorder, particularly encouragement to use non-biological approaches, as well as reducing the amount of time he spent on the Internet. He was able to do this and, in a very positive postscript to his treatment, while on holiday overseas he organised to see one of the psychiatric researchers he had come to know on the Internet for a second opinion. I organised this appointment for him and he was pleased with the outcome. Back to text

Peter M Yellowlees

Christmas Offerings De-skilling me softly: a cautionary ballad MJA 2000; 173: 661 To the tune of "My darling Clementine" Once were doctors, we were doctors practising psychiatry, Many long years spent preparing for this complex specialty. Yet vital skills were clearly lacking post-FRANZCP; Some sought more training and supervision in intensive therapy. This for patients that politicians crudely scorned as "worried well", Though some outwardly successful, their private lives an empty hell. Chorus: Oh psychiatry, dear psychiatry, shame what they have done to thee, Evidence-based undertreatment, protocols for you and me. Abe's1 parents both were war survivors for whom a hug felt like a shark, His wife and colleagues fear his rages; his son swaps needles in the park. Sue's1 father scorned her, uncle raped her, mother feared her infant cry, A PhD, gym and many lovers, constant achievement keep Sue alive. My old consultant taught his interns such patients need skilled care for years, Perverse enactments, somatic crises, destructive mood swings, holiday fears. (Chorus) College leaders in New Zealand mock this profligate waste of time, College leaders in Australia want us to toe the Kiwi line. With SBE,2 McKay3 and Tolkien,4 all government consultancies Farewell depth of understanding, hail the glib technocracy. Costed guidelines, sector funding, managers loom at the door, Now are doctors health providers, integrated to the core. (Chorus) Psychologists and health diplomates give CBT5 and strategies, GPs prescribe medication and short-term "cures" for anxiety. The New Psychiatrist does brief assessments then supervises from afar, Coordinating treatment modules, schizoid omniscience so bizarre. Short-term treatments deemed "world's best practice", just deliver and you'll score Academical promotion, fancy titles, gongs galore. (Chorus) Group therapy died when they closed outpatients, CL's6 been slashed, will it survive? Complex skills lost or devalued by economic triage, political guile. Dollars galore for administrators, publicity, consultancies, Those least skilled in treating patients design and guide health policy. Though Abe and Sue need long-term treatment, such skills dismissed as "luxuries", Health-strategy oligarchy's newspeak is "evidence", "community". (Chorus) Soul-death, despair, basic trust, self-hatred, these DSM7 cannot define, Only thoughtful understanding of patients' "I" and "you" through time. But Canberra has plans and timelines at whose behest ambitions soar, Though psychic pain crosses generations, demo projects this truth ignore. Dare you oppose their naive hubris they'll dismiss it as elitist greed, Those bureaucrats and academics who've never heard a psyche bleed. (Chorus) With platitudes and stats aplenty they'll prove how great a job they've done, Then off they'll go to some bigger office or a salary package in the sun. High talk of ethics, academic standards, yet which professor rose to protest When these were crudely violated, 3198 was the first test. How my heart is sick with anger, for Abe and Sue have been betrayed, Bio-psycho-social wisdom has become a glib charade. (Chorus) From Maimonides, Osler and Bleuler, to Engel and Oliver Sacks, To know the patient as a person guided wise doctors more than stats. Interns now learn from their elders treatment's just a recipe, Don't spend too much time with patients, call them "clients" and you'll see That there's no need to understand what shapes a life from womb to grave, The less explored their loves and traumas, faster the throughput, more money saved. (Chorus) Once were doctors, we were doctors practising psychiatry, Now the tame, generic workforce of the health bureaucracy. Understanding loss and illness or mind-body takes too much time, Sacrificed to symptom checklists, rating scales and stats so blind. Acronyms and showcase projects, Australia's mental health strategy, Dictated by the performance values of global markets ideology. (Chorus) Edwin Harari Psychiatrist North Carlton, VIC "Abe" and "Sue" are false names of actual patients. Solomon, Buckingham and Epstein report (1993), subtitled "A consultancy report for the Mental Health Workforce Committee on medical workforce financing arrangements". McKay report (1996), "Issues and options. Optimum supply and effective use of psychiatrists; a project for the National Mental Health Strategy". Tolkien report (1994), "A model for matching the available workforce with the demands for services". Cognitive behaviour therapy. Consultation-liaison psychiatry. Diagnostic and Statistical Manual. Item 319, introduced in the Medical Benefits Schedule of fees in November 1996, limiting the rebate for psychiatric treatment.

Edwin Harari

Christmas Offerings MJA 2000; 173: 662-663 Introduction The proprietary names of new drugs not only lack imagination but, via the mindless assemblage of concatenated consonants, resemble the loser's board in a last round of Scrabble. Disenfranchised consonants, particularly Xs, Zs and Qs, appear in drug names with as much logic as their appearance in a cup of alphabet soup (albeit my second favourite after soup de jour). While prescribing doctors require no scientific proof that there has been a secular change to idioglossia, I explore this proposition scientifically, using the proprietary names of two classes of psychotropic drugs. Methods The database for my study was the list of oral antipsychotic and antidepressant drugs in the 1998 MIMS Annual.1 The proprietary names for all currently listed "older" and "newer" (ie, pre- and post-1990) drugs were examined for the relative frequency of vowels and consonants. (See Box for names compared.) Results Quantitative analyses I surveyed a total of 33 psychotropic drug names, but was unable to demonstrate a difference between "old" and "new" drugs by the chi-squared test (chi-squared = 0.008; df = 1; NS). It was time for a post hoc ad hoc ergo propter hoc hypothesis, viz., that there had been an increase in specific letters, such as V, I and Z. The latter (ie letter) analysis predictably revealed shifts, with the most notable changes being -- for the consonants -- a distinct increase in the representation of Cs (from 2% of the letter distribution in the "old" drugs to 5% in the "new" drugs) and, even more distinctly, increases in Xs (from 0 to 7%) and Zs (from 1% to 6%). For the vowels, Is had decreased from 6% to 1%, while Os had increased from 6% to 13%. I undertook a validity check by making a comparison with the distribution of these letters in Scrabble, where Cs = 2%, Xs = 1%, Zs = 1%, Is = 9% and Os = 8%. Thus, the older drugs had a distribution of those letters in accord with our Scrabble control, while their current distribution was quite out of kilter and thus, QED, seriously discordant with the English language, the games we play, the rules of sport and the Olympic ideal. Qualitative analyses I read the lists to all hospital support staff cleaning the doctors' corridor in spring 2000, with each (n = 2) asked to assess each drug name for resonance, melodiousness, assonance and assiness. Against expectation, they unanimously rated the "newer" drugs far higher. Post hoc analysis determined, however, that both were non-English-speaking, but they did express thanks for trying to talk to them in their own language. I then undertook a second study involving all unit registrars who had expressed (at their appointment interview) a keen interest in undertaking research if offered a position. These 23 registrars were similarly required to rate each drug set on the evaluative parameters. All three respondents rated the older psychotropic drug names as more attractive, with one noting that it was not the price -- but the excess of Xs -- that prevented her prescribing the new atypical antipsychotics, so rejecting the "null" hypothesis that "nothing succeeds like XS". Discussion My study demonstrated an increased use of discordant consonants in proprietary names for two psychotropic drug classes. Z is climbing up the alphabet, but its appeal is questionable, as any parent knows who has asked their child to eat a zucchini. The only Z that ever had any style belonged to the graffiti artist Zorro. But Zs for drug names? Perhaps a hypnotic? Zizzzz, or even Zizzzzzzzzzzzzzz. X has risen from near x-tinction, C is coming in, and O is on the rise as a leavening vowel. Current analyses allow the confident prediction that "XOCZ" will be the proprietary name to be launched next. But do we want the alphabet-ordered also-rans (the Xs, Ys and Zs) to run? Why not capture the beauty of the English language? How truly evocative then are the names for the new "atypical antipsychotic" drugs -- Clopixol, Clozaril, Risperdal and Zyprexa, which my computer spell-check renders as Claypool, Closure, Dispersal and Pyrexia. Surely, they lack the majestic evocation of the older drug names. Again my spell-check assists us -- Largactil "reframed" as "LargeAction", Anatensol as "Intensely", Navane as "Nirvana", Stelazine as "Stabilize", Anafranil as "Unafraid", Endep as "Endow" and Surmontil as "Surmountable" provide a subliminal message of hope, action and therapeutic success, like the lovely and pleasing word "placebo". Are the "new drug names" not building to treatment resistance? What's in a name? In the old days, lots. The alcohol deterrent drug Antabuse evocatively told us a story. It was anti-abusers and self-abusing, belonged to the right (ie left) end of the dictionary in being close to AA (so assisting prescribing doctors), and was nicely balanced in its mix of vowels and consonants. A fine achievement for a drug that made you vomit. Another example is the hypnotic, Halcion. Only when there was no wind and the waters were quiet and tranquil could the albatross take off, the so-called "halcyon days". Thus was the prescriber encouraged to prescribe Halcion for tranquillity, for wind and for plane phobia. But now we have drugs like Xanax (presumably a computer-driven palindrome). What next? A drug labelled ZZQQZZ? You wouldn't even accept that as a number plate. The rumbelow conjunction of compounding consonants presents the medical profession with a number of deceptively important problems. First, the written equivalent of "Chinese whispers". A handwritten script for Zantac may emerge, after some pharmacist confusion, as one for Zactin, or Zestril, or Zarontin. Second, we are now ankle deep in xenoglossia -- being required to understand a language we have never learned. Third, where is the placebo effect in offering a patient a new wonder drug named "Prozolox"? Fourthly, where is the appeal? What respectable canine, after years of eating affiliative, affirmative and affectionately labelled "Pal", would take a chunk out of a tin labelled Zbra or Quale? What are the marketing and advertising sections of the pharmaceutical companies doing? We know that recognition and verbal learning relate to the pleasantness and association value of words,2 with such research empirically establishing the high appeal of words like "caress", "Christmas", "comfort", "delight", "flower", "kindness", "pleasure" and "sunshine". Presuming that those companies wish us to use their product, are their marketing divisions out to lunch on this issue? If so, and before they get back from lunch, should we in the medical profession not show some leadership? Perhaps to get the ball rolling, I could offer some suggestions for the next "Drugs R Us" company that appreciates gratuitous advice. A search for appealing words can take many roads. James Joyce held that "cuspidor" was the most beautiful word in the English language, but, despite his genius, his inability to call a spittoon a spittoon confirms that beauty is in the eye of the beholder. We need, then, an author "of the people", someone who could sit comfortably with the "man on the Clapham bus". Barbara Cartland! Dame Barbara once listed the 12 "most beautiful" words in the English language as ecstasy, love, God, divine, pure, innocent, rapture, moonlight, shimmering, radiance, magical and mysterious. What an evocative list, and not a Q, X or Z to be seen! But, returning to psychiatry, we need psychotropic drug names that invoke the domain and the suggested impact, increase compliance, have a placebo component and make us all feel good. Cartland provides a semantic base for a thesaurus search. For an antidepressant, recognising that others have stolen Cartland's suggestion of "ecstasy", why not "Cloud9" or "BlissPill"? For anti-manic drugs, why not "Glidedown" or "Asymptote", and perhaps "Astoic", "Flatline" or "Earthbound" for a mood stabiliser. For antipsychotics, if not "SangFroid" (which might be misconstrued as "Sane Freud"), why not "Equanimity", or "Anodine" or "Chillout"? For an anxiolytic, "C-Rene", "Care-less" or "Earthed", perhaps. Of course, such concerns also hold for other classes of drugs. One of the most successful drug releases in the past decade was that of Viagra. But, as a treatment for erectile dysfunction, it has quite the wrong connotation. Viagra rhymes with Niagara. As in Niagara Falls. An unfortunate choice. How about "PeckUp" (note the neat diffusion into "Pickup" -- suggesting both a tonic and the means of acquiring a partner for the night). It would have been a real sales winner if the naming had been more prescient. I rest my case. References MIMS Annual. Sydney: MIMS Australia, 1998. Silverstein A, Dienstbier RA. Rated pleasantness and association value of 101 English nouns. J Verbal Learning Verbal Behav 1968; 7: 81-86. Authors' details School of Psychiatry, University of New South Wales, Sydney, NSW. Gordon B Parker, Professor, and Head. Reprints will not be available from the author. Correspondence: Professor G B Parker, School of Psychiatry, Prince of Wales Hospital, High Street, Randwick, NSW 2031. g.parkerATunsw.edu.au We appreciate your comments. Psychotropic drug names compared Oral antipsychotic drugs: Old: Anatensol, Largactil, Melleril, Navane, Neulactil, Orap, Serenace, Sparine, Stelazine New: Clopixol, Clozaril, Risperdal, Zyprexa Oral antidepressant drugs: Old: Allegron, Anafranil, Deptran, Endep, Nardil, Parnate, Pertofran, Prothiaden, Surmontil, Tofranil, Tolvon, Tryptanol New: Aropax, Aurorix, Cipramil, Efexor, Luvox, Prozac, Serzone, Zoloft Return to text

Gordon B Parker

Personal Perspective Depression: dispirited or spiritually deprived? Craig S Hassed MJA 2000; 173: 545-547 The 20th century has seen a widespread decline in mental health in Western society. One important factor may be the lack of meaning and spiritual fulfilment that is part of our increasingly secular and materialistic society. In medical education and practice, religious issues are often marginalised or "pathologised", despite consistent evidence from the literature of the protective effect of "religiosity" or "spirituality" on mental and physical health. Spirituality and religiosity - Spirituality and mental health - Relevance to clinical medicine - References - Authors' details - - More articles on General practice and primary care The increasing incidence of mental illness, especially depression, in the 20th century1,2probably reflects both increased recognition and an absolute rise in prevalence. World Health Organization figures released in 1996 revealed that depression was expected to be a leading contributor to the burden of disease in the 21st century.1 Recent figures suggesting that depression is the most important component of the disability burden in Australia would tend to support that prediction.3 Approximately 20% of adults are expected to have a major depressive episode at some time in their lives, and 16% of people aged over 65 years have persistent symptoms.4 Stress levels, whether real or perceived, among people living a "Western" lifestyle have risen by approximately 45% over the past 30 years.5 Youth suicide rates are particularly alarming,2 and one Australian study revealed that 20% of 15-24-year-olds had contemplated suicide in the preceding fortnight.6 In keeping with our predominant "illness model" we are more often concerned with risk factors for depression, youth suicide, substance misuse and violence than the less-publicised protective factors, which include "connectedness" and "spirituality".7 Spirituality and religiosity The terms used most commonly in the medical literature are "religious commitment" or "religiosity", referring to the "participation in or endorsement of practices, beliefs, attitudes, or sentiments that are associated with an organised community of faith".8 One can be "extrinsically religious" in adopting the trappings, religious behaviours and attitudes, but if one holds a strong inner belief then one is "intrinsically religious". "Spirituality" generally refers to concepts that are much harder to define and measure, such as "personal views and behaviours that express a sense of relatedness to the transcendental dimension or to something greater than the self".9 Spirituality can encompass belief in a higher being, the search for meaning, and a sense of purpose and connectedness. Obviously, there can be a wide overlap between religiosity and spirituality. Spirituality and mental health For many years science and ethics have tended to become increasingly secular, thus neglecting or "pathologising" spiritual issues. Sigmund Freud, for example, saw religion as "a universal obsessional neurosis", and described the mystical experience of unity as a "regression to primary narcissism".10 Carl Jung, on the other hand, saw the search for spiritual enlightenment as the central, but often ignored, core of human experience. He described the lack of meaning in life as a "soul-sickness" whose full import our age had not yet begun to comprehend. This was one of the main reasons why these two pioneers of psychology parted company. The observation that Freudian psychoanalysis is probably associated with negative effects on people's health may, however, throw into question Freud's understanding of human nature.11 Nevertheless, many of Freud's attitudes have deeply etched their way into psychiatric theory and practice: Mainstream psychiatry, in its theory, research and practice, as well as its diagnostic classification system, has tended to either ignore or pathologise the religious and spiritual issues that clients bring into treatment.12 The negative attitude towards religiosity in many quarters of contemporary medicine and psychiatry is out of keeping with the weight of evidence which clearly shows that it has a beneficial effect on mental and physical health.8 The findings are consistent across prospective and retrospective studies, whether or not they control for other lifestyle and socioeconomic factors, and whether they examine prevention of illness, coping with illness, or recovery (see Box). Many studies have linked a lack of religiosity to depression. Religious commitment is associated with a reduced incidence of depression13 and a quicker recovery from depressive illness for the elderly.15 Two separate reviews of the literature have supported this: those with high levels of "religious involvement", "religious salience" and "intrinsic religious motivation" were at reduced risk,14 and religious commitment was inversely related to suicide risk in 13 of 16 studies reviewed.13 One study showed a fourfold increased risk of suicide for non-churchgoers compared with regular attenders,22 and no study has shown an increased risk of suicide among churchgoers. Other data suggest that religiosity protects against drug and alcohol misuse, one of the most commonly used and maladaptive ways for dealing with depression. One study showed that 89% of alcoholics (but only 20% of the control group) had lost interest in religious issues during their teenage years.20 In another study it was found that doctors (who are a high-risk group for substance misuse) were less likely to develop an alcohol problem in later life if they had had a religious commitment while in medical school.21 Religious affiliation, even if accompanied by alcohol misuse, seemed to protect against heavy use or the associated extreme clinical and social consequences. The reasons why people with a sense of religious commitment are less likely to become depressed may include a feeling of social connectedness, exposure to messages about healthy living, or perhaps the reduced exposure to drug-taking behaviour. However, studies controlling for these factors have still found religiosity to be independently protective. So there may be other reasons, such as the comfort that comes from believing in a benevolent and caring God, the view that justice always prevails in the end, or that adverse events always have a meaning and a message. Such attitudes would buffer enormously against the ill-effects of life stresses and the depression that often follows. The important role that mental health plays in the development and progression of physical illness goes part way to explaining why religious commitment is associated with reduced risk of conditions such as hypertension, heart disease and cancer.26,27,29,30 A population study over nine years showed that all-cause mortality was significantly reduced and life expectancy increased (to 82 years v. 75 years) for regular churchgoers. The findings were not explainable by the accepted lifestyle and social variables,24 and were consistent with other data.25 Unfortunately, examples of the negative effects of religion are generally more newsworthy in the medical and general press than the positive ones. For example, in a review of a series of preventable paediatric deaths, it was found that some parents' religious views played an important part in delaying the seeking of medical care.31 Sometimes this negative press is for a good reason, but this is not an argument against spirituality, but rather against blind faith unsupported by reason. Relevance to clinical medicine The rise in mental illness seems paradoxical in view of our unprecedented levels of physical health, relative affluence, technological advancement and social freedom. Also paradoxical is the fact that suicide rates generally fall in times of adversity, such as during major wars.2 Although one doesn't generally court adversity, it can teach us something about ourselves if we pay attention to the lesson. As William Shakespeare so aptly put it: This is no flattery: these are counsellors That feelingly persuade me what I am. Sweet are the uses of adversity, Which, like the toad, ugly and venomous, Wears yet a precious jewel in his head. (As You Like It; Act 2, Scene 1) Gauging a patient's spiritual awareness, at very least, should form an important part of a thorough history. One can not really be said to know another person without an understanding of his or her responses to the most important questions that human beings ask themselves. Without this knowledge, treatment of especially sensitive conditions like depression or terminal illness will take place in the dark. Broaching philosophical and spiritual issues requires considerable sensitivity, cultural tolerance and the ability to be non-dogmatic. When done effectively, it can facilitate counselling and psychotherapy enormously,32 but each doctor and patient needs to explore these issues in his or her own way. Even if we are not religious ourselves, we should invite discussion in a respectful way, taking care not to push a line of thought, whether it be religious or secular. Religious sensitivities and biases, like political ones, can make discussion divisive and difficult. More in-depth questions about spirituality and religion should probably be referred to culturally appropriate "non-medical experts". At present, despite the large body of evidence on the connection between religiosity and health, little if any reference is made to this issue in medical education and practice. If a physical factor was found to be of as much importance to health it would certainly not be ignored, but then science is always most comfortable with what it can most easily measure. It is reasonable for medical students and practitioners to be aware of this field of evidence so that they can provide a more holistic approach to information giving, psychotherapy and treatment. Unfortunately, a perceived lack of holism is a central reason why many people look outside the biomedical model for their healthcare.33 For many people, especially the young, the search for meaning is becoming a rarer pursuit in the bustle of modern material life. People pursue meaning and fulfilment by as many paths as there are people, but perhaps we often search in places which can not provide it. If the search is misdirected, disappointment, stress, depression and social conflict may be inevitable sequelae of such existential pain. Perhaps these issues will become increasingly relevant for future generations, for whom the lack of meaning will come at an increasing cost. Maybe a balanced form of spirituality which is not scientifically naive nor culturally intolerant may be a prerequisite for the mental and material wellbeing of an all too often dispirited community and healing profession. "Science without religion is lame, religion without science is blind" (Albert Einstein).34 References Murray C, Lopez A. The global burden of disease. Cambridge, Massachusetts: Harvard School of Public Health, on behalf of the World Health Organization and the World Bank, 1996. Cantor C, Neulinger K, De Leo D. Australian suicide trends 1964-1997: youth and beyond? Med J Aust 1999; 171: 137-141. Mathers CD, Vos ET, Stevenson CE, Begg SJ. The Australian Burden of Disease Study: measuring the loss of health from diseases, injuries and risk factors. Med J Aust 2000; 172: 592-596. Rey J. The Epidemiological Catchment Area (ECA) study: implications for Australia. Med J Aust 1992; 156: 200-203. Miller M, Rahe R. Life changes scaling for the 1990s. J Psychosom Res 1997; 43: 279-292. McKelvey R, Davies L, Pfaff J, et al. Psychological distress and suicidal ideation among 15-24 year olds presenting to a general practice: a pilot study. Aust N Z J Psychiatry 1998; 32: 344-348. Resnick M, Bearman P, Blum R, et al. Protecting adolescents from harm: findings from the National Longitudinal Study on Adolescent Health. JAMA 1997; 278: 823-832. Matthews D, McCullough M, Larson D, et al. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med 1998; 7: 118-124. Reed P. Spirituality and wellbeing in terminally ill hospitalised patients. Res Nurs Health 1987; 9: 35-41. Freud S. Civilisation and its discontents. In: Strachey J, editor. The standard edition of the complete psychological works of Sigmund Freud. Vol. 20. London: Hogarth, 1959. Grossarth-Maticek R, Eysenck H. Prophylactic effects of psychoanalysis on cancer-prone and coronary heart disease-prone probands, as compared with control groups and behaviour therapy groups. J Behav Ther Exp Psychiatry 1990; 21: 91-99. Lukoff D, Fu FG, Turner R. Cultural considerations in the assessment and treatment of religious and spiritual problems. Psychiatr Clin North Am 1995; 18(3): 467-485. Gartner J, Larson D, Allen G. Religious commitment and mental health: a review of the empirical literature. J Psychol Theol 1991; 19: 6-25. McCullough M, Larson D. Religion and depression: a review of the literature. Twin Research 1999; 2(2): 126-136. Koenig H, George L, Peterson B. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry 1998; 155: 536-542. Oxman T, Freeman D, Manheimer E. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosom Med 1995; 57: 5-15. Saudia TL, Kinney MR, Brown KC, et al. Health locus of control and helpfulness of prayer. Heart Lung 1991; 20: 60-66. Koenig H, Cohen H, Blazer D, et al. Religious coping and depression in elderly, hospitalised medically-ill men. Am J Psychiatry 1992; 149: 1693-1700. Williams D, Larson D, Buckler R, et al. Religion and psychological distress in a community sample. Soc Sci Med 1991; 32: 1257-1262. Larson D, Wilson W. The religious life of alcoholics. South Med J 1980; 73: 723-727. Moore R, Mead L, Pearson T. Youthful precursors of alcohol abuse in physicians. Am J Med 1990; 88: 332-336. Comstock G, Partridge K. Church attendance and health. J Chronic Dis 1972; 25: 665-672. Propst LR, Ostrom R, Watkins P, et al. Comparative efficacy of religious and nonreligious cognitive-behavioral therapy for the treatment of clinical depression in religious individuals. J Consult Clin Psychol 1992; 60: 94-103. Hummer R, Rogers R, Nam C, et al. Religious involvement and U. S. adult mortality. Demography 1999; 36: 273-285. Clark K, Friedman H, Martin L. A longitudinal study of religiosity and mortality risk. Journal of Health Psychology 1999; 4: 381-391. Fraser G, Sharlik D. Risk factors for all-cause and coronary heart disease mortality in the oldest old: the Adventist Health Study. Arch Intern Med 1997; 157: 2249-2258. Kune G, Kune S, Watson L. Perceived religiousness is protective for colorectal cancer: data from the Melbourne Colorectal Cancer Study. J R Soc Med 1993; 86: 645-647. Larson DB, Koenig HG, Kaplan BH, et al. The impact of religion on men's blood pressure. J Religion Health 1989; 28: 265-278. Levin J, Vanderpool H. Is frequent religious attendance really conducive to better health? Toward an epidemiology of religion. Soc Sci Med 1987; 24: 589-600. Craigie F, Larson D, Liu I. References to religion in the Journal of Family Practice: dimensions and valency of spirituality. J Fam Pract 1990; 30: 477-480. Asser S, Swan R. Child fatalities from religion motivated medical neglect. Pediatrics 1998; 101: 625-629. Hassed C. Western psychology meets Eastern philosophy. Aust Fam Physician 1999; 28: 1057-1058. Astin J. Why patients use alternative medicine: results of a national study. JAMA 1998; 279: 1548-1553. Einstein A. Out of my later years. New York: Philosophical Library, 1950. Authors' details Department of Community Medicine and General Practice, Monash University Craig S Hassed, MB BS, FRACGP, Senior Lecturer. Reprints will not be available from the author. Correspondence: Dr C S Hassed, Department of Community Medicine and General Practice, Monash University, 867 Centre Road, East Bentleigh, VIC 3165. craig.hassedATmed.monash.edu.au Make a comment Apparent relationships between religiosity and health* Mental health Reduced incidence of depression7,8,13,14 Quicker recovery from depression15 Better recovery from major surgery,16with less depression17 Improved coping with disability,18 illness and stress19 Reduced substance misuse, including misuse of alcohol and illicit drugs20,21 Reduced suicide risk in adolescents22 Facilitation of psychotherapy23 Improved coping with serious illness8 Physical health Reduced all-cause mortality24,25 Greater longevity24,25 Reduced incidence of heart disease and hypertension26 Improved recovery from cardiac surgery16 Reduced incidence of and longer survival with cancer27 Modification of physical risk-factors with associated reductions in lifestyle-related illnesses such as emphysema and cirrhosis22,28 * Causal relationships between religiosity and health are sometimes hard to define, although many studies control for other known physical and socioeconomic risk factors. Refining methodology and further research are required to more fully elucidate the relationship. Back to text

Craig S Hassed

Editorial Depressed Australians: should we worry? Prescribing an antidepressant should be one component of a pluralistic approach MJA 2000; 173: 452-453 The "decade of the brain", as the 1990s were designated, accorded psychiatry a place in the sun, with depressive illness an obvious focus because of its magnitude and potential for improved management. Disability and suicide, two of the consequences of depression, command broad community interest. The World Health Organization Global Burden of Disease Study quantified "unipolar depression" as the leading cause and "bipolar disorder" (or manic depressive illness) the sixth leading cause of disability in 1990.1 The Australian Burden of Disease Study also established depression as the top-ranking cause of non-fatal disease burden in Australia.2 Other recent Australian data in effect established that, over one year, 1 in 16 Australian adults would be expected to meet the criteria for clinical depression,3 while indicative international data suggest a 20% lifetime rate.4In 1996, Australia's National Health Priority Area initiative identified mental health as a priority area, and, currently, a draft Depression Action Plan has been released for community consideration. This year, a National Depression Initiative has been set up, with Jeff Kennett, the former Premier of Victoria, as chairman. Both these processes recognise the magnitude of the problem and the need for management strategies, while indirectly contributing powerfully to destigmatisation. In this issue of the Journal, McManus and colleagues 5 report a tripling in antidepressant prescriptions in the 1990s in Australia and most other developed countries, and illustrate the "diffusion of an innovation", clearly in line with the noted explosion of information about depression. In contrast, when antidepressants were discovered in the late 1950s, companies were reluctant to release them commercially, as the market was judged too small.6 Depression then was a disorder virtually confined to asylums, and only later formally defined. The American Psychiatric Association's DSM-III manual introduced "major depression" in 1980, an entity then quantified as dominating psychiatric practice, and highly prevalent in general practice and the community. Minor depressive disorders were defined and, more recently, entities such as "sub-clinical depression" and "sub-syndromal depression" have appeared. These have been shown to be associated with considerable disability and amenable to intervention, and thus postulated as disorders.7 If such trends continue, depression will soon be destigmatised by virtue of a depressive subtype for everyone! Such extensions raise predictable questions. Where should the line be drawn in determining "caseness"? As a consequence of stigma or other factors, were we previously minimising, misinterpreting and missing depression? Or are we now excessively "pathologising" aspects of human distress? When psychiatry emerged from its quaintness in the 1960s by adopting a dominant biological model, the "barons" advocating the new Zeitgeist joined with the pharmaceutical industry to promote depression as a medical disorder, and a singularly effective treatment modality -- antidepressant drugs. New drugs were then marketed to redress both the clinical and profit limitations of the old antidepressants. But let's not be critical of the pharmaceutical industry for doing its job, and instead question whether its advertised message should be echoed by professionals. In essence, the message has three components: depression is a distinct medical condition, best treated by antidepressant drugs; the new drugs are as effective as their predecessors; and the new drugs have few side effects, are well tolerated and safe. Each of these issues is worth examining. First, is depression a distinct medical condition?8 Not so. Depression can be a normal mood state -- brief, self-remitting, and ubiquitous. It also exists as a disease, now commonly termed "melancholia", having negligible spontaneous and placebo response rates, with strong biological origins mandating physical treatments. More problematic is the group of disorders once termed neurotic or reactive depression, representing the heterogeneous residue left after excluding the melancholic disorders. It has no distinct or defining clinical features, and high placebo and spontaneous remission rates. This group is better viewed as comprising "spectrum disorders", whereby people with certain temperament styles (eg, anxious worrying, introverted, volatile, obsessional) are disposed to develop depression as a consequence of their temperament style when facing certain stressors. As these temperament styles reflect extremes of normal personality dimensions, the non-melancholic conditions are themselves dimensional, allowing disorder status and need for intervention to be arbitrarily defined, and, as detailed by McManus and colleagues,5 providing the growth arena for the new antidepressant drugs. Second, how effective are our current antidepressant drugs? For psychotic melancholia,9 psychotherapies have no primary role. An antidepressant drug alone will benefit only a quarter, an antipsychotic drug alone a third, while their combination (as with electroconvulsive therapy) will benefit 80% -- distinctly differing levels of effectiveness.9 For non-psychotic depression, the dissonance between drug efficacy data and clinical observation is perturbing. A recent review considered 150 efficacy studies involving 160 000 patients with major depression, concluding that the newer and older antidepressants were equally efficacious.10 However, clinical effectiveness data suggest that the older antidepressants (ie, the tricyclics and the irreversible monoamine oxidase inhibitors) are more effective for melancholia, while, for non-melancholic depression, the newer antidepressants appear (overall) to be as effective.11 Thus, by "homogenising" depression as an entity, specificity of drug action is submerged, assisting marginalisation of the older (low-profit) antidepressants. Thirdly, how safe, acceptable and tolerable are the newer antidepressants? Drop-out rates due to adverse effects only slightly favour them,12 with an appreciable percentage of patients experiencing side effects, which range from alarming (serotonergic reactions on commencement, discontinuation reactions, drug-drug interactions) to inconvenient. Perhaps the most-conceded benefits are their clear-cut cardiac advantages and their non-lethality when taken in overdose. But how truly beneficial are the newer antidepressants? The selective serotonin reuptake inhibitors (SSRIs) are generally considered to be safe and well tolerated. Rarely conceded, and often unrecognised, is that they have the potential to modify several personality styles that dispose to non-melancholic depression (eg, anxious worrying).13 This gives SSRIs a powerful prophylactic role, strongly underpinning patient and prescriber acceptability. Their anti-worry role is neither trivial nor worthy of inciting "cosmetic psychopharmacology" claims. For many who develop non-melancholic depression, taking an SSRI is associated with a normalising of worry and a lessening of both anxiety and irritability. Real-world problems remain, but are viewed and addressed more normally, and resilience to stressful events is increased. Such properties of the SSRIs are noteworthy and, in light of the prevalence of "at-risk" temperament styles (let alone depression), offer a strong utilitarian argument for the SSRIs and some other new antidepressant classes. Regrettably, current alternatives for managing non-melancholic depression are few, when practice and training issues are considered along with efficiency and effectiveness. Many chant the utility of cognitive behaviour therapy, but we need to be assured that advocacy is not merely "non-drug" voting. Although cognitive behaviour therapy (CBT) has high treatment credibility, King, after reviewing several major trials, argues that CBT has little treatment specificity for depression, is highly demanding of time and requires well-trained therapists.14 The high non-specific remission rate attests to the importance of CBT having non-specific therapeutic ingredients, which, together with the high spontaneous remission rate, argue for wise counselling for those with non-melancholic disorders. Finally, should we worry about increased prescribing? Alone, the growth of any effective treatment should be welcomed. But the new Zeitgeist may encourage doctors to reach for a prescription pad at the first suggestion of "depression", welcoming the time and cost efficiency. Such a narrow approach may meet the doctor's practice needs, but is rarely welcomed by patients. Mental health literacy data reveal that the public rates antidepressant medication poorly and as addictive, issues which need redressing.15 Any prescription of an antidepressant should be one component of a pluralistic approach, with the prescriber appreciating the patient's world and predicaments, and providing counselling to assist the patient to come to terms with depression's manifestations, consequences and "meanings". Gordon B Parker Professor, School of Psychiatry, University of New South Wales Research Director, Mood Disorders Unit, Prince of Wales Hospital, Sydney, NSW World Health Organization and the World Bank. The Global Burden of Disease: summary. Cambridge, Mass: The Harvard School of Public Health, Harvard University Press, 1996. Mathers CD, Vos ET, Stevenson CE, et al. The Australian Burden of Disease Study: measuring the loss of health from diseases, injuries and risk factors. Med J Aust 2000; 172: 592-596. Andrews G, Hall W, Teeson M, et al. National Survey of Mental Health and Wellbeing. Report 2. The Mental Health of Australians. Canberra: Mental Health Branch, Department of Health and Aged Care, 1999. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry 1994; 51: 8-19. McManus P, Mant A, Mitchell PB, et al. Recent trends in the use of antidepressants in Australia, 1990-1998. Med J Aust 2000; 173: 458-461. Healy D. The antidepressant era. Cambridge, Mass: Harvard University Press, 1997. Judd LL, Paulus MP, Wells KB, et al. Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population. Am J Psychiatry 1996; 153: 1411-1417. Parker G. Classifying depression: should paradigms lost be regained? Am J Psychiatry 2000; 157: 1204-1211. Parker G, Roy K, Hadzi-Pavlovic D, et al. Psychotic (delusional) depression: a meta-analysis of physical treatments. J Affect Dis 1992; 24: 17-24. Anderson IM. Selective serotonin reuptake inhibitors versus tricyclic antidepressants: a meta-analysis of efficacy and tolerability. J Affect Dis 2000; 58: 19-36. Parker G, Mitchell O, Wilhelm K, et al. Are the newer antidepressant drugs as effective as established physical treatments? Results from an Australasian clinical panel review. Aust N Z J Psychiatry 1999; 33: 874-881. Mitchell PB. The new antidepressants -- are they worth the cost? Aust Prescriber 1995; 4: 82-84. Andrews W, Parker G, Barret E. The SSRI antidepressants: defining their "other" possible properties. J Affect Dis 1998; 49: 141-144. King R. Evidence-based practice: where is the evidence? The case of cognitive behaviour therapy and depression. Aust Psychol 1998; 33: 83-88. Jorm AF, Korten AE, Jacomb PA et al. Mental health literacy: a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med J Aust 1997; 166: 182-186. Make a comment

Gordon B Parker

Medicine and the Community The perpetrators of domestic violence Sarah E Romans, Marion R Poore and Judy L Martin MJA 2000; 173: 484-488 See Articles 1, 2 and 4 of this series Abstract - Our understanding - Why? - Who? - Problems with research - What can be done? - Issues - Treatment - How effective? - Conclusions - References - Authors' details - - More articles on General practice and primary care

Sarah E Romans · Marion R Poore · Judy L Martin

Editorial Psychotropic drugs and preschoolers With little evidence for the safety and effectiveness of these drugs in the very young, doctors are in a difficult position MJA 2000; 173: 172-173 Disturbingly, recent overseas reports suggest that the prescribing of stimulant, antipsychotic, antidepressant and other psychotropic drugs for very young children is increasing.1,2 Of even greater concern is that a significant number of these children may be given more than one psychotropic drug concurrently.3While no systematic data are available to show whether the same phenomena are occurring in Australia, there are indications that prescribing of psychotropics for preschoolers is not uncommon in this country. A survey of 788 parents whose children were treated with stimulants found that 8% were aged under five years when diagnosed with attention deficit hyperactivity disorder;4 presumably, many were given medication. Preliminary data provided by the Pharmaceutical Services Branch of the New South Wales Department of Health (NSW Health) show that in the past decade stimulant treatment was initiated (an authority was given) in NSW for 5819 children younger than six years: 67 (1%) were aged two and 715 (12%) three. There was a 12-fold increase in the number of preschool children treated with stimulants between 1990 and 1999. There are no Australian data about the use of other psychotropic drugs in this age group, but our clinical experience shows that antidepressants, antipsychotics and clonidine are being used. Reports suggesting an increase in the prescribing of clonidine in preschoolers, often concurrently with stimulants, are appearing. The result is a disturbing number of clonidine poisonings in very young children.5,6 ...medication, rightly or wrongly, has become more common in managing problematic behaviour, even in the very young. It is worrying that psychotropics are being prescribed for preschoolers. Firstly, with few exceptions, in most countries these medications are not approved for use in the very young. Secondly, there are very few controlled data showing whether they are effective in this age group.7 Thirdly, psychiatric diagnoses in preschoolers generally lack validity and reliability. This is because preschool-age children have a limited repertoire of emotions and behaviours and a reduced ability to communicate, which leads to a reliance on parental reports. Further complications are an overlap of symptoms with temperamental characteristics, difficulties in establishing the range of age-appropriate behaviours in the context of differences in maturation, and the fact that children of this age are highly reactive to environmental stressors, family conflict and inadequate parenting. Fourthly, there is little knowledge and considerable apprehension about the long-term effect of psychotropics on the developing brain. Fifthly, there are scarce data about the pharmacokinetic and pharmacodynamic characteristics of these drugs in the very young. Finally, rather than placing the best interests of the child first, some practitioners may react to pressure from preschools, childcare services or parents. For all of these reasons, prescribing psychotropics in preschoolers is of concern. The problem is magnified if the child is reviewed infrequently, as seems the case for many of those taking stimulants.3 A review of 624 children hospitalised for any reason in five European countries showed that over two-thirds had received medications that were not licensed for use in children or "off label" (ie, used for indications or in patient groups other than those approved by the regulatory bodies).8 Thus, the prescribing of psychotropics to preschoolers is part of the world-wide pattern of prescribing drugs for children off label. This situation is the result of most drugs' not having been tested in children, let alone preschoolers. Drugs are studied in adults, and physicians assume they will be effective and safe for the young. However, such an assumption is unwarranted, as the experience with tricyclic antidepressants in the treatment of depression in children has shown.9 That experience also shows that clinicians find it difficult to wait for the evidence and, in its absence, may prescribe medications that are not only ineffective but also potentially hazardous. With society and families undergoing rapid change, physicians are confronted with growing numbers of young children with severe behavioural problems, with many parents who have limited parenting skills and with an increasingly demanding public. This is compounded by overwhelmed and inadequate social and mental health services for young people. It is not surprising that medication, rightly or wrongly, has become more common in managing problematic behaviour, even in the very young. At the same time, there are preschool children who present with severe symptoms and impairment who do not respond to appropriate psychosocial treatments.7,10,11 Depriving them of potentially effective medication (eg, stimulants, for which there is ample evidence of effectiveness in older children) may be unwarranted. Clinicians find themselves in an all-too-familiar predicament: urged to prescribe but having no evidence base for doing so. None the less, sympathy with the physician's predicament does not justify potentially unsafe practices. Education in paediatric psychopharmacology -- made more necessary by the large number of new drugs marketed recently -- and increasing awareness of the range of effective, non-pharmacological interventions available7,10,11 are probably better alternatives for minimising unproven practices than greater control of prescribing. These problems are not new. Many were identified in a 1997 report which emphasised that labelling of medications for children was poor, that liability was transferred to prescribers, that lack of research could deprive children of access (including subsidised access) to effective treatments, and that ethical concerns made it difficult to conduct treatment trials in this age group, thus creating a vicious cycle.12 We wonder whether the recommendations in this report have been implemented with the diligence this matter deserves. For example, are all relevant new drugs which are submitted for registration required to include paediatric indications? (This requirement has already been implemented in the United States.) Have disincentives for research and for registration of medications for use in children been reviewed or removed? The NHMRC needs to make funding of research on the use of drugs in children a priority, and to tackle the difficult ethical issues involved. This is not something other stakeholders, like the pharmaceutical industry, are likely to take on. It is clear that clinicians are not the only ones responsible for the current state of affairs. Joseph M Rey Professor, Department of Psychological Medicine University of Sydney and Director of Child and Adolescent Mental Health Services Northern Sydney Health Garry Walter Clinical Lecturer, Department of Psychological Medicine University of Sydney and Acting Director Central Sydney Child and Adolescent Mental Health Services Philip L Hazell Conjoint Professor of Child and Adolescent Psychiatry University of Newcastle and Director of Child and Youth Mental Health Services, Hunter Mental Health Zito JM, Safer DJ, dosReis S, et al. Trends in the prescribing of psychotropic medications to preschoolers. JAMA 2000; 283: 1025-1030. Minde K. The use of psychotropic medication in preschoolers: some recent developments. Can J Psychiatry 1998; 43: 571-575. Rappley MD, Mullan PB, Alvarez FJ, et al. Diagnosis of attention-deficit/hyperactivity disorder and use of psychotropic medication in very young children. Arch Pediatr Adolesc Med 1999; 153: 1039-1045. Hazell P, McDowell MJ, Walton JM. Management of children prescribed psychostimulant medication for attention deficit hyperactivity disorder in the Hunter region of NSW. Med J Aust 1996; 165: 477-480. Erickson SJ, Duncan A. Clonidine poisoning -- an emerging problem: epidemiology, clinical features, management and preventative strategies. J Paediatr Child Health 1998; 34: 280-282. Kappagoda C, Schell DN, Hanson RM, Hutchins P. Clonidine overdose in childhood: implications of increased prescribing. J Paediatr Child Health 1998; 34: 508-512. Hazell P. Attention deficit hyperactivity disorder in preschool children. Adelaide: The Australian Early Intervention Network for Mental Health in Young People, 2000: 15-28. Conroy S, Choonara I, Impicciatore P, et al. Survey of unlicensed and off label drug use in paediatric wards in European countries. BMJ 2000; 320: 79-82. Hazell P, O'Connell D, Heathcote D, et al. Efficacy of tricyclic drugs in treating child and adolescent depression: a meta-analysis. BMJ 1995; 310: 897-901. Barkley RA, Shelton TL, Crosswait C, et al. Preliminary findings of an early intervention program with aggressive hyperactive children. Ann N Y Acad Sci 1996; 794: 277-289. Sanders MR, Gooley S, Nicholson J. Early intervention in conduct problems in children. Adelaide: The Australian Early Intervention Network for Mental Health in Young People, 2000: 43-50. Australian Drug Evaluation Committee. Report of the working party on the registration of drugs for use in children. Canberra: Australian Drug Evaluation Committee, October 1997. Make a comment

Joseph M Rey · Garry Walter · Phillip L Hazell