Mental health

Peer support initiatives can help health professionals experiencing mental health and wellbeing challenges during the COVID-19 pandemic and beyond

Tahnee L Bridson · Kym Jenkins · Kieran G Allen · Brett M McDermott

The voltaren has kicked in. Back pain has eased

Heather Cameron

The MJA–Lancet Countdown on health and climate change was established in 2017, and produced its first Australian national assessment in 2018 and its first annual update in 2019. It examines indicators across five broad domains: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co‐benefits; economics and finance; and public and political engagement. In the wake of the unprecedented and catastrophic 2019–20 Australian bushfire season, in this special report we present the 2020 update, with a focus on the relationship between health, climate change and bushfires, highlighting indicators that explore these linkages. In an environment of continuing increases in summer maximum temperatures and heatwave intensity, substantial increases in both fire risk and population exposure to bushfires are having an impact on Australia’s health and economy. As a result of the “Black Summer” bushfires, the monthly airborne particulate matter less than 2.5 μm in diameter (PM2.5) concentrations in New South Wales and the Australian Capital Territory in December 2019 were the highest of any month in any state or territory over the period 2000–2019 at 26.0 μg/m3 and 71.6 μg/m3 respectively, and insured economic losses were $2.2 billion. We also found growing awareness of and engagement with the links between health and climate change, with a 50% increase in scientific publications and a doubling of newspaper articles on the topic in Australia in 2019 compared with 2018. However, despite clear and present need, Australia still lacks a nationwide adaptation plan for health. As Australia recovers from the compounded effects of the bushfires and the coronavirus disease 2019 (COVID‐19) pandemic, the health profession has a pivotal role to play. It is uniquely suited to integrate the response to these short term threats with the longer term public health implications of climate change, and to argue for the economic recovery from COVID‐19 to align with and strengthen Australia’s commitments under the Paris Agreement.

Ying Zhang · Paul J Beggs · Alice McGushin · Hilary Bambrick · Stefan Trueck · Ivan C Hanigan · Geoffrey G Morgan · Helen L Berry · Martina K Linnenluecke · Fay H Johnston · Anthony G Capon · Nick Watts

Objective: To assess the demographic, social, and clinical characteristics of young Australians who die by suicide. Design: Retrospective analysis of National Coronial Information System (NCIS) data. Setting, participants: People aged 10–24 years who died by suicide in Australia during 2006–2015. Main outcome measures: Demographic, social, and clinical characteristics of young people who died by suicide; circumstances of death recorded in the NCIS. Results: 3365 young people died of suicide during 2006–2015 (including 2473 boys and men, 73.5%); 1292 people (38.4%) lived in areas of greater socio‐economic disadvantage. Free text reports were included in the NCIS for 3027 people (90%), of whom 1237 (40.9%) had diagnosed mental health disorders and 475 (15.7%) had possible mental health disorders. Alcohol consumption near the time of death was detected in 1015 of 3027 cases (33.5%); histories of self‐harm were recorded in 940 cases (31.1%) and of illicit substance misuse in 852 (28.1%). Adverse life events included history of abuse or neglect (223, 7.4%), suicide of relatives, friends, or acquaintances (202, 6.7%), and financial difficulties (174, 5.8%). Conclusions: Three‐quarters of the young people who died by suicide were boys or young men, and 57% had diagnosed or possible mental health disorders, suggesting that the mental health and wellbeing of young Australians should be a key target for youth suicide prevention. To reduce the number of youth suicides, it is imperative that prevention strategies target the mental health and psychosocial stressors that lead to suicidal crises in young people.

Nicole TM Hill · Katrina Witt · Gowri Rajaram · Patrick D McGorry · Jo Robinson

A public mental health response that includes universal, selective and indicated clinical interventions is needed

Jane RW Fisher · Thach D Tran · Karin Hammarberg · Jayagowri Sastry · Hau Nguyen · Heather Rowe · Sally Popplestone · Ruby Stocker · Claire Stubber · Maggie Kirkman

The pandemic is a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses The coronavirus disease 2019 (COVID‐19) pandemic has been a once‐in‐100‐years event. The scale of the disaster overshadows all others in living memory. Most disasters are focal and time‐limited. This one will span a considerable period of time and the economic impact will last years. This means the mental health effects will be deeper and more sustained than in other disasters. A survey during the first month of the pandemic in Australia assessed the nation's “temperature” early, as reported in this issue of the Journal.1 This survey and other information2,3 confirm that the initial mental health impact has been severe, and worse may be coming. Scientific models predicted that Australia would face a second curve of mental ill health and suicide,4,5 and this has now clearly arrived. We have been willing to turn our society and lives upside down to flatten the COVID‐19 curve. The same commitment is now required to flatten the mental health curve. After acute disasters, most people experience a transitory wave of distress that is considered normal and they do not generally require professional care. COVID‐19 is fundamentally different. It is not a single shock, but a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses, and many of the usual mitigation strategies are banned or unavailable. Modelling and earlier recessions show that it is the economic consequences, especially financial stress, unemployment, and educational failure, that fuel mental ill health and suicide risk.4,6 This impact is anything but short lived, and will produce a long, deep second wave of mental ill health and suicide. The impact is not uniform and there are groups at especial risk: notably, the already marginalised and disadvantaged, young people, women, those living alone and those already unemployed. Young people are especially disproportionately affected, and face a generation‐defining disruption that will have a multifaceted, long term impact on their lives. Socio‐economic inequality is a major risk factor for an array of negative health and social outcomes, including mental illness,7 and the potency of this risk factor will be magnified by a pandemic followed by a recession. We may all be in this together, but some are further in than others. The response so far has been based upon thinking from earlier crises and disasters. The focus is on the general public and aims to stress the normative aspect, that “it is OK to not be OK”, that simple coping mechanisms will get people through the crisis, and wishful thinking that professional help is available if needed. Crisis lines have been bolstered, but there has been no major effort to increase the capacity of the system, although the pivot to telehealth has sought to maintain access. These steps are welcome, but they will be inadequate on their own. The scale and sustained nature of the stress, the undermining effect of the containment measures, especially second lockdowns, and economic collapse mean that a much larger proportion of the population may need mental health care and be at risk for suicide than in more focal disasters. The capacity of the mental health system, even before COVID‐19, had been inadequate for responding to the demand.8,9 The system is now expected to respond to the surge in need for mental health care. It has been admirable how single‐mindedly governments and the health system have responded with public health measures and a boost to intensive care capacity10 in order to flatten the infection curve and to treat infected patients. At the time of writing, 886 people have died of COVID‐19 in Australia. During the same time period (February to October), more than 2000 Australians will have died from suicide,11 let down by an inadequate health and social system response. Most suffered from clear‐cut mental ill health, although only a minority had accessed mental health care.12 It is predicted that the number of suicides will rise in parallel with the COVID‐19 crisis and associated recession.4 These lives are surely just as precious as the ones directly lost to and threatened by COVID‐19. They have not yet been lost, and many, if not all, can be saved. What can be done? Firstly, policymakers must accept that this is not a routine disaster and that the times call for a very different approach. I believe the Prime Minister and some premiers are engaged with resolving this problem. Economic measures to soften the impact of the recession are the paramount preventive strategy, and the federal government has acted promptly with the JobKeeper and JobSeeker schemes, which have been partially extended while being reduced in stages. The global financial crisis showed how destructive austerity policies are, increasing inequality and social determinants of mental ill health, as well as weakening the social fabric and democracy itself. Secondly, the crisis provides a unique opportunity to create the “new mental health care” by dramatically reforming and strengthening the current system. An international position paper13 has been published, but Australia is ahead of the curve with key innovations, such as home‐based care and hospital in the home, assertive outreach models, and a national youth mental health platform (headspace), supported by digital and telehealth, which not only suit the times but are evidence‐based and strongly preferred by patients and families to emergency and inpatient care. Shifting the centre of gravity of mental health care to local communities via integrated care hubs linked closely with primary care is an innovation strongly supported by the federal government and Health Minister Hunt, not only through headspace, but also through the adult mental health hub model announced in 2019.14 Integrated care hubs with deeper capacity and expertise in helping people (young and older) with more complex needs could easily be fast tracked in the shadow of COVID‐19, initially as pop‐ups boosted by digital technology and outreach. State governments should consider releasing the governance of community mental health care from large hospital‐centric health networks so that it is embraced and can be accessed by local communities. And federal commissioning of community mental health care should be more coherent, guided by national evidence‐based standards, with the goal of regional integration of services, reversing the fragmentation produced by the competitive tendering policies of the excessively devolved primary health network model. The coming months will reveal whether we are really all in this together or whether the 5 million15 Australians (and rapidly growing) who confront mental ill health each year will continue to be treated as second class citizens.

Patrick McGorry

Depression as a systemic illness

Gin S Malhi

To the Editor: Takotsubo syndrome, also known as stress cardiomyopathy, apical ballooning syndrome, or broken heart syndrome, is a reversible cardiomyopathy frequently precipitated by a stressful event. Its clinical presentation is indistinguishable from a myocardial infarction,1 with electrocardiogram (ECG) changes and elevation in cardiac enzymes. The syndrome was first described in 1991 in Japan and named in reference to the left ventricle morphological features that resemble a pot used for trapping octopuses. Takotsubo syndrome has recently been reported in association with coronavirus disease 2019 (COVID‐19),2 but we report a case of takotsubo cardiomyopathy brought on by the stress of isolation as a result of social distancing. A 71‐year‐old woman presented to the emergency department complaining of chest pain. On arrival, an ECG demonstrated diffuse ST elevation (Box) and troponin was elevated (7800 ng/L). Coronary angiography was performed immediately which did not demonstrate any obstructive lesion and she was admitted to the intensive care unit (ICU) for ongoing haemodynamic support. Echocardiography performed in the ICU showed a dilated left ventricle with an akinetic apex and preserved contraction of the basal segments (Box) suggestive of takotsubo cardiomyopathy. On questioning regarding recent stressors, our patient, who lived alone, reported significant anxiety about not being able to visit family due to social distancing, and was particularly saddened by being unable to see her grandchildren. Public health interventions undertaken by governments around the world in an attempt to reduce the rate of transmission of COVID‐19, or to “flatten the curve”, have included measures such as social distancing.3 While being effective in the aim of lowering infections, these measures may have many unintended consequences. Social isolation is detrimental to mental health, associated with increased stress levels and anxiety, especially in older people, who may be less able to use technology to stay in contact with friends and family.4 In our patient, this stress was enough to trigger takotsubo cardiomyopathy. Box – Electrocardiogram (A) showing diffuse ST elevation. Echocardiogram (B) showing a dilated left ventricle with an akinetic apex and preserved contraction of the basal segments (arrows)

Jon Rivers · Joshua F Ihle

To the Editor: There has been recent important discourse about the adverse impact of coronavirus disease 2019 (COVID‐19) on mental health, with modelling from the Brain and Mind Centre predicting increases in suicide in the wake of the pandemic.1 Links with the economic downturn have been emphasised, with financial stressors and loss of productivity among the youth and working adults playing a large part, leading to a call for proactive investment in mental health services.1 This is of undisputed, urgent importance. However, there has been relative silence about the effects of the pandemic on suicide risk in older adults, especially men aged 85 years or over, who have the highest rate of suicide of all age groups in Australia.2 Older adults are particularly vulnerable to the social ramifications of the pandemic, including social distancing, if not frank social exclusion by quarantine, exacerbating pre‐existing loneliness,3 particularly for those in residential care. Management of older people with pre‐existing mental illness as well as the expected increases in depression and anxiety3,4 have been confounded by changes in service provision and access to mental health services.3 Similarly, delays in presentation and management of physical illness combined with the suspension of elective procedures4 may contribute to untreated pain and other distressing physical symptoms, also identified as risk factors for suicide.5 Furthermore, calls to reopen the economy knowing the risk this poses to older people — seen by some as “expendable” — reflects societal ageism and adds to older people's own internalised ageism.6 Perceptions of disconnection from society and feeling burdensome and devalued are already known associations with late‐life self‐harm and suicide.5 In addition to fuelling active self‐harm, there has been speculation regarding links between the pandemic and increased requests for voluntary assisted dying.7,8 These reports suggest that such requests have been driven by anxiety about dying, fears of loss of control, and inability to access help for distressing symptoms. This is not unfounded, given the complexity of providing appropriate palliative care to older patients who are dying, particularly to those in nursing homes, ever more so during the COVID‐19 pandemic.4 We add to the call to act urgently and flatten the mental illness and suicide curve1 for Australians of all ages.

Anne P F Wand · Carmelle Peisah

To the Editor: Australia's social distancing policies to contain the spread of coronavirus disease 2019 (COVID‐19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), have had social consequences. Social distancing and school disruptions have increased parental responsibilities. There has also been an increased opportunity for parents to use alcohol to cope with increased stress.1 Parents, especially mothers, have taken to social media to share “memes” about needing a drink to survive staying at home (Box). These posts are mostly shared with the aim of creating an online environment for peer support and stress relief, but they risk normalising the use of alcohol as a coping strategy and promoting the false belief that alcohol is good for mental health.2 Alcohol is a central nervous system depressant that may relieve stress in the short term, but regular drinking increases psychological distress and the risk of alcohol‐related harm.3 A review of recent advertising complaints indicated that some alcohol advertisers have been quick to capitalise on COVID‐19.4 An investigation of a social media account found an average of one alcohol advertisement every 35 seconds, with themes of easy access without leaving home (58%), buy more (35%), drink during COVID‐19 (24%), and drink to cope (16%).5 Australia has a regulation system for alcohol advertising, which most people mistakenly believe is government‐funded.6 It is in fact an industry‐funded quasi‐regulatory system that is activated by consumer complaints and lacks systematic independent monitoring.7 Further, regulations do not prevent certain social media platforms from being used by alcohol brands to post advertisements and engage with consumers.8 In light of the alcohol industry's opportunistic advertising through social media, it is questionable how well Australia's regulatory system protects parents and other targeted populations at risk from exposure to constant encouragements to drink during these challenging times. Box – Examples of parental drinking‐related memes during the coronavirus disease 2019 (COVID‐19) lockdown

Janni Leung · Jason Connor · Leanne Hides · Wayne D Hall

Objective: To develop a casemix classification to underpin a new funding model for residential aged care in Australia. Design, setting: Cross‐sectional study of resident characteristics in thirty non‐government residential aged care facilities in Melbourne, the Hunter region of New South Wales, and northern Queensland, March 2018 – June 2018. Participants: 1877 aged care residents and 1600 residential aged care staff. Main outcome measures: The Australian National Aged Care Classification (AN‐ACC), a casemix classification for residential aged care based on the attributes of aged care residents that best predict their need for care: frailty, mobility, motor function, cognition, behaviour, and technical nursing needs. Results: The AN‐ACC comprises 13 aged care resident classes reflecting differences in resource use. Apart from the class that included palliative care patients, the primary branches were defined by the capacity for mobility; further classification is based on physical capacity, cognitive function, mental health problems, and behaviour. The statistical performance of the AN‐ACC was good, as measured by the reduction in variation statistic (RIV; 0.52) and class‐specific coefficients of variation. The statistical performance and clinical acceptability of AN‐ACC compare favourably with overseas casemix models, and it is better than the current Australian aged care funding model, the Aged Care Funding Instrument (64 classes; RIV, 0.20). Conclusions: The care burden associated with frailty, mobility, function, cognition, behaviour and technical nursing needs drives residential aged care resource use. The AN‐ACC is sufficiently robust for estimating the funding and staffing requirements of residential aged care facilities in Australia.

Kathy Eagar · Rob Gordon · Milena F Snoek · Carol Loggie · Anita Westera · Peter David Samsa · Conrad Kobel

COVID‐19‐related unemployment may significantly increase suicide rates; implementation of appropriate preventive measures is critical In response to the coronavirus disease 2019 (COVID‐19) pandemic, the imposition of social distancing policies and related labour market impacts have resulted in extensive job losses. Globally, the International Monetary Fund has predicted the steepest economic downturn since the Great Depression.1 In May 2020, 2.3 million Australians (one in five employed people) were either unemployed or had work hours reduced for economic reasons, resulting in the steepest rise in rates of unemployment on record — a change from 5.2% in March to 7.1%2 — with Treasury predicting a rate of 8% by September 2020. Unemployment alone is associated with a two‐ to threefold increased relative risk of death by suicide compared with being employed,3 and sudden spikes in unemployment are associated with corresponding surges in the population rates of suicide.4 The global financial crisis, which led to the deepest recession since the 1930s and the loss of 30 million jobs worldwide, is estimated to have resulted in at least 10 000 additional economic suicides between 2008 and 2010 in Europe and North America.5 Projections using historical data suggest suicide rates may increase by 3.3–8.4% over the 2020–2021 period in the United States6 and up to 27% in Canada.7 Of course, all this is speculative and although the links between economic recessions and suicide are well documented, what is less clear is how the relationship plays out in the context of larger sociocultural and health events such as COVID‐19. The 1918–1920 influenza pandemic caused around 39 million deaths worldwide and resulted in governments implementing quarantine, public hygiene and social distancing policies, but evidence regarding its impact on world economies and suicide is limited. The severe acute respiratory syndrome (SARS) epidemic of 2003 came at the height of the Asian financial crisis, so disentangling the two is difficult. However, during this period, suicide rates in a number of Asian nations increased in tandem with unemployment, reaching historical peaks in 2003.8 As the situation continues to change daily, an accurate estimate of likely unemployment resulting from the COVID‐19 pandemic is difficult. Even current estimates under‐represent the impact, as individuals who are still employed but at significantly reduced hours are discounted. This is of particular concern when considering the global financial crisis, which saw Australian unemployment take a comparatively minor increase from 4.0% to 5.8% and coincided with an increase in suicide rates of 22% and 12% for unemployed men and women respectively.9 As the present crisis may potentially double the current unemployment rate, one can extrapolate to alarming conclusions, with some (albeit unpublished) modelling reflecting this projection.10 Despite this grim speculative forecast, this is not the whole story. There are marked differences between the present crisis and those that have come before. For instance, the current recession is supply (rather than demand) driven, and the prospect of recovery, although slow, is conceivable and may bolter optimism. Although major industries will be severely affected, there is potential for increased local spending as the borders remain closed. In addition, some hope may be found in the resilience shown by civilians in times of global unrest — for instance, the often cited “Blitz spirit”11 — and the possibility that the shared experience of the pandemic might bring a sense of social cohesion, which may prove life‐preserving. Notwithstanding considerable evidence of the psychosocial impacts of mass unemployment, we argue that the impact of the COVID‐19 pandemic on suicide rates is far from predetermined, and that early and sustained action can prevent many suicides and other adverse mental health outcomes. During prior recessions, Austria, Sweden and Finland have each displayed resilience in the face of substantially increased unemployment.5 In fact, despite sizeable rises in unemployment rates in Sweden and Finland in the early 1990s, the rate of suicide decreased.4 We suggest that, based on the available literature, there are several factors that may moderate the impacts of widespread unemployment. These include both early prevention measures and crisis care: sustained welfare spending; labour market programs and protections; and adequate funding of, and access to, mental health services, including prevention programs and engaging new technologies in the reporting and care response. Firstly, countries with sustained welfare spending during recessions have less marked increases in suicide rates than those that cut spending on welfare and job search initiatives for the unemployed.12 Robust social policies to ensure adequate welfare benefits for people with low or sudden loss of income are thought to be central to offsetting the impact of the recession on suicide.13 Where governments expand public welfare spending in the wake of disasters, there is good evidence for a reduction in suicide. The federal government's introduction of the JobKeeper and JobSeeker payment schemes are likely to mitigate suicide risk while simultaneously stimulating the economy and require long term investment. Secondly, countries with active labour market programs, which assist the unemployed to find work or retrain, and those with labour market protections have lower rates of unemployment‐related suicide than countries that do not.12 It has been estimated that, during European recession periods in the past 50 years, each US$100 per capita of investment in active labour market programs reduced the association of unemployment with suicide by 0.4%.4 Thirdly, it is critical that investment is made immediately in mental health, not just in terms of treatment but also in evidence‐based prevention programs. Different approaches are required to reduce attempts, and deaths, involving both public health and clinical services. In terms of direct suicide prevention interventions, there is increasing evidence for multilevel systems approaches — using components ranging from individual‐level (eg, assertive aftercare, psychosocial interventions) to public health interventions (eg, general practitioner and gatekeeper training),14 in addition to indirect interventions (targeting risk factors). Critical to effectiveness is the degree of penetration of these services, based on early population modelling, and the types of factors likely to differentially affect communities, including indigenous communities. Improving quality, availability and access to programs and crisis support services is vital to preventing suicide,14 with the current crisis both creating new challenges and compounding pre‐existing systemic issues. While the mental health sector is rapidly mobilising to improve access and the government has been quick to revise the Medicare rebate in this regard, it is vital that resource allocation and innovation continues beyond the span of the physical distancing measures. While increasing telehealth services is critical, the health professionals available to support them are unlikely to increase to meet need, and blended services that include automatised digital components may be a more efficient solution. The additional $48.1 million in mental health funding announced in May 2020 is a positive step; however, further funding for evidence‐based prevention initiatives is more important than ever to alleviate demand on treatment services. In terms of suicide prevention, digital interventions may hold some utility for both at‐risk and actively suicidal individuals, especially where other health services are lacking.15 Of course, economies undergoing recessions by their very nature have significant financial constraints, and governments will inevitably have to review spending across all services. It is critical that these limited funds are directed toward the most viable and cost‐effective services. Importantly, not all groups are affected equally, and subgroup consideration is vital. In crisis periods, it can be the most disadvantaged groups that are disproportionately affected, and marginalised and at‐risk populations require specific attention. It is also important to consider that many of the adverse consequences of job loss, including house repossession, mounting debt, mental health problems and relationship strain, are delayed and, therefore, long term investment is required.16 Finally, engaging new technologies in the fight against suicide may present a valuable new tool. This includes information technology‐enabled coordinated care and the dynamic reporting of suicide risk using immediate and real‐time data so that developing hotspots can be identified and shut down and local services can be mobilised. Although this field of study is in its infancy, the potential for concepts such as integrated, geospatial mapping, hotspot surveillance, and real‐time reporting could lead to significant advancements in predicting and intervening in suicidal behaviour.17 Ultimately, the economic fallout resulting from the COVID‐19 pandemic represents a threat, requiring urgent mobilisation and planning. There are certain steps required to moderate the mental health impacts of widespread unemployment, including sustained welfare spending; labour market programs; adequate investment in, and access to, mental health treatment and prevention services; and the dynamic reporting of suicide risk to aid regional responses and means restriction. The current economic crisis presents an opportunity to implement policies that would not only mitigate the impact of the recession on suicide but may incidentally reduce the national health and economic burden presented by emotional distress in any economic cycle. In doing so, there may be the ability to emerge from the current crisis stronger and more resilient as a nation.

Mark Deady · Leona Tan · Nathasha Kugenthiran · Daniel Collins · Helen Christensen · Samuel B Harvey

The current reduced capacity of post‐release services may compound offender vulnerabilities, increasing their risk of harm to themselves and others The coronavirus disease 2019 (COVID‐19) pandemic has affected many countries internationally and has been implicated in more than 445 000 deaths worldwide.1 The speed at which this infectious disease is transmitted has led to calls to immediately release prisoners from custody in some countries, including Australia, and has already led to the release of some prisoners in others. The reasons for these calls to action are intuitively rational. Custodial environments are susceptible to a COVID‐19 outbreak given the confined conditions and potential for overcrowding.2 Moreover, prison populations are often vulnerable, having poorer physical and mental health and other social challenges (eg, substance misuse, homelessness) compared with the general population.3 At the time of writing, Australian governments have yet to immediately release select prisoners into the community as part of efforts to mitigate the spread of COVID‐19, despite recent advocacy to do so. Experts across a number of sectors have recommended the early release of prisoners from vulnerable groups if possible, including Indigenous Australians, women, children, older prisoners, victims of domestic violence, and those with chronic health issues.4 However, the proposed early release strategy requires a nuanced assessment of its potential societal consequences and, most importantly, its immediate impact on the health and wellbeing of candidate prisoners for release. Victoria and New South Wales — Australia's most populous states — provide a useful case in point. Stage 3 restrictions — home confinement except for restricted essential activities5 — have been in effect for approximately 2 months. Some restrictions were eased in late May, although limits on public and private gatherings remain in place. Prisons in both Victoria and NSW have yet to record a single case of COVID‐19 within the inmate population. In Victoria, a number of safety mechanisms have been introduced by correctional centres to help manage the potential transmission of the virus.6 These include: temperature testing of all staff before entry to the facility; sending staff home who present with high temperatures and other flu‐like symptoms, and requiring them to undertake a COVID‐19 test before returning; isolating all new prison admissions for up to 14 days; isolating prisoners who display cold or flu‐like symptoms; adjusting programs to abide by physical distancing; and enabling prisoners to connect with family members via video calls on tablet devices (“video visits”) as an alternative to in‐prison visitation. Moreover, conventional medical, psychological and cultural support services continue to be available to prisoners. Similar precautions have been implemented in NSW correctional centres,7 which hold the largest proportion of prisoners in Australia. With no confirmed cases in both Victorian and NSW correctional centres and ongoing efforts to restrict the materialisation of COVID‐19 in custodial settings, the potential costs of releasing vulnerable prisoners into the community necessitates scrutiny. Any prisoners released under anti‐COVID‐19 preventive measures will return to a general community enduring social restrictions and society‐wide economic contraction. The post‐release community support services ordinarily available to released offenders are currently compromised or are experiencing significant delays.8,9,10,11 Moreover, government social security services (ie, Centrelink), which are heavily relied upon by individuals after release, are currently overwhelmed as they service thousands of newly unemployed clients.12 Mental health and crisis support services are also strained as they adjust to remote service delivery and contend with an elevated spike in community‐wide help seeking.13 The reduced capacity for intensive case management, monitoring and re‐entry assistance for released prisoners is a serious concern given their higher levels of complex mental and physical health needs, as well as histories of unemployment, addiction, social disadvantage and homelessness.3 Australian research points to high rates of mortality and self‐harm shortly after release from custody.14 Key predictors of post‐release mortality include mental disorder, suicide and substance misuse — concerns that transitional support programs and other post‐release interventions will be unable to optimally manage during the national lockdown. This scenario poses an increased health risk for released prisoners, compounding their vulnerability and increasing the likelihood of problem behaviour and recidivism. Without readily available coping strategies and assistance with pro‐social functioning, released prisoners with histories of violence, aggression, impulsivity and serious mental illness may put themselves and others (particularly cohabitants) at risk. Calls to release prisoners who are survivors of domestic violence must also consider the heightened risk of revictimisation after release. The social isolation, economic stress and reduced options for support during stage 3 restrictions may exacerbate unhealthy relationship dynamics, especially among those with complex needs. Moreover, physical distancing may not be adhered to by those whose behavioural and psychological needs are untreated. Proposals to immediately release vulnerable prisoners to avert the ostensible threat of COVID‐19 in Australian custodial environments warrant consideration. The potential for a COVID‐19 outbreak in custody is a genuine concern, notwithstanding proactive measures employed in Victorian and NSW correctional centres. However, this advocacy must consider the broader social context. A focus on early release cannot be uncoupled from the current compromised community environment prisoners will face after detainment. Community support services are increasingly strained at a time when released prisoners will have a greater need for them. As such, it is important to balance the relative health and safety trade‐offs of remaining in custody — in Victorian and NSW prisons, there are no confirmed cases of COVID‐19 and health supports remain available — with early release into a resource‐depleted community. The real prospect of harmful outcomes for immediately released vulnerable prisoners must be weighed heavily during this challenging period.

Stephane Shepherd · Benjamin L Spivak

To the Editor: Harms related to the inappropriate use of prescription drugs include fatal and non‐fatal overdose and are a significant public health concern in Australia.1 In response, Victoria recently introduced SafeScript (https://www2.health.vic.gov.au/safescript) — a system similar to the widely implemented real time prescription monitoring (RTPM) systems in the United States.2 The Victorian RTPM system is designed to help health professionals make safer decisions when supplying high risk medicines.3 RTPM systems have been associated with unintended consequences, such as a transition from pharmaceutical opioid use to illicit opioid use, which has been associated with an increased risk of overdose and spread of blood‐borne viruses.2,4 Indeed, a 2019 American study suggests that lowering prescription opioid supply through initiatives such as RTPM use will only have a modest effect on opioid‐related deaths, unless supported with a multipronged approach including increased access to pharmacotherapy and harm‐reduction services.5 In Victoria, the implementation of an RTPM system may be of more benefit than seen in the US since these services are widely available. We have begun to explore effects of the introduction of SafeScript through analysis of data collected through the Burnet Institute's SuperMIX study — a prospective cohort study of about 1300 people who inject drugs (https://www.burnet.edu.au/projects/89_supermix_the_melbourne_injecting_drug_user_cohort_study). We introduced questions related to RTPM use in March 2019, with a total of 387 interviews conducted since the implementation of SafeScript in Victoria. We found that 20% of participants (48/242) who used a medicine monitored by SafeScript reported being refused a prescription by a general practitioner. One‐third (16/44) of those who have been refused were requesting the prescriptions for the treatment of anxiety and 45% were refused two or more times by doctors. Three per cent of participants (8/245) reported having a prescription they had already been receiving withdrawn. In addition, six out of 241 participants were refused dispensing of a prescribed medicine by a pharmacist. One‐third of participants (15/47) who had been refused a prescription were told this was due to a risky combination of medicines or having multiple providers. A third of participants (14/45) who had been refused a prescription reported an intention to not seek medication from their doctors in the future. Most had moderate to severe anxiety (33/41) and depression (36/41) disorders measured through a self‐administered Patient Health Questionnaire (PHQ). In the case of refused prescriptions requested for the treatment of anxiety, ten out of 13 patients had moderate to severe anxiety disorder and 11/13 patients had severe depression disorder, suggesting unmet treatment needs in patients denied prescriptions. RTPM systems such as SafeScript may help prevent the inappropriate use of prescription medications. Our initial analysis provides early insights on the impacts of SafeScript on this cohort, indicating careful implementation is required, particularly for people who inject drugs living with concurrent mental illnesses. The use of RTPM systems may reduce medicine‐related harm if integrated mental health and drug treatment services are adequate. It is not clear whether this is the case in Victoria. It is important to understand what happens when people are refused prescriptions — what care they receive and whether this care is appropriate for their needs. Increased mortality following restrictions to prescribed medicines is reported elsewhere.2 Rigorous research should evaluate the impact of RTPM use in Australia to understand if similar outcomes are observed.

Dagnachew M Fetene · Peter Higgs · Suzanne Nielsen · Filip Djordjevic · Paul Dietze

Individualised care plans that take greater account of the behavioural and psychological needs of residents are needed

Gerard J Byrne

Variation in Australian law concerning self-binding directives for mental illness is unnecessarily complex for clinicians

Katrine Del Villar · Christopher J Ryan

The evidence from real world implementation is compelling

Mike Daube · Julia Stafford

Sexual dysfunction is a frequent, potentially distressing, adverse effect of antidepressants and a leading cause of medication non‐adherence. Sexual function should be actively assessed at baseline, at regular intervals during treatment, and after treatment cessation. Trials comparing the risk of sexual dysfunction with individual antidepressants are inadequate, but it is reasonable to conclude that the risk is greatest with selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs), less with tricyclic antidepressants (except clomipramine) and mirtazapine, and least with moclobemide, agomelatine, reboxetine and bupropion. Management of antidepressant‐induced sexual dysfunction requires an individualised approach (eg, considering other causes, dose reduction, addition of medication to treat the adverse effect, switching to a different antidepressant). Post‐SSRI sexual dysfunction has been recently identified as a potential, although rare, adverse effect of SSRIs and SNRIs. Consider the possibility of post‐SSRI sexual dysfunction in patients in whom sexual dysfunction was absent before starting antidepressants but develops during or soon after antidepressant treatment and still persists after remission from depression and discontinuation of the drug.

Jody Rothmore

Child protection services in Australia require fundamental workforce and organisational reform

Steve Kisely · Jake Najman

Mental disorders in children known to child protection services during early childhood

Melissa J. Green · Gabrielle Hindmarsh · Maina Kariuki · Kristin R. Laurens · Amanda L Neil · Ilan Katz · Marilyn Chilvers · Felicity Harris · Vaughan J Carr

To the Editor: The editorial by Murnion and Conigrave1 and the article by Crossin and colleagues2 on the dangers of misuse of pregabalin are a timely warning to all prescribers. The black market utility (based on testimonies) and frequent misuse of pregabalin is well known both academically and to prescribers in prison environments.3,4 Harm relating to gabapentinoid use is noted to be increasing globally. A 2017 case–control study showed a dramatic increase in relative risk of death with opioid and gabapentinoid versus opioid alone.5 People leaving prison are at a higher risk of opioid overdose death, partly because of loss of tolerance.6,7 This will likely be compounded by inappropriate gabapentinoid prescribing. In New South Wales prisons, the Justice Health and Forensic Mental Health Network sees many patients who present seeking pregabalin and other prescription drugs in our health clinics. Patients often enter custody using high doses of medications prescribed in the community, including gabapentinoids, benzodiazepines and opiates. The Network applies a multidisciplinary team approach between primary care, pharmacy, and drug, alcohol and mental health services for these complex patients. Furthermore, clinicians undertake regular medication reviews of patients; medications that are not indicated are deprescribed to reduce potential harm to patients.8,9 The Network has developed management guidelines around gabapentinoid use, including regular review of prescriptions by general practitioners and the clinical director. Off‐label use is discouraged. Pregabalin is always a supervised medication, and dose limits and deprescribing programs are in place to limit availability if not indicated. Alternate medications for the management of diagnosed neuropathic pain are effective and may pose less risk in prison environments.8,9 Gabapentinoid drugs are not used as an alternative to opiate pain medications in NSW prisons. Patients are assessed and given appropriate medications according to the quality and safe use of medicines approach, and medication charts are regularly audited to ensure safe prescription of medications. There has been an overall reduction in actual gabapentinoid prescribing in NSW prisons in recent years. We encourage all Australian prescribers to ensure care around prescribing of gabapentinoid and other medications, especially for complex patients with drug and alcohol misuse and polypharmacy issues.

Gary Nicholls · Peter Samios · Stephen Hampton

The lack of national policy means that Australia remains at significant risk of declines in health due to climate change — substantial and sustained national action is urgently required

Paul J Beggs · Ying Zhang · Hilary Bambrick · Helen L Berry · Martina K Linnenluecke · Stefan Trueck · Peng Bi · Sinead M Boylan · Donna Green · Yuming Guo · Ivan C Hanigan · Fay H Johnston · Diana L Madden · Arunima Malik · Geoffrey G Morgan · Sarah Perkins‐Kirkpatrick · Lucie Rychetnik · Mark Stevenson · Nick Watts · Anthony G Capon

New health information technologies have the potential to transform the delivery of mental health care

Ian B Hickie

Young people who play sport are exposed to a range of neurological, emotional and developmental benefits but are also at risk of injuries that can threaten these

Amanda Clacy · Daniel F Hermens · Kathryn Broadhouse · Jim Lagopoulos

More research is needed to understand the barriers to optimal adolescent immunisation for students with disabilities

Jenny O'Neill · Fiona Newall · Giuliana Antolovich · Sally Lima · Margie H Danchin