Mental health

Although mental health problems represent the largest burden of disease in young people, access to mental health care has been poor for this group

Sarah E Hetrick · Alan P Bailey · Kirsten E Smith · Ashok Malla · Steve Mathias · Swaran P Singh · Aileen O'Reilly · Swapna K Verma · Laelia Benoit · Theresa M Fleming · Marie Rose Moro · Debra J Rickwood · Joseph Duffy · Trissel Eriksen · Robert Illback · Caroline A Fisher · Patrick D McGorry

Promoting routine, consistent collection of clinical stage data may enhance appropriate targeting of mental health care delivery

Matthew P Hamilton · Sarah E Hetrick · Cathrine Mihalopoulos · David Baker · Vivienne Browne · Andrew M Chanen · Kerryn Pennell · Rosemary Purcell · Heather Stavely · Patrick D McGorry

More economic evaluations are required in youth mental health

Matthew P Hamilton · Sarah E Hetrick · Cathrine Mihalopoulos · David Baker · Vivienne Browne · Andrew M Chanen · Kerryn Pennell · Rosemary Purcell · Heather Stavely · Patrick D McGorry

To the Editor:Whitely and colleagues1 reported that children born in June were more likely to receive treatment for attention deficit/hyperactivity disorder (ADHD) than children born in July. It is unfortunate that they did not measure the year of school intake, and rather made the assumption that all children entered school at the recommended age. The authors concluded that “there are significant concerns about the validity of ADHD as a diagnosis,” which is a large leap not substantiated by the data presented. We are conducting Australia’s first community-based longitudinal study of children with (n = 179) and without ADHD (n = 212), the Children’s Attention Project.2,3 Our design is ideal for examining this research question as children were all recruited across one year of school, enabling us to accurately categorise children as early or late starters. We rigorously assessed for ADHD (ie, via parent and teacher surveys and diagnostic interviews) and also recorded the use of ADHD medications. To investigate the same question within our cohort, we defined early starters as those children with birth months in February, March or April (age at entry, 4 years 9 months to 4 years 11 months; n = 46) and late starters as those children born in May, June or July (age at entry, 5 years 6 months to 5 years 8 months; n = 123). We found no relationship between being an early or late starter and meeting the criteria for ADHD at either age 7 years or age 10 years. Our sample size for these analyses was small because most children with ADHD were born outside the months encapsulating early and late start date definitions (n = 112; 63% of our ADHD sample). Only nine children were prescribed medication across the early and late starter definitions — one early starter and eight late starters. In conclusion, our data show that when school commencement year is considered, there is little evidence to support early versus late school starter status as a predictor of ADHD and treatment in Victoria. The overall rate of ADHD medication prescribing for children aged 6–15 years reported by Whitely and colleagues was 1.9%.1 ADHD has a prevalence of about 5%,4 thus, these data provide further reassurance that the rates of prescribing of ADHD medications in Australia remain moderate.

Emma Sciberras · Alisha Gulenc · Daryl Efron

In reply

Martin Whitely · John Phillimore · Leanne Lester · Suzanne Robinson

To the Editor:I thank Kritharides and colleagues1 for their review Cardiovascular disease in patients with schizophrenia. I agree with them and support their work, which seeks to improve the physical health of patients living in the community with a chronic mental illness such as schizophrenia, through an innovative, coordinated and multidisciplinary model of care. Clozapine side effects, including risks of myocarditis and cardiomyopathy, hypercholesterolaemia and weight gain, reduce years of life and require medical attention. But the management is not always straightforward. One challenge is patient compliance with often demanding allied health therapies. How do we keep our patients motivated to continue with prescribed regular exercise most days of the week? How do we encourage compliance with a weight-reducing, low salt, low glycaemic index diet? Multidisciplinary primary care and specialist teams may consider a rehabilitation approach to complement the model of care. Two essential elements are goal setting and measurement of function.2 Some patients will be motivated by their personal goals (eg, getting back to weighing 80 kg or playing a game of table tennis) and other patients will appreciate their gain in terms of function (eg, walking up the stairs without a rest or shopping for groceries independently) more so than in terms of presented data (eg, cholesterol levels or absolute cardiovascular risk reduction). For motivating patients with schizophrenia and significant cardiovascular risk, a rehabilitation approach may be worth a try.

David Skalicky

To the Editor:We commend Milner and colleagues on their most important and timely study, which investigated the age-standardised rates and methods of suicide by health professionals compared with other occupational groups.1 They established that suicide rates for female health professionals, including medical professionals, were higher than for women in other occupations. While suicide rates were higher for male nurses and midwives, those for male medical practitioners were not significantly higher compared with other occupational groups.1 Milner and colleagues considered sex-related stressors in their discussion, in an attempt to understand the gender differences in suicide rates among medical professionals. The authors considered that women working in male-dominated areas face “considerable gender role stress” and may feel pressure to undertake traditional household roles and family responsibilities.1 It is highly conceivable that the abovementioned sex-related stressors may contribute to the sex differential in suicide rates. However, sexual harassment is an important sex-related stressor2 that was not included in their discussion or in Goldney’s accompanying editorial on this topic.3 There is overwhelming evidence to suggest that sexual harassment disproportionately affects women and is an entrenched problem in the medical profession.4,5 Indeed, sexual harassment has been demonstrated to be associated with suicide attempts among female doctors.5 Goldney argues that “ensuring good workplace relationships and equal opportunity, eliminating bullying [and] reducing access to means of suicide” are important pragmatic approaches to overcoming the problem of suicide among health care professionals.3 We propose that redressing sexual inequalities in medicine and eliminating sexual harassment might represent some additional approaches.

Nikki R Adler · Kimberley A Adler

In reply:In their comment on our article,1 Adler and Adler are correct in noting that sexual harassment is a significant issue facing female doctors, as it is for women in many occupations.2 Those who experience sexual harassment are also more likely to experience bullying and other forms of workplace incivility.3 Workplace bullying has also been found to be related to higher risk of suicidality.4 In view of this, we agree that these would be worthwhile targets for prevention initiatives. But the question remains as to whether sexual harassment and the problems regarding gender role stress discussed in our article1 all stem from the same set of causes. A meta-analysis3 noted two systematic sources of sexual harassment: (i) organisational context, including a climate that permits sexual harassment, and policies that do not support the reporting of and action against perpetrators; and (ii) the context of gender in the workplace — for example, the extent to which traditional gender roles are able to be maintained, such as through gender differences in the organisation of work, and the overall proportion of women employed in the job. In our article, we specifically highlighted the maintenance of gender-normative behaviour in medicine as potential stressors for suicide. While we agree that sexual harassment is a significant issue that needs to be addressed, we suggest that this be incorporated into a wider and overall strategy to overcome gender inequality in medicine. This strategy should target the negative personal and organisational (eg, organisation commitment, work withdrawal, job satisfaction) outcomes of harassment,3 and include measures to allow both male and female doctors to care for their families. In addition, to align with best practice in workplace suicide prevention,5 we would also support a stigma reduction campaign, access to treatment for health practitioners who experience poor mental health and suicidal ideation, and support for colleagues and families following bereavement from suicide within the medical profession.

Allison J Milner · Matthew J Spittal · Marie M Bismark

In reply:I thank Adler and Adler for their comment on my editorial on suicide by health care professionals.1 Their proposal of “redressing sexual inequalities in medicine and eliminating sexual harassment” appears to be encompassed in my statement about “ensuring good workplace relationships and equal opportunity [and] eliminating bullying”,1 which they quote in their letter. Regrettably, sexual harassment is common and not unique to medicine, with an estimated prevalence in the workplace of 35–50%.2 Although Adler and Adler refer to the work of Frank and colleagues3 in demonstrating an association between sexual harassment and suicide attempts in female doctors, they do not mention the caveats that the study authors noted. These include that it was “a relationship we cannot determine”; that earlier studies were “based on small numbers and the subject of considerable controversy”; and that “these problems are not unique to women physicians”. Bearing in mind the low base rate discussed in my article, ensuring that equal opportunity, good workplace relations and anti-bullying approaches are standard for health practitioners, and that health practitioners can access general and mental health care, are more realistic and achievable goals that are more likely to return dividends.

Robert Goldney

In reply

Briony J Murphy