Treating depression with antibiotics

Researchers at Deakin University have undertaken a trial using an antibiotic to treat depression.

The trial added a daily dose of minocycline – a broad-spectrum antibiotic that has been prescribed since 1971 – to the usual treatment of 71 people experiencing major depression.

The research team, led by Deakin’s Centre for Innovation in Mental and Physical Health and Clinical Treatment within the School of Medicine, then compared the effects to a control group taking a placebo.

The results have been published in the Australian & New Zealand Journal of Psychiatry and show that those taking minocycline reported improved functioning and quality of life.

Lead researcher Dr Olivia Dean said the minocycline trial was small, but had some significant results.

“We found that those on minocycline reported significant improvements in functioning, quality of life, global impression of their illness, and there was also a trend towards improvements in anxiety symptoms,” Dr Dean said.

The trial was based upon evidence that suggests people with a major depressive disorder have increased levels of inflammation in their body.

Dr Dean said that: “Specifically, minocycline reduces brain inflammation in cell models, and thus we wanted to see if it was useful for people.”

There is a huge need for improved treatment options for people with major depression. Beyond Blue estimates that In Australia, 45 per cent of people will experience a mental health condition in their lifetime. In any one year, around one million Australian adults have depression.

The World Health Organisation released data this year that shows more than 300 million people around the globe are now living with depression.

“Current antidepressants are useful, but many people find a gap between their experience before becoming unwell and their recovery following treatment,” Dr Dean said.

Dr Dean said her team was now in the process of applying for funding to expand the trial to a larger group.

This research was supported by Deakin University, the Florey Institute of Neuroscience and Mental Health, the University of Melbourne, Barwon Health, Chulalongkorn University, the Brain and Behavior Foundation (USA), and an Australasian Society for Bipolar and Depressive Disorders/Servier grant.

MEREDITH HORNE

AMA’s forward direction examined at National Conference

BY AMA SECRETARY GENERAL ANNE TRIMMER

Another AMA National Conference over with a stimulating and varied program, including appearances from the political leadership. It is rare to have a full hand of senior politicians – the Prime Minister, Health Minister, Minister for Ageing and Indigenous Health, Leader of the Opposition, Shadow Health Minister, and Leader of the Greens. It reinforces the fact that health is front and centre of national politics and will remain there as the next Federal election approaches.

Beyond national politics the Conference considered policy issues as diverse as obesity, organ and tissue donation, and the important topic of doctors’ health. It was pleasing to hear the announcement by Health Minister Greg Hunt that the Government would commit funding to assist in addressing the issue of the mental health of doctors and medical students. This will form part of a larger piece of work that the AMA is embarking on to develop a framework for doctors’ health and wellbeing.

In a year when there is no AMA election (as is the case in the odd-numbered years) delegates have more freedom to consider the policy topics, away from the politics of an election. Delegates have the opportunity to meet informally, as they did over breakfast on Sunday, when groups of members with interests in common came together to share a meal. As one psychiatry delegate commented, it provided a great opportunity to meet with other psychiatry members to realise shared interests and passions.

It was encouraging that members who had never before attended a National Conference were able to participate and see first-hand the work of the AMA. With the move in 2016 to representation from among practice groups, a more diverse representation of members is now supported to participate.

At the Annual General Meeting held during National Conference, the Chair of the Board, Dr Iain Dunlop, and I reflected on the year that was 2016. It was a strong year of medico-political advocacy and member engagement which can be seen in more detail in the Annual Report, available through the website.

I reported on the inaugural Future Leaders program, held in Canberra in early August. Calls for applications are currently open for doctors within the first five years of taking up a leadership position in a State, Territory or Federal AMA. The AMA Board is committed to investing in the development of the next generation of AMA leaders – I encourage you to apply if you qualify. Applications and selection criteria are available through the website.

At the Annual General Meeting the Chair announced to members the decision of the Board, taken after considerable research and reflection, to sell and lease back AMA House in Canberra. The Board took the view that more flexible investment of the capital tied up in the building would provide a better return on members’ funds. The building is fully capitalised following an extensive upgrade to its infrastructure over the past four years. A sale is likely later in 2017 following a marketing campaign.

For those who were not able to attend National Conference, this edition of Australian Medicine provides a good overview.

Seven keys to dealing with adverse events

Someone dies unexpectedly on the ward; a baby is born with a severe abnormality; a surgical patient wakes up with paralysis – so many things can and do go wrong in the daily life of a hospital. Nearly half a million adverse events occur every year in Australian healthcare, so it’s likely that you’ll one day find yourself dealing with a patient who has been harmed under your care.

Although clearly the first priority in such circumstances are the patients themselves, doctors too can find themselves traumatised when something goes badly wrong. Managing doctors’ mental health after serious adverse events is extremely important and often overlooked.

Common responses when things go wrong are shock, disbelief, guilt and shame, along with a loss of confidence in your abilities as a practitioner. Some doctors can even develop PTSD symptoms or suffer survivor guilt. Reactions can be more extreme with patients with whom we feel a closer connection, which is why establishing some separation is important to maintaining your ability to be effective.

The reactions to avoid are denial, obsessively going over the events in your mind, worrying about things you can’t control and isolating yourself from those who can help.

Open disclosure with the patient harmed or the patient’s family is a crucial process. This needs to be honest as well as consistent over time, with a primary point of contact. You need to have all the information at hand before starting this process, and be honest about what is not known. Avoid speculating or elaborating to try and comfort the patient or family, and let them know what more is being done and when.

Express sympathy, and offer to listen if they feel like talking. Ask how you can help in other ways. Saying nothing can be misconstrued as rejection, or reinforce the notion of a “code of silence” around the event.

Here are some keys for coping after an adverse event in your professional life:

Look after your physical health; make sure you’re getting enough sleep and exercise;
Don’t obsess about the adverse event, and make sure you debrief after the incident;
Try stress reduction techniques such as yoga or meditation;
Take an active role in the open disclosure process
Learn from the incident and consider what you can proactively do to prevent the same thing happening again;
Seek advice from your GP if you’re concerned about how the incident is affecting your health;
Contact a medico-legal advisory service about how to handle the event and notify your insurer.

Sources: Avant and Stanford Medicine

For more information about health issues for doctors, access a range of online resources from Doctors’ Health Services Pty Ltd.

The disparity between changes in the prevalence of mental illness and disability support rates in Australia

Clarifying the type of support needed by people with a psychiatric disability must be a priority

One major focus of Australia’s national mental health strategy has been to increase access to treatment for those with common mental disorders, particularly anxiety and depressive disorders. Despite indications that treatment rates have increased in Australia,1 there is little evidence that the population prevalence of these disorders has declined, a phenomenon also reported in other high income countries where increased treatment has been made available.2

Harvey and colleagues also conclude, as reported in this issue of the MJA, that the prevalence of probable common mental disorders among working age Australians has remained stable or even decreased slightly between 2001 and 2014.3 Prevalence was estimated by measuring the levels of psychological distress in respondents to Australian national health surveys, using scores on the Kessler Psychological Distress Scale (K10) as an indicator of the likelihood of a mental disorder diagnosis. Their finding that the prevalence of probable common mental disorders has not changed is consistent with conclusions drawn from Australian surveys in which the presence of a mental disorder was assessed by interview4 and from the Global Burden of Disease studies,5 each of which required that prevalence be established according to diagnostic criteria. But Harvey and his co-authors also found a 51% increase over the same period in the number of people receiving disability support pensions (DSPs) for mental disorders, and ask why this is so, given the prevalence of probable common mental disorders had not changed.

With respect to the epidemiology of mental disorders, two observations can be made regarding these findings. The first is to consider whether the proportion of people receiving DSPs for psychological and psychiatric reasons who have more disabling mental disorders, such as psychoses, is increasing. However, there is no evidence for such an increase in Australia.6 Further, the disability component of the burden of disease metric (disability-adjusted life years) is years lived with disability (YLD), and this measure is more aligned with the need for a DSP than the prevalence of psychological distress. However, there was no change in age-standardised YLD rates for anxiety or depressive disorders in Australia between 1990 and 2015 (Global Burden of Disease Study 2015 data, accessed via https://vizhub.healthdata.org/gbd-compare/).

Second, the number of individuals with a disorder can increase even if its prevalence does not change. The Global Burden of Disease analysis found no change in the prevalence of anxiety and depressive disorders, but nevertheless reported that the number of people with these disorders increased by 36% between 1990 and 2010 as a result of population growth and changing population age structures.5 The same modelling of the impact of population growth and changing age structure in Australia indicated that the number of people aged 15–69 years with a major depressive disorder increased between 2000 and 2015 from 649 000 to 853 000 (31% increase), and that the number of those with an anxiety disorder increased from 1 041 000 to 1 356 000 (30% increase; Global Burden of Disease Study 2015 data). The extent to which this increase in the absolute number of individuals with a disorder has contributed to the increase in the number of individuals receiving DSPs in Australia is unclear.

Harvey and his co-authors offer four other reasons that might explain the change in the number of DSPs granted to people with mental disorders. The first and second possibilities, an increasing tendency to apply a psychiatric disability label and a change in disability policy settings for welfare support payments, seem most plausible, and should be further explored. Empirical evidence about how providers select the disability type is scarce, as is information on how changes in disability policy have affected the awarding of pensions to people with mental health problems. The third explanation offered by the authors is that more people with psychiatric disability are seeking DSP benefits because of the reduced availability of appropriate employment opportunities. This is possible, but a more common outcome for previously employed individuals would be unemployment rather than disability benefits. The fourth explanation, an increased incidence of common mental disorders masked by treatments that reduce symptom but not disability levels, seems implausible. Had incidence increased, there would also have been an increase in prevalence, unless their remission rates had also increased; this, however, would be unlikely if the disability persisted long enough for a DSP to be awarded.

The challenges posed by the introduction of the National Disability Insurance Scheme (NDIS) for people with psychiatric disability are significant, and are currently being examined by the Joint Parliamentary Standing Committee on the NDIS.7 As part of this examination, clarifying the threshold for the allocation of DSPs and the type of support needed by those with psychiatric disability must be a priority.

Is the prevalence of mental illness increasing in Australia? Evidence from national health surveys and administrative data, 2001–2014

The known The rising cost of mental disorders has been interpreted as indicating that the prevalence of mental health problems is increasing.

The new The prevalence of probable common mental disorders in Australia was fairly stable between 2001 and 2014. Over this same period, however, the number of working age individuals receiving disability support pensions for psychiatric conditions increased by about 50%.

The implications While the costs and level of disability associated with mental disorders is rising, there has been no corresponding change in the prevalence of probable common mental disorders in Australia.

It is popularly believed that we are in the midst of an epidemic of mental health problems.1 The most recent Global Burden of Diseases study found that the number of disability-adjusted life years (DALYs) attributed to mental disorders increased by 37% between 1990 and 2010, with depression becoming the fourth highest cause of disability in Australia.2 Studies in the United States, the United Kingdom and Australia have found that rates of antidepressant prescribing have more than doubled in recent decades.3–5 At the same time, a worldwide trend of mental disorders displacing musculoskeletal conditions as the predominant reason for illness-related absences and work incapacity has been noted.6,7 While these changes in rank represent, to some extent, a reduction in the burden of many somatic illnesses, the expense associated with mental illness has continued to rise, with the annual cost of depression in Australia now estimated to be $12.6 billion.8

The increasing societal and economic costs of common mental disorders (CMDs) have provoked the question of whether their underlying rates have actually increased, particularly in the working age population.9 Despite various indirect measures which indicate that the disability burden associated with CMDs has increased, studies of trends in CMD prevalence over recent decades have yielded mixed results; some have found rising rates of depression,10 for instance, while others have not.11,12 This inconsistency of findings might be explained by methodological differences. The main diagnostic tool for research studies, the Diagnostic and Statistical Manual of Mental Disorders (DSM), has been revised several times in recent decades. As a result, many sequential cross-sectional surveys have applied different diagnostic instruments or criteria for defining and diagnosing CMDs during individual survey periods,11,12 so that the prevalence rates at different time points may not be directly comparable. A second problem is that earlier studies analysed data for only two time points, often many years apart, making it difficult to draw definitive conclusions about trends in CMD prevalence. Finally, a number of published studies have used different sampling techniques at each time point, or have had significant differences in response rates, again making direct comparisons of prevalence at different time points very difficult.

In our study, we used data from multiple waves of the National and Australian Health Surveys, conducted by the Australian Bureau of Statistics (ABS), to assess changes in the prevalence of probable CMDs in Australia between 2001 and 2014. The data from these surveys are a unique resource for overcoming key limitations of previous studies. We also examined changes over the same period in the rates of disability support pensions (DSPs) granted for psychiatric disorders, allowing comparisons of changes in measures of the burden of CMDs with changes in CMD prevalence.

Methods

National health surveys

The National Health Survey (NHS) and Australian Health Survey (AHS) are household-based surveys undertaken at 3-year intervals to monitor health trends over time. Their methodologies have been described in detail.13 Trained ABS interviewers conducted face-to-face interviews over an 11-month period in each of 2001, 2004, and 2007 for the NHS and during 2011 and 2014 for the AHS. We analysed responses from adults aged 18–65 years.

Household and person weights were assigned to adjust for the probability of sample selection. Further adjustments were made for seasonality and non-response, and the data were then calibrated to the population benchmarks. Calibration ensures that the estimates are representative of population distributions and helps compensate for the over- or under-representation of particular categories of persons or households.

Assessment of common mental disorders

CMDs were assessed using the 10-item Kessler Psychological Distress Scale (K10). This scale, designed to assess non-specific psychological distress (predominantly symptoms of anxiety and depression), has been validated in various settings14 and found to have sound psychometric properties.15 K10 scores have been grouped into four categories: low (10–15), moderate (16–21), high (22–29) and very high (≥ 30) distress. Although there are no established cut-off standards for CMD caseness according to K10 scores, very high levels of psychological distress have been associated with a risk for meeting diagnostic criteria for anxiety or depression ten times greater than the overall population risk.14 We therefore defined two groups of probable CMD:

probable CMD (very high symptom level): respondents with K10 scores of 30 or more, reflecting the cut-off level adopted by the Australian National Survey of Mental Health and Wellbeing (NSMHWB);16 and
probable CMD (high symptom level): respondents with a K10 score of 22 or more.

Disability support pensions

We retrieved national data on the numbers of people receiving DSPs for psychological or psychiatric primary medical conditions17 between 2001 and 2014 from the website of the Department of Families, Housing, Community Services and Indigenous Affairs (now: Department of Social Services), and compared changes in their rates with trends in CMD prevalence. The proportion of the Australian working age population receiving a DSP for a mental illness was calculated by dividing the number of DSP recipients by the working age population (aged 16–64 years) for each year (ABS data).

Data analysis

All statistical analyses were performed in Stata 12.0 (StataCorp). Time trends in CMD prevalence and the proportion of the population receiving DSPs for psychiatric conditions were assessed in Cochran–Armitage trend tests. When not stratified by age, data were directly age-standardised against the estimated resident population of Australia at 30 June 2001.

Ethics approval

As is all data collection by the ABS, the gathering of data analysed in this study was covered by the Census and Statistics Act 1905, and the analyses were approved by both the Australian Parliament and the Privacy Commissioner.

Results

In 2001, 19 408 dwellings were selected for survey, of which 15 792 households provided full or adequate responses, a response rate of 81%. In 2004, 2007, 2011 and 2014, the numbers of participating households were 19 501, 15 792, 15 475 and 14 723 respectively (response rates, 82–91%). For all five survey periods, the study sample included a higher proportion of women than men. The age distributions for the five waves of data collection were similar, with the highest participation rates among those aged 25–64 years (data not shown).

The prevalence rate in the Australian working age population of probable CMD with very high symptom levels did not vary significantly between 2001 and 2014 (for trend, P = 0.92). There was, however, a slight but statistically significant decrease in the estimated prevalence of CMD with high symptom levels, from 13.3% (95% confidence interval [CI], 12.7–13.8) in 2001 to 12.2% (95% CI, 11.6–12.8) in 2014 (for trend, P < 0.001), with a low point of 11.0% (95% CI, 10.5–11.6) in 2011 (Box 1). The estimated prevalence of probable CMD with high level symptoms exhibited a similarly small but statistically significant decline among those aged 25–34 (P = 0.002) or 35–44 years (P = 0.007); the decline for those aged 18–24 years was not statistically significant (P = 0.052) (Box 2).

Although there was a significant decrease in the proportion of working age people receiving DSPs during the same time period (18.9%; for trend, P < 0.001; data not shown), there was a 51% increase in the proportion receiving DSPs for psychiatric conditions between 2001 and 2014 (for trend, P < 0.001), equivalent to one additional DSP for mental ill health for every 182 working age Australians (Box 3). Despite this increase, the proportion of people receiving DSPs remained substantially lower than the prevalence estimates for even the most severe probable CMD, suggesting that most people with depression or anxiety continued to work in some capacity. The proportion of DSPs granted for psychological and psychiatric conditions rose from 23% in 2001 to 32% in 2014.

Discussion

The data from repeated, nationally representative health surveys indicate that the prevalence of probable CMD among working age Australians has remained stable or even declined slightly between 2001 and 2014. This finding is contrary to the popular narrative of an increasing prevalence of mental health problems. Over the same period, we found that the proportion of working age people receiving DSPs for mental health problems had increased by about 50%. Although the costs and level of disability associated with mental disorders are rising in Australia, the increases do not appear to be linked with an increase in the underlying prevalence of common mental health problems.

Previous analyses of trends in the prevalence of mental disorders have often been hampered by changes in sampling methodology or diagnostic criteria at different time points. The main strength of our study is that the sampling methods and measuring instrument were consistent across the five survey periods, enabling direct comparison of prevalence rates. The response rates were high for all surveys (at least 81%), reducing potential inaccuracies in estimates caused by non-response bias.18

Limitations include the fact that caseness of probable CMD was defined by K10 scores. Using a measure of symptom severity rather than a diagnostic scale allowed us to avoid problems arising from changes in diagnostic classification, but high levels of self-reported symptoms are not the same as a diagnosed disorder, and the potential bias inherent to self-reports can lead to misclassification; this bias, however, should be stable over time. Further, the K10 is designed to detect only symptoms of depression and anxiety, but DSPs are awarded for the full spectrum of mental disorders. People with psychoses have very low rates of employment, although data from repeat rounds of the Australian Survey of High Impact Psychosis (SHIP) indicated that these rates have not changed over recent decades,19 suggesting that psychoses are unlikely to account for the rising rate of DSPs for mental disorders. Further, substance misuse problems included in some definitions of CMD are not captured by the K10; however, other data sources, such as the National Drug Strategy Household Survey, suggest that overall rates of substance misuse did not increase in Australia during the period of our study.20 Our assessment of DSP rates was based on administrative data, and relied on the recorded primary diagnosis. Receiving a disability pension may often depend on a combination of factors, and we had no information about non-primary diagnoses. Finally, we used the number of Australians aged 16–64 years as the denominator for calculating DSP rates, but the age pension eligibility age for women varied slightly during the study period; further, a very small proportion of DSP recipients remained on this benefit after turning 65. However, the numbers of people involved would have been very small, and should not have affected our results significantly.

We found no increase in psychological distress and probable CMD in Australia over the past decade, a result consistent with findings from large national surveys conducted in the USA,11 the UK,21 and the Netherlands.12 Interestingly, our findings conflict with two earlier studies of the prevalence of CMDs in Australia. Goldney and colleagues10 reported that the prevalence of major depression increased significantly between 1998 and 2008, although their study examined a South Australian population that may have had different demographic features from ours. In contrast, the NSMHWB found that CMD prevalence decreased by 20% between 1997 and 2007;16 the decline might, however, be explained by the use of different versions of diagnostic tools across the survey periods.

Despite the constant prevalence of probable CMD over the past ten years, we observed a significant increase in the proportion of people receiving DSPs for psychological or psychiatric medical conditions, consistent with findings in other developed countries.6,22 We propose four possible explanations for the conundrum of an increasing discrepancy between rates of mental health symptoms and the level of work disability attributed to mental illness.

Firstly, there could have been a change in labelling the causes of disability; practitioners may now be more inclined to apply the diagnostic labels of psychiatric disorders, or to identify the main cause of disability as a mental disorder when it is comorbid with physical disorders. The corresponding decrease in the proportion of disability benefits for some other common comorbid conditions, such as musculoskeletal problems, indirectly supports this possibility.22 That is, the apparent rise in the rates of disability attributed to mental disorders may reflect a correction of their historically being under-reported.

Secondly, the apparent rise in disability attributed to mental illness may reflect policy changes. Australians may receive any of a range of different income support payments, according to their personal or family circumstances and to whether they are temporarily unemployed or are deemed unfit for work because of a disability or impairment. In spite of the notional separation between different support types, it has been reported that many people with mental illnesses receive income support payments other than a DSP.23 A range of policy initiatives in Australia have attempted to promote greater connection between those on income support and potential work opportunities, an unintended consequence of which may have been to transfer people with mental health problems from more work-focused income support payments to schemes such as the DSP.23

Thirdly, it is possible that workplaces in Australia are becoming less tolerant of CMDs because of the changing nature and demands of contemporary work or because of social stigmas, forcing more people with CMDs to leave the workforce.

The final possibility is that the incidence of CMDs may be increasing, but this has been offset by the increased use of treatments that effectively control symptoms without having a substantial effect on functional outcomes. It has been reported, for instance, that pharmacological and non-pharmacological interventions significantly reduced the symptoms of depression, although their impact on the patient’s capacity to work was relatively small.24

Our findings are reassuring in that they provide robust evidence that the popular perception of an epidemic of CMDs in Australia is mistaken. However, the fact that functional impairment associated with mental health problems nevertheless continues to rise is a paradox. While the increase may reflect better recognition of and greater willingness to diagnose mental disorders in working Australians, it also means that greater emphasis on and more research into improving occupational outcomes for people with mental illness are needed.

Box 1 –
Age-standardised prevalence of probable common mental disorders (CMDs) in the Australian working age population, 2001–2014

Box 2 –
Prevalence of probable common mental disorders (CMDs)* in different age bands of the Australian working age population, 2001–2014

Age group (years)

Prevalence of probable common mental disorders (95% CI)

2001

2004

2007

2011

2014

P^†

18–24

16.3% (14.5–18.1)

15.5% (13.8–17.2)

11.8% (10.1–13.5)

11.8% (10.0–13.6)

15.4% (13.3–17.5)

0.052

25–34

13.2% (12.1–14.3)

11.8% (10.7–12.9)

12.3% (11.1–13.6)

10.9% (9.7–12.1)

0.002

35–44

12.9% (11.9–13.9)

14.0% (12.9–15.1)

11.5% (10.4–12.6)

10.9% (9.8–12.0)

11.9% (10.7–13.1)

0.007

45–54

12.7% (11.6–13.9)

13.5% (12.4–14.6)

13.2% (12.0–14.4)

11.4% (10.2–12.6)

12.4% (11.1–13.7)

0.12

55–64

11.7% (10.4–13.0)

12.2% (11.0–13.4)

13.2% (11.9–14.5)

10.4% (9.2–11.6)

11% (9.8–12.3)

0.08

Total (18–64 years)

13.3% (12.7–13.8)

13.4% (12.8–13.9)

12.4% (11.9–13.0)

11.1% (10.5–11.6)

12.2% (11.6–12.8)

< 0.001

* K10 score ≥ 22. † Cochran–Armitage trend test.

Box 3 –
Proportion of working age Australians receiving disability support pensions (DSPs), 2001–2014; age-standardised

Federal money announced for doctors’ mental health

Health Minister Greg Hunt will work directly with doctors to develop a mental health care package for the medical profession.

Addressing the AMA National Conference on May 26, Mr Hunt (pictured) said a recent spate of young doctor suicides – including that of Deputy Chair of the AMA Doctors-in-Training Council Dr Chloe Abbott – has been a cause for great concern.

The Minister said that after speaking with AMA President Dr Michael Gannon and former President Dr Mukesh Haikerwal, he was determined to develop a mental health package targeting doctors.

“One of the main things we introduced in the Budget was prioritising mental health. For the first time, this has been raised to the top level as one of the four pillars of the long-term national health Plan,” Mr Hunt said.

“And we were able to invest significantly in mental health, both in the election, but in particular, in the Budget as well. There’s a very strong focus on suicide prevention with support for suicide prevention hotspots and an $11 million initiative, but also complementing that with the rural telehealth initiative for psychological services.

“Much of this is deeply important preventive health work on the mental health side and it goes with what has to happen in, I think, the medical work force. The case of Chloe Abbott was outlined and I’m aware that many people have been affected by Chloe’s loss, as well as others.

“And Michael and I have been speaking this week, and also been speaking in recent weeks with Mukesh Haikerwal, and I am determined to offer a partnership with the Government and the AMA for us to provide new investment directly into caring for carers.

“And so I want to announce that we will offer a partnership going forward and we will develop the suicide prevention, mental health programs with the AMA and the broader medical work force for suicide prevention and mental health support, specifically for doctors and other medical work force professionals.

“One of the critical roles that you have is psycho-social services. There’s the clinical work with those with mental health issues, but then there is the support services.”

The Minister offered few details of the partnership, stressing that it was still in its conception stage.

But he was determined to take action.

Following his address to the conference, he spoke more to the media about the plan.

“There have been some terrible tragedies in the sector. Michael Gannon and other doctors, Mukesh Haikerwal, have talked to me about that,” he said.

“What we’ll be doing is developing a caring for carers package which will be assisting with specialist channels, because sometimes, and this is what’s been explained to me, those who are doctors or nurses (a) will feel that they shouldn’t be seeking help even though they’re just the same as everybody, and (b) they might feel professionally uncomfortable. Even though they might be in the depths of despair they’ll still feel that professional discomfort at reaching out.

“And so if they have some specialised services for them then they will feel more comfortable, we hope, and that’s what’s been proposed by the profession.”

He did not know if the plan would address the mandatory reporting lines, where doctors might fear they would be reported to the Medical Board when they seek help.

He also promised funds to the partnership, but could not say how much at this stage.

“There’s been no proposal put to me yet, but as I’ve said, in designing of this, what I really want to do is work with the AMA and the GPs,” he said.

“What we’re doing is we’re designing together, and from that we’ll have the outcome.”

This article was originally published in Australian Medicine. Read the original piece here.

Doctorportal hosts a dedicated doctors’ health service providing support in the medical community.

What links anxiety, depression and insomnia

Good sleep is essential for our mental well-being. Just one night of disturbed sleep can leave us feeling cranky, flat, worried, or sad the next day. So it’s no surprise sleeping problems, like difficulty falling asleep, not getting enough sleep, or regularly disrupted sleep patterns, are associated with anxiety and depression.

Anxiety and depression, which can range from persistent worry and sadness to a diagnosed mental illness, are common and harmful.

Understanding the many interacting factors likely to cause and maintain these experiences is important, especially for developing effective prevention and treatment interventions. And there is growing recognition sleep problems may be a key factor.

Which problem comes first?

The majority of evidence suggests the relationship between sleep problems and anxiety and depression is strong and goes both ways.

This means sleep problems can lead to anxiety and depression, and vice versa. For example, worrying and feeling tense during bedtime can make it difficult to fall asleep, but having trouble falling asleep, and in turn not getting enough sleep, can also result in more anxiety.

Sleep disturbance, particularly insomnia, has been shown to follow anxiety and precede depression in some people, but it is also a common symptom of both disorders.

Trying to tease apart which problem comes first, in whom, and under what circumstances, is difficult. It may depend on when in life the problems occur. Emerging evidence shows sleep problems in adolescence might predict depression (and not the other way around). However, this pattern is not as strong in adults.

The specific type of sleep problem occurring may be of importance. For example, anxiety but not depression has been shown to predict excessive daytime sleepiness. Depression and anxiety also commonly occur together, which complicates the relationship.

Although the exact mechanisms that govern the sleep, anxiety and depression link are unclear, there is overlap in some of the underlying processes that are more generally related to sleep and emotions.

Some aspects of sleep, like the variability of a person’s sleep patterns and their impact on functioning and health, are still relatively unexplored. More research could help further our understanding of these mechanisms.

Sleep interventions

Disentangling which problems come first, and under what circumstances, is difficult.
masha krasnova shabaeva/Flickr, CC BY

The good news is we have effective interventions for many sleep problems, like cognitive behaviour therapy for insomnia (CBT-I).

So there is the possibility that targeting sleep problems in people who are at risk of experiencing them – like teenagers, new mothers and people at risk for anxiety – will not only improve sleep but also lower their risk of developing anxiety and depression.

Online interventions have the potential to increase cost-effectiveness and accessibility of sleep programs. A recent study found a six-week online CBT-I program significantly improved both insomnia and depression symptoms. The program included sleep education and improving sleep thoughts and behaviours, and participants kept sleep diaries so they could receive feedback specific to their sleep patterns.

We’re conducting some research to improve and even prevent physical and mental health problems early in life by targeting sleep problems. Using smart phone and activity tracker technology will also help tailor mental health interventions in the future.

General improvements to sleep might be beneficial for a person with anxiety, depression, or both. Targeting one or more features common to two or more mental disorders, like sleep disturbance, is known as a “transdiagnostic” approach.

Interventions that target transdiagnostic risk factors for anxiety and depression, like excessive rumination, have already shown some success.

A good foundation

For many people, treating sleep problems before treating symptoms of anxiety and depression is less stigmatising and might encourage people to seek further help. Addressing sleep first can develop a good foundation for further treatment.

For example, people with a depressive disorder are less likely to respond to treatment and more likely to relapse if they have a sleep problem like insomnia.

Many of the skills learned in a sleep intervention, such as techniques for relaxation and reducing worry, can also be used to help with daytime symptoms of both anxiety and depression. And this is not to mention the physical benefits of getting a good night’s sleep!

If you’re concerned about your sleep or mental health, speak to a health care professional such as your GP. There are already a number of effective treatments for sleeping problems, depression and anxiety, and when one is treated, the other is likely to improve.

And with research in this area expanding, it’s only a matter of time before we find more ways to use sleep improvement interventions as a key tool to enhance our mental health.

Professor Emeritus John Trinder contributed to this article.

Joanna Waloszek, Postdoctoral Research Fellow in Psychology, University of Melbourne and Monika Raniti, Master of Psychology (Clinical)/PhD Candidate, University of Melbourne

This article was originally published on The Conversation. Read the original article.

Coronary occlusion, denial and dissociation

A doctor puts emotions aside in an emergency, but dissociation does not help when the illness is in the family

The speedometer reads 160 km/h. I am driving. My husband Anthony is in the passenger seat. He groans and writhes clutching his chest in that classic closed-fist gesture. We are two rural general practitioners in personal crisis. It is only 45 minutes since he won a bike race in the mountains.

The paramedics know we are coming. We round a bend. There is the ambulance. Both vehicles stop. His blood pressure is 80/40. His pulse is 42. They do an electrocardiogram and hand it to me. “Oh, no ST elevation,” I say, relieved. One. They snatch it back. “There’s elevation everywhere.” I am dismissed.

The paramedic regional manager arrives. He says they’ll thrombolyse here. Anthony is saying, “I want a hot cath.” This is ridiculous; soon the charade will stop. He is not having a heart attack. Two.

Our adult children who followed in another car are here now and standing on the roadside like white posts. I return to the ambulance. The paramedics are injecting tenecteplase intravenously. They have given morphine. Anthony’s groaning continues. They give more morphine, antiemetic, morphine, close the doors and drive the 5 minutes to the hospital where the protocol is completed. His myocardium throws off some cardiac arrhythmias as it reperfuses.

The subsequent urgent coronary angiogram shows only minimal irregularity at the origin of the left anterior descending coronary artery. It seems that this small plaque ruptured and a clot formed during his extreme effort racing to the finish line. No clot can now be seen. Perhaps if he was less fit, if his heart was less used to contracting in a lactic acidotic environment, it might have stopped. He has had an acute myocardial infarction though; even I must admit that. I must.

So there we are, husband and wife, lovers, the parents of four children, co-workers and protagonists in many a clinical argument. He, wired and dripped with tenecteplase bruises spreading like black flowers on his limbs, is forcedly chipper. I sit holding his hand with a strained smile. I ask what I should do about the conference trip to South Korea in 3 days’ time. I am an invited keynote speaker. He says, “Oh of course you should go.” I say, “Yes, of course.” “Grace will be here with me,” he says. “I’ll be fine.” Grace is our 21-year-old daughter. “Oh yes,” I say. We agree that he’s through the worst. Three. I don’t want him to think I am worried about him. I think I mustn’t fuss. Four.

My time in Korea passes in a disconnected blur. Everything I care about is too far away. I can’t even pray. Then I am on the plane heading home. When I arrive we are formal with each other. He might break. I might break. The whole world might break.

One day I look at him and say, “You could have died.” “I knew that,” he replies. What confounds me was that I did not. What use was all my training if I could not see the ST elevation in my beloved husband’s electrocardiogram, if I did not have the wisdom to stay by his bed on day three? I made four critical errors in caring for him. Both of us exhibited impaired clinical reasoning.

On reflection, I think that the training to put our emotions aside and get on with the job in an emergency situation did not serve us well in this personal emergency. My job in this instance was to be there emotionally and practically, but I pushed the emotions away and my judgement was affected. I did not acknowledge how close death had been. A month passed before I cried.

In the weeks following his heart attack, whenever anyone asked, Anthony said he felt 97%. I believed him. Months later he admitted that he felt like crap. He tells me that he coped by rationalising, by talking with chosen experts about the pathology, the prognosis, the pharmaceuticals and their risks. For a while he claimed that he didn’t have an acute myocardial infarction; he had a “coronary occlusion”. As our children say, “Whatever…”. His task was to discover his path through life under this shadow, whatever it is called.

I misrepresented, denied and dissociated from the emotionally loaded information I was attempting to process. When that happens, personal decision making is impaired. Seriously.

Reducing the burden of neurological disease and mental illness

The key to finding solutions for brain disorders is cooperation and collaboration, from the laboratory to the clinic

Australia is challenged by the rising economic and social costs of neurological disease and mental illness, which together account for one-third of the total disease burden in Australia.1 The financial cost of these disorders — about $45.5 billion annually1–4 — does not take into account the emotional impact and social isolation they cause. Many are chronic conditions with limited options for even ameliorative treatment, so that research into finding new approaches to their management is urgently needed. Translation of research into improved clinical practice, however, requires a continuum of process, including basic research, application of research findings, clinical trials, and implementation. Involving both basic researchers and clinicians in this process is crucial to its success. The Australasian Neuroscience Society (ANS; www.ans.org.au) recognises this need both by representing neuroscientists and clinicians in Australia and New Zealand active in neuroscience and mental health research, and by acting as a conduit for clinicians to interact more closely with researchers to achieve their shared goals.

This issue of the MJA highlights examples of current progress in the neuroscience of neurological disease and mental health conditions. As discussed by Koblar and colleagues,5 restoring brain function in people who have had a stroke or incurred other damage to the central nervous system remains an area of unmet need. Australian researchers play significant roles in international efforts to develop regenerative neurology; for example, the 2017 Australian of the Year, Professor Alan Mackay-Sim, was recognised for his work in developing stem cell therapies for people with spinal cord injuries. Australians have long played an important role in developing devices for restoring central nervous system function. For instance, the cochlear implant, invented by Professor Graeme Clark and colleagues at the University of Melbourne in 1978, has restored hearing to nearly 350 000 individuals across the world with sensorineural hearing dysfunction. Australians continue to operate at the cutting edge of the development of devices at the brain–computer interface, such as those described in this issue by Rosenfeld and colleagues.6

The burden of neurodegenerative disorders is rising as the Australian population ages. Dharmadasa and her co-authors7 review advances in the treatment of motor neurone disease, including three ongoing Australian clinical trials of potentially neuroprotective therapies; that is, of interventions that aim to slow the progress of the disease, not just provide symptomatic relief.

2017 promises to be an exciting year for accelerating progress in understanding the human brain. Major research projects seeking to deepen our understanding of its function and to translate this understanding into practical therapies are underway in the United States, Europe, Japan, and China, and the number of participating countries is rapidly expanding.8 Australia itself has a national brain project; developed by the Australian Brain Alliance and coordinated by the Australian Academy of Science, it is a collaboration of 28 organisations (including ANS) involved in brain research.9 The Australian Brain Project aims to understand how the brain encodes, stores and retrieves information, and its goals will be the focus of a proposal to be presented to the federal government in 2018. The Australian Brain Alliance also participated in an historic meeting at Rockefeller University (New York) in September 2016 with the goal of promoting collaboration and cooperation between large scale brain research projects around the world.10

The fundamental brain functions investigated by the members of ANS and the Australian Brain Project are intrinsic to our humanity, and they are often compromised by neurological disease and mental illness. Comprehensive understanding of these processes, and of precisely how and why they are disrupted in disease states, will provide us with new opportunities for improving diagnostics and developing more effective therapies that enhance the lives of the many Australians burdened by these disorders.

Indexation freeze hits veterans’ health care

A recent survey of some AMA members has highlighted the impact of the Government’s ongoing indexation freeze on access to Department of Veterans’ Affairs (DVA) funded specialist services for veterans.

The DVA Repatriation Medical Fee Schedule (RMFS) has been frozen since 2012.

The AMA conducted the survey following anecdotal feedback from GP and other specialist members that veterans were facing increasing barriers to accessing specialist medical care.

Running between March 3 and 10, the survey was sent to AMA specialist members (excluding general practice) across the country.

It attracted interest from most specialties, although surgery, medicine, anaesthesia, psychiatry and ophthalmology dominated the responses.

More than 98 per cent of the 557 participants said they treat or have treated veterans under DVA funded health care arrangements.

For the small number of members who said they did not, inadequate fees under the RMFS was nominated as the primary reason for refusing to accept DVA cards.

When asked, 79 per cent of respondents said they considered veteran patients generally had a higher level of co-morbidity or, for other reasons, required more time, attention and effort than other private patients.

According to the survey results, the indexation freeze is clearly having an impact on access to care for veterans and this will only get worse over time.

Table 1 highlights that only 71.3 per cent of specialists are currently continuing to treat all veterans under the DVA RMFS, with the remainder adopting a range of approaches including closing their books to new DVA funded patients or treating some as fully private or public patients.

If the indexation freeze continues, the survey confirmed that the access to care for veterans with a DVA card will become even more difficult.

Table 2 shows that less than 45 per cent of specialists will continue to treat all veterans under the DVA RMFS while the remainder will reconsider their participation, either dropping out altogether or limiting the services provided to veterans under the RMFS.

In 2006, a similar AMA survey found that 59 per cent of specialists would continue to treat all veteran patients under the RMFS.

There was significant pressure on DVA funded health care at the time, with many examples of veterans being forced interstate to seek treatment or being put on to public hospital waiting lists.

The Government was forced to respond in late 2006 with a $600m funding package to increase fees paid under the RMFS and, while the AMA welcomed the package at the time, it warned that inadequate fee indexation would quickly erode its value and undermine access to care.

In this latest survey, this figure appears likely to fall to 43.8 per cent – underlining the AMA’s earlier warnings. The continuation of the indexation freeze puts a significant question mark over the future viability of the DVA funding arrangements and the continued access to quality specialist care for veterans.

The AMA continues to lobby strongly for the lifting of the indexation freeze across the Medicare Benefits Schedule and the RMFS, with these survey results provided to both DVA and the Health Minister’s offices. The Government promotes the DVA health care arrangements as providing eligible veterans with access to free high quality health care and, if it is to keep this promise to the veterans’ community, the AMA’s latest survey shows that it clearly needs to address this issue with some urgency.

Chris Johnson

Table 1

Which of the following statements best describes your response to the Government’s freeze on fees for specialists providing medical services to veterans under the Repatriation Medical Fee Schedule (RMFS):
Answer Options	Response Percent
I am continuing to treat all veterans under the RMFS	71.3%
I am continuing to treat existing patients under the RMFS, but refuse to accept any more patients under the RMFS	9.9%
I am treating some veterans under the RMFS and the remainder either as fully private patients or public patients depending on an assessment of their circumstances	10.8%
I am providing some services to veterans under the RMFS (e.g. consultations) but not others (e.g. procedures)	5.6%
I no longer treat any veterans under the RMFS	2.4%

Table 2

Which of the following statements best describes your likely response if the Government continues its freeze on fees for specialists providing medical services to veterans under the RMFS:
Answer Options	Response Percent
I will continue to treat all veterans under the RMFS	43.8%
I will continue to treat existing patients under the RMFS, but refuse to accept any more patients under the RMFS	15.5%
I will treat some veterans under the RMFS and the remainder either as fully private patients or public patients depending on an assessment of their circumstances	21.1%
I will provide some services to veterans under the RMFS (e.g. consultations) but not others (e.g. procedures)	8.4%
I will no longer treat any veterans under the RMFS	11.2%