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SSRIs do not increase teen suicide risk: study - ■ Gemma Collins  - 6Minutes

Antidepressants do not increase the risk of suicide among adolescents, a study suggests.

An analysis of data from 41 clinical trials involving more than 9,000 adults and adolescents found that there was no evidence of an increased suicide risk in young people taking fluoxetine.

The study published in the Archives of General Psychiatry also found that the adults who were taking either fluoxetine or venlafaxine had a decreased risk of suicidal thoughts and behaviours.

And in all age groups, severity of depression improved with medication and was significantly related to suicide ideation or behaviour, according to the government-funded study.

The authors found that among the 700 young patients receiving SSRIs, there was a 50% decrease in the probability of suicidal thoughts or behaviour after eight weeks, compared to 61% among control patients.

Young patients receiving fluoxitine decreased their depressive symptoms more quickly than patients receiving placebo.

“Despite a strong association between depression severity and suicide risk in youths, treatment with fluoxetine was not found to be related to suicide risk when compared with placebo”, the authors conclude.

However the authors do point out that their findings are limited to fluoxetine only.

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Doubts over early intervention for psychosis - ■ Michael Woodhead 
- 6 Minutes

A major trial has prompted calls for a re-appraisal of the antipsychotic “early intervention” model for schizophrenia after it found low transition rates to psychosis and significant benefits from early intervention for psychosis. 

While Australian psychiatrists including Professor Patrick McGorry have championed early intervention for people at high risk of psychosis, a study of 288 such patients in the UK found that transition rates were only around 8% and many patients recovered without any active treatment.

The study, in the BMJ (online April 5) found that early intervention with CBT did not reduce the already low rates of transition or symptom-related distress, but it was effective in reducing the severity of psychosis.

The study authors say the lack of any effect of early intervention on transition to psychosis is disappointing, but the low transition rates are reassuring and show that young people can be given “an important and optimistic message” about their prognosis.

“Our observations also suggest that a review of the ultra high risk strategy ... is required,” they say.

The findings show it is highly premature to consider adding a “psychosis risk” category to DSM diagnostic criteria, and also put in question the ethics of using antipsychotics in young people deemed at high risk of psychosis. 

“We would suggest that antipsychotics are not delivered as a first line treatment to people meeting the criteria for being in an at-risk mental state,” they conclude.

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Perinatal depression justifies SSRI use - ■ Kate Cowling - 6Minutes

Cautious use of SSRIs during pregnancy may be preferable to medication discontinuation, new beyondblue guidelines suggest.

However, the risks and benefits should ultimately be discussed on a case-by-case basis, according to new NHMRC-endorsed guidelines launched by Minister for Mental Health and Ageing, Mark Butler, this week.
 

The recommendations note that there have been only limited studies into the efficacy of antidepressants in pregnancy, and some evidence indicates that maintaining rather than discontinuing medication reduces the chance of relapse.

However, preterm births and low birth weights have been linked to use of antidepressants such as SSRIs as well as benzodiazapines and antipsychotics.
 

“While there are risks associated with the use of psychotropic medications in this period, it should not be assumed that it is always better to avoid medication,” the guideline authors say.

The use of antidepressants during the perinatal period also needs to be weighed against minimal possible exposure to the infant during breastfeeding, the guidelines say.
 
Other recommendations from the "Clinical Practice Guidelines for Depression and Related Disorders – Anxiety, Bipolar and Puerperal Psychosis – in the Perinatal Period" include routine assessment of emotional health and wellbeing during both pregnancy and the following year as part of GP management. They also recommend that women with perinatal depression have access to CBT and other non-drug therapies.

SSWAHS = SWSLHD + SLHD and the Medicare Locals - 72

Loss of divisions' support will hit rural GPs - ■ Michael Woodhead - 6Minutes

Rural areas may see an exodus of GPs if Medicare Locals do not maintain the support services to GP practices that have been provided by divisions, a Senate inquiry has heard.
 

Chris Mitchell, CEO of Health Workforce Queensland, says GPs are becoming “disenfranchised” in the transition to Medicare Locals as GP divisions have their funding terminated.

Speaking at a Senate rural health hearing in Townsville, Mr Mitchell said GP practices had relied heavily on divisions for areas such as IT support.
 

“The divisions did a lot of boutique work for practices and I do not think that stuff is going to continue [with Medicare Locals].
 

The IT support in some of these divisions has been sensational and it has kept those GP businesses going ... But I am not sure that that is going to continue,” he told the hearing. Mr Mitchell said the town of Weipa was likely to lose its GP practice because the GP division in Cairns that had supported the practice had lost its funding and been replaced by a Medicare Local.
 
He said Medicare Locals were preoccupied with setting up and focusing on developing after hours care and population planning programs rather than on support for local practices.

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Why do smokers wait until it is too late? - Dr Viv - 6Minutes

Smoking makes me angry. Of course, there’s nothing novel or innovative in that statement, and everything that I am about to write has been said many times before. And probably by
me!
 
But, by chance, I’ve had a recent run of smoking related deaths and severe morbidity in my practice, and I’m beginning to become frustrated at the futility of anti smoking campaigns, and at the willingness of my patients, friends and work colleagues to give up fifteen years of their lives, and a substantial portion of their hard earned income to the cigarette companies.
 
My mind hearkens back to the early days of debate about seatbelt legislation. (Yes, that’s how old I am). “If I want to take the risk, and not wear a seatbelt, it’s my civil right as an individual, and affects no one but myself”.
 
The hospital wards and cemeteries are full of people who have made the “individual choice” to smoke. The emotional cost to their loved ones is huge, as they spend their long awaited retirement caring for permanently disabled spouses, or grieving prematurely for the years of which they have been robbed.
 
The perplexing part for me is the complete inability to give up the smokes – that is, until they get the dreaded diagnosis. Suddenly, after numerous failed attempts, they can inevitability give up in one day. Unfortunately, by this stage, it’s usually too late, and all the regrets in the world do not give them back the lost years.
 
Joan had her first brush with lung cancer fifteen years earlier. By the time she finally managed to give up, she had her second,complete with metastases. Admittedly she was well advanced in years, and some might say “well, you’ve got to die of something”!
 
But Joan’s death was painful and drawn out,and came soon after nursing her terminally ill husband. She had planned to travel, and finally enjoy all the grandchildren. Cigarettes robbed her of that chance.
 
Barry is only in his early seventies. A loving husband, father and grandfather, he loved his fishing and his work in the Lions’ Club. I tried for years to get him to give up the smokes. He couldn’t. The day that I diagnosed his lung cancer with cerebral metastases, he stopped smoking – easily. He doesn’t miss it. He can now no longer drive, fish or make independent decisions. The brain secondaries are killing him by inches. He should have had another fifteen happy years.
 
Charles died of emphysema. His last ten years were spent in a chair, too dyspnoeic to walk. He repeatedly offered to visit schools to espouse the evils of smoking, thinking that one look at him would deter the children from ever lighting up. It probably wouldn’t have worked, and he couldn’t even manage a sentence without oxygen, so it didn’t happen.
 
I recently attended a funeral of a young mother who died of a smoking related illness. As the hearse departed, her devastated eldest daughter lit up a smoke, as did many of the
mourners. I just don’t get it.

Dr Viv is a rural GP

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Active surveillance urged for prostate cancer - ■ Michael Woodhead - 6Minutes

The anxiety-provoking term “cancer” should be modified for patients with low grade prostate pathology who have favourable outcomes, according to new advice released this week.

A consensus statement from the National Institutes of Health (NIH) in the US notes that most of PSA screen-detected cases of cancer are now low-risk and are unlikely to cause death.

It says the natural history of prostate cancer has changed dramatically in the past three decades because of PSA screening, and about two thirds of men with prostate cancer are currently diagnosed with Gleason 6 scores.

The NIH statement says curative treatment of low-risk prostate cancer with radical prostatectomy or radiation therapy leads to side effects, such as impotence and incontinence, in a substantial number of patients.

In recent years, active surveillance has emerged as a viable option that should be offered to patients with low-risk prostate cancer, according to the statement published in the Annals of Internal Medicine.

Although no randomised clinical trials have assessed whether patients who undergo active surveillance have better or worse outcomes than those who receive immediate curative treatment, there have been reassuring results with cohort studies, the statement says.

“Early results demonstrate disease-free and survival rates that compare favourably with those reported for curative therapy.” The NIH statement emphasises that active surveillance is not the same as “watchful waiting”, and involves follow-up assessments including PSA levels, digital rectal examination, and repeat biopsy.

However, the NIH panel of clinicians express particular concern about the complications from image-guided transrectal biopsies of the prostate.

“Standardised protocols need to be developed to minimize the frequency and intervals of biopsies and to reduce associated pain and infection rates,” they suggest.

The consensus statement also notes that there are still unanswered questions about active surveillance strategies for prostate cancer, which require further research and clarification.

“These include improvements in the accuracy and consistency of pathologic diagnosis of prostate cancer, consensus on which men are the most appropriate candidates for active surveillance, the optimal protocol for active surveillance and the potential for individualizing the approach on the basis of clinical and patient factors, optimal ways to communicate the option of active surveillance to patients, methods to assist patient decision making, reasons for accepting or rejecting active surveillance as a treatment strategy, and short- and long-term outcomes of active surveillance.”

SWSLHD and Bowral's Health - 69

After-hours care falls short

BY ISABELL PETRINIC

17 Apr, 2012 12:00 AM

IF you need a doctor between 11pm and 7am you must go to an emergency room at Blacktown, Hornsby or Hawkesbury public hospital and join the queue.
There's always the phone (nurses and GPs give advice on the National After Hours GP Helpline) or you can visit Norwest Private's emergency department, where fees are not reimbursable — even for those who are privately insured.

There are only 55 general practices open for 10 or more hours a week during the after-hours period but that is across all western Sydney (264 of a total of 303 practices were contacted) — nowhere near enough, according to medical educators WentWest.

WentWest have found through careful analysis of western Sydney's health needs that in Rouse Hill there are no practices open after-hours and in the semi-rural area above Glenorie even a registered home-visiting is not available.

Parramatta's north-east is serviced by only one practice providing after-hours service — at Epping — and Baulkham Hills North could do with chemists that open longer.
But the real problem is finding GPs to work outside normal hours.

The five doctors' rooms at Round Corner Medical Centre in Dural operate at 95 per cent capacity with 12 GPs on rotation, but doctors find it difficult to cope with demand after hours, even turning people away on Sundays.
The centre began operating after hours three years ago with financial assistance from the federal government.

Peter Szekely, the centre's financial officer, said they aim to stay open until 9pm weekdays and 5pm on Saturday and Sunday.
The ideal, he said, would be to stay open till 10pm every night.

"But we don't always have doctors available to do these hours," Mr Szekely said.

"At the moment the only weeknights we can do are Monday and Thursday.

"If we could expand the premises we would, but we can't, so the only thing we can do is expand the hours."

Mr Szekely praised the GP placement program, saying two junior doctors had stayed on at his centre, and saw this as encouraging.

Dural is among the many suburbs in The Hills identified by the Department of Health and Ageing as being in a district of workforce shortage, defined as an area of Australia in which the population's need for healthcare has not been met.

The others are Annangrove, Beaumont Hills, Bella Vista, Kenthurst, Oatlands and Rouse Hill.

Beaumont Hills and Rouse Hill are also among the growth suburbs in The Hills, which is of major concern given The Hills population is expected to rise 1.94 per cent every year until 2031, bringing the total population from 177,245 to 255,270 people - a rise of 44.02 per cent — over the next 19 years.

WentWest will submit its first after-hours plan to the Department of Health and Ageing in May, highlighting these and other service gaps in the Western Sydney Local Health District, which stretches from Auburn in the east to Blacktown in the west and to The Hills in the north.

 

Medicare Local defines after-hours as:

1. before 8am and after 6pm weekdays;
2. before 8am and after noon Saturdays;
3. all day Sundays and public holidays.

After-hours is further divided into:

1. the unsociable after-hours period of 11pm to 7pm; and
2. the sociable after-hours period which is all other after-hours times.
   A map showing the current District of Workforce Shortage areas is available at: http://www.doctorconnect.gov.au/i nternet/otd/Publishing.nsf/Conten t/locator
   
   
   Socrates says: While this article details the issues for the north-west of Sydney it can be replicated even more so for  rural and regional areas like the Southern Highlands.

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Woman's treatment 'tragic', inquest told

• From: AAP
• April 16, 2012 2:23PM

A SYDNEY mother was discharged from hospital after falling victim to a "comedy of errors" that ended in her death from multi-organ failure, an inquest has been told.

Marie Haywood, 43, was admitted to Campbelltown Hospital on December 21 when she had fluid drained from her abdomen due to a chronic liver condition.

Mrs Haywood, who had been on the liver transplant list since August of that year, was also diagnosed with pneumonia and given increasing levels of morphine and other pain medication, a coronial inquest heard today.

By Christmas Day she told nurses that she was "always in pain", counsel assisting the coroner Kristina Stern told Glebe Coroner's Court.

On Boxing Day, when she was discharged, Mrs Haywood reportedly complained of chest pain and having a red, pussy wound where a cannular had been inserted.

She had also vomited and was having trouble walking.

On the same day, blood test results showed a clear deterioration in her renal function.

"It appears that no one actually checked those results ... and they were not taken into account," Ms Stern said in her opening address.

"The only doctor that had physical contact with her was an intern who had no experience of her case."

She was discharged despite test results showing that her "overall condition had clearly deteriorated during her admission", Ms Stern added.

Mrs Haywood wasn't given a discharge summary or plan, and the doctor who signed off on her discharge did not physically review her.

Her condition worsened and she returned to hospital with her husband 16 hours later.

When she died on December 29 her primary cause of death was listed as multi-organ failure.

In a report read to the inquest, Professor David Morris described Mrs Haywood's time in hospital from December 21 to 26 as a "comedy of errors" that ended in her "spiralling into multi-organ failure".

He said the lack of co-ordination and communication between medical staff was ``tragic'', and the managing of her urine was "seriously inadequate".

Speaking outside the inquest, her husband John Haywood said he hoped the coronial investigation would result in improvements to the way hospitals are run.

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Mental health patients lose out under new funding plan

Anna Patty

February 23, 2012

 

"The architect of a new system of activity-based hospital funding to be introduced in NSW this year says it can't be applied to mental health care". Photo: Tamara Voninski

MENTAL health patients would be seriously disadvantaged under hospital funding arrangements to be introduced in July, health authorities have warned.

The architect of a system of hospital funding to be introduced in NSW this year says it can't be applied to mental health care.

Leading psychiatrists have also raised serious concerns the new system of ''casemix'' funding will dismantle mental health services and encourage patients to use hospital emergency departments instead of community care.

NSW hospitals receive block grants each year under the existing funding system. Under the new casemix system to be introduced in July, hospitals will be funded on the basis of a fixed cost for each medical procedure, such as hip replacement or a birth.

While the cost of a prosthesis can be easily predicted, the cost of treating a mental health patient is much harder to forecast because the length of hospital stay can vary from days to months.

Professor Kathy Eagar, the executive director of the national casemix and classification centre at the University of Wollongong, is in charge of developing the clinical codes for the new casemix classification system.

In a submission to the Independent Hospital Pricing Authority on the national pricing framework, she says the casemix classification system must allocate a fixed cost to be fair and transparent. However she says mental health costs cannot be predicted.

Professor Eagar, who is developing clinical coding to be introduced in 2013, says the mental health category is the ''worst performer'' of the whole classification system.

She recommends mental health be recognised as a distinct form of care to separate it from the care given to other patients treated in the same hospital ward.

Professor Alan Rosen, a psychiatrist from the universities of Sydney and Wollongong, said mental health should continue to be funded under block hospital grants and not on a casemix basis, until it was fixed, because the existing system would fragment care and make it hospital-centred..

Tony Sherbon, the chief executive of the Independent Hospital Pricing Authority, said he recognised the existing system was inadequate when applied to mental health care. But he said the ''sky won't fall in'' when it is introduced, despite calls from psychiatrists for mental health to be exempted for a year until the problems with casemix can be fixed.

''The casemix [funding arrangement] for 2012-13 will involve mental health inpatient emergency department attendances and outpatient services, which is an enhanced version of what has been operating in Victoria and South Australia,'' he said.

''It needs significant improvement and we will need a new system on July 1, 2013 which will take into account the issues that Professor Rosen has been raising.''

Professor Rosen said he was concerned that casemix may not be updated once introduced.

''They shouldn't even consider starting it that way,'' he said. ''It will encourage people to come into the emergency department to get short-term crisis work because that will be squarely funded by activity-based funding.''

Read more: http://www.smh.com.au/national/health/mental-health-patients-lose-out-under-new-funding-plan-20120222-1to5w.html#ixzz1u2s1lAvI

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Recreational drug use missed in diabetes - ■ Michael Woodhead - 6Minutes

About half of young people with type 1 diabetes have recently used recreational drugs, and this may be affecting the control of their condition, a study suggests.

A national survey of more than 500 young people with diabetes found that 77% had used drugs and 47% had used them recently.

Among users of illicit drugs, the most commonly used substances were cannabis, ecstasy and speed.

Almost 30% of those surveyed were smokers and half were regular drinkers. Drug use also
appeared to be a significant and hidden contributor to poor diabetes control, according to the study published in the Internal Medicine Journal.

The use of drugs was significantly associated with poor glycaemic control and a higher risk of diabetic ketoacidosis, it found. Almost 20% of drug users omitted insulin before drug use and several ecstasy users said they needed to increase their insulin glargine dose by 100-150% to reduce hyperglycaemia.

However, only 7% of drug users with diabetes had informed health professionals about their drug use.

The study authors, from the Garvan Institute in Sydney, say medical staff should elicit a drug history from young diabetic patients in a non-judgemental way, and a drug screening questionnaire may need to be incorporated into routine diabetes care.

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One in five still think antidepressants harmful - ■ Michael Woodhead - 6Minutes

There has been a drop in the number of people who believe antidepressants may be harmful in depression, but this view is still held by one in five Australians.
 
A national survey (link) of more than 2000 Australian adults carried out in 2011 found that about 20% believed that antidepressants would be harmful for a person who is depressed, while 16% believed that antidepressants would be harmful for a person who is depressed and has suicidal thoughts.

Negative perceptions of antidepressant medications were most common among men and
among people from non-English speaking backgrounds, according to researchers from the Orygen Youth Health Research Centre at the University of Melbourne.
 
Writing in the Journal of Affective Disorders, they say belief in the harmfulness of antidepressants appears to have fallen since the last survey was carried out in 2004, when about 25% of people had negative views about the medications. The change to a more positive attitude was most noticeable among younger people and people with lower levels of
education.
 
People with negative views about depression tended to have had less exposure to depression and be less likely to recognise it, they found. Such people also tended to have negative views about all treatments for depression, and they also had overly optimistic views about depression and the possibility of overcoming the illness without professional help.

SWSLHD and Bowral's Health - 64

Troops face mental health risks

• by: Mark Dodd
• From: The Australian
• April 19, 2012 12:00AM

A "PROFOUND" number of Diggers returning from operational deployment in Afghanistan will be afflicted with post-traumatic stress disorder, a senior former army commander has warned.

Major General John Cantwell, who in 2010 served as commander of Australian forces in the Middle East, told the ABC he was concerned the majority of home-bound troops would try to hide the affliction.

The Department of Defence needed to do more to encourage potential sufferers to seek treatment, he told ABC1's Lateline on Tuesday.

His comments followed the announcement on Tuesday by Julia Gillard advancing the timetable for the withdrawal of Australia's 1550 Afghanistan-based troops over the next 18 months.

A total of 26,000 Australian Defence Force personnel have served in Afghanistan since 2004. Since 2001, more than 200 have been wounded in action and 32 killed, most victims of insurgent roadside bombs.

PTSD cases will be most prevalent among troops directly exposed to combat, General Cantwell said.
"We will have a lot of soldiers who have seen a lot of things that they probably wish they'd never seen.

"It's going to mean that you have more people suffering post-traumatic stress disorder and other disorders as a result.

"So it stands to reason we just need to be ready to pick up the pieces and help them get back to a normal life."

The ADF, slow in the past to acknowledge the scope of the problem, is now much better equipped to identify PTSD, said David Forbes, director of the Melbourne-based Centre for Post Traumatic Mental Health.

"The closer you are to the point of threat and the longer it goes on for, there's an increased risk," Professor Forbes said.

"If you are in a combat troop and have had one experience in the course of your deployment, you are probably at the lower risk than a special forces trooper exposed (to combat) on a frequent basis."

However, the closely knit special forces fraternity and their specialised training would help mitigate against PTSD, he added.

SWSLHD and Bowral's Health - 63

Widespread ignorance over antibiotics

• by: Adam Cresswell, Health editor
• From: The Australian
• April 19, 2012 12:00AM

James Best treats Charlie Hutchison as mother Fiona looks on at a medical centre in Summer Hill, Sydney, yesterday Picture: Sam Mooy Source: The Australian

NEARLY half of Australians do not realise that antibiotics kill only bacteria, according to research that suggests widespread ignorance about the drugs may be fuelling the rise of antibiotic-resistant superbugs.

Research by the National Prescribing Service to be released today shows that while more than two-thirds of Australians (69 per cent) understand that overusing antibiotics erodes their effectiveness, less than half (48 per cent) know that failing to complete the prescribed course allows resistance to spread.

Less than one-third (29 per cent) of the 1013 respondents understood that taking antibiotics to combat a viral illness also helped make bacteria more invulnerable to the drugs.
And only 38 per cent knew that taking antibiotics when they were not needed fuelled resistance.
The National Prescribing Service will use the figures to call for greater restraint by both patients and GPs, arguing that the continued spread of resistance within a couple of decades will see a sharp rise in complications and deaths from many operations now regarded as safe.

NPS chief executive Lynn Weekes said mothers with children younger than five appeared to have some of the poorest understanding of sensible antibiotic use, and improving their knowledge was a priority, given they tended to be "health gatekeepers" for the entire family.
"At a summit last year, experts said that by 2030 we will have a situation that looks more like 1830 because antibiotics won't be working against common infections," she said.

The survey shows that while most patients accepted they did not need antibiotics to treat a cold, nearly 80 per cent expected them to be prescribed.

Even when these infections were bacterial, Dr Weekes said antibiotics were not worth taking because they would shave a mere two days from a week-long illness.

James Best, a GP at the Your Doctors practice in Sydney's Summer Hill, said doctors sometimes found it hard to deny an antibiotic prescription to patients who asked for one, particularly if there was a long-standing doctor-patient relationship.
"Or there can be time pressure - it can take time to overcome inappropriate expectations, and sometimes there's a temptation to end the conversation quicker by giving in to the demands," he said.

Fiona Hutchison , whose son Charlie is almost two, said she understood the dangers of overuse and never asked for an antibiotic, but she acknowledged the reassurance a prescription could provide for worried parents.

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Nicotine patches concern for bipolar patients - ■ Kate Cowling - 6Minutes

Caution should be exercised when prescribing nicotine replacement therapies for patients with mental illness, psychiatrists warn, after a patch appeared to trigger a manic episode in a man with bipolar disorder.

Their case report documents the mental deterioration of a 35-year-old man who had a history of bipolar disorder but no “unremarkable” lifestyle changes, except for recently quitting smoking and commencing maximum (21 mg) strength nicotine patches.

After starting the patches, the patient was unable to sleep, became irritable and showed uncontrollable anger and physically aggression, the authors write in the Australia and NZ Journal of Psychiatry.

“The quick resolution of his manic symptoms on a relatively low dose of quetiapine and with the cessation of nicotine patches... suggested a possible correlation between excessive nicotine levels and the precipitation of a manic episode,” they say.

Nicotine may have triggered mania by disrupting the patient’s sleep/wake cycle, or possibly through the stimulation of his dopaminergic system, the psychiatrists suggest.

“The understanding of this potential risk is of clinical relevance given increased use of nicotine patches after the implementation of the non-smoking policy within health settings,” they say.

They add it also highlights the importance of educating patients about potential stimulant and/or overdose effects of nicotine patches.