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Project Synergy aims to test the potential of new and emerging technologies to enhance the quality of mental health care provided by traditional face-to-face services. Specifically, it seeks to ensure that consumers get the right care, first time (delivery of effective mental health care early in the course of illness). Using co-design with affected individuals, Project Synergy has built, implemented and evaluated an online platform to assist the assessment, feedback, management and monitoring of people with mental disorders. It also promotes the maintenance of wellbeing by collating health and social information from consumers, their supportive others and health professionals. This information is reported back openly to consumers and their service providers to promote genuine collaborative care. The online platform does not provide stand-alone medical or health advice, risk assessment, clinical diagnosis or treatment; instead, it supports users to decide what may be suitable care options. Using an iterative cycle of research and development, the first four studies of Project Synergy (2014-2016) involved the development of different types of online prototypes for young people (i) attending university; (ii) in three disadvantaged communities in New South Wales; (iii) at risk of suicide; and (iv) attending five headspace centres. These contributed valuable information concerning the co-design, build, user testing and evaluation of prototypes, as well as staff experiences during development and service quality improvements following implementation. Through ongoing research and development (2017-2020), these prototypes underpin one online platform that aims to support better multidimensional mental health outcomes for consumers; more efficient, effective and appropriate use of health professional knowledge and clinical skills; and quality improvements in mental health service delivery.

Greatly enhanced accountability can drive mental health reform. As extant approaches are ineffective, we propose a new approach. Australia spends around $7.6 billion on mental health services annually, but is anybody getting better? Effective accountability for mental health can reduce variation in care and increase effective service provision. Despite 20 years of rhetoric, Australia's approach to accountability in mental health is overly focused on fulfilling governmental reporting requirements rather than using data to drive reform. The existing system is both fragmented and outcome blind. Australia has failed to develop useful local and regional approaches to benchmarking in mental health. New approaches must address this gap and better reflect the experience of care felt by consumers and carers, as well as by service providers. There are important social priorities in mental health that must be assessed. We provide a brief overview of the existing system and propose a new, modest but achievable set of indicators by which to monitor the progress of national mental health reform. These indicators should form part of a new, system-wide process of continuous quality improvement in mental health care and suicide prevention.

In 2003, the National Heart Foundation of Australia position statement on "stress" and heart disease found that depression was an important risk factor for coronary heart disease (CHD). This 2013 statement updates the evidence on depression (mild, moderate and severe) in patients with CHD, and provides guidance for health professionals on screening and treatment for depression in patients with CHD. The prevalence of depression is high in patients with CHD and it has a significant impact on the patient's quality of life and adherence to therapy, and an independent effect on prognosis. Rates of major depressive disorder of around 15% have been reported in patients after myocardial infarction or coronary artery bypass grafting. To provide the best possible care, it is important to recognise depression in patients with CHD. Routine screening for depression in all patients with CHD is indicated at first presentation, and again at the next follow-up appointment. A follow-up screen should occur 2-3 months after a CHD event. Screening should then be considered on a yearly basis, as for any other major risk factor for CHD. A simple tool for initial screening, such as the Patient Health Questionnaire-2 (PHQ-2) or the short-form Cardiac Depression Scale (CDS), can be incorporated into usual clinical practice with minimum interference, and may increase uptake of screening. Patients with positive screening results may need further evaluation. Appropriate treatment should be commenced, and the patient monitored. If screening is followed by comprehensive care, depression outcomes are likely to be improved. Patients with CHD and depression respond to cognitive behaviour therapy, collaborative care, exercise and some drug therapies in a similar way to the general population. However, tricyclic antidepressant drugs may worsen CHD outcomes and should be avoided. Coordination of care between health care providers is essential for optimal outcomes for patients. The benefits of treating depression include improved quality of life, improved adherence to other therapies and, potentially, improved CHD outcomes.

Mental health policy expert Sebastian Rosenberg and psychiatrist Ian Hickie want more change.

Bipolar disorder follows a staged trajectory in which persistence of illness is associated with a number of clinical features such as progressive shortening of the inter-episode interval and decreased probability of treatment response. This neuroprogressive clinical process is reflected by both progressive neuroanatomical changes and evidence of cognitive decline. The biochemical foundation of this process appears to incorporate changes in inflammatory cytokines, cortisone, neurotrophins and oxidative stress. There is a growing body of evidence to suggest that these markers may differ between the early and late stages of the disorder. The presence of a series of tangible targets raises the spectre of development of rational neuroprotective strategies, involving judicious use of current therapies and novel agents. Most of the currently used mood stabilisers share effects on oxidative stress and neurotrophins, while novel potentially neuroprotective agents are being developed. These developments need to be combined with service initiatives to maximise the opportunities for early diagnosis and intervention.

Reach Out Central (ROC) is a serious game drawing on the principles of cognitive behaviour theory that has been designed to improve the mental health and wellbeing of young people, particularly men. ROC was developed over a 3-year period from 2003 to 2006, in consultation with young people aged 16-25 years who use the Reach Out mental health website http://www.reachout.com). ROC was launched online in September 2007. A traditional and viral awareness campaign was designed to engage young men, particularly "gamers". In the first month after launch, ROC had 76 045 unique website visits, with 10 542 new members (52% male) joining Reach Out. An independent online evaluation involving 266 young people aged 18-25 years was conducted between August 2007 and February 2008 to examine psychological wellbeing, stigma and help seeking in ROC players. Overall results indicated that ROC was successful in attracting, engaging and educating young people. Young women reported reduced psychological distress and improved life satisfaction, problem solving and help seeking; however, no significant changes were observed for young men. Although ROC was successful in attracting young men, demonstrating that the concept resonates with them, the service failed to keep them engaged. Further research is needed to explore how (or what changes need to be made) to sustain young men's engagement in the game.

Objective To explore patterns of internet use by young people in Australia and assess the usefulness of online resources for mental health problems, exploring functionality that may be relevant in the development of online mental health services. Design and participants Cross-sectional survey of a nationally representative sample of young people (2000 randomly selected participants aged 12-25 years), via telephone interview, conducted in January-March 2008. Main outcome measures Patterns of internet use including type of use, social networking, sources of information about mental health, alcohol or other substance use problems and levels of satisfaction with the information, and type of information accessed via websites. Results Young people reported using the internet to connect with other young people (76.9%; 1464/1905) and to seek information about a mental health problem, regardless of whether they had a problem themselves (38.8%; 735/1894). Twenty per cent of young people (398/1990) had personally experienced a mental health problem in the previous 5 years; when these people were asked about sources of information used for this problem, 30.8% (70/227) reported searching the internet. Patterns of internet use and types of resources used differed by age and sex. Conclusion Our findings suggest that technology is important in the everyday lives of young people, and online mental health services that encompass promotion and prevention activities should include a variety of resources that appeal to all ages and both sexes, such as "question and answer" forums and email.

Objective: To determine the feasibility of conducting a cluster randomised trial in Australia of the effectiveness of general practitioner-supported delivery of internet-based cognitive behaviour therapy (CBT) and enhanced psychological care. Design, setting and participants: Cluster randomised trial involving patients attending general practices in Australia. Participating practices were randomly allocated to interventions. The study was conducted between January 2004 and January 2007. Interventions: Enhanced GP care was delivered by doctors who had completed specific mental health training; the experimental condition consisted of enhanced GP care plus MoodGYM, an internet-based CBT intervention. Main outcome measures: Demographic and behavioural characteristics of patients, and demographic and practice characteristics of GPs; time to resolution of psychological symptoms for patients involved in the longitudinal phase of the trial. Results: 1571 patients attending 90 GPs from 84 general practices were identified as potentially suitable for recruitment. These patients had a mean age of 35 years, 76% were female, 84% had access to the internet for personal use, and 22% reported high or very high levels of psychological distress on the Kessler Psychological Distress Scale. The 90 GPs had a mean age of 49 years, 53% were female and 25% had completed formal mental health training. Of the 1571 screened patients, 340 reported high levels of psychological distress, but only 140 of these could be further assessed for eligibility in the trial. Of these 140, 83 patients with depression (attending 10 GPs in eight general practices) proceeded to randomisation. For these patients, the experimental intervention (enhanced GP care plus MoodGYM) tended to result in prompt and more sustained resolution of depressive symptoms. Conclusion: Our capacity to conduct a definitive trial was limited by available resources. Preliminary data suggest that primary care patients with depression may derive additional benefits from an internet-based CBT program delivered in conjunction with enhanced psychological care from GPs.

• Postnatal infection may represent a preventable risk factor for onset of psychotic disorders in adolescence and early adulthood. • The mechanism of action is likely to involve site-directed triggering of the brain's innate immune system, mediated principallythrough localised activation of microglial cells. This triggering may occur in response to systemic inflammatory stimuli, without direct involvement of the central nervous system. • Microglial activation can represent a primary response or a secondary phenomenon at sites made vulnerable by prior injury; that is, areas containing previously activated microglia will respond more strongly to a new stimulus. • The presence of activated microglia is indicative of a recent insult or active disease. It is not characteristic of long-established neurodevelopmental abnormalities. • Activated microglia, acting through a variety of cytokine and other signal systems, have the capacity to significantly interfere with synaptic turnover and thus, over time, alter synaptic architecture and function. • This pathophysiological path should be investigated more systematically as it may explain a novel "neuroprotective" mode of action for some existing antipsychotic compounds.

The aetiology of schizophrenia remains complex, although proposed models have identified genetic markers and environmental pathogens as important risk factors. Researchers have found no large-effect or unique genetic elements, and only a small number of putative environmental agents have been identified. Use of amphetamine-type stimulants (ATSs) is an exemplar environmental pathogen, as it is known to trigger schizophrenia-like illness and other psychotic and manic episodes. To date, the ATS model of illness onset has been under-utilised. It has the potential to reveal key neurobiological elements of schizophrenia and related psychoses. The model proposed here has the capacity to inform detection of those at risk of ATS-related psychoses, and therefore help develop early intervention strategies. It is possible that the same approach may be used in young people known to be at risk of schizophrenia and related disorders, by informing models that involve other environmental or genetic risks.

headspace, Australia's national youth mental health initiative, was created in 2006 in response to the recognition that the existing health system needed to be much more accessible and effective for young people with mental and substance use disorders. With funding of more than $54 million from the Australian Government, a carefully constructed and selected system of 30 "communities of youth services", or integrated service hubs and networks, across the nation is being established, supported by programs for community awareness, workforce training and evidence-based resource material. headspace aims to improve access, and service cohesion and quality, and ultimately health and social outcomes, for young people aged 12-25 years experiencing mental illness and related substance use problems. Within the Council of Australian Governments framework, this will require synergistic planning with, and co-investment on behalf of, state and territory governments, as well as the support and involvement of local communities and the wider Australian society.

Young people experiencing their first onset of depression are a group at risk of relapse and recurrence to whom early intervention and prevention efforts should be targeted. Despite the argument for a significant research effort addressing these issues, the evidence regarding optimal intervention strategies for first episodes is lacking. Cognitive behaviour therapy is an effective approach to treatment and relapse prevention among depressed adolescents, and is likely to be an important component of any evidenced-based approach to early intervention. Antidepressants are not recommended as first-line treatment for most first episodes of depression. The role that they may play in patients with severe depression, or those who do not respond to psychological therapies, requires further evaluation. Given the high prevalence of depressive disorders, and the significant burden of disease they represent within our community, early intervention in depressive disorders is a critical research agenda for the future.

• New Australian government funding for the Better Outcomes in Mental Health Care initiative is a significant step forward for mental health, with general practitioners now able to offer direct referrals to psychologists, social workers, occupational therapists and Aboriginal health workers. • Incentives for better teamwork between GPs and other mental health professionals have been introduced, but may have unintended consequences, including an exacerbation of workforce shortages in rural and remote areas. • Possible solutions to these shortages include rural scholarships for students in the mental health professions; recruitment and retention of students coordinated by university departments of rural health; better access to continuing professional development; and federally funded rural positions and additional financial incentives for rural MJA 2007; 186: 587–589 mental health practitioners.

To explore the experiences of carers and families of people with depression.Structured focus groups conducted in six Australian capital cities between February 2002 and July 2002. Thematic analyses were conducted using the QSR NUD*IST software package for qualitative data.Thirty-seven carers or family members.Thematic analyses highlighted five key themes. Most notably, the carer's role is made more difficult by the lack of community awareness about depression, and, in some instances, an unwillingness of other family and friends to provide ongoing support. Carers experience a resulting sense of isolation, often exacerbated by adverse experiences with healthcare providers. Carers and family members are frequently excluded when key decisions are made, and report that emergency services are relatively unresponsive to their concerns. By contrast, community support organisations usually provided a sense of inclusion and common purpose.The experiences of carers and families of people with depression highlight the urgent need for more extensive community education about the illness and more productive collaboration within the healthcare system.

OBJECTIVES To examine the uptake by general practitioners (GPs) of the five key components of the Better Outcomes in Mental Health Care (BOiMHC) initiative: education and training for GPs; the three-step mental health process; focussed psychological strategies; access to allied health services; and access to psychiatrist support. SETTING All Australian states and territories during the first 15 months of the initiative (1 July 2002 - 30 September 2003). DESIGN Retrospective survey of de-identified registration data held by the General Practice Mental Health Standards Collaboration (training uptake), de-identified Health Insurance Commission (HIC) billing data (provision of the three-step mental health process, focussed psychological strategies and case conferences with psychiatrists), and reports from "access to allied health services" projects to the Australian Department of Health and Ageing (project participation). MAIN OUTCOME MEASURES Number and percentage of Australian GPs certified as eligible to participate in the initiative; provision of the three-step mental health process and focussed psychological strategies by GPs; participation in allied health pilot projects; and access to psychiatrist support. RESULTS Within 15 months of the BOiMHC initiative commencing, 3046 GPs (about 15% of Australian GPs) had been certified as eligible to participate, including 387 who had registered to provide focussed psychological strategies. GPs had completed 11 377 three-step mental health processes and 6472 sessions of focussed psychological strategies. Sixty-nine "access to allied health services" projects had been funded, with the original 15 pilot projects enabling 346 GPs to refer 1910 consumers to 134 individual allied health professionals and 10 agencies. In contrast, the "access to psychiatrist support" component was less successful, with the HIC billed for 62 case conferences at which a psychiatrist and a GP were present. CONCLUSION The level of uptake of the main components of the BOiMHC initiative has expanded the national capacity to respond to the needs of people with common mental disorders, such as depression and anxiety.

To examine trends in types of antidepressant medications prescribed in Australia between 1975 and 2002.Sales data from the Australian pharmaceutical industry were used to examine trends in overall antidepressant prescribing and changes in the types of antidepressants prescribed between 1975 and 2002.Antidepressant sales were expressed as defined daily doses (DDDs) per 1000 people per day, using the estimated Australian population for each year obtained from the Australian Bureau of Statistics.Average annual growth in the sales of antidepressants was 1.1% per year from 1975 to 1990, after which growth rose steeply to reach 29% in 1995. By 2002 the rate of growth had slowed to 6.6%. Eighty per cent of total sales were accounted for by four drugs in 1975, 1980 and 1985; five in 1990; seven drugs in 1995 and 2000; and six drugs in 2001 and 2002.The rapid growth in antidepressant prescribing that was characteristic of the early 1990s, and reflected the emergence of new classes of agents, did not continue into the late 1990s. Selective serotonin reuptake inhibitors now dominate antidepressant prescribing in Australia.

OBJECTIVE: To develop a National Depression Index for measuring the depression status of the Australian population. DESIGN: Cross-sectional data were analysed from two random samples of the Australian adult population - the National Survey of Mental Health and Wellbeing (2000) and the National Health Survey (2001). PARTICIPANTS: The National Survey of Mental Health and Wellbeing (2000) - 10 641 participants; and the National Health Survey (2001) - 17 918 participants. MAIN OUTCOME MEASURES: Selected items from the Kessler Psychological Distress Scale (K10); and diagnoses of a major depressive episode according to DSM-IV criteria using a computerised interview. RESULTS: Six items from the K10 that were most closely related to the DSM-IV diagnosis of "major depressive episode" were identified. Scores on an index calculated from these items were rescaled to form an index reflecting relative risk of depression and having a value of 100 for the Australian adult population. Taking into account sex, employment status and income, index values were higher in younger people, females, unemployed people and those socioeconomically disadvantaged. This pattern provides additional support for the validity of the index, as well as establishing benchmark levels to which index values from future surveys and in other groups may be compared. CONCLUSIONS: The proposed National Depression Index is a valid indicator of depression and level of depressive symptoms. It is suitable for monitoring depression at the population level. The scaling characteristics of the measure ensure that it can be interpreted by members of the general public.

Provision of "Focussed Psychological Strategies" by general practitioners is one component of the recent Better Outcomes in Mental Health Care (BOiMHC) initiative. The BOiMHC initiative requires GPs to undertake minimum training requirements before they may provide services under the new Medicare Benefits Schedule item number. We argue that GPs need further training and ongoing clinical interaction with mental health specialists (beyond the minimum training requirements) for refinement of psychological skills. Research focusing on GP training and how GPs interact with specialist services in the provision of psychological treatments is urgently required.

Objective: To determine if screening in general practice and related medical settings improves management and clinical outcomes in people with depression. Data sources: The Medline (1966-2002), EMBASE (1980-2002) and PsycINFO (1966-2002) databases were searched. These were supplemented by searching the Cochrane databases (to 2002); performing additional specific searches on Medline, EMBASE and PsycINFO; scrutinising reference lists of selected articles; and querying experts. Study selection: Inclusion criteria were: review of prospective studies with a primary focus of depression screening in general practice settings; review of studies of healthy populations or people with known depression; publication in a peer-reviewed journal; and written in English. Eleven reviews that satisfied these criteria were assessed for quality using the Oxman and Guyatt Index. Four reviews met the criterion of a score of five or more. Data extraction: One author tabulated relevant material (including number and type of studies, outcomes/endpoints, measures of association/statistical results, and findings) from the four key reviews. A second author independently checked the accuracy of this extracted material. Data synthesis: Brief self-report instruments have acceptable psychometric properties and are practical for use in general practice settings. Screening increases the recognition and diagnosis of depression and, when integrated with a commitment to provide coordinated and prompt follow-up of diagnosis and treatment, clinical outcomes are improved. Conclusions: Although controversial, the evidence is now in favour of the appropriate use of screening tools in primary care.

To determine the degree of recognition and understanding of depression and its treatments in Australia in 2001, and detail factors and personal experiences that influence awareness of and attitudes to depression.Cross-sectional survey of a representative community sample (900 randomly selected respondents), via telephone interview, conducted 5-7 October 2001.Reports of community awareness, knowledge and attitudes to depression and its treatments in Australia.The Australian community does not view mental health as a major general health issue. When asked specifically, depression was recognised as the most common mental health problem. Recognition of depression was greater among women and younger people. Most people (58%; 508/879) reported that they or a family member had experienced depression. People younger than 55 years and people with personal or family experiences of depression viewed depression as more disabling than other chronic medical conditions. Half the respondents differentiated depression from normal sadness. Awareness of common risk versus protective factors was limited. Most people endorsed a preference for self-help and non-pharmacological treatments, but community views of antidepressant drugs were less negative than expected. General practitioners were identified as the preferred point of first contact among healthcare professionals.Although mental health is still not highlighted as a major health issue, Australians do recognise depression as the major mental health problem. Women and younger people have more substantial knowledge about key aspects of depression and its treatments.

Objective To determine in patients attending general practice 1) the extent of comorbidity of mental disorders and alcohol or other substance misuse, and consequent disability; and 2) GPs' diagnosis and management of patients with comorbidity. Design and setting Cross-sectional national audit of general practices throughout Australia in 1998-1999. Participants 46 515 ambulatory care patients attending 386 GPs. Screening tools Prevalence of common mental disorders--12 items from the 34-item SPHERE self-report questionnaire and associated classification system; prevalence of alcohol or other substance misuse--two self-report screening questions, defining "probable" misuse (a positive response to both questions) and "possible" misuse (a positive response to one of the questions); disability--four items from the Brief Disability Questionnaire, and self-reported "days out of role" and "days in bed" in the past month; and rates of psychological diagnosis, treatment and referral by GPs, and GPs' rating of patients' psychological risk. Main outcome measures Comorbidity of mental disorders and alcohol or other substance misuse; disability; and correlation with GPs' diagnosis and management. Results The screening questions revealed possible alcohol or other substance misuse in 11% of patients (5171/46515), and probable misuse in an additional 8% of patients (3593/46515). Comorbidity of mental disorders and substance misuse occurred in 12% (5672/46515) of patients. Patients with comorbidity (compared with those with alcohol or other substance misuse alone) were: more disabled--mean "days out of role in the last month", 8.4 (95% CI, 7.7-9.1) v 3.6 (95% CI, 2.9-4.3); at greater psychological risk (as rated by GPs)--22% v 7%, respectively; more frequently given psychological diagnoses by GPs--51% v 21%; more frequently treated for a psychological condition by GPs--47% v 17%; and more frequently referred to mental health specialists by GPs--9% v 2%. Conclusion Comorbidity of mental disorders and alcohol or other substance misuse is common in patients attending general practice, and results in considerable disability. Such patients receive inadequate attention (diagnosis and management) from GPs. GPs identifying one of these two types of behaviour disorder in a patient should ascertain whether the other type is also present.

Objective: To determine the rate and predictors of unmet need for recognition of common mental disorders in Australian general practice. Design and setting: Cross-sectional national audit of general practices throughout Australia in 1998-1999. Participants: 46 515 ambulatory care patients attending 386 GPs. Screening tools: Prevalence of common mental disorders - 12 items from the 34-item SPHERE self-report questionnaire and associated classification system; prevalence of recognition of mental disorders by GPs - GPs reporting whether patients had depression, anxiety, mixed depression/anxiety, somatoform, or other psychological disorder; predictors of unmet need for recognition of mental disorders - self-report questions about demography for patients and GPs, and about practice organisation for GPs. Main outcome measures: Reported recognition of psychological disorders by GPs; actual prevalence of disorders; and patient, GP and practice characteristics predicting the failure to recognise disorders. Results: GPs did not recognise mental disorder in 56% (11 922/21210) of patients. These comprised 46% (5134/11 060) of patients in the higher level of mental disorders, and (in the second level of disorders) 58% (2906/5036) of patients with predominantly psychological symptoms, and 76% (3882/5114) of those with predominantly somatic symptoms. Patients more likely to have their need for psychological assessment met had the following characteristics: middle-aged (odds ratio [OR], 1.76; 95% Cl, 1.59-1.96), female (OR, 1.19; 95% Cl, 1.12-1.27), Australian-born (OR, 1.16; 95% Cl, 1.08-1.24), unemployed (OR, 1.75; 95% Cl, 1.64-1.89), single (OR, 1.52; 95% Cl, 1.41-1.61), presenting with mainly psychological symptoms (OR, 3.54; 95% Cl, 3.28-3.81), and presenting for psychological reasons (OR, 4.20; 95% Cl, 3.02-5.82). Characteristics of doctors associated with meeting patients' need for assessment were being aged over 35 years (OR, 1.51; 95% Cl, 1.09-2.08), having an interest in mental health (OR, 1.27; 95% CI, 1.15-1.41), having had previous mental health training (OR, 1.29; 95% Cl, 1.15-1.45), being in part-time practice (OR, 1.23; 95% Cl, 1.09-1.39), seeing fewer than 100 patients per week (OR, 1.29; 95% Cl, 1.13-1.47), working in practices with fewer than 2000 patients (OR, 1.28; 95% Cl, 1.13-1.45) and working in regional centres (OR, 1.16; 95% Cl, 1.05-1.28). Conclusion: Unmet need for recognition of common mental disorders remains high. Predictors of unmet need include a somatic symptom profile and practitioner and organisational characteristics which impede the provision of high quality mental health services.

Detection of depression in primary care can be enhanced by use of self-report assessment forms. With the new classes of antidepressants, there is the opportunity to choose specific drug classes for different types of depressive disorders. Depression is frequently a relapsing illness. Treatment goals should include long term reduction of vulnerability factors. An active therapeutic partnership can be facilitated by providing accurate detailed information early in the course of the illness. Behavioural therapies, which focus on modification of the sleep-wake cycle, activity planning and reduction of substance abuse, are essential. Structured problem solving is the most accessible form of cognitive intervention that general practitioners can readily provide. More complex cognitive therapies are usually provided by mental health professionals or general practitioners with extensive training.

Clinical practice guidelines for psychiatry are now being developed, but important deficits in the evidence base are apparent. For many of the new treatments, clinical decisions can be idiosyncratic or based on limited knowledge. There is a need not only to perform properly constructed trials, but also to make immediate use of less rigorous forms of evidence, such as clinical practice surveys. An example is a recent survey of psychiatrists' use of antidepressant drugs. Such surveys are now part of a wider movement towards a more coordinated system of practice-based outcome assessment.

OBJECTIVE To describe clinical and laboratory guidelines for assessment and management of patients presenting with chronic fatigue syndrome (CFS). DATA SOURCES Relevant international consensus diagnostic criteria and research literature on the epidemiology, pathophysiology, concurrent medical and psychological disturbance and clinical management of CFS. CONCLUSIONS Medical and psychiatric morbidity should be carefully assessed and actively treated, while unnecessary laboratory investigations and extravagant treatment regimens should be avoided. No single infective agent has been demonstrated as the cause of CFS, and immunopathological hypotheses remain speculative. The aetiological role of psychological factors is debated, but they do predict prolonged illness. The rate of spontaneous recovery appears to be high. Effective clinical management requires a multidisciplinary approach, with consideration of the medical, psychological and social factors influencing recovery.

OBJECTIVE We report the findings of the first survey of the practice of electroconvulsive therapy (ECT) for the treatment of depression in Australia and New Zealand. The major aim was to examine the frequency of use of unilateral and bilateral electrode placement, as bilateral ECT has been recently recommended as the treatment of choice by the Royal College of Psychiatrists (UK). DESIGN A questionnaire about details of ECT given in the second half of 1989 was forwarded to the medical superintendents of 130 psychiatric hospitals and units in Australia and New Zealand. RESULTS Reports were received from 96 psychiatric institutions representing a response rate of 74%. In these units, 915 patients were treated with ECT during the study period. In contrast to depressed patients in the United Kingdom or the United States, a majority of Australian and New Zealand patients given ECT were found to receive unilateral ECT (63%). There were marked regional differences in practice, with patients in New South Wales being more likely to receive unilateral ECT, and those in Queensland and New Zealand bilateral ECT. In the majority of units, bilateral ECT was not considered to be indicated in preference to unilateral ECT for either severe, suicidal or psychotic depression. CONCLUSION The discrepancies between regional practices probably reflect the current uncertainty regarding the balance between the relative efficacy and morbidity of these two forms of treatment. Until these central issues of relative efficacy and morbidity are clarified, it would be inappropriate for local professional bodies to recommend a preferred mode of ECT administration.

A case of anorexia nervosa that presented in a prepubertal boy is reported. It seemed that particular maternal attitudes towards dieting, paternal criticism of the boy's body shape and size, and severe family disruption were the major factors in the aetiology of this disorder. If such attitudes to food intake and body size and shape and major family disruptions become more prevalent in the community, then one might expect to see an increase in the prevalence of this serious disorder in younger children, which results in serious physical and psychological sequelae.