{'fraction_non_alphanumeric': 0.025496389891696752, 'fraction_numerical': 0.008348375451263539, 'mean_word_length': 5.42463768115942, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Risks, benefits and finding the best way forward

Australian & New Zealand Journal of Psychiatry, 51(10) In this month’s Australian and New Zealand Journal of Psychiatry (ANZJP), the paper with immediate clinical impact addresses the tragic situation that occurs when a patient who has responded to clozapine has to stop treatment due to agranulocytosis. Often gains in functional recovery are lost, and more severe symptoms return. Myles et al. (this issue) demonstrate that by co-prescribing granulocyte-colony stimulating factor (GCSF), successful clozapine rechallenge is possible, with 76% of people treated with the combination remaining on clozapine after 12 months. Using GCSF will be a new skill for clozapine prescribers, working in collaboration with clinical haematology services. Only 30 cases have been reported, so it would make sense to set up a national database to record patient characteristics, the rechallenge protocol and outcomes. Those interested could begin by emailing the author. Thabrew et al. (this issue) ponder the future of child psychiatry. They offer a list of recommendations to be implemented by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and strategies that individual child psychiatrists could adopt to improve their effectiveness. They observe that child mental health services often have flatter hierarchies than other areas of health and that child psychiatrists may avoid leadership positions due to time pressure, lack of confidence and lack of financial incentive. The South Australian (SA) coroner, in 2010,1 wrote that in his opinion ‘the Child and Adolescent Mental Health Services (CAMHS) “extremely flat structure” is fundamentally flawed’. He recommended that the number of psychiatrists employed within CAMHS be increased and that ‘all services provided by CAMHS should be provided under the same level of consultant supervision as a surgical service in a public hospital. To be absolutely clear, I refer to supervision by a consultant psychiatrist’. Thabrew et al. describe 12 clinical issues where the contribution of a child psychiatrist is essential, but there is no discussion about whether the psychiatrist should be the lead clinician in these situations. If child psychiatry is to grow up, maybe this includes advocating for system change and taking on leadership roles. Brett et al. (this issue) report changes in psychotropic medication use by concessional beneficiaries in Australia 2007–2015. The study raises as many questions as it answers. For example, there was an increase in antipsychotic use, particularly of quetiapine, which may reflect increasing off-label use of this drug (Brett, 2015). This could parallel the reduced prescription of benzodiazepines; perhaps quetiapine is being prescribed instead of benzodiazepines. The authors are concerned that high rates of single dispensing of haloperidol and amitriptyline might also reflect off-label uses that lack a firm evidence base. Psychological treatments tend to be considered harmless, but any potent intervention has the capacity to cure and to harm (Berk and Parker, 2009). Gordon et al. (this issue) set out to identify adverse effects associated with mindfulness, reviewing papers specifically reporting negative effects of mindfulness. There is a lack of delineation between mindfulness-based interventions, mindfulness practice in general and meditation. However, numerous studies have evaluated well-defined, manualised mindfulness interventions; a review of these studies looking for negative effects, and finding out more about those participants who did not do well, might be useful. Perhaps future studies of mindfulness and other psychological interventions should include adverse event monitoring; this is very well developed in pharmaceutical clinical trials and could readily be adapted to trials of psychological treatments. Spencer (this issue) examines the balance between autonomy and protection, around the issue of participation of prisoners in research. The recent expansion of ethics and governance approval processes can delay and sometimes block research (Posselt et al., 2014). These requirements are more extensive with vulnerable populations, such as prisoners, children and the elderly, forming a barrier to research with these groups. Spencer asserts that measures to protect these people risk them Risks, benefits and finding the best way forward