Topics

The evidence that reducing trading hours reduces alcohol-related violence is compelling

Alcohol-related violence has a large impact on the Australian health care system and on society. Emergency departments (EDs) and acute surgical services are the frontline in dealing with these presentations. A prospective study of eight EDs in Australia and New Zealand found that almost one in ten presentations are alcohol-related throughout the week.1 Further, ED clinicians frequently experience violence and aggression inflicted by patients affected by alcohol.2

1 Monash University, Melbourne, VIC
2 Monash Health, Melbourne, VIC

Correspondence: diana.egertonwarburton@monashhealth.org

Competing interests:

No relevant disclosures.

1. Egerton-Warburton D, Gosbell A, Moore K, et al. Alcohol-related harm in emergency departments: a prospective, multicenter study. Addiction 2018; https://doi.org/10.1111/add.14109 [Epub ahead of print].
2. Egerton-Warburton D, Gosbell A, Wadsworth A, et al. Perceptions of Australasian emergency department staff of the impact of alcohol-related presentations. Med J Aust 2016; 204: 155. <MJA full text>
3. Holmes RF, Lung T, Fulde GWO, Fraser CL. Fewer orbital fractures treated at St Vincent’s Hospital after lock-out laws introduced in Sydney. Med J Aust 2018; 208: 174.
4. Egerton-Warburton D, Gosbell A, Wadsworth A, et al. Survey of alcohol-related presentations to Australasian emergency departments. Med J Aust 2014; 201: 584-587. <MJA full text>
5. Fulde GW, Smith M, Forster LS. Presentations with alcohol-related serious injury to a major Sydney trauma hospital after 2014 changes to liquor laws. Med J Aust 2015; 203: 366. <MJA full text>
6. Menéndez P, Kypri K, Weatherburn D. The effect of liquor licensing restrictions on assault: a quasi-experimental study in Sydney, Australia. Addiction 2017; 112: 261-268.
7. Kypri K, McElduff P, Miller P. Restrictions in pub closing times and lockouts in Newcastle, Australia five years on. Drug Alcohol Rev 2014; 33: 323-326.
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Guideline summary

Updated evidence-based clinical practice guidelines for the diagnosis and management of melanoma: definitive excision margins for primary cutaneous melanoma

Michael J Sladden, Omgo E Nieweg, Julie Howle, Brendon J Coventry and John F Thompson

Med J Aust 2018; 208 (3): . || doi: 10.5694/mja17.00278
Published online: 19 February 2018

Topics

Skin and connective tissue diseases

Surgical procedures, operative

General medicine

Abstract

Introduction: Definitive management of primary cutaneous melanoma consists of surgical excision of the melanoma with the aim of curing the patient. The melanoma is widely excised together with a safety margin of surrounding skin and subcutaneous tissue, after the diagnosis and Breslow thickness have been established by histological assessment of the initial excision biopsy specimen. Sentinel lymph node biopsy should be discussed for melanomas ≥ 1 mm thickness (≥ 0.8 mm if other high risk features) in which case lymphoscintigraphy must be performed before wider excision of the primary melanoma site. The 2008 evidence-based clinical practice guidelines for the management of melanoma (http://www.cancer.org.au/content/pdf/HealthProfessionals/ClinicalGuidelines/ClinicalPracticeGuidelines-ManagementofMelanoma.pdf) are currently being revised and updated in a staged process by a multidisciplinary working party established by Cancer Council Australia. The guidelines for definitive excision margins for primary melanomas have been revised as part of this process.

Main recommendations: The recommendations for definitive wide local excision of primary cutaneous melanoma are:

melanoma in situ: 5–10 mm margins
invasive melanoma (pT1) ≤ 1.0 mm thick: 1 cm margins
invasive melanoma (pT2) 1.01–2.00 mm thick: 1–2 cm margins
invasive melanoma (pT3) 2.01–4.00 mm thick: 1–2 cm margins
invasive melanoma (pT4) > 4.0 mm thick: 2 cm margins

Changes in management as a result of the guideline: Based on currently available evidence, excision margins for invasive melanoma have been left unchanged compared with the 2008 guidelines. However, melanoma in situ should be excised with 5–10 mm margins, with the aim of achieving complete histological clearance. Minimum clearances from all margins should be assessed and stated. Consideration should be given to further excision if necessary; positive or close histological margins are unacceptable.

1 University of Tasmania, Launceston, TAS
2 Melanoma Institute Australia, Sydney, NSW
3 University of Sydney, Sydney, NSW
4 Westmead Hospital, Sydney, NSW
5 Royal Adelaide Hospital, Adelaide, SA

Correspondence: m.sladden@doctors.org.uk

Acknowledgements:

The guidelines were developed by Cancer Council Australia and Melanoma Institute Australia with financial support from Skin Cancer College Australasia. We acknowledge the Cancer Council Australia and Melanoma Institute Australia project staff, in particular Lani Teddy and Jackie Buck, who were involved in the systematic review.

Competing interests:

No relevant disclosures.

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3. Sladden M, Nieweg O, Howle J, et al. What are the recommended definitive margins for excision of primary melanoma? In: Cancer Council Australia Melanoma Guidelines Working Party. Clinical practice guidelines for the diagnosis and management of melanoma. Sydney: Cancer Council Australia, 2016. http://wiki.cancer.org.au/australia/Guidelines: Melanoma (viewed Sept 2017).
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29. Jejurikar SS, Borschel GH, Johnson TM, et al. Immediate, optimal reconstruction of facial lentigo maligna and melanoma following total peripheral margin control. Plast Reconstr Surg 2007; 120: 1249-1255.
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Narrative review

Cannabis for paediatric epilepsy: challenges and conundrums

Kerrie-Anne Chen, Michelle A Farrar, Michael Cardamone and John A Lawson

Med J Aust 2018; 208 (3): . || doi: 10.5694/mja17.00699
Published online: 19 February 2018

Topics

Nervous system diseases

Pharmaceutical preparations

Pediatric medicine

Summary

Research is expanding for the use of cannabidiol as an anticonvulsant drug. The mechanism of cannabidiol in paediatric epilepsy is unclear but is thought to play a role in modulation of synaptic transmission.
Evidence for its efficacy in treating epilepsy is limited but growing, with a single pharmaceutical company-funded randomised double-blind controlled trial in children with Dravet syndrome.
Progress towards the use of medicinal cannabinoids incorporates a complex interplay of social influences and political and legal reform.
Access to unregistered but available cannabidiol in Australia outside of clinical trials and compassionate access schemes is state dependent and will require Therapeutic Goods Administration approval, although the cost may be prohibitive.
Further clinical trials are needed to clearly define efficacy and safety, particularly long term.

1 Sydney Children's Hospital, Randwick, Sydney, NSW
2 UNSW Sydney, Sydney, NSW

Correspondence: john.lawson@health.nsw.gov.au

Competing interests:

John Lawson is the lead investigator in the NSW Ministry of Health-funded medical cannabis trials.

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Research

Administrative encounters in general practice: low value or hidden value care?

Lyndal J Trevena, Christopher Harrison and Helena C Britt

Med J Aust 2018; 208 (3): . || doi: 10.5694/mja17.00225
Published online: 19 February 2018

Topics

General medicine

Health services administration

Abstract

Objective: To determine the frequency of general practice administrative encounters, and to determine whether they represent low value care.

Design: Secondary analysis of data from the Bettering Evaluation and Care of Health (BEACH) dataset.

Setting: 1 568 100 GP–patient encounters in Australia, 2000–01 to 2015–16.

Participants: An annual nationally representative random sample of about 1000 GPs, who each recorded the details of 100 consecutive encounters with patients.

Main outcome measures: Proportions of general practice encounters that were potentially low value care encounters (among the patient’s reasons for the encounter was at least one administrative, medication, or referral request) and potentially low value care only encounters (such reasons were the sole reason for the encounter). For 2015–16, we also examined other health care provided by GPs at these encounters.

Results: During 2015–16, 18.5% (95% CI, 17.7–19.3%) of 97 398 GP–patient encounters were potentially low value care request encounters; 7.4% (95% CI, 7.0–7.9%) were potentially low value care only encounters. Administrative work was requested at 3.8% (95% CI, 3.5–4.0%) of GP visits, 35.4% of which were for care planning and coordination, 33.5% for certification, and 31.2% for other reasons. Medication requests were made at 13.1% (95% CI, 12.4–13.7%) of encounters; other health care was provided at 57.9% of medication request encounters, counselling, advice or education at 23.4%, and pathology testing was ordered at 16.7%. Referrals were requested at 2.8% (95% CI, 1.7–3.0%) of visits, at 69.4% of which additional health care was provided. The problems managed most frequently at potentially low value care only encounters were chronic diseases.

Conclusion: Most patients requested certificates, medications and referrals in the context of seeking help for other health needs. Additional health care, particularly for chronic diseases, was provided at most GP administrative encounters. The MBS Review should consider the hidden value of these encounters.

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Sydney School of Public Health, University of Sydney, Sydney, NSW

Correspondence: lyndal.trevena@sydney.edu.au

Competing interests:

No relevant disclosures.

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12. Haggan M. Sick notes one way to take up GP burden. AJP.com.au [website]; 6 Sept 2016. https://ajp.com.au/news/sick-notes-one-way-take-gp-burden/ (viewed Nov 2017).
13. Wammes JJ, Jeurissen PP, Verhoef LM, et al. Is the role as gatekeeper still feasible? A survey among Dutch general practitioners. Fam Pract 2014; 31: 538-544.
14. Greenfield G, Foley K, Majeed A. Rethinking primary care’s gatekeeper role. BMJ 2016; 354: i4803.

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Editorials

Maternal overweight and obesity: where to from here?

David A Ellwood and Leonie K Callaway

Med J Aust 2018; 208 (3): . || doi: 10.5694/mja17.01128
Published online: 19 February 2018

Topics

Nutritional and metabolic diseases

Women's health

It is time to examine how the health of young women can be improved prior to pregnancy

The report by Cheney and colleagues in this issue of the MJA clearly shows the increasing contribution by the effects of overweight and obesity during pregnancy to adverse perinatal outcomes.1 The authors analysed pregnancy outcomes at a large teaching hospital in central Sydney, and found that the population attributable fractions (PAFs) of pre-eclampsia, gestational diabetes, and fetal macrosomia associated with overweight and obesity (defined by maternal body mass index [BMI] categories) have risen significantly during the past 25 years. As troubling as these findings are, it is worth noting that nearly 80% of the study population had BMIs in the low or normal ranges. However, in the parts of Australia where overweight and obesity are more prevalent, intertwined with socio-economic disadvantage, the PAF associated with overweight and obesity will be higher. Cheney and her co-authors also report interesting trends in their nulliparous population with respect to other risk factors for adverse pregnancy outcomes, such as increasing age and falling smoking rates, and changes in the ethnic profile and dramatic improvements in socio-economic status of the hospital catchment area. The authors modelled the impact of reducing the overall BMI category distribution of first-time mothers, and the prospective improvements in outcomes are remarkable, suggesting that pre-pregnancy weight loss interventions need to be a priority for improving perinatal health.

1 Griffith University, Gold Coast, QLD
2 Gold Coast University Hospital, Gold Coast, QLD
3 Royal Brisbane and Women's Hospital, Brisbane, QLD
4 University of Queensland, Brisbane, QLD

Correspondence: d.ellwood@griffith.edu.au

Competing interests:

No relevant disclosures.

1. Cheney K, Farber R, Barratt AL, et al. Population attributable fractions of perinatal outcomes for nulliparous women associated with overweight and obesity, 1990–2014. Med J Aust 2018; 208: 119-125.
2. Watson M, Howell S, Johnston T, et al. Pre-pregnancy BMI: costs associated with maternal underweight and obesity in Queensland. Aust N Z J Obstet Gynaecol 2013; 53: 243-249.
3. Flenady V, Koopmans L, Middleton P, et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet 2011; 377: 1331-1340.
4. Sullivan EA, Dickinson JE, Vaughan G, et al. Maternal super-obesity and perinatal outcomes in Australia. BMC Pregnancy Childbirth 2015; 15: 322.
5. Darmasseelane K, Hyde MJ, Santhakumaran S, et al. Mode of delivery and offspring body mass index, overweight and obesity in adult life: a systematic review and meta-analysis. PLoS One 2014; 9: e87896.
6. Opray N, Grivell RM, Deussen AR, Dodd JM. Directed preconception health programs and interventions for improving outcomes for women who are overweight or obese. Cochrane Database Syst Rev 2015; (7): CD010932.
7. Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care — United States: A report of the CDC/ATSDR Preconception Care Work Group and the select panel on preconception care. MMWR Recomm Rep 2006; 55 (RR-06): 1-23.
8. Skouteris H, Huang T, Millar L, et al. A systems approach to reducing maternal obesity: the Health in Preconception, Pregnancy and Post-birth HIPPP Collaborative. Aust N Z J Obstet Gynaecol 2015; 55: 397-400.

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Editorials

The value of food fortification as a public health intervention

Kenneth J Harvey and Basia O Diug

Med J Aust 2018; 208 (3): . || doi: 10.5694/mja17.01095
Published online: 19 February 2018

Topics

Nutritional and metabolic diseases

Environment and public health

Making iodine fortification of bread mandatory in Tasmania successfully improved population iodine levels

Iodine is a micronutrient essential for thyroid hormone synthesis. Inadequate dietary intake is associated with preventable iodine deficiency disorders, including neurological impairment, goitre, and hypothyroidism. The effectiveness of iodised salt for improving population iodine levels and of urine iodine assessment for detecting deficits have led to iodine deficiency being eliminated in many countries where it was once a problem.1

1 Monash University, Melbourne, VIC
2 Medreach Pty Ltd, Melbourne, VIC

Correspondence: kenneth.harvey@monash.edu

Competing interests:

No relevant disclosures.

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8. Vaish S, White M, Daly L, et al. Synthetic folic acid intakes and status in children living in Ireland exposed to voluntary fortification. Am J Clin Nutrition 2016; 103: 512-518.
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10. Harvey K, Li E, Stanton R, Dashper S. Kids’ vitamin gummies: unhealthy, poorly regulated and exploitative. The Conversation 29 May 2017. https://theconversation.com/kids-vitamin-gummies-unhealthy-poorly-regulated-and-exploitative-76466 (viewed Nov 2017).
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Medical education
Lessons from practice

Encephalopathy after chocolate consumption

Amy Kunchok, Penelope J Spring and Michael W Hayes

Med J Aust 2018; 208 (3): . || doi: 10.5694/mja16.01444
Published online: 19 February 2018

Topics

Substance‐related disorders

Nervous system diseases

Pharmaceutical preparations

Clinical record

Concord Repatriation General Hospital, Sydney, NSW

Correspondence: amykunchok@gmail.com

Competing interests:

No relevant disclosures.

1. Lavi E, Rekhtman D, Berkun Y, Wexler I. Sudden onset unexplained encephalopathy in infants: think of cannabis intoxication. Eur J Pediatr 2016; 175: 417-420.
2. Cao D, Srisuma S, Bronstein AC, Hoyte CO. Characterization of edible marijuana product exposures reported to United States poison centers. Clin Toxicol (Phila) 2016; 54: 840-846.
3. Benjamin DM, Fossler MJ. Edible cannabis products: it is time for FDA oversight? J Clin Pharmacol 2016; 56: 1045-1057.

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Systematic review

Identifying and treating codeine dependence: a systematic review

Suzanne Nielsen, Tim MacDonald and Jacinta L Johnson

Med J Aust 2018; 208 (10): . || doi: 10.5694/mja17.00749
Published online: 12 February 2018

Topics

Substance‐related disorders

Pharmaceutical preparations

Abstract

Objectives: Codeine dependence is a significant public health problem, motivating the recent rescheduling of codeine in Australia (1 February 2018). To provide information for informing clinical responses, we undertook a systematic review of what is known about identifying and treating codeine dependence.

Study design: Articles published in English that described people who were codeine-dependent or a clinical approach to treating people who were codeine-dependent, without restriction on year of publication, were reviewed. Articles not including empirical data were excluded. One researcher screened each abstract; two researchers independently reviewed full text articles. Study quality was assessed, and data were extracted with standardised tools.

Data sources: MEDLINE and EMBASE were searched for relevant publications on 22 November 2016. The reference lists of eligible studies were searched to identify further relevant publications. 2150 articles were initially identified, of which 41 were eligible for inclusion in our analysis.

Data synthesis: Studies consistently reported specific characteristics associated with codeine dependence, including mental health comorbidity and escalation of codeine use attributed to psychiatric problems. Case reports and series described codeine dependence masked by complications associated with overusing simple analgesics and delayed detection. Ten studies described the treatment of codeine dependence. Three reports identified a role for behavioural therapy; the efficacy of CYP inhibitors in a small open label trial was not confirmed in a randomised controlled trial; four case series/chart reviews described opioid agonist therapy and medicated inpatient withdrawal; two qualitative studies identified barriers related to perceptions of codeine-dependent people and treatment providers, and confirmed positive perceptions and treatment outcomes achieved with opioid agonist treatments.

Conclusion: Strategies for identifying problematic codeine use are needed. Identifying codeine dependence in clinical settings is often delayed, contributing to serious morbidity. Commonly described approaches for managing codeine dependence include opioid taper, opioid agonist treatment, and psychological therapies. These approaches are consistent with published evidence for pharmaceutical opioid dependence treatment and with broader frameworks for treating opioid dependence.

PROSPERO registration: CRD42016052129.

1 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW
2 Currumbin Clinic, Gold Coast, QLD
3 Griffith University, Gold Coast, QLD
4 University of South Australia, Adelaide, SA
5 Southern Adelaide Local Health Network, Adelaide, SA

Correspondence: suzanne.nielsen@unsw.edu.au

Acknowledgements:

Suzanne Nielsen holds a National Health and Medical Research Council Research Fellowship (1132433).

Competing interests:

Suzanne Nielsen is a named investigator on untied educational grants from Reckitt–Benckiser and Indivior. Tim MacDonald has received honoraria, fees and professional development resources from Servier, the Australian and New Zealand Mental Health Association, and Healthe Care; he works in the private sector and receives income for clinical services.

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Research

Population attributable fractions of perinatal outcomes for nulliparous women associated with overweight and obesity, 1990–2014

Kate Cheney, Rachel Farber, Alexandra L Barratt, Kevin McGeechan, Bradley de Vries, Robert Ogle and Kirsten I Black

Med J Aust 2018; 208 (3): . || doi: 10.5694/mja17.00344
Published online: 12 February 2018

Topics

Nutritional and metabolic diseases

Women's health

Abstract

Objective: To examine the prevalence across 25 years of overweight and obesity among nulliparous Australian women during early pregnancy; to estimate the proportions of adverse perinatal outcomes attributable to overweight and obesity in this population.

Design: Cohort study; retrospective analysis of electronic maternity data.

Setting, participants: 42 582 nulliparous women with singleton pregnancies giving birth at the Royal Prince Alfred Hospital, an urban teaching hospital in Sydney, January 1990 – December 2014.

Main outcome measures: Maternal body mass index (BMI), socio-demographic characteristics, and selected maternal, birth and neonatal outcomes; the proportion of adverse perinatal outcomes that could be averted by reducing the prevalence of overweight and obesity in women prior to first pregnancies (population attributable fraction, PAF).

Results: The prevalence of overweight among nulliparous pregnant women increased from 12.7% (1990–1994) to 16.4% (2010–2014); the prevalence of obesity rose from 4.8% to 7.3% in the same period, while the proportion with normal range BMIs fell from 73.5% to 68.2%. The PAFs for key adverse maternal and neonatal outcomes increased across the study period; during 2010–2014, 23.8% of pre-eclampsia, 23.4% of fetal macrosomia, and 17.0% of gestational diabetes were attributable to overweight and obesity. Were overweight and obese women to have moved down one BMI category during 2010–2014, 19% of pre-eclampsia, 15.9% of macrosomia, 14.2% of gestational diabetes, 8.5% of caesarean deliveries, 7.1% of low for gestational age birthweight, 6.8% of post partum haemorrhage, 6.5% of admissions to special care nursery, 5.8% of prematurity, and 3.8% of fetal abnormality could have been averted.

Conclusions: Over the past 25 years, the proportions of adverse perinatal outcomes attributable to overweight and obesity have risen with the increasing prevalence of maternal overweight and obesity. A substantial proportion of these outcomes might be averted with obesity prevention strategies that reduce pre-pregnancy maternal weight.

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1 Royal Prince Alfred Hospital, Sydney, NSW
2 Sydney School of Public Health, University of Sydney, Sydney, NSW
3 University of Sydney, Sydney, NSW

Correspondence: kate.cheney@sswahs.nsw.gov.au

Competing interests:

No relevant disclosures.

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Guideline summary

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders: major depression summary

Gin S Malhi, Tim Outhred, Amber Hamilton, Philip M Boyce, Richard Bryant, Paul B Fitzgerald, Bill Lyndon, Roger Mulder, Greg Murray, Richard J Porter, Ajeet B Singh and Kristina Fritz

Med J Aust 2018; 208 (4): . || doi: 10.5694/mja17.00659
Published online: 5 February 2018

Topics

Mental disorders

General medicine

Abstract

Introduction: In December 2015, the Royal Australian and New Zealand College of Psychiatrists published a comprehensive set of mood disorder clinical practice guidelines for psychiatrists, psychologists and mental health professionals. This guideline summary, directed broadly at primary care physicians, is an abridged version that focuses on major depression. It emphasises the importance of shared decision making, tailoring personalised care to the individual, and delivering care in the context of a therapeutic relationship. In practice, the management of depression is determined by a multitude of factors, including illness severity and putative aetiology, with the principal objectives of regaining premorbid functioning and improving resilience against recurrence of future episodes.

Main recommendations: The guidelines emphasise a biopsychosocial lifestyle approach and provide the following specific clinical recommendations:

Alongside or before prescribing any form of treatment, consideration should be given to the implementation of strategies to manage stress, ensure appropriate sleep hygiene and enable uptake of healthy lifestyle changes.
For mild to moderate depression, psychological management alone is an appropriate first line treatment, especially early in the course of illness.
For moderate to severe depression, pharmacological management is usually necessary and is recommended first line, ideally in conjunction with psychosocial interventions.

Changes in management as a result of the guidelines: The management of depression is anchored within a therapeutic relationship that attends to biopsychosocial lifestyle aspects and psychiatric diagnosis. The guidelines promote a broader approach to the formulation and management of depression, with treatments tailored to depressive subtypes and administered with clear steps in mind. Lifestyle and psychological therapies are favoured for less severe presentations, and concurrent antidepressant prescription is reserved for more severe and otherwise treatment-refractory cases.

1 CADE Clinic, Royal North Shore Hospital, Sydney, NSW
2 Northern Clinical School, University of Sydney, Sydney, NSW
3 Westmead Clinical School, University of Sydney, Sydney, NSW
4 UNSW Sydney, Sydney, NSW
5 Epworth Clinic, Epworth Healthcare, Melbourne, VIC
6 Monash Alfred Psychiatry Research Centre, Central Clinical School, Monash University, Melbourne, VIC
7 Mood Disorders Unit, Northside Clinic, Sydney, NSW
8 University of Otago, Christchurch, NZ
9 Swinburne University of Technology, Melbourne, VIC
10 Deakin University, Geelong, VIC

Correspondence: gin.malhi@sydney.edu.au

Acknowledgements:

The development of the clinical practice guidelines for mood disorders was supported and funded by the RANZCP.

Competing interests:

Gin Malhi has received grant or research support from Australian Rotary Health, the NHMRC, the American Foundation for Suicide Prevention, NSW Health, Ramsay Health, the University of Sydney, AstraZeneca, Eli Lilly, Organon, Pfizer, Servier and Wyeth; has been a speaker for AstraZeneca, Eli Lilly, Janssen-Cilag, Lundbeck, Pfizer, Ranbaxy, Servier and Wyeth; and has been a consultant for AstraZeneca, Eli Lilly, Janssen-Cilag, Lundbeck and Servier. Phillip Boyce has received consultation fees, sponsorship and speaker fees from Servier; is a member of the advisory board for Lundbeck, Eli Lilly, AstraZeneca and Janssen; has received speaker fees from Lundbeck, AstraZeneca and Janssen; and has received funding for a clinical trial from Brain Resource Company. Richard Bryant has received an NHMRC Program Grant and Project Grant. Paul Fitzgerald is supported by an NHMRC Practitioner Fellowship Grant; and has received equipment for research from MagVenture A/S, Medtronic Ltd, Neuronetics and Brainsway Ltd, and funding for research from Neuronetics. He is on scientific advisory boards for Bionomics Ltd and LivaNova and is a founder of TMS Clinics Australia. Bill Lyndon has received personal fees from Lundbeck Australia, AstraZeneca and Eli Lilly Australia. Greg Murray has received an NHMRC Project Grant and personal fees from Servier and CSL Biotherapies. Ajeet Singh has received personal fees from Servier Australia and Lundbeck Australia; has received a grant from Pfizer Australia; has equity in ; is the founder and owner of website; and has a patent on the Antidepressant Pharmacogenetics Report.

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