Factors associated with common mental disorders during the transition to adulthood : do emerging adults and ‘early starters’ differ? Findings from an Australian birth cohort study

Background: Despite increasing diversity in pathways to adulthood, choices available to young people are influenced by environmental, familial and individual factors, namely access to socioeconomic resources, family support and mental and physical health status. Young people from families with higher socioeconomic position (SEP) are more likely to pursue tertiary education and delay entry to adulthood, whereas those from low socioeconomic backgrounds are less likely to attain higher education or training, and more likely to partner and become parents early. The first group are commonly termed ‘emerging adults’ and the latter group ‘early starters’. Mental health disorders during this transition can seriously disrupt psychological, social and academic development as well as employment prospects. Depression, anxiety and most substance use disorders have early onset during adolescence and early adulthood with approximately three quarters of lifetime psychiatric disorders having emerged by 24 years of age. Aims: This thesis aimed to explore the relationships between mental health, sociodemographic factors and family functioning during the transition to adulthood. Four areas were investigated: 1) The key differences between emerging adults and ‘early starters’, were examined and focused on a series of social, economic, and demographic factors as well as DSM-IV diagnoses; 2) Methodological issues associated with the measurement of depression and anxiety in young adults were explored by comparing a quantitative measure of symptoms of anxiety and depression (Achenbach’s YSR and YASR internalising scales) with DSM-IV diagnosed depression and anxiety. 3) The association between family SEP and DSM-IV depression and anxiety was examined in relation to the different pathways to adulthood. 4) Finally, the association between pregnancy loss, abortion and miscarriage, and DSM-IV diagnoses of common psychiatric disorders was assessed in young women who reported early parenting, experiencing a pregnancy loss, or who had never been pregnant. Methods: Data were taken from the Mater University Study of Pregnancy (MUSP), a large birth cohort started in 1981 in Brisbane, Australia. 7223 mothers and their children were assessed five times, at 6 months, 5, 14 and 21 years after birth. Over 3700 young adults, aged 18 to 23 years, were interviewed at the 21-year phase. Respondents completed an extensive series of self-reported questionnaires and a computerised structured psychiatric interview. Three outcomes were assessed at the 21-year phase. Mental health disorders diagnosed by a computerised structured psychiatric interview (CIDI-Auto), the prevalence of DSM-IV depression, anxiety and substance use disorders within the previous 12-month, during the transition (between ages of 18 and 23 years) or lifetime were examined. The primary outcome “current stage in the transition to adulthood” was developed using a measure conceptually constructed from the literature. The measure was based on important demographic markers, and these defined four independent groups: emerging adults (single with no children and living with parents), and three categories of ‘early starter’, singles (with no children or partner, living independently), those with a partner (married or cohabitating but without children) and parents. Early pregnancy loss was assessed using a measure that also defined four independent groups and was based on pregnancy outcomes in the young women This categorised the young women into those who were never pregnant, women who gave birth to a live child, and women who reported some form of pregnancy loss, either an abortion or a spontaneous miscarriage. A series of analyses were undertaken to test the study aims. Potential confounding and mediating factors were prospectively measured between the child’s birth and the 21-year phase. Binomial and multinomial logistic regression was used to estimate the risk of relevant outcomes, and the associations were reported as odds ratios (OR) and 95% confidence intervals (95%CI). Key findings: The thesis makes a number of important contributions to our understanding of the transition to adulthood, particularly in relation to the mental health consequences associated with different pathways. Firstly, findings from the thesis clearly showed that young people who parented or partnered early fared worse across most of the economic and social factors as well as the common mental disorders when compared to emerging adults. That is, young people who became early parents were also more likely to experience recent anxiety (OR=2.0, 95%CI 1.5-2.8) and depression (OR=1.7, 95%CI 1.1-2.7) than were emerging adults after taking into account a range of confounding factors. Singles and those partnering early also had higher rates of lifetime anxiety and depression than emerging adults. Young people who partnered early, but were without children, had decreased odds of recent depression; this may be due to the protective effect of early marriage against depression. It was also found that young people who form families early had an increased risk of cigarette smoking (parents OR=3.7, 95%CI 2.9-4.8) compared to emerging adults, but not heavy alcohol (parents OR=0.4, 95%CI 0.3-0.6) or recent illicit drug use. The high rates of cigarette smoking and tobacco use disorders in ‘early starters’ were explained by common risk factors related to early adversity and lower SEP. Having a child and early marriage may well function as a ‘turning point’ for some young people, it is not clear whether this is due to a conscious decision to disengage from a previous ‘substance using’ lifestyle or simply that they no longer have the time to devote to such activities because of child caring. In relation to the methodological issues associated with assessing common mental disorders in young adults, it was found that although the Achenbach empirical internalising scales successfully predicted both later DSM-IV depression (YSR OR=2.3, 95%CI 1.7-3.1) and concurrently diagnosed depression (YASR OR=6.9, 95%CI 5.0- 9.5) and anxiety (YASR OR=5.1, 95%CI 3.8- 6.7), the scales discriminated poorly between young people with or without DSM-IV diagnosed mood disorder. Sensitivity values (the proportion of true positives) for the internalising scales were surprisingly low. Only a third of young people with current DSM-IV depression (range for each of the scales was between 34% to 42%) were correctly identified as cases by the YASR internalising scales, and only a quarter with current anxiety disorder (range of 23% to 31%) were correctly identified. Also, use of the DSM-oriented scales increased sensitivity only marginally (for depression between 2-8%, and anxiety between 2-6%) above the standard Achenbach scales. This is despite the fact that the DSM-oriented scales were originally developed to overcome the poor prediction of DSM-IV diagnoses by the Achenbach scales. The internalising scales, both standard and DSM-oriented, were much more effective at identifying young people with comorbid depression and anxiety, with OR’s 10.1 to 21.7 depending on the internalising scale used. SEP is an important predictor of both an early transition to adulthood and the experience of anxiety during that time Family income during adolescence was a strong predictor of early parenting and partnering before age 24 but not early independent living. Compared to families in the upper quintile, young people from families with low income were nearly twice as likely to live with a partner and four times more likely to become parents (OR ranged from 2.6 to 4.0). This association remained after adjusting for current employment and education level. Children raised in low income families were 30% more likely to have an anxiety disorder (OR=1.3, 95%CI 0.9-1.9), but not depression, as young adults when compared to children from wealthier families. Emerging adults and ‘early starters’ from low income families did not differ in their likelihood of having a later anxiety disorder. Young women reporting a pregnancy loss had nearly three times the odds of experiencing a lifetime illicit drug disorder (excluding cannabis) [abortion OR=3.6, 95%CI 2.0-6.7 and miscarriage OR=2.6, 95%CI 1.2-5.4]. Abortion was associated with alcohol use disorder (OR=2.1, 95%CI 1.3- 3.5) and 12-month depression (OR=1.9, 95%CI 1.1- 3.1). These finding suggest that the association identified by Fergusson et al between abortion and later psychiatric disorders in young women may be due to pregnancy loss and not to abortion, per se. Conclusion: Findings from this thesis support the view that young people who parent or partner early have a greater burden of depression and anxiety when compared to emerging adults. As well, young women experiencing pregnancy loss, from either abortion or miscarriage, are more likely to experience depression and anxiety than are those who give birth to a live infant or who have never been pregnant. Depression, anxiety and substance use disorders often go unrecognised and untreated in young people; this is especially true in young people from lower SEP. Early identification of these common mental health disorders is important, as depression and anxiety experienced during the transition to adulthood have been found to seriously disrupt an individual’s social, educational and economic prospects in later life.

Comprehensive Addictive Behaviors and Disorders, Volume 1 : Principles of Addiction

"Principles of Addiction provides a solid understanding of the definitional and diagnostic differences between use, abuse, and disorder. It describes in great detail the characteristics of these syndromes and various etiological models. The book's three main sections examine the nature of addiction, including epidemiology, symptoms, and course; alcohol and drug use among adolescents and college students; and detailed descriptions of a wide variety of addictive behaviors and disorders, encompassing not only drugs and alcohol, but caffeine, food, gambling, exercise, sex, work, social networking, and many other areas. This volume is especially important in providing a basic introduction to the field as well as an in-depth review of our current understanding of the nature and process of addictive behaviors. Principles of Addiction is one of three volumes comprising the 2,500-page series, Comprehensive Addictive Behaviors and Disorders. This series provides the most complete collection of current knowledge on addictive behaviors and disorders to date. In short, it is the definitive reference work on addictions."--publisher website

Substance use disorders

Substance use disorders involve alcohol and a range of other legal and illicit drugs, and are characterised by a preoccupation with or craving for the substance, a greater priority to substance use than other goals, and/or a difficulty controlling consumption. Use of the substance may continue despite negative impacts on other activities, roles, relationships, and physical and mental health. Increased physical tolerance to the substance and withdrawal symptoms may also occur. Broad impacts on social and cognitive functioning and on physical and mental health emerge with increasing problem severity. Diffuse cognitive impairment may persist for up to 12 months post-detoxification in alcohol dependence. Psychological comorbidity is common, particularly mood and anxiety disorders. A quarter of all Australians will have a substance use disorder in their lifetime. One in five will consume alcohol at a level that puts them at risk of harm from an alcohol-related disease or injury over their lifetime. Australians aged 18 to 29 years are at higher risk than other age groups.

The use of prescribed drugs for common chronic conditions in South Africa in 1998

Purpose To determine the prescribed drug-utilisation pattern for six common chronic conditions in adult South Africans in a cross-sectional survey. Methods 13 826 randomly selected participants, 15 years and older, were surveyed by trained fieldworkers at their homes in 1998. Questionnaires included socio-demographic, chronic-disease and drug-use data. The prescribed drugs were recorded from participants' medication containers. The Anatomical Therapeutic Classification (ATC) code of the drugs for tuberculosis (TB), diabetes, hypertension, hyperlipidaemia, other atherosclerosis-related conditions, such as heart conditions or cerebrovascular accidents (CVA), and asthma or chronic obstructive pulmonary disease (COPD), was recorded. The use of logistic regression analyses identified the determinants of those patients who used prescription medication for these six conditions. Results 18.4% of the women and 12.5% of the men used drugs for the six chronic conditions. Men used drugs most frequently for hypertension (50.9%) and asthma or chronic bronchitis (24.3%), while in women it was for hypertension (59.9%) and diabetes (17.5%). The logistic regression analyses showed that women, wealthier and older people, and those with medical insurance used these chronic-disease drugs more frequently compared to men, younger or poor people, or those without medical insurance. The African population group used these drugs less frequently than any other ethnic group. The inappropriate use of methyldopa was found for 14.8% of all antihypertensive drugs, while very few people used aspirin. Conclusions The methodology of this study provides a means of ascertaining the chronic-disease drug-utilisation pattern in national health surveys. The pattern described, suggests an inequitable use of chronic-disease drugs and inadequate use of some effective drugs to control the burden of chronic diseases in South Africa. Copyright © 2004 John Wiley & Sons, Ltd.

Music in the prevention and treatment of substance misuse

Issues Research shows that young people at risk of developing a substance use disorder often use substances to deal with problems, particularly relationship problems and emotional problems. Music listening is a widely available and engaging activity that may help young people address these problem areas. This study was part of a larger project to develop a phone app for young people in which they use music for emotional wellbeing. Approach Three focus groups with young people aged 15–25 years were conducted and the transcripts were analysed by three of the authors using a thematic analysis procedure (Braun & Clarke, 2006). Key Findings: Young people used music in four main ways to achieve wellbeing: relationship building through sharing music; cre- ating an ambience using music; using music to experience an emotion more fully; and using music to modify an emotion. Several mecha- nisms by which music achieved these functions were identified. Par- ticipants also articulated specific times when they would not use music and why. Discussion and Conclusions The information from these focus groups provides many avenues for the development of the app and for understanding how music listening helps young people to achieve wellbeing. These ideas can readily be used with young people at risk of developing substance use problems as it gives them an engaging and low cost alternative for managing their emotions and building relationships.

A comprehensive neuropsychiatric study of elderly twins: The Older Australian Twins Study

The Older Australian Twins Study (OATS) was recently initiated to investigate genetic and environmental factors and their associations and interactions in healthy brain ageing and ageing-related neurocognitive disorders. The study extends the classic MZ-DZ design to include one or two equivalently aged siblings for each twin pair and utilizes the rich resources of the Australian Twin Registry. The study has a number of distinguishing features including comprehensive psychiatric, neuropsychological, cardiovascular, metabolic, and neuroimaging assessments, a longitudinal design and links with a brain donor program. The study measures many behavioral and environmental factors, but in particular lifetime physical and mental activity, physical and psychological trauma, loss of parent early in life, later losses and life events, early-life socioeconomic environment, alcohol and drug use, occupational exposure, and nutrition. It also includes comprehensive cardiovascular assessment, blood biochemistry, genetics and proteomics. The socio-demographic and health data on the first 172 pairs of twins participating in this study are presented. Prevalence of mild cognitive impairment is 12.8% and of dementia 1.5% in the sample. The target sample size is 1000, with at least 400 pairs of twins aged 65-90 years. The cohort will be assessed every two years, with in-depth assessments being repeated. OATS offers an excellent opportunity for collaboration with other similar studies as well as researchers who share the same interests.

Irrational addicts and responsible pleasure seekers: Constructions of the drug user

Historically, drug use has been understood as a problem of epidemiology, psychiatry, physiology, and criminality requiring legal and medical governance. Consequently drug research tends to be underpinned by an imperative to better govern, and typically proposes policy interventions to prevent or solve drug problems. We argue that categories of ‘addictive’ and ‘recreational’ drug use are discursive forms of governance that are historically, politically and socially contingent. These constructions of the drug problem shape what drug users believe about themselves and how they enact these beliefs in their drug use practices. Based on qualitative interviews with young illicit drug users in Brisbane, Australia, this paper uses Michel Foucault’s concept of governmentality to provide insights into how the governance of illicit drugs intersects with self-governance to create a drug user self. We propose a reconceptualisation of illicit drug use that takes into account the contingencies and subjective factors that shape the drug experience. This allows for an understanding of the relationships between discourses, policies, and practices in constructions of illicit drug users.

Monitoring substance use in prisons: Assessing the potential value of wastewater analysis

Prison substance use is a major concern for prison authorities and the wider community. Australia has responded to this problem by implementing the National Corrections Drug Strategy. Across Australia, the true extent of prison substance use cannot be determined. As a result, the effectiveness of the interventions employed as part of this strategy cannot be properly assessed. This has important implications for the allocation of corrective services resources and future policy development. This article explores the benefits and limitations, as well as the ethical and practical issues in using wastewater analysis (WWA) to measure levels of substance use in prisons. It reports results from the first application of WWA to an Australian prison, which supports the use of WWA in this context. Given the increasing concern for prescription misuse in prisons, we also highlight the novel use of WWA to measure the extent of prescription misuse by prisoners. The article concludes that as a result of its objectivity, sensitivity and cost-effectiveness, the use of WWA in prisons warrants further consideration in Australia.

Drink and drug driving in Australian young adult users and non-users of illicit stimulants

- Introduction There is limited understanding of how young adults’ driving behaviour varies according to long-term substance involvement. It is possible that regular users of amphetamine-type stimulants (i.e. ecstasy (MDMA) and methamphetamine) may have a greater predisposition to engage in drink/drug driving compared to non-users. We compare offence rates, and self-reported drink/drug driving rates, for stimulant users and non-users in Queensland, and examine contributing factors. - Methods The Natural History Study of Drug Use is a prospective longitudinal study using population screening to recruit a probabilistic sample of amphetamine-type stimulant users and non-users aged 19-23 years. At the 4 ½ year follow-up, consent was obtained to extract data from participants’ Queensland driver records (ATS users: n=217, non-users: n=135). Prediction models were developed of offence rates in stimulant users controlling for factors such as aggression and delinquency. - Results Stimulant users were more likely than non-users to have had a drink-driving offence (8.7% vs. 0.8%, p < 0.001). Further, about 26% of ATS users and 14% of non-users self-reported driving under the influence of alcohol during the last 12 months. Among stimulant users, drink-driving was independently associated with last month high-volume alcohol consumption (Incident Rate Ratio (IRR): 5.70, 95% CI: 2.24-14.52), depression (IRR: 1.28, 95% CI: 1.07-1.52), low income (IRR: 3.57, 95% CI: 1.12-11.38), and male gender (IRR: 5.40, 95% CI: 2.05-14.21). - Conclusions Amphetamine-type stimulant use is associated with increased long-term risk of drink-driving, due to a number of behavioural and social factors. Inter-sectoral approaches which target long-term behaviours may reduce offending rates.

Systematic analysis of changes in cannabis use among participants in control conditions of randomised controlled trials

Introduction Cannabis remains the most used illegal substance across the globe, and negative outcomes and disorders are common. A spotlight therefore falls on reductions in cannabis use in people with cannabis use disorder. Current estimates of unassisted cessation or reduction in cannabis use rely on community surveys, and few studies focus on individuals with disorder. A key interest of services and researchers is to estimate effect size of reductions in consumption among treatment seekers who do not obtain treatment. Effects within waiting list or information-only control conditions of randomised controlled trials offer an opportunity to study this question. Method This paper examines the extent of reductions in days of cannabis use in the control groups of randomised controlled trials on treatment of cannabis use disorders. A systematic literature search was performed to identify trials that reported days of cannabis use in the previous 30 (or equivalent). Results Since all but one of the eight identified studies had delayed treatment controls, results could only be summarised across 2–4 months. Average weighted days of use in the previous 30 days fell from 24.5 to 19.9, and a meta-analysis using a random effects model showed an average reduction of 0.442 SD. However, every study had at least one significant methodological issue. Conclusions While further high-quality data is needed to confirm the observed effects, these results provide a baseline from which researchers and practitioners can estimate the extent of change required to detect effects of cannabis treatments in services or treatment trials.

A quantitative-trait genome-wide association study of alcoholism risk in the community: findings and implications

BACKGROUND Given moderately strong genetic contributions to variation in alcoholism and heaviness of drinking (50% to 60% heritability) with high correlation of genetic influences, we have conducted a quantitative trait genome-wide association study (GWAS) for phenotypes related to alcohol use and dependence. METHODS Diagnostic interview and blood/buccal samples were obtained from sibships ascertained through the Australian Twin Registry. Genome-wide single nucleotide polymorphism (SNP) genotyping was performed with 8754 individuals (2062 alcohol-dependent cases) selected for informativeness for alcohol use disorder and associated quantitative traits. Family-based association tests were performed for alcohol dependence, dependence factor score, and heaviness of drinking factor score, with confirmatory case-population control comparisons using an unassessed population control series of 3393 Australians with genome-wide SNP data. RESULTS No findings reached genome-wide significance (p = 8.4 x 10(-8) for this study), with lowest p value for primary phenotypes of 1.2 x 10(-7). Convergent findings for quantitative consumption and diagnostic and quantitative dependence measures suggest possible roles for a transmembrane protein gene (TMEM108) and for ANKS1A. The major finding, however, was small effect sizes estimated for individual SNPs, suggesting that hundreds of genetic variants make modest contributions (1/4% of variance or less) to alcohol dependence risk. CONCLUSIONS We conclude that: - 1) meta-analyses of consumption data may contribute usefully to gene discovery; - 2) translation of human alcoholism GWAS results to drug discovery or clinically useful prediction of risk will be challenging, and; - 3) through accumulation across studies, GWAS data may become valuable for improved genetic risk differentiation in research in biological psychiatry (e.g., prospective high-risk or resilience studies).

Coping style and ecstasy use motives as predictors of current mood symptoms in ecstasy users

Background Elevated depressive and anxiety symptoms during childhood and adolescence have been associated with greater risk of later ecstasy use. Ecstasy users have reported using ecstasy to reduce depression or worry, or to escape. While these findings suggest that some people use ecstasy as a form of self-medication, limited research has been conducted examining the relationship between affective symptoms, coping styles and drug use motives in ecstasy users. This cross-sectional study aimed to determine if coping style and/or ecstasy use motives are associated with current mood symptoms in ecstasy users. Methods A community sample (n = 184) of 18–35 year olds who had taken ecstasy at least once in the past 12 months completed self-report measures of depression, anxiety, ecstasy use motives and coping styles. Timeline followback methods were used to collect information on lifetime ecstasy, recent drug use and life stress. Trauma exposure was measured using the Composite International Diagnostic Interview—Trauma List. Results Coping motives for ecstasy use and an emotion-focused coping style were significantly associated with current depressive and anxiety symptoms. Emotion-focused coping mediated the relationship between a history of trauma and current anxiety symptoms and moderated the relationship between recent stressful life events and current depressive symptoms. Conclusions These findings highlight the importance of interventions targeting motives for ecstasy use, and providing coping skills training for managing stressful life events among people with co-occurring depressive/anxiety symptoms and ecstasy use.