A brief motivational intervention for substance misuse in recent-onset psychosis

Substance misuse is common in early psychosis, and impacts negatively on outcomes. Little is known about effective interventions for this population. We report a pilot study of brief intervention for substance misuse in early psychosis ( Start Over and Survive: SOS), comparing it with Standard Care(SC). Twenty-five in-patients aged 18 - 35 years with early psychosis and current misuse of non-opioid drugs were allocated randomly to conditions. Substance use and related problems were assessed at baseline, 6 weeks and 3, 6 and 12 months. Final assessments were blind to condition. All 13 SOS participants who proceeded to motivational interviewing reported less substance use at 6 months, compared with 58% (7/12) in SC alone. Effects were well maintained to 12 months. However, more SOS participants lived with a relative or partner, and this also was associated with better outcomes. Engagement remained challenging: 39% (16/41) declined participation and 38% (5/13) in SOS only received rapport building. Further research will increase sample size, and address both engagement and potential confounds.

How common is comorbidity and why does it occur?

Comorbidity is most generally defined as the co-occurrence of two or more mental health problems. Comorbidity between drug and other psychological disorders has emerged as a major clinical, public health and research issue over the past few decades. The reasons for comorbidity are complex. Furthermore, comorbidity is often associated with poor treatment outcome, severe illness course, and high service utilisation. This presents a significant challenge with respect to the identification, prevention and management of people with comorbid disorders. The unmet need for treatment within this group is considerable and the lack of research is unacceptable. This paper will give a brief overview of epidemiological research into comorbidity; and examine the reasons why comorbidity might occur.

Is cannabis a gateway drug? Testing hypotheses about the relationship between cannabis use and the use of other illicit drugs

We outline and evaluate competing explanations of three relationships that have consistently been found between cannabis use and the use of other illicit drugs, namely, ( 1) that cannabis use typically precedes the use of other illicit drugs; and that ( 2) the earlier cannabis is used, and ( 3) the more regularly it is used, the more likely a young person is to use other illicit drugs. We consider three major competing explanations of these patterns: ( 1) that the relationship is due to the fact that there is a shared illicit market for cannabis and other drugs which makes it more likely that other illicit drugs will be used if cannabis is used; ( 2) that they are explained by the characteristics of those who use cannabis; and ( 3) that they reflect a causal relationship in which the pharmacological effects of cannabis on brain function increase the likelihood of using other illicit drugs. These explanations are evaluated in the light of evidence from longitudinal epidemiological studies, simulation studies, discordant twin studies and animal studies. The available evidence indicates that the association reflects in part but is not wholly explained by: ( 1) the selective recruitment to heavy cannabis use of persons with pre-existing traits ( that may be in part genetic) that predispose to the use of a variety of different drugs; ( 2) the affiliation of cannabis users with drug using peers in settings that provide more opportunities to use other illicit drugs at an earlier age; ( 3) supported by socialisation into an illicit drug subculture with favourable attitudes towards the use of other illicit drugs. Animal studies have raised the possibility that regular cannabis use may have pharmacological effects on brain function that increase the likelihood of using other drugs. We conclude with suggestions for the type of research studies that will enable a decision to be made about the relative contributions that social context, individual characteristics, and drug effects make to the relationship between cannabis use and the use of other drugs.

Addition of cue exposure to cognitive-behaviour therapy for alcohol misuse: a randomized trial with dysphoric drinkers

Aim To test whether addition of moderation-orientated cue exposure (CE) or CE after dysphoric mood induction ( emotional CE, ECE) improved outcomes above those from cognitive-behaviour therapy alone (CBT) in people who drank when dysphoric. Design Multi-site randomized controlled trial comparing CBT with CBT + CE and CBT + ECE. Setting Out-patient rooms in academic treatment units in Brisbane and Sydney, Australia. Participants People with alcohol misuse and problems controlling consumption when dysphoric (n = 163). Those with current major depressive episode were excluded. Intervention Eight weekly 75-minute sessions of individual treatment for alcohol problems were given to all participants, with CBT elements held constant across conditions. From session 2, CBT + CE participants resisted drinking while exposed to alcohol cues, with two priming doses of their preferred beverage being given in some sessions. After an initial CE session, CBT + ECE participants recalled negative experiences before undertaking CE, to provide exposure to emotional cues of personal relevance. Measurements Alcohol consumption, related problems, alcohol expectancies, self-efficacy and depression. Results Average improvements were highly significant across conditions, with acceptable maintenance of effects over 12 months. Both treatment retention and effects on alcohol consumption were progressively weaker in CBT + CE and CBT + ECE than in CBT alone. Changes in alcohol dependence and depression did not differ across conditions. Conclusions These data do not indicate that addition of clinic-based CE to standard CBT improves outcomes. A different approach to the management of craving may be required.

Assortative Mating for Cigarette Smoking and for Alcohol Consumption in Female Australian Twins and their Spouses

Background Non-random mating affects population variation for substance use and dependence. Developmentally, mate selection leading to positive spousal correlations for genetic similarity may result in increased risk for substance use and misuse in offspring. Mate selection varies by cohort and thus, assortative mating in one generation may produce marked changes in rates of substance use in the next. We aim to clarify the mechanisms contributing to spousal similarity for cigarette smoking and alcohol consumption. Methods Using data from female twins and their male spouses, we fit univariate and bivariate twin models to examine the contribution of primary assortative mating and reciprocal marital interaction to spousal resemblance for regular cigarette smoking and nicotine dependence, and for regular alcohol use and alcohol dependence. Results We found that assortative mating significantly influenced regular smoking, regular alcohol use, nicotine dependence and alcohol dependence. The bivariate models for cigarette smoking and alcohol consumption also highlighted the importance of primary assortative mating on all stages of cigarette smoking and alcohol consumption, with additional evidence for assortative mating across the two stages of alcohol consumption. Conclusions Women who regularly used, and subsequently were dependent on cigarettes or alcohol were more likely to marry men with similar behaviors. After mate selection had occurred, one partner's cigarette or alcohol involvement did not significantly modify the other partner's involvement with these psychoactive substances.

Alcohol use and risk taking among regular ecstasy users

We examine alcohol use in conjunction with ecstasy use and risk-taking behaviors among regular ecstasy users in every capital city in Australia. Data on drug use and risks were collected in 2004 from a national sample of 852 regular ecstasy users (persons who had used ecstasy at least monthly in the preceding 6 months). Users were grouped according to their typical alcohol use when using ecstasy: no use, consumption of between one and five standard drinks, and consumption of more than five drinks (binge alcohol use). The sample was young, well educated, and mainly working or studying. Approximately two thirds (65%) of the regular ecstasy users reported drinking alcohol when taking ecstasy. Of these, 69% reported usually consuming more than five standard drinks. Those who did not drink alcohol were more disadvantaged, with greater levels of unemployment, less education, higher rates of drug user treatment, and prison history. They were also more likely than those who drank alcohol when using ecstasy to be drug injectors and to be hepatitis C positive. Excluding alcohol, drug use patterns were similar between groups, although the no alcohol group used cannabis and methamphetamine more frequently. Binge drinkers were more likely to report having had three or more sexual partners in the past 6 months and were less likely to report having safe sex with casual partners while under the influence of drugs. Despite some evidence that the no alcohol group were more entrenched drug users, those who typically drank alcohol when taking ecstasy were as likely to report risks and problems associated with their drug use. It appears that regular ecstasy users who binge drink are placing themselves at increased sexual risk when under the influence of drugs. Safe sex messages should address the sexual risk associated with substance use and should be tailored to reducing alcohol consumption, particularly targeting heavy alcohol users. The study's limitations are noted.

Improving family functioning and child outcome in methadone maintained families: the Parents Under Pressure programme

Twelve families responded to posters displayed in a methadone clinic for inclusion in a pilot study assessing the viability and potential utility of an intensive, multi-component family-focused intervention, the Parents Under Pressure programme. The programme was designed to improve child behaviour, decrease parental stress and improve family functioning in methadone-maintained families by targeting affect regulation, mood, views of self as a parent, drug use and parenting skills. Nine of the families completed the programme delivered in their homes; eight were recontacted at 3 months. Each family reported significant improvements in three domains: parental functioning, parent - child relationship and parental substance use and risk behaviour. In addition to the changes in family functioning, the majority of families reported a decrease in concurrent alcohol use, HIV risk-taking behaviour and maintenance dose of methadone. The families reported high levels of satisfaction with the programme. It is recommended that future studies include independent measures (e.g. behavioural observations) of child outcome and parental functioning. The results were optimistic and provided the impetus to evaluate the treatment programme using a randomized controlled trial.

The epidemiology and genetics of smoking initiation and persistence: Crosscultural comparisons of twin study results

We examined whether there are crosscultural differences in the magnitude of genetic and environmental contributions to risk of becoming a regular smoker and of persistence in smoking in men and women. Standard methods of epidemiologic and genetic analysis were applied to questionnaire data on history of cigarette use obtained from large samples of male and female like-sex twins from three different countries: Australia (N = 2284 pairs), Sweden (N = 8651 pairs), and Finland (N = 10,948 pairs). Samples were subdivided into three age groups (AG), 18-25 years, 26-35 years, and 36-46 years of age. The magnitude of genetic influence for lifetime smoking was found to be consistent across country and AG for women (46%) and men (57%), and estimates of the contribution from environmental influences shared by twin and co-twin could be equated across all countries by AG for the women (from youngest to oldest AG: 45%, 35%, and 26%), but not for men, with separate estimates obtained for the Scandinavian (33%, 29%, and 19%) and the Australian men (26%, 9%, and 11 %). There was no evidence for an important role for shared environmental influences on persistent smoking, and the genetic contribution was found to be consistent in magnitude in men and women, and the same across country and AG (52%). There are strong genetic influences on smoking behavior, and that risk of becoming a smoker (but not persistence in smoking) may be modified by experiences shared by twins that differ by AG and, at least for men, cultural background.

Occupational therapy and evidence-based practice in mental health

Evidence-based practice (EBP) represents a paradigm shift in health care. This review has two aims. The first is to consider the merits of EBP,especially in respect of its use in mental health settings. The second is both to identify psychosocial interventions that have an established evidence base for effectiveness and to provide an analysis of the quality of this evidence and its implications for occupational therapy. Supported employment, family psychoeducation, assertive case management and integrated substance use treatment are examined in detail. It is proposed that occupational therapists working in mental health give priority to psychosocial interventions that are based on evidence and incorporate these into their practice. It is further proposed that, in implementing EBP,practitioners take an active evaluating position in relation to published evidence, paying particular attention to the evidence of effectiveness in equivalent clinical environments.

Role of culture in gambling and problem gambling

There has been a significant gap in the gambling literature regarding the role of culture in gambling and problem gambling (PG). This paper aims to reduce this gap by presenting a systematic review of the cultural variations in gambling and PG as well as a discussion of the role cultural variables can play in the initiation and maintenance of gambling in order to stimulate further research. The review shows that although studies investigating prevalence rates of gambling and PG among different cultures are not plentiful, evidence does suggest certain cultural groups are more vulnerable to begin gambling and to develop PG. Significant factors including familial/genetic, sociological, and individual factors have been found in the Western gambling literature as playing important roles in the development and maintenance of PG. These factors need to be examined now in other cultural groups so we can better understand the etiological processes involved in PG and design culturally sensitive treatments. In addition, variables, such as cultural values and beliefs, the process of acculturation, and the influence of culturally determined help-seeking behaviors need to be also examined in relation to the role they could play in the initiation of and maintenance of gambling. Understanding the contribution of cultural variables will allow us to devise better prevention and treatment options for PG. Methodological problems in this area of research are highlighted, and suggestions for future research are included. (C) 2004 Elsevier Ltd. All rights reserved.

The relationship between acute alcohol consumption and consequent injury type

Aims: The aim of this study was to quantify the relationship between acute alcohol consumption and injury type (nature of injury, body region injured), while adjusting for the effect of known confounders (i.e. demographic and situational variables, usual drinking patterns, substance use and risk-taking behaviour). Methods: A cross-sectional study was conducted between October, 2000 and October, 2001 of patients aged >= 15 years presenting to a Queensland Emergency Department for treatment of an injury sustained in the preceding 24 h. There were three measures of acute alcohol consumption: drinking setting, quantity, and beverage type consumed in the 6 h prior to injury. Two variables were used to quantify injury type: nature of injury (fracture/dislocation, superficial, internal, and CNS injury) and body part injured (head/neck, facial, chest, abdominal, external, and extremities). Both were derived from patient medical records. Results: Five hundred and ninety three patients were interviewed. Logistic regression analyses indicated that, after controlling for relevant confounding variables, there was no significant association between any of the three measures of acute alcohol consumption and injury type. Conclusions: The effects of acute alcohol consumption are not specific to injury type. Interventions aimed at reducing the incidence of alcohol-related injury should not be targeted at specific injury types.

A genetically informed study of the processes underlying the association between parental marital instability and offspring adjustment

Parental divorce is associated with problematic offspring adjustment, but the relation may be due to shared genetic or environmental factors. One way to test for these confounds is to study offspring of twins discordant for divorce. The current analyses used this design to separate the mechanisms responsible for the association between parental divorce, experienced either before or after the age of 16, and offspring well-being. The results were consistent with a causal role of divorce in earlier initiation of sexual intercourse and emotional difficulties, in addition to a greater probability of educational problems, depressed mood, and suicidal ideation. In contrast, the increased risk for cohabitation and earlier initiation of drug use was explained by selection factors, including genetic confounds.

Family structure and age at menarche: A children-of-twins approach

Girls who grow up in households with an unrelated adult male reach menarche earlier than peers, a finding hypothesized to be an evolutionary strategy for families under stress. The authors tested the alternative hypothesis that nonrandom selection into stepfathering due to shared environmental and/or genetic predispositions creates a spurious relation between stepfathering and early menarche. Using the unique controls for genetic and shared environmental experiences offered by the children-of-twins design, the authors found that cousins discordant for stepfathering did not differ in age of menarche. Moreover, controlling for mother's age of menarche eliminated differences in menarcheal age associated with stepfathering in unrelated girls. These findings strongly suggest selection, and not causation, accounts for the relationship between stepfathering and early menarche.