Client-reported reasons for non-engagement in drug and alcohol treatment

Introduction and Aims.To examine client-reported reasons for missed early appointments at a drug and alcohol treatment service and to compare characteristics of those who missed appointments with those who attended. Design and Methods. Clients who missed a first or second appointment between 1 May and 31 August 2007 at a public community-based outpatient treatment facility were invited to participate in a semistructured telephone interview.This consisted of an open-ended question asking the reason(s) for nonattendance, followed by a questionnaire of items for therapeutic alliance and service satisfaction, perceived impact of substance use and previous treatment experience, mostly rated on Likert scales. Database information on demographic and clinical variables was gathered for all clients who were accepted for treatment within the study time frame. Characteristics of those who missed a first or second appointment (n = 66) were compared with those who attended at least their first two appointments (n = 97). Results. Of clients who missed their appointments, 80.6% provided reasons for nonattendance, which included extraneous factors (50.0%), service shortcomings (29.7%), no further need for service (16.2%) and motivational ambivalence (4.1%). They generally had high ratings of therapeutic alliance and service satisfaction and identified their substance use as having a negative impact on their lives. Clients who missed appointments were more likely to be male, unmarried and have a history of polysubstance use. Discussion and Conclusions. Extraneous issues relating to the client may be a dominant obstacle in early treatment engagement. Efforts to overcome these issues may therefore improve early engagement.

An integration of attachment theory and reinforcement sensitivity theory

This thesis examined how relationship experiences shape people's sensitivity to detect threat and reward in romantic relationships and substance use scenarios. Findings indicated that anxious individuals experienced difficulty in distinguishing between threat and reward. In contrast, avoidant individuals were quick to detect threat either fleeing or confronting the problem aggressively.

Implementation and evaluation of brief depression and anxiety screening in clients contacting a drug and alcohol service

Introduction and Aims. High prevalence mental health (HPMH) comorbidity is common in clients seeking alcohol and other drug (AOD) treatment yet can remain undetected. Although research has reported on the introduction of screening into AOD services, little research has reported on the processes surrounding the introduction or evaluated its effectiveness.This study reports on the implementation and evaluation of brief anxiety and depression screening within a specialised, publicly funded AOD service in South-East Victoria.
Design and Methods. Study one examined the implementation of standardised HPMH screening with 114 adult clients (Mean age = 35.49, SD = 9.53; 64% male) telephoning an AOD service over a 5 week period. Measures included severity of HPMH problems,AOD use, care plans and referrals. Study two used semistructured interviews with nine staff/managers to evaluate the effectiveness of screening and its impact on service delivery.
Results. Ninety-four per cent of clients were identified at risk of anxiety or depression. Most care plans incorporated counselling, and concurrent referrals commonly involved a general practitioner. Staff and management found systematic screening increased identification and understanding of comorbid issues and enhanced client interaction but impacted on resource requirements.
Discussion and Conclusions. Most AOD treatment seekers were identified HPMH comorbid and care plans generally included counselling.Adjunctive referrals were more common for severely depressed clients. Screening was effective and enhanced client rapport.Evaluations revealed low confidence in treating HPMH issues in-house.Training may increase worker confidence in managing mental health interventions with subclinical cases, enhancing services’ ability to move towards dual diagnosis capability.

The influence of parents, siblings and peers on pre- and early-teen smoking : a multilevel model

Introduction and Aims. Despite considerable success in tobacco control, many teenagers in Australia and other industrialised countries still smoke tobacco. There is mixed evidence on the relative influence of proximal social networks (parents/siblings/peers) on pre- and early-teen smoking, and no research has examined how these influences compare after accounting for school- and community-level effects.The aim of this study was to compare the relative influences of parents, siblings and peers, after accounting for school- and community-level variation in smoking.

Design and Methods. A cross-sectional fixed and random effects model of smoking prevalence was used, with individuals (n = 7314) nested within schools (n = 231) nested within communities (n = 30). Grade 6 and 8 students (modal ages 11 and 13 years) completed an on-line survey. Key variables included parent/sibling/peer use. Controls included alcohol involvement, sensation seeking, pro-social beliefs, laws/norms about substance use and school commitment.

Results.There was significant variation in smoking at both the school and community levels, supporting the need for a multilevel model. Individual-level predictors accounted for much of the variance at higher levels. The strongest effects were for number of friends who smoke, sibling smoking and alcohol involvement. Smaller significant effects were found for parent smoking. At the community level, socioeconomic disadvantage was significant, but community-level variance in pro-social and drug-related laws/norms was not related to smoking.

Discussion and Conclusions. Cross-level interactions were generally non-significant. Early teenage smoking was best explained by sibling and peer smoking, and individual risks largely accounted for the substantial variation observed across schools and communities. In terms of future tobacco control, findings point to the utility of targeting families in disadvantaged communities.[Kelly AB, O'Flaherty M, Connor JP, Homel R, Toumbourou JW, Patton GC, Williams J. The influence of parents, siblings and peers on pre- and early-teen smoking: A multilevel model.

Variation in the gene coding for the M5 muscarinic receptor (CHRM5) influences cigarette dose but is not associated with dependence to drugs of addiction : evidence from a prospective population based cohort study of young adults

Background: The mesolimbic structures of the brain are important in the anticipation and perception of reward. Moreover, many drugs of addiction elicit their response in these structures. The M5 muscarinic receptor (M5R) is expressed in dopamine-containing neurones of the substantia nigra pars compacta and ventral tegmental area, and regulates the release of mesolimbic dopamine. Mice lacking M5R show a substantial reduction in both reward and withdrawal responses to morphine and cocaine. The CHRM5, the gene that codes for the M5R, is a strong biological candidate for a role in human addiction. We screened the coding and core promoter sequences of CHRM5 using denaturing high performance liquid chromatography to identify common polymorphisms. Additional polymorphisms within the coding and core promoter regions that were identified through dbSNP were validated in the test population. We investigated whether these polymorphisms influence substance dependence and dose in a cohort of 1947 young Australians.

Results: Analysis was performed on 815 participants of European ancestry who were interviewed at wave 8 of the cohort study and provided DNA. We observed a 26.8% increase in cigarette consumption in carriers of the rs7162140 T-allele, equating to 20.1 cigarettes per week (p=0.01). Carriers of the rs7162140 T-allele were also found to have nearly a 3-fold increased risk of developing cannabis dependence (OR=2.9 (95%CI 1.1-7.4); p=0.03).

Conclusion: Our data suggest that variation within the CHRM5 locus may play an important role in tobacco and cannabis but not alcohol addiction in European ancestry populations. This is the first study to show an association between CHRM5 and substance use in humans. These data support the further investigation of this gene as a risk factor in substance use and dependence.

The life conditions of Australian ex-prisoners : an analysis of intrapersonal, subsistence, and support conditions

Successful reintegration of ex-prisoners into the community is multifaceted. The life conditions of 36 adult Australian ex-prisoners (20 male and 16 female) were examined via a questionnaire administered at 1 to 4 weeks post release, and a subset of 19 of the original respondents were interviewed again at 3 to 4 months post release. Interviews focused on intrapersonal conditions (physical and psychological health and substance use), subsistence conditions (housing, employment, and finance), and support conditions (social support, support services/program participation, and criminal justice support). The majority of ex-prisoners self-reported chronic physical and mental health problems as well as a history of substance use and/or current substance use. Although the housing conditions of ex-prisoners were largely favourable and constant, the employment and financial conditions of this group were generally unfavourable. Level of social support was variable. Theoretical implications and practical applications of the present investigation for reintegration theory are discussed.

The notion of self in the journey back from addiction

In this study we explored how those recovering from addiction negotiated self, and the role supported accommodation played in the journey back from addiction. Transcripts from 11 in-depth interviews were analyzed by 2 coders who identified the most salient themes relevant to the self in recovery within the personal contexts of participants. The participants noted that reclaiming the self that had been lost to addiction was of primary importance to them. The recovery journey exposed a self that had reached the lowest point in life; one that was hardly recognizable; one that was undesirable. Engaging with supported accommodation provided participants with a sanctuary within which to reclaim the self, and was seen as central to their recovery.

Gender differences in first episode psychotic mania

Background : The aim of this paper was to delineate the impact of gender on premorbid history, onset, and 18 month outcomes of first episode psychotic mania (FEPM) patients.
Methods : Medical file audit assessment of 118 (male = 71; female = 47) patients with FEPM aged 15 to 29 years was undertaken on clinical and functional measures.
Results : Males with FEPM had increased likelihood of substance use (OR = 13.41, p < .001) and forensic issues (OR = 4.71, p = .008), whereas females were more likely to have history of sexual abuse trauma (OR = 7.12, p = .001). At service entry, males were more likely to be using substances, especially cannabis (OR = 2.15, p = .047), had more severe illness (OR = 1.72, p = .037), and poorer functioning (OR = 0.96, p = .045). During treatment males were more likely to decrease substance use (OR = 5.34, p = .008) and were more likely to be living with family (OR = 4.30, p = .009). There were no gender differences in age of onset, psychopathology or functioning at discharge.
Conclusions : Clinically meaningful gender differences in FEPM were driven by risk factors possibly associated with poor outcome. For males, substance use might be associated with poorer clinical presentation and functioning. In females with FEPM, the impact of sexual trauma on illness course warrants further consideration.

A proof of concept for using brief Dialectical Behavior Therapy as a treatment for problem gambling

Fourteen ‘treatment resistant’ problem gamblers received 9 weeks of Dialectical Behavior Therapy (DBT) at specialist problem gambling services delivered in Melbourne, Australia. This study is the first to investigate the effectiveness of a brief DBT treatment for problem gambling, with a focus on measuring change in the four DBT process skills (mindfulness, distress tolerance, emotion dysregulation, and negative relationships). Although there were no statistically significant improvements in measures of gambling behaviour, 83% of participants were abstinent or reduced their gambling expenditure pre- to post-treatment. Participants also reported statistically and clinically significant improvements in psychological distress,  mindfulness, and distress tolerance. Moreover, there were no increases in alcohol or substance use. These results are discussed in the context of focusing on a single DBT process skill, and the benefits of using group-based approaches.

Trauma-related symptoms in Sri Lankan adult survivors after the tsunami: pretraumatic and peritraumatic factors

Limited research has addressed factors associated with psychological distress following disasters among non-Western populations. The 2004 tsunami affected 1.7 million people across South Asia and Africa, with considerable variations in trauma-related outcomes. Pretraumatic and peritraumatic conditions associated with trauma-related symptoms in 305 Sri Lankan adult survivors (28% male, aged 18-83 years; mean = 39.9 years; standard deviation = 15.3), clinically assessed 1 month posttsunami, were evaluated retrospectively. Outcome measures were total scores on 11 trauma-related symptoms. Multivariate linear regression analyses tested for associations between pretraumatic and peritraumatic conditions and symptom scores, with peritraumatic conditions adjusted for pretraumatic variables. Pretraumatic conditions of female gender, employment, prior health and social issues, and substance use and peritraumatic conditions of loss of family, witnessing the tsunami, or suffering an injury were associated with trauma-related symptoms. The findings facilitate understanding cultural contexts that define risk factors associated with trauma-related symptoms in Sri Lankans, which are critical for developing culturally appropriate interventions.

Student and school factors associated with school suspension : A multilevel analysis of students in Victoria, Australia and Washington State, United States.

One of the common issues schools face is how best to handle challenging student behaviors such as violent behavior, antisocial behavior, bullying, school rule violations, and interrupting other students' learning. School suspension may be used to remove students engaging in challenging behaviors from the school for a period of time. However, the act of suspending students from school may worsen rather than improve their behavior. Research shows that suspensions predict a range of student outcomes, including crime, delinquency, and drug use. It is therefore crucial to understand the factors associated with the use of school suspension, particularly in sites with different policy approaches to problem behaviors. This paper draws on data from state-representative samples of 3,129 Grade 7 and 9 students in Washington State, United States and Victoria, Australia sampled in 2002. Multilevel modeling examined student and school level factors associated with student-reported school suspension. Results showed that both student (being male, previous student antisocial and violent behavior, rebelliousness, academic failure) and school (socioeconomic status of the school, aggregate measures of low school commitment) level factors were associated with school suspension and that the factors related to suspension were similar in the two states. The implications of the findings for effective school behavior management policy are that, rather than focusing only on the student, both student and school level factors need to be addressed to reduce the rates of school suspension.

Student perspectives on the reasons for physical violence in a Thai vocational college: an exploratory study

Physical violence in Bangkok schools has been the subject of considerable public concern in recent years and yet relatively little is known about the nature of violence perpetrated by vocational college students. This study sought to understand the reasons for such violence through a series of semi-structured interviews with 32 male students. The analysis identified revenge from previous fights as a key motivation for violence. Students described a range of different responses to threats of violence, including renting safe accommodation and concealing weapons. These findings are discussed in relation to how an understanding of cross-cultural risk factors for violence is important for the development of effective prevention strategies.

Design and rationale of a 16-week adjunctive randomized placebo-controlled trial of mitochondrial agents for the treatment of bipolar depression

Objective: Bipolar disorder places a significant burden on individuals, caregivers and family, and the broader community. Current treatments are believed to be more effective against manic symptoms, leaving a shortfall in recovery during the depressive phase of the illness. The current study draws on recent evidence suggesting that, in addition to increased oxidative load, alterations in mitochondrial function occur in bipolar disorder. Methods: This 16-week study aims to explore the potential benefits of N-acetylcysteine (NAC) alone or in combination (CT) with selected nutraceuticals believed to enhance mitochondrial function. The study includes adults diagnosed with bipolar disorder currently experiencing an episode of depression. Participants are asked to take NAC, CT, or placebo in addition to any usual treatments. A post-discontinuation visit is conducted 4 weeks following the treatment phase. Results: The primary outcome of the study will be mean change on the Montgomery-Asberg Depression Rating Scale. Secondary outcomes include functioning, substance use, mania ratings, and quality of life. Blood samples will be collected at baseline and week 16 to explore biochemical alterations following treatment. Conclusion: This study may provide a novel adjunctive treatment for bipolar depression. Analysis of biological samples may assist in understanding the therapeutic benefits and the underlying etiology of bipolar depression. Trial registration: Australian and New Zealand Clinical Trial Registry ACTRN12612000830897.

Problem gambling and intimate partner violence : a systematic review and meta-analysis

This study provides a systematic review of the empirical evidence related to the association between problem gambling and intimate partner violence (IPV). We identified 14 available studies in the systematic search (8 for victimisation only, 4 for perpetration only and 2 for both victimisation and perpetration). Although there were some equivocal findings, we found that most of the available research suggests that there is a significant relationship between problem gambling and being a victim of IPV. There was more consistent evidence that there is a significant relationship between problem gambling and perpetration of IPV. Meta-analyses revealed that over one third of problem gamblers report being victims of physical IPV (38.1%) or perpetrators of physical IPV (36.5%) and that the prevalence of problem gambling in IPV perpetrators is 11.3%. Although the exact nature of the relationships between problem gambling and IPV is yet to be determined, the findings suggest that less than full employment and clinical anger problems are implicated in the relationship between problem gambling and IPV victimization and that younger age, less than full employment, clinical anger problems, impulsivity, and alcohol and substance use are implicated in the relationship between problem gambling and IPV perpetration. The findings highlight the need for treatment services to undertake routine screening and assessment of problem gambling, IPV, alcohol and substance use problems, and mental health issues and provide interventions designed to manage this cluster of comorbid conditions. Further research is also required to investigate the relationship between problem gambling and violence that extends into the family beyond intimate partners.