Health professionals' recognition of co-occurring alcohol and depressive disorders in youth: a survey of Australian general practitioners, psychiatrists, psychologists and mental health nurses using case vignettes

Objective: To examine whether health professionals who commonly deal with mental disorder are able to identify co occurring alcohol misuse in young people presenting with depression. Method: Between September 2006 and January 2007, a survey examining beliefs regarding appropriate interventions for mental disorder in youth was sent to 1710 psychiatrists, 2000 general practitioners (GPs), 1628 mental health nurses, and 2000 psychologists in Australia. Participants within each professional group were randomly given one of four vignettes describing a young person with a DSM-IV mental disorder. Herein is reported data from the depression and depression with alcohol misuse vignettes. Results: A total of 305 psychiatrists, 258 GPs, 292 mental health nurses and 375 psychologists completed one of the depression vignettes. A diagnosis of mood disorder was identified by at least 83.8% of professionals, with no significant differences noted between professional groups. Rates of reported co-occurring substance use disorders were substantially lower, particularly among older professionals and psychologists. Conclusions: GPs, psychologists and mental health professionals do not readily identify co-occurring alcohol misuse in young people with depression. Given the substantially negative impact of co-occurring disorders, it is imperative that health-care professionals are appropriately trained to detect such disorders promptly, to ensure young people have access to effective, early intervention.

Psychotic symptom and cannabis relapse in recent-onset sychosis

Background Cannabis use appears to exacerbate psychotic symptoms and increase risk of psychotic relapse. However, the relative contribution of cannabis use compared with other risk factors is unclear. The influence of psychotic symptoms on cannabis use has received little attention. Aims To examine the influence of cannabis use on psychotic symptom relapse and the influence of psychotic symptom severity on relapse in cannabis use in the 6 months following hospital admission. Method At baseline, 84 participants with recent-onset psychosis were assessed and 81 were followed up weekly for 6 months, using telephone and face-to-face interviews. Results A higher frequency of cannabis use was predictive of psychotic relapse, after controlling for medication adherence, other substance use and duration of untreated psychosis. An increase in psychotic symptoms was predictive of relapse to cannabis use, and medication adherence reduced cannabis relapse risk. Conclusions The relationship between cannabis use and psychosis may be bidirectional, highlighting the need for early intervention programmes to target cannabis use and psychotic symptom severity in this population.

Assessment of function and clinical utility of alcohol and other drug web sites : an observational, qualitative study

Background The increasing popularity and use of the internet makes it an attractive option for providing health information and treatment, including alcohol/other drug use. There is limited research examining how people identify and access information about alcohol or other drug (AOD) use online, or how they assess the usefulness of the information presented. This study examined the strategies that individuals used to identify and navigate a range of AOD websites, along with the attitudes concerning presentation and content. Methods Members of the general community in Brisbane and Roma (Queensland, Australia) were invited to participate in a 30-minute search of the internet for sites related to AOD use, followed by a focus group discussion. Fifty one subjects participated in the study across nine focus groups. Results Participants spent a maximum of 6.5 minutes on any one website, and less if the user was under 25 years of age. Time spent was as little as 2 minutes if the website was not the first accessed. Participants recommended that AOD-related websites should have an engaging home or index page, which quickly and accurately portrayed the site’s objectives, and provided clear site navigation options. Website content should clearly match the title and description of the site that is used by internet search engines. Participants supported the development of a portal for AOD websites, suggesting that it would greatly facilitate access and navigation. Treatment programs delivered online were initially viewed with caution. This appeared to be due to limited understanding of what constituted online treatment, including its potential efficacy. Conclusions A range of recommendations arise from this study regarding the design and development of websites, particularly those related to AOD use. These include prudent use of text and information on any one webpage, the use of graphics and colours, and clear, uncluttered navigation options. Implications for future website development are discussed.

A novel SNP in COMT is associated with alcohol dependence but not opiate or nicotine dependence: a case control study

Background It is well established that COMT is a strong candidate gene for substance use disorder and schizophrenia. Recently we identified two SNPs in COMT (rs4680 and rs165774) that are associated with schizophrenia in an Australian cohort. Individuals with schizophrenia were more than twice as likely to carry the GG genotype compared to the AA genotype for both the rs165774 and rs4680 SNPs. Association of both rs4680 and rs165774 with substance dependence, a common comorbidity of schizophrenia has not been investigated. Methods To determine whether COMT is important in substance dependence, rs165774 and rs4680 were genotyped and haplotyped in patients with nicotine, alcohol and opiate dependence. Results The rs165774 SNP was associated with alcohol dependence. However, it was not associated with nicotine or opiate dependence. Individuals with alcohol dependence were more than twice as likely to carry the GG or AG genotypes compared to the AA genotype, indicating a dominant mode of inheritance. The rs4680 SNP showed a weak association with alcohol dependence at the allele level that did not reach significance at the genotype level but it was not associated with nicotine or opiate dependence. Analysis of rs165774/rs4680 haplotypes also revealed association with alcohol dependence with the G/G haplotype being almost 1.5 times more common in alcohol-dependent cases. Conclusions Our study provides further support for the importance of the COMT in alcohol dependence in addition to schizophrenia. It is possible that the rs165774 SNP, in combination with rs4680, results in a common molecular variant of COMT that contributes to schizophrenia and alcohol dependence susceptibility. This is potentially important for future studies of comorbidity. As our participant numbers are limited our observations should be viewed with caution until they are independently replicated.

Stress and addiction : contribution of the corticotropin releasing factor (CRF) system in neuroplasticity

Corticotropin releasing factor (CRF) has been shown to induce various behavioral changes related to adaptation to stress. Dysregulation of the CRF system at any point can lead to a variety of psychiatric disorders, including substance use disorders (SUDs). CRF has been associated with stress-induced drug reinforcement. Extensive literature has identified CRF to play an important role in the molecular mechanisms that lead to an increase in susceptibility that precipitates relapse to SUDs. The CRF system has a heterogeneous role in SUDs. It enhances the acute effects of drugs of abuse and is also responsible for the potentiation of drug-induced neuroplasticity evoked during the withdrawal period. We present in this review the brain regions and circuitries where CRF is expressed and may participate in stress-induced drug abuse. Finally, we attempt to evaluate the role of modulating the CRF system as a possible therapeutic strategy for treating the dysregulation of emotional behaviors that result from the acute positive reinforcement of substances of abuse as well as the negative reinforcement produced by withdrawal.

Diagnostic Dilemmas in Comorbidity

This high prevalence of comorbid mental health and substance use disorders makes the accurate diagnosis of comorbid disorders an important clinical priority. However, the presence of comorbid disorders creates a number of diagnostic dilemmas, which have hindered our understanding of the comorbid disorders. This chapter discusses these diagnostic dilemmas, including issues with the reliability, validity and clinical utility of current systems of psychiatric nomenclature’s approach to diagnosing comorbid disorders. A number of alternative models for understanding comorbid disorders are briefly discussed, followed by suggestions for how research can improve our understanding of comorbid disorders.

Study protocol : Screening and treatment of alcohol-related trauma (START): a randomised controlled trial

Background: The incidence of mandibular fractures in the Northern Territory of Australia is very high, especially among Indigenous people. Alcohol intoxication is implicated in the majority of facial injuries, and substance use is therefore an important target for secondary prevention. The current study tests the efficacy of a brief therapy, Motivational Care Planning, in improving wellbeing and substance misuse in youth and adults hospitalised with alcohol-related facial trauma. Methods and design: The study is a randomised controlled trial with 6 months of follow-up, to examine the effectiveness of a brief and culturally adapted intervention in improving outcomes for trauma patients with at-risk drinking admitted to the Royal Darwin Hospital maxillofacial surgery unit. Potential participants are identified using AUDIT-C questionnaire. Eligible participants are randomised to either Motivational Care Planning (MCP) or Treatment as Usual (TAU). The outcome measures will include quantity and frequency of alcohol and other substance use by Timeline Followback. The recruitment target is 154 participants, which with 20% dropout, is hoped to provide 124 people receiving treatment and follow-up. Discussion: This project introduces screening and brief interventions for high-risk drinkers admitted to the hospital with facial trauma. It introduces a practical approach to integrating brief interventions in the hospital setting, and has potential to demonstrate significant benefits for at-risk drinkers with facial trauma.

Sensory imagery in craving : from cognitive psychology to new treatments for addiction

Sensory imagery is a powerful tool for inducing craving because it is a key component of the cognitive system that underpins human motivation. The role of sensory imagery in motivation is explained by Elaborated Intrusion (EI) theory. Imagery plays an important role in motivation because it conveys the emotional qualities of the desired event, mimicking anticipated pleasure or relief, and continual elaboration of the imagery ensures that the target stays in mind. We argue that craving is a conscious state, intervening between unconscious triggers and consumption, and summarise evidence that interfering with sensory imagery can weaken cravings. We argue that treatments for addiction can be enhanced by the application of EI theory to maintain motivation, and assist in the management of craving in high-risk situations.

Effect of mobile phone-based psychotherapy in suicide prevention : a randomized controlled trial in Sri Lanka

We conducted a randomized controlled trial to test whether a Brief Mobile Treatment (BMT) intervention could improve outcomes relative to usual care among suicide attempters. The intervention included training in problem solving therapy, meditation, a brief intervention to increase social support as well as advice on alcohol and other drugs, and mobile phone follow-up. The effect of the intervention was measured in terms of a reduction in suicidal ideation, depression and self-harm at Baseline, six and 12 months. A wait-list control group received usual care. A total of 68 participants was recruited from a Sri Lankan hospital following a suicide attempt. Participants who received the intervention were found to achieve significant improvements in reducing suicidal ideation and depression than those receiving usual care. The BMT group also experienced a significant improvement of social support when compared to the control group. However, the BMT group did not demonstrate a significant effect in reducing actual self-harm and most substance use, and differential effects on alcohol use were restricted to men. Although the present study was limited in revealing which component of the intervention was more effective in preventing suicide, it showed its efficacy in reducing suicide as a whole.

Craving : a research update [Editorial to a special issue]

Craving has long been associated with addictive disorders. It has received much attention over the last two decades, partly through the advent of pharmacotherapies that attempt to address it (Jonson, 2008; Yahyavi-Firouz-Abadi & See, 2009). More recently, craving for substances has attained increased prominence, with the inclusion of “Craving or a strong desire or urge” in the draft of DSM-5 (APA, 2012). Studies generally support craving as occurring on a single diagnostic dimension alongside existing dependence criteria (Hasin, et al., 2012; Keyes, et al., 2011). Some (e.g. Keyes, et al., 2011) demonstrate that the addition of craving to DSM-IV alcohol abuse and alcohol dependence criteria contributes novel variance in predicting severity, and improves discrimination above that offered by existing DSM-IV criteria. Within the current volume, the paper by Agrawal et al. confirms that craving strongly loads on a single dimension that also incorporates DSM-IV alcohol dependence criteria. Craving was a relatively severe symptom: It was least often endorsed, and did not exceed 50% endorsement until 6 of the remaining 7 criteria were present...

I know, but I don’t care : how awareness of Queensland’s drug driving testing methods impact upon perceptions of deterrence and offending behaviours

An increasing body of research is highlighting the involvement of illicit drugs in many road fatalities. Deterrence theory has been a core conceptual framework underpinning traffic enforcement as well as interventions designed to reduce road fatalities. Essentially the effectiveness of deterrence-based approaches is predicated on perceptions of certainty, severity, and swiftness of apprehension. However, much less is known about how the awareness of legal sanctions can impact upon the effectiveness of deterrence mechanisms and whether promoting such detection methods can increase the deterrent effect. Nevertheless, the implicit assumption is that individuals aware of the legal sanctions will be more deterred. This study seeks to explore how awareness of the testing method impacts upon the effectiveness of deterrence-based interventions and intentions to drug drive again in the future. In total, 161 participants who reported drug driving in the previous six months took part in the current study. The results show that awareness of testing had a small effect upon increasing perceptions of the certainty of apprehension and severity of punishment. However, awareness was not a significant predictor of intentions to drug drive again in the future. Importantly, higher levels of drug use were a significant predictor of intentions to drug drive in the future. Whilst awareness does have a small effect on deterrence variables, the influence of levels of drug use seems to reduce any deterrent effect.

Factors associated with suboptimal adherence to antiretroviral therapy in Viet Nam: A cross-sectional study using audio computer-assisted self-interview (ACASI)

Background: Optimal adherence to antiretroviral therapy (ART) is necessary for people living with HIV/AIDS (PLHIV). There have been relatively few systematic analyses of factors that promote or inhibit adherence to antiretroviral therapy among PLHIV in Asia. This study assessed ART adherence and examined factors associated with suboptimal adherence in northern Viet Nam. Methods: Data from 615 PLHIV on ART in two urban and three rural outpatient clinics were collected by medical record extraction and from patient interviews using audio computer-assisted self-interview (ACASI). Results: The prevalence of suboptimal adherence was estimated to be 24.9% via a visual analogue scale (VAS) of past-month dose-missing and 29.1% using a modified Adult AIDS Clinical Trial Group scale for on-time dose-taking in the past 4 days. Factors significantly associated with the more conservative VAS score were: depression (p < 0.001), side-effect experiences (p < 0.001), heavy alcohol use (p = 0.001), chance health locus of control (p = 0.003), low perceived quality of information from care providers (p = 0.04) and low social connectedness (p = 0.03). Illicit drug use alone was not significantly associated with suboptimal adherence, but interacted with heavy alcohol use to reduce adherence (p < 0.001). Conclusions: This is the largest survey of ART adherence yet reported from Asia and the first in a developing country to use the ACASI method in this context. The evidence strongly indicates that ART services in Viet Nam should include screening and treatment for depression, linkage with alcohol and/or drug dependence treatment, and counselling to address the belief that chance or luck determines health outcomes.

Risk-taking, harm and help-seeking : reported by young people in treatment at a youth alcohol and drug counselling service

Regarded as a normative component of development, risk-taking by young people is a well-researched subject, and some risk-taking behaviours, such as substance use, are particularly well covered because of their potential to adversely affect health and wellbeing. What has remained unclear is the extent of young people's risk-taking while engaged in alcohol and other drug (AOD) treatment, their awareness of the related harms of risk-taking behaviours, and their prior help-seeking for these harms - information which may have a significant impact on the quality and relevance of the care they receive. This paper reports the findings from a brief pilot study exploring those factors in a clinical sample of young people engaged in ongoing AOD counselling.

Pregnancy loss and psychiatric disorders in young women : an Australian birth cohort study

Background Recent evidence has linked induced abortion with later adverse psychiatric outcomes in young women. Aims To examine whether abortion or miscarriage are associated with subsequent psychiatric and substance use disorders. Method A sample (n=1223) of women from a cohort born between 1981 and 1984 in Australia were assessed at 21 years for psychiatric and substance use disorders and lifetime pregnancy histories. Results Young women reporting a pregnancy loss had nearly three times the odds of experiencing a lifetime illicit drug disorder (excluding cannabis): abortion odds ratio (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). Conclusions These findings add to the growing body of evidence suggesting that pregnancy loss per se, whether abortion or miscarriage, increases the risk of a range of substance use disorders and affective disorders in young women.