Volume 173 Issue 10

For editorial comment, see Saunders & Richards Abstract - Methods - Results - Discussion - Conclusions - Acknowledgements - References - Authors' details Abstract Objective: To estimate the prevalence of dependent or daily heroin users in Australia, and to compare the prevalence in Australia with that in other developed countries. Design: We applied three different methods of estimation (back-projection, capture-recapture, and multiplier) to data on national opioid overdose deaths in Australia, first-time entrants to methadone maintenance treatment, and heroin-related arrests in New South Wales. We compared our estimates with estimates derived by similar methods in countries of the European Union. Data sources: Data on national opioid overdose deaths were obtained from the Australian Bureau of Statistics. Data on methadone entrants in NSW were extracted from a database maintained by the NSW Department of Health. Data on arrests for heroin-related offences were supplied by the NSW Police Service. Results: The best estimates of the number of dependent heroin users in Australia in 1997-1998 from the three methods of estimation were between 67 000 and 92 000 and the median estimate was 74 000. The population prevalence was 6.9 per 1000 adults aged 15-54 years. The prevalence of heroin dependence in Australia is the same as that in Britain (7 per 1000) and within the range of recently derived estimates in the European Union (3-8 per 1000 adults aged 15-54 years). Conclusions: Although the exact figures need to be interpreted with caution, our estimates suggest that Australia has a substantial public health problem with dependent heroin use that is of a magnitude similar to that in comparable European societies. In Australia, dependent heroin users are typically daily, or near-daily, injectors of heroin, and of other opioid and sedative drugs when heroin is not available. They continue to use heroin despite the risks of being arrested for drug or property crimes, imprisoned for heroin-related offences, contracting infectious diseases, and overdosing.1Credible estimates of the number of dependent heroin users are needed to plan appropriate public policy responses to the consequences of dependent heroin use.2 These consequences, which have negative effects on the community and public health,3 include bloodborne virus transmission,4 premature death from overdose,5 and crime.6 The need for credible estimates is especially pertinent now, because an increased rate of fatal overdoses over the past five years4 has prompted claims in the popular media that there has been a substantial increase in heroin use in Australia in recent years. Household surveys of drug use are not well suited to estimating the prevalence of dependent heroin use, for several reasons. First, heroin use is likely to be under-reported in household surveys because it is an illegal and stigmatised behaviour.7 Second, dependent heroin users' lifestyles also make them less likely to live in conventional households and less likely to participate in household surveys, because of either their unavailability at the time the interviewer calls or their reluctance to be interviewed.8 Third, household surveys may underestimate the number of dependent heroin users in the population, because heroin users are heavily concentrated in a small number of geographic areas where heroin is most readily available.8 When these areas are represented in national samples in proportion to the contribution to the total population, the estimated population rates of heroin use are usually underestimated in national surveys.9 There is no widely accepted "gold standard" method for estimating the size of the "hidden population" of dependent heroin users. The most widely used approach has been to look for a convergence of estimates derived by applying a number of different indirect methods of estimation to data on the consequences of dependent heroin use, such as overdose death and persons seeking treatment.10 We used this strategy to estimate the number of dependent heroin users in Australia. Our aims were: to estimate the number of dependent heroin users in Australia; and to compare the estimated population prevalence in Australia with that in comparable European societies. Methods Data sources Estimates were derived from secondary analyses of the following datasets: national data on the number of fatal opioid overdoses per year between 1964 and 1997 compiled by the Australian Bureau of Statistics; the NSW Health Department's methadone client database between 1987 and 1998, provided by the Pharmaceutical Services Branch (PSB); and data on arrests for heroin offences in the period 1997-1999 from the NSW Police Service. Each of these datasets is likely to be incomplete to different degrees and in different ways. The number of opioid overdose deaths may be underestimated if the cause of death is not recognised as opioid-related. Data on methadone entrants are more likely to be complete because methadone can not be prescribed in NSW until a registration form is completed and identity checks are undertaken to prevent a person registering more than once. Data on arrests for heroin-related offences do not include heroin-dependent people who are arrested for non-drug-related offences, such as property offences. The aim of the study was to look for convergence of estimates derived from "multiple measures of independent imperfection".11 Methods of estimation Three indirect methods were used to estimate the number of dependent heroin users in NSW and Australia. Multiplier methods used the number of national opioid overdose fatalities and NSW methadone maintenance therapy (MMT) clients. For mortality, we used both the conventional multiplier of 100 (which assumes an annual overdose mortality rate of 1%),12 and a multiplier of 125, derived from a meta-analysis of cohort studies of treated heroin users (which suggests an annual mortality rate of 0.8%).9 The multiplier of 3 for MMT was derived from a study of demand for this type of treatment in Australia.13 Capture-recapture estimates were based on the numbers of individuals entering MMT (1995-1998) and arrested for heroin offences (1997-1998), using methods described elsewhere.9 The capture-recapture estimates were across periods of one year, rather than capture-recapture across different data sources in the same time period.14 Back-projection methods were applied to data on national fatal opioid overdose and first-time entrants to MMT in NSW to estimate the incidence and prevalence of heroin dependence. The form of back-projection used was that suggested by Becker and colleagues15,16 (see ref. 17 for details). The current study examined the degree of convergence between the back-projection estimates derived from the two different data sources. A national estimate was derived directly from national opioid overdose deaths. NSW estimates were derived from NSW MMT and arrest data. The NSW estimates were doubled to produce national estimates. This was done because NSW has consistently accounted for just under half of all opioid overdose deaths in Australia since 1979,5 and for just over half of the number of people enrolled in MMT in Australia.6 Results National estimates The estimates produced by the various methods are shown in Box 1. The best estimate for each method for Australia varied between 67 000 and 92 000, with a median of 74 000 and a mean of 77 000. The range of individual estimates was much wider, between 39 000 and 120 000. The degree of consistency between the best estimates derived from different methods from different data sources was reassuring, especially the agreement between the trends in the two back-projection methods over the period 1970-1997 (Box 2). This consistency provides some reassurance that the true estimate of the number of dependent heroin users in Australia is within our range of estimates. In the absence of any consensus on differential weighting of the estimates, we have taken the median national estimate of 74 000 as the best estimate. This represents a population prevalence of dependent heroin use in Australia of 6.9 per 1000 adults aged 15-54 years, with a range of 5.8-8.6 per 1000. Crude estimates of the number of heroin-dependent people in each of the Australian States and Territories can be derived by allocating the estimated number of heroin users in Australia as a whole (74 000) to each jurisdiction in proportion to the contribution that each jurisdiction made to national opioid overdose deaths in the period 1994-1998. On this basis, NSW is estimated to have 35 400 dependent heroin users, just under half of the national estimate (48%). The estimated number of 19 600 heroin-dependent persons in Victoria accounted for 27% of the national estimate. NSW and Victoria therefore account for 75% of all the estimated number of heroin-dependent persons in Australia. The smaller States accounted for the remaining 25%. The estimated numbers of dependent heroin users in the smaller States, particularly Queensland and Tasmania, appear to be underestimates in that they imply that an implausibly high proportion of dependent heroin users are currently receiving treatment. Because better local estimates need to be derived by applying our methods to data in each of the smaller States, we have not reported these estimates here. Discussion Several methods of estimating the size of the population of people who are heroin dependent in Australia have produced estimates that vary between 67 000 and 92 000 people. The median estimate is 74 000, which equals a population prevalence of 6.9 per 1000 population aged 15-54 years. Each estimation method makes assumptions that are of uncertain validity. Although these uncertainties mean that the estimates presented here should be interpreted with caution, there are a number of reasons why our estimates provide a better basis for public policy than more speculative estimates in the popular media. Firstly, there is reassuring convergence between estimates produced by different methods. The two back-projection estimation methods, applied to two very different datasets (new entrants to methadone treatment and opioid overdose deaths), produced estimates that were in close agreement. The ranges of estimates derived by plausibly varying the assumptions also substantially overlapped.17 The estimates produced by the mortality and treatment multiplier methods and the capture-recapture estimates were similar to those produced by the back-projection methods. Secondly, the estimated national prevalence rate is in the middle of the range of estimates of problem drug use derived recently by similar methods in Europe (3-8 per 1000 adults aged 15-54 years).18 The Australian prevalence is the same as the estimated prevalence of heroin dependence in the United Kingdom (7 per 1000 adults aged 15-54 years).18 Several factors explain the discrepancy between our estimates and media estimates of 200 000 Australian heroin users. Our estimate is of dependent heroin users, who are highly visible in a small number of geographic areas in Sydney and Melbourne. This means that they often attract media attention out of all proportion to their numbers. Within these areas, intoxicated dependent heroin users are often highly visible, dealing and using drugs, and leaving discarded injecting equipment in public places. Dependent heroin users who are involved in criminal activities engage in high rates of breaking and entering houses.19 The national estimate for 1997 (74 000) represents a doubling of the 34 000 estimated in 1984-198720 and a 25% increase on the estimate of 59 000 in the period 1988-1993.13 During this time, there was a corresponding increase in the rate of heroin dependence from 3.7 per 1000 in 1984-1987 to 5.9 per 1000 in 1988-1993 and to 6.9 per 1000 in 1997. The back-projection estimates produce trends in numbers that are consistent with these earlier estimates (Box 2). There are three plausible reasons why the number of dependent heroin users has increased in Australia over the past decade. First, there has been a substantial increase in the availability of very pure and very cheap heroin in Australia in the past two decades. The very limited historical data indicate that the purity of street heroin in Sydney has increased from 10% in 197921 to a mean of 60% in 1993-1995.22 The nominal price has remained stable at $30 for a street "cap", but the effective price per ounce of pure heroin has declined from about $16 000 in 1979 dollars to $5000 in 1999 dollars; the difference is even greater when account is taken of inflation.9 Second, the high purity and low price have meant that it has been easier for new users to initiate heroin use by non-injecting routes, such as smoking or inhaling the fumes of heroin heated on aluminium foil. This may have permitted more naive users to begin heroin use before making a transition to injecting.19 Third, the rise in heroin use in birth cohorts born in the latter half of the 20th century is paralleled by similar trends in a range of psychosocial disorders among young adults,23 including depression, suicide, antisocial behaviour and eating disorders. These trends and the reasons for them have been extensively reviewed by Rutter and Smith,23 who conclude that the increases are real. Conclusions Our estimated prevalence of heroin dependence in Australia (74 000 people; a population rate of 6.9 per 1000 adults aged 15-54 years) is similar to that in countries of the European Union. The media attention given to opioid overdose deaths in Australia in recent years has created a false impression that the prevalence of heroin dependence is unusually high in Australia. Other data suggest that, in Australia, dependent heroin use causes a substantial public health5 and public order problem,9 but the current estimates suggest that the number of dependent heroin users is of the same order of magnitude as in Britain and other European societies from which Australia's population has largely derived. Acknowledgements Both the National Centre in HIV Epidemiology and Clinical Research and the National Drug and Alcohol Research Centre are funded by the Commonwealth Department of Health and Aged Care. References Hall W, Lynskey M, Degenhardt L. Heroin use in Australia: its impact on public health and public order. NDARC Monograph No. 42. Sydney: UNSW, 1999. Stimson GV, Judd A. Estimating the scale and nature of drug problems: the relationship between science, policy and drug strategy. In: European Monitoring Centre for Drugs and Drug Addiction. Estimating the prevalence of problem drug use in Europe. EMCDDA Scientific Monograph No. 1. Luxembourg: Office for Official Publications of the European Communities, 1997; 19-26. Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. Canberra: AIHW, 1999. National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, hepatitis C and sexually transmissible infections in Australia. Annual Surveillance Report. Sydney: NCHECR, 1999. Hall W, Degenhardt L, Lynskey M. Opioid overdose mortality in Australia, 1964-1997: birth cohort trends. Med J Aust 1999; 171: 34-37. Hall W. Methadone maintenance treatment as a crime control measure. Crime Justice Bull 1996; 29: 1-12. Griffiths P, Farrell M, Howe S. Local prevalence estimation: can an inner city prevalence survey produce useful information? In: European Monitoring Centre for Drugs and Drug Addiction. Estimating the prevalence of problem drug use in Europe. EMCDDA Scientific Monograph No. 1. Luxembourg: Office for Official Publications of the European Communities, 1997; 67-72. Darke S, Ross J, Zador D, Sunjic S. Heroin-related deaths in New South Wales, Australia, 1992-1996. Drug Alcohol Depend 2000; 60: 141-150. Hall W, Ross J, Lynskey M, et al. How many dependent opioid users are there in Australia? NDARC Monograph No. 44. Sydney: UNSW, 2000. Hartnoll R. Cross-validating at local level. In: European Monitoring Centre for Drugs and Drug Addiction. Estimating the prevalence of problem drug use in Europe. EMCDDA Scientific Monograph No. 1. Luxembourg: Office for Official Publications of the European Communities, 1997; 247-161. Cook TD, Campbell DT. Quasi-experimentation: design and analysis issues for field settings. Chicago: Rand McNally, 1979. Frischer M. Estimating the prevalence of drug abuse using the mortality multiplier method: an overview. In: European Monitoring Centre for Drugs and Drug Addiction. Estimating the prevalence of problem drug use in Europe. EMCDDA Scientific Monograph No. 1. Luxembourg: Office for Official Publications of the European Communities, 1997; 113-126. Hall W. The demand for methadone maintenance treatment in Australia. NDARC Technical Report No. 28. Sydney: UNSW, 1995. Hook EB, Regal RR. Capture-recapture methods in epidemiology: methods and limitations. Epidem Rev 1995; 17: 243-264. Becker NG, Watson LF, Carlin JB. A method of non-parametric back-projection and its application to AIDS incidence data. Stat Med 1991; 10: 1527-1542. Becker NG, Watson LF, Marschner IC, et al. Assessing the extent of the Australian HIV epidemic from AIDS surveillance data. Aust J Pub Health 1993; 17: 226-231. Law M, Ross J, Lynskey M, Hall W. Back projection estimates of the number of dependent heroin users in Australia. Addiction 2000; in press. European Monitoring Centre for Drugs and Drug Addiction. Extended annual report on the state of the drugs problem in the European Union 1999. Luxembourg: Office for Official Publications of the European Communities, 1999. Maher L, Dixon D, Lynskey M, Hall W. Running the risks. Heroin, health and harm in South Western Sydney. Sydney: UNSW, 1998. National Drug Abuse Data System NDADS. How many heroin users are there in Australia? Statistical Update No. 5. March 1988. Williams ES. Australian Royal Commission of Inquiry into Drugs. Canberra: AGPS, 1980. Weatherburn D, Lind B. Drug law enforcement policy and its impact on the heroin market. Sydney: NSW Bureau of Crime Statistics and Research, 1995. Rutter M, Smith DJ, editors. Psychosocial disorders in young people: time trends and their causes. Chichester: John Wiley and Sons, 1995. (Received 5 Jun, accepted 25 Aug, 2000) Authors' details University of New South Wales, Sydney, NSW. Wayne D Hall, PhD, Professor and Executive Director, National Drug and Alcohol Research Centre; Joanne E Ross, PhD, Lecturer, National Drug and Alcohol Research Centre; Michael T Lynskey, PhD, Lecturer, National Drug and Alcohol Research Centre; Matthew G Law, PhD, Senior Lecturer, National Centre in HIV Epidemiology and Clinical Research; Louisa J Degenhardt, BA(Hons), Senior Research Assistant, National Drug and Alcohol Research Centre. Reprints: Professor W D Hall, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052. w.hallATunsw.edu.au 1: Estimates of the number of dependent heroin users in New South Wales and Australia (rounded to nearest 1000) Method of estimation Estimate for Australia Range of estimates Back-projection National overdose deaths NSW methadone maintenance therapy entrants 67000 71000 39000-120000* 47000-109000* Capture-recapture Methadone maintenance therapy episodes Arrests for heroin offences 82000 86000 68000-109000† 78000-102000† Multiplier estimates Overdose fatalities (x 100) (x 125) MMT entrants (x 3) 74000 92000 68000 - - - Median estimate 74000 - *Ranges from sensitivity analyses. †95% confidence intervals around estimates. Back to text Back to text

Wayne D Hall · Joanne E Ross · Michael T Lynskey · Matthew G Law · Louisa J Degenhardt

Medicine and the Community What can we do about domestic violence? Danielle Mazza, Joan M Lawrence, Gwenneth L Roberts and Sheila M Knowlden MJA 2000; 173: 532-535 See Articles 1, 2 and 3 of this series For editorial comment, see Raphael Abstract - What can individual doctors do? - What can be done in the institutional or hospital setting? - What can governments do? - Conclusions - References - Authors' details - - More articles on General practice and primary care Abstract Domestic violence is a complex issue at both an individual and public health level. Barriers to disclosure often lie with the doctor rather than the victim. Assessment of risk and devising a safety plan are important steps for the doctor to undertake with the victim. Recommendations for joint counselling or marriage guidance for the couple are usually not appropriate. The efficacy of population screening for domestic violence has not yet been demonstrated. More limited opportunistic screening is recommended, especially in the emergency department, mental health and obstetric settings, and general practice. Health professionals can be a bridge to resources within the community, but this requires knowledge of and liaison with those services. Domestic violence is a social, economic and political issue that has ramifications for the health of the whole community. It affects not only the physical and mental health of up to 20% of women at some stage of their lives,1 but also the health of children living with domestic violence.2There is increasing awareness of the benefits of taking a public health approach to domestic violence -- in considering it analogous to a chronic and complex condition, the burden of care on individual doctors can be lessened and the healthcare system can take a more constructive approach to this difficult issue. We examine here the role of individual practitioners, healthcare institutions and government in managing domestic violence, and propose some preventive strategies. What can individual doctors do? Doctors often fail to suspect domestic violence. In one study of a family practice in which the prevalence of domestic violence was 7% for physical abuse and 23% for emotional abuse, only 1% of doctors' files documented the abuse.3 In another study of 492 patients who completed a questionnaire after presenting at a hospital emergency department (ED), 22% admitted to being victims of domestic violence, but ED records identified only 5% of these victims.4It may be that some doctors who are aware of abuse experienced by their patients fail to document it. However, documentation is essential for the patient in case legal action ensues. Easteal and Easteal5 surveyed 96 Australian general practitioners on their attitudes and practices towards victims of domestic violence. The most common reasons given for suspecting spouse abuse were physical signs and injuries (56.3%), excess alcohol consumption by the patient and/or partner (11.0%), and the patient's case history (11.5%). Only about a third of doctors reported that they look for emotional problems as "symptoms" when determining assault cases. In a similar Canadian study of 505 physicians, respondents estimated that 14%-17% of their female patients had been victims of abuse, but over 70% of respondents believed that they identified fewer than half of these patients in their practice. The most common reasons given for failure to uncover domestic violence were patient unresponsiveness, lack of physician initiative and infrequent visits by the patients.6 Doctors perceive spouse abuse to be a complex and multifaceted problem.7 Many feel powerless to deal with domestic violence,8 and fear that in broaching the subject they are "opening Pandora's box".7 Barriers to instituting helpful intervention in cases of domestic violence include: close identification by doctors with patients of similar background, which may preclude the consideration of domestic violence as a differential diagnosis;9 a perception, especially among female doctors, that dealing with patients' domestic violence issues will expose their own fear of vulnerability and lack of control;9 a fear of offending patients by asking questions about a subject culturally defined as "private";9 reluctance to accept a patient's claims of domestic violence without corroboration from an outside source;9 time constraints in a busy practice that make it difficult to deal with complex problems such as domestic violence;7,10 lack of training of doctors in the area of domestic violence.9,11 Abused women are more likely to disclose domestic violence to their GP than to other health workers and, when they do, the GP needs to be prepared. Useful advice for doctors on dealing with domestic violence, and an illustrative case scenario, are given in Boxes 1 and 2. What can be done in the institutional or hospital setting? Research over the past decade has demonstrated the high prevalence of domestic violence and the physical and psychological consequences that bring victims into contact with the hospital system.4,21,22 Failure to identify and manage these victims appropriately has led to some changes in management within the hospital setting and in the integration of care between the hospital and the wider community. However, further changes are needed. The effectiveness of population screening of women for domestic violence has not been proven,23 and at this stage the more limited goals associated with opportunistic screening are recommended. Routine screening should only be undertaken in situations where there is likely to be a high prevalence, such as among people attending hospital EDs, antenatal clinics and psychiatric services. Routine screening within the hospital setting will raise ethical and practical issues. An important ethical issue is the acceptability of asking people directly about their experience of domestic violence. Studies conducted in EDs demonstrate high response rates to screening questionnaires by women and men.24 The current pilot study being conducted by Queensland Health Domestic Violence Initiative to introduce routine screening in EDs and antenatal clinics has met with strong acceptance from the women being surveyed (Ms J Webster, Co-manager, The Domestic Violence Initiative, personal communication). Screening will require the choice of appropriate tools and training of staff. Staff will need broader knowledge in the areas of documentation of history and injuries, photographs, safety of the victim, confidentiality, legal rights, and reporting of attempted or suspected criminal assault. (Reporting of violence is a controversial issue -- for example, several states in the United States have mandatory reporting of domestic violence, but there are concerns about patient autonomy and risk of retaliation for the victim.25) Training also needs to deal with the barriers to enquiry about domestic violence, including negative attitudes of health professionals towards victims. Staff who have themselves experienced domestic violence may require particular care. Knowledge of the dynamics of domestic violence is important -- staff need to understand that domestic violence can manifest as both mental and physical injury, and to accept that there is often no immediate solution to the problem (eg, a victim may return to a violent partner). Hospitals need to assess their resources for dealing with domestic violence and devise policies and protocols for the use of those resources. Health professionals can be a bridge to services in the community if they are familiar with the appropriate referral services within the hospital and in the wider community. For years, legal and community advocacy services have acted as community resources for women seeking help with domestic violence problems. A recent development in the United States has been to enlist the help of advocates in medical settings.26While this is not common practice in Australian hospitals, the service is worthy of consideration given the success of other services such as breast cancer volunteer visitors (ie, women who, having experienced the condition themselves, give support and comfort to other women with breast cancer). Advocates can assist victims with legal information and safety planning, and help them develop independence. What can governments do? Domestic violence is an important issue for government not only because of its effect on the physical and mental health of the community, but because of the costs it incurs for the healthcare system, especially as victims of violence are often misidentified and incorrectly treated.22Governments can enact policies aimed at prevention, supply resources for effective management of perpetrators and victims of domestic violence, and educate the community about domestic violence. Government policy can also target the training that medical, nursing and allied health personnel receive to ensure that all clinicians are aware of their role in managing domestic violence, know how and when to screen for domestic violence and know which management strategies are likely to be effective.22 Governments could also ensure that the different departments dealing with domestic violence and child abuse are able to work together effectively and communicate information on cases they have in common. This is because the strategies for managing child abuse in this context are different from those required for dealing with other forms of child abuse. When asked how government services relating to domestic violence could be improved, women have suggested improving the responsiveness of individual police members when dealing with domestic violence; ensuring that a wider range of organisations and professional services are aware of domestic violence issues and how to manage them; increasing awareness of how to access the domestic violence services that are available; increasing the services in remote and rural areas; and providing more practical support with housing, employment and the law.15,27 Governments also need to address the continuing shortage of refuge accommodation,28 and to examine the effect of recent changes to legal aid funding that have made it available only for cases going through the Family Court. Conclusions There are no simple solutions to the problem of domestic violence. Like other public health issues, it must be tackled at all levels of the healthcare system. Doctors, both in general practice and in the hospital system, should be more proactive in diagnosing situations where domestic violence is occurring. Multidisciplinary approaches that cut through bureaucratic divides need to be put in place to support victims and their children, and funds should be invested in teaching and research so that health professionals can be informed about what is best practice. References Roberts GL, Lawrence JM, Williams GM, Raphael B. The impact of domestic violence on women's mental health. Aust N Z J Public Health 1998; 22: 796-801. Carroll J. The protection of children exposed to marital violence. Child Abuse Review 1994; 3: 6-14. Martins R, Holzapfel S, Baker P. Wife abuse: are we detecting it? J Womens Health 1992; 1: 77-80. Goldberg WG, Tomlanovich MC. Domestic violence victims in the emergency department. New findings. JAMA 1984; 251: 3259-3264. Easteal PW, Easteal S. Attitudes and practices of doctors toward spouse assault victims: an Australian study. Violence Vict 1992; 7: 217-228. Ferris LE, Tudiver F. Family physicians' approach to wife abuse: a study of Ontario, Canada, practices. Fam Med 1992; 24: 276-282. Brown JB, Sas G. Focus groups in family practice research: an example study of family physicians' approach to wife abuse. Family Practice Research Journal 1994; 14: 19-28. Hegarty KL. Barriers to disclosure of domestic violence in general practice. Final Report. General Practice Evaluation Program. Canberra: Department of Health and Aged Care, 1997. Sugg NK, Inui T. Primary care physicians' response to domestic violence. Opening Pandora's box. JAMA 1992; 267: 3157-3160. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992; 24: 283-287. Kurz D, Stark E. Not so benign neglect: the medical response to battering. In: Yllo K, Bograd M, editors. Feminist perspectives on wife abuse. Newbury Park, California: Sage Publications, 1988: 249-266. Hegarty K, Hindmarsh ED, Gilles MT. Domestic violence in Australia: definition, prevalence and nature of presentation in clinical practice. Med J Aust 2000; 173: 363-367. White DG. Wearing a wife-assault-prevention button: impact on a family practice. CMAJ 1991; 145: 1005-1012. Friedman L, Samet J, Roberts M, Hans P. Inquiry into victimisation experiences: a survey of patient preferences and physician practice. Arch Intern Med 1992; 152: 1186-1190. Gerbst B, Abercrombie P, Carfers N, et al. How health care providers help battered women: the survivor's perspective. Women Health 1999; 29: 115-135. Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence against women: a general practice-based prevalence study. Med J Aust 1996; 164: 14-17. Romans SE, Poore MR, Martin JL. The perpetrators of domestic violence. Med J Aust 2000; 173: 484-488. Roberts GL, Williams GM, Lawrence JM, Raphael B. How does domestic violence affect women's mental health? Women Health 1998; 28: 118-129. Rittmayer J, Roux G. Relinquishing the need to "fix it": medical intervention with domestic abuse. Qual Health Res 1999; 2: 66-81. Roberts GL, Lawrence JM, O'Toole BI, Raphael B. Domestic violence in the emergency department: two case-control studies of victims. Gen Hosp Psychiatr 1997; 19: 5-12. Eisenstat SA, Bancroft L. Domestic violence. N Engl J Med 1999; 341: 886-892. Kilpatrick D, Resnick H, Acierno R. Health impact of interpersonal violence. 3: Implications for clinical practice and public policy. Behav Med 1997; 23: 79-85. Lawler VA. Routine screening for domestic violence: A review of the literature [dissertation]. Melbourne: University of Melbourne; 1996. Roberts GL, O'Toole BI, Lawrence JM, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1993; 159: 307-310. Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence: do they promote patient well-being? JAMA 1995; 273: 1781-1787. Worcester N. Health systems response to battered women: our "successes" are creating new challenges. National Women's Health Network News 1995; 20(2): 1-6. Against the odds: how women survive domestic violence. Canberra, Office of the Status of Women, Department of Premier and Cabinet, 1998. Supported Accommodation Report 1997/98. Canberra: Australian Institute of Health and Welfare, 1998. Authors' details Royal Australian College of General Practitioners, South Melbourne, VIC. Danielle Mazza, MD, FRACGP, Director of Quality Assurance and Continuing Education. Watkins Medical Centre, Brisbane, QLD. Joan M Lawrence, AM, FRANZCP, Adjunct Professor of Psychiatry. Research Unit, Department of Psychiatry, CYMHS, Fortitude Valley, QLD. Gwenneth L Roberts, PhD, B Bus (Health Admin), Research Manager. Department of General Practice, University of New South Wales, Kensington, NSW. Sheila M Knowlden, MB BS, FRACGP, Senior Lecturer. Reprints will not be available from the authors. Correspondence: Danielle Mazza, MD, FRACGP, Director of Quality Assurance and Continuing Education, Royal Australian College of General Practitioners, 1 Palmerston Crescent, South Melbourne, VIC 3205. danielle.mazzaATracgp.org.au Make a comment 1: Advice for doctors on dealing with domestic violence Learn to recognise the typical symptoms (both physical and emotional),12 and be alert to the possibility of domestic violence. Display posters and brochures about domestic violence in the waiting room or in toilet facilities, or wear a lapel badge showing you do not condone domestic violence. This increases patients' willingness to discuss their situation.13 If domestic violence is suspected, ask the patient about it in a direct manner. Abused women often feel relieved when asked about the violence, provided the questioning is handled sensitively and their response is validated by the doctor (eg, by reassuring the woman that domestic violence is common and that she has been very courageous in disclosing the information).14-16 Document any injuries in detail (even if the patient does not, at the time, wish to take legal action), and provide treatment if necessary. Assess the immediate and short-term risks to the patient. Questions that could be asked include what has the pattern of violence been? have you ever feared for your life? what is the worst assault you have suffered? does your partner have a gun or other weapon at home? has your partner ever used a weapon against you? Assist in devising a safety plan, which should include asking the patient about support persons (who are they? are they easily accessible? are they aware of what is going on?); establishing whether the patient has the financial resources to leave; giving the patient an excuse, if needed, to come back for regular follow-up visits; providing contact details for a refuge service and explaining how the system works. Planning for a worst-case scenario ahead of time can provide practical support for a person who chooses to stay with an abusive partner. Be ready in advance with information about appropriate resources, support services, women's shelters, legal advice and restraining orders, to help victims if and when they decide to leave their abusive partner. Information about local contacts can be obtained from local community health centres, sexual assault centres, women's health centres and legal aid organisations. If you feel comfortable doing so, provide supportive and educative counselling for victims of domestic violence (see example in Box 2); otherwise, refer patients to a social worker, psychologist, or psychiatrist (while accepting the patient's right to refuse the referral). If the perpetrator admits to the violence and agrees to attend counselling, arrange assistance for that person. Recommendations for joint counselling or marriage guidance for the couple are not usually appropriate unless issues of violence have already been directly addressed and the relationship continues. If both the victim and the perpetrator are your patients, issues of confidentiality, disclosure and management of the possible competing needs of the couple can present real difficulties. In this situation, try to arrange for another doctor to take on the care of either the victim or the perpetrator. If the victim consents to your raising the issue with the perpetrator,17 inform both parties that your highest priority is the safety of all concerned and that violence is illegal. Accept that there is no simple solution to the problem, and respect the patient's autonomy, even if you do not agree with his or her decision. It is the patient who must decide whether to stay in a violent relationship or leave.18 Counselling about substance misuse may be indicated. Avoid prescribing medication with habit-forming properties (eg, benzodiazepines) in view of the identified increased rates of substance-use disorders in victims of violence.1,19,20 Remember that doctors are obliged, under "mandatory reporting" legislation, to report situations in which children are at risk of violence and abuse. Back to text 2: Case scenario for dealing with domestic violence in general practice "Margaret" is a 35-year-old woman who lives on a dairy farm, which she manages with her husband of 10 years. They have three children aged between eight and three years. Over the time that she has been consulting you she has presented repeatedly with soft tissue injuries that she acknowledges have been inflicted by her husband. She believes that her husband only becomes violent when he drinks. She is isolated on the farm and says she is unable to leave her husband or to seek support in the local community because she feels ashamed and because her husband is good friends with the local policeman. One day she attends requesting "counselling" for her husband. At that initial consultation you offer Margaret support and acknowledge her efforts in trying to get the violence to stop. You point out that domestic violence is common and that you have dealt with other women experiencing similar problems. You explore with her the degree of risk she feels and whether there is any child abuse occurring. Over the course of several consultations you discuss with Margaret the dynamics of domestic violence and the history of violence perpetrated by her husband. You challenge her beliefs about the nature of domestic violence by asking why her husband is never violent with his male companions in the pub but only at home with her. You provide her with the name and number of the domestic violence outreach worker with the local women's health service and offer her patient information brochures. You discuss with her the nature of support she might receive from friends, family and government should she choose to leave her partner and whether or not she has discussed the violence with anyone else. After a particularly violent episode, Margaret takes the children and goes to stay with her parents for a few weeks. Fearing that more people will find out about his violence and that Margaret might leave for good, her husband agrees to attend counselling to placate her. Margaret decides to return to the family home. Back to text

Danielle Mazza · Joan M Lawrence · Gwenneth L Roberts · Sheila M Knowlden

New Drugs, Old Drugs Forty years of combined oral contraception: the evolution of a revolution Ian S Fraser MJA 2000; 173: 541-544 Abstract - A historical perspective - Revolutions, evolutions and controversies - Conclusions - References - Authors' details - - More articles on Obstetrics & gynaecology and women's health Abstract The combined oral contraceptive (COC) pill has become an integral part of fertility choice in almost every country since its introduction in 1960 in the United States. It was the first contraceptive method to provide sexual freedom of choice for women through reliable personal, private control of fertility. Modern, very low-dose pills have maintained a high degree of contraceptive efficacy, but the margin for error in pill-taking appears much smaller. These COCs have a much lower incidence of side effects and serious complications than early high-dose COCs. Serious health risks from venous thromboembolism are rare, and not measurably higher for pills containing third-generation compared with earlier progestogens. Most women feel very well taking modern COCs, but myths about these drugs still abound. Most non-contraceptive health benefits of COCs are still not widely appreciated in spite of much evidence. Controversy still persists over the association between COC use and breast cancer. Although slightly more breast cancers are detected in current COC users (relative risk 1.24; 95% CI, 1.15-1.33), they are less advanced and less aggressive. Some women have pre-existing medical risk factors for COC use, and a detailed history for cardiovascular risk factors is one of the most important precautions. One of the most far-reaching events of the 20th century occurred in May 1960 with the marketing of the first combined oral contraceptive (COC) in the United States. The trade name of this daily combination of mestranol (150 µg) and ethynodiol diacetate (10 mg) was Enovid (marketed by G D Searle), but the popular name had already been coined by Aldous Huxley in Brave new world revisited -- "the Pill".1 Huxley had foreseen the infinite complexity of the role of the oral contraceptive in birth control: "It is not merely a problem in medicine, in chemistry, in biochemistry, in physiology; it is also a problem in sociology, in psychology, in theology, and in education."2 He went on to discuss the difficulties of gaining population acceptance of such complex ideas: "The English Fabians, Beatrice and Sidney Webb, made an historical study of the average time it took for an idea which, at its first enunciation, seemed revolutionary and revolting, to be taken for granted and to be acted upon by the whole population. They concluded that the average time is 28 years -- roughly the length of a generation. It is very difficult to persuade adults to change their points of view; they have to die off before a new generation can accept new ideas."2 Although uptake of the Pill was rapid by a minority, acceptance and understanding by the majority took at least two to three decades. The Pill still faces opposition from some religious groups, and some controversies about its safety, albeit minor, persist. A historical perspective The possibility of contraception by use of reproductive hormones was first suggested by Ludwig Haberlandt, a physiologist at the University of Innsbruck, who first showed in the 1920s that injections of extracts of the corpus luteum would render rabbits infertile. With remarkable foresight he suggested that similar extracts might provide an ideal method of birth control in women.3 The first clinical evidence of this came with the demonstration in 1940 that dysmenorrhoea could be relieved and ovulation simultaneously inhibited by administration of oestrogens.4The development of modern hormonal contraception awaited synthesis of orally effective progestogens and oestrogens in the early 1950s. Pincus, Rock and Garcia then showed that ovulation in women could be suppressed with these compounds, which were first marketed in the US in 1957 for "menstrual regulation".5 After further refinement and political lobbying, Enovid was marketed as a contraceptive in mid-1960.5 These early versions of the Pill contained much higher doses of both oestrogen and progestogen than were pharmacologically necessary to suppress ovulation, and the subsequent history of the Pill has been dominated by a progressive and continuing reduction in dosage. This has been driven by the desire to reduce perceived side effects and the requirements of pharmaceutical companies to have clearly marketable characteristics for their new preparations. The newest COCs in Australia have a daily oestrogen (ethinyloestradiol) content of 20 µg and a daily progestogen (levonorgestrel) content of 100 µg.6 This total steroid intake is only 1.2% of the original daily intake, and the modern combinations are just as effective as contraceptives, although the margin for error in tablet-taking may be less. A brief profile of COCs is shown in Box 1. Revolutions, evolutions and controversies This pharmacological revolution has been accompanied by equally impressive social and sexual revolutions. Oral contraception provided women, for the very first time, with the possibility of reliably controlling their fertility. This gave women the opportunity to separate career choices from relationships and family planning, and to begin to compete with men in the career marketplace. It also gave them the opportunity to express their full sexuality with minimal risk of an unwanted pregnancy. Women were at last able to consider their opportunities on an equal basis to men. However, controversy has never been far away, and the Pill has probably engendered more articles, opinions, research studies and research investment than any other single class of drug. The progressive evolution of the Pill has, in addition to the dramatic reduction in dosage, been accompanied by an increasing awareness of a range of positive and negative attributes. Contraceptive effects COCs have extraordinarily high contraceptive reliability, if taken meticulously (including protection against ectopic pregnancies)7 (E1) (see Box 2 for an explanation of level-of-evidence codes). However, there is a considerable difference between the very low contraceptive failure rates in clinical trials and the high failure rates in general use, caused by missed pills and factors which interfere with absorption.9 Compliance can be optimised by good counselling, health education and effective packaging. Non-contraceptive health benefits COCs have remarkable non-contraceptive health benefits.10 These include dramatic reductions in lifetime risk of ovarian and endometrial cancer,11 and more variable reductions in colorectal cancer, benign breast disease,12 uterine myomata (fibroids),13 endometriosis,14,15 acute episodes of pelvic inflammatory disease,16 benign ovarian cysts,12 toxic shock syndrome, androgenic skin conditions such as acne, and perhaps even rheumatoid arthritis and some thyroid diseases (E32). COCs greatly reduce the risk of infertility17 (presumably through protection against acute pelvic inflammatory disease, ectopic pregnancy and endometriosis). They also appear to have a beneficial effect on bone density. In many of these conditions, benefits become more marked with longer duration of COC use. In most women, COCs are also able to provide amazingly effective control of menstrual cycle symptoms,10,12 such as menorrhagia (E2), dysmenorrhoea (E1), premenstrual syndrome (E1) and perimenstrual symptoms (E32) (eg, migraine, epilepsy, depression, toxic shock syndrome, and diarrhoea) and mid-cycle pain (E32). COCs can be used to treat these menstrual symptoms and, sometimes, the symptoms of endometriosis, uterine myomata, recurrent ovarian cysts and adenomyosis. Decreased menstrual blood loss reduces iron-deficiency anaemia (E1). COCs are not as effective in preventing transmission of sexually transmitted diseases (STDs) as in preventing pregnancy. Although they reduce the risk of acute upper genital tract pelvic inflammatory disease (E32),16 they do not prevent cervical colonisation, and those at risk of encountering STDs are best advised to use condoms as well as COCs. Adverse effects Side effects are still poorly understood by the general public, who appear to believe long-standing myths about COCs. Several well executed, randomised, double-blind, placebo studies have shown that the incidence of so-called "minor" side effects differs little between the placebo group and the active COC-taking group (E1).18,19 In modern double-blind clinical trials, the incidence of these so-called side effects is almost always quite high in women taking placebo (E2), and this seems to mirror preconceived expectations. The only side effects which have slightly higher incidence in the COC group are mild nausea (in early cycles), breast tenderness, chloasma and occasional mild effects on mood and sexual function. Contrary to popular belief, weight change does not differ between COC users and control subjects (E32). For most women, feelings of well-being are usually greater when taking the Pill. For the few women who do experience minor adverse effects, it usually means that the particular preparation does not suit them. They may do well with a different preparation or may sometimes need to consider an alternative contraceptive. Of more importance is the incidence of potentially serious complications. The main serious, albeit rare, complication is venous thromboembolism, which has a spontaneous incidence of 1-2 per 10 000 women per year. Incidence increases to 3-4 per 10 000 women per year in COC users,20 much less than originally described, because of the reduction in hormone dosage and better identification of women with risk factors. The 1995 "scare" about increased risk of venous thromboembolism with COCs containing third-generation progestogens has been largely discounted by substantial subsequent epidemiological work identifying biases and risk factors in the original studies.2 Many women who develop venous thromboembolism while using COCs have evidence of an inheritable thrombophilia, and there does appear to be a significant adverse interaction between the thrombophilias and COC use (E32). This complex and ongoing debate was recently well summarised.21 For many years, it has been recognised that cardiovascular diseases such as myocardial infarction and stroke are exacerbated by COC use, but considerable research has demonstrated that this risk is almost entirely confined to women who smoke cigarettes and those with hypertension (E32).22,23 Women using Pills containing third-generation progestogens may actually have a reduced risk of acute myocardial infarction (E32).24 Certain liver conditions may be exacerbated in predisposed individuals (eg, obstetric cholestasis and congenital hepatic enzyme disorders such as Dubin-Johnson syndrome). Breast cancer is one of the most emotive conditions in our cancer-phobic society, and the media have publicised scientific articles that suggest a possible increase in risk of breast cancer in COC users. The largest epidemiological study ever undertaken in the field of reproduction was a thorough reanalysis of 54 epidemiological studies of the relationship between COC and breast cancer.25 This did indeed show that more breast cancers were detected in current COC users than in control women, and that the relative risk was 1.24 (95% CI, 1.15-1.33). However, the tumours in COC users were clinically less advanced and less aggressive, and the relative risk had disappeared within a few years of stopping COC use. There is no evidence that COCs cause breast cancer, but they may have a subtle modulating effect on the rate of tumour growth. The important clinical messages are that all women are at some risk of breast cancer, and that appropriate screening techniques should be undertaken depending on age and other risk factors. There are a number of other rare associations with COC use, including a significant increase in benign hepatic adenomas (E32).26 COCs may also be a weak cofactor for cervical cancer, but this is uncertain because of the difficulty of adequately controlling for sexual risk factors (E32).27 Conclusions Modern oral contraceptives are remarkably effective and safe drugs for long-term use by women without cardiovascular risk factors. The World Health Organization and others have developed a series of evidence-based guidelines to assess medical eligibility criteria for initiating and continuing use of COCs and other contraceptive methods.28,29 This evidence suggests that there are only two prerequisites for the safe provision of COCs: a careful personal and family medical history, with particular attention to risk factors for venous and arterial cardiovascular disease; and an accurate blood pressure measurement. To this we would generally add an annual review with blood pressure measurement, breast check and pelvic examination with a cervical smear every second year. References Huxley A. Brave new world revisited. New York: Harper and Row, 1958: 138-139. Huxley A. The population explosion. In: The human situation, a series of lectures delivered at the University of California, Santa Barbara, in 1969. London: Chatto and Windus, 1978: 40-55. Haberlandt L. Hormonal sterilisation of female animals. Munchner Med Wochenschr 1921; 68: 1577-1588. Sturgis SH, Albright R. Mechanism of estrin therapy in the relief of dysmenorrhoea. Endocrinol 1940; 26: 68-73. Diczfalusy E. Gregory Pincus and steroidal contraception: a new departure in the history of mankind. J Steroid Biochem 1979; 11: 3-11. Archer DF, Maheux R, Del Conte A, O'Brien FB. A new low-dose monophasic combination oral contraceptive with levonorgestrel 100 µg and ethinyl oestradiol 20 µg. Contraception 1997; 55: 139-144. Ketting G. The relative reliability of oral contraceptives: findings of an epidemiological study. Contraception 1988; 37: 343-353. National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra: NHMRC, AusInfo, 1999. Jones ES, Forest JD. Contraceptive failure in the United States: revised estimates from the 1982 National Survey of Family Growth. Fam Plann Perspect 1989; 21: 103-109. Fraser IS. Benefits and risks of steroidal contraception. In: Salamonsen LA, editor. Hormones and women's health: the reproductive years. Amsterdam: Harwood Academic Publishers, 2000: 161-171. Schlesselman JJ, Collins JA. The influence of steroids on gynecologic cancers. In: Fraser IS, Jansen RPS, Lobo RA, Whitehead MI, editors. Estrogens and progestogens in clinical practice. London: Churchill Livingstone, 1998: 831-864. Mishell DR Jr. Non-contraceptive health benefits of oral steroidal contraceptives. Am J Obstet Gynecol 1982; 142: 809-818. Ross RK, Pike MC, Vessey MP, et al. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. BMJ 1986; 293: 359-362. Vessey MP, Villard-Mackintosh L, Painter R. Epidemiology of endometriosis in women attending family planning clinics. BMJ 1993; 306: 182-184. Chiaffarino F, Parazzini F, LaVecchia C, et al. Oral contraceptive use and benign gynecologic conditions. Contraception 1998; 57: 11-18. Rubin GL, Ory HW, Layde PM. Oral contraceptives and pelvic inflammatory disease. Am J Obstet Gynecol 1982; 144: 640-649. Bagwell MA, Coker AL, Thompson SJ, et al. Primary infertility and oral contraceptive steroid use. Fertil Steril 1995; 63: 1161-1166. Goldzieher JW, Moses LE, Averkin E, et al. A placebo-controlled, double-blind crossover investigation of the side-effects attributed to oral contraception. Fertil Steril 1971; 22: 609-618. Graham CA, Ramos R, Bancroft J, et al. The effects of steroidal contraceptives on the well-being and sexuality of women. Contraception 1995; 52: 363-370. Farmer RDT, Lawrenson RA, Todd JC, et al. Oral contraceptives and venous thromboembolic disease. Analyses of the UK General Practice Research Data Base and the UK MediPlus Data Base. Hum Reprod Update 1999; 5: 688-706. Edwards RG, Cohen J, editors. Reproductive choices in 2000: the relative safety of current oral contraceptives. Hum Reprod Update 1999; 5: 563-771. Croft P, Hannaford P. Risk factors for acute myocardial infarction in women. BMJ 1995; 298: 165-168. Thorogood M. Stroke and steroidal hormonal contraception. Contraception 1998; 57: 157-167. Carr BA, Ory HW. Estrogen and progestin components of oral contraception: relationship to vascular disease. Contraception 1997; 55: 267-272. Collaborative Group on Hormonal Risk Factors in Breast Cancer. Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53,297 women with breast cancer and 100,239 women without breast cancer from 54 epidemiological studies. Lancet 1996; 347: 1713-1727. Rooks JB, Ory HW. Epidemiology of hepatocellular adenoma: the role of oral contraceptive use. JAMA 1979; 242: 644-648. Irwin KL, Rosero-Bixby L, Oberle MW, et al. Oral contraceptives and cervical cancer risk in Costa Rica: detection bias or causal association? JAMA 1988; 259: 59-66. World Health Organization, Family and Reproductive Health. Improving access to quality care in family planning: medical eligibility criteria for initiating and continuing use of contraceptive methods. Geneva: World Health Organization, 1995. Hannaford P, Webb A. Evidence-guided prescribing of combined oral contraceptives: a consensus statement. Contraception 1996; 54: 125-129. Authors' details Department of Obstetrics and Gynaecology, University of Sydney, NSW. Ian S Fraser, MD, FRACOG, Professor in Reproductive Medicine, and Head, Department of Reproductive Endocrinology and Infertility, King George V and Royal Prince Alfred hospitals, Sydney, NSW. Reprints will not be available from the author. Correspondence: Professor I S Fraser, Department of Obstetrics and Gynaecology, University of Sydney, NSW 2006. helenaATobsgyn.usyd.edu.au Make a comment 1: Profile of combined oral contraceptives Action: Combined oral contraceptives (COCs) act predominantly at a hypothalamic level to block the cyclical release of gonadotropin-releasing hormone and prevent follicular development and ovulation. Secondary actions on the corpus luteum, endometrium and cervical secretions may contribute. Dosage: This is based on the daily ethinyloestradiol content, which varies from 20µg to 50µg in current Australian COCs. The oestrogen is balanced by an appropriate dosage of one of six progestogens in a variety of formulations known as monophasic, biphasic or triphasic. Tablet-taking: Most COC packages are 28-day (every day) bubble-pack designs containing seven inactive or placebo tablets, designed to assist meticulous daily tablet-taking (at about the same time each day), with an exact seven-day break between successive cycles of active tablets. Starting: Most packs are designed to begin tablet-taking in the placebo section on Day 1 of the last normal menstrual period. Most experts recommend condom use during the first 10-14 days of initial COC use in case of breakthrough ovulation. However, if "active" tablets are taken from Day 1, then full contraceptive action begins immediately. Metabolism: Peak plasma levels are achieved in 1-2 hours and a gradual decline occurs over the next 36 hours or so. Metabolism occurs during gastrointestinal absorption and during the first pass through the liver. Drug interactions: Numerous subtle interactions occur with several drug groups, but the most important clinical interactions are with several anticonvulsant drugs (not including sodium valproate and gabapentin) and with the antibiotics rifampicin and griseofulvin, which reduce serum levels of the contraceptive steroids and may lead to breakthrough bleeding, ovulation and contraceptive failure. Contraceptive efficacy: This is extremely high if tablets are taken optimally (less than one failure per 500 women per year), but is much higher in general use, when missed pills, absorption problems (caused by diarrhoea and vomiting) and drug interactions may play a greater role. Non-contraceptive health benefits: These are increasingly recognised as important in the benefit-risk equation, with significant reductions in incidence of ovarian, endometrial and colon cancer, acute episodes of pelvic inflammatory disease, infertility, iron-deficiency anaemia, benign breast lumps, benign ovarian cysts, uterine myomata and severe cyclical menstrual symptoms. There are probably also reductions in endometriosis. Adverse effects: Mild side effects are commonly reported but are often not caused by the COC. The most important (but very rare) complication is venous thromboembolism. Other cardiovascular diseases, such as hypertension, myocardial infarction and stroke, are either not, or only minimally, increased by modern low-dose COCs. Slightly more breast cancers are detected in current COC users, but the tumours are less aggressive and less advanced than in controls. Back to text 2: Level-of-evidence codes Evidence for the statements made in this article is graded according to the NHMRC system8 for assessing the level of evidence. E1 Level I: Evidence obtained from a systematic review of all relevant randomised controlled trials. E2 Level II: Evidence obtained from at least one properly designed randomised controlled trial. E31 Level III-1: Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method). E32 Level III-2: Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case-control studies, or interrupted time series with a control group. E33 Level III-3: Evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group. E4 Level IV: Evidence obtained from case-series, either post-test, or pre-test and post-test. Back to text 3: Important messages for patients Modern low-dose combined oral contraceptives (COCs) are highly effective contraceptives if taken meticulously COCs are remarkably free of side effects and serious complications, but some very rare complications, such as venous thromboembolism, can occur. They may not be suitable for some women with pre-existing medical risk factors. They have some very important, non-contraceptive health benefits. Back to text

Ian S Fraser

Personal Perspective Depression: dispirited or spiritually deprived? Craig S Hassed MJA 2000; 173: 545-547 The 20th century has seen a widespread decline in mental health in Western society. One important factor may be the lack of meaning and spiritual fulfilment that is part of our increasingly secular and materialistic society. In medical education and practice, religious issues are often marginalised or "pathologised", despite consistent evidence from the literature of the protective effect of "religiosity" or "spirituality" on mental and physical health. Spirituality and religiosity - Spirituality and mental health - Relevance to clinical medicine - References - Authors' details - - More articles on General practice and primary care The increasing incidence of mental illness, especially depression, in the 20th century1,2probably reflects both increased recognition and an absolute rise in prevalence. World Health Organization figures released in 1996 revealed that depression was expected to be a leading contributor to the burden of disease in the 21st century.1 Recent figures suggesting that depression is the most important component of the disability burden in Australia would tend to support that prediction.3 Approximately 20% of adults are expected to have a major depressive episode at some time in their lives, and 16% of people aged over 65 years have persistent symptoms.4 Stress levels, whether real or perceived, among people living a "Western" lifestyle have risen by approximately 45% over the past 30 years.5 Youth suicide rates are particularly alarming,2 and one Australian study revealed that 20% of 15-24-year-olds had contemplated suicide in the preceding fortnight.6 In keeping with our predominant "illness model" we are more often concerned with risk factors for depression, youth suicide, substance misuse and violence than the less-publicised protective factors, which include "connectedness" and "spirituality".7 Spirituality and religiosity The terms used most commonly in the medical literature are "religious commitment" or "religiosity", referring to the "participation in or endorsement of practices, beliefs, attitudes, or sentiments that are associated with an organised community of faith".8 One can be "extrinsically religious" in adopting the trappings, religious behaviours and attitudes, but if one holds a strong inner belief then one is "intrinsically religious". "Spirituality" generally refers to concepts that are much harder to define and measure, such as "personal views and behaviours that express a sense of relatedness to the transcendental dimension or to something greater than the self".9 Spirituality can encompass belief in a higher being, the search for meaning, and a sense of purpose and connectedness. Obviously, there can be a wide overlap between religiosity and spirituality. Spirituality and mental health For many years science and ethics have tended to become increasingly secular, thus neglecting or "pathologising" spiritual issues. Sigmund Freud, for example, saw religion as "a universal obsessional neurosis", and described the mystical experience of unity as a "regression to primary narcissism".10 Carl Jung, on the other hand, saw the search for spiritual enlightenment as the central, but often ignored, core of human experience. He described the lack of meaning in life as a "soul-sickness" whose full import our age had not yet begun to comprehend. This was one of the main reasons why these two pioneers of psychology parted company. The observation that Freudian psychoanalysis is probably associated with negative effects on people's health may, however, throw into question Freud's understanding of human nature.11 Nevertheless, many of Freud's attitudes have deeply etched their way into psychiatric theory and practice: Mainstream psychiatry, in its theory, research and practice, as well as its diagnostic classification system, has tended to either ignore or pathologise the religious and spiritual issues that clients bring into treatment.12 The negative attitude towards religiosity in many quarters of contemporary medicine and psychiatry is out of keeping with the weight of evidence which clearly shows that it has a beneficial effect on mental and physical health.8 The findings are consistent across prospective and retrospective studies, whether or not they control for other lifestyle and socioeconomic factors, and whether they examine prevention of illness, coping with illness, or recovery (see Box). Many studies have linked a lack of religiosity to depression. Religious commitment is associated with a reduced incidence of depression13 and a quicker recovery from depressive illness for the elderly.15 Two separate reviews of the literature have supported this: those with high levels of "religious involvement", "religious salience" and "intrinsic religious motivation" were at reduced risk,14 and religious commitment was inversely related to suicide risk in 13 of 16 studies reviewed.13 One study showed a fourfold increased risk of suicide for non-churchgoers compared with regular attenders,22 and no study has shown an increased risk of suicide among churchgoers. Other data suggest that religiosity protects against drug and alcohol misuse, one of the most commonly used and maladaptive ways for dealing with depression. One study showed that 89% of alcoholics (but only 20% of the control group) had lost interest in religious issues during their teenage years.20 In another study it was found that doctors (who are a high-risk group for substance misuse) were less likely to develop an alcohol problem in later life if they had had a religious commitment while in medical school.21 Religious affiliation, even if accompanied by alcohol misuse, seemed to protect against heavy use or the associated extreme clinical and social consequences. The reasons why people with a sense of religious commitment are less likely to become depressed may include a feeling of social connectedness, exposure to messages about healthy living, or perhaps the reduced exposure to drug-taking behaviour. However, studies controlling for these factors have still found religiosity to be independently protective. So there may be other reasons, such as the comfort that comes from believing in a benevolent and caring God, the view that justice always prevails in the end, or that adverse events always have a meaning and a message. Such attitudes would buffer enormously against the ill-effects of life stresses and the depression that often follows. The important role that mental health plays in the development and progression of physical illness goes part way to explaining why religious commitment is associated with reduced risk of conditions such as hypertension, heart disease and cancer.26,27,29,30 A population study over nine years showed that all-cause mortality was significantly reduced and life expectancy increased (to 82 years v. 75 years) for regular churchgoers. The findings were not explainable by the accepted lifestyle and social variables,24 and were consistent with other data.25 Unfortunately, examples of the negative effects of religion are generally more newsworthy in the medical and general press than the positive ones. For example, in a review of a series of preventable paediatric deaths, it was found that some parents' religious views played an important part in delaying the seeking of medical care.31 Sometimes this negative press is for a good reason, but this is not an argument against spirituality, but rather against blind faith unsupported by reason. Relevance to clinical medicine The rise in mental illness seems paradoxical in view of our unprecedented levels of physical health, relative affluence, technological advancement and social freedom. Also paradoxical is the fact that suicide rates generally fall in times of adversity, such as during major wars.2 Although one doesn't generally court adversity, it can teach us something about ourselves if we pay attention to the lesson. As William Shakespeare so aptly put it: This is no flattery: these are counsellors That feelingly persuade me what I am. Sweet are the uses of adversity, Which, like the toad, ugly and venomous, Wears yet a precious jewel in his head. (As You Like It; Act 2, Scene 1) Gauging a patient's spiritual awareness, at very least, should form an important part of a thorough history. One can not really be said to know another person without an understanding of his or her responses to the most important questions that human beings ask themselves. Without this knowledge, treatment of especially sensitive conditions like depression or terminal illness will take place in the dark. Broaching philosophical and spiritual issues requires considerable sensitivity, cultural tolerance and the ability to be non-dogmatic. When done effectively, it can facilitate counselling and psychotherapy enormously,32 but each doctor and patient needs to explore these issues in his or her own way. Even if we are not religious ourselves, we should invite discussion in a respectful way, taking care not to push a line of thought, whether it be religious or secular. Religious sensitivities and biases, like political ones, can make discussion divisive and difficult. More in-depth questions about spirituality and religion should probably be referred to culturally appropriate "non-medical experts". At present, despite the large body of evidence on the connection between religiosity and health, little if any reference is made to this issue in medical education and practice. If a physical factor was found to be of as much importance to health it would certainly not be ignored, but then science is always most comfortable with what it can most easily measure. It is reasonable for medical students and practitioners to be aware of this field of evidence so that they can provide a more holistic approach to information giving, psychotherapy and treatment. Unfortunately, a perceived lack of holism is a central reason why many people look outside the biomedical model for their healthcare.33 For many people, especially the young, the search for meaning is becoming a rarer pursuit in the bustle of modern material life. People pursue meaning and fulfilment by as many paths as there are people, but perhaps we often search in places which can not provide it. If the search is misdirected, disappointment, stress, depression and social conflict may be inevitable sequelae of such existential pain. Perhaps these issues will become increasingly relevant for future generations, for whom the lack of meaning will come at an increasing cost. Maybe a balanced form of spirituality which is not scientifically naive nor culturally intolerant may be a prerequisite for the mental and material wellbeing of an all too often dispirited community and healing profession. "Science without religion is lame, religion without science is blind" (Albert Einstein).34 References Murray C, Lopez A. The global burden of disease. Cambridge, Massachusetts: Harvard School of Public Health, on behalf of the World Health Organization and the World Bank, 1996. Cantor C, Neulinger K, De Leo D. Australian suicide trends 1964-1997: youth and beyond? Med J Aust 1999; 171: 137-141. Mathers CD, Vos ET, Stevenson CE, Begg SJ. The Australian Burden of Disease Study: measuring the loss of health from diseases, injuries and risk factors. Med J Aust 2000; 172: 592-596. Rey J. The Epidemiological Catchment Area (ECA) study: implications for Australia. Med J Aust 1992; 156: 200-203. Miller M, Rahe R. Life changes scaling for the 1990s. J Psychosom Res 1997; 43: 279-292. McKelvey R, Davies L, Pfaff J, et al. Psychological distress and suicidal ideation among 15-24 year olds presenting to a general practice: a pilot study. Aust N Z J Psychiatry 1998; 32: 344-348. Resnick M, Bearman P, Blum R, et al. Protecting adolescents from harm: findings from the National Longitudinal Study on Adolescent Health. JAMA 1997; 278: 823-832. Matthews D, McCullough M, Larson D, et al. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med 1998; 7: 118-124. Reed P. Spirituality and wellbeing in terminally ill hospitalised patients. Res Nurs Health 1987; 9: 35-41. Freud S. Civilisation and its discontents. In: Strachey J, editor. The standard edition of the complete psychological works of Sigmund Freud. Vol. 20. 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Religious involvement and U. S. adult mortality. Demography 1999; 36: 273-285. Clark K, Friedman H, Martin L. A longitudinal study of religiosity and mortality risk. Journal of Health Psychology 1999; 4: 381-391. Fraser G, Sharlik D. Risk factors for all-cause and coronary heart disease mortality in the oldest old: the Adventist Health Study. Arch Intern Med 1997; 157: 2249-2258. Kune G, Kune S, Watson L. Perceived religiousness is protective for colorectal cancer: data from the Melbourne Colorectal Cancer Study. J R Soc Med 1993; 86: 645-647. Larson DB, Koenig HG, Kaplan BH, et al. The impact of religion on men's blood pressure. J Religion Health 1989; 28: 265-278. Levin J, Vanderpool H. Is frequent religious attendance really conducive to better health? Toward an epidemiology of religion. Soc Sci Med 1987; 24: 589-600. Craigie F, Larson D, Liu I. References to religion in the Journal of Family Practice: dimensions and valency of spirituality. J Fam Pract 1990; 30: 477-480. Asser S, Swan R. Child fatalities from religion motivated medical neglect. Pediatrics 1998; 101: 625-629. Hassed C. Western psychology meets Eastern philosophy. Aust Fam Physician 1999; 28: 1057-1058. Astin J. Why patients use alternative medicine: results of a national study. JAMA 1998; 279: 1548-1553. Einstein A. Out of my later years. New York: Philosophical Library, 1950. Authors' details Department of Community Medicine and General Practice, Monash University Craig S Hassed, MB BS, FRACGP, Senior Lecturer. Reprints will not be available from the author. Correspondence: Dr C S Hassed, Department of Community Medicine and General Practice, Monash University, 867 Centre Road, East Bentleigh, VIC 3165. craig.hassedATmed.monash.edu.au Make a comment Apparent relationships between religiosity and health* Mental health Reduced incidence of depression7,8,13,14 Quicker recovery from depression15 Better recovery from major surgery,16with less depression17 Improved coping with disability,18 illness and stress19 Reduced substance misuse, including misuse of alcohol and illicit drugs20,21 Reduced suicide risk in adolescents22 Facilitation of psychotherapy23 Improved coping with serious illness8 Physical health Reduced all-cause mortality24,25 Greater longevity24,25 Reduced incidence of heart disease and hypertension26 Improved recovery from cardiac surgery16 Reduced incidence of and longer survival with cancer27 Modification of physical risk-factors with associated reductions in lifestyle-related illnesses such as emphysema and cirrhosis22,28 * Causal relationships between religiosity and health are sometimes hard to define, although many studies control for other known physical and socioeconomic risk factors. Refining methodology and further research are required to more fully elucidate the relationship. Back to text

Craig S Hassed