Volume 195 · Issue 3 · Supplement

Support for addiction medicine is the key Over the past decade or so, care of people affected by comorbidities of substance use disorder and mental health problems has been a focus of Australian state, territory and national campaigns. Despite these efforts, true coordinated treatment models remain the exception rather than the rule. Patients with “dual diagnosis” (a term that must now be close to its use-by date) present substantial challenges to existing treatment models. Various mechanisms conspire against these patients getting better: addictive substances exacerbate psychiatric symptoms; patients with mental illness may continue to use psychoactive drugs in an effort to attenuate symptoms; and substances of misuse in themselves can induce psychiatric disorders.1 Active use of substances often substantially interferes with psychiatric pharmacotherapies. For example, standard antidepressant treatment may not provide the expected benefits in patients with mood disorder and comorbid untreated addiction.2 The field of addiction medicine struggles to recruit doctors, while the level of complexity of patients and the expectations of the community for evidence-supported care across all health fields have increased. Workforce challenges are fed by the perception of clinical complexity, such as that associated with DSM-IV Axis II disorders and substance use.3 These “heart-sink” patients are often referred to alcohol and drug treatment services, where staff expertise in managing behaviours that interfere with treatment delivery may vary. In Australia, patients with substance use and high-prevalence mental health disorders tend to be treated by alcohol and other drug agencies, while those with low-prevalence disorders, many of whom have significant associated drug problems, are core clinical business for public mental health services. The heterogeneous nature of these services and the complexity of much of this patient group make it hard to know how well either sector performs this clinical work. The mantra is that we must deliver “integrated care” for optimal patient outcomes. Supporting this is the review by Smith and colleagues, which concludes that an approach that addresses psychiatric and substance use problems is likely to benefit outcomes in problem gamblers.4 Alcohol and nicotine are our most popular drugs and carry a corresponding burden of disease that dwarfs illicit substance use. Industries backing these drugs are powerful and tenacious, as seen by the response to recent moves to change tobacco packaging and introduce volumetric taxing of alcoholic beverages. Tobacco and cannabis use is associated with high levels of anxiety and depressive disorders, as evidenced in the 1997 and 2007 National Survey of Mental Health and Wellbeing.5 Nevertheless, in some inpatient psychiatric and alcohol and other drug treatment settings, smoking is not assertively addressed, sometimes based on the myth that cessation will exacerbate mental illness or interfere with recovery from other drug use. Such an idea is unsupported by the study of smokers by Segan and colleagues, which found that smoking cessation was not associated with an exacerbation of depression.6 Programs with enhanced approaches to co-occurring disorders often focus on screening and assessment mechanisms. Effective (and clinician-accepted) screening and assessment tools enable clinicians to identify comorbidity in patients and plan comprehensive management. Identification of comorbidities by both alcohol and other drug and mental health services is a good start, but does assume that integrated care is accessible. The availability of services, particularly those that are able to support mental health care in management of people with identified comorbid addictive disorders, remains a substantial challenge for Australia. Although medical care is yet be delivered by robots, technologies using online social networks, handheld devices, phone, text, internet and global positioning system functions, videoconferencing and software-assisted care have a huge scope in mitigating workforce issues. Computer-assisted treatments offer promise by addressing issues of access (given that care for comorbidity is often not reaching patients in need) and potentially ensuring structure and consistency in approach.7 Pleasingly, treatment approaches using new technologies are now seen as important enough to warrant Medicare telehealth items. Developing a workforce capable of providing good medical care of comorbid disorders requires a foundation of specialist support from psychiatry and addiction medicine. Given the burden of addictive diseases on the community, including those co-occurring with mental illness, the specialty of addiction medicine is embarrassingly poor in trainee and consultant positions, a balanced mixed public and private specialist sector, and a critical mass of clinical leadership. Over the past decade, Australia, like North America, has experienced increasing harm from prescription medication, with an exponential growth in numbers of patients with the trio of opioid addiction, mental illness and chronic pain (rendering the term “dual” diagnosis obsolete). Publicly funded health care, including mental health care, has always struggled to deliver services due to ever-tightening health budgets. If we want to grow the capacity of Australian health care to manage co-occurring disorders, we must recognise all the medical crafts that provide expertise and leadership in this area, and particularly in the field of addiction medicine.

Matthew Y Frei MB BS, FAChAM · David M Clarke MB BS, PhD, FRANZCP

Objectives: To report smokers’ evaluations and uptake of Quitline–doctor comanagement of smoking cessation and depression, a key component of the Victorian Quitline’s tailored call-back service for smokers with a history of depression and to explore its relationship to quitting success.Design, participants and setting: Prospective study followed Quitline clients disclosing doctor-diagnosed depression (n = 227). Measures were taken at baseline (following initial Quitline call), posttreatment (2 months) and 6 months from recruitment (77% and 70% response rates, respectively).Main outcome measures: Uptake of comanagement (initiated by fax-referral to Quitline), making a quit attempt (quit for 24 hours), sustained cessation (> 4 months at 6-month follow-up).Results: At 2-month follow-up, 83% thought it was a good idea to involve their doctor in their quit attempt, 74% had discussed quitting with their doctor, and 43% had received comanagement. In all, 72% made a quit attempt, 37% and 33% were abstinent posttreatment and at 6 months, respectively, and 20% achieved sustained cessation. Among participants who discussed quitting with their doctor, those receiving comanagement were more likely to make a quit attempt than those who did not receive comanagement (78% v 63%). Participants with comanagement also received more Quitline calls (mean 4.6 v 3.1) — a predictor of sustained cessation. Exacerbation of depression between baseline and 6 months was reported by 18% of participants but was not related to cessation outcome.Conclusion: Quitline–doctor comanagement of smoking cessation and depression is workable, is valued by smokers, and increases the probability of quit attempts. Smoking cessation did not increase the risk of exacerbation of depression.

Catherine J Segan PhD · Ron Borland PhD, MSc · Kay A Wilhelm MD, MB BS, FRANZCP · Sunil S Bhar PhD · Ainslie T Hannan BAGD, BSW, BA(Hons) · David R Dunt PhD, MB BS · Ian T Ferretter HDTA

Objective: To examine changes in the prevalence of affective disorders and psychological distress among smokers and people with cannabis dependence between 1997 and 2007.Design, participants and setting: Cross-sectional analysis of the 1997 and 2007 National Survey of Mental Health and Wellbeing.Main outcome measures: The Composite International Diagnostic Interview generated diagnoses of cannabis dependence and affective disorders based on criteria of the Diagnostic and statistical manual of mental disorders, fourth edition. Psychological distress was measured using the Kessler Psychological Distress Scale. Logistic regressions examined the relationship between affective disorders, psychological distress and (i) smoking status (current, former and never-smoker) and (ii) cannabis dependence.Results: Affective disorders and psychological distress were more common among smokers than non-smokers and among cannabis-dependent participants in both years. The prevalence of affective disorders and psychological distress among smokers, ex-smokers and non-smokers did not change between 1997 and 2007. Psychological distress and affective disorders were more common in cannabis-dependent participants in 2007 than in 1997.Conclusion: Affective disorders were more common in current than never-smokers and in people with cannabis dependence than without. We did not find strong evidence that the prevalence of these disorders changed in smokers between 1997 and 2007, but we did find such evidence in cannabis-dependent people.

Rebecca R S Mathews MPH · Wayne D Hall PhD · Coral E Gartner PhD

Objective: To determine the relationship between personality disorders (PDs) and substance use severity, mental health symptoms and disorders and quality of life (QoL) among injecting drug users (IDUs).Design, setting and participants: A cross-sectional study of 103 IDUs accessing a needle and syringe program and a primary health centre in Melbourne, Australia.Main outcome measures: Presence of PDs was assessed using the International Personality Disorder Examination ICD-10 Screener. Axis I mental health disorders, psychological distress and QoL were also assessed.Results: Ninety per cent of participants scored positive for one or more PD. Having a Cluster A or Cluster B PD was associated with greater severity of substance use. The presence of a current mental health disorder was associated with all types of PD except dissocial PD. Only Cluster C PDs were associated with self-reported levels of psychological distress. Cluster C PDs were more strongly associated with substance use, mental health and QoL variables than Cluster A or B, although the number of PDs present had the strongest associations with these variables.Conclusions: IDUs had high rates of PD symptoms, which were associated with the presence of concurrent mental health disorders, more severe levels of psychological distress and substance use and low perceived QoL. IDUs require comprehensive models of care, including access to mental health practitioners with expertise in co-occurring disorders.

Tania M Gibbie BBSc(Hons), MPsych(Health) · Leanne Hides BBehSc(Hons), PhD(Clin) · Sue M Cotton BBSc(Hons), MAppSc(Statistics), PhD · Dan I Lubman PhD, FRANZCP, FAChAM · Campbell Aitken BSc(Hons), PhD · Margaret Hellard PhD, FRACP, FAFPHM

Objective: To analyse the links between other people’s drinking and mental health and to explore the effects on mental health of heavy and problematic drinkers both within and outside spousal relationships.Design, setting and participants: A secondary analysis of data obtained as part of the Alcohol’s Harm to Others survey from 2622 randomly sampled Australian adults interviewed by telephone between October and December 2008.Main outcome measures: Self-reported anxiety or depression and satisfaction with mental wellbeing; the presence of heavy and problematic drinkers in respondents’ lives.Results: Identification of at least one heavy drinker in the respondents’ social network of friends, family and co-workers was significantly negatively associated with self-reported mental wellbeing and anxiety or depression. If the heavy drinker was identified by the respondent as someone whose drinking had had a negative impact on their life in the past year, the adverse effect on mental wellbeing and anxiety was much greater.Conclusions: Our findings support a causal pathway between alcohol use and mental health problems by way of someone else’s drinking. The association with adverse mental health is substantial regardless of the type of relationship an individual has with the heavy drinker whose drinking has had an adverse effect on them.

Jason A Ferris BPsych(Hons), MBioStats · Anne-Marie Laslett BDSc, MDSc, MPH · Michael Livingston BAppSc(Maths), BInfTech, BA(Hons) · Robin Room MA, MSoc, PhD(Soc) · Claire Wilkinson BASc, DipModLang(Japanese)

Objective: To examine the association of adolescent depression and anxiety symptoms with alcohol abuse or dependence in young adulthood.Design, setting and participants: Cohort study of the health and wellbeing of adolescents and young adults in Victoria, assessed at 8 waves (periods) of data collection, from age 14 to 24 years, between 1992 and 2003. Young people who participated in the cohort study at least once during the six adolescent assessment points (conducted 6 months apart, from age 14 to 17 years), at least once during young adulthood and who were alive at Wave 8 (n = 1758).Main outcome measure: Alcohol abuse or dependence assessed using the alcohol and substance abuse modules of the Composite International Diagnostic Interview at age 24 years.Results: Adolescents with moderate to high levels of depression and anxiety symptoms (measured by the revised Clinical Interview Schedule) had an increased risk of alcohol abuse or dependence in young adulthood, compared with young adults with low levels of adolescent depression and anxiety symptoms, after adjusting for potential confounding factors. Risk was higher for those with symptoms at more than two adolescent assessment points (odds ratio [OR] 1.9; 95% CI, 1.7–2.0) and for those with symptoms at one or two assessment points (OR 1.3; 95% CI, 1.2–1.4), compared with those with no above-threshold symptoms in adolescence.Conclusions: Adolescents with depression and anxiety symptoms are at increased risk for alcohol use disorders into young adulthood. They warrant vigilance from primary care providers in relation to alcohol use well into adulthood.

Maria McKenzie BBSc(Hons) · Anthony F Jorm PhD, DSc · Helena Romaniuk BSc, MSc, PhD · Craig A Olsson PhD · George C Patton MB BS, MD

Objective: To determine whether the addition of cognitive behaviour therapy and motivational interviewing (CBT/MI) to standard alcohol and other drug (AOD) care improves outcomes for young people with comorbid depression and substance misuse.Participants and setting: Participants were young people with comorbid depression (Kessler Psychological Distress Scale score ≥ 17) and substance misuse (mainly alcohol and/or cannabis) seeking treatment at two youth AOD services in Melbourne, Australia. The study was conducted between September 2006 and September 2008. Sixty young people received CBT/MI in addition to standard care (SC) (the SC+CBT/MI group) and 28 received SC only (the SC group).Main outcome measures: Depressive symptoms and AOD use in the previous 30 days, measured at baseline and at 3-month and 6-month follow-up.Results: Compared with participants in the SC group, those in the SC+CBT/MI group showed significant reductions in depression and cannabis use and increased social contact and motivation to change substance use at 3-month follow-up. However, at 6-month follow-up, the SC group had achieved similar improvements to the CBT/MI group on these variables. All young people achieved significant improvements in functioning and quality of life variables over time, regardless of treatment group. No changes in AOD use were found in either group at 6-month follow-up.Conclusion: The delivery of CBT/MI in addition to SC may achieve accelerated treatment gains in the short term.

Leanne M Hides BBehavSc(Hons), PhD(Clin) · Kathryn S Elkins BA(Hons) · Antonietta Scaffidi BSc(Hons), PGDipPsych · Sue M Cotton PhD · Steve Carroll DPsych · Daniel I Lubman MB ChB, FRANZCP, PhD

Objective: To determine whether the presence of comorbid depression influences response to psychological treatment for methamphetamine use.Design: Randomised controlled clinical trial.Setting and participants: Our study was conducted between 2001 and 2005 at two sites in Australia: the Hunter Region of New South Wales and the city of Brisbane, Queensland. The 214 participants, who were all using methamphetamine at least once a week in the month prior to the study, were self-referred or referred from health services or drug and alcohol clinical services. Participants were divided into two groups based on whether or not they had depressive symptoms at baseline.Interventions: The control group received only a self-help booklet; the two treatment groups received either two or four counselling sessions involving cognitive behaviour therapy and motivational interviewing techniques to manage methamphetamine use.Main outcome measures: Changes in methamphetamine use and depression at 5 weeks and 6 months after baseline.Results: Over 70% of participants met criteria for depression at baseline, and depression was associated with significantly greater severity of methamphetamine use and related issues. Benzodiazepine use was significantly higher among depressed than non-depressed participants. Reductions in methamphetamine use between baseline and 5 weeks were independently predicted by comorbid depression, in favour of increased change among those with baseline depression. Depressed participants who received three or four counselling sessions showed a significant reduction in depression at 5 weeks. However, reductions in methamphetamine use and depression compared with baseline were no longer evident at 6 months.Conclusions: Over the short term, comorbid depression did not negatively affect response to treatment, with some evidence of a dose–response treatment effect for reduction in depression. This was not maintained at 6 months, indicating that methamphetamine-focused treatment may not enable people with comorbid depression to make sustained improvement at the level of their counterparts without depression.Trial registration number: ACTRN12611000355976.

Frances J Kay-Lambkin BSc(Psych)(Hons), PhD · Amanda L Baker BA(Hons), MPsych, PhD · Nicole M Lee BSc(Hons), MAPS, PhD · Linda Jenner BHSc, MAppSc · Terry J Lewin BComm(Psych)(Hons)

Objective: To compare computer-delivered and therapist-delivered treatments for people with depression and comorbid addictive disorders.Design: Randomised controlled clinical trial.Setting and participants: Our study was conducted between January 2005 and August 2007 at seven study clinics in rural and urban New South Wales. Participants were 274 people who had a Beck Depression Inventory II (BDI-II) score ≥ 17 and were using alcohol and/or cannabis at harmful levels in the month before baseline. They were self-referred or referred from other sources such as outpatient drug treatment clinics, general practices and non-government support agencies.Interventions: Participants were randomly allocated to receive (1) integrated cognitive behaviour therapy and motivational interviewing (CBT/MI) delivered by a therapist; (2) integrated CBT/MI delivered by computer, with brief therapist assistance at the end of each session (clinician-assisted computerised [CAC] treatment), or (3) person-centred therapy (PCT), consisting of supportive counselling given by a therapist (the control group). All three treatments were delivered according to a manual developed specifically for the study.Main outcome measures: Changes in depression, alcohol use and cannabis use at 3 months after baseline; significant predictors of change in the primary outcome variables.Results: Compared with computer- or therapist-delivered CBT/MI, PCT was associated with significantly less reduction in depression and alcohol consumption at 3 months. CAC therapy was associated with improvement at least equivalent to that achieved by therapist-delivered treatment, with superior results as far as reducing alcohol consumption. Change in depression was significantly predicted by change in alcohol use (in the same direction) and an ability to determine primacy, irrespective of whether this was for drug use or depression. Change in alcohol use was significantly predicted by changes in cannabis use and depression, and change in cannabis use by change in alcohol use. In the regression model, treatment allocation did not independently predict change, but was associated with significant reduction in depression and alcohol use at 3 months.Conclusions: Over a 3-month period, CBT/MI was associated with a better treatment response than supportive counselling. CAC therapy was associated with greater reduction in alcohol use than therapist-delivered treatment.Trial registration number: ACTRN12610000274077.

Frances J Kay-Lambkin BSc(Psych)(Hons), PhD · Amanda L Baker BA(Hons), MPsych, PhD · Brian Kelly BMed, FRANZCP, PhD · Terry J Lewin BComm(Psych)((Hons)

Objective: To determine the prevalence of major depression among people entering treatment for methamphetamine use.Design, setting and participants: The study was a cross-sectional survey involving 41 specialised drug and alcohol treatment agencies in Brisbane and Sydney. Services provided by these agencies included residential rehabilitation, detoxification and counselling. Participants were 400 people entering treatment for methamphetamine use who were recruited from participating treatment agencies between January 2006 and November 2007. Participants underwent a structured, face-to-face, 1.5-hour interview. Assessment instruments included the Composite International Diagnostic Interview and the Short Form 12.Main outcome measure: Diagnosis of a major depressive episode in the year prior to the study.Results: The prevalence of major depression in the year prior to the study was 40% (95% CI, 35%–44%). A noteworthy post-hoc observation was that a further 44% of participants met the symptom criteria for major depression but were excluded from a diagnosis because their symptoms were better accounted for by psychoactive substance use. Both major depression and these latter cases of “substance-induced depression” were associated with severe symptoms of depression, high levels of disability and suicidal ideation.Conclusion: Most people entering treatment programs for methamphetamine use have levels of depression that require clinical management. Making a diagnosis of major depression in the context of heavy methamphetamine use is problematic because of substance-induced symptoms of depression.

Rebecca McKetin BSc(Psych)(Hons), PhD · Daniel I Lubman FRANZCP, FAChAM, PhD · Nicole M Lee BSc(Hons), MAPS, PhD · Joanne E Ross BSc(Hons), PhD · Tim N Slade BSc(Psych), PhD

Objective: To examine the influence of co-occurring conditions on gambling treatment outcomes.Design, setting and participants: Prospective cohort study of problem gamblers. Participants were recruited from consecutive referrals to a gambling therapy service in 2008. Inclusion criteria were: (i) assessed as a problem gambler based on a screening interview including DSM-IV criteria for pathological gambling, and (ii) suitable for admission to a treatment program. Cognitive-behavioural therapy was based on graded exposure-to-gambling urge. One-to-one treatment was conducted with 1-hour sessions weekly for up to 12 weeks.Main outcome measures: Problem gambling screening and co-occurring conditions including depression, anxiety and alcohol use.Results: Of 127 problem gamblers, 69 were males (54%), mean age was 43.09 years, and 65 (51%) reported a duration of problem gambling greater than 5 years. Median time for participants’ enrolment in the study was 8.9 months. Results from mixed effects logistic regression analysis indicated that individuals with higher depression levels had a greater likelihood (13% increase in odds [95% CI, 1%–25%]) of problem gambling during treatment and at follow-up.Conclusion: Addressing depression may be associated with improved treatment outcomes in problem gambling; conversely, treatment of problem gambling improves affective instability. We therefore recommend a dual approach that treats both depression and problem gambling.

David P Smith MAppStats · Malcolm W Battersby MB BS, FRANZCP, PhD · Peter W Harvey PhD · Rene G Pols MB BS, FRANZCP · Michael F Baigent MB BS, FRANZCP · Jane E Oakes MMHSc

Objective: To identify the type and proportion of depressive and related mental health disorders in a group of individuals seeking outpatient treatment at an alcohol and other drug (AOD) service.Design, setting and participants: A cross-sectional study using diagnostic interviews with 95 participants (56 men, 39 women) seeking treatment from an AOD service.Main outcome measures: Mental health and substance disorders were measured using the Composite International Diagnostic Interview, Posttraumatic Stress Disorder Checklist, Beck Depression Inventory, and State–Trait Anxiety Inventory (Trait Version).Results: This was a complex group with addiction, mental health and physical health conditions; 76% had a depressive disorder and 71% had an anxiety disorder. Most were diagnosed with at least two mental health disorders and 25% were diagnosed with four or more different disorders. Alcohol and cannabis use were the most commonly diagnosed AOD disorders. Further, those diagnosed with a drug use disorder reported significantly higher levels of depression compared with those with an alcohol-only disorder. Finally, 60% of the sample reported chronic health conditions, with over one-third taking medication for a physical condition on a regular basis.Conclusions: Primary care providers such as general practitioners are likely to be increasingly called on to assess, treat and/or coordinate care of patients with AOD disorders. We show that this group will likely present to their GP with more than one mental health disorder in addition to acute and chronic physical health conditions.

Petra K Staiger PhD · Anna C Thomas PhD · Lina A Ricciardelli PhD · Marita P McCabe PhD