Mental health

Build youth-centric services and they will come.

Elizabeth M Scott BSc(Hons), MB BS, FRANZCP · Daniel F Hermens BSc, GDipSci, PhD · Nicholas Glozier MB BS, FRANZCP, PhD · Sharon L Naismith MCN, DCN, CCN · Adam J Guastella PhD · Ian B Hickie MD, FRANZCP, AM

The Problem Gambling Research and Treatment Centre (PGRTC) has developed the first evidence-based guideline to address problem gambling in Australia — Guideline for screening, assessment and treatment in problem gambling. The entire guideline and related appendices have been approved by the Chief Executive Officer of the National Health and Medical Research Council (NHMRC) under s. 14A of the National Health and Medical Research Council Act 1992. In approving the guideline, the NHMRC considered that it meets the NHMRC’s standard for clinical practice guidelines. The guideline will be available on the PGRTC websites (http://www.med.monash.edu.au/sphc/pgrtc and http://www.education.unimelb.edu.au/problemgambling). The full guideline addresses screening, assessment and treatment issues relating to problem gambling; in this abridged outline, we focus solely on treatment interventions for problem gamblers. Definition and prevalence of problem gamblingA range of terms have been used to describe problematic gambling, including pathological, disordered, compulsive and problem gambling. In Australia, “problem gambling” is the most commonly used term and describes the situation in which a person has “difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community”.1 The Productivity Commission found that the prevalence of problem gambling was approximately 2.1% of the adult Australian population.2 Recent statewide gambling surveys suggest that between 1.4% and 3.1% of adults report problem or moderate-risk gambling, based on the Problem Gambling Severity Index (PGSI) of the Canadian Problem Gambling Index.3-9 Some variation in rates between states may be the result of variable administration of the PGSI.10 Guideline development processA comprehensive and systematic process was used to develop the guideline (Box 1), as outlined in the NHMRC standards and procedures for externally developed guidelines.11 Due to the impact of internal validity on studies of interventions for problem gambling, articles were only included if they were classified as Level I or Level II evidence. Treatment recommendationsA total of 34 randomised controlled trials, reported in 37 articles, met the inclusion criteria for the clinical questions and formed the basis of seven evidence-based recommendations for treatment (Box 2). Each recommendation was accompanied by a grade that reflected the volume, consistency, clinical impact, generalisability and applicability of the evidence (Box 3), and practice points to provide practical advice and information. Considerations for practiceThe recommendations are expected to result in a consolidation of current practices in the treatment of problem gambling in Australia. CBT is already widely used as the therapy of choice for problem gambling and is a standard component in clinical training curricula for psychology and psychiatry. In comparison, motivational interviewing and motivational enhancement therapy are not commonly included in standard training programs, and practitioners who wish to deliver these interventions for problem gambling should undertake training. Furthermore, as outlined in the practice points, appropriately qualified and trained practitioners are advised to consider client preferences, availability of services, and manualised delivery of any chosen intervention. These considerations are especially pertinent given that practitioner-delivered psychological interventions largely underpinned the recommendations and, importantly, were found to be more effective than self-help interventions. Two of the seven recommendations related to pharmacological interventions, and only one of these provided support for the use of a medication (naltrexone) to reduce gambling severity. Despite this recommendation, pharmacological interventions for the treatment of problem gambling should be applied with caution and with careful consideration of each patient’s needs. Specific details in the product information for each drug regarding dosage, adverse effects, method and route of administration, and contraindications should be studied and followed carefully. As yet, no drugs have been approved by the Australian Therapeutic Goods Administration in the form of a registered indication or approved use for treatment of problem gambling. However, this does not preclude the use of drugs for non-registered indications or off-label prescribing. Registered indications ensure that the appropriate research and approval processes have been followed to ensure effectiveness and safety of the drug. While the clinical questions and inclusion/exclusion criteria developed for the guideline ensured that all relevant evidence was retrieved with respect to different subgroups (based on co-occurring psychiatric symptoms, sex, age, and gambling type), the paucity of available evidence means that the final recommendations must be applied with caution with respect to specific groups. However, this limitation in the evidence base has been acknowledged and accounted for in the formulation and grading of the recommendations. Considerations for researchGiven the current immaturity of the research literature in the field of problem gambling, relevant and high-quality evidence could be found to address only six of the 22 clinical questions regarding treatment, leading to the formulation of only seven evidence-based recommendations. This outcome was not unexpected. Rather, it was intended that by conducting this review, formal identification of the gaps in knowledge would assist the strategic advancement of the field through targeted research and development, as well as in guiding practitioners regarding the evidence available to inform their practice. The Guideline Development Group made several recommendations for further research that can be found in the full guideline. 1 Guideline development process The Guideline Development Group and the multidisciplinary Expert Advisory Panel devised 22 clinical questions regarding treatment A broad-ranging and comprehensive systematic search was done to identify all available literature All identified articles were scanned to determine if they met the predefined inclusion or exclusion criteria Data were extracted and critical appraisal of each included study was undertaken Sufficient evidence was found to make evidence-based recommendations for six clinical questions 2 Evidence-based treatment recommendations and practice points Recommendation (evidence grade) Practice points Individual or group cognitive behaviour therapy (CBT) should be used to reduce gambling behaviour, gambling severity and psychological distress in people with gambling problems (Grade B) Where CBT is to be prescribed, the following could be considered: Appropriate qualifications and training of practitioners Manualised delivery of the intervention Motivational interviewing and motivational enhancement therapy should be used to reduce gambling behaviour and gambling severity in people with gambling problems (Grade B) Where motivational interviewing and motivational enhancement therapy are to be prescribed, the following could be considered: Appropriate qualifications and training of practitioners Manualised delivery of motivational enhancement therapy Practitioner-delivered psychological interventions should be used to reduce gambling severity and gambling behaviour in people with gambling problems (Grade B) Where practitioner-delivered psychological interventions are to be prescribed, the following could be considered: Client preferences Appropriate qualifications and training of practitioners Availability of services Manualised delivery of the intervention Practitioner-delivered psychological interventions should be used over self-help psychological interventions to reduce gambling severity and gambling behaviour in people with gambling problems (Grade B) Where practitioner-delivered psychological interventions are to be prescribed, the following could be considered: Client preferences Appropriate qualifications and training of practitioners Availability of services Manualised delivery of the intervention Group psychological interventions could be used to reduce gambling behaviour and gambling severity in people with gambling problems (Grade C) Where group psychological interventions are to be prescribed, the following could be considered: Client preferences Appropriate qualifications and training of practitioners Availability of services Manualised delivery of the intervention Antidepressant medications should not be used to reduce gambling severity in people with gambling problems alone (Grade B) Due to the nature of the samples studied, this recommendation is applicable to those with gambling problems only, and not those who may have comorbidities such as depression and anxiety This recommendation is predominantly based on evidence evaluating the effectiveness of selective serotonin reuptake inhibitors Naltrexone could be used to reduce gambling severity in people with gambling problems (Grade C) Where naltrexone is to be prescribed, the following could be considered: Problem gambling is not (at the time of reporting) a registered indication for naltrexone, so a Pharmaceutical Benefits Scheme subsidy would not apply for this indication Appropriate skills and training of the prescribing practitioner Recommended contraindications 3 Grades of recommendations Grade Description A Body of evidence can be trusted to guide practice B Body of evidence can be trusted to guide practice in most situations C Body of evidence provides some support for recommendation but care should be taken in its application D Body of evidence is weak and recommendation must be applied with caution

Shane A Thomas BA, DipPubPoli, PhD · Stephanie S Merkouris BPsych, GradDipPsych · Harriet L Radermacher BSc, DPsych · Nicki A Dowling BSc, MPsych(Clinical), PhD · Marie L Misso PhD, BSc(Hons) · Christopher J Anderson BScEd, BTheol(Hons) · Alun C Jackson BA, MSc, PhD

Objectives: To examine the levels and growth rates of absolute funding to mental health research from 2001 to 2010, compared with other National Health Priority Areas (NHPAs), and the relative rate of mental health funding compared with other NHPAs, by taking disease burden into account. The quality of Australian research in mental health was also examined using objective indicators of research strength.Design and setting: Retrospective analysis of levels of funding overall and as a function of mental health domains using data from the National Health and Medical Research Council, with and without adjustment for burden of disease. A keyword analysis was used to assess the success rate of mental health project grant applications. Objective indicators of the quality of Australian mental health research were sought from citation indicators.Main outcome measures: Funding for mental health research relative to disease burden; funding according to disease category; project grant success rates.Results: Using actual and adjusted figures, mental health research received a lower proportion of health funding than other NHPAs, including cancer, diabetes and cardiovascular disease. Research projects into substance misuse and autism were proportionately better funded than those in anxiety, depression or schizophrenia. A significant proportion of mental health research funding was awarded to research into ageing. Citation data indicated that mental health research in Australia performed better than research in neuroscience, clinical medicine, microbiology, and pharmacology and toxicology, and at a comparable level to immunology research, despite poor levels of funding.Conclusions: Low levels of funding for mental health research appear to be largely attributable to low capacity. Mental health research in Australia is of high quality, and efforts are needed to build capacity.

Helen Christensen PhD, MPsychol(Hons) · Philip J Batterham MPH, PhD · Ian B Hickie MD · Patrick D McGorry PhD · Philip B Mitchell AM, MD, FRANZCP · Jayashri Kulkarni PhD

Objective: To examine the effects of paternal depression during children’s first year on their wellbeing at 4–5 years of age using a large, representative sample of Australian families.Design, setting and participants: Prospective study of Australian families from 2004 to 2008. Two-biological-parent families (n = 2620) from the Longitudinal Study of Australian Children were included if depression measures were available for both parents in 2004, behavioural and developmental measures were available for children in 2008, and the families had not separated by 2008.Main outcome measure: Child scores on the Strengths and Difficulties Questionnaire and on a set of Derived Outcome Indices, measured when the child was 4–5 years old. Logistic regression modelling was used to investigate how early paternal depression in 2004 influenced child outcomes 4 years later.Results: Early paternal depression was a significant predictor of a range of poorer child outcomes (odds ratio [OR] for behavioural difficulties, 3.34 [95% CI, 3.06–3.65]; OR for a low development and wellbeing score, 2.70 [95% CI, 2.44–2.98]). These effects remained significant after controlling for both early maternal depression and later paternal depression (adjusted OR for behavioural difficulties, 1.93 [95% CI, 1.75–2.14]; OR for a low development and wellbeing score, 1.65 [95% CI, 1.48–1.85]).Conclusions: Depression in fathers during the first year of a child’s life can have a detrimental impact on their child’s behaviour, and social and emotional development at the point of school entry, in addition to and uniquely compared with depression in mothers. Early intervention to identify and address the mental health needs of fathers is required for the benefit of fathers, children and families.

Richard J Fletcher PhD · Emily Feeman PhD · Craig Garfield MD, MAPP · Graham Vimpani FRACP, FAFPHM, PhD

Objective: To determine whether emergency department (ED) patients’ self-rated levels of anxiety are affected by exposure to purpose-designed music or sound compositions with and without the audio frequencies of embedded binaural beat.Design, setting and participants: Randomised controlled trial in an ED between 1 February 2010 and 14 April 2010 among a convenience sample of adult patients who were rated as category 3 on the Australasian Triage Scale.Interventions: All interventions involved listening to soundtracks of 20 minutes’ duration that were purpose-designed by composers and sound-recording artists. Participants were allocated at random to one of five groups: headphones and iPod only, no soundtrack (control group); reconstructed ambient noise simulating an ED but free of clear verbalisations; electroacoustic musical composition; composed non-musical soundtracks derived from audio field recordings obtained from natural and constructed settings; sound composition of audio field recordings with embedded binaural beat. All soundtracks were presented on an iPod through headphones. Patients and researchers were blinded to allocation until interventions were administered. State–trait anxiety was self-assessed before the intervention and state anxiety was self-assessed again 20 minutes after the provision of the soundtrack.Main outcome measure: Spielberger State–Trait Anxiety Inventory.Results: Of 291 patients assessed for eligibility, 170 patients completed the pre-intervention anxiety self-assessment and 169 completed the post-intervention assessment. Significant decreases (all P < 0.001) in anxiety level were observed among patients exposed to the electroacoustic musical composition (pre-intervention mean, 39; post-intervention mean, 34), audio field recordings (42; 35) or audio field recordings with embedded bianaural beats (43; 37) when compared with those allocated to receive simulated ED ambient noise (40; 41) or headphones only (44; 44).Conclusion: In moderately anxious ED patients, state anxiety was reduced by 10%–15% following exposure to purpose-designed sound interventions.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN 12608000444381.

Tracey J Weiland BBSc(Hons), PhD/MPsych · George A Jelinek MB BS, MD, FACEM · Keely E Macarow BA, MA, PhD · Philip Samartzis GradDipArt · David M Brown DipArt, MA · Elizabeth M Grierson LicDip, MA, PhD · Craig Winter MB BS, MBA, FACEM

Objectives: To describe the prevalence of lifetime and 12-month stimulant use disorders in the Australian population, and to compare the prevalence estimates from a population survey with prevalence estimates derived using indirect methods.Design and setting: Data were drawn from the 2007 National Survey of Mental Health and Wellbeing, which sampled 8841 residents of private dwellings in Australia in 2007. Interviews were conducted by lay interviewers using the Composite International Diagnostic Interview.Main outcome measures: Lifetime and 12-month rates of stimulant use and stimulant use disorders (abuse, dependence) diagnosed according to the Diagnostic and statistical manual of mental disorders, 4th edition.Results: Lifetime prevalence of stimulant use disorders was 3.3%, and 12-month prevalence was 0.6%, equating to more than 97 000 Australians. Nearly half of those who had used stimulants on more than five occasions met criteria for a lifetime disorder. More than 8% of men aged 16–29 years met criteria for a lifetime stimulant use disorder. Prevalence estimates were consistent with recent estimates using indirect methods.Conclusions: Stimulant use disorders affect a significant number of Australians, and are most common in the age groups at greatest risk for development of psychosis.

Grant E Sara MM, MM(Psychother), FRANZCP · Philip M Burgess MA, PhD · Meredith G Harris BA(Hons), MPASR, MPH · Gin S Malhi MD, FRCPsych, FRANZCP · Harvey A Whiteford MB BS, MPH, FRANZCP

Understanding troubled minds. A guide to mental illness and its treatment . Sidney Bloch. Melbourne: Melbourne University Press, 2011 (371 pp, $39.99). ISBN 9780522857542. This is a new version of a similar volume published over 10 years ago (The foundations of clinical psychiatry), co-edited by Bruce Singh and Sidney Bloch. The influence of the original work can be seen in the coverage of standard psychiatric topics — the history of psychiatry, perspectives of understanding mental illness, the work and role of psychiatrists, stress and coping, clinical syndromes, special clinical populations, drugs and physical treatments, psychotherapies, mental health promotion and ethics — and, perhaps, in the practitioner-centric view of the field. Since that first edition, much has happened in the field of mental health. This progress (and, in some instances, backsliding) has been included in the current volume, which has Bloch as sole author. Bloch is emeritus professor of psychiatry at the University of Melbourne and an honorary consultant psychiatrist at St Vincent’s Hospital, Melbourne. He is a respected academic with a wealth of clinical experience in adult psychiatry and psychotherapy, and in the role of ethics in psychiatric practice. It would be difficult to find a colleague with better qualifications to author a book of this nature. But this is not a textbook. It is a guide to mental illness for the general public, and for patients, their families and friends. The single authorship has allowed Bloch the opportunity to add valuable personal insights and experiences to the text. Indeed, this is one of the most enjoyable aspects of the book. He uses literature and art to illustrate ideas and clinical phenomena without overwhelming the basic narrative of describing mental illness and its treatment. The level of language used requires a relatively sophisticated readership; probably one with at least secondary-level education. The book will fill a gap in providing authoritative information about mental illness for patients and concerned individuals, as well as for non-clinical workers and government and non-government agencies in the mental health area. I can see it being used in general practices, and in the libraries of community service providers and advocacy agencies. The price is modest and should not be a barrier to access. Understanding troubled minds is a valuable addition to the literature on mental illness, aimed at the educated layperson.

Philip L P Morris

Health reporter Ray Moynihan explores disturbing new data about the ever-popular pills After analysing antidepressant use among older people in Britain for more than a decade, a team of researchers has come up with some alarming new findings. Released recently, their study barely raised a murmur in Australia, but its implications are potentially enormous.1 If the new data are to be believed, for older people, the most commonly prescribed drugs for depression may be associated with an increased risk of serious health problems and death compared with less common antidepressants or none at all. Conducted as part of the Health Technology Assessment program, this British prospective cohort study investigated the risks associated with antidepressants being used by people aged 65 years or older during the decade or so to 2008. Its database included more than 60 000 people from 570 general practices across the United Kingdom who had been newly diagnosed with depression. Results published in the BMJ show that more than half of the antidepressant prescriptions issued to this group were for drugs from the selective serotonin reuptake inhibitor (SSRI) class, almost a third were for older tricyclics, and just over one in 10 were for other antidepressants.1 Eleven per cent of the people in the study did not take any drugs for depression. For those who did take antidepressants, the median duration of use was 1 year. Interestingly, more than two-thirds of the older people had the severity of their depression classified as mild, a quarter as moderate, and just under 5% as severe — and these proportions were similar for those who were and those who were not prescribed antidepressants. The researchers then compared the adverse events experienced by people during the time they were taking the drugs with those experienced by people during periods when they weren’t taking the drugs, and it was these comparisons that produced the unexpected and disturbing associations. The absolute risk of death from all causes over 1 year was 10.6% for patients taking SSRIs, 8.1% for those taking tricyclics, 11.4% for those taking other antidepressants, and 7.0% for people not taking any antidepressants. Moreover, those taking antidepressants suffered a significantly greater number of serious adverse events: All classes of antidepressant drug were associated with significantly increased risks of all cause mortality, attempted suicide/self harm, falls, fractures, and upper gastrointestinal bleeding compared with when these drugs were not being used.1 Despite being heavily promoted as better than the older medicines, the study found that, compared with tricyclic antidepressants, the newer SSRI class “may be associated with an increased risk of ... all cause mortality, stroke/transient ischaemic attack, falls, fracture, epilepsy/seizures, and hyponatraemia”. The obvious limitation here is that the study was observational, rather than a randomised controlled trial. However, as is made clear in their full 200-page report for the Health Technology Assessment program,2 the researchers went to great lengths to identify a wide range of potentially confounding variables, including age, sex, comorbidities and the severity of depression. Yet after adjusting the results for the confounding variables, key associations were largely unaffected. For example, after adjusting for confounders, taking SSRIs was still associated with a roughly 50% higher chance of death in relative terms, as well as an increased risk of serious adverse events including attempted suicide, falls and fractures, compared with those diagnosed with depression who were not taking antidepressants. In discussing the findings of their observational study, the authors highlight the difficulty of untangling the effect of the drugs from the effect of the underlying condition, particularly as they were unable to adjust for the way the severity of a patient’s depression might have changed during the decade of the study. Putting their results in the context of other data, the researchers conclude that their findings of higher rates of attempted suicide for all classes of antidepressants “suggest an effect of depression itself rather than a direct causal effect” of the drugs.2 By contrast, they conclude their findings of higher rates of falls, fractures and hyponatraemia associated with some antidepressants are generally in line with existing data. Importantly, the study’s limitation is also its strength. Looking at the serious health problems experienced by many thousands of people taking antidepressants over a long period, these real-world results are potentially more relevant than small, short-term, company-funded trials with extensive exclusion criteria, which may lead to overstating benefits and playing down harms of drugs. Whatever your view of the benefits of these heavily marketed medicines, this latest study provides important new information about their associated downsides.

Ray Moynihan BA

Objective: To investigate how Australian print news media portray psychiatric genetics.Design and setting: Content and framing analysis of a structured sample of print news items about psychiatric genetics published in Australian newspapers between 1996 and 2009.Main outcome measures: Identify dominant discourses about aetiology of mental illness, and perceived clinical outcomes and implications of psychiatric genetics research.Results: We analysed 406 eligible items about the genetics of psychiatric disorders. News coverage of psychiatric genetics has steadily increased since 1996. Items attributing the aetiology of psychiatric disorders to gene–environment interactions (51%) outnumbered items attributing only genetic (30%) or only environmental factors (20%). Of items that referred to heritability of mental illness, frames of genetic determinism (78%) occurred more frequently than probabilistic frames (22%). Of frames related to genetic prophesy, genetic optimism frames (78%) were used more frequently than frames of genetic pessimism (22%). Psychosocial and ethical implications of psychiatric genetics received comparatively relatively little coverage (23%). The analysis identified 22 predictions about psychiatric genetic discoveries and the availability of molecular-based interventions in psychiatry, most of which (20/22, 91%) failed to manifest by the predicted year.Conclusions: Excessive optimism about the power of genetic technology in psychiatric health care, perceived clinical benefits, and largely unfulfilled predictions about availability of these benefits could encourage unrealistic expectations about future molecular-based treatment options for mental health.

Alex Wilde BSc(Hons),PhD · Catriona Bonfiglioli BA(Hons), PhD · Bettina Meiser PhD · Philip B Mitchell AM, MD · Peter R Schofield PhD, DSc

Time to examine a system harming the health of both detainees and detention centre staff On 29 July this year, Commonwealth Ombudsman Allan Asher confirmed that his office would undertake an investigation into suicide and self-harm in Australian immigration detention facilities.1 The investigation will examine rates of suicide and self-harm relative to those in the broader Australian community, and factors such as length of time in detention and the design of mental health services for detainees. Our view is that the Ombudsman is right to undertake such an inquiry. Simply put, there is a crisis within the detention system, requiring an urgent need to identify contributory factors. More than 1100 incidents of threatened or actual self-harm across all places of detention were reported in the 2010–11 financial year.1 Fifty-four incidents of self-harm were reported during the first week of July this year alone. After a lengthy period of no suicides,2 there have been five since September 2010.3 There have been reports of many “near-miss” cases and of a culture of hopelessness and despair inside detention centres.3 Given that suicidal behaviour can be considered as a continuum of thoughts and behaviours, ranging from suicidal ideation to completed suicide,4 we think the need for such an investigation raises important questions about how much is known within immigration detention centres about: the determinants of detainee self-harm and suicide risk;5 a detainee’s preparatory acts toward imminent suicidal behaviour (eg, locating ligature points and assembling the necessary apparatus); how detainees are managed after a serious suicide attempt; the type and cultural appropriateness of the support being provided to detainees; the possibility of possible contagion surrounding suicide and self-harm; and how effective existing policies and staff training are in preventing suicidal behaviour. These considerations are important because the detention environment is known to harm both mental and physical health. Detainees express their distress in ways that are in keeping with their culture and the setting they are in. Strong evidence confirms poor health among immigration detainees, which deteriorates over time, and shows a clear association between time in detention and rates of mental illness.6 Overcrowding within immigration detention is a major concern and most likely magnifies mental ill health through factors such as tense patterns of interaction and an inability to buffer stressful events or uncomfortable physical factors such as heat. Living in limbo and uncertainty can manifest in feelings of fear, anxiety, sleep disturbance and self-harm, along with irritability and frustration. A recent systematic review of studies investigating the impact of immigration detention on the mental health of children, adolescents and adults identified high levels of mental health problems in detainees.7 Time in detention was found to be associated with severity of distress. Anxiety, depression and post-traumatic stress disorder were commonly reported, as were self-harm and suicidal ideation. There is evidence for an initial improvement in mental health shortly after release, although mental health effects may be prolonged, extending well beyond the point of release into the community.8 In the months leading up to the Commonwealth Ombudsman’s announcement, significant incidents had been unfolding, including detainees stitching their lips together, hunger strikes, violent confrontations and property damage. There are also reports of isolation cells being converted into full-time behaviour management units where detainees who are distressed or disturbed, or who try to kill themselves, are fitted with soft helmets and handcuffs to stop them cracking their heads against the floor or walls or harming themselves in other ways.9 Such claims must be examined. They raise serious issues about the commitment of the detention system to human rights. In addition to these matters, the detention environment is also known to impact heavily on the mental and physical health of the people who work there. A national humanitarian solution is critical. Without this, the consequences will be catastrophic for all who are engaged in this system. We urge the government to act swiftly to prevent more human tragedy.

Louise K Newman MB BS, PhD, FRANZCP · Nicholas G Procter PhD, MBA, RN · Michael J Dudley MB BS, BD, FRANZCP

Objectives: To compare the findings of the 1997 and 2007 Australian national surveys of mental health and wellbeing (NSMHWBs) with respect to the role of general practitioners in providing mental health services.Design, setting and participants: There were 10 641 participants Australia-wide in the 1997 survey and 8841 in the 2007 survey. Data were gathered through face-to-face interviews using a written questionnaire.Main outcome measures: Rates of use of GPs and other health care providers for treatment of mental health problems; levels of met and unmet need for mental health services reported by those accessing GP services.Results: Between 1997 and 2007, the proportion of people accessing any mental health care service within the previous 12 months increased significantly, from 12.4% to 21.4% (P < 0.01), although the proportion accessing GP care for mental health problems did not increase. In both surveys, nearly 60% of individuals with self-assessed mental health problems sought no professional help for their problems, although about 80% of these non-users had seen GPs about other matters. The proportions of participants who reported receiving sufficient information, medication and/or therapy for their mental health problem increased significantly over the 10-year period. However, unmet need for information also increased. In both surveys, over 90% of participants aged 60 years or over with self-assessed mental health problems reported obtaining no help for their mental health problem despite seeing a GP for other reasons.Conclusion: Despite a significant rise in the use of mental health services, the role of GPs in providing such services has not increased.

Ruth A Parslow MPH, PhD · Virginia Lewis PhD · Geraldine Marsh BEd, GradDipHlth AdminEduc

CorrectionsIncorrect percentage: In “Prevalence and predictors of anxiety and depression in women with invasive ovarian cancer and their carergivers” in the Anxiety, depression and cancer supplement to the 6 September 2010 issue of the Journal (Med J Aust 2010; 193: S52-S57), the percentage given in Box 2 (page S54) for participants categorised as having a normal score for anxiety on the Hospital Anxiety and Depression Scale was 60.8%. The correct percentage is 66.8%. This error has no impact on any of the analyses, results or conclusions of the article; it has been corrected in the online version (http://www.mja.com.au/public/issues/193_05_060910/pri11382_fm.html).

Melanie A Price · Phyllis N Butow · Daniel S J Costa · Madeleine T King · Lynley J Aldridge · Joanna E Fardell · Anna DeFazio · Penelope M Webb

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

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

Improving health outcomes for mothers, children and families Mental health morbidity associated with the perinatal period — from conception to the end of the first postnatal year — is now recognised as a major public health issue, with depression affecting up to 15% of women during this period.1 It has been reported that 45% of postnatal depression begins in pregnancy,2 and about 38% of women with postnatal depression have a comorbid anxiety disorder.3 About 3% of women experience moderate to severe depression during the perinatal period and 0.2% experience a puerperal psychosis,4 and maternal suicide continues to be identified as one of the leading causes of indirect maternal mortality.5 There is growing evidence of the negative impact of poor mental health outcomes not only for the mother, but also for her child and family.6 The existence of well established maternal and infant health care systems across Australia has provided a unique opportunity for integrating mental health care into mainstream services. Increasingly, the maternal and infant health care sectors are introducing routine, universal psychosocial assessment aimed at detecting women who are at risk of, or suffering from, mental health morbidity. This approach, underpinned by a philosophy of prevention and early intervention, has been developed in the Australian perinatal setting over the past decade through the work and advocacy of leading clinicians and researchers, policymakers and beyondblue: the national depression initiative.7-9 Feasibility of widespread screening for depression in the perinatal period was evaluated in the National Postnatal Depression Research Program (2001–2005).7 It was concluded that screening for depression was feasible in routine clinical settings and acceptable to women and their health care providers (including general practitioners). In addition, maternal mental health morbidity often went undetected and untreated if routine screening was not used. The National Action Plan for Perinatal Mental Health (2008) went on to recommend implementing universal psychosocial assessment, training primary health care staff who administer the assessments, and establishing structures that optimise coordination of, and access to, appropriate services.8 This was followed by the establishment, by the Department of Health and Ageing, of the National Perinatal Depression Initiative (2008–2013), which enabled the introduction of a specific perinatal mental health Medicare stream (under the Access to Allied Psychological Services initiative) and the development of national clinical practice guidelines for depression and related disorders in the perinatal period.9 The clinical practice guidelines are aimed at all clinicians who have a “primary health care” role in detecting possible mental health morbidity in the perinatal period — including midwives, GPs, child and family health nurses, obstetricians and paediatricians. They are underpinned by a systematic literature review that points to a paucity of quality evidence, especially on routine psychosocial assessment and the safety of psychotropic medication in pregnancy. The guidelines recommend routine, universal screening for depression (antenatal and postnatal) using the Edinburgh Postnatal Depression Scale (EPDS)10 and treatment of mild to moderate postnatal depression with evidence-based psychological interventions (eg, cognitive behaviour therapy). Where there is insufficient evidence for recommendations, good practice points (based on lower-quality evidence and/or expert consensus) have been formulated. These include using comprehensive, universal psychosocial assessment (eg, the Antenatal Risk Questionnaire11) in addition to the EPDS, considering mother–infant interaction and risk to infant as integral parts of the assessment, monitoring women with an existing mood disorder closely to reduce risk of relapse, and providing specific advice about the safety of psychotropic medication during pregnancy and breastfeeding.9 While the guidelines recommend routine use of the EPDS in the perinatal period, they emphasise that it should only be used as an adjunct to clinical assessment in the primary care setting. They also highlight that universal psychosocial assessment is an area of debate, has significant resource implications (including training, service organisation and workload requirements), and needs to be closely integrated with access to mental health services. The clinical effectiveness of routine psychosocial assessment remains to be evaluated. A recent randomised controlled trial of early postnatal screening using the EPDS (including supportive counselling where indicated) demonstrated improved maternal mental health outcomes at 6 months postpartum for women receiving the intervention compared with those receiving usual care.12 In a meta-analysis of screening interventions for general depression, screening was found to be beneficial as long as it was integrated with clear pathways to care.13 This is in line with the National Action Plan for Perinatal Mental Health and the clinical practice guidelines — the first steps in translating evidence into practice and developing a broader evidence base. There is now a need to evaluate the effectiveness of combining psychosocial assessment with integrated pathways to care. In addition, an evaluation of the impact of the National Perinatal Depression Initiative on mental health outcomes for mothers is critical if we are to optimise the quality and uptake of services for this vulnerable, yet highly accessible, population.

Marie-Paule V Austin MB BS, FRANZCP, MD · Philippa F Middleton BSc(Hons), GradDipLibSt, MPH · Nicole J Highet DPsych

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