Anxiety, depression and risk of cannabis use: examining the internalising pathway to use among Chilean adolescents

Background: Adolescents who experience internalising symptoms may be susceptible to the use of alcohol and other substances in an attempt to alleviate or cope with these symptoms. We examined the hypothesised internalising pathway from symptoms of depression, generalised anxiety, social anxiety and panic, to incidence and frequency of cannabis use 18 months later. Method: Longitudinal cohort study of participants (n = 2508; 45% female; mean age 14.5 years) recruited from the 9th grade at 22 low-income secondary schools in Santiago, Chile. Baseline internalising symptoms were assessed using the Beck Depression Inventory and the Revised Child Anxiety and Depression Scale. Frequency of cannabis was assessed at baseline, 6 month and 18 month follow-up. Results: High rates of use were observed in this sample, with 40.3% reporting cannabis use at least once over the study period. Adjusted for baseline cannabis use, symptoms of depression, panic and generalised anxiety were associated with greater cannabis use frequency 18 months later. When all predictors were considered simultaneously, only generalised anxiety symptoms showed an independent association with subsequent cannabis use frequency (OR: 1.23, 95% CI: 1.08–1.41). Generalised anxiety symptoms were also associated with a 25% increased risk of transitioning from non-user to use of cannabis during the study (OR: 1.25, 95% CI: 1.09–1.44). Conclusions: Internalising symptoms, and in particular symptoms of generalised anxiety, increase risk of cannabis use during adolescence. Targeted interventions that promote adaptive anxiety management among high-risk adolescents may represent a promising strategy to prevent uptake of cannabis use during adolescence

Depression symptom trajectories and associated risk factors among adolescents in Chile.

Adolescence is a key period for studying the development of depression, with studies in Europe and North America showing a pattern of elevated risk that begins in early adolescence and continues to increase as adolescents age. Few studies have examined the course of adolescent depression and associated risk factors in low and middle-income countries. This longitudinal cohort study examined depression symptom trajectories and risk factors in a sample of socio-economically disadvantaged adolescents in Chile (n = 2,508). Data were collected over an 18-month period as part of a clinical trial for secondary students aged 12 to 18 (median age 14). Clinical levels of depression were prevalent in this sample at baseline (35% for girls and 28% for boys); yet latent growth models of symptom trajectories revealed a pattern of decreasing symptoms over time. There was evidence of an anxiety-depression developmental pathway for girls, with elevated anxiety levels initially predicting poorer depression outcomes later on. Poor problem-solving skills were associated with initial depression levels but did not predict the course of depressive symptoms. Critically, the declining symptom trajectories raise important methodological issues regarding the effects of repeated assessment in longitudinal studies

Peer victimization during adolescence: concurrent and prospective impact on symptoms of depression and anxiety

BACKGROUND: Peer victimization is ubiquitous across schools and cultures, and has the potential for long-lasting effects on the well-being of victims. To date, research has focused on the consequences of peer victimization during childhood but neglected adolescence. Peer relationships and approval become increasingly important during adolescence; thus, peer victimization at this age may have a damaging psychological impact. METHODS: Participants were 5030 adolescents aged 11-16 recruited from secondary schools in the UK. Self-report measures of victimization and symptoms of anxiety and depression were administered on three occasions over a 12-month period. Latent growth models examined concurrent and prospective victimization-related elevations in anxiety and depression symptoms above individual-specific growth trajectories. RESULTS: Peer victimization was associated with a concurrent elevation of 0.64 and 0.56 standard deviations in depression and anxiety scores, respectively. There was an independent delayed effect, with additional elevations in depression and anxiety (0.28 and 0.25 standard deviations) six months later. These concurrent and prospective associations were independent of expected symptom trajectories informed by individual risk factors. CONCLUSIONS: Adolescent peer victimization was associated with immediate and delayed elevations in anxiety and depression. Early intervention aimed at identifying and supporting victimized adolescents may prevent the development of these disorders

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations

Summary of recommendations and levels of evidence Chapter 2: Screening and assessment for unhealthy alcohol use Screening Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C). Quantity–frequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B). The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A). Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B). Assessment Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C). Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP). Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C). Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patient’s needs (Level D). Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C). Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up Brief interventions Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A). Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A). Psychosocial interventions Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A). Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A). Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D). Alcohol withdrawal management Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B). Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP). Pharmacotherapies for alcohol dependence Acamprosate is recommended to help maintain abstinence from alcohol (Level A). Naltrexone is recommended for prevention of relapse to heavy drinking (Level A). Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A). Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B). Peer support programs Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A). Relapse prevention, aftercare and long-term follow-up Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP). A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP). Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations Gender-specific issues Screen women and men for domestic abuse (Level C). Consider child protection assessments for caregivers with alcohol use disorder (GPP). Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B). Pregnant and breastfeeding women Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B). Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP). Young people Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B). Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B). Aboriginal and Torres Strait Islander peoples Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP). Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B). Culturally and linguistically diverse groups Use an appropriate method, such as the “teach-back” technique, to assess the need for language and health literacy support (Level C). Engage with culture-specific agencies as this can improve treatment access and success (Level C). Sexually diverse and gender diverse populations Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C). Seek to incorporate LGBTQ-specific treatment and agencies (Level C). Older people All new patients aged over 50 years should be screened for harmful alcohol use (Level D). Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D). Consider shorter acting benzodiazepines for withdrawal management (Level D). Cognitive impairment Cognitive impairment may impair engagement with treatment (Level A). Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A). Summary of key recommendations and levels of evidence Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities Polydrug use and dependence Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP). Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP). Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C). Co-occurring mental disorders More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP). The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A). People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C). Physical comorbidities Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A). In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A). Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A)

Seeking safety on the internet: Relationship between social anxiety and problematic internet use

As internet use becomes increasingly integral to modern life, the hazards of excessive use are also becoming apparent. Prior research suggests that socially anxious individuals are particularly susceptible to problematic internet use. This vulnerability may relate to the perception of online communication as a safer means of interacting, due to greater control over self-presentation, decreased risk of negative evaluation, and improved relationship quality. To investigate these hypotheses, a general sample of 338 completed an online survey. Social anxiety was confirmed as a significant predictor of problematic internet use when controlling for depression and general anxiety. Social anxiety was associated with perceptions of greater control and decreased risk of negative evaluation when communicating online, however perceived relationship quality did not differ. Negative expectations during face-to-face interactions partially accounted for the relationship between social anxiety and problematic internet use. There was also preliminary evidence that preference for online communication exacerbates face-to-face avoidance.9 page(s

Fear and perceived uncontrollability of emotion: Evaluating the unique contribution of emotion appraisal variables to prediction of worry and generalised anxiety disorder

Novel theoretical frameworks place the symptom profile of generalised anxiety disorder (GAD) within the context of dysfunctional emotional processes. It is suggested that fear and intolerance of emotions exacerbate subjective distress and motivate the use of maladaptive coping strategies, such as worry. To date, studies evaluating these models have suffered two key limitations. Firstly, few studies have involved treatment-seeking samples, and secondly, none have evaluated the unique variance attributable to emotion appraisal variables above and beyond previously established predictors of worry and GAD. The present study begins to address these limitations by assessing the contribution of fear and perceived uncontrollability of emotions in predicting worry and clinical GAD status after controlling for variance attributable to depressive symptoms, meta-cognitive beliefs, intolerance of uncertainty, and perceptions of external threat. Supporting current models, results showed that perceived control over emotional reactions was a unique predictor of GAD diagnostic status and both clinical and non-clinical worry.8 page(s

Development and validation of the affect intolerance scale to assess maladaptive beliefs and avoidance of emotion

Cognitive processes are considered integral to the conceptualisation of emotional disorders and distress. Contemporary models have emphasised the importance of individual differences in the interpretation of internal events, including emotions. Maladaptive beliefs about emotional experience may motivate unhelpful control strategies, and impact negatively on psychological wellbeing. Building on existing measures of emotion, an integrative scale was developed to assess a range of maladaptive beliefs about the experience of negative emotions. Psychometric evaluation provided preliminary support for the reliability and validity of the Affect Intolerance Scale (AIS). Furthermore, the scale demonstrated a unique relationship with clinical symptomatology (i.e., depression, anxiety, stress and worry) above and beyond existing measures assessing dimensions of emotional experience. Potential utility of the measure for clinical practice and avenues for future research are discussed.17 page(s

Evaluating the cognitive avoidance model of generalised anxiety disorder: Impact of worry on threat appraisal, perceived control and anxious arousal

Generalised anxiety disorder (GAD) is characterised by persistent and uncontrollable worry. According to the cognitive avoidance theory of GAD, worry may function as an affective dampening strategy motivated by intolerance of negative emotional states. By facilitating avoidance of more distressing cognitions and associated affect, worry is said to preclude modification of the fear representation in memory, maintaining threat associations and perpetuating further anxiety and worry. The present study evaluated these assumptions in a treatment-seeking GAD sample. Sixty-one participants were randomly allocated to conditions in which they were instructed to worry, imaginally process or relax in response to an anxiety trigger. Results supported the detrimental impact of worry, showing maintained threat expectancies and decreased control perceptions compared to other modes of processing. However, skin conductance level increased as a function of worry and there was no suggestion that worry suppressed affective responding. These findings highlight the need for clarification of the mechanisms involved in the maintenance of threat associations and worry in GAD.9 page(s

The Reliability and validity of the Australian moral disengagement scale

Background: The present study explored the reliability, validity, and factor structure of a modified version of the Moral Disengagement Scale (MDS), which comprehensively assesses proneness to disengage from different forms of conduct specific to Australian adolescents. Methods: A sample of 452 students (Mage = 12.79; SD = 1.93) completed the modified MDS and the Australian Self-Report Delinquency Scale. A multistep approach was used to evaluate the factor structure of the MDS. The sample was divided into exploratory (n = 221) and cross-validation samples (n = 231). Principal component analysis was conducted with the exploratory sample and multiple factor solutions compared to determine the optimal factor structure of the modified MDS. The final factor solution was confirmed in the cross-validation sample using confirmatory factor analysis. Internal consistency of the final scale and convergent validity with the delinquency questionnaire was also assessed. Results: Analyses resulted in a 22-item MDS for use in Australia, with four factors mapping onto the four conceptual categories of moral disengagement. The individual subscales demonstrated adequate to good internal consistency, and the total scale also demonstrated high internal consistency (α = 0.87). Convergent validity of the scale was established. Conclusions: The 22-item Australian MDS is a reliable and valid instrument for use within an Australian population.14 page(s