The mental health of adolescents and young people experiencing traumatic stress and problematic substance use.

Introduction and Aims: Up to 80% of adolescents have experienced trauma and one-in-seven suffer from post­ traumatic stress disorder (PTSD). For 50% of these adoles­cents, the course of their illness is further complicated by a co-occurring substance use disorder (SUD). Despite high rates of comorbidity, treatment options remain sparse and there is limited understanding of the clinical profile associated with this comorbidity. We aimed to examine the clinical profile of adolescents seeking treat­ment for their substance use and traumatic stress.Method: Data were collected as part of a randomised controlled trial examining the efficacy of an integrated psychological treatment for SUD and PTSD among young people aged 12-25 years were assessed for history of trauma, PTSD, substance use and a variety of other domains relating to mental health, social and family functioning and service utilisation.Results: Almost all participants met Diagnostic and Sta­tistical Manual of Mental Disorders, Fifth Edition, cri­teria for a severe SUD. The most common substances of concern were cannabis and alcohol. All participants expe­rienced multiple traumatic events and >85% met Diag­nostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for PTSD. High levels of clinically ele­vated depression and anxiety were present in the sample and almost half had a history of attempted suicide.Discussions and Conclusions: Comorbid PTSD and SUD in young people are associated with a complex and severe clinical profile. It is imperative to intervene early in the trajectory in order to prevent the severe and long­ lasting burden associated with this common comorbidity

Comorbidity: Trauma, substance use and mental health

Substance use and mental health disorders commonly co-occur and they are frequently underpinned by history of psychological trauma. This symposium presents new data on the clinical presentation and documentation of trauma exposure, trauma-related disorders, and their treatment among adults entering substance use treatment, the implementation of integrated trauma-focused therapy in substance use treatment, and presenting issues among adolescents seeking integrated treatment for substance use and traumatic stress

Improving alcohol and mental health treatment for lesbian, bisexual and queer women: identity matters

Abstract Objective: Lesbian, bisexual and queer (LBQ) women experience substantial unmet alcohol and mental health treatment needs. This paper explores the way in which sexual identity shapes experience, and needs, in relation to alcohol and mental health treatment, and presents key messages for improving treatment. Methods: Twenty‐five in‐depth interviews were undertaken with same‐sex attracted Australian women, aged 19–71. Interview transcripts were analysed thematically. Results: Key messages offered by participants focused on language, disclosure and practitioner training. Variation in sexual identity did not alter treatment expectations or needs; however, we noted an important difference with respect to identity salience, with high LBQ identity salience linked with preference for disclosure and acknowledgement of sexual identity in treatment interactions, and low identity salience linked with a preference not to disclose and for sexual identity not to require acknowledgement in treatment. Conclusions: Treatment providers may find it useful to gather information about the centrality of sexual identity to LBQ women as a means of overcoming treatment barriers related to heteronormative conventions and discrimination, language and disclosure. Implications for public health: Treatment providers should adopt more inclusive language, seek information about identity salience and the importance of sexual identity to the current treatment, and regularly pursue LBQ‐related professional development upskilling

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)

Studies of the simulation of drifting oil by polyethylene sheets

Rudimentary, comparative tests in laboratory tanks suggested that thin, polyethylene sheet will drift with the uppermost layer of surface water and thereby simulate the movement of an oil slick in the ocean. A series of drift experiments with circular polyethylene sheets in Narragansett Bay showed that both tidal currents and surface with friction were of equal importance in producing the motion of a thin surface layer. In Narragansett Bay, theoretical predictions of the surface motion suggested that errors in the available tidal-current charts produce the major uncertainty in estimates of this motion. © 1970

Substance use and mental health in longitudinal perspective

Comorbidity between substance use disorders and other psychological disorders has emerged as a major clinical, public health and research issue over the past few decades thanks in large part to population surveys of mental disorders that have highlighted that comorbidity is common. The reasons for comorbidity are complex but longitudinal research has begun to provide insights into the underlying mechanisms. This chapter will give a brief overview of epidemiological research into comorbidity and examines the most recent longitudinal data on patterns and causal pathways of comorbidity. The chapter highlights the increasingly consistent evidence of shared risk factors for both mental disorders and substance use disorders as well as suggesting that causal relationships may operate in both directions, that is from substance use to mental disorders and vice versa. In particular, there is a causal pathway from depression to substance use in males, and from daily cannabis use to depression and anxiety in females. There is also evidence that cannabis use precipitates psychosis in persons who are vulnerable because of a personal or family history of psychosis. Externalizing behavior problems in children, particularly conduct disorder and aggressive behavior emerging prior to age 12, have been shown to predict a greater likelihood of progressing to adolescent poly-drug use and or alcohol use problems in adulthood. The effect of childhood internalizing problems such as anxiety and depression on the subsequent development of substance use problems is less clear. Finally, the chapter addresses the implications of this information for prevention. While we should intervene to prevent or delay the onset of substance use and mental disorders during adolescence, such interventions should not focus solely on substance use or mental disorders alone. They should target a range of potentially health-threatening behaviors including substance use, sexual risk-taking and problems of personal adjustment since many of these behaviors co-occur because of shared risk factors

Trialling exposure-based therapy for adolescent traumatic stress and substance use: Challenges and observations from a randomized controlled trial.

Background: For up to 50% of adolescents experiencing PTSD, the course of their illness is further complicated by co-occurring substance use. Despite this, evidence-based integrated treatment options for adolescents with this comorbidity remain sparse. To address this gap, we are conducting an RCT examining the efficacy of exposure-based therapy for co-occurring PTSD and substance use among adolescents. In this paper, we discuss some of the challenges associated with conducting an RCT in the population group and early observations from the trial. Method: A total of 100 adolescents aged 12–18 years will be recruited. Participants are randomized to receive up to 16 sessions of (i) the integrated exposure-based treatment (COPE-A) or (ii) supportive counselling (control). Blind interviews are conducted at baseline, 4- and 12-months. Substance use and PTSD are measured each therapy session. Results: To date, 20 people have been referred to the study with 17 screened for eligibility. A total of 13 were eligible to participate with nine consented and allocated to a condition. Challenges to trial execution include issues relating to the population group itself, involvement of parents/guardians and other health care providers, logistics, ethical and governance approvals, and resources. Discussion: Although there are significant challenges involved in conducting a trial such as this, they are by no means insurmountable. The study findings will improve our understanding of how to best treat PTSD and substance use during this critical develop-mental period. By intervening early in the trajectory ofthese disorders, it may be possible to prevent thesevere and long-lasting burden associated withcomorbidity across the lifespan