Improving treatment for people with cognitive impairment and substance misuse issues: Lessons from an inclusive residential treatment program pilot in Australia.

BACKGROUND: Approximately half of the substance dependence treatment population is estimated to have a cognitive impairment, which reduces participation, retention, and post-treatment outcomes. Cognitive behaviour change approaches are less effective for this population and cognitive remediation strategies have been found to improve outcomes. Evidence on modified programs to remove environmental barriers for treatment seekers with disability does not exist. OBJECTIVE: A modified residential substance misuse treatment program in New South Wales, Australia, was piloted and evaluated to address this knowledge gap. METHOD: Of 67 residents who received treatment during the evaluation period, 33 were screened as having cognitive impairment. Twelve residents took part in an interview and 10 staff in a focus group to understand their views of the pilot program. Resident characteristics and retention rates and themes about program benefits and challenges are reported. RESULTS: Treatment completion was up to five times higher for residents with cognitive impairment after the new program was implemented. The pilot program provided simplified written and visual materials and concrete examples and introduced a daily virtues program to embed new learning and support behaviour change. Resources to allow staff to engage more intensively with residents and provision of ongoing staff training were viewed as essential for program success. CONCLUSIONS: Environmental adaptations, including a combination of conventional treatment modalities with accessible design and person-centred principles, removed barriers to treatment for residents with cognitive impairment. Creating a climate where respect, tolerance and peer support were normalised was likely to have been particularly beneficial for these residents.

Home and the social worlds beyond: exploring influences in the lives of children of mothers with intellectual disability.

BACKGROUND: Mothers with intellectual disability are likely to raise their children in socially disadvantaged circumstances, and many face social isolation; however, the impact of a potentially restricted home context on children's social worlds has not been examined. This study was conducted to explore influences in the social worlds of children of mothers with intellectual disability from a child's perspective. METHODS: Seven children aged 7 to 11 years took part in at least two semi-structured interviews over a year. Narrative accounts of each child's social interactions were analysed to ascertain if a pattern was present across the group. RESULTS: Home was found to influence the children's social interactions elsewhere by providing (or not) predictable routines and rules, and support from a significant adult other than a mother. Home environments were found to influence other social worlds by establishing a foundation for children's expectations about social interactions. CONCLUSIONS: The social worlds of school-aged children of mothers with intellectual disability are shaped by influences in the home that cannot be attributed exclusively to having a parent with intellectual disability. Significant adults provide an important support role and can be fulfilled by social service workers when a family-centred approach is applied.

Motivational interviewing to enhance adolescent mental health treatment engagement: a randomized clinical trial.

BACKGROUND: The prevalence of anxiety and mood disorders in adolescents is a growing public health concern worldwide. Given the high rates of drop-out and limited resources available in psychiatric settings, the importance of engaging adolescents in evidence-based treatments cannot be understated. The aim of the study was to determine the efficacy of motivational interviewing (MI), as a brief pre-treatment intervention, to enhance treatment engagement in a standard therapy setting (group cognitive behavioral therapy; gCBT) for adolescents with anxiety and mood disorders. METHOD: Ninety-six adolescents (13-18 years) with a principal diagnosis of an anxiety or mood disorder participated in a trial conducted at two publicly funded outpatient services. Participants were randomly assigned to individual MI for treatment engagement prior to gCBT (MI + gCBT), or to an individually administered active control (befriending) prior to gCBT (befriending + gCBT). Eight pairs of gCBT were run in parallel. Outcome measures were the mean number of gCBT sessions attended, treatment initiation, and ratings of readiness for treatment. RESULTS: Participants randomized to MI as a pretreatment intervention attended significantly more group therapy sessions compared to those in the active control condition. The MI group also demonstrated greater treatment initiation, and ratings of treatment readiness were significantly higher for those randomized to MI. CONCLUSIONS: MI, used as a pre-treatment intervention, enhanced group treatment engagement in adolescents diagnosed with anxiety and mood disorders compared to the active control condition. MI is a promising intervention to facilitate engagement in adolescent mental health settings.

The WHO START study: suicidal behaviors across different areas of the world.

BACKGROUND: The World Health Organization (WHO) study entitled Suicide Trends in At-Risk Territories (START) is an international multisite initiative that aims to stimulate suicide research and prevention across different areas of the globe. A central component of the study is the development of registration systems for fatal and nonfatal suicidal behaviors. AIMS: This paper provides an overview of the data collected on suicidal behaviors from the participating locations in the START study. METHOD: Descriptive statistics on the data are presented in terms of age, sex, and method. RESULTS: A greater proportion of suicide deaths occurred among males. In all areas except the Philippines more females than males engaged in nonfatal suicidal behaviors. Compared to Australia, Italy, New Zealand, the Philippines, and Hong Kong SAR, in the Pacific Islands suicide most often occurs in younger age groups. Results indicate notable variations between countries in choice of method. A greater proportion of suicides occurred by hanging in Pacific Islands, while inhalation of carbon monoxide, use of firearms, ingestion of chemicals and poisons, and drug overdose were the most frequent methods of choice in other areas. CONCLUSION: The information drawn from this study demonstrates the enormous variation in suicidal behavior across the areas involved in the START Study. Further research is needed to assess the reliability of the established data-recording systems for suicidal behaviors. The baseline data established in START may allow the development of suicide prevention initiatives sensitive to variation in the profile of suicide across different locations.

New Zealand general practice nurses' roles in mental health care.

AIM: To examine the roles of nurses in general practice interdisciplinary teams caring for people with mild to moderate mental health conditions. BACKGROUND: Supporting mental health and well-being is an important aspect of primary care. Until now nurses in general practice settings have had variable roles in providing mental health care. The New Zealand Primary Mental Health Initiatives are 26 government-funded, time-limited projects using different service delivery models. METHODS: An analysis was undertaken of a qualitative data set of interviews, which included commentary about nurses mental health work collected from the different project stakeholders throughout a 29-month external evaluation. FINDINGS: Two main groups of roles for nurses within the general practice interdisciplinary team were identified: specialist mental health nurses working in newly created roles and practice nurses working in existing roles. Barriers exist to the development of the latter roles. CONCLUSIONS: Mental health care is a key role in general practice as this is where people frequently present. Internationally, nurses represent a large workforce with the potential to provide effective mental health care. This study found that attitudinal, structural and professional barriers are restricting New Zealand practice nurse role development in the care of those with mild to moderate mental health conditions. There is potential to develop their role within a structured pathway by workforce development and recognition of the value of interdisciplinary care. Given the shortage of mental health professionals this will be an important aspect of the improvement of primary mental health care.

Authorship issues at a New Zealand academic institution.

BACKGROUND: Authorship of peer-reviewed publications can create conflict among academics. OBJECTIVE: To document authorship conflicts of academics at a tertiary faculty. METHODS: An anonymous questionnaire eliciting authorship conflicts and knowledge of authorship criteria was administered online to 154 academic staff members at a New Zealand university. RESULTS: 43 academics responded, a response rate of 27.9%. About half of the academics reported authorship conflicts, mainly regarding ownership of data, gift authorship and academic competition. Of the 43 academics, 31 were aware of formal authorship criteria but only 21 could identify the appropriate source. 23 academics correctly identified all the appropriate criteria for authorship according to the International Committee of Medical Journal Editors guidelines. CONCLUSION: Authorship conflicts are prevalent in a New Zealand university that may be related to lack of knowledge of authorship criteria.

Gender and the association between mental disorders and disability.

BACKGROUND: Prior data, especially population data, on gender differences in the association between mental disorders and disability are very sparse and therefore earlier conclusions that women with mental disorders are more disabled than men may be premature. The aim of this study was to determine whether gender moderates the associations between 30 day mood, anxiety and substance use disorders and self-reported 30 day disability in five domains of functioning, in a general population sample. METHODS: Nationally representative face-to-face household survey of New Zealanders (n=7435) aged 16 years and older, with a response rate of 73.3%. Mental disorders were measured with the Composite International Diagnostic Interview (CIDI 3.0). Health-related disability was measured in all participants with a version of the World Health Organisation Disability Assessment Schedule (WHODAS-II). RESULTS: Men with either mood or anxiety disorders (aggregated into one category) reported significantly more Role, Social and Cognitive disability than did women with those disorders. There were no gender differences in the associations between mental disorders and the Mobility or Self-Care disability domains, nor were there gender differences in the associations between substance use disorders and any disability domain. LIMITATIONS: The temporal direction of the association between mental disorders and disability is unknown. Disability is measured by self-report only, which is affected by insight. CONCLUSIONS: Men with emotional disorders experience disproportionately greater role, social and cognitive disability than women with these disorders. More needs to be understood about how to engage and retain men in mental disorder treatment.

Are neighbourhood social fragmentation and suicide associated in New Zealand? A national multilevel cohort study.

BACKGROUND: Studies of the association between neighbourhood fragmentation and suicide have yielded varied results, and none has simultaneously adjusted for neighbourhood fragmentation, neighbourhood deprivation and individual-level factors. METHOD: A multilevel analysis of a 3-year cohort study was carried out using probabilistic linkage of census and mortality records, and two measures of neighbourhood fragmentation. A total of 2.8 million respondents to the 1996 New Zealand census were followed up for 3 years for mortality (1101 suicide deaths in the analysis), aged from 20 to 74 years at follow-up. RESULTS: No consistent association was observed between either measure of neighbourhood social fragmentation and suicide, after controlling for individual-level confounders and neighbourhood deprivation. There was some evidence of a U-shaped relationship between neighbourhood fragmentation and suicide, especially for the Congdon(NZ) index. There was no evidence of an association for a nine-variable index that captured family-type variables as well as the usual attachment-type variables. Neighbourhood deprivation remained as an important predictor of suicide rates. CONCLUSION: This paper highlights the importance of understanding both the measure and the wider national context when considering neighbourhood effects on suicide.

What is the association between wealth and mental health?

BACKGROUND: Socioeconomic inequalities in mental health have been shown in a number of populations. This study aims to investigate the association between asset wealth and psychological distress in New Zealand and whether it is independent of other socioeconomic measures and baseline health status. METHODS: Data for this study were from the first three waves of the Survey of Families, Income and Employment (SoFIE) conducted in New Zealand (2002-2004/05) (n = 15 340). The Kessler-10 was used as a measure of psychological distress. The association of quintiles of wealth with psychological distress was investigated using logistic regression, controlling for confounders, socioeconomic variables and prior health status. RESULTS: The odds ratio (OR) of reporting high psychological distress were greater in the lowest wealth quintile compared with the highest (OR 3.06, 95% CI 2.68 to 3.50). Adjusting for age and sex did not alter the relationship; however, adjusting for income and area deprivation attenuated the OR to 1.73 (95% CI 1.48 to 2.04). Further controlling for baseline health status reduced the OR to 1.45 (95% CI 1.23 to 1.71), although the confidence interval still excluded the null. CONCLUSIONS: Inequalities in wealth are strongly associated with psychological distress, over and above other confounding demographic variables and baseline health status. Much, but not all, of that association is confounded by adult socioeconomic position. This suggests that policy measures to improve asset wealth, through savings and home ownership, may have positive health implications and help to reduce health inequalities.

How much do mental disorders contribute to New Zealand's tobacco epidemic?

OBJECTIVE: To quantify the share of tobacco consumed by people with 12-month mental disorders in New Zealand. METHODS: Estimates of current smoking prevalence and the 12-month prevalence of three groups of mental disorders--anxiety, mood and substance use disorders--were derived from the New Zealand Mental Health Survey, a nationally representative survey of almost 13,000 adults (16+ years) fielded in 2003-4. Estimates of the smoking intensity ratio (comparing smokers with mental disorders to those without mental disorders) were derived from the 2006-7 New Zealand Health Survey. RESULTS: Approximately 33% of all cigarettes are consumed by people with 12-month mental disorders (males 27%, females 39%), using an estimated smoking intensity ratio of 1.21. Among this group, anxiety disorders account for almost one-half of consumption, mood disorders for over one-quarter and substance use disorders for about one-fifth. CONCLUSION: This study quantifies for the first time the contribution of mental disorders to tobacco consumption in New Zealand. In particular, it identifies anxiety disorders as an important risk factor for tobacco use. People with mental disorders are an important target group for tobacco control. Enhanced collaboration and sharing of expertise between smoking cessation service providers and community mental health services are urgently needed.

Unemployment and suicide. Evidence for a causal association?

OBJECTIVES: To determine the independent associations of labour force status and socioeconomic position with death by suicide. DESIGN: Cohort study assembled by anonymous and probabilistic record linkage of census and mortality records. PARTICIPANTS: 2.04 million respondents to the New Zealand 1991 census aged 18-64 years. MAIN OUTCOME MEASURE: Suicide in the three years after census night. RESULTS: The age adjusted odds ratios (95% confidence intervals) of death by suicide among 25 to 64 year olds who were unemployed compared with employed were 2.46 (1.10 to 5.49) for women and 2.63 (1.87 to 3.70) for men. Similarly increased odds ratios were observed for the non-active labour force compared with the employed. Strong age only adjusted associations of suicide death with the socioeconomic factors of education (men only), car access, and household income were observed. Compared with those who were married on census night, the non-married had odds ratios of suicide of 1.81 (1.22 to 2.69) for women and 2.08 (1.66 to 2.61) for men. In a multivariable model the association of socioeconomic factors with suicide reduced to the null. However, marital status and labour force status remained strong predictors of suicide death. Unemployment was also strongly associated with suicide death among 18-24 year old men. Sensitivity analyses suggested that confounding by mental illness might explain about half, but not all, of the association between unemployment and suicide. CONCLUSIONS: Being unemployed was associated with a twofold to threefold increased relative risk of death by suicide, compared with being employed. About half of this association might be attributable to confounding by mental illness.

Lesbians in New Zealand: their mental health and satisfaction with mental health services.

OBJECTIVES: To describe the mental health of lesbians in New Zealand, and to document their accounts of their experience of mental health services. METHOD: This is a descriptive cross-sectional study. A postal questionnaire, the Lesbian Mental Health Survey, was distributed via lesbian newsletters to 1222 women throughout New Zealand. Mental health measures included the General Health Questionnaire (GHQ-28), Interview Schedule for Social Interaction (ISSI), and respondents' histories of sexual abuse and psychiatric histories. Experiences of mental health services were sought. RESULTS: The estimated response rate was 50.8%. The respondent group were predominantly New Zealand European, highly educated, urban women between 25 and 50 years of age. Three-quarters had identified as lesbian for more than 5 years. Recent self-identification as lesbian was associated with higher GHQ score, as was being younger than 35, having a history of sexual abuse, and not living with a partner. Eighty percent of respondents had used mental health services sometime in their lives and nearly 30 percent of users had received 'lesbian-unfriendly' treatment at some point. One-sixth of respondents had experienced discrimination from service providers in the previous 5 years. CONCLUSION: While the mental health of lesbians is influenced by factors similar to those influencing women's mental health in general, because of social factors, such as stigma and isolation, lesbians may be more vulnerable to common mental illnesses. Health professionals, mental health professionals in particular, need to raise their awareness of the issues lesbians face in dealing with their sexuality, therapeutic relationships and mental health services. Increased training about sexuality for health professionals, as well as further research into areas such as stress and stigma, sexual abuse and attempted suicide among lesbian women, is recommended.

Survey of drug and alcohol use by lesbian women in New Zealand.

The objective of this study is to describe the prevalence of alcohol and drug use and attitudes towards alcohol use in a group of New Zealand lesbian women. The method used is 1,222 copies of a postal questionnaire (the Lesbian Mental Health Survey [LMHS]) were distributed via lesbian newsletters over a 4-month period. Responses were received from 561 women, an estimated response rate of 50.8%. The respondents were predominantly New Zealand European, highly educated, urban women in the 25- to 50-year age bracket; 30.1% smoked cigarettes, and 90.2% had drunk alcohol at some time in the past year, over half once per week or less. The median number of drinks per week was 1.5 drinks, equivalent to 22.5 ml alcohol per week. Despite a comparatively low reported use of alcohol, 48.1% of respondents expressed the view that alcohol is used excessively in the lesbian community; 75.8% had used cannabis at least once, 32.6% in the past year; 30.8% had used recreational drugs other than cannabis and alcohol at some time, 4.5% in the past year.

Have the most recent Pap smear guidelines affected GP practices?

OBJECTIVE: To assess the attitudes and knowledge of a sample of NSW general practitioners on issues concerning Papanicolaou (Pap) smear tests after the 1991 National Guidelines were established. DESIGN: During January-March 1994, a sample of Sydney general practitioners obtained from a list from the Department of General Practice, Royal North Shore Hospital, were asked to complete a questionnaire based on Pap smear screening. Issues explored included the perceived value of Pap smears, views on recommended screening intervals and the type of patients believed to be at highest risk of developing cervical cancer. SETTING: Northern Sydney metropolitan area. RESULTS: Seventy of 104 general practitioners from the Department of General Practice, Royal North Shore Hospital, returned completed questionnaires. Ninety-five per cent of respondents rated the Pap-smear as an extremely valuable screening test for cervical cancer prevention. The majority of GPs surveyed tended to overscreen younger patients and underscreen both older women and those at highest risk of developing cervical cancer. Seventy-seven per cent of doctors indicated the use of a patient reminder system, in most cases provided by a pathology laboratory but 43% were unaware of the NSW Cancer Council's reminder service. CONCLUSION: Our study suggests that Pap smears are viewed as an important means of cervical cancer prevention. Unfortunately the majority of respondents did not adhere to the recommended guidelines of 2-yearly screening. Possible changes to the current system include improved awareness of the 1991 National Guidelines, greater public awareness of the NSW Cancer Council reminder service, and the establishment of a state cytology registry.

The long-term effects of contact and noncontact forms of child sexual abuse in a sample of university men.

The long-term effects of child sexual abuse were examined in a sample of 284 university men. After controlling for the effects of dysfunctional parenting behaviors, a history of abuse involving physical contact was found to be associated with elevated scores on all subscales of the Brief Symptom Inventory. The comparison involving noncontact forms of abuse produced no significant abuse related effects. These findings are discussed in terms of their implications for research, intervention, and social policy.

Ten-year follow-up of 50 patients with bulimia nervosa.

Long-term outcome studies for people suffering from bulimia nervosa are few. Ten years after presentation, we followed up 50 patients (49 women, 1 man) who were originally involved in a double-blind, controlled trial of the antidepressant mianserin. Standardised interviews and questionnaires were used to assess eating attitudes and behaviour, psychiatric status and social functioning. A DSM-III-R diagnosis was given where appropriate. Sufficient information to make a diagnosis was obtained for 44 subjects (88%). Of patients traced, 52% had recovered fully and only 9% continued to suffer the full syndrome; 39% continued to experience some symptoms. Significant predictors of favourable outcome were younger age at onset, higher social class and a family history of alcohol abuse. Outcome for bulimia nervosa continues to improve over ten years with the majority of patients eventually making a full recovery or suffering only moderate abnormalities in eating attitudes. Although predictors of recovery were few, it would appear that intervention has a significant impact on ultimate outcome.