Achieving gender equity in academic psychiatry - barriers to involvement and solutions for success.

OBJECTIVE: Women face considerable barriers in pursuing careers in academic psychiatry. METHODS: A group of Australian and New Zealand academic women psychiatrists convened in September 2022 to identify and propose solutions to increase opportunities for women in academic psychiatry. RESULTS: Limiting factors were identified in pathways to academia including financial support, engagement and coordination between academia and clinical services, and flexible working conditions. Gender biases and the risk of burnout were additional and fundamental barriers. Potential solutions include offering advanced training certificates to enable trainees to commence a PhD and Fellowship contemporaneously; improved financial support; expanding opportunities for research involvement; establishing mentoring opportunities and communities of practice; and strategies to enhance safety at work and redress gender bias and imbalance in academia. CONCLUSIONS: Support for women in research careers will decrease gender disparity in academic psychiatry and may decrease problematic gender bias in research. Fellows and trainees, the RANZCP, universities, research institutes, governments, industry and health services should collaborate to develop and implement policies supporting changes in working conditions and training. Facilitating the entry and retention of women to careers in academic psychiatry requires mentoring and development of a community of practice to provide and enable support, role modelling, and inspiration.

A phase 3 randomised double-blind placebo-controlled trial of mirtazapine as a pharmacotherapy for methamphetamine use disorder: a study protocol for the Tina Trial.

BACKGROUND: There are no approved pharmacotherapies for methamphetamine use disorder. Two preliminary phase 2 randomised controlled trials have found mirtazapine, a tetracyclic antidepressant, to be effective in reducing methamphetamine use. The proposed Tina Trial is the first phase 3 placebo-controlled randomised trial to examine the effectiveness and safety of mirtazapine as an outpatient pharmacotherapy for methamphetamine use disorder. METHODS: This is a multi-site phase 3 randomised, double-blind, placebo-controlled parallel trial. Participants are randomly allocated (1:1) to receive either mirtazapine (30 mg/day for 12 weeks) or matched placebo, delivered as a take-home medication. The target population is 340 people aged 18-65 years who have moderate to severe methamphetamine use disorder. The trial is being conducted through outpatient alcohol and other drug treatment clinics in Australia. The primary outcome is measured as self-reported days of methamphetamine use in the past 4 weeks at week 12. Secondary outcomes are methamphetamine-negative oral fluid samples, depressive symptoms, sleep quality, HIV risk behaviour and quality of life. Other outcomes include safety (adverse events), tolerability, and health service use. Medication adherence is being monitored using MEMS® Smart Caps fitted to medication bottles. DISCUSSION: This trial will provide information on the safety and effectiveness of mirtazapine as a pharmacotherapy for methamphetamine use disorder when delivered as an outpatient medication in routine clinical practice. If found to be safe and effective, this trial will support an application for methamphetamine use disorder to be included as a therapeutic indication for the prescription of mirtazapine. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12622000235707. Registered on February 9, 2022.

Rotation from methadone to buprenorphine using a micro-dosing regime in patients with opioid use disorder and serious mental illness: A case series.

INTRODUCTION: Inducting buprenorphine from methadone has traditionally involved initial opioid withdrawal, with risk of mental state deterioration in patients with serious mental illness (SMI). Micro-dosing of buprenorphine, with small incremental doses, is a novel off-label approach to transitioning from methadone and does not require a period of methadone abstinence. Given the limited literature about buprenorphine microdosing, we aimed to evaluate the feasibility and safety of inducting buprenorphine in a series of patients on methadone with SMI. METHODS: For this retrospective case series, we reviewed the records of 16 patients with SMI at a Melbourne addiction treatment centre, from January 2021 to July 2022, who transitioned via micro-dosing, from high-dose methadone (>30 mg) to buprenorphine and depot-buprenorphine. Psychiatric diagnoses, mental state, other substance withdrawal, transfer success, transition time, opioid withdrawal symptoms and overall patient experience were collected via objective and subjective reporting. RESULTS: Methadone to buprenorphine transfer was completed by 88% of patients. Mental health measures remained stable with the exception of mildly increased anxiety. Median transfer time was 6.5 days for inpatients, 9 days for mixed setting and 10 days for outpatients. Most patients (93%) rated their experience 'manageable' reporting mild withdrawal symptoms. One patient met study criteria for precipitated withdrawal. DISCUSSION AND CONCLUSIONS: This retrospective case series provides evidence that the use of a micro-dosing buprenorphine induction for methadone to buprenorphine transitions, including to depot-buprenorphine, has negligible risk, is tolerated by patients with SMI and is unlikely to precipitate an exacerbation of their mental illness.

The reflections of health service providers on implementing contingency management for methamphetamine use disorder in Australia.

INTRODUCTION: Contingency management (CM) is the most effective treatment for reducing methamphetamine use. We sought to understand why CM has not been taken up to manage methamphetamine use disorder in Australia. METHODS: Six focus groups (4-8 participants per group) were conducted with health workers from agencies in Australia that provided drug-related health care to people who use methamphetamine. These agencies had no previous experience delivering CM for substance use. The potential acceptability and feasibility of implementing CM in their services were discussed. RESULTS: Participants felt that it would be beneficial to have an evidence-based treatment for methamphetamine use disorder. This sentiment was offset by concerns that CM conflicted with a client-centred harm-reduction approach and that it dictated the goal of treatment as abstinence. It was also perceived as potentially coercive and seen to reify the power imbalance in the therapeutic relationship and therefore potentially reinforce stigma. There was also concern about the public's perception and the political acceptability of CM, who would fund CM, and the inequity of providing incentives only to clients with a methamphetamine use disorder. Some concerns could be ameliorated if the goals and structure of CM could be tailored to a client's needs. DISCUSSION AND CONCLUSIONS: Many healthcare workers were keen to offer CM as an effective treatment option for people with methamphetamine use disorder, but CM would need to be sufficiently flexible to allow it to be tailored to client needs and implemented in a way that did not adversely impact the therapeutic relationship.

Trait anger as a predictor of dangerous driving behaviour amongst people who use methamphetamine.

INTRODUCTION: Despite increased prevalence of methamphetamine in road trauma, it remains unclear how its use translates to an increased risk of traffic-related harm. Exploration of psychosocial factors may thus help identify relevant predictors of dangerous driving behaviour among people who regularly consume methamphetamine. METHODS: Licenced individuals who report predominant and sustained methamphetamine use (at least 1-time/month for 6 months at heaviest use) were recruited from the Australian community and via targeted campaign (Eastern Health). Psychosocial, substance use and driving behaviour data (Dula Dangerous Driving Index, DDDI) were collected via a secure anonymous online forced-entry survey platform (Qualtrics). RESULTS: Seventy-seven individuals (65.5 % male) aged between 20-50 years [mean = 29.7, ± Standard Deviation (SD) 6.1] were included. Most (90 %) respondents met criteria for problematic methamphetamine use [Severity of Dependency Scale (SDS) score ≥ 5], and 75 % were high-risk alcohol consumers [Alcohol Use Disorders Identification Test (AUDIT-C) score ≥ 4 for men and ≥ 3 for women]. On average, age of first methamphetamine use occurred at 23.3 years (±5.2). A best-possible subset's regression selection method with dangerous driving behaviour as the dependent variable determined the model with three predictors (alcohol use, substance dependence severity and trait anger) as most parsimonious. After controlling for substance use, trait anger strongly and positively predicted dangerous driving behaviour as measured by the DDDI ([F(3,74) = 26.06, p < .001, adjusted R2 = 0.50, Cohens f2 = 0.42). DISCUSSION AND CONCLUSIONS: Trait anger is a strong predictor of risky driving among road users who use methamphetamine. Interactions between stable negative-emotional and situational traffic and driving-related factors may increase risk of harm through greater engagement in risk-taking behaviour.

Co-design of digital public health substance use resources: A collaboration between young people and experts.

ISSUE ADDRESSED: Substance use and mental illness remain critical issues for young Australians, however, engagement with evidence-based health resources is challenging among this age group. This study aimed to develop engaging, useful digital health resources, underpinned by neuroscience principles, to build awareness of the harms of electronic cigarettes (e-cigarettes) and concurrent alcohol and antidepressant use. METHODS: A mixed-methods approach was adopted to co-design two evidence-based videos resources. The resources were co-designed with the Matilda Centre's Youth Advisory Board Centre's Youth Advisory Board through a series focus groups and individual feedback reviews. Young people residing in New South Wales were then invited to complete a survey to evaluate the usefulness, relatability and impact on perceived harms associated with each substance pre- and post-viewing resources. RESULTS: A total of 100 participants completed the survey (mean age = 21.5 years, SD = 2.77, 42% Female, 2% Non-binary). The animated videos were well received, with the large majority (91% and 87% respectively) of participants rating them 'excellent' or 'very good'. After viewing the videos, there was a significant increase in the perception of harm associated with e-cigarette use, monthly (t(99) = 2.76, p = .003), weekly (t(99) = 4.82, p < .001) and daily (t(99) = 4.92, p < .001), and consuming alcohol whilst taking antidepressants both weekly (t(100) = 2.93, p = .004) and daily (t(100) = 3.13, p = .002). CONCLUSIONS: This study describes a successful co-design process demonstrating how meaningful involvement of young people, alongside traditional research methods, can produce substance use prevention resources that are useful, engaging and increase knowledge of harms among young people. SO WHAT?: To achieve meaningful public health impact researchers, experts and digital creators can work together to co-create substance use educational materials that are engaging, well-liked, while imparting important health knowledge.

Drug dependence and prescribing ketamine for treatment-resistant depression in Australia and New Zealand.

Ketamine is a restricted and regulated medication in Australia and New Zealand, which has implications when considering treatment for patients with treatment-resistant depression and a history of illicit drug use, abuse or dependence. Regulations governing prescription of ketamine for treatment-resistant depression vary between jurisdictions in Australia and New Zealand, though most restrict use in those with drug dependence. There is substantial variation in definitions of drug dependence used in each jurisdiction, and between the legal and clinical definitions, with the latter specified in the current International Classification of Diseases, Eleventh Revision and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. This paper reviews the literature assessing the risk of ketamine misuse and dependence in patients with a history of illicit drug use, abuse or dependence and presents recommendations for psychiatrists who prescribe ketamine in such patients with treatment-resistant depression.

The dynamics of more-than-human care in depot buprenorphine treatment: A new materialist analysis of Australian patients' experiences.

BACKGROUND: Long-acting injectable depot buprenorphine has become an important treatment option for the management of opioid dependence. However, little is known about patients' experiences of depot buprenorphine and its embodied effects. This qualitative study aims to explore patients' experiences of depot buprenorphine treatment, including how it feels within the body, experiences of dosing cycles across time, and how this form of treatment relies on wider ecologies of care beyond the clinical encounter. METHODS: Participants were recruited from sites in Sydney, regional New South Wales, and Melbourne, Victoria, Australia. Thirty participants (16 men, 14 women) participated in semi-structured interviews. Participants had histories of both heroin and prescription opioid consumption, and opioid agonist therapy including daily dosing of buprenorphine and methadone. RESULTS: Our analysis illuminates: (1) how patients' expectations and concerns about treatment are linked to past embodied experiences of withdrawal and uncertainty about the effectiveness of depot buprenorphine; (2) the diverse meanings patients attribute to the depot buprenorphine substrate 'under the skin'; and, (3) how depot buprenorphine is embedded within wider ecologies of care, such as counselling and social supports. CONCLUSION: Our analysis destabilises commonplace assumptions about a linear, causal relationship between the pharmacological action of depot buprenorphine and experiences of treatment. Instead, it highlights patients' variable experiences of depot buprenorphine, tracing the everyday practices, embodied feelings, expectations and wider networks of care that shape patient experiences. We conclude with some reflections on the implications of our analysis for alcohol and other drug treatment, specifically how they might inform the design of client education materials and care.

World addiction medicine reports: formation of the International Society of Addiction Medicine Global Expert Network (ISAM-GEN) and its global surveys.

Addiction medicine is a dynamic field that encompasses clinical practice and research in the context of societal, economic, and cultural factors at the local, national, regional, and global levels. This field has evolved profoundly during the past decades in terms of scopes and activities with the contribution of addiction medicine scientists and professionals globally. The dynamic nature of drug addiction at the global level has resulted in a crucial need for developing an international collaborative network of addiction societies, treatment programs and experts to monitor emerging national, regional, and global concerns. This protocol paper presents methodological details of running longitudinal surveys at national, regional, and global levels through the Global Expert Network of the International Society of Addiction Medicine (ISAM-GEN). The initial formation of the network with a recruitment phase and a round of snowball sampling provided 354 experts from 78 countries across the globe. In addition, 43 national/regional addiction societies/associations are also included in the database. The surveys will be developed by global experts in addiction medicine on treatment services, service coverage, co-occurring disorders, treatment standards and barriers, emerging addictions and/or dynamic changes in treatment needs worldwide. Survey participants in categories of (1) addiction societies/associations, (2) addiction treatment programs, (3) addiction experts/clinicians and (4) related stakeholders will respond to these global longitudinal surveys. The results will be analyzed and cross-examined with available data and peer-reviewed for publication.

A phase III multisite randomised controlled trial to compare the efficacy of cannabidiol to placebo in the treatment of cannabis use disorder: the CBD-CUD study protocol.

BACKGROUND: Cannabis use disorder (CUD) is increasingly common and contributes to a range of health and social problems. Cannabidiol (CBD) is a non-intoxicating cannabinoid recognised for its anticonvulsant, anxiolytic and antipsychotic effects with no habit-forming qualities. Results from a Phase IIa randomised clinical trial suggest that treatment with CBD for four weeks reduced non-prescribed cannabis use in people with CUD. This study examines the efficacy, safety and quality of life of longer-term CBD treatment for patients with moderate-to-severe CUD. METHODS/DESIGN: A phase III multi-site, randomised, double-blinded, placebo controlled parallel design of a 12-week course of CBD to placebo, with follow-up at 24 weeks after enrolment. Two hundred and fifty adults with moderate-to-severe CUD (target 20% Aboriginal), with no significant medical, psychiatric or other substance use disorders from seven drug and alcohol clinics across NSW and VIC, Australia will be enrolled. Participants will be administered a daily dose of either 4 mL (100 mg/mL) of CBD or a placebo dispensed every 3-weeks. All participants will receive four-sessions of Cognitive Behavioural Therapy (CBT) based counselling. Primary endpoints are self-reported cannabis use days and analysis of cannabis metabolites in urine. Secondary endpoints include severity of CUD, withdrawal severity, cravings, quantity of use, motivation to stop and abstinence, medication safety, quality of life, physical/mental health, cognitive functioning, and patient treatment satisfaction. Qualitative research interviews will be conducted with Aboriginal participants to explore their perspectives on treatment. DISCUSSION: Current psychosocial and behavioural treatments for CUD indicate that over 80% of patients relapse within 1-6 months of treatment. Pharmacological treatments are highly effective with other substance use disorders but there are no approved pharmacological treatments for CUD. CBD is a promising candidate for CUD treatment due to its potential efficacy for this indication and excellent safety profile. The anxiolytic, antipsychotic and neuroprotective effects of CBD may have added benefits by reducing many of the mental health and cognitive impairments reported in people with regular cannabis use. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry: ACTRN12623000526673 (Registered 19 May 2023).

Economic evaluations of alcohol pharmacotherapy: Systematic review of economic evaluations of pharmacotherapy for the treatment of alcohol use disorder.

OBJECTIVE: Alcohol use disorders confer a significant burden of disease and economic cost worldwide. However, the utilisation of pharmacotherapies to manage alcohol use disorder is poor. We aimed to conduct a systematic review of economic evaluation studies of alcohol use disorder pharmacotherapies. METHODS: A search was conducted in Embase, Medline, CINAHL, PsychINFO and EconLit (August 2019, updated September 2022). Full economic evaluations using pharmacotherapy to treat alcohol use disorders were included. Included studies were stratified by medication and summarised descriptively. The Consensus on Health Economic Criteria list was used to assess the methodological quality. RESULTS: A total of 1139 studies were retrieved, of which 15 met the inclusion criteria. All studies were conducted in high-income countries. Four studies analysed nalmefene, four studies assessed acamprosate, three for naltrexone and four for stand-alone and/or combinations of naltrexone and acamprosate. There were 21 interventions synthesised from 15 studies as some studies evaluated multiple interventions and comparators. More than half of the included studies (73%) reported pharmacotherapy as dominant (less costly and more effective than comparators). From healthcare payer perspectives, five studies found that pharmacotherapy added to psychosocial support was dominant or cost-effective, accruing additional benefits at a higher cost but under accepted willingness to pay thresholds. Three analyses from a societal perspective found pharmacotherapy added to psychosocial support was a dominant or cost-effective strategy. Quality scores ranged from 63% to 95%. CONCLUSION: Pharmacotherapy added to psychosocial support was cost-effective from both healthcare and societal perspectives, emphasising an increased role for pharmacotherapy to reduce the burden of alcohol use disorders.

Examining the association between psychological distress and alcohol use in Australian adolescents over a period of declining consumption.

INTRODUCTION: Youth drinking rates have declined over the past 15 years while self-reported psychological distress has increased, despite a well-recognised positive relationship between the two. The current study aimed to identify changes in the relationship between psychological distress and alcohol use in adolescents from 2007 to 2019. METHODS: This study used survey responses from 6543 Australians aged 14-19 years who completed the National Drug Strategy Household Survey in 2007, 2010, 2013, 2016 or 2019. Logistic and multivariable linear regressions with interactions (psychological distress × survey wave) predicted any alcohol consumption, short-term risk and average quantity of standard drinks consumed per day. RESULTS: Psychological distress was a positive predictor of alcohol use and this association remained stable across survey waves as alcohol consumption decreased. DISCUSSION AND CONCLUSIONS: The relationship between distress and alcohol consumption remained relatively steady, even as youth drinking declined and distress increased. The proportion of drinkers experiencing distress did not increase as consumption rates dropped, suggesting that the decline in youth drinking is occurring independently of the increase in self-reported and diagnosed mental health issues.

Evaluation of the Everyday Memory Questionnaire-Revised in a menopausal population: understanding the brain fog during menopause.

OBJECTIVE: Brain fog (ie, memory complaints and concentration difficulties) is frequently reported during the menopausal transition. There is lack of standardized scales available to measure brain fog across the menopausal transition. This study aimed to evaluate the factor structure of the Everyday Memory Questionnaire-Revised (EMQ-R) and to determine the most commonly reported everyday cognitive symptoms in a menopausal population. METHODS: Four hundred seventeen eligible women aged from 40 to 60 years (107 premenopausal, 149 perimenopausal, and 161 early postmenopausal) were recruited from the general community and were included in the analyses. Confirmatory factor analysis was conducted to test the model fit of the bifactor structure (ie, 4-item attentional subscale ranged 0-16, 7-item retrieval subscale ranged 0-28) of the 13-item EMQ-R (ranged 0-52) in a menopausal populations. Typical items in the retrieval subscale include "difficulty finding words," the attentional subscale include "difficulty following the thread of a story," and analysis of variance and multivariate analysis of covariance were used to investigate the group differences of individual items and two subscales. RESULTS: Confirmatory factor analysis indicated the bifactor structure of the EMQ-R has a good fit in all three groups. A significant difference was identified in the mean retrieval scores (pre: 11.8, peri: 13.6, early post: 11.7) but not in the mean attentional scores (pre: 4.53, peri: 5.01, early post: 4.65). CONCLUSIONS: The EMQ-R retrieval subscale may serve as a potential instrument to assess memory retrieval symptoms that contribute to "brain fog" in menopause. Increased memory retrieval complaints reported by the perimenopausal group suggests a transition-related memory retrieval dysfunction during menopausal transition.

Hypothalamic-pituitary-adrenocortical response in alcohol-dependent patients during baclofen treatment and association with clinical outcome: Preliminary results.

Baclofen has been shown to reduce alcohol consumption in some individuals with alcohol use disorder. This preliminary study aimed to evaluate i) the effect of baclofen versus placebo on hypothalamic-pituitary-adrenocortical activity (HPA axis), as measured by cortisol, and ii) the relationship between clinical outcomes such as alcohol consumption on a randomized controlled trial of baclofen (BAC) versus placebo (PL) (Kirsten C. Morley et al., 2018; K. C. Morley, Leung, Baillie, & Haber, 2013). We hypothesized that baclofen will reduce HPA-axis activity following a mild stressor in patients with alcohol dependence. Plasma cortisol levels were taken from N = 25 alcohol-dependent patients at two time points, approximately 60 (pre-MRI scan: PreCortisol) and 180 min (post MRI scan: PostCortisol) following administration of PL, BAC 10 mg, or BAC 25 mg. Participants were followed up for the remaining 10 weeks as part of the trial for clinical outcome (percentage days abstinent). Mixed models revealed a significant main effect of medication on cortisol levels (F = 3.88, p = 0.037), no significant effect of time (F = 0.04, p = 0.84), and a significant time × medication interaction (F = 3.54, p = 0.049). Linear regression (F = 6.98, p = 0.01, R2 = 0.66) revealed that abstinence at follow-up, weighted by gender, was predicted by blunted cortisol response (ß = -0.48 p = 0.023), in addition to medication (ß = 0.73 p = 0.003). In conclusion, our preliminary data suggest that baclofen moderates HPA-axis activity, as measured by blood cortisol, and that these alterations may play a role in long-term treatment response.

Perspectives and sentiments on contingency management from people who use methamphetamine.

INTRODUCTION: Contingency management (CM) is currently the most efficacious treatment for methamphetamine use, yet it is rarely available in routine care. We examined the viewpoints of people who use methamphetamine on CM as a potential treatment for methamphetamine use disorder. METHODS: Semi-structured qualitative interviews with 30 Australians aged 18 years or older who had used methamphetamine at least weekly in the past 6 months. RESULTS: Participants reported overall positive attitudes towards CM as a potential treatment option for methamphetamine use disorder. However, there was need for greater flexibility in meeting participant treatment goals (e.g., reduced use or complete abstinence), with particular concern about the viability of initiating abstinence, both in terms of the sufficiency of the initial financial incentive and managing withdrawal symptoms. There was strong interest in the use of digital technologies to provide remote CM, particularly around the convenience and flexibility this offered. Despite this, participants remained keen to access adjunctive treatment and support services but stressed that engagement with these additional services should not be mandatory. Marketing of CM will need to address preconceptions about drug-testing used in abstinence-based CM being punitive (especially urine testing) and its connotations with criminal justice interventions. DISCUSSION AND CONCLUSION: Positive attitudes towards CM bode well for potential uptake should CM be made available in routine clinical practice. However, there is a need to adapt CM to ensure it is feasible and attractive to people who are seeking treatment for methamphetamine use disorder.