Evaluation of the introduction of a healthy food and drink policy in 13 community recreation centres on the healthiness and nutrient content of customer purchases and business outcomes: An observational study.

INTRODUCTION: This observational study assessed the introduction of a comprehensive healthy food and drink policy across 13 community organisation managed aquatic and recreation centres in Victoria, Australia, and the associated changes on business outcomes, and the healthiness of purchases. The policy, based on state government guidelines, mandated that food and drink availability be based on healthiness classification: 'red' (limit) <10%, and 'green' (best choice) >50%, and the remainder 'amber' (choose carefully). METHODS: Six years of monthly sales data were split into three periods, prior to (1/01/2013-31/12/2014), during (1/01/2015-31/12/2016) and post (1/1/2017-31/12/2018), policy implementation. Using point-of-sale data, food and drink nutrient content, and state guidelines, items were classified as 'red'/'amber'/'green'. Linear models with Newey West standard errors were fitted to compare the mean value of outcomes between post- to pre-policy implementation periods, for each outcome and centre; and were pooled using random effect meta-analyses. RESULTS: Comparing post- to pre-policy implementation periods, total food sales did not change (mean percentage difference: -3.2% (95% confidence interval (CI) -21% to 14%), though total drink sales declined -27% (CI -37% to -17%). The mean percentage of 'red' foods sold declined by -15% (CI -22% to -7.7%), 'amber' food sales increased 11% (CI 5.5% to 16%). 'Green' food sales did not change (3.3%, CI -1.4% to 8.0%). The mean percentage of 'red' drinks sold declined -37% (CI -43% to -31%), 'amber' and 'green' drink sales increased by 8.8% (CI 3.6% to 14%) and 28% (CI 23% to 33%), respectively. The energy density and sugar content (percentage of total weight/volume) of both food and drinks decreased. CONCLUSIONS: This study has shown that the implementation of a policy to improve the health of retail food environments can result in a shift towards healthier purchases. Sales revenue from foods did not decline, though revenue from drinks did, indicating future research needs to explore mitigation of this.

Impact of a heart failure nurse practitioner service on rehospitalizations, emergency presentations, and survival in patients hospitalized with acute heart failure.

AIMS: Heart failure nurse practitioners (HF NPs) are an emerging component of the heart failure (HF) specialist workforce but their impact in an inpatient setting is untested. The aim of this paper is to explore the impact of an inpatient HF NP service on 12-month all-cause rehospitalizations, emergency department (ED) presentations, and mortality in patients hospitalized with HF compared with usual hospital care. METHODS AND RESULTS: Retrospective, two-group comparative design involving patients (n = 408) admitted via ED with acute HF to a metropolitan quaternary hospital between January 2013 and August 2017. Doubly robust estimation with augmented inverse probability weighting (DR-AIPW) was used to account for the non-random allocation of patients to usual hospital care or the HF NP service in addition to usual in-hospital care. Among 408 patients (186 usual care and 222 HF NP service) admitted with acute HF, the mean age was 76.5 [standard deviation (SD) 12.0] years and 56.4% (n = 230) were male. After IPW adjustment, patients seen by the HF NP service had a lower risk of 12-month rehospitalization (61.3 vs. 78.3% usual care; difference -16.9%, 95% CI: -26.4%, -6.6%) and ED presentations (12.6 vs. 22.0%; difference -9.4%, 95% CI: -17.3%, -1.4%) with no difference in 6- or 12-month mortality. The HF NP service improved referrals to a home visiting programme that was available to HF patients (64.4 vs. 45.4%; difference 19%, 95% CI: 8.8%, 28.8%). CONCLUSION: Additional support by an inpatient HF NP service has the potential to significantly reduce rehospitalizations and ED presentations over 12 months. Further evidence from a multicentre randomized control trial is warranted.

Failure to attend radiation oncology appointments during COVID-19: Analysis of data from an Australian public hospital.

INTRODUCTION: COVID-19 has impacted lives worldwide. Public health guidance has advocated for minimisation of infection risk by encouraging social isolation and physical distancing. In response, many health services have changed delivery practices to increased use of telehealth. We undertook an audit of hospital attendance data collected from a radiation oncology service in a large public hospital in Victoria, Australia between January and September in 2019, and the same period in 2020. The aim was to discern the impact of COVID-19 on attendance at appointments and whether attendance rates differed by appointment type. METHODS: Attendance data and appointment type for the two targeted periods (a total of 62,528 appointments for 3383 patients) were extracted from the database maintained by the radiation oncology service. Logistic generalised estimating equation (GEE) models were run with the final model including the COVID-19 period (pre, during) and all patient and appointment characteristics. RESULTS: Results indicated a small decrease in attendance in 2020 (OR = 1.13, 95% CI 1.01-1.25, P = 0.026) with this predominantly reported for the non-treatment appointments, which consisted of follow-up appointments, nurse appointments, and treatment review appointments. CONCLUSION: Attendance for radiation oncology treatment was largely unaffected by COVID-19 although other services experienced slight reductions. Changes to work practices, specifically the increased use of telehealth, may have moderated the impact. Given the focus on one service in one location, it is not possible to generalise these results and future research should closely monitor both patient and staff satisfaction with services delivered via modified processes.

Implementation and sales impact of a capacity building intervention in Australian sporting facility food outlets: a longitudinal observational study.

Background: Few studies have explored behavioural and financial impacts of retail initiatives after 2 years to address the unhealthy food environments common in local government sporting settings. Aims: To evaluate the impact of a 2-year local government capacity building intervention in sporting facility food outlets on (1) the healthiness of refrigerated drink choices available and visible to customers, (2) healthiness of refrigerated drinks sold and (3) refrigerated drink revenue. Methods: 52 sporting facilities within 8 local governments from Victoria, Australia, participated in an intervention between March 2018 and February 2020 by limiting 'red' (least healthy) drinks to ≤20% of refrigerator display and increasing 'green' (healthiest) drinks to ≥50% of display. Mixed models assessed changes in mean percentage of 'red', 'amber' and 'green' drinks displayed over time, compared with baseline.Facilities provided electronic weekly itemised sales data (December 2015 to February 2020). Weekly volume of 'red' or 'green' drinks sold as a proportion of total drinks sold, and total refrigerated drinks revenue were compared preimplementation and postimplementation using mixed models (seasonal facilities), and mixed-effect interrupted time series models (non-seasonal facilities). Results: Display of 'red' drinks decreased by mean -17.1 percentage points (pp) (95% CI -23.9 to -10.3) and 'green' drinks increased 16.1 pp (95% CI 9.30, 22.9) between baseline and 18-month audits.At nine seasonal facilities, compared with the summer preimplementation, the mean volume of 'red' drinks sold decreased by -19.0 pp (95% CI -28.6, to -9.51) and refrigerated drink revenue decreased by-AU$81.8 (95% CI -AU$123 to -AU$40.8) per week. At 15 non-seasonal facilities, by February 2020, the volume of 'red' drinks sold decreased on average by -11.0 pp (95% CI -21.6 to -0.41) with no change in drink revenue. Conclusion: Reducing the display of unhealthy drinks can be an effective public health policy to improve the healthiness of customer purchases, provided there is consideration of potential impacts on revenue.

Multiple imputation of semi-continuous exposure variables that are categorized for analysis.

Semi-continuous variables are characterized by a point mass at one value and a continuous range of values for remaining observations. An example is alcohol consumption quantity, with a spike of zeros representing non-drinkers and positive values for drinkers. If multiple imputation is used to handle missing values for semi-continuous variables, it is unclear how this should be implemented within the standard approaches of fully conditional specification (FCS) and multivariate normal imputation (MVNI). This question is brought into focus by the use of categorized versions of semi-continuous exposure variables in analyses (eg, no drinking, drinking below binge level, binge drinking, heavy binge drinking), raising the question of how best to achieve congeniality between imputation and analysis models. We performed a simulation study comparing nine approaches for imputing semi-continuous exposures requiring categorization for analysis. Three methods imputed the categories directly: ordinal logistic regression, and imputation of binary indicator variables representing the categories using MVNI (with two variants). Six methods (predictive mean matching, zero-inflated binomial imputation, and two-part imputation methods with variants in FCS and MVNI) imputed the semi-continuous variable, with categories derived after imputation. The ordinal and zero-inflated binomial methods had good performance across most scenarios, while MVNI methods requiring rounding after imputation did not perform well. There were mixed results for predictive mean matching and the two-part methods, depending on whether the estimands were proportions or regression coefficients. The results highlight the need to consider the parameter of interest when selecting an imputation procedure.

Growth and adrenarche: findings from the CATS observational study.

BACKGROUND: There is increasing evidence that patterns of pubertal maturation are associated with different patterns of health risk. This study aimed to explore the associations between anthropometric measures and salivary androgen concentrations in pre-adolescent children. METHODS: We analysed a stratified random sample (N=1151) of pupils aged 8-9 years old from 43 primary schools in Melbourne, Australia from the Childhood to Adolescence Transition Study. Saliva samples were assayed for dehydroepiandrosterone (DHEA), DHEA-sulfate and testosterone. Anthropometric measures included height, weight, body mass index (BMI) and waist circumference. Associations between (1) anthropometric measures and each androgen, and (2) hormone status with obesity and parental report of pubertal development were investigated using linear regression modelling with general estimating equations. RESULTS: Greater height, weight, BMI and waist circumference were positively associated with higher androgen concentrations, after adjusting for sex and socioeconomic status. Being overweight or obese was associated with higher testosterone and DHEA concentrations compared with the normal BMI category. Those who were obese were more likely (OR=2.7, 95% CI 1.61 to 4.43, p<0.001) to be in the top tertile of age-adjusted androgen status in both sexes. CONCLUSION: This study provides clear evidence for an association between obesity and higher androgen levels in mid-childhood. The adrenal transition may be a critical time period for weight management intervention strategies in order to manage the risk for metabolic problems in later life for high-risk individuals.

Do risk factors for adolescent internalising difficulties differ depending on childhood internalising experiences?

PURPOSE: This study aimed to examine the continuity of internalising difficulties from childhood to adolescence, and determine if the influence of established risk factors on adolescent mental health differed depending on childhood internalising experiences. METHODS: Data were used from the Kindergarten cohort of the Longitudinal Study of Australian Children (LSAC, N = 4983, est. 2004). Internalising difficulties were measured via parent report on the Strengths and Difficulties Questionnaire (SDQ) at each wave from 4-5 to 14-15 years of age, and defined as symptoms in the borderline or abnormal range (≥ 4). Logistic generalised estimating equations were used to characterise associations between childhood internalising problems (4-9 years) and previously identified risk factors with adolescent internalising difficulties at three time points (10-11, 12-13 and 14-15 years). RESULTS: The risk of internalising problems was elevated at each adolescent age for those who previously experienced internalising symptoms in childhood compared to those who did not (10-11 years: OR 3.67, 95% CI 3.01-4.47, 12-13 years: OR 2.84, 95% CI 2.32-3.46, and 14-15 years: OR 2.33, 95% CI 1.90-2.87). Other known risk factors were found to be associated with adolescent internalising problems as expected. We found no statistical evidence that these associations differed for adolescents who previously experienced internalising symptoms in childhood. CONCLUSION: Findings of this study confirm the continuity of childhood mental health problems and the role of individual and family characteristics in the aetiology of adolescent internalising difficulties. The same risk factors appear relevant to target for adolescents who first experienced internalising symptoms in childhood.

Adolescent antecedents of maternal and paternal perinatal depression: a 36-year prospective cohort.

BACKGROUND: Rates of common mental health problems (depression/anxiety) rise sharply in adolescence and peak in young adulthood, often coinciding with the transition to parenthood. Little is known regarding the persistence of common mental health problems from adolescence to the perinatal period in both mothers and fathers. METHODS: A total of 393 mothers (686 pregnancies) and 257 fathers (357 pregnancies) from the intergenerational Australian Temperament Project Generation 3 Study completed self-report assessments of depression and anxiety in adolescence (ages 13-14, 15-16, 17-18 years) and young adulthood (ages 19-20, 23-24, 27-28 years). The Edinburgh Postnatal Depression Scale was used to assess depressive symptoms at 32 weeks pregnancy and 12 months postpartum in mothers, and at 12 months postpartum in fathers. RESULTS: Most pregnancies (81%) in which mothers reported perinatal depression were preceded by a history of mental health problems in adolescence or young adulthood. Similarly, most pregnancies (83%) in which fathers reported postnatal depression were preceded by a preconception history of mental health problems. After adjustment for potential confounders, the odds of self-reporting perinatal depression in both women and men were consistently higher in those with a history of persistent mental health problems across adolescence and young adulthood than those without (ORwomen 5.7, 95% CI 2.9-10.9; ORmen 5.5, 95% CI 1.03-29.70). CONCLUSIONS: Perinatal depression, for the majority of parents, is a continuation of mental health problems with onsets well before pregnancy. Strategies to promote good perinatal mental health should start before parenthood and include both men and women.

Combined Influence of Waist and Hip Circumference on Risk of Death in a Large Cohort of European and Australian Adults.

Background Waist circumference and hip circumference are both strongly associated with risk of death; however, their joint association has rarely been investigated. Methods and Results The MONICA Risk, Genetics, Archiving, and Monograph (MORGAM) Project was conducted in 30 cohorts from 11 countries; 90 487 men and women, aged 30 to 74 years, predominantly white, with no history of cardiovascular disease, were recruited in 1986 to 2010 and followed up for up to 24 years. Hazard ratios were estimated using sex-specific Cox models, stratified by cohort, with age as the time scale. Models included baseline categorical obesity measures, age, total and high-density lipoprotein cholesterol, systolic blood pressure, antihypertensive drugs, smoking, and diabetes mellitus. A total of 9105 all-cause deaths were recorded during a median follow-up of 10 years. Hazard ratios for all-cause death presented J- or U-shaped associations with most obesity measures. With waist and hip circumference included in the same model, for all hip sizes, having a smaller waist was strongly associated with lower risk of death, except for men with the smallest hips. In addition, among those with smaller waists, hip size was strongly negatively associated with risk of death, with ≈20% more people identified as being at increased risk compared with waist circumference alone. Conclusions A more complex relationship between hip circumference, waist circumference, and risk of death is revealed when both measures are considered simultaneously. This is particularly true for individuals with smaller waists, where having larger hips was protective. Considering both waist and hip circumference in the clinical setting could help to best identify those at increased risk of death.

Adolescent and young adult mental health problems and infant offspring behavior: Findings from a prospective intergenerational cohort study.

BACKGROUND: Parental depression and anxiety have been consistently linked to offspring behavior problems across childhood. However, many of the risks for these common mental health problems are established well before pregnancy. This study takes advantage of rare, prospective data to examine relations between parental mental health histories (from adolescence onwards) and next generation offspring behavior problems. METHODS: Data were drawn from a multi-generational cohort study that has followed Australians from infancy to adulthood since 1983, and 1171 of their offspring assessed prospectively from pregnancy. Generalized estimating equation models were used to estimate associations between parents' depression/anxiety symptoms in adolescence and young adulthood and offspring behavior problems at 1 year. RESULTS: In analyses of 648 mother-infant and 423 father-infant dyads, after adjustment for confounders and concurrent mental health problems, mean behavior problem scores in infants of mothers with a history of mental health problems in both adolescence and young adulthood were over half a standard deviation higher than those of mothers without problems during these periods, B = 2.19, 95% CI 1.21 - 3.17, ß = 0.52. No association was observed for fathers. LIMITATIONS: We only included infants born to participants aged 29-35 years and we assessed behavior problems via parent-report. CONCLUSIONS: A mother's history of persistent depression and anxiety from adolescence to young adulthood can predict higher levels of behavior problems in her infant. Findings support calls for greater policy and prevention focus on preconception and postnatal mental health, particularly a mother's early emotional health history, prior to parenthood.

Antidepressant treatment for primary care patients with depressive symptoms: Data from the diamond longitudinal cohort study.

BACKGROUND: In light of emerging evidence questioning the safety of antidepressants, it is timely to investigate the appropriateness of antidepressant prescribing. This study estimated the prevalence of possible over- and under-treatment with antidepressants among primary care attendees and investigated the factors associated with potentially inappropriate antidepressant use. METHODS: In all, 789 adult primary care patients with depressive symptoms were recruited from 30 general practices in Victoria, Australia, in 2005 and followed up every 3 months in 2006 and annually from 2007 to 2011. For this study, we first assessed appropriateness of antidepressant use in 2007 at the 2-year follow-up to enable history of depression to be taken into account, providing 574 (73%) patients with five yearly assessments, resulting in a total of 2870 assessments. We estimated the prevalence of use of antidepressants according to the adapted National Institute for Health and Care Excellence guidelines and used regression analysis to identify factors associated with possible over- and under-treatment. RESULTS: In 41% (243/586) of assessments where antidepressants were indicated according to adapted National Institute for Health and Care Excellence guidelines, patients reported not taking them. Conversely in a third (557/1711) of assessments where guideline criteria were unlikely to be met, participants reported antidepressant use. Being female and chronic physical illness were associated with antidepressant use where guideline criteria were not met, but no factors were associated with not taking antidepressants where guideline criteria were met. CONCLUSIONS: Much antidepressant treatment in general practice is for people with minimal or mild symptoms, while people with moderate or severe depressive symptoms may miss out. There is considerable scope for improving depression care through better allocation of antidepressant treatment.

The Victorian Intergenerational Health Cohort Study (VIHCS): Study design of a preconception cohort from parent adolescence to offspring childhood.

BACKGROUND: There is increasing evidence that parental determinants of offspring early life development begin well before pregnancy. OBJECTIVES: We established the Victorian Intergenerational Health Cohort Study (VIHCS) to examine the contributions of parental mental health, substance use, and socio-economic characteristics before pregnancy to child emotional, physical, social, and cognitive development. POPULATION: Men and women were recruited from the Victorian Adolescent Health Cohort (VAHCS), an existing cohort study beginning in 1992 that assessed a representative sample of 1943 secondary school students in Victoria, Australia, repeatedly from adolescence (wave 1, mean age 14 years) to adulthood (wave 10, mean age 35 years). METHODS: Victorian Adolescent Health Cohort participants with children born between 2006 and 2013 were recruited to VIHCS and invited to participate during trimester three, at 2 months postpartum, and 1 year postpartum. Parental mental health, substance use and socio-economic characteristics were assessed repeatedly throughout; infant characteristics were assessed postnatally and in infancy. Data will be supplemented by linkage to routine datasets. A further follow-up is underway as children reach 8 years of age. PRELIMINARY RESULTS: Of the 1307 infants born to VAHCS participants between 2006 and 2013, 1030 were recruited to VIHCS. At VIHCS study entry, 18% of recruited parents had preconception common mental disorder in adolescence and young adulthood, 18% smoked daily in adolescence and young adulthood, and 6% had not completed high school. Half of VIHCS infants were female (48%), 4% were from multiple births, and 7% were preterm (<37 weeks' gestation). CONCLUSIONS: Victorian Intergenerational Health Cohort Study is a prospective cohort of 1030 children with up to nine waves of preconception parental data and three waves of perinatal parental and infant data. These will allow examination of continuities of parental health and health risks from the decades before pregnancy to offspring childhood, and the contributions of exposures before pregnancy to offspring outcomes in childhood.

Maternal mental health and infant emotional reactivity: a 20-year two-cohort study of preconception and perinatal exposures.

BACKGROUND: Maternal mental health during pregnancy and postpartum predicts later emotional and behavioural problems in children. Even though most perinatal mental health problems begin before pregnancy, the consequences of preconception maternal mental health for children's early emotional development have not been prospectively studied. METHODS: We used data from two prospective Australian intergenerational cohorts, with 756 women assessed repeatedly for mental health problems before pregnancy between age 13 and 29 years, and during pregnancy and at 1 year postpartum for 1231 subsequent pregnancies. Offspring infant emotional reactivity, an early indicator of differential sensitivity denoting increased risk of emotional problems under adversity, was assessed at 1 year postpartum. RESULTS: Thirty-seven percent of infants born to mothers with persistent preconception mental health problems were categorised as high in emotional reactivity, compared to 23% born to mothers without preconception history (adjusted OR 2.1, 95% CI 1.4-3.1). Ante- and postnatal maternal depressive symptoms were similarly associated with infant emotional reactivity, but these perinatal associations reduced somewhat after adjustment for prior exposure. Causal mediation analysis further showed that 88% of the preconception risk was a direct effect, not mediated by perinatal exposure. CONCLUSIONS: Maternal preconception mental health problems predict infant emotional reactivity, independently of maternal perinatal mental health; while associations between perinatal depressive symptoms and infant reactivity are partially explained by prior exposure. Findings suggest that processes shaping early vulnerability for later mental disorders arise well before conception. There is an emerging case for expanding developmental theories and trialling preventive interventions in the years before pregnancy.

Alcohol and parenthood: An integrative analysis of the effects of transition to parenthood in three Australasian cohorts.

AIMS: To determine the extent to which the transition to parenthood protects against heavy and problematic alcohol consumption in young men and women. DESIGN: Integrated participant-level data analysis from three population-based prospective Australasian cohort studies. SETTING: General community; participants from the Australian Temperament Study, the Christchurch Health and Development Study, and the Victorian Adolescent Health Cohort Study. MEASUREMENTS: Recent binge drinking, alcohol abuse/dependence and number of standard drinks consumed per occasion. FINDINGS: 4015 participants (2151 females; 54%) were assessed on four occasions between ages 21 and 35. Compared to women with children aged <12 months, women who had not transitioned to parenthood were more likely to meet the criteria for alcohol abuse/dependence (fully adjusted risk ratio [RR] 3.5; 95% CI 1.5-7.9) and to report recent binge drinking (RR 3.0; 95% CI 2.1-4.3). The proportion of women meeting the criteria for alcohol abuse/dependence and/or binge drinking increased with the age of participants' youngest child, as did the mean number of standard drinks consumed on each occasion (1.8 if the youngest child was <1 year of age vs. 3.6 for 5+ years of age). Associations between parenthood and male drinking behaviour were considerably weaker. CONCLUSIONS: For most women in their twenties and thirties, parenting a child <1 year of age was associated with reduced alcohol consumption. However, this protective effect diminished after 12 months with drinking levels close to pre-parenthood levels after five years. There was little change in male drinking with the transition to parenthood.

Body Image Dissatisfaction and the Adrenarchal Transition.

BACKGROUND: Puberty marks a transition in risk for body image disturbance and disordered eating. Yet few studies have examined these symptoms across puberty and none have examined links with adrenarche, the earliest phase in the pubertal hormonal cascade. METHOD: Levels of adrenal androgens (dehydroepiandrosterone, dehydroepiandrosterone sulphate, and testosterone) were measured in a population-based study of 8- to 9-year-old children (516 males and 621 females). Body dissatisfaction was measured using the Kids' Eating Disorder Scale Silhouettes. Covariates included body mass index, age, and socioeconomic status. RESULTS: There were significant associations between adrenal androgen levels and greater body dissatisfaction in both males and females. Specifically, females with more advanced levels of dehydroepiandrosterone and testosterone relative to peers, and males with more advanced levels of testosterone relative to peers, reported greater body dissatisfaction. However, after adjusting for covariates, hormones levels were no longer associated with body dissatisfaction, and only higher body mass index had a clear association with body dissatisfaction. CONCLUSIONS: The adrenarchal transition brings a heightened risk for body dissatisfaction. Whether this arises from the neuroendocrine effects of adrenal androgens or as a reaction to the greater body mass that accompanies adrenarche requires further exploration.

Academic Performance in Primary School Children With Common Emotional and Behavioral Problems.

BACKGROUND: Many emotional and behavioral problems first emerge in primary school and are the forerunners of mental health problems occurring in adolescence. However, the extent that these problems may be associated with academic failure has been explored less. We aimed to quantify the association between emotional and behavioral problems with academic performance. METHODS: A stratified random sample of 8- to 9-year-olds (N = 1239) were recruited from schools in Australia. Data linkage was performed with a national assessment of academic performance to assess reading and numeracy. Parent report assessed emotional and behavioral problems with students dichotomized into "borderline/abnormal" and "normal" categories. RESULTS: One in 5 grade 3 students fell in the "borderline/abnormal" category. Boys with total difficulties (ß = -47.8, 95% CI: -62.8 to -32.8), conduct problems, and peer problems scored lower on reading. Numeracy scores were lower in boys with total difficulties (ß = -37.7, 95% CI: -53.9 to -21.5) and emotional symptoms. Children with hyperactivity/inattention scored lower in numeracy. Girls with peer problems scored lower in numeracy. CONCLUSIONS: Boys with emotional and behavioral problems in mid-primary school were 12 months behind their peers. Children with emotional and behavioral problems are at high risk for academic failure, and this risk is evident in mid-primary school.

Preconception personality disorder and antenatal maternal mental health: A population-based cohort study.

BACKGROUND: Prior anxiety and depression have been identified as risk factors for maternal perinatal mental health problems, but other preconception mental disorders have not been prospectively examined. This study investigated prospectively whether women with preconception personality disorder have increased rates of antenatal anxiety and/or depressive symptoms. METHODS: 244 women in a population cohort were assessed for personality disorder at age 24 using the Standardised Assessment of Personality. Five to twelve years later, women were screened with the Clinical Interview Schedule, Revised Anxiety Subscale and the Edinburgh Postnatal Depression Scale during the third trimester of 328 pregnancies. RESULTS: Preconception personality disorder was associated with a three-fold increase in the odds of antenatal anxiety symptoms, which remained with adjustment for preconception background factors and preconception common mental disorder (adjusted OR 2.84, 95% CI 1.31-6.15). Preconception personality disorder was associated with doubled odds of antenatal depressive symptoms, however this was attenuated with adjustment for preconception background factors and preconception common mental disorder (adjusted OR 1.98, 95% CI 0.81-4.81). LIMITATIONS: Our findings are restricted to pregnant women aged 29-35 years. Anxiety and depression may have been under-identified because they were assessed at a single antenatal time point. Residual confounding of the associations by preconception common mental disorder at other time points may have occurred. CONCLUSIONS: Women with personality disorder are at heightened risk of anxiety symptoms in pregnancy, over and above risks associated with prior common mental disorder. This raises a possibility that pregnancy brings particular emotional challenges for women with personality disorders.

The influence of personality disorder on the future mental health and social adjustment of young adults: a population-based, longitudinal cohort study.

BACKGROUND: Existing knowledge about the consequences of personality disorders is substantially derived from the study of clinical populations. To gain a fuller understanding of the disease burden associated with personality disorders, we report their long-term mental health and social consequences in a large population-based sample of young adults. METHODS: We used data from a population-based, ten-wave cohort study of a stratified random sample of non-treatment-seeking young adults recruited from Victoria, Australia, between Aug 20, 1992, and March 3, 2014. The population sample was originally recruited in adolescence: here we report the analysis of data collected from wave 8 (participants aged 24-25 years) and wave 10 (participants aged 34-35 years). Presence and severity of personality disorder were assessed at age 24 years with a semi-structured, informant-based interview (the Standardised Assessment of Personality). At age 35 years, participants were assessed on the occurrence of the following outcomes: major depressive disorder, anxiety disorder, smoking and alcohol consumption, illicit substance use, ever having separated from a long-term partner or been divorced, not currently in a relationship, not currently in paid employment, and in receipt of government welfare. We used multiple imputation to address potentially biased estimates resulting from the reduction of the analysis sample to participants who had completed both survey waves. The imputation dataset contained 1635 individuals. FINDINGS: For the 1520 participants in wave 8, 1145 (75%) informant interviews for personality disorder in these participants took place. At age 24 years, 305 (27%) of the observed sample had either personality difficulties or personality disorder. At age 24 years, in the imputed analysis sample, the severity of personality disorder was associated with the absence of a degree or vocational qualification (adjusted odds ratio [aOR] for the effect of complex and severe personality disorder vs no personality disorder 1·76, 95% CI 1·11-2·76), receipt of welfare (2·52, 1·33-4·78), the presence of common mental disorders (1·77, 1·08-2·90), and cigarette smoking (2·01, 1·29-3·14). At age 35 years, severity of personality disorder was independently associated with not being in a relationship (aOR for the effect of complex and severe personality disorder vs no personality disorder or personality difficulty 2·05, 95% CI 1·21-3·45), increased odds of an anxiety disorder (2·27, 1·2-4·28), and major depression (2·23, 1·24-4·01). INTERPRETATION: The presence of personality disorder predicts the occurrence of later anxiety and depression, as well as the absence of long-term relationships, effects that are not attributable to pre-existing mental health, substance use or social problems. Our study provides strong support for including personality disorder in global studies of the burden of mental disorders to improve the understanding of population mental health. FUNDING: Australia's National Health and Medical Research Council (NHMRC) and Victoria's Operational Infrastructure Support Program.

Drinking patterns of adolescents who develop alcohol use disorders: results from the Victorian Adolescent Health Cohort Study.

OBJECTIVE: We identify drinking styles that place teens at greatest risk of later alcohol use disorders (AUD). DESIGN: Population-based cohort study. SETTING: Victoria, Australia. PARTICIPANTS: A representative sample of 1943 adolescents living in Victoria in 1992. OUTCOME MEASURES: Teen drinking was assessed at 6 monthly intervals (5 waves) between mean ages 14.9 and 17.4 years and summarised across waves as none, one, or two or more waves of: (1) frequent drinking (3+ days in the past week), (2) loss of control over drinking (difficulty stopping, amnesia), (3) binge drinking (5+ standard drinks in a day) and (4) heavy binge drinking (20+ and 11+ standard drinks in a day for males and females, respectively). Young Adult Alcohol Use Disorder (AUD) was assessed at 3 yearly intervals (3 waves) across the 20s (mean ages 20.7 through 29.1 years). RESULTS: We show that patterns of teen drinking characterised by loss of control increase risk for AUD across young adulthood: loss of control over drinking (one wave OR 1.4, 95% CI 1.1 to 1.8; two or more waves OR 1.9, CI 1.4 to 2.7); binge drinking (one wave OR 1.7, CI 1.3 to 2.3; two or more waves OR 2.0, CI 1.5 to 2.6), and heavy binge drinking (one wave OR 2.0, CI 1.4 to 2.8; two or more waves OR 2.3, CI 1.6 to 3.4). This is not so for frequent drinking, which was unrelated to later AUD. Although drinking was more common in males, there was no evidence of sex differences in risk relationships. CONCLUSIONS: Our results extend previous work by showing that patterns of drinking that represent loss of control over alcohol consumption (however expressed) are important targets for intervention. In addition to current policies that may reduce overall consumption, emphasising prevention of more extreme teenage bouts of alcohol consumption appears warranted.