Katherine L. Mills

Lifetime prevalence of gender-based violence in women and the relationship with mental disorders and psychosocial function.

CONTEXT Intimate partner physical violence, rape, sexual assault, and stalking are pervasive and co-occurring forms of gender-based violence (GBV). An association between these forms of abuse and lifetime mental disorder and psychosocial disability among women needs to be examined. OBJECTIVES To assess the association of GBV and mental disorder, its severity and comorbidity, and psychosocial functioning among women. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study based on the Australian National Mental Health and Well-being Survey in 2007, of 4451 women (65% response rate) aged 16 to 85 years. MAIN OUTCOME MEASURES The Composite International Diagnostic Interview version 3.0 of the World Health Organizations World Mental Health Survey Initiative was used to assess lifetime prevalence of any mental disorder, anxiety, mood disorder, substance use disorder, and posttraumatic stress disorder (PTSD). Also included were indices of lifetime trauma exposure, including GBV, sociodemographic characteristics, economic status, family history of mental disorder, social supports, general mental and physical functioning, quality of life, and overall disability. RESULTS A total of 1218 women (27.4%) reported experiencing at least 1 type of GBV. For women exposed to 3 or 4 types of GBV (n = 139), the rates of mental disorders were 77.3% (odds ratio [OR], 10.06; 95% confidence interval [CI], 5.85-17.30) for anxiety disorders, 52.5% (OR, 3.59; 95% CI, 2.31-5.60) for mood disorder, 47.1% (OR, 5.61; 95% CI, 3.46-9.10) for substance use disorder, 56.2% (OR, 15.90; 95% CI, 8.32-30.20) for PTSD, 89.4% (OR, 11.00; 95% CI, 5.46-22.17) for any mental disorder, and 34.7% (OR, 14.80; 95% CI, 6.89-31.60) for suicide attempts. Gender-based violence was associated with more severe current mental disorder (OR, 4.60; 95% CI, 2.93-7.22), higher rates of 3 or more lifetime disorders (OR, 7.79; 95% CI, 6.10-9.95), physical disability (OR, 4.00; 95% CI, 1.82-8.82), mental disability (OR, 7.14; 95% CI, 2.87-17.75), impaired quality of life (OR, 2.96; 95% CI, 1.60-5.47), an increase in disability days (OR, 3.14; 95% CI, 2.43-4.05), and overall disability (OR, 2.73; 95% CI, 1.99-3.75). CONCLUSION Among a nationally representative sample of Australian women, GBV was significantly associated with mental health disorder, dysfunction, and disability.

Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: a randomized controlled trial.

CONTEXT There is concern that exposure therapy, an evidence-based cognitive-behavioral treatment for posttraumatic stress disorder (PTSD), may be inappropriate because of risk of relapse for patients with co-occurring substance dependence. OBJECTIVE To determine whether an integrated treatment for PTSD and substance dependence, Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE), can achieve greater reductions in PTSD and substance dependence symptom severity compared with usual treatment for substance dependence. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial enrolling 103 participants who met DSM-IV-TR criteria for both PTSD and substance dependence. Participants were recruited from 2007-2009 in Sydney, Australia; outcomes were assessed at 9 months postbaseline, with interim measures collected at 6 weeks and 3 months postbaseline. INTERVENTIONS Participants were randomized to receive COPE plus usual treatment (n = 55) or usual treatment alone (control) (n = 48). COPE consists of 13 individual 90-minute sessions (ie, 19.5 hours) with a clinical psychologist. MAIN OUTCOME MEASURES Change in PTSD symptom severity as measured by the Clinician-Administered PTSD Scale (CAPS; scale range, 0-240) and change in severity of substance dependence as measured by the number of dependence criteria met according to the Composite International Diagnostic Interview version 3.0 (CIDI; range, 0-7), from baseline to 9-month follow-up. A change of 15 points on the CAPS scale and 1 dependence criterion on the CIDI were considered clinically significant. RESULTS From baseline to 9-month follow-up, significant reductions in PTSD symptom severity were found for both the treatment group (mean difference, -38.24 [95% CI, -47.93 to -28.54]) and the control group (mean difference, -22.14 [95% CI, -30.33 to -13.95]); however, the treatment group demonstrated a significantly greater reduction in PTSD symptom severity (mean difference, -16.09 [95% CI, -29.00 to -3.19]). No significant between-group difference was found in relation to improvement in severity of substance dependence (0.43 vs 0.52; incidence rate ratio, 0.85 [95% CI, 0.60 to 1.21), nor were there any significant between-group differences in relation to changes in substance use, depression, or anxiety. CONCLUSION Among patients with PTSD and substance dependence, the combined use of COPE plus usual treatment, compared with usual treatment alone, resulted in improvement in PTSD symptom severity without an increase in severity of substance dependence. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN12908171.

Changes in Comorbid Conditions After Prolonged Exposure for PTSD: a Literature Review

Prolonged exposure (PE) is an effective psychological treatment for patients who suffer from PTSD. The majority of PTSD patients have comorbid psychiatric disorders, and some clinicians are hesitant to use PE with comorbid patients because they believe that comorbid conditions may worsen during PE. In this article, we reviewed the evidence for this question: what are the effects of PE on comorbid symptoms and associated symptomatic features? We reviewed findings from 18 randomized controlled trials of PE that assessed the most common comorbid conditions (major depression, anxiety disorders, substance use disorders, personality disorders, and psychotic disorders) and additional symptomatic features (suicidality, dissociation, negative cognitions, negative emotions, and general health and work/social functioning). Although systematic research is not available for all comorbid populations, the existing research indicates that comorbid disorders and additional symptomatic features either decline along with the PTSD symptoms or do not change as a result of PE. Therefore, among the populations that have been studied to date, there is no empirical basis for excluding PTSD patients from PE due to fear of increases in comorbid conditions or additional symptomatic features. Limitations of the existing research and recommendations for future research are also discussed.

Comorbidity in Australia: Findings of the 2007 National Survey of Mental Health and Wellbeing

Objective: The aim of the present study was to report the prevalence and patterns of 12 month comorbidity in the 2007 National Survey of Mental Health and Wellbeing (2007 NSMHWB). In this paper the comorbidity between common mental disorders (affective, substance use and anxiety) and between physical and mental disorders is examined. Method: The 2007 NSMHWB was a nationally representative household survey of 8841 Australian adults (16–85 years) that assessed participants for symptoms of the most prevalent ICD-10 mental disorders. Results: The common mental disorder classes (affective, anxiety and substance use disorders) often occur together and 25.4% of persons with an anxiety, affective or substance use disorder had at least one other class of mental disorder. A small proportion (3.5%, 95% confidence interval (CI) = 2.3–4.7%) had all three classes of disorder. Mental disorder and physical disorder comorbidity was also common, with 28% (95%CI = 25.1–30.9%) of those with a chronic physical disorder also having a mental disorder. Comorbidity was associated with greater severity and greater health service use. Conclusions: Comorbidity is widespread and remains a significant challenge for the delivery of effective health-care services and treatment.

Prevalence and correlates of DSM-IV alcohol abuse and dependence in Australia: findings of the 2007 National Survey of Mental Health and Wellbeing.

AIMS To report nationally representative data on the prevalence and correlates (including psychiatric comorbidity and treatment) of DSM-IV alcohol abuse and dependence in Australian adults. DESIGN The 2007 National Survey of Mental Health and Wellbeing (NSMHWB). SETTING Australian nationally representative household survey. PARTICIPANTS 8841 Australian adults (16-85 years). MEASUREMENTS Interview schedule that assessed symptoms of the most prevalent DSM-IV mental disorders in the life-time and the past 12 months. FINDINGS Prevalence of life-time and 12-month disorders was 18.3% and 2.9% for alcohol abuse and 3.9% and 1.4% for alcohol dependence. Current alcohol abuse and dependence was significantly more common in males and younger adults. There were significant associations between current alcohol use and other drug use disorders (OR 18.2) and between anxiety disorders and alcohol use disorders (OR 2.6). Only 22.4% of those with alcohol use disorders were treated for their alcohol disorder. CONCLUSIONS Alcohol use disorders are highly prevalent, especially among young adult males. Comorbidity between anxiety and other drug use disorders is common and remains a significant challenge for the delivery of effective health-care services and treatment. The low rate of effective interventions for alcohol problems is a significant public health concern.

Examining potential contraindications for prolonged exposure therapy for PTSD

Although prolonged exposure (PE) has received the most empirical support of any treatment for post-traumatic stress disorder (PTSD), clinicians are often hesitant to use PE due to beliefs that it is contraindicated for many patients with PTSD. This is especially true for PTSD patients with comorbid problems. Because PTSD has high rates of comorbidity, it is important to consider whether PE is indeed contraindicated for patients with various comorbid problems. Therefore, in this study, we examine the evidence for or against the use of PE with patients with problems that often co-occur with PTSD, including dissociation, borderline personality disorder, psychosis, suicidal behavior and non-suicidal self-injury, substance use disorders, and major depression. It is concluded that PE can be safely and effectively used with patients with these comorbidities, and is often associated with a decrease in PTSD as well as the comorbid problem. In cases with severe comorbidity, however, it is recommended to treat PTSD with PE while providing integrated or concurrent treatment to monitor and address the comorbid problems.

Remission from post-traumatic stress disorder in the general population

BACKGROUND Few studies have focused on post-traumatic stress disorder (PTSD) remission in the population, none have modelled remission beyond age 54 years and none have explored in detail the correlates of remission from PTSD. This study examined trauma experience, symptom severity, co-morbidity, service use and time to PTSD remission in a large population sample. METHOD Data came from respondents (n=8841) of the 2007 Australian National Survey of Mental Health and Wellbeing (NSMHWB). A modified version of the World Health Organizations World Mental Health Composite International Diagnostic Interview (WMH-CIDI) was used to determine the presence and age of onset of DSM-IV PTSD and other mental and substance use disorders, type, age, and number of lifetime traumas, severity of re-experiencing, avoidance and hypervigilance symptoms and presence and timing of service use. RESULTS Projected lifetime remission rate was 92% and median time to remission was 14 years. Those who experienced childhood trauma, interpersonal violence, severe symptoms or a secondary anxiety or affective disorder were less likely to remit from PTSD and reported longer median times to remission compared to those with other trauma experiences, less severe symptoms or no co-morbidity. CONCLUSIONS Although most people in the population with PTSD eventually remit, a significant minority report symptoms decades after onset. Those who experience childhood trauma or interpersonal violence should be a high priority for intervention.

Rates and correlates of mortality amongst heroin users: findings from the Australian Treatment Outcome Study (ATOS), 2001-2009.

The study aimed to determine mortality rates, standardised mortality ratios (SMRs), and correlates of mortality amongst the Australian Treatment Outcome Study (ATOS) cohort of 615 heroin users over the period 2001-2009. The cohort was followed for a total of 4820.1 person years. A total of 31 deaths (5% of the cohort) occurred across follow-up. The mean age at death was 34.5 years, and 58% were male. The most common cause of death was overdose (68%). The crude mortality rate was 6.43 per 1000 person years, with no gender difference, and the SMR was 4.56 (males=2.95, females=18.57). The only significant bivariate (hazard ratio=3.69) and multivariate (adjusted hazard ratio=3.03) correlate of mortality was a history of opioid overdose prior to baseline. Mortality rates were lower than those seen outside Australasia. Screening for overdose by those treating heroin users would be appropriate, and may contribute to reductions in overall mortality.

Patterns of major depression and drug-related problems amongst heroin users across 36 months.

The study aimed to determine patterns of major depression (MD) across 36 months, and the relationship to outcomes for the treatment of heroin dependence. As part of a longitudinal cohort study, 429 heroin users were interviewed at 36 month follow-up. MD declined from 23.8% at baseline to 8.2% at 36 months. Females were more likely to have MD at both baseline (31.1 vs. 19.8) and 36 months (11.9 vs. 6.1%). Those with MD at baseline were significantly more likely to be diagnosed with MD at a follow-up interview (40.2 vs. 15.9%) and at 36 months (14.7 vs. 6.1%). Antidepressant use did not decrease across 36 months amongst either gender. Baseline MD was not related to treatment exposure across 36 months. There were large and significant declines in drug use and drug-related problems, and improvements in physical health with no group differences evident at 36 months. Despite improvements in global mental health, at both baseline and 36 months those with MD at baseline had significantly lower SF12 mental health scores. It was concluded that, with the exception of depression, the prognosis of depressed heroin users is not worse than that of non-depressed users.

Post‐traumatic stress disorder, depression and suicidality in inpatients with substance use disorders

INTRODUCTION AND AIMS The international literature suggests that traumatic events are common for patients with substance use disorders (SUDs), and are often associated with the development of post-traumatic stress disorder (PTSD) and other psychiatric comorbidities. However, limited research has been conducted among Australian SUD patients. The aim of the present study was to examine the prevalence of these disorders in a group of Australian patients admitted for detoxification. DESIGN AND METHODS Data were collected from 253 inpatients using a modified version of the Composite International Diagnostic Interview, the 10-item Trauma Screening Questionnaire, the Zung Self-rating Depression Scale and questions from the PsyCheck. RESULTS Approximately 20% of inpatients experienced moderate to severe depressive symptoms, and 37% had a lifetime history of self-harm or attempted suicide. Approximately 80% of patients had experienced at least one traumatic event, most experiencing multiple traumas. The mean age of first trauma was 14years. Almost 45% of patients screened positive for current PTSD symptoms. Women were nine times more likely to have been raped and five times more likely to have been sexually molested than men. PTSD symptoms were associated with greater trauma exposure, younger age of first trauma, specific trauma types, moderate to severe depressive symptoms and a history of self-harm or attempted suicide. Despite their difficulties, patients with PTSD symptoms had high rates of retention in treatment. DISCUSSION AND CONCLUSIONS Patients entering treatment for SUDs should be assessed for PTSD, depression and suicidality. These conditions impact significantly on treatment outcomes, and require the development of appropriate treatment strategies.