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Co-occurring depression and alcohol/other drug use problems: developing effective and accessible treatment options
No full textA large body of population- and treatment-based evidence exists to indicate depression and alcohol/other drug (AOD) use are highly prevalent on a global scale, and co-occur with considerable frequency. Despite this evidence, significant gaps exist in treatment research and clinical services, as people with co-occurring depression and AOD use problems have typically been excluded from randomised controlled treatment trials, and also face many individual- and service-level barriers to accessing treatment. Consequently, a well-defined and adequately tested treatment strategy does not currently exist for people experiencing the complexities of concurrent depression and AOD use problems. A small body of evidence exists to suggest that co-occurring mental and AOD use disorders (“comorbidity”) leads to poorer treatment outcomes, increased risk of relapse, higher levels of problematic symptomatology, and poorer quality of life. However, little consistent information is currently available to suggest what additional impact comorbid depression and AOD misuse produces relative to the experience of a “single” condition (such as depression or AOD misuse in isolation). Studies 1 and 2 attempted to address this important gap in knowledge by examining the presenting characteristics of 246 people with AOD use problems, according to the presence of comorbid depressive symptoms. One hundred and thirty seven participants were drawn from AOD treatment services, and a further 109 were referred via mental health services and also met criteria for a psychotic disorder. Results indicated that the presence of depression was associated with a significantly higher severity of psychiatric symptoms and personality disorder, significantly decreased social and occupational functioning and significantly reduced quality of life. Current depression was also associated with a significant increase in the experience of cravings and self-reported dependence on amphetamines. These difficulties were over and above the already high rates of disability and distress reported by each sample as a whole. Furthermore, treatment for mental health problems was rare among the AOD treatment participants, as was AOD treatment among the mental health sample. This is despite the presence of moderate to severe levels of depression and AOD use reported by each sample. In particular, Studies 1 and 2 highlight the vulnerabilities for people with comorbid mental health and AOD use problems who present to treatment in the mental health or AOD use settings, and in particular how depression significantly increases the disability and other challenges experienced by these people. These results provide a strong rationale for the development of an appropriate treatment protocol for depression and AOD use comorbidity. No clear treatment model or evidence-based approach exists to suggest how depression and AOD use comorbidity is best managed. When people with this comorbidity do manage to access clinical treatment services, they typically receive treatment targeted at one aspect of their presentation (e.g. depression-focussed or AOD-focussed treatment). Yet, it is not known whether a singular focus of treatment is effective in producing sustainable change in the outcomes of people with comorbid problems, nor whether failure to treat all components of the comorbid presentation confers a worse outcome. Studies 3 and 4 reported on two randomised controlled clinical trials of psychological treatment for AOD use problems among a sample of 246 people with AOD use problems, drawn from AOD treatment services (n=137) or mental health services (n=109). In doing so, these studies provide some of the first available data on these issues. Participants were categorised according to the presence of comorbid depression (as per Studies 1 and 2) and response to treatment was analysed over a six- to 12-month follow-up period. In spite of high levels of current depressive symptoms at entry to the studies, and equally hazardous use thresholds of a range of substance, people enrolled in Studies 3 and 4 reported some gains via their experiences with these single-focussed treatments. Attendance and retention rates were higher than reported in previous research, and the presence of depression did not adversely influence the motivation of project participants to change their current AOD use patterns. A treatment effect was generally not detected among the Study 3 and 4 participants, regardless of the presence of depression, with those receiving an assessment-only control treatment in both studies reporting similar patterns of change in outcome. Regardless of the magnitude of change reported by all study participants, people with depression reported significantly higher levels of depression, poly-drug use, amphetamine dependence, hazardous use of a range of substances, HIV risk taking and criminal activity and lower levels of functioning and self-concept across the follow-up assessment period. These residual symptoms were present at sufficiently high levels of severity to increase the risk of relapse to AOD use and continued morbidity. These results suggested the potential value of targeting depression in the context of comorbid AOD use problems. [More detail in thesis abstract]. In the first study of its kind, Study 5 developed and evaluated the efficacy of an integrated psychological treatment program for comorbid depression and AOD use problems. Sixty-seven participants received integrated treatment delivered by a therapist, computer-delivered integrated treatment or a brief intervention (control) treatment delivered by a therapist. Depression scores, daily use of alcohol and cannabis, hazardous use of a range of substance and poly-drug use fell significantly over a 12-month follow-up period across the integrated treatments and brief intervention (control) conditions. The small sample size of Study 5 meant that very few treatment effects were detected at a statistically significant level, however important reductions in key outcomes for depression, AOD use, quality of life and general functioning were noted for people in the integrated treatment relative to controls over a 12-month period. The magnitude of change in Study 5 across these domains was comparable with the only other study of psychological treatment of depression and alcohol-use disorders described above. [More detail in thesis abstract]. The results further suggest that a brief intervention targeting both depression and AOD drug use problems is associated with reductions in key outcomes in the short-term, with integrated, lengthier psychological treatment potentially associated with longer-term changes on the same outcomes. No previous study has directly compared the outcomes for people completing psychological treatment delivered via a computer program with those completing treatment with a ‘live’ clinician over an extended follow-up period of 12-months. Given the barriers people with comorbid depression and AOD use problems face in accessing available treatment services, the consideration of alternative modes of delivery of evidence-based treatment to this group is timely. Study 6 expanded on the Study 5 results by presenting further analysis of the performance of the computer-delivered version of the integrated treatment relative to the clinician-delivered equivalent, matched for content. Given the small sample size of participants, Study 6 devised a four-point criterion which, if satisfied, would suggest that the computer-delivered and clinician-delivered integrated treatments were approximately equal. Based on these criteria, the results indicated that the outcome profiles for people engaged in the computer-delivered treatment were equivalent to those reported by people involved in clinician-delivered therapy over a 12¬month follow-up period. Additionally, computer-delivered integrated treatment was associated with similar rates of improvement as the therapist-equivalent on depression scores, risky drinking patterns, hazardous use of substances, poly-drug use, levels of daily cannabis use, suicidality, treatment retention and therapeutic alliance. This result requires further replication to test these assumptions, however it is promising that a treatment requiring an average of 12-minutes face-to-face of “generic” clinician time per weekproduces a similar pattern of improvement to a treatment requiring an average of 60 minutes of face-to-face specialist psychologist input over the same time period. Studies 1-6 resulted in the development of a menu of treatment options for people with depression and AOD use comorbidity, with each treatment approach providing evidence for at least some benefit among the study participants. While encouraging, these results again raise the issue of how treatment may be incorporated into existing services (mental health, AOD use, primary care, etc.), which typically remain segregated, with little opportunity for collaboration and cross-fertilisation of skills and expertise between service settings. Chapter 7 discusses a new model of treatment for comorbid depression and AOD use problems that incorporates the results of Studies 1-6, and involves a stepped care approach to developing a treatment plan tailored to the specific needs and levels of distress experienced by people with depression and AOD use comorbidity. The stepped care model of treatment could be incorporated into existing service settings and structures, with the potential for computer-based therapy to provide access to specialised treatment for depression and AOD use comorbidity that might otherwise be unavailable. As a result, stepped care treatment could foster earlier engagement with treatment services and encourage motivation and optimism among people with comorbid depression and AOD use problems. These are important issues for service development and delivery of appropriate treatments to this underserved population
Illuminating the scrolls: illustrating Australian nature in response to the biblical texts of Lamentations, Ruth, Ecclesiastes and Esther
No full textHow may ancient Hebrew texts be presented to a contemporary audience,
remaining faithful to the original and at the same time relevant yet timeless?
I am painting four series of watercolours, each focussing on a particular
Australian habitat. These artworks form decorative borders to the four biblical
texts of Lamentations, Ruth, Ecclesiastes and Esther, four of the Jewish Scrolls, and
act as visual metaphors of underlying themes and indicators of structure and
literary devices.
My research is into the texts themselves, reading and responding to them; into
natural subjects that express my response; and into the art-making process from
which the final artworks are created.
The end product of my research is an exhibition of these watercolour works and
an A4-sized book combining the complete printed text of the Scrolls in the
English Standard Version (ESV) as I have formatted it, with my illustrations as
border designs. My aim is that through the manuscripts’ overall design, I honour
the authors’ literary artistry, including symmetry, acrostic and reversal. Through
my choice of subjects for each illustration, I aim to suggest themes in the
adjoining text
Improving Student Retention and Success Within the Context of Complex Lives and Diverse Circumstances
No full textThrough its more flexible approach, online learning is providing a significant opportunity for further widening of participation in Australian higher education. Increasingly, students from backgrounds and circumstances historically under-represented in higher education are able to enter online postgraduate programs based on prior learning and work experiences, not necessarily previous university studies. The online postgraduate student cohort now contains more students who may have little or no experience of university expectations, including those who are first in their families to study at university, let alone at postgraduate level. This more diverse cohort of students needs to be well supported within teaching and learning practices and broader support mechanisms to increase student retention and completion rates. While online postgraduate completion rates within Australia are higher than online undergraduate completion rates, they nevertheless still lag behind the completion rates for on-campus postgraduate studies. This chapter explores findings from recent research into the online student experience, applying them particularly to postgraduate online education. Based on these findings, this chapter proposes that the delivery of online postgraduate study cannot be separated from the social and cultural context within which students are living and managing busy and complex lives. It offers recommendations for institutions on strategies to ensure that the lived reality of the student cohort is properly understood and taken into account in the design and delivery of online postgraduate study, thereby enhancing student retention and success
Global, regional, and national burden of Alzheimer's disease and other dementias, 1990-2016: a systematic analysis for the global burden of disease study 2016
No full textBackground: The number of individuals living with dementia is increasing, negatively affecting families, communities, and health-care systems around the world. A successful response to these challenges requires an accurate understanding of the dementia disease burden. We aimed to present the first detailed analysis of the global prevalence, mortality, and overall burden of dementia as captured by the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016, and highlight the most important messages for clinicians and neurologists. Methods: GBD 2016 obtained data on dementia from vital registration systems, published scientific literature and surveys, and data from health-service encounters on deaths, excess mortality, prevalence, and incidence from 195 countries and territories from 1990 to 2016, through systematic review and additional data-seeking efforts. To correct for differences in cause of death coding across time and locations, we modelled mortality due to dementia using prevalence data and estimates of excess mortality derived from countries that were most likely to code deaths to dementia relative to prevalence. Data were analysed by standardised methods to estimate deaths, prevalence, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs; computed as the sum of YLLs and YLDs), and the fractions of these metrics that were attributable to four risk factors that met GBD criteria for assessment (high body-mass index [BMI], high fasting plasma glucose, smoking, and a diet high in sugar-sweetened beverages). Findings: In 2016, the global number of individuals who lived with dementia was 43·8 million (95% uncertainty interval [UI] 37·8–51·0), increased from 20.2 million (17·4–23·5) in 1990. This increase of 117% (95% UI 114–121) contrasted with a minor increase in age-standardised prevalence of 1·7% (1·0–2·4), from 701 cases (95% UI 602–815) per 100 000 population in 1990 to 712 cases (614–828) per 100 000 population in 2016. More women than men had dementia in 2016 (27·0 million, 95% UI 23·3–31·4, vs 16.8 million, 14.4–19.6), and dementia was the fifth leading cause of death globally, accounting for 2·4 million (95% UI 2·1–2·8) deaths. Overall, 28·8 million (95% UI 24·5–34·0) DALYs were attributed to dementia; 6·4 million (95% UI 3·4–10·5) of these could be attributed to the modifiable GBD risk factors of high BMI, high fasting plasma glucose, smoking, and a high intake of sugar-sweetened beverages. Interpretation: The global number of people living with dementia more than doubled from 1990 to 2016, mainly due to increases in population ageing and growth. Although differences in coding for causes of death and the heterogeneity in case-ascertainment methods constitute major challenges to the estimation of the burden of dementia, future analyses should improve on the methods for the correction of these biases. Until breakthroughs are made in prevention or curative treatment, dementia will constitute an increasing challenge to health-care systems worldwide
Economic analysis of maternal health behaviours
No full textBackground and aims: Identifying, measuring and valuing the economic impact of antenatal guidelines and their implementation has been identified as a key strategy for informing investment in health promotion and improving efficiency in healthcare. The research question of this thesis was: what is the economic impact of improving the modifiable maternal health risk behaviours, alcohol and dietary intake, on health care resource use during the antenatal period? To address this question, the thesis aims were: 1. Identify and synthesize evidence regarding the costs and impacts of antenatal nutrition and alcohol interventions and their associated implementation strategies. 2. Assess the cost, cost-consequence and cost-effectiveness of a multi-strategy practice change intervention in increasing antenatal care addressing the consumption of alcohol by pregnant women. 3. Assess the economic impact of maternal diet quality and weight status of pregnant women and their impact on resource use in the delivery period. Methods: To address the first objective, a systematic review of economic evaluations of antenatal nutrition and alcohol interventions and their associated implementation strategies was conducted. For the second objective, an economic evaluation was undertaken alongside a randomised controlled trial (RCT) of a multi-strategy practice change intervention designed to support antenatal care staff in providing a model of care consistent with clinical guideline recommendations for alcohol consumption in pregnancy. For the third objective, an observational study was conducted to gather self-report data and inpatient medical records for N=670 pregnant women in Newcastle, Australia, to examine the economic impact of maternal diet quality on resource use in the antenatal period. Results: The systematic review identified a paucity of economic evidence regarding antenatal nutrition and alcohol interventions and no economic evaluations of associated implementation strategies. The trial-based economic analysis determined the practice change intervention to be both more effective and more costly than usual care. The average incremental cost per eligible clinician was 640-591 (range: 940) per woman who received all guideline elements. The observational study found higher body mass index (BMI) was associated with increased odds of caesarean delivery; women in obese class II (35.0–39.9 kg/m2) had significantly higher odds of caesarean delivery compared to women of normal weight (OR = 2.13, 95% CI 1.03 to 4.39; p = 0.04). The average cost per patient increased with BMI, being 9309 and $9914 for women in the normal, obese class II and obese class III weight categories. Higher diet quality was associated with a small statistically significant reduction in maternal length of stay. Conclusion: The research included in this thesis addressed a small and significant gap in the evidence base necessary to inform greater understanding of the cost and cost-effectiveness of current nutrition and alcohol recommendations in pregnancy. The thesis provides new evidence regarding the economic impact of maternal health behaviours and antenatal health promotion interventions. Specifically, the economic evidence available to inform investment in future maternal alcohol and nutrition interventions was mapped, synthesized, and the gaps in the literature identified. The trial-based economic evaluation was the first to identify, measure, and value investment in antenatal guideline implementation efforts. Whilst healthcare funders’ willingness to pay for the incremental effect of this intervention is unknown, the strategic investment in systems change is expected to improve the efficiency of the practice change intervention over time. The observational study identified that poor dietary patterns are common during pregnancy; thus, interventions to improve maternal BMI and diet quality could deliver substantive economic benefits to the healthcare system and community. The evidence presented in this thesis addresses the need for decision makers to be cognisant of the resource use implications of policy implementation
Child-level evaluation of a web-based intervention to improve dietary guideline implementation in childcare centers: A cluster-randomized controlled trial
No full textAlthough it is recommended that childcare centers provide foods consistent with dietary guidelines, the impact of implementing sector-specific guidelines on child outcomes is largely unknown. Objectives: This study aims to examine the impact of a web-based program and support to implement dietary guidelines in childcare centers on children's 1) diet; 2) BMI z scores; and 3) child health-related quality of life (HRQoL). Methods: This study was a cluster-randomized controlled trial utilizing a Type-3 Hybrid implementation-effectiveness design conducted between October 2016 and March 2018. This study reports on child outcomes. Fifty-four childcare centers in New South Wales, Australia were randomly assigned to the intervention (a web-based menu-planning tool and support) or control group (usual care). The intervention was designed to address barriers and enablers to dietary guideline implementation according to the Theoretical Domains Framework. A quota of 35 consenting childcare centers undertook child-level evaluation of dietary intake where 522 parents consented to completing =1 component of data collection for their child. Child consumption of core and discretionary (unhealthy) foods while in care was assessed via dietary observations by blinded research assistants, childcare diet quality was assessed via educator-completed questionnaires, BMI z scores were assessed via measured weight and height, and child HRQoL was assessed via parent report at baseline and 12-mo follow-up. Results: There was a significant increase in mean child consumption of fruit (0.39 servings; 95% CI: 0.12, 0.65 servings) and dairy foods (0.38 servings; 95% CI: 0.19, 0.57 servings) and a significant reduction in consumption of discretionary foods (-0.40 servings; 95% CI: -0.64, -0.16 servings) in care in the intervention group, relative to control at 12-mo follow-up. No significant differences were observed in diet quality, BMI z scores, or HRQoL. Conclusions: A web-based intervention to support planning of childcare menus consistent with dietary guidelines can improve child consumption of healthier foods in daycare. This trial was registered at www.anzctr.org.au as ACTRN12616000974404
Sleep-disordered breathing in haemodialysis
No full textBackground: Patients with End Stage Kidney Disease (ESKD) often suffer from high symptom burdens that affect physical and mental health and lead to reduced quality of life. Sleep disturbance is one of the most common symptoms reported by patients with ESKD. Literature suggests up to 80% of patients with ESKD self-report sleep difficulty, and consequences of untreated sleep disturbance, particularly sleep apnoea which is strongly associated with cardiovascular diseases, depression and increased mortality. Despite this, sleep apnoea and sleep disturbance are under-recognised and under treated in the routine practice of dialysis units. Consequently, patients with ESKD continue to report/experience a high burden of sleep disturbance. There is a need for research that identifies effective ways to assess sleep apnoea and explore methods to improve sleep quality in the dialysis population. Methods: The broad aims of this thesis were to identify a practical and effective way to assess sleep apnoea and manage sleep disturbance in the dialysis population. This has been addressed in three separate but inter-related studies in this thesis. Results: The finding of the cross-sectional study (study 1) indicated that the prevalence of sleep apnoea in patients receiving haemodialysis was high; up to 70% of local patients receiving haemodialysis had an abnormal oxygen desaturation index. A large neck circumference and anaemia were the independent risk factors, and nocturnal oximetry was an adequate tool to screen for sleep apnoea in the dialysis population. The second study which employed mixed methods revealed that ESKD patients with co-existing sleep apnoea had poor sleep quality despite a weak correlation between the severity of sleep apnoea and objective sleep quality and daytime symptoms. Many patients reported broken sleep and feeling unrefreshed upon wakening and described that these symptoms had a significant impact on their physical and mental health, ability to self-manage their illness and overall health-related quality of life. This study highlighted the need to assess sleep disturbance routinely to improve health –related quality of life of patients with ESKD. The final study (a randomised cross-over trial) showed that there was no statistically difference in AHI between OL-HDF and HD. However, when sleep apnoea was stratified into obstructive and central apnoeas, patients had less obstructive episodes after treated by OL-HDF; a sensitivity analysis was performed excluding outliers, and the treatment effect for obstructive episodes was found to be statistically significant. Patient-reported outcomes and inflammatory biomarkers were not statistically different between OL-HDF and HD in this study. Conclusion: Sleep apnoea is prevalent and the impact of sleep disturbance in quality of life of ESKD patients is profound. This thesis provides new evidence into the characteristics of sleep apnoea, the effective way of screening sleep apnoea in ESKD patients. It also demonstrated the potential role of OL-HDF in sleep apnoea symptoms. Given that sleep apnoea is common in patients receiving dialysis, the findings of this thesis will have clinical implications on the management of sleep apnoea in patients with kidney disease
Writing the self: sense and sensibility
No full textThis paper makes an argument for the inclusion of emerging and local forms of DIY autobiographical writing in a life writing course, by placing some of the newer and less conventional examples of the genre in a meaningful relationship to older styles. It examines how life writing pedagogy can be expanded to engage with contemporary cultures of writing and publishing the self, such as zines and blogs, and the effect this has on opening up styles and notions of authorship. The work of a younger generation of Australian writers is suggested as a way of connecting with students’ lives at the level of the quotidian and everyday