Pathways to risk:What can we do?

Ian Webster

PATHWAYS TO RISK

Sven Silburn 2003

PATHWAYS TO RISK

Sven Silburn 2003

Society & social

Educational development

Early development

MHS

Emotional development

Opportunities for prevention - Anticipatory care

Impairmentof body &mind

Misuse

Loss offunctionperformance

Socialdisadvantage

DiseaseInjury

Use

Addiction

Mental health & suicide risk

Alcohol and suicide (Sher, L 2006)

• Suicides 33-69% alcohol positive• Alcohol intoxication – suicide risk 90 x

increased• Alcohol – more lethal means eg firearms• Alcohol reduces serotonin in brain • Low serotonin – increased aggression and

impulsiveness• Association – countries with high alcohol –

high suicide rates (11/13 studies)

Dependence Criteria* Depression

Tolerance (to a drug) physiological Not specific to depression

Withdrawal symptoms (from a drug) physiological

Not specific to depression

Excess use; longer periods of drug Not specific to depression

Persistent desire, failure to cut down or control

Loss of control not specific to depression

Time spent drug seeking Not specific to depression

Important activities are given up or reduced

Consistent with depressive state

Continued use despite adverse effects

Consistent with depressive state

*definitions are changing; addiction is a problem of reward systems

Relationship between dependence and depression

Depression and chronic illness/disease

Most chronic illnesses High rates of depression approx 20% - 80%

Disability and inability to work

Increased rates of depression

Distressing symptoms – breathlessness

Increased depression

Pain Very high depression; high suicide rates

Isolation Increased depression and suicide risk

Treatment Treatment may be depressing

Medications Drugs may be depressing eg. cortisone, anticholinergics, phenothiazines

SensingBrain

SeeingBrain

MotorBrain

PlanningBrain

Smelling & Tasting Brain

Balancing & Coordinating

Brain

Messaging system

PAINFEELINGANXIETY

DRIVES

MOTIVATION

HUNGER

APPETITES

SOMATOSENSORYBRAIN

HIGHER LEVEL – Context, Planning, Action

LOWER LEVEL – Safety, Drives, Emotion

You and me?

The remarkable human being

Mental distressAlcohol and other drug misuse

Mental illness Addiction/dependence

Physical illness and disabilities

(The special case of chronic pain.)

Chronic physical disorders and mental illness

• 77% Australians - one or more medical conditions• 19 % physically disabled – 10% out of work• 80% of those with psychosis – out of work• NSMHWB in 2007 in Australia

– 58% mental or physical disorder»8.2% mental disorder only

• 19.9%»11.7% mental and physical

Common mental disorders - homeless

Hodder T et al., 1998

Schizophrenia

Any alcohol use disorder

Any drug use disorder

Any mood disorder

Any anxiety disorder

Any mental disorder

0 20 40 60 80 100

Males %

Females %

All %

Homeless - Sydney 1998

• 3 in 4 have a mental disorder

• 1 in 2 have a chronic physical illness

Keys to success

• Engagement• Harm minimisation/anticipatory care/limit setting• Long haul & follow-up (‘chain of care’)• Patient’s autonomy• Practical focus - ‘material’ & ‘structural’• Medication choice• Dependence treatment works

Connections – “Chain of Care”

• Ensuring links in the chain to -

– Structured follow through– Other health services– Social welfare (‘fare well’)– Housing, corrections, law enforcement,

homeless agencies, Indigenous organisations