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