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Introduction: Opioid dependence is a global health priority, currently making the biggest contribution to drug-related deaths. The chronic, long-term persistence of heroin dependence over the life course requires investigation in prospective longitudinal studies, to better understand patterns and predictors of remission and relapse, as well as the impact of changes in substance use on a range of physical and mental health outcomes. Such knowledge is critical in order to identify modifiable risk factors that can be targeted for intervention. Crucial unanswered questions include the following: What are the long-term rates of mortality? What are the long-term patterns and predictors of heroin use, remission, psychiatric health and health service use? What are the long-term physical health consequences of heroin use?, Methods and Analysis: The 18-20-year follow-up of the Australian Treatment Outcome Study (ATOS) cohort will examine the natural history of heroin dependence of an existing cohort of 615 people with heroin dependence, who were recruited into the study in 2001-2002. Five waves of follow-up interviews have since been completed, at 3-month, 1-year, 2-year, 3-year and 10-11-year post-baseline. At the 18-20-year follow-up, the ATOS cohort is (on average) approaching their 50s and an average of 30 years have passed since they first used heroin. The 18-20-year follow-up will consist of: (1) a structured interview; (2) physical health assessment; and (3) data linkage. The results of this follow-up will improve our understanding and management of age-related disorders in this population, which if not addressed in the immediate future, has the capacity to overwhelm treatment centres and aged care facilities., Ethics and Dissemination: Ethical approval has been granted for the study (Sydney Local Health District Royal Prince Alfred Zone, Human Research Ethics Committee X18-0512 & HREC/18/RPAH/733). The results of the study will be disseminated through published manuscripts, bulletins and technical reports, as well as conference, seminars, webinar and workshop presentations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objectives: Injection and inhalational heroin use are associated with different levels of brain exposure to heroin and its metabolites and differences in the severity of dependence, which might lead to differential impacts on neuropsychological functions. We examined the difference and the magnitude of difference in the neuropsychological functions between inhalational and injection heroin-dependent subjects and also compared them with healthy controls., Methods: The study sample comprised three groups: 73 subjects with injection heroin dependence, 74 with inhalational heroin dependence, and 75 healthy controls (HC). We excluded patients with HIV, head injury, epilepsy, and severe mental illness. Neuropsychological assessments were done by Standard Progressive Matrices, Wisconsin Card Sorting Test (WCST), Iowa Gambling Task, Trail-Making Tests A and B (TMT), and Verbal and Visual Memory 1 and 2 Backtests (NBT). We estimated independent effects of the groups on various neuropsychological test parameters, adjusted for age and duration of dependence., Results: In the WCST, the inhalational heroin-dependent group took more trials to complete the first category and had higher scores in the failure to maintain set than controls. The intravenous group had higher total errors than controls in verbal working memory tests and Visual Working Memory 2 Backtest. This group scored higher commission errors in the Verbal 2 Backtest than the controls. The two groups of heroin users differed in failure to maintain set and Verbal Working Memory 2 Backtests. The effect sizes of the group differences were modest., Conclusion and Scientific Significance: Either route of heroin use is associated with cognitive impairments; inhalational and injection use involve different cognitive domains., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Aims: Little is known about transition pathways among heroin users prior to treatment. This study examined the demographic and clinical predictors of transition speed from heroin use, to dependence, to first treatment episode., Methods: 1149 heroin-dependent participants recruited from opioid agonist treatment clinics in Sydney, Australia, underwent a structured interview. Age of onset (AOO) was collected for heroin use, dependence and treatment-seeking, childhood maltreatment, psychiatric history and other substance dependence. Discrete-time survival analyses modelled years from onset of use to dependence, and from dependence to treatment-seeking, including demographic and clinical covariates., Findings: Median AOO for first heroin use, dependence and treatment-seeking was 18 years (inter-quartile range, or IQR = 6), 21 years (IQR = 7), and 24 years (IQR = 10) respectively. In adjusted models, younger birth cohorts (vs. born <1960), greater childhood maltreatment and later AAO of first heroin use were associated with more rapid transitions from heroin use to dependence. Living independently, parental violence, and alcohol dependence were associated with slower transitions. Earlier treatment-seeking was associated with younger birth cohorts, having dependent children and later AOO of dependence. Delayed treatment-seeking was associated with <10 years school education, living independently, depression and alcohol dependence., Conclusions: In this treatment sample, onset of heroin use occurred during late adolescence, suggesting the need for targeted interventions in mid-adolescence. Transitions to heroin dependence, then treatment-seeking, occurred during early adulthood. Rapid transitions from use to dependence were associated with younger birth cohorts, greater exposure to childhood maltreatment, and later onset of use., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The high prevalence of post traumatic stress disorder (PTSD) among people with heroin dependence and its impact on short term outcomes has been well established. The impact of PTSD on long-term recovery is, however, unknown. This paper examines the impact of current and lifetime PTSD on long-term recovery from heroin dependence among participants who took part in the 11-year follow-up of the Australian Treatment Outcome Study (ATOS), a prospective naturalistic longitudinal study of 615 people with heroin dependence recruited from Sydney, Australia, in 2001-2002. Seventy-one percent of the cohort (n = 431) were re-interviewed 11-years post study entry. Outcomes examined included heroin and other drug use, dependence, general physical and mental health, depression, PTSD, employment, and the incidence of trauma exposure, overdose, imprisonment, and attempted suicide over the 11- year follow-up. Despite having a poorer profile at baseline, individuals with current PTSD or a history of PTSD at baseline demonstrated similar levels of improvement to those without a history of PTSD in all outcome domains across the 11-year follow-up, PTSD was associated with consistently higher levels of major depression, and attempted suicide, subsequent trauma exposure, and poorer occupational functioning across the 11-year follow-up. These findings highlight the importance of interventions aimed at occupational rehabilitation, reducing the likelihood of retraumatisation, and addressing PTSD and associated comorbidities among people with heroin dependence., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aims: To identify trajectories of heroin use in Australia, predictors of trajectory group membership and subsequent outcomes among people with heroin dependence over 10-11 years., Design: Longitudinal cohort study., Setting: Sydney, Australia., Participants: A total of 615 participants were recruited between 2001 and 2002 as part of the Australian Treatment Outcome Study (66.2% male; mean age 29 years). The predominance of the cohort (87.0%) was recruited upon entry to treatment (maintenance therapies, detoxification and residential rehabilitation), and the remainder from non-treatment settings (e.g. needle and syringe programmes). This analysis focused upon 428 participants for whom data on heroin use were available over 10-11 years following study entry., Measurements: Structured interviews assessed demographics, treatment history, heroin and other drug use, overdose, criminal involvement, physical health and psychopathology. Group-based trajectory modelling was used to: (i) identify trajectory groups based on use of heroin in each year, (ii) examine predictors of group membership and (iii) examine associations between trajectory group membership and 10-11-year outcomes., Findings: Six trajectory groups were identified [Bayesian Information Criterion (BIC) = -1927.44 (n = 4708); -1901.07 (n = 428)]. One in five (22.1%) were classified as having 'no decrease' in heroin use, with the probability of using remaining high during the 10-11 years (> 0.98 probability of use in each year). One in six (16.1%) were classified as demonstrating a 'rapid decrease to maintained abstinence'. The probability of heroin use among this group declined steeply in the first 2-3 years and continued to be low (< 0.01). The remaining trajectories represented other fluctuating patterns of use. Few baseline variables were found to predict trajectory group membership, but group membership was predictive of demographic, substance use and physical and mental health outcomes at 10-11 years., Conclusions: Long-term trajectories of heroin use in Australia appear to show considerable heterogeneity during a decade of follow-up, with few risk factors predicting group membership. Just more than a fifth continued to use at high levels, while fewer than a fifth become abstinent early on and remained abstinent. The remainder showed fluctuating patterns., (© 2017 Society for the Study of Addiction.)

Background: Heroin use carries the highest burden of disease of any drug of dependence. The study aimed to determine mortality rates of the Australian Treatment Outcome Study cohort over the period 2001-2015, and the years of potential life lost (YPLL)., Methods: The cohort consisted of 615 heroin users. Crude mortality rates per 1000 person years (PY) and Standardised Mortality Ratios (SMR) were calculated. YPLL were calculated using two criteria: years lost prior to age 65, and years lost prior to average life expectancy., Results: The cohort was followed for 7,790.9 PY. At 2015, 72 (11.7%) of the cohort were deceased, with a crude mortality rate of 9.2 per 1000 PYs. Neither age nor gender associated with mortality. The SMR was 10.2 (males 7.3, females 17.2), matched for age, gender and year of death. The most common mortality cause was opioid overdose (52.8%). Using the<65 years criterion, there were 1988.3 YPLL, with a mean of 27.6 (males 27.6, females 27.7). Using the average life expectancy criterion, there were 3135.1 YPLL, with a mean of 43.5 (males 41.9, females 46.3). Accidental overdose (<65 yr 63.0%, average life expectancy 63.7%) and suicide (<65 yr 12.8%, average life expectancy 13.3%) accounted for three quarters of YPLL where cause of death was known., Conclusions: YPLL associated with heroin use was a quarter of a century, or close to half a century, depending on the criteria used. Given the prominent role of overdose and suicide, the majority of these fatalities, and the associated YPLL, appear preventable., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Longitudinal studies are often threatened by difficulties with sample attrition, high rates of which threaten the validity of study findings. The present study examined methodological and participant characteristics associated with sample retention in the Australian Treatment Outcome Study (ATOS) across 3years., Method: Follow-up interviews were conducted at 3-, 12-, 24-, and 36-months post baseline, with follow-up rates of 89%, 81%, 76% and 70%, respectively. Structured interviews measuring past-month drug use, mental health, criminal involvement and demographic characteristics were administered to participants at baseline and each follow-up. Data were analysed using multinomial logistic regression and generalised estimating equations to produce odds ratios with 95% confidence intervals., Results: Completing all follow-up interviews was associated with being in treatment (OR 3.62), using other opiates at baseline (OR 3.45), more years of schooling (OR 1.20), and having completed the previous interview (OR 35.04). A history of incarceration was independently associated with not completing follow-up interviews (OR 0.47)., Conclusion: Retention can largely be predicted at study entry, and is unaffected by changes that occur in the interim. These findings highlight the importance of obtaining and maintaining comprehensive locator information, maintaining strong relationships with treatment agencies, as well as the necessity of patience, perseverance and flexibility., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: The study aimed to determine long-term alcohol use patterns and correlates amongst heroin users., Methods: Longitudinal cohort. 11-year post-baseline follow-up of the Australian Treatment Outcome Study cohort., Results: At 11-year follow-up, 431 (70%) participants were interviewed. Alcohol was used in the preceding month by 56%, with 27% reporting daily use and 11% heavy daily drinking. Alcohol use patterns showed remarkable consistency across waves, with the proportion who drank in the preceding month ranging between 49 and 56%, with no significant trend across time. Daily drinking ranged between 20 and 27%, and heavy daily drinking between 7 and 12%. Both declined slightly from baseline to 3-year follow-up, but by 11 years were at levels similar to baseline. Compared to female referents, males were more likely to drink (OR 1.6, CI 1.3-2.1, p < .05), to drink daily (OR 1.8, CI 1.4-2.4, p < .05) and to drink heavily (OR 1.7, 1.1-2.5, p < .05). Compared to those not in enrolled in a drug treatment programme, those enrolled were significantly less likely to drink (OR 0.7, CI 0.5-0.8, p < .05) and to drink daily (OR 0.6, 0.5-0.8, p < .05). Compared to those who did not drink heavily, heavy drinking was associated with a higher likelihood of recent overdose (OR 1.6, CI 1.0-2.4, p < .05), of criminality (OR 1.9, 1.3-2.7, p < .001), and with lower SF12 physical (mean difference -3.0, CI -4.7 to -1.4, p < .001) and mental (-2.4, CI -4.3 to -0.5, p < .001) health scores., Conclusions: There were consistently high levels of both abstinence and regular drinking, with drinking patterns staying relatively stable across the decade. From the clinical perspective, the high rates of heavy drinking are of particular relevance, given the observed associations with a poorer clinical profile., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: We report on patterns and correlates of sustained abstinence at the 11-year follow-up of the Australian Treatment Outcome Study cohort., Method: This report is a longitudinal cohort analysis of patterns of recent and sustained abstinence., Results: A total of 431 (70.1%) of the original 615 participants were interviewed, and 10.2% were deceased. The mean elapsed time since heroin initiation was 20.4 years (SD = 7.2). At the 11-year follow-up, heroin abstinence over the preceding month was reported by 75.2%. A period of at least 1 month's abstinence across the follow-up was reported by 97.7% and at least 1 year by 89.9%, whereas 52.2% reported an abstinence period of 5 or more consecutive years. Sustained abstinence across the entire follow-up period was reported by 5.6%. Independent correlates of 5 or more consecutive years of heroin abstinence were female gender (odds ratio [OR] = 1.73), not being currently enrolled in a drug treatment program (OR = 2.16), and fewer treatment episodes across the follow-up (OR = 0.90, 95% CI [0.85, 0.96])., Conclusions: The clinical profile of the cohort at the 11-year follow-up was encouraging, with the majority currently heroin abstinent, a proportion that has increased across time. Although only a small minority maintained abstinence over the entire period, half had sustained abstinence for at least 5 consecutive years. With the exception of gender, baseline characteristics made poor predictors of long-term abstinence. Treatment stability, however, appears crucial in maintaining abstinence.

Lifetime and recent rates of attempted suicide and suicidal ideation amongst the Australian Treatment Outcome Study cohort of heroin users at 11-year follow-up were examined. The mean elapsed time since heroin initiation was 20.4 years. At 11-year follow-up, 42.2% of the cohort reported ever having made a suicide attempt, 11.1% having made a first attempt subsequent to baseline. In the year preceding 11-year follow-up, 1.6% had made an attempt, suicidal ideation was reported by 10.4%, and 4.2% had a current suicide plan. After controlling for other variables, past 12 month attempts, current ideation or plans were independently associated with a current diagnosis of Major Depression (odds ratios (OR) 1.67) and more extensive polydrug use (OR 1.39), while each standard deviation higher on the SF12 physical health scale (reflecting better health) was associated with reduced odds (OR 0.66). Suicide and suicidal ideation remained a significant clinical issue for heroin users, some 20 years after their heroin use commenced., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Aims: To determine the long-term mortality, remission, criminality and psychiatric comorbidity during 11 years among heroin-dependent Australians., Design: Longitudinal cohort study., Setting: Sydney, Australia., Participants: A total of 615 participants were recruited and completed baseline interviews between 2001 and 2002. Participants completed follow-up interviews at 3, 12, 24 and 36 months post-baseline, and again at 11 years post-baseline; 431 (70.1%) of the original 615 participants completed the 11-year follow-up., Measurements: Participants were administered the Australian Treatment Outcome Study (ATOS) structured interview, addressing demographics, treatment history, drug use, heroin overdose, criminality, health and mental health at all interviews. Overall, 96.1% of the cohort completed at least one follow-up interview., Findings: At 11 years, 63 participants (10.2%) were deceased. The proportion of participants who reported using heroin in the preceding month decreased significantly from baseline (98.7%) to 36-month follow-up (34.0%; odds ratio = 0.01; 95% confidence interval = 0.00, 0.01) with further reductions evident between 36 months and 11 years (24.8%). However, one in four continued to use heroin at 11 years, and close to one-half (46.6%) were in current treatment. The reduction in current heroin use was accompanied by reductions in risk-taking, crime and injection-related health problems, and improvements in general physical and mental health. The relationship with treatment exposure was varied. Major depression was associated consistently with poorer outcome., Conclusions: In an 11-year follow-up of patients undergoing treatment for heroin dependence, 10.2% had died and almost half were still in treatment; the proportion still using heroin fell to a quarter, with major depression being a significant predictor of continued use., (© 2015 Society for the Study of Addiction.)

Background: Overdose is a major cause of morbidity and mortality amongst opioid users. This paper reported recent non-fatal overdose amongst the Australian Treatment Outcome Study (ATOS) cohort at 11-year follow-up, and characteristics that predict recent overdose., Methods: Longitudinal cohort, with 431 (70.1%) of the original 615 participants interviewed. Participants were administered the ATOS structured interview, addressing demographics, treatment history, drug use, heroin overdose, criminality, health and psychopathology., Findings: Mean time since heroin initiation was 20.4 years. By 11-year follow-up, the proportion who had overdosed was 67.5%, and 24.4% had experienced five or more overdoses. In the 12 months preceding 11-year follow-up, 4.9% had overdosed (11.8% of those who had used heroin in that period). Of the 21 participants who had recently overdosed, 20 (95.2%) had overdosed previously, and 19 (90.5%) were not enrolled in a treatment programme at the time. Those who had recently overdosed reported higher levels of use of opiates other than heroin (57.1% vs 24.9%), benzodiazepines (61.9% vs 30.5%,), methamphetamine (38.1% vs 16.8%) and cocaine (19.0% vs 3.7%). They also had exhibited higher levels of heroin use and other drug use at baseline, 12 and 24 month follow-ups., Conclusions: While the prevalence had declined, overdoses still occurred. A history of overdose and polydrug use patterns continued to provide strong markers for those at continued risk., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: The link between heroin use and crime has been well established; however, there has been little opportunity to examine this relationship longitudinally. This study examines the relationship between static and dynamic predictors of criminal involvement, and the degree to which changes in dynamic risk factors moderate the risk of criminal involvement over time., Method: Data were collected as part of the Australian treatment outcome study, a 3-year longitudinal study of 615 people with heroin dependence conducted in Sydney, Australia. Past-month criminal involvement (property crime, drug dealing, fraud, violent crime), demographic, drug use and mental health characteristics were assessed at each interview., Results: Criminal involvement was consistently and independently predicted by lack of wage/salary as a main source of income, (OR 2.17), meeting diagnostic criteria for anti-social personality disorder (OR 1.91) and major depression (OR 1.41), screening positive for borderline personality disorder (OR 1.47), male sex (OR 1.44), a criminal history (OR 1.33), greater severity of dependence (OR 1.21), more extensive heroin use (OR 1.09), and younger age (OR 0.96) over the 3-year period., Conclusions: These findings provide strong evidence of the robust nature of the association between more extensive heroin use, severity of dependence, the co-occurrence of mental health conditions, and an individual's capacity for employment, and criminal involvement. Interventions aimed at increasing an individual's employability and improving mental health in particular, may reduce the risk of criminal involvement among people with heroin dependence., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background and Aims: Globally, more than 100 000 people die annually from opioid overdose. Opportunities to study physiological events in at-risk individuals are limited. This study examined variation of opioid dose and impact on respiratory depression in a chronic injecting heroin user at separate time-points during his long-term diamorphine maintenance treatment., Design: A single-subject study over 5 years during which participant underwent experimental studies on diamorphine-induced respiratory depression, at changing maintenance doses., Setting: A clinical research facility. Participant Male subject on long-term injectable diamorphine (pharmaceutical heroin) maintenance treatment for heroin addiction., Measurements: Physiological measures of oxygen saturation (SpO 2 ), end-tidal carbon dioxide (ETCO 2 ) and respiratory rate (RR) were used to indicate severity of respiratory depression., Findings: (1) After diamorphine injection, respiratory regulation became abnormal, with prolonged apnoea exceeding 20 sec (maximum 56 sec), elevated ETCO 2 (maximum 6.9%) and hypoxaemia (minimum SpO 2 80%). (2) Abnormalities were greater with highest diamorphine dose: average SpO 2 was 89.3% after 100 mg diamorphine versus 93.6% and 92.8% for the two 30-mg doses. (3) However, long apnoeic pauses and high levels of ETCO 2 % were also present after lower doses., Conclusions: With marked inter-session variability, these findings corroborate observations of inconsistent relationships between opioid dose and overdose risk., (© 2020 Society for the Study of Addiction.)

The self-medication hypothesis emphasizes the role of distressing affect as the primary motivator for the compulsive use that leads to substance dependence. The model also postulates that there will be psychopharmacological specificity between symptom presentation and the primary drug of dependence. In this review, the self-medication hypothesis is examined in relation to the development and chronicity of heroin dependence. It is argued that if self-medication has a role in engendering and extending substance dependence, it should be apparent in the use of a drug that carries such overwhelming personal risk. The psychopathology seen among adult users is certainly consistent with the model. More importantly, however, are the extraordinarily high levels of childhood trauma and psychopathology that occur typically well before the initiation of heroin use. In contrast, the postulate of drug specificity appears less supported by the polydrug use patterns typical of heroin users, and does not appear to be a necessary corollary of the model., (© 2012 The Author, Addiction © 2012 Society for the Study of Addiction.)

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., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Introduction and Aims: Benzodiazepine use is associated with elevated levels of harm. The current study aimed to ascertain the long-term nature of the relationship between benzodiazepine use and clinical profile among heroin users., Design and Methods: Longitudinal cohort, with follow-up at 3, 12, 24 and 36 months. Participants were 615 heroin users recruited for the Australian Treatment Outcome Study., Results: At baseline, current benzodiazepine users were more likely to be committing crime, had poorer psychological health and poorer physical health. Baseline benzodiazepine use was not associated with the likelihood across follow-up of heroin use (P = 0.44), committing crime (P = 0.17), poorer psychological health (P = 0.31) or poorer physical health (P = 0.48). Current benzodiazepine use was, however, associated with a greater likelihood of concurrent heroin use (OR 2.77), crime (OR 2.04), poorer psychological health (beta = -4.47) and poorer physical health (beta = -2.33)., Discussion and Conclusions: Clinicians should be aware that reductions in benzodiazepine use are associated with reductions in harm, and that baseline benzodiazepine status does not equate to poor long-term outcome.

Aims: To determine the comparative levels of violent offending and victimization among regular methamphetamine and heroin users., Design: Cross-sectional Setting Sydney, Australia., Participants: A total of 400 regular methamphetamine (METH) and heroin (HER) users (118 methamphetamine users: METH; 161 regular heroin users: HER; 121 regular users of both: BOTH)., Findings: Eighty-two per cent reported a life-time history of committing violent crime, 41% in the past 12 months. There were no group differences in life-time violence, but the METH group were significantly more likely than the HER group to have committed violence in the past 12 months (odds ratio 1.94). Nearly all (95%) reported that they had been a victim of violent crime, 46% in the preceding 12 months, with no group differences. Those who had committed a violent crime in the past 12 months were 13.23 times more likely to have been a victim in that period. The majority believed it unlikely that they would be a victim of (78%), or commit (87%), a violent crime in the next 12 months., Conclusions: Regular methamphetamine use appears to be associated with an increased risk of violent offending, but not victimization, compared with heroin use.

Introduction and Aims: The study examined the relationships between length of career (LOC), clinical presentation and outcomes across 36 months among a cohort of 615 heroin users., Design and Methods: Longitudinal cohort study., Results: At baseline, each additional year of heroin use was associated with increased likelihood of: being male, exposure to treatment, having been imprisoned, daily injecting, lifetime and recent polydrug use, having overdosed, poorer physical health and reduced likelihood of heroin smoking. In contrast, LOC was not related to frequency of heroin use, current polydrug use, recent heroin overdose, recent imprisonment, recent criminality or psychopathology. There were also no associations between LOC and outcomes across 36 months in terms of treatment, drug use, crime, severe psychiatric disability or major depression. Longer LOC was associated across 36 months, however, with daily injecting, poorer physical health, severe physical disability and poorer mental health., Discussion and Conclusions: The data point to the maintenance of heroin-related harms well into the third decade of use.

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.

Aims: (i) To describe the course of physical health among the ATOS cohort over 24 months; and (ii) to examine the effects of treatment, drug use patterns and social and psychological factors on health status over 24 months., Design: Longitudinal cohort., Setting: Sydney, Australia., Participants: A total of 615 heroin users recruited for the Australian Treatment Outcome Study (ATOS)., Findings: The general health of the cohort improved significantly over 24 months. Significant predictors of poor health over 24 months were: being older, being female, past month heroin, other opiate and tobacco use, past month unemployment and current major depression. Spending a greater proportion of time in residential rehabilitation (RR) was associated with better health over 24 months. No other treatment factors demonstrated a significant, independent relationship with health., Conclusions: The physical health of dependent heroin users is affected by drug use and psychosocial problems. RR treatment appears to be particularly beneficial to the health of heroin users, suggesting the importance of a comprehensive approach to improving health among this group.

Aim: To examine the impact of treatment for heroin dependence on drug use, injection-related risk-taking, health problems, criminality and general physical and mental health over 3 years among heroin-dependent Australians., Design: Longitudinal prospective cohort study., Participants: A total of 615 heroin users enrolled in the Australian Treatment Outcome Study; 94.5% of the sample completed at least one follow-up interview over 36-month follow-up., Findings: The proportion who reported using heroin in the preceding month continued to decrease significantly from baseline to 24-month follow-up (99% versus 35%), with this rate remaining stable to 36-month follow-up. The reduction in heroin use was accompanied by reductions in other drug use. There were also substantial reductions in risk-taking, crime, injection-related health problems and improvements in general physical and mental health. Positive outcomes were associated with more time in maintenance therapies and residential rehabilitation and fewer treatment episodes. Time spent in detoxification was not associated with positive outcomes. Major depression was also associated consistently with poorer outcome., Conclusions: At 3 years, there were impressive reductions in drug use, criminality, psychopathology and injection-related health problems following treatment exposure.

Aims: To compare the blood toxicology of heroin overdose cases and morphine positive homicide victims., Design: Analysis of coronial cases., Setting: Sydney, Australia. Cases A total of 705 cases of death due to opioid toxicity and 28 morphine positive homicide cases (1 January 1998-31 December 2002)., Findings: There was no significant difference between the median morphine concentrations of the overdose and homicide groups (0.50 versus 0.45 mg/l). The overdose group was more likely to have blood alcohol (OR 3.21) present, but less likely to have methadone (OR 0.26) and cannabis (OR 0.04). There was a significant negative correlation between blood morphine and alcohol concentrations among the overdose group (rho = -0.32), but not among the homicide group (rho = -0.03). Independent predictors of a higher blood morphine concentration were a lower alcohol concentration and a higher methadone concentration., Conclusions: Morphine concentrations per se are not diagnostic of overdose. The study confirms the salience of concomitant alcohol consumption in such events.

Aims: The aim of this study was to determine the effects of baseline cocaine use on treatment outcomes for heroin dependence over a 24-month period., Design: A longitudinal cohort (24 months) study was carried out. Interviews were conducted at baseline, 3, 12, and 24 months., Setting: The study setting was Sydney, Australia., Participants: Six hundred fifteen heroin users were recruited for the Australian Treatment Outcome Study., Findings: Cocaine use was common at baseline (40%) but decreased significantly over the study period. Even after taking into account age, sex, treatment variables, current heroin use, and baseline polydrug use, baseline cocaine use remained a significant predictor of poorer outcomes across a range of areas. Baseline cocaine users were more likely to report heroin use, unemployment, needle sharing, criminal activity, and incarceration over the 24-month study period., Conclusions: Cocaine consumption among heroin users has repercussions across a range of areas that persist far beyond the actual period of use. Consequently, treatment providers should regard cocaine use among clients as an important marker for individuals who are at risk of poorer treatment outcome.

Aims: To determine patterns of past month, 12 month and sustained 36 month heroin abstinence., Methods: As part of a longitudinal cohort study, 429 heroin users re-interviewed at 36 month follow-up for the Australian Treatment Outcome Study (ATOS)., Results: The proportion who had sustained heroin abstinence since baseline declined from 14% at 12 months to 8% at 36 months. The proportion who reported abstinence over the preceding 12 months, however, increased significantly from 14% at 12 months to 40% at 36 months. There were no significant gender differences in the proportions reporting sustained 36 month abstinence. Females, however, were significantly more likely to have maintained abstinence over the 12 months preceding 36 month follow-up. Independent predictors of sustained abstinence over 36 months were fewer treatment episodes since baseline, not committing crime at baseline and higher levels of global psychological distress., Conclusions: Despite a decline in the proportion who had maintained complete heroin abstinence over 36 months, there were substantial increases in 12 month abstinence patterns. The results illustrate the importance of stable treatment retention.

Aims: To determine the effects of borderline personality disorder (BPD) on 36-month outcomes for the treatment of heroin dependence., Design: Longitudinal cohort study., Setting: Sydney, Australia., Participants: A total of 429 heroin users enrolled in the Australian Treatment Outcome Study, interviewed at 36-month follow-up., Findings: The BPD group enrolled in significantly more different treatment episodes across follow-up, but there was no difference in the cumulative number of treatment days received. At 36 months, there were no group differences in sustained or current heroin abstinence, daily heroin use or level of polydrug use. BPD patients maintained significantly higher levels of crime, injection-related health problems, heroin overdose, major depression and poorer global mental health. In contrast to 12-month follow-up, at 36 months there were no group differences in the proportions who attempted suicide over the preceding 12 months or had recently borrowed used injection equipment., Conclusions: The clinical picture provided some cause for optimism since 12-month follow-up. Despite this, BPD patients maintained elevated risk levels across a number of domains. The fact that these risks were maintained indicates that this is a group that requires specific clinical attention for BPD-related risks.

Estimates of trauma exposure rely almost exclusively on retrospective self-reports; however, the reliability of these reports has received little attention. The present study examined the reliability of self-reported lifetime trauma exposure among 309 dependent heroin users over 2 years, and the factors associated with inconsistent recall. The correlation between the number of events reported at baseline and follow-up was .72; however, 87% of the sample reported at least one event inconsistently. Variability in reporting was associated with trauma type, a lifetime posttraumatic stress disorder, and antisocial personality disorder. These findings suggest that dependent heroin users are moderately reliable in their reports of trauma exposure, and their reports of trauma exposure are as reliable as those of nonsubstance use disordered samples.

In order to determine patterns and correlates of attempted suicide amongst heroin users across 3 years, a cohort of 387 heroin users (134 entering maintenance treatment, 134 entering detoxification, 81 entering residential rehabilitation and 38 not entering treatment) were interviewed about suicide attempts at baseline, 12, 24 and 36 months. Across the follow-up period, 11.6% attempted suicide. There were declines in the proportion who attempted suicide each year amongst both males and females and significant declines in Major Depression, suicidal ideation and current suicide plans. Despite this, levels of attempted suicide, suicidal ideation and Major Depression in the cohort remained higher than in the general population. Those who had made a previous suicide attempt were five times more likely to make an attempt across follow-up and there was a strong association between an attempt in any 1 year and increased probability of an attempt in the subsequent year. A quarter of those who reported suicidal ideation at baseline made an attempt across follow-up. At each interview point, current suicidal ideation was strongly associated with increased risk of a suicide attempt in the following year. Independent predictors of a suicide attempt across follow-up were a lifetime suicide history, baseline suicidal ideation, social isolation and the extent of baseline polydrug use. Given the strong predictive value of suicidal ideation and previous attempts, regular brief screening would appear warranted to identify those at greatest risk.

To determine annual patterns and correlates of nonfatal heroin overdose across 3 years, data were analyzed on 387 heroin users recruited for the Australian Treatment Outcome Study (ATOS), interviewed at 12, 24, and 36 months. A heroin overdose across follow-up was reported by 18.6%, and naloxone had been administered to 11.9%. Annual rates of overdose declined between baseline and 12 months and then remained stable. Previous overdose experience was strongly related to subsequent overdose. Those with a history of overdose before ATOS were significantly more likely to overdose during the study period. In particular, there was a strong association between overdose experience in any 1 year and increased overdose risk in the subsequent year. This is the first study to examine long-term annual trends in nonfatal heroin overdose. While overdose rates declined after extensive treatment, substantial proportions continued to overdose in each year, and this was strongly associated with overdose history.

The study aimed to determine patterns of use of medical services and prescriptions for pharmaceuticals among 438 heroin users interviewed for the Australian Treatment Outcome Study (ATOS) at baseline, 12 and 24 months. Drug use declined markedly, and there were significant improvements in health. There were declines in the proportion of participants who had attended a general practitioner (GP) (baseline: 60%, 12 months: 53%, 24 months: 52%), who had an ambulance attendance (11%, 7%, 5%), and who were treated in an accident and emergency department (11%, 6%, 5%). While there was no decrease in the proportion who obtained a prescription (47%, 45%, 46%), there was a decrease in the mean number of reported prescriptions obtained (2.3, 1.0, 0.9). There were also differences across follow-up in the reported types of medications obtained, with a significant decrease in the proportion obtaining psychotropic medications (38%, 21%, 19%). In particular, there were large declines in the proportion who reported benzodiazepines (30%, 12%, 10%) or narcotic analgesics (8%, 3%, 4%) on prescription. While ATOS participants continued to be frequent users of health services, the cohort reported reduced levels of drug-seeking and risk commensurate with their reductions in drug use.

Aims: To examine the impact of post-traumatic stress disorder (PTSD) on 2-year treatment outcomes for heroin dependence., Design: Prospective longitudinal study., Participants: Data were obtained from a predominantly treatment seeking sample of 615 dependent heroin users who were followed-up at 3, 12 and 24 months (follow-up rates: 89%, 81% and 76%, respectively)., Measurements: Outcomes examined include treatment retention and exposure, substance use, general physical and mental health and employment., Findings: Despite improvements in substance use, PTSD was associated with continued physical (beta - 1.69, SE 0.61, P < 0.01) and mental disability (beta - 2.07, SE 0.66, P < 0.01), and reduced occupational functioning (OR 0.67, 95% CI: 0.48-0.93) throughout the 2-year follow-up., Conclusions: Although conventional treatment services are successful in producing improvements in substance use and associated disability, the disability associated with PTSD remains. An intervention targeting both heroin dependence and PTSD may help to improve the outcomes of those with PTSD.

Opioids make the single largest contribution to illicit drug-related mortality and morbidity worldwide In this paper we reflect upon what has been learnt regarding treatment outcome and the natural history of heroin use from the Australian Treatment Outcome Study (ATOS). We focus on what we knew prior to ATOS, what ATOS revealed that is novel, and the implications for research, practice and policy. ATOS provided strong evidence for sustained improvement attributable to treatment across the three years of the study. It is argued that treatment for heroin dependence is money well spent, and leads to clear and sustained benefits to both heroin users and society.

Aims: To determine whether reductions in frequency of heroin use were associated with reductions in the use of other drugs over a 24-month period., Design: Longitudinal cohort, with follow-up at 3, 12 and 24 months., Participants: Six hundred and fifteen heroin users recruited for the Australian Treatment Outcome Study., Setting: New South Wales, Australia., Findings: The proportion reporting weekly heroin use declined significantly at 3, 12 and 24 months. Reductions in heroin use were associated with longer periods in both residential rehabilitation (RR) and maintenance treatment (MT). Less frequent use of other opioids, cocaine, amphetamine, cannabis and benzodiazepines were noted over follow-up, with alcohol use remaining stable. Across follow-up, lower frequency heroin use was associated with reduced likelihood of frequent use of other opioids, cocaine, amphetamine and benzodiazepines. Alcohol and cannabis use were unrelated to heroin use. Longer periods spent in RR were associated with declines in the use of all other drug classes, with MT associated with declines in other opioid and alcohol use., Conclusions: There was no evidence for drug substitution in the face of reduced heroin use in this cohort of treatment seekers. The fear that a successful reduction in heroin use amongst treatment seekers will precipitate an increase in the use of other drugs appears ill-founded.

Aim: To determine 1 year outcomes for drug use, criminality, psychopathology and injection-related health problems in those entering treatment for heroin dependence in Australia., Design: Longitudinal prospective cohort study., Participants: Seven hundred and forty five individuals entering treatment (methadone/buprenorphine maintenance therapy; detoxification; residential rehabilitation) and 80 heroin users not seeking treatment., Setting: Sydney, Melbourne and Adelaide, Australia., Findings: A total of 657 individuals were re-interviewed at 1 year, 80% of the original sample. There were substantial reductions in heroin and other drug use across all three treatment modalities. The majority of those who had entered treatment were heroin abstinent at 1 year (maintenance therapy 65%, detoxification 52%, residential rehabilitation 63%) compared to 25% of the non-treatment sample. The reduction in heroin use among the treatment samples was paralleled by reductions in poly drug use. There were also substantial reductions in risk-taking, crime and injection-related health problems across all treatment groups, and less marked reductions among the non-treatment group. Psychopathology was dramatically reduced among the treatment modalities, while remaining stable among the non-treatment group. Positive outcomes at 1 year were associated with a greater number of cumulative treatment days experienced over the 1 year follow-up period ('treatment dose') and fewer treatment episodes undertaken in that time ('treatment stability')., Conclusions: At 1 year, there were impressive reductions in drug use, criminality, psychopathology and injection-related health problems following treatment exposure. The positive findings were associated with a greater "dose" of treatment, and with more treatment stability over the follow-up period.

A cohort comprising 495 heroin users were interviewed for the Australian Treatment Outcome Study and were re-interviewed at 12-month follow-up. The rate of current major depression declined significantly from 26% to 11% for the follow-up period. Those with current major depression on follow-up experienced fewer total days in treatment, but engaged in more treatment episodes. In comparison to those without depression, depressed individuals had less exposure to methadone/buprenorphine maintenance and residential rehabilitation for the follow-up period, but spent more time in detoxification. Those with current major depression on follow-up also reported heavier heroin and other drug use, more risk-taking behaviors, poorer physical health, and greater psychopathology than those without a diagnosis of current major depression. Although caution in interpreting these relationships is advised given the potential for confounding by client characteristics, the findings of this study illustrate the need to consider depression in the treatment of heroin dependence.

As part of the Australian Treatment Outcome Study (ATOS), 177 (88%) heroin users entering detoxification (DTX) and 66 (83%) heroin users not in treatment (NT) were interviewed at baseline and 3 months to examine drug use, risk-taking, overdose, crime and psychopathology outcomes. The majority (76%) of the DTX group had entered additional treatment at 3 months, mainly further detoxification, and 54% were currently in treatment, mainly maintenance and residential rehabilitation. There were reductions in heroin use and other drug use in those entering detoxification. Forty-two per cent were abstinent at 3 months compared to 20% in the NT group. There were also reductions in crime among those entering DTX, and less marked reductions in the NT group. Psychopathology showed less change. Detoxification may, in some part, function as a gateway to further treatment and those entering DTX showed modest but significant improvements across drug use and crime at 3 months.

The aim of this study was to determine the prevalence of cocaine use among individuals presenting for treatment for heroin dependence, describe the clinical profile of heroin users who also use cocaine and to establish the effects of cocaine use on short term outcomes for the treatment for heroin dependence. A longitudinal follow-up of 549 heroin users recruited in Sydney for the Australian Treatment Outcome Study was conducted at 3-month post-baseline interview. At baseline, current cocaine use was common (39%) and was associated with increased drug use, needle risk taking and criminality. The 3-month prevalence of cocaine use declined significantly to 19%. Thirty-five per cent of those who had used cocaine at baseline continued to use at 3 months, while 9% of the sample had commenced cocaine use. Those who entered residential rehabilitation at baseline were less likely than other treatment entrants and the non-treatment group to have used cocaine at follow-up. Treatment retention was not affected by baseline cocaine use status; however, baseline cocaine users (CU) displayed higher levels of heroin use, polydrug use and drug-related problems. A poorer outcome was associated with the commencement or continuation of cocaine use, while cessation of cocaine use resulted in significant improvements on these measures. Cocaine use was common among individuals seeking treatment for heroin dependence and was an important moderator of treatment outcome. It appears that cocaine use has a strong negative effect on treatment outcome over and above that caused by polydrug use generally.

Aims: To determine the effects of cocaine use across the study period on outcomes of treatment for heroin dependence 12 months post-treatment entry., Design: Longitudinal cohort (12 months). Interviews were conducted at baseline, 3 and 12 months., Setting: Sydney, Australia., Participants: Four hundred ninety-five heroin users recruited for the Australian Treatment Outcome Study and re-interviewed at 12-month follow-up., Findings: Cocaine was widely used among treatment entrants in NSW, with almost all having a lifetime history of cocaine use and almost half having used in the month preceding baseline. While there was an overall decline in cocaine use across the study period, individual use patterns varied widely. Approximately half of the cohort did not report cocaine use at any data point, with the remainder reporting having used at one (29%), two (12%), or at all three (5%) points. Cocaine use across the study period was an independent predictor of most major treatment outcomes, with more cocaine use points predicting poorer outcome. Persistent cocaine use predicted a higher prevalence of homelessness, heroin use, daily injecting, needle sharing and injection-related health problems at 12 months as well as more extensive recent polydrug use., Conclusions: Cocaine use was common among individuals seeking treatment for primary heroin dependence in NSW. Any cocaine use over the study period was associated with poorer outcomes in virtually all areas. Persistent cocaine use over the study period, however, appeared particularly detrimental. Cocaine use among clients should evidently be a cause for concern amongst treatment providers and may warrant being specifically targeted during treatment.

The current study aimed to describe the characteristics (demographics, drug use, mental and physical health) of entrants to treatment for heroin dependence in three treatment modalities; and to compare these characteristics with heroin users not in or seeking treatment. Participants were 825 current heroin users recruited from Sydney, Adelaide and Melbourne: 277 entering methadone/buprenorphine maintenance treatment (MT), 288 entering detoxification (DTX), 180 entering drug-free residential rehabilitation (RR) and 80 not in treatment (NT). Treatment entrants were generally long-term heroin users with previous treatment experience. The majority of the sample (55%) were criminally active in the month preceding interview. Injection-related health problems (74%) and a history of heroin overdose (58%) were commonly reported. There were high degrees of psychiatric co-morbidity, with 49% reporting severe psychological distress, 28% having current major depression, 37% having attempted suicide and 42% having a lifetime history of post-traumatic stress disorder. Personality disorders were also prevalent, with 72% meeting criteria for antisocial personality disorder and 47% screening positive for borderline personality disorder. Striking similarities were noted between the non-treatment and treatment groups in length of heroin use career, drug use and treatment histories.

The relationship between treatment exposure, drug use, psychosocial variables and non-fatal heroin overdose was examined among a cohort of 495 heroin users, re-interviewed at 12 months. The 12-month overdose rate declined from 24% to 12%, and the proportion administered naloxone declined from 15% to 7%. There were significant reductions in overdose among those who entered maintenance therapies (22% to 4%) and residential rehabilitation (33% vs. 19%) at baseline, but not among those who entered detoxification or were not entering treatment. The total number of treatment days received over the follow-up period was associated independently with a reduced risk of overdose. Each extra treatment day was associated with a 1% reduction in risk of overdose over the follow-up period. By contrast, more treatment episodes were associated with an increased risk of overdose (OR 1.62). Other independent predictors of overdose over follow-up were more extensive polydrug use (OR 1.40), and having overdosed in the year preceding the study (OR 7.87).

Aims: To determine the effects of borderline personality disorder (BPD) on 12-month treatment retention and outcomes for the treatment of heroin dependence., Design: Longitudinal cohort study. Setting Sydney, Australia., Participants: A cohort of 495 heroin users enrolled in the Australian Treatment Outcome Study., Findings: Criteria for BPD were met by 45% of the cohort. At baseline there were no differences in heroin use, but the BPD group had higher levels of polydrug use, crime, needle risk-taking, more injection-related health problems, higher levels of overdose, poorer psychological health and more extensive suicide histories. At 12 months there was no group difference in the cumulative number of treatment days received, but the BPD group had enrolled in more different treatment episodes. Within both groups reductions had occurred in drug use and drug-related problems, with no differences in heroin use, polydrug use or global physical health at 12 months. After taking into account the effects of treatment on outcome, however, BPD was associated independently with a higher level of needle sharing [odds ratio (OR) 3.21], more injection-related health problems (OR 1.90), a higher likelihood of heroin overdose (OR 1.92), poorer global psychological health (OR 2.43), higher levels of current major depression (OR 3.19) and a higher likelihood of attempted suicide (OR 3.89). While BPD participants showed similar reductions in heroin and other drug use to other patients at 12 months, they continued to exhibit higher levels of risk and harm across a range of outcomes., Conclusions: Screening would appear to be warranted to identify a group who may overtly respond to treatment in terms of drug use per se, but remain at substantially greater risk.

Objective: This study examined the costs and outcomes of treatment for opiate dependence associated with posttraumatic stress disorder (PTSD)., Methods: Data were collected on the use of opiate treatment over a 12-month period for a cohort of 495 individuals, of whom 42 percent had PTSD. Total treatment costs were calculated as the sum of the time spent in each treatment modality multiplied by the appropriate unit cost. Outcome measures included occupational functioning, use of heroin and other drugs, and physical and mental health., Results: No significant difference was noted in the cost of treatment over the 12-month period for persons with and without PTSD (5,394+/-5,136 and 4,821+/-5,144 [Australian dollars], respectively). However, persons with PTSD had poorer treatment outcomes in terms of occupational functioning, overdose, and physical and mental health., Conclusions: Although the same resources were invested in opiate treatment for persons with and without PTSD, PTSD continued to be associated with poorer functioning in a number of domains at 12-month follow-up. A well-designed intervention targeting both heroin dependence and PTSD may help to improve the outcomes of persons with PTSD.

Aim: To determine the rate of current major depressive disorder (MDD) among entrants to treatment for heroin dependence in three treatment modalities and a non-treatment comparison group; and to ascertain factors associated with depression., Design: Cross sectional structured interview., Setting: Sydney, Australia., Participants: 615 current heroin users: 201 entering methadone/buprenorphine maintenance (MT), 201 entering detoxification (DTX), 133 entering drug free residential rehabilitation (RR) and 80 not in treatment (NT)., Findings: Current major depressive episode was reported by 25%. The rates of major depressive disorder ranged from 26% in the treatment groups (23% MT, 25% DTX, 31% RR) to 16% of those not in treatment. Females were more likely to have current major depressive episode (31% versus 21% OR 1.70, 95% CI 1.16-2.48). Factors associated with depression in the treatment groups were post traumatic stress disorder (PTSD), attempted suicide in the last 12 months and severe physical disability. Among the non-treatment group those with depression were also more likely to have PTSD. Women entering treatment were three times more likely to meet criteria for current major depression than women not in treatment. Among men however, the rates were not significantly different., Conclusion: Depression is a significant concern among entrants to treatment for heroin dependence. An essential component of treatment should be a consideration of depression, with the provision of appropriate treatment were required.

A cohort of 495 heroin users, recruited for the Australian Treatment Outcome Study (ATOS), were re-interviewed at 12 months regarding suicide attempts over the follow-up period. The proportion who had attempted suicide in the 12 months since baseline was not significantly different from that reported in the 12 months preceding ATOS enrolment (12.2% versus 9.1%), and attempted suicide did not decline significantly in any of the index treatment groups. Among males, there was no significant reduction in attempted suicide (8.7% versus 8.1%). Among females, however, the proportion reporting an attempt declined significantly from 19.7 to 9.8%. Of those who reported suicidal ideation at baseline, 22.8% made an attempt over the follow-up period, as did 19.0% of those who had major depression. Large, and significant, declines in suicidal ideation (23.1% versus 6.9%) and major depression (25.5% versus 10.9%) occurred over the study period. Independent predictors of a suicide attempt over the follow-up period were: social isolation, having made an attempt in the preceding 12 months, suicidal ideation at baseline, a greater number of treatment episodes and higher levels of baseline polydrug use.