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Purpose Integrated care is widely supported as a means of improving treatment outcomes for people with co-occurring mental health and substance use disorders. Over the past two decades, Australian state and federal governments have identified integrated care as a policy priority and invested in a number of research and capacity building initiatives. This study aims to examine Australian research evaluating the effectiveness of integrated treatment approaches to provide insight into implications for future research and practice in integrated treatment. Design/methodology/approach This narrative review examines Australian research evaluating empirical evidence of the effectiveness of integrated treatment approaches within specific populations and evidence from initiatives aimed at integrating care at the service or system level. Findings Research conducted within the Australian context provides considerable evidence to support the effectiveness of integrated approaches to treatment, particularly for people with high prevalence co-occurring disorders or symptoms of these (i.e. anxiety and depression). These have been delivered through various modalities (including online and telephone-based services) to improve health outcomes in a range of populations. However, there is less evidence regarding the effectiveness of specific models or systems of integrated care, including for more severe mental disorders. Despite ongoing efforts on behalf of the Australian government, attempts to sustain system-level initiatives have remained hampered by structural barriers. Originality/value Effective integrated interventions can be delivered by trained clinicians without requiring integration at an organisational or structural level. While there is still considerable work to be done in terms of building sustainable models at a system level, this evidence provides a potential foundation for the development of integrated care models that can be delivered as part of routine practice.

Background Australia has one of the highest rates of methamphetamine (MA) use in the world; however, uptake of in-person psychological treatment remains extremely low due to numerous individual (e.g., stigma, shame) and structural (e.g., service accessibility, geographical location) barriers to accessing care. Telephone-delivered interventions are ideally placed to overcome many of the known barriers to treatment access and delivery. This randomised controlled trial (RCT) will examine the efficacy of a standalone, structured telephone-delivered intervention to reduce MA problem severity and related harms. Methods This study is a double-blind, parallel group RCT. We will recruit 196 ± 8 individuals with mild to moderate MA use disorder from across Australia. After eligibility and baseline assessments, participants will be randomly allocated to receive either the Ready2Change-Methamphetamine (R2C-M) intervention (n = 98 ± 4; four to six telephone-delivered intervention sessions, R2C-M workbooks, and MA information booklet) or control (n = 98 ± 4; four to six ≤ 5-minute telephone check-ins and MA information booklet including information on accessing further support). Telephone follow-up assessments will occur at 6-weeks and 3-, 6- and 12-months post-randomisation. The primary outcome is change in MA problem severity (Drug Use Disorders Identification Test, DUDIT) at 3 months post-randomisation. Secondary outcomes are: MA problem severity (DUDIT) at 6- and 12-months post-randomisation; amount of methamphetamine used, methamphetamine use days, methamphetamine use disorder criteria met, cravings, psychological functioning, psychotic-like experiences, quality of life, and other drug use days (at some or all timepoints of 6-weeks and 3-, 6- and 12-month post-randomisation). Mixed-methods program evaluation will be performed and cost effectiveness will be examined. Discussion This study will be the first RCT internationally to assess the efficacy of a telephone-delivered intervention for MA use disorder and related harms. The proposed intervention is expected to provide an effective, low-cost, scalable treatment for individuals otherwise unlikely to seek care, preventing future harms and reducing health service and community costs. Trial registration: ClinicalTrials.gov NCT04713124, pre-registered 19 January, 2021. Protocol version V5 01 September 2022

Pharmacological interventions for disordered and problem gambling have been employed in clinical practice. Despite the availability of several reviews of the efficacy of pharmacological interventions for disordered or problem gambling, few have employed systematic search strategies or compared different categories of pharmacological interventions. Systematic reviews of high-quality evidence are therefore essential to provide guidance regarding the efficacy of different pharmacological interventions for disordered or problem gambling.The primary aims of the review were to: (1) examine the efficacy of major categories of pharmacological-only interventions (antidepressants, opioid antagonists, mood stabilisers, atypical antipsychotics) for disordered or problem gambling, relative to placebo control conditions; and (2) examine the efficacy of these major categories relative to each other. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase, and PsycINFO (all years to 11 January 2022).We included randomised trials evaluating a pharmacological intervention for the treatment of disordered or problem gambling. Eligible control conditions included placebo control groups or comparisons with another category of pharmacological intervention.We used standard methodological procedures, including systematic extraction of included study characteristics and results and risk of bias assessment. Our primary outcome was reduction in gambling symptom severity. Our secondary outcomes were reduction in gambling expenditure, gambling frequency, time spent gambling, depressive symptoms, anxiety symptoms, and functional impairment; and responder status. We evaluated treatment effects for continuous and dichotomous outcomes using standardised mean difference (SMD) and risk ratios (RR), respectively, employing random-effects meta-analyses. A minimum of two independent treatment effects were required for a meta-analysis to be conducted (with only meta-analytic findings reported in this abstract).We included 17 studies in the review (n = 1193 randomised) that reported outcome data scheduled for end of treatment. Length of treatment ranged from 7 to 96 weeks. Antidepressants: Six studies (n = 268) evaluated antidepressants, with very low to low certainty evidence suggesting that antidepressants were no more effective than placebo at post-treatment: gambling symptom severity (SMD -0.32, 95% CI -0.74 to 0.09, n = 225), gambling expenditure (SMD -0.27, 95% CI -0.60 to 0.06, n = 144), depressive symptoms (SMD -0.19, 95% CI -0.60 to 0.23, n = 90), functional impairment (SMD -0.15, 95% CI -0.53 to 0.22, n = 110), and responder status (RR 1.24, 95% CI 0.93 to 1.66, n = 268). Opioid antagonists: Four studies (n = 562) evaluated opioid antagonists, with very low to low certainty evidence showing a medium beneficial effect of treatment on gambling symptom severity relative to placebo at post-treatment (SMD -0.46, 95% CI -0.74 to -0.19, n = 259), but no difference between groups in responder status (RR 1.65, 95% CI 0.86 to 3.14, n = 562). Mood stabilisers: Two studies (n = 71) evaluated mood stabilisers (including anticonvulsants), with very low certainty evidence suggesting that mood stabilisers were no more effective than placebo at post-treatment: gambling symptom severity (SMD -0.92, 95% CI -2.24 to 0.39, n = 71), depressive symptoms (SMD -0.15, 95% CI -1.14 to 0.83, n = 71), and anxiety symptoms (SMD -0.17, 95% CI -0.64 to 0.30, n = 71). Atypical antipsychotics:Two studies (n = 63) evaluated the atypical antipsychotic olanzapine, with very low certainty evidence showing a medium beneficial effect of treatment on gambling symptom severity relative to placebo at post-treatment (SMD -0.59, 95% CI -1.10 to -0.08, n = 63). Comparative effectiveness: Two studies (n = 62) compared antidepressants with opioid antagonists, with very low certainty evidence indicating that antidepressants were no more effective than opioid antagonists on depressive symptoms (SMD 0.22, 95% CI -0.29 to 0.72, n = 62) or anxiety symptoms (SMD 0.21, 95% CI -0.29 to 0.72, n = 62) at post-treatment. Two studies (n = 58) compared antidepressants with mood stabilisers (including anticonvulsants), with very low certainty evidence indicating that antidepressants were no more effective than mood stabilisers on depressive symptoms (SMD 0.02, 95% CI -0.53 to 0.56, n = 58) or anxiety symptoms (SMD 0.16, 95% CI -0.39 to 0.70, n = 58) at post-treatment. Tolerability and adverse events: Several common adverse effects were reported by participants receiving antidepressants (e.g. headaches, nausea, diarrhoea/gastrointestinal issues) and opioid antagonists (e.g. nausea, dry mouth, constipation). There was little consistency in the types of adverse effects experienced by participants receiving mood stabilisers (e.g. tiredness, headaches, concentration difficulties) or atypical antipsychotics (e.g. pneumonia, sedation, increased hypomania). Discontinuation of treatment due to these adverse events was highest for opioid antagonists (10% to 32%), followed by antidepressants (4% to 31%), atypical antipsychotics (14%), and mood stabilisers (13%).This review provides preliminary support for the use of opioid antagonists (naltrexone, nalmefene) and atypical antipsychotics (olanzapine) to produce short-term improvements in gambling symptom severity, although a lack of available evidence precludes a conclusion regarding the degree to which these pharmacological agents can improve other gambling or psychological functioning indices. In contrast, the findings are inconclusive with regard to the effects of mood stabilisers (including anticonvulsants) in the treatment of disordered or problem gambling, and there is limited evidence to support the efficacy of antidepressants. However, these conclusions are based on very low to low certainty evidence characterised by a small number of included studies, high risk of bias, modest pooled sample sizes, imprecise estimates, moderate between-study heterogeneity, and exclusion of participants with psychiatric comorbidities. Moreover, there were insufficient studies to conduct meta-analyses on many outcome measures; to compare efficacy across and within major categories of interventions; to explore dosage effects; or to examine effects beyond post-treatment. These limitations suggest that, despite recommendations related to the administration of opioid antagonists in the treatment of disordered or problem gambling, pharmacological interventions should be administered with caution and with careful consideration of patient needs. A larger and more methodologically rigorous evidence base with longer-term evaluation periods is required before definitive conclusions can be drawn about the effectiveness and durability of pharmacological treatments for disordered or problem gambling.

PurposeThe OPPICO cohort is a population-based cohort based on non-identifiable electronic health records routinely collected from 464 general practices in Victoria, Australia, created with the aim of understanding opioid prescribing, policy impacts and clinical outcomes. The aim of this paper is to provide a profile of the study cohort by summarising available demographic, clinical and prescribing characteristics.ParticipantsThe cohort described in this paper comprises people who were aged at least 14 years at cohort entry, and who were prescribed an opioid analgesic at least once at participating practices for a total of 1 137 728 person-years from 1 January 2015 to 31 December 2020. The cohort was formed using the data collected from electronic health records through the Population Level Analysis and Reporting (POLAR) system. The POLAR data primarily consist of patient demographics, clinical measurements, Australian Medicare Benefits Scheme item numbers, diagnoses, pathology testing and prescribed medications.Finding to dateIn total, the cohort consists of 676 970 participants with 4 389 185 opioid prescription records from 1 January 2015 to 31 December 2020. Approximately half (48.7%) received a single opioid prescription, and 0.9% received more than 100 opioid prescriptions. The mean number of opioid prescriptions per patient was 6.5 (SD=20.9); prescriptions for strong opioids accounted for 55.6% of all opioid prescriptions.Future plansThe OPPICO cohort data will be used for various types of pharmacoepidemiological research, including examining the impact of policy changes on coprescription of opioids with benzodiazepines and gabapentin, and monitoring trends and patterns of other medication utilisation. Through data-linkage between our OPPICO cohort and hospital outcome data, we will examine whether policy changes for opioid prescribing lead to changes in prescription opioid-related harms, and other drug and mental health-related outcomes.Trial registration numberEU PAS Register (EUPAS43218, prospectively registered).

BACKGROUND People with gambling problems frequently report repeated unsuccessful attempts to change behaviour. Even though a range of behaviour change techniques are available to individuals to reduce gambling harm, they can be challenging to implement or maintain in the moment. The provision of implementation support, tailored for immediate, real-time individualised circumstances, may improve attempts at behaviour change. OBJECTIVE The aim of the current study is to develop and evaluate a Just-In-Time Adaptive Intervention (JITAI) for individuals who want support sticking to their gambling limits. The JITAI development is based on the principles of the Health Action Process Approach with delivery in alignment with the principles of Self-Determination Theory. The primary objective is to determine the effect of action and coping planning compared to no intervention on the goal of subsequently adhering to gambling expenditure limits. METHODS Gambling Habit Hacker is delivered as a JITAI providing in-the-moment support for adhering to gambling expenditure limits (primary proximal outcome). Delivered via smartphone app, this JITAI delivers tailored Behaviour Change Techniques relating to goal setting, action planning, coping planning and self-monitoring. The Gambling Habit Hacker app will be evaluated with a 28-day micro-randomised trial (MRT). Up to 200 individuals seeking support for their own gambling from Australia and New Zealand will set a gambling expenditure limit (i.e., goal). They will then be asked to complete three Ecological Momentary Assessments (EMAs) per day over a 28-day period. EMAs will assess real-time adherence to gambling limits, strength of intention to adhere to goals, goal self-efficacy, urge self-efficacy and being in a high-risk situation. Based on responses to each EMA, participants will be randomised to the control (a set of 25 self-enactable strategies containing names only and no implementation information) or intervention (self-enactable strategy implementation information with facilitated action and coping planning) conditions. This MRT will be supplemented with: (i) a 6-month within-group follow-up which explores the longer-term impact of the app on gambling expenditure (primary distal outcome) and a range of secondary outcomes (gambling frequency, gambling symptom severity, psychological distress, well-being, situational confidence and planning propensity); (ii) an evaluation of acceptability of the JITAI via post-intervention surveys, app usage and engagement indices, and in-depth interviews. RESULTS The intervention has been subject to expert user testing, with high acceptability scores. The results will inform a more nuanced version of the Gambling Habit Hacker app for wider use. CONCLUSIONS Gambling Habit Hacker is part of a suite of interventions for addictive behaviours that deliver implementation support grounded in lived experience. This study may inform the usefulness of delivering implementation intentions in real-time and in real-world settings. It potentially offers people with gambling problems new support to set gambling intentions and stick to their limits. CLINICALTRIAL This trial has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622000497707) and has been approved by the Deakin University Human Research Ethics Committee (2020-304).

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This study aimed to examine the environmental and operational factors that disrupt sleep in the acute, non-ICU hospital setting.This was a prospective study of adult patients admitted to an acute tertiary hospital ward (shared versus single room) and sleep laboratory (single room conducive to sleep).This study measured ambient light (lux) and sound (dB), number of operational interruptions, and questionnaires assessing sleep and mental health.Sixty patients were enrolled, 20 in a double bedroom located close to the nursing station ('shared ward'), 20 in a single bedroom located distant to the nursing station ('single ward') and 20 attending the sleep laboratory for overnight polysomnography ('sleep laboratory'). Sleep was disturbed in 45% of patients in the shared and single ward groups (Pittsburgh Sleep Quality Index 5). Light levels were appropriately low across all 3 locations. Sound levels (significant effect of room F(1.38) = 6.452, p = 0.015) and operational interruptions (shared ward 5.6 ± 2.5, single ward 6.2 ± 2.9, sleep laboratory 2.7 ± 2.1 per night, p 0.05 wards compared to sleep laboratory) were higher in the shared and single ward group compared to the sleep laboratory but not compared to each other. Noise was rated as the greatest environmental disturbance by 70% of ward patients compared to 10% in the sleep laboratory.Higher noise levels and frequent operational interruptions are potential barriers to sleep and recovery on an acute medical ward which are not ameliorated by being in a single bedroom located distant to the nursing station.

The release of the National Ice Taskforce report in late 2015 highlights the need for greater investment in and promotion of drug treatment. In response, the Australian government recently announced the allocation of almost $300 million in new money, predominantly for drug treatment, as part of a four-year strategy of improved treatment, aftercare, education, prevention, support and community engagement to address issues relating to methamphetamine. While such an investment is essential, addressing low rates of help‐seeking for alcohol and drug problems remains a significant challenge, partly because of the stigma associated with these disorders, prevailing pessimism amongst some in the community regarding the effectiveness of drug treatment, and the finding that many methamphetamine users do not see drug treatment services as relevant or necessary. Indeed, people who use methamphetamine have poor engagement with specialist treatment, with data suggesting that only one‐third of dependent methamphetamine users in the community have ever received help for their methamphetamine use.

Cellular release of nucleotides is of physiological importance to regulate and maintain cell function and integrity. Also in the tubular and collecting duct system of the kidney, nucleotides are released in response to changes in cell volume or luminal flow rate and act in a paracrine and autocrine way on basolateral and luminal P2Y receptors. Recent studies using gene knockout mice assigned a prominent role to G protein-coupled P2Y(2) receptors, which are activated by both ATP and UTP. The antidiuretic hormone, arginine-vasopressin (AVP), and possibly an increase in collecting duct cell volume induce ATP release. The subsequent activation of P2Y(2) receptors inhibits AVP-induced cAMP formation and water reabsorption, which stabilizes cell volume and facilitates water excretion. An increase in NaCl intake enhances luminal release of ATP and UTP in the aldosterone-sensitive distal nephron which by activating apical P2Y(2) receptors and phospholipase C lowers the open probability of the epithelial sodium channel ENaC, thereby facilitating sodium excretion. Thus, the renal ATP/UTP/P2Y(2) receptor system not only serves to preserve cell volume and integrity but is also regulated by stimuli that derive from body NaCl homeostasis. The system also inhibits ENaC activity during aldosterone escape, i.e. when sodium reabsorption via ENaC is inappropriately high. The P2Y(2) receptor tone inhibits the expression and activity of the Na-K-2Cl cotransporter NKCC2 in the thick ascending limb and mediates vasodilation. While the role of other P2Y receptors in the kidney is less clear, the ATP/UTP/P2Y(2) receptor system regulates NaCl and water homeostasis and blood pressure.

Combining energy drinks (such as 'Red Bull(®)') with alcohol is becoming increasingly popular, particularly among young people. However, as yet, limited research has been conducted examining the harms associated with this form of drinking.To review current evidence associated with combining energy drinks with alcohol and provide recommendations for addressing this issue within primary care.Combining alcohol with energy drinks can mask the signs of alcohol intoxication, resulting in greater levels of alcohol intake, dehydration, more severe and prolonged hangovers, and alcohol poisoning. It may also increase engagement in risky behaviours (such as drink driving) as well as alcohol related violence. General practitioners should be aware of the harms associated with this pattern of drinking, and provide screening and relevant harm reduction advice.

To assess dosing, efficacy, and tolerability of quetiapine fumarate in drug-naive first-episode psychosis.We present a prospective, randomized, controlled, single-center, double-blind, fixed-dose, 4-week comparison study of 200 mg/day versus 400 mg/day of quetiapine in 141 drug-naive acutely ill first-episode psychosis patients (diagnosed according to DSM-IV) aged 15 to 25 years. The double-blind 4-week trial (Part 1) was followed by a single-blind, naturalistic, flexible-dose 8-week period (Part 2). The main outcome measures were symptomatic change, functioning, and tolerability. Data were collected from July 2003 until January 2006.The estimated time trends of the linear mixed-effects modeling indicated that efficacy between the 2 treatment groups in Part 1 was similar for most outcome measures except for 5 measures: the Scale for the Assessment of Negative Symptoms (SANS) anhedonia-asociality subscale (p = .011), the Social and Occupational Functioning Assessment Scale (p = .020), the Global Assessment of Functioning scale (p = .070), the SANS affective flattening or blunting subscale (p = .051), and the Udvalg for Kliniske Undersogelser total (p = .056), suggesting that the 200-mg group improved more for the SANS anhedonia-asociality subscale, whereas the 400-mg group showed a slight deterioration. Social and global functioning also improved more in the 200-mg group than in the 400-mg group. Part 2 of the study revealed that, independent of the initial target dose, when clinicians were able to adjust the dose flexibly, the dose at 12 weeks was similar between groups and averaged 268 mg/day.Our study in acutely ill drug-naive first-episode psychosis patients suggests that quetiapine is a safe and well-tolerated antipsychotic medication. In contrast to multiepisode patients, dosing should be more conservative in untreated new-onset cases. An initial dose of 250 to 300 mg/day of quetiapine is proposed as a primary target dose in drug-naive first-episode psychosis patients.clinicaltrials.gov Identifier: NCT00449397.

Chapter 16 describes how to apply brief motivational interviewing (MI) interventions to the treatment of depression and anxiety as applied to the a case study, along with some of the challenges and potential solutions to applying MI in practice.

Alcohol is Australia's most socially acceptable legal drug; however alcohol-related harms have increased significantly over time. Encouraging safer levels of alcohol consumption should be a national health priority and a key focus for health practitioners.The purpose of this paper is to discuss some of the reasons that alcohol is such a popular and valued commodity in Australia, as well as some of the common problems caused by alcohol. We outline the most effective policy and treatment approaches to reduce alcohol consumption and related harms.Research evidence suggests that the most effective policies for reducing alcohol consumption and related harms are those focused on restricting its availability and accessibility; however, such strategies are often not implemented or enforced for political and economic reasons. Undertaking screening and brief intervention are effective ways of addressing problematic alcohol consumption within primary care and can be further supported through promoting community-organised periods of abstinence.