1. Pathways to risk: What can we do? Ian Webster

2. PATHWAYS TO RISK Sven Silburn 2003

3. PATHWAYS TO RISK Sven Silburn 2003 Society & social Educational development Early development MHS Emotional development

4. Opportunities for prevention - Anticipatory care Impairment of body & mind Misuse Loss of function performance Social disadvantage Disease Injury Use Addiction Mental health & suicide risk

7. 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)

8. Dependence Criteria*Depression Tolerance (to a drug) physiologicalNot specific to depression Withdrawal symptoms (from a drug) physiological Not specific to depression Excess use; longer periods of drugNot specific to depression Persistent desire, failure to cut down or control Loss of control not specific to depression Time spent drug seekingNot 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

9. Depression and chronic illness/disease Most chronic illnessesHigh rates of depression approx 20% - 80% Disability and inability to work Increased rates of depression Distressing symptoms – breathlessness Increased depression PainVery high depression; high suicide rates IsolationIncreased depression and suicide risk TreatmentTreatment may be depressing MedicationsDrugs may be depressing eg. cortisone, anticholinergics, phenothiazines

10. Sensing Brain Seeing Brain Motor Brain Planning Brain Smelling & Tasting Brain Balancing & Coordinating Brain Messaging system PAIN FEELING ANXIETY DRIVES MOTIVATION HUNGER APPETITES SOMATOSENSORY BRAIN HIGHER LEVEL – Context, Planning, Action LOWER LEVEL – Safety, Drives, Emotion

11. You and me? The remarkable human being Mental distress Alcohol and other drug misuse Mental illnessAddiction/dependence Physical illness and disabilities (The special case of chronic pain.)

12. 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

19. Homeless - Sydney 1998 3 in 4 have a mental disorder 1 in 2 have a chronic physical illness

20. 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

21. 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