Intergenerational transmission of post-traumatic stress disorder in Australian Vietnam veterans' families.

OBJECTIVE: To assess the association between parental post-traumatic stress disorder (PTSD) and offspring PTSD and its specificity for other disorders in a non-clinical epidemiological cohort of Australian Vietnam veterans, their partners and their sons and daughters. METHOD: Veterans were interviewed twice, in 1992-1994 and 2005-2006; partners were interviewed in 2006-2007, and their offspring in 2012-2014. A total of 125 sons and 168 daughters were interviewed from 197 families, 137 of which also included partners who were the mothers of the children. Statistical analysis used multi-level modelling to compute odds ratios and 95% confidence intervals while controlling for clustering effects within families. Parent PTSD diagnoses were examined for associations with offspring trauma exposure, PTSD and other psychiatric diagnoses. RESULTS: Veteran PTSD increased the risk of PTSD and no other disorder in both sons and daughters; partner PTSD did not. Veteran depression was also a risk factor for sons' PTSD, and alcohol disorder was linked to alcohol dependence in sons and PTSD in daughters, but not when controlling for veteran PTSD. CONCLUSION: We conclude that PTSD in a Vietnam veteran father increases the risk specifically for PTSD in his sons and daughters.

Cancer incidence in patients with schizophrenia and their first-degree relatives - a meta-analysis.

OBJECTIVE: Controversy concerning cancer incidence in schizophrenia exists because of heterogeneous study findings. METHOD: A meta-analysis was performed on standardized incidence ratios (SIR) of cancer in patients with schizophrenia and first-degree relatives and compared with general population samples. RESULTS: The pooled overall cancer incidence in patients was not significantly increased (SIR = 1.05, CI 0.95-1.15). Lung cancer incidence was slightly increased (SIR = 1.31, CI 1.01-1.71), but was reduced after adjusting for smoking prevalence. The incidence of several cancers unrelated to smoking was reduced in patients. Breast cancer rates were significantly increased in female patients. The pooled overall cancer incidence in siblings (SIR = 0.89, CI 0.84-0.94) and parents (SIR = 0.90, CI 0.88-0.93) was significantly reduced. A meta-regression detected a significant relationship between cancer risk in the general population and relative risk in patients. CONCLUSION: The meta-analysis aided exploration of inconsistent study findings. There is a discrepancy between cancer risk exposure and cancer incidence in schizophrenia consistent with a protective effect.

Communication across the divide. A trial of structured communication between general practice and emergency departments.

AIM: To evaluate the impact of structured form letters for general practitioner to emergency department (ED) communication. STUDY POPULATION: one hundred and fifty-five GPs with practices in the Liverpool local government area in metropolitan Sydney and patients referred by them to ED at Liverpool over five months from June to October 1998. DESIGN: randomised control trial of GPs as unit of randomisation; intervention GPs were encouraged to follow a structured proforma for their written communication with the ED. Control GPs were left to usual referral procedures. The ED was encouraged to fax a brief report back to GPs using the form. Impact measures: the quality of the referral letters was evaluated using a checklist that included: reason for referral; examination finding; medical history; investigations; psychosocial history; allergies; drugs given in the surgery and present medication. Surveys were sent every month to GPs to assess communication from the ED and adverse events observed by GPs. RESULTS: Most letters from GPs to the ED contained information on reasons for referral, medical history and examination findings. Reasons for referral were present in 95% of the intervention group GPs' letters compared with 99% of those of the control group. Investigations were included with 27% and present medications in 37%. Letters from GPs in the intervention group were more likely to contain a psychosocial history than those in the control group (13% compared with 1%). Most GPs reported receiving a letter from the ED although this was rarely by fax; most were brought to them by the patient. Phone calls were received by about one in five GPs each month. Most GPs found both of these to be useful. There were no differences between communication received by GPs in the intervention and control groups. CONCLUSION: This study demonstrates that improvements to communication between GPs and EDs are difficult and may require a systemic change within general practice and the hospital. Electronic systems may allow the sort of reciprocal communication required to establish and sustain improvement.

Are survey measures of medical care utilisation misleading? A comparison of self-reported medical care consumption with actual medical care utilisation.

A substantial over-estimate of medical care consumption cost was found when estimates from self-report data from an epidemiological study were compared to actual cost data extracted from administrative records. Even though the few subjects who were actually provided with two or more services in the two-week self-report period substantially under-reported their medical care consumption, a large net over-estimate of medical care consumption was produced by the self-report data. This finding has important implications for use of self-report data from surveys such as the Australian Bureau of Statistics (ABS) National Health Survey for estimating health service consumption. By combining epidemiological survey data from the Australian Vietnam Veterans Health Study (AVVHS), with data on actual medical care for which the Health Insurance Commission (HIC) or the Department of Veterans' Affairs (DVA) paid benefits, we were able to directly compare self-reported medical care consumption with actual medical care utilisation. The comparison revealed that veterans' self-reports were a valid measure of relative medical care consumption because those who reported care over the past two weeks were much more likely to have been recent consumers than those who did not. This relationship became even stronger if the comparison of self-report was extended to data on benefits paid beyond the two-week self-report period. However, the HIC and DVA data confirmed only 51% of veterans self-reporting medical care consumption during the past two weeks actually received a service.

Suicide risk following child sexual abuse.

OBJECTIVE: To determine the suicide rate and prevalence of suicide attempts and suicidal ideation in 183 young people who had experienced child sexual abuse and to examine variables related to the abuse, which may correlate with suicide attempts or suicidal ideation. METHODS: Adolescents and young adults who had experienced child sexual abuse and individuals from a nonabused comparison group were asked about suicide attempts and suicidal ideation 5 and 9 years after intake to the study. Nine years after the abuse, a national death search was carried out to ascertain the number and causes of death in the 2 groups. Logistic regression was used to assess information on demographic and family functioning variables, the sexual abuse, notifications for other child abuse, criminal convictions, and out-of-home placements that were related to the outcome variables. RESULTS: Young people who had experienced child sexual abuse had a suicide rate that was 10.7 to 13.0 times the national Australian rates. There were no suicides in the control group. Thirty-two percent of the abused children had attempted suicide, and 43% had thought about suicide since they were sexually abused. CONCLUSIONS: Little information seems to be available to clinicians at the time of investigations for child sexual abuse in children that may identify those who are at increased risk of suicide. Abuse by an acquaintance, parental denial, or being angry with the child and not the abuser may predispose to suicide attempts but not necessarily to a completed suicide.

Medical-care costs associated with posttraumatic stress disorder in Vietnam veterans.

OBJECTIVE: This study examined the relationship between medical-care costs of Vietnam veterans and predictor factors, including posttraumatic stress disorder (PTSD). METHOD: We merged medical-care cost data from the Department of Veterans' Affairs and the Health Insurance Commission with data from an epidemiological study of 641 Australian Vietnam veterans. Posttraumatic stress disorder and other factors were examined as predictors of medical-care cost using regression analysis. RESULTS: We found that a diagnosis of PTSD was associated with medical costs 60% higher than average. Those costs appeared to be partly associated with higher treatment costs for physical conditions in those with PTSD and also related mental health comorbidities. Major predictors of medical-care cost were age ($137 per year for each 5-year increase in age) and number of diagnoses reported ($81 to $112 per year for each diagnosis). Mental health factors such as depression ($14 per year for each symptom reported) and anxiety ($27 per year for each symptom reported) were also important predictors. CONCLUSIONS: The findings indicate that, however they are incurred, high healthcare and, presumably, also economic and personal costs are associated with PTSD. There is an important social obligation as well as substantial economic reasons to deal with these problems. From both perspectives, continued efforts to identify and implement effective prevention and treatment programs are warranted.

Screening for low prevalence disorders.

OBJECTIVE: To examine the epidemiologic theory of screening as it applies to low prevalence disorders, such as schizophrenia, in order to identify the tasks required for primary and secondary prevention. METHOD: Review of principles of screening, computation of prevented fraction for varying sensitivities, specificities and prevalences of disease, and review of prevalence of schizophrenia in Australian general practice. RESULTS: There is no currently available efficient method of screening for schizophrenia or for prodromal symptoms. From the genesis of disease to eventual outcome, the milestones that are passed in the case of schizophrenia are uncertain in their nature and the intervening time periods are of uncertain and possibly varying duration. The extent of false positives and negatives in low prevalence disorders is high unless the specificity is very high. CONCLUSION: It may be feasible to screen for behaviours that are precursors to schizophrenia; however, screening depends upon the existence of a reliable screening instrument that can be shown to discriminate accurately between diseased and disease-free individuals. Development of a method for screening requires comparison against formal clinical assessment of both screen positives and screen negatives. For low prevalence disorders the predictive values may be low unless specificity is high.

Distress experienced by participants during an epidemiological survey of posttraumatic stress disorder.

We examined the potential for epidemiological studies of mental disorders, specifically of posttraumatic stress disorder (PTSD), to cause further harm to participants involved. Of 1,000 randomly selected Australian Vietnam veterans, 641 agreed to participate in an epidemiological survey. Participants were asked about distress experienced during the interview when traumatic events were raised. Significant distress attributed to the interview was reported by 75.3% of those with current PTSD, 56.5% of those with past PTSD, and 20.6% of those with no PTSD diagnosis. Distress did not affect participants' use of medical services following the interview nor did it affect their willingness to continue participating in the study. We concluded that research interviews about PTSD may cause short-term distress, but found no evidence of long-term harm.

Acute effects of low levels of ambient ozone on peak expiratory flow rate in a cohort of Australian children.

BACKGROUND: We enrolled a cohort of primary schoolchildren with a history of wheeze (n = 148) in an 11-month longitudinal study to examine the relationship between ambient ozone concentrations and peak expiratory flow rate. METHODS: Enrolled children recorded peak expiratory flow rates (PEFR) twice daily. We obtained air pollution, meteorological and pollen data. In all, 125 children remained in the final analysis. RESULTS: We found a significant negative association between daily mean deviation in PEFR and same-day mean daytime ozone concentration (beta-coefficient = 0.88; P = 0.04) after adjusting for co-pollutants, time trend, meteorological variables, pollen count and ALTERNARIA: count. The association was stronger in a subgroup of children with bronchial hyperreactivity and a doctor diagnosis of asthma (beta-coefficient = -2.61; P = 0.001). There was no significant association between PEFR and same-day daily daytime maximum ozone concentration. We also demonstrated a dose-response relationship with mean daytime ozone concentration. CONCLUSIONS: Moderate levels of ambient ozone have an adverse health effect on children with a history of wheezing, and this effect is larger in children with bronchial hyperreactivity and a doctor diagnosis of asthma.

Acute effects of bushfires on peak expiratory flow rates in children with wheeze: a time series analysis.

OBJECTIVES: To determine the effects of the January 1994 Sydney bushfire on evening peak expiratory flow rates (PEFR) in children with wheeze. METHODS: Children with a history of wheeze were enrolled in the longitudinal study and completed a daily asthma diary. We obtained daily air pollution, meteorological, pollen and alternaria data. We then used generalised estimating equation techniques to determine associations between the bushfire period and particulate matter less than 10 microns (PM10) and PEFR. RESULTS: The maximum daily PM10 level peaked at 210 ug/m3, which was nearly seven times the usual PM10 level for the rest of January and February 1994. There was no significant association between mean PM10 and PEFR (beta-coefficient = -0.009, p = 0.86). Children without bronchial hyper-reactivity had a significant negative association between PEFR and PM10 (beta-coefficient = -0.1029, p = 0.03). The bushfire period was not significant in any of the models. CONCLUSIONS: We did not find an association between the bushfire period or PM10 and evening PEFR, although in a subgroup of children without bronchial hyper-reactivity, a significant negative association was present between PM10 and evening PEFR. IMPLICATIONS: We conclude that the high levels of particulate pollution caused by the Sydney bushfires did not lead to any clinically significant reductions in PEFR in symptomatic children. Our results have implications for community risk communication during future bushfires.

Where's the common ground? A survey of hospitals, community health centres and divisions of general practice in Australia.

BACKGROUND: Divisions of general practice are key structures for integration between general practice and other health services in Australia. AIM: To compare the views of divisions of general practice toward integration of care with those of hospitals and community health services. METHOD: Representative national samples of public hospitals and community health centres (CHCs) and a census of divisions of general practice (DGP) were surveyed on their current collaborations and links as well as barriers to and factors that enhance integration between general practitioners and other health services. RESULTS: There is wide agreement on the need for greater integration. Personal links (via letter, phone and face to face) were thought to be useful. However, general practice liaison officers were seen as especially useful. All organizations rated different accountabilities and responsibilities as a highly significant barrier. Resources, structures for collaboration and high level organisational support were rated as being more useful in enabling greater integration. CONCLUSION: Formalizing collaboration will require changes to funding and accountability. However there is also a need for cultural change to support greater integration of patient care between general practice and both hospitals and community health services.

Hoping and coping in young people who have been sexually abused.

BACKGROUND: Very little research has been conducted on the relationship between sexual abuse, reduced hopefulness and impaired coping. METHOD: The sample consisted of 22 abused young people (2 males (9%) and 20 females (91%)) and 29 nonabused young people (4 males (14%) and 25 females (86%)). Hopefulness, despair, depression, self-esteem, anxiety, number of negative life events and various parent, family and demographic variables were measured. The aim was to establish significant predictors of outcome, with outcome measured at the extreme end of the spectrum by self-injury and suicidal ideation and attempts. RESULTS: Depression predicted hopefulness and despair. Depression, anxiety, number of caregiver changes, despair and global personal hopefulness were significant predictors of outcome. Child sexual abuse itself was not a significant predictor of self-injury, suicidal ideation or suicide attempts in this sample. CONCLUSIONS: Each of the significant predictors of outcome, other than caregiver changes, has been linked to the learned helplessness paradigm. Depression and anxiety may be mediated by despair and hopefulness in their prediction of self-injury and suicidal attempts and ideation. To modify young people's long-term view of their futures and thereby reduce their vulnerability to depression and anxiety and in turn their tendency toward self-injury and suicide, something more than generic casework will be necessary. If self-injury, suicidal ideation and behaviour are to be effectively addressed, it is likely that anxiety and depression will need to be treated vigorously and attention will need to be paid to the perceived future.

Combat, dissociation, and posttraumatic stress disorder in Australian Vietnam veterans.

The specificity of various wartime stressors for different posttraumatic stress disorder (PTSD) symptoms is inconsistently reported in the literature. Combat, wounding, and peritraumatic dissociation have not been assessed together in their effects on each of the various PTSD symptom clusters. This cohort study of a random sample of male Australian Army Vietnam veterans yielded psychiatric assessments of 641 subjects. PTSD measures comprised symptom criteria for reexperiencing, numbing and avoidance, hyperarousal, and PTSD diagnosis both lifetime and current within the past month. Logistic regression is used to examine the effects of combat, wounding, and peritraumatic dissociation together on PTSD. Combat experiences comprised four components derived from a principal components analysis of combat experiences: direct combat exposure, exposure to death and injury, exposure to civilian death and injury, and exposure to mutilation. Each was differentially related to reexperiencing, avoidance, hyperarousal, and PTSD diagnosis. Being wounded was not related to lifetime or current PTSD and peritraumatic dissociation was related to all diagnostic components of PTSD in the presence of other variables.

Posttraumatic stress disorder and other predictors of health care consumption by Vietnam veterans.

A total of 641 randomly selected Australian veterans of the Vietnam War were interviewed about their use of health care in the previous two weeks to determine what factors contributed to health care consumption. Seventy-three variables were examined by univariate linear regression and then grouped into seven categories relating to age, physical and mental health, predisposition to posttraumatic stress disorder (PTSD), deployment and repatriation experiences, and membership in veterans groups. PTSD was associated with an additional cost of $79 in health care for the two-week period. Each physical diagnosis was associated with an additional $28. Alcohol consumption was not related to health care costs. Other important variables contributing to costs were depression, educational status, the quality of the repatriation experience, and social support.

Prior childhood sexual abuse in mothers of sexually abused children.

OBJECTIVE: To see if mothers who were sexually abused in their own childhood are at increased risk of their children being sexually abused and to see if prior sexual abuse in mothers affects their parenting abilities. METHOD: Sixty-seven mothers whose children had been sexually abused by others and 65 control mothers were asked about sexual abuse in their own childhood. The sexually abused children of mothers who had been sexually abused in their own childhood were compared with the sexually abused children of mothers who had not suffered child sexual abuse as children. Comparisons were made on self-esteem, depression and behavior in the children. RESULTS: Thirty-four percent of mothers of sexually abused children gave a history of sexual abuse in their own childhoods, compared with 12% of control mothers. Assessment of the sexually abused children for self-esteem, depression and behavior at the time of diagnosis, after 18 months and after 5 years showed no difference in any of these measures at any of the three time intervals between those whose mothers had suffered child sexual abuse and those whose mothers had not been abused. CONCLUSION: In this study, sexual abuse in a mother's own childhood was related to an increased risk of sexual abuse occurring in the next generation, although prior maternal sexual abuse did not effect outcome in children who were sexually abused.

A training strategy for personnel working in developing countries.

Throughout the world a common consensus has emerged that community based services offer the best prospect of meeting the needs of people with disabilities and their families. However the shift away from specialist centres and institutions has not been accompanied as yet by a reappraisal of the training required by personnel working in these new forms of services. This paper describes the training strategy which has been developed by the Community Based Rehabilitation Programme in Guyana, South America. This has three components. First, the identification of training needs of families and support workers, second, the production of video-based training packages on specific topics and third, the utilisation of available personnel to act as local tutors. This strategy has resulted in over 7000 CBR volunteers, health workers, teachers in mainstream schools, families and villagers having access to information and skills which otherwise they would be denied. An immediate priority in developing countries is to nurture the human resources required to develop and sustain this sort of training strategy and proposals for doing this are outlined.