In a statement, Victoria police said it was “extremely saddened to confirm that one of our members from the southern metropolitan region died last night following an apparent suicide”.

“He was off-duty at the time,” the statement said.

“Our thoughts and deepest sympathies are with his family, friends and colleagues at this very difficult time.”

Three Victoria police members have killed themselves so far this year.

“The death by suicide of a police member is always cause for enormous concern,” Victoria police said.

“Looking after our people is one of our highest priorities. We know that anxiety, depression and post-traumatic stress can all be triggered by the stressful situations our people can find themselves in.”

In October, the Victoria police chief commissioner, Graham Ashton, launched a review into the mental health and wellbeing of Victoria police employees. His announcement came two weeks after a senior constable took her own life while on duty at a Melbourne centre for victims of sexual assault.

The review will examine how Victoria police can support police officers during and after their career and make recommendations on how this support can be strengthened.

On Wednesday, Ashton told ABC radio that police stress and suicides were a “worsening situation” in Victoria.

“I’m seeing a lot more police suicides than I ever used to,” he told the ABC.

“This affects everyone differently and people absorb issues, absorb trauma and absorb things that they’re exposed to in different ways, and we have to understand that.”

The deaths follow the announcement on Monday by the Victorian police minister, Wade Noonan, that he would take three months’ leave from parliament due the toll of “constant exposure to details of unspeakable crimes and traumatic events”.

“It has been difficult to cope with the constant exposure to details of unspeakable crimes and traumatic events that are an everyday part of my role and accumulation of these experiences has taken an unexpected toll,” he said.

In December the National Coronial Information System released data on intentional self-harm rates among emergency services personnel, revealing 62 police service members took their own life across Australia between 2000 and 2012.

This article first appeared on ‘The Guardian’ on 11 February 2016.

After a lifetime of profound depression, 25 years of therapy and cycling through 18 antidepressants and mood stabilisers, Mr Hartman, then 46, had settled on a date and a plan to end it all. This clinical trial would be his last stab at salvation.

For 40 minutes, he sat in a hospital room as an IV drip delivered ketamine through his system. Several more hours passed before it occurred to him that all his thoughts of suicide had evaporated.

“My life will always be divided into the time before that first infusion and the time after,” Mr Hartman says today. “That sense of suffering and pain draining away. I was bewildered by the absence of pain.”

Ketamine, popularly known as the psychedelic club drug Special K, has been around since the early 1960s. It is a staple anaesthetic in emergency rooms, regularly used for children when they come in with broken bones and dislocated shoulders.

It’s an important tool in burn centres and veterinary medicine, as well as a notorious date-rape drug, known for its power quickly to numb and render someone immobile.

Since 2006, dozens of studies have reported that it can also reverse the kind of severe depression that traditional antidepressants often don’t touch. The momentum behind the drug has now reached the American Psychiatric Association (APA), which, according to members of a ketamine taskforce, seems headed towards a tacit endorsement of the drug for treatment-resistant depression.

Experts are calling it the most significant advance in mental health in more than half a century. They point to studies showing ketamine not only produces a rapid and robust antidepressant effect; it also puts a quick end to suicidal thinking.

Traditional antidepressants and mood stabilisers, by comparison, can take weeks or months to work. In 2010, a major study published in JAMA, the journal of the American Medical Association, reported that drugs in a leading class of antidepressants were no better than placebos for most depression.

A growing number of academic medical centres, including Yale University, the University of California at San Diego, the Mayo Clinic and the Cleveland Clinic, have begun offering ketamine treatments off-label for severe depression, as has Kaiser Permanente in Northern California.

“This is the next big thing in psychiatry,” says L. Alison McInnes, a San Francisco psychiatrist who over the past year has enrolled 58 severely depressed patients in Kaiser’s San Francisco clinic.

She says her long-term success rate of 60 per cent for people with treatment-resistant depression who try the drug has persuaded Kaiser to expand treatment to two other clinics in the Bay Area.

The excitement stems from the fact that it’s working for patients who have spent years cycling through antidepressants, mood stabilisers and various therapies.

“Psychiatry has run out of gas” in trying to help depressed patients for whom nothing has worked, she says.

“There is a significant number of people who don’t respond to antidepressants, and we’ve had nothing to offer them other than cognitive behaviour therapy, electroshock therapy and transcranial stimulation.”

Dr McInnes is a member of the APA’s ketamine taskforce, assigned to codify the protocol for how and when the drug will be given. She says she expects the APA to support the use of ketamine treatment early this year.

The guidelines, which follow the protocol used in the NIMH clinical trial involving Mr Hartman, call for six IV drips over a two-week period. The dosage is very low, about a 10th of the amount used in anaesthesia. And when it works, it does so within minutes or hours.

“It’s not subtle,” says Enrique Abreu, an anaesthesiologist from Portland, Oregon, who began treating depressed patients with it in 2012.

“It’s really obvious if it’s going to be effective. And the response rate is unbelievable. This drug is 75 per cent effective, which means that three-quarters of my patients do well. Nothing in medicine has those kind of numbers.”

So far, there is no evidence of addiction at the low dose in which infusions are delivered. Ketamine does, however, have one major limitation: its relief is temporary.

Clinical trials at NIMH have found that relapse usually occurs about a week after a single infusion.

Ketamine works differently from traditional antidepressants, which target the brain’s serotonin and noradrenalin systems. It blocks N-methyl-D-aspartate (NMDA), a receptor in the brain that is activated by glutamate, a neurotransmitter.

In excessive quantities, glutamate becomes an excitotoxin, meaning that it overstimulates brain cells.

“Ketamine almost certainly modifies the function of synapses and circuits, turning certain circuits on and off,” explains Carlos Zarate, NIMH’s chief of neurobiology and treatment of mood disorders, who has led the research on ketamine.

“The result is a rapid antidepressant effect.”

A study published in the journal Science in 2010 suggested that ketamine restores brain function through a process called synaptogenesis.

Scientists at Yale University found that ketamine not only improved depression-like behaviour in rats but also promoted the growth of new synaptic connections between neurons in the brain.

Even a low-dose infusion can cause intense hallucinations. Patients often describe a kind of lucid dreaming or dissociative state in which they lose track of time and feel separated from their bodies. Many enjoy it; some don’t. But studies at NIMH and elsewhere suggest that the psychedelic experience may play a small but significant role in the drug’s efficacy.

“It’s one of the things that’s really striking,” says Steven Levine, a psychiatrist from Princeton, New Jersey, who estimates that he has treated 500 patients with ketamine since 2011.

“With depression, people often feel very isolated and disconnected. Ketamine seems to leave something indelible behind. People use remarkably similar language to describe their experience: ‘a sense of connection to other people’, ‘a greater sense of connection to the universe.’ ”

Although bladder problems and cognitive deficits have been reported among long-term ketamine abusers, none of these effects have been observed in low-dose clinical trials.

In addition to depression, the drug is being studied for its effectiveness in treating obsessive-compulsive disorder, post-traumatic stress disorder, extreme anxiety and Rett syndrome, a rare developmental disorder on the autism spectrum.

Fleeting remission effect

The drug’s fleeting remission effect has led many patients to seek booster infusions. Mr Hartman began his search before he even left his hospital room in Bethesda.

Four years ago, he couldn’t find a doctor in the Pacific Northwest willing to administer ketamine.

“At the time, psychiatrists hovered between wilful ignorance and outright opposition to it,” says Mr Hartman, whose depression began creeping back a few weeks after his return to Seattle.

It took nine months before he found an anaesthesiologist in New York who was treating patients with ketamine. Soon, he was flying back and forth across the country for bimonthly infusions.

Upon his request, he received the same dosage and routine he’d received in Bethesda: six infusions over two weeks. And with each return to New York, his relief seemed to last a little longer. These days, he says that his periods of remission between infusions often stretch to six months. He says he no longer takes any medication for depression besides ketamine.

“I don’t consider myself permanently cured, but now it’s something I can manage like diabetes or arthritis,” Mr Hartman says. “Before, it was completely unmanageable. It dominated my life and prevented me from functioning.”

In 2012, he helped found the Ketamine Advocacy Network, a group that vets ketamine clinics, advocates for insurance coverage and spreads the word about the drug.

And word has indeed spread. Ketamine clinics, typically operated by psychiatrists or anaesthesiologists, are popping up in major cities around the country.

Dr Levine, for one, is about to expand from New Jersey to Denver and Baltimore. Dr Abreu recently opened a second clinic in Seattle.

Depression is big business. An estimated 15.7 million adults in the United States experienced at least one major depressive episode in 2014, the NIMH says.

“There’s a great unmet need in depression,” says Gerard Sanacora, director of the Yale Depression Research Program.

“We think this is an extremely important treatment. The concern comes if people start using ketamine before CBT [cognitive behavioral therapy] or Prozac. Maybe someday it will be a first-line treatment. But we’re not there yet.”

‘More research needed’

Dr Sanacora says a lot more research is required. “It’s a medication that can have big changes in heart rate and blood pressure. There are so many unknowns, I’m not sure it should be used more widely until we understand its long-term benefits and risks.”

While a single dose of ketamine is cheaper than a $2 bottle of water, the cost to the consumer varies wildly, running from between $US500 and $US1500 per treatment. The drug itself is easily available in any pharmacy, and doctors are free to prescribe it – as with any medication approved by the Food and Drug Administration – for off-label use. Practitioners attribute the expense to medical monitoring of patients and IV equipment required during an infusion.

There is no registry for tracking the number of patients being treated with ketamine for depression, the frequency of those treatments, dosage levels, follow-up care and adverse effects.

“We clearly need more standardisation in its use,” Dr Zarate says. “We still don’t know what the proper dose should be. We need to do more studies. It still, in my opinion, should be used predominantly in a research setting or a highly specialised clinic.”

As a drug once known almost exclusively to anaesthesiologists, ketamine now falls into a grey zone.

“Most anaesthesiologists don’t do mental health, and there’s no way a psychiatrist feels comfortable putting an IV in someone’s arm,” Dr Abreu says.

It’s a drug, in other words, that practically demands collaboration. Instead, it has set off a turf war. As the use of ketamine looks likely to grow, many psychiatrists say that use of ketamine for depression should be left to them.

“The bottom line is you’re treating depression,” says psychiatrist David Feifel, director of the centre for Advanced Treatment of Mood and Anxiety Disorders at the University of California at San Diego.

“And this isn’t garden-variety depression. The people coming in for ketamine are people who have the toughest, potentially most dangerous depressions. I think it’s a disaster if anaesthesiologists feel competent to monitor these patients. Many of them have bipolar disorder and are in danger of becoming manic. My question [to anaesthesiologists] is: ‘Do you feel comfortable that you can pick up mania?’ ”

But ketamine has flourished from the ground up and with little or no advertising. The demand has come primarily from patients and their families; Dr Zarate, for instance, says he receives “at least 100 emails a day” from patients.

Nearly every one of them wants to know where they can get it.

This article first appeared on ‘Sydney Morning Herald’ on 2 February 2016.

Hunter Partners in Recovery aims to better support people with mental illness by getting multiple services to work in a more collaborative and integrated way.

The service is hosting a forum today, called ‘Working Together for Change’, in a bid to identify and address gaps in the system.

Hunter Primary Care CEO Kevin Sweeney said the service has already helped more than 550 people.

“It’s very important that we retain a consistent strategy and approach for these people,” he said.

“Clearly they need a comprehensive suite of services to be able to assist them to recover, to function well in society.

“So it’s important that the funding continues in whatever form.”

The forum’s keynote speakers are Frank Quinlan from Mental Health Australia, and Leanne Wells from Consumer Health Forum Australia.

Doctor Sweeney said support services are already working together, but more can be done.

“It’s a question of bringing them together and looking at the particular issues of this client group,” he said.

This article first appeared on ‘ABC’ on 28 October 2015.

The study appears in the Journal of Gerontology: Social Sciences, and finds gender differences when long-married partners are asked about their marital relationship.

“The men don’t really want to talk about it or spend too much time thinking about it,” said Carr. “Men often don’t want to express vulnerable emotions, while women are much more comfortable expressing sadness or worry.”

The finding supports Carr’s belief that men and women have very different emotional reactions to the strain and support they experience in marriage. While talking about issues and offering support makes the wives — who traditionally feel responsible for sustaining the emotional climate of a marriage — feel good, this only frustrated the husbands surveyed.

“For women, getting a lot of support from their spouse is a positive experience,” said Carr. “Older men, however, may feel frustrated receiving lots of support from their wife, especially if it makes them feel helpless or less competent.”

In the study, 722 couples, married an average of 39 years, were asked how their marital experience and the reactions of their spouse affected them.

They responded to whether they could open up to their spouse if they needed to talk about their worries, whether their spouse appreciates them, understands the way they feel about things, argues with them, makes them feel tense, and gets on their nerves.

“Men who provide high levels of support to their wives may feel this frustration if they believe that they would rather be focusing their energies on another activity,” Carr said.

It may also have something to do with the age of the couples, with one spouse in the study having to be at least 60. Men of this generation may feel less competent if they need too much support from their wives, Carr said.

This article first appeared on ‘Psych Central’ on 27 October 2015.

Professor Mike Slade, from King’s College London’s Institute of Psychiatry, says the current attitude of mental health professionals is one of “do what we tell you to do and you will be well again.”

He says stigma against mental illness is alive and well among health professionals, who continue to maintain “hope-destroying” practices.

While developed countries have closed most asylums, they’ve inadvertently created “virtual institutions”, where sufferers who appear to live in the community are actually stuck in a “mental illness-defined bubble”.

Prof Slade is calling for a shift to a ‘nothing about us without us’ attitude, where those affected by mental health problems are involved in the debate about their future.

“If we only listen to professional constructions and narratives, we inadvertently oppress,” he told Mental Health Australia’s Grace Groom Memorial Oration in Canberra on Wednesday night.

Treatment should be offered as a resource in someone’s recovery, “rather than done to them in their best interests”.

Prof Slade wants the mental health system to employ more people with lived experience of mental illness.

Instead of focusing only on patients, the system should be working with employers, educating them on how to accommodate workers with mental illness.

Mental health needed to move from a treatment-based model to a citizenship model, focusing on supporting people to make their own way rather than providing interventions.

“Living well for most of us does not happen in the hospital or in mental health service settings” Prof Slade said.

“It happens as we live our lives in our chosen community.”

This article first appeared on ‘SBS’ on 21 October 2015.

German researchers analysed data from 20,000 people from three nations in the most comprehensive and largest study to date on the issue.

They found that birth order had no effect on five key personality traits: extroversion, emotional stability, agreeableness, conscientiousness and imagination.

However, the paper, published in the journal Proceedings of the National Academy of Sciences, supported earlier findings that the first child in a family was likely to be more intelligent.

Co-author Julia Rohrer, from the University of Leipzig, said the link between birth order and personality was first mooted in the early 1900s by psychiatrist and philosopher Alfred Adler — the second of six children.

He claimed firstborns were privileged, but also burdened by feelings of excessive responsibility and a fear of dethronement and were more likely to score high on neuroticism.

However, the idea became firmly entrenched in the modern era when United States academic, Professor Frank Sullaway, developed the Family Niche Theory of birth-order effects in 1996.

Based on Darwin’s theories of evolution, he argued that siblings adapted to certain roles within the family to reduce competition and enhanced the family unit’s “fitness”.

According to Professor Sulloway’s theory, because firstborns were physically superior to their siblings at a young age, they were more likely to show dominant behaviour and become less agreeable.

Laterborns, searching for other ways to assert themselves, tended to rely on social support and become more sociable and thus more extroverted.

Personality theory deeply entrenched

Ms Rohrer said this theory had become deeply entrenched in the public psyche.

“Whether you have younger or older siblings appears to be of such great importance as a child, that the assumption that this has a lasting impact on personality just seems ‘natural’,” Ms Rohrer said.

“I think there are some biases at work that help firm those beliefs. For example, parents might infer their firstborn is emotionally unstable and very anxious because their infant cries a lot and is easily scared.

“The second-born child might actually cry just as much, but now the parents already know that this is just the way that children are, and stop attributing this behaviour to the child’s character.”

To test Professor Sullaway’s theory, Ms Rohrer’s team used data from three large national studies in Great Britain, the US and Germany.

The team undertook a range of analysis and looked for effects that were evident within families and also more generally expressed across all families.

“We tried our best, but we simply couldn’t find the majority of the expected effects in our data sets,” she said.

Their finding that birth order had no lasting impact on later personality traits was consistent across all three national studies, across the different measures of personality and across the participants’ whole of life span, she said.

The study could be the final nail in the coffin of Professor Sullaway’s theory.

Ms Rohrer said there was now a large body of work that had been unable to detect the birth-order effects as predicted by the Family Niche Theory.

“Rationally, we might want to abandon its main ideas or maybe modify its content in a way that it is more in line with empirical findings,” she said.

Firstborn IQ effects ‘rather humble’

Ms Rohrer said the study did confirm IQ is impacted by birth order and said it was likely this was due to social effects rather than biological.

“One theory is that later children ‘dilute’ the resources of the parents, including attention,” she said.

While the firstborn gets full parental attention for at least some time, laterborns would have to “share” from the beginning.

Another possible contributing factor was that a firstborn could “tutor” their younger siblings, explaining to them how the world worked.

“Teaching other people has high cognitive demands,” Ms Rohrer said.

“The children need to recall their own knowledge, structure it and think of a good way to explain it to youngsters, which could be a boost to intelligence for some firstborns.”

However, she said the IQ effects were “rather humble” and not deterministic.

“The effect does not imply that every firstborn is slightly more intelligent than his or her younger siblings. It means that if you assess the intelligence of a large number of sibships, you will find more sibships in which the firstborn is smarter than sibships in which the laterborn is smarter,” she said.

“So as a thirdborn, you could very well be more intelligent than your older siblings, and birth order is only one of multiple factors that can contribute to differences in intelligence amongst siblings.”

This article first appeared on ‘ABC‘ on 20 October 2015.

“It makes the world of difference, especially today,” he said after meeting with Ms Thorp in his home for a phone consultation with a doctor in Broken Hill. “I wouldn’t go outside, I wouldn’t go anywhere else to see a doctor.”  Too sick to drive 200 kilometres from the South Australian town to Broken Hill for help, the texts and the subsequent meeting with Ms Thorp were a “lifeline”.

While Pete (last name withheld) finds the openness and the nothingness of the bush “almost uplifting”, the lack of privacy in a small town was suffocating: “Everybody knows what everyone’s doing, everybody knows what everyone’s saying.” Ms Thorp is part of a push by the Royal Flying Doctor Service to expand its mental health services to meet growing demand. In 2014, demand for mental health services grew 30 per cent, and in 2013, they jumped 28 per cent. In response, the RFDS will offer mental health services in the Central West, out of its Dubbo base, and has increased the number of mental health experts like Thorp based in Broken Hill. They visit towns like Wilcannia, White Cliffs, Packsaddle, Menindee, Tibooburra, and Wanaaring.
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To maintain patients’ privacy, discretion, decoys and improvisation are needed. Ms Thorp sees patients wherever she can: on a park bench, near a toilet block, the front seat of a hot car or in a corridor of an abandoned railway building. Another man, who has a history of depression and was angry after a heart attack, talked informally to her in the shade of an old corrugated iron wall that had become her defacto office in Yunta on a hot spring day. Later that day, the same man sent a friend over to meet Ms Thorp. Referrals like these are one reason why demand has grown, RFDS said.

“Sometimes we have to be discrete so it may mean wandering away, having a walk with someone, or if we have access to a vehicle, we may take them for a drive down the river so we are not actually seen with that person,” Ms Thorp, who is a highly experienced and credentialed nurse who has also run area hospitals, said.

To throw others off the scent, she makes a point of talking to as many as people as possible. That was not hard in Yunta where nearly half the population and some station owners and families visited the improvised clinic or dropped in for a chat. “Whether it is g’day, how are you, just to pass the time of day so you can’t necessarily put two and two together,” she said.

To gain trust in towns where newcomers are viewed with suspicion, the mental health nurses hit the streets – visiting the police, the school, roadhouses and local businesses to introduce themselves.

Problems range from depression to relationship issues, which can be a real challenge when families live and work together as closely as they do on properties and businesses in remote areas. She also visits schools to talk to children about developing healthy mental habits and building on their own strengths.

Vicki Hemley, of Packsaddle Station, about 200kms north of Broken Hill, sought counselling and advice after a young family friend killed himself.

“Mental health problems are not unique to the bush, but the uniqueness of the bush is where do we go to get help and who do we talk to now? If we can’t get an appointment for a week, that week may be the difference between someone getting help or making a rash decision.”

A 42-year-old with no children of her own, she was heartbroken by the boy’s death, and she also wanted advice on what to say to his family.

“Glynis told me to listen,” Ms Hemley, who added that Ms Thorp had also listened to her, said.

About 20 per cent of Australians suffer a mental illness each year and women are twice as likely to seek help for mental health issues as men, especially in the rural and remote areas serviced by the RFDS. Yet the amount of mental services in the bush lags behind those in the city.

This article first appeared on ‘Sydney Morning Herald’ on 15 October 2015.

During Mental Health Week last week, Health Minister Cameron Dick unveiled the Queensland Mental Health Promotion, Prevention and Early Intervention Plan 2015-17, which aims to improve the mental health and wellbeing of Queenslanders by taking early action.

Mr Dick also announced more than $450,000 in funding to improve mental health through greater social inclusion and community participation, particularly in regional areas.

In Parliament yesterday Ms Howard highlighted the government’s commitment to youth mental health, in light of the LNP’s closure of the Barrett Adolescent Centre, which is currently the subject of a commission of inquiry headed by the Hon. Margaret A Wilson QC.

“The Palaszczuk Government values the mental health of our youth and has committed $11.8 million over four years to rebuild mental health care for young people in Queensland after the last three years of neglect,” she said.

Ms Howard also emphasised the importance of working together as a society that values mental health.

“Mental health is an issue that touches all of our lives at some point, either personally or through the experiences of friends and family,” Ms Howard said.

“Most of us can manage these issues and get on with our lives, but others need help.

“Whether as a government, a community or individually, we must do everything we can to assist them.”

Meanwhile the Opposition today sought a bipartisan approach to mental health support services by harmonising two bills currently before Parliament.

Shadow Minister for Health Mark McArdle said it was crucial politics was left at the door when dealing with such an important issue as mental health.

“Currently there are two bills before Parliament, one introduced by the LNP in April and the other introduced by Labor in September,” Mr McArdle said.

“Both bills aim to improve and maintain the health and wellbeing of persons with a mental illness and ensure Queenslanders are supported through evidence based clinical practice.

“In the Minister’s speech introducing the government bill into the house he said, the ‘bills have many reform directions in common’.

“Given the Minister’s comments, it makes sense to present one single Mental Health bill supported by all sides of politics.

“The LNP has written to the Minister for Health and the Chair of the Parliamentary Health and Ambulance Services Committee Leanne Linard calling for one, unified bill on Mental Health.

“In the letter we have requested an extension of the reporting time to allow for this process to occur.

“We are also open to work with the government on any differences within the bills, proposing for any issue to be set aside and worked through individually to form a set of consensus clauses.”

Mr McArdle said one bill, being supported by all sides of politics sends a clear message that mental health is a clinical area where a great deal of bipartisanship exists.

“By working together we can deliver a bill that improves the lives of the nearly 20% of Queenslanders affected by a mental disorder each year,” he said.

The West Moreton Mental Health Collaborative held a number of free community events around the Ipswich region during Mental Health Week last week, including a morning walk, a community showcase at The Park Centre for Mental Health, an information night and a free breakfast in Queens Park and held a silent art auction at the Ipswich Community Art Gallery. Aftercare also hosted an early childhood mental health forum.

This article first appeared on ‘Queensland Times’ on 14 October 2015.

Last year in the Northern Territory, 86% of those in prison and 96% of those in juvenile detention were Indigenous. In Western Australia, Indigenous people account for only 3% of the population, but 40% of prisoners.

It is unacceptable to ignore the intellectual capacity of a person facing the court and it’s vital to ensure that youth put behind bars have been properly assessed before sentencing. This is particularly important for Australians affected by fetal alcohol spectrum disorders (FASD). These occur throughout society and in high levels in some Indigenous communities.

The capacity to screen for prenatal alcohol exposure – as well as to diagnose FASD – must urgently be increased. This echoes recent calls by Perth Children’s Court magistrate Catherine Crawford for clinicians to assess children and youth before sentencing, so the court understands their cognitive limitations.

Cognitive limitations

Fetal alcohol spectrum disorders are a group of preventable conditions resulting from exposure to alcohol in the womb. Alcohol readily crosses the mother’s placenta, entering the circulation of the developing fetus with devastating effects.

Significantly, it can disrupt brain development and that of other organs, causing lifelong problems. These include developmental delay, intellectual and memory impairment, as well as a range of behavioural, emotional and mental health disorders.

People with FASD can suffer from attention-deficit hyperactivity disorders (ADHD), communication disorders, poor impulse control, disobedience and hostility issues, and learning difficulties.

They often struggle to distinguish right from wrong and fail to learn from mistakes. Few with FASD will live and work independently. Many have mental health and substance misuse problems.

It is no surprise that many also come in contact with the law. An adolescent living with a FASD in Canada or the United States, for instance, is estimated to have a 19 times higher risk of incarceration than someone without a FASD.

Despite this, the condition remains poorly recognised and few obtain a diagnosis prior to offending. Offenders with FASD are often poor witnesses and fail to understand why they have been detained. Unable to negotiate the justice system, they are adversely influenced by others and often enter a cycle of re-offending.

FASD and the justice system

Rosie Fulton, a 21-year-old Aboriginal woman with FASD and significant intellectual impairment, was arrested last year after stealing and crashing a car. Declared unfit to stand trial, Rosie was sent to Western Australia’s Kalgoorlie Prison for lack of alternative accommodation.

She stayed in jail for 21 months with no trial or conviction. Only after her story broke, mounting pressure on the health ministers of Western Australia and the Northern Territory led to Rosie being transferred to supervised community accommodation close to her family in Alice Springs.

In Australia, we don’t know how many people deemed “unfit to plead” are in prison and how many have cognitive impairment, as we lack recent data regarding rates of FASD in prisons. US studies suggest up to 60% of young people with FASD will at some time enter the juvenile justice system.

Another study, conducted in a forensic mental health facility in Canada, showed 23% of resident youth had one type of FASD. This figure may be higher in vulnerable Australian populations, particularly in some remote regions where alcohol use in pregnancy is prevalent.

The economic impact of incarcerating people with FASD is huge. In Canada, the direct cost to the correctional system between 2011 and 2012 was CAD$17.5 million for youth and CAD$356.2 million for adults.

Screening for FASD

Diagnosing FASD is a challenge because as children get older, a firm history of prenatal alcohol exposure may be elusive. With age, the characteristic facial features (small eye openings, a thin upper lip and flat philtrum, the area between the upper lip and base of the nose) of fetal alcohol syndrome – a subset of FASD – diminish, and growth deficits correct.

Thorough assessment by a physician, a psychologist and, if necessary, allied health professionals, can identify impairments required for a FASD diagnosis, whether fetal alcohol syndrome or a neuro-developmental disorder associated with prenatal alcohol exposure. Such impairments can be in IQ, communication, memory, motor and executive function, and other areas.

In Canada, youth probation officers are using a tool for screening young offenders for FASD, and identifying the need for referral and assessment.

Another tool for health professionals with accompanying guidelines for assessing and diagnosing people with FASD is being developed in Australia. This will standardise the diagnostic approach.

Tools such as these are necessary to increase screening and diagnostic capacity in the justice and health systems. If a diagnosis is known, the associated behavioural and cognitive deficits can be taken into account when considering the reliability of evidence given by an offender, the supervision required in detention, and the sentence.

Appropriate care

There has been a call for better legal support for people with vulnerabilities in their journey through the criminal justice system. Consideration should be given to the defence of diminished responsibility in conditions such as FASD.

And alternative models of care need to be found to avoid imprisonment of those unable to plead. As identified in the case of Rosie Fulton, this poses a significant challenge, particularly in remote Australia where alternative accommodation is not readily available and would be costly to establish.

But prison is far more costly. In Canada, the justice system accounts for 40% of the total costs of FASD (including health and education). And Australia’s Senate inquiry on justice reinvestment heard that the estimated cost of detaining a juvenile offender in New South Wales in 2010–11 was much higher ($A652 per day) than the cost of supervision in the community ($A16.73 per day).

To end the cycle of re-offending, we urgently need evidence-based strategies to ensure offenders with FASD are recognised early and receive the care they deserve.

This article first appeared on ‘The Conversation’ on 13 October 2015.