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.

To gather their results, researchers went to the eastern Democratic Republic of Congo, a region routinely called “the worst place in the world” to be a woman, said Darlene A. Kertes, the study’s lead author and an assistant professor in UF’s department of psychology. Women in this unstable region are routinely the target of rape and other war-related traumas.

“Our research shows that stressful life experiences affect our bodies all the way down to our genes,” said Kertes, who also is affiliated with the University of Florida Genetics Institute.

The study was published in the January/February issue of Child Development, the flagship journal for the Society for Research in Child Development. The results showed that mothers’ stressful life experiences were linked with epigenetic markers in key genes that regulate the body’s response to stress, in both mothers and newborns.

“The study is one of the first of its kind to be conducted in a developing country,” Kertes said. “Most information to date about effects of stress and trauma on prenatal development has been gathered in a Western context.”

Samples of umbilical cord blood, placenta and the mothers’ blood were collected at birth and tested for impacts of war trauma and chronic stress. The researchers looked at DNA methylation, an epigenetic process that makes genes more or less able to respond to biochemical signals in the body.

During pregnancy, a mother’s bodily responses to stress are passed onto the fetus, affecting a child’s brain development, birth weight and functioning of the children’s own HPA axis even after they are born.

The researchers looked at the babies’ birth weight as an indicator of children’s overall development. They found that stress-linked DNA methylation differences predicted lower birth weight.

“The stress exposure affected the maternal and fetal tissues differently, which shows that the impact of stress differs depending on an individual’s life phase,” Kertes said, adding that stress experienced at very young ages affects the way the body responds to stress throughout life.

This is the first time researchers have documented stress effects, either pre- or postnatal, on methylation of a gene called CRH in humans. CRH makes a hormone that triggers the body’s stress response. The study also confirmed stress effects on several other genes known to be involved in the stress response.

Kertes and her colleagues have started to examine the longer term effects of stress on child development in conflict-ridden regions. She emphasized that traumatic events can also have cross-generational impacts.

“War and conflict do not just impact the health and well-being for people who experience it directly,” she said. “It can potentially have long-term consequences for future generations.”

This article first appeared on ‘Eurek Alert’ on 2 February 2016.

People get more depressed after the age of 65, says an English study using data on older Australians.

It’s the first to show depressive symptoms continue to increase throughout old age, says lead researcher Dr Helena Chui from the University of Bradford.

“We are in a period of unprecedented success in terms of people living longer than ever and in greater numbers and we should be celebrating this but it seems that we are finding it hard to cope,” she said.

Both men and women reported increasingly more depressive symptoms as they aged, with women initially having more than men.

“However, men showed a faster rate of increase in symptoms so that the difference in the genders was reversed at around the age of 80,” the researchers said.

Levels of physical impairment, the onset of medical conditions and the approach of death all played a part in having the symptoms.

“It seems that we need to look carefully at the provision of adequate services to match these needs, particularly in the area of mental health support and pain management,” Dr Chui said.

“Social policies and ageing-friendly support structures, such as the provision of public transport and access to health care services are needed to target the ‘oldest-old’ adults as a whole.”

This article first appeared on ‘9 News’ on 16 November 2015. ]]> http://www.newsinmind.com/research/depression-increases-with-age-study/feed 0 http://www.newsinmind.com/politics/government-urged-to-continue-supporting-mental-health-program http://www.newsinmind.com/politics/government-urged-to-continue-supporting-mental-health-program#respond Wed, 28 Oct 2015 00:55:32 +0000 http://www.newsinmind.com/?p=7605 There are calls for the Federal Government to continue funding a program that is making a massive difference for people with severe and persistent mental illness.

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.

Researchers at the Centers for Disease Control and Prevention (CDC) report that excessive drinking cost the U.S. $249 billion in 2010, or $2.05 per drink, a significant increase from $223.5 billion, or $1.90 per drink, in 2006.

Binge drinking, defined as drinking five or more drinks on one occasion for men or four or more drinks on one occasion for women, played a significant role in the expenditures. This behavior was responsible for most of these costs (77 percent).

The study appears in the American Journal of Preventive Medicine.

Notably, two of every five dollars of costs — more than $100 billion — were paid by governments.

“The increase in the costs of excessive drinking from 2006 to 2010 is concerning, particularly given the severe economic recession that occurred during these years,” said Robert Brewer, M.D., M.S.P.H., head of CDC’s Alcohol Program and one of the study’s authors.

“Effective prevention strategies can reduce excessive drinking and related costs in states and communities, but they are under used.”

Excessive alcohol use cost states and the District of Columbia a median of $3.5 billion in 2010, ranging from $488 million in North Dakota to $35 billion in California. Washington, D.C., had the highest cost per person ($1,526, compared to the $807 national average), and New Mexico had the highest cost per drink ($2.77, compared to the $2.05 national average).

The 2010 cost estimates were based on changes in the occurrence of alcohol-related problems and the cost of paying for them since 2006.

Even so, the researchers believe that the study underestimates the cost of excessive drinking because information on alcohol is often underreported or unavailable, and the study did not include other costs, such as pain and suffering due to alcohol-attributable harms.

This article first appeared on ‘Psych Central’ on 19 October 2015.

Over 35 per cent had experienced some form of mental health issue and more than 80 per cent knew a close friend or relative with similar experiences. Nearly three in ten said they had been discriminated against or knew someone who had, for mental health problems. And while most said they would be happy to talk about their mental health problems at church, seven in ten said their churches offered no resources to deal with it.

Previous research by ComRes showed that mental health issues account for nearly 25 per cent of the disease quota in Britain yet attracts just 11 per cent of NHS spending.

A recent BBC story stated that universities are facing a 10 per cent rise in demand for counselling services from students, with recorded mental health cases having risen from 8,000 to 18,000 between 2008 and 2012.

The online research was conducted via Christian Research’s panel of around 17,000 practising Christians across the UK, with 1,275 responding between 5 and 7 October.

“This is a clear sign that churches need to provide a more supportive space for their congregations to explore these issues,” said Maddy Fry, the researcher behind the study.

Earlier this year the UK’s largest Christian disability charity, Livability, joined forces with Premier Mind and Soul to create new resource to help churches better understand people with mental health needs in their congregations.

Christian Today reported that Katharine Welby-Roberts, an associate at Livability and the Archbishop of Canterbury’s daughter, who has spoken publicly regarding her struggles with depression, said: “As anti-stigma campaigns, such as Time to Change, begin to see societal attitudes towards mental health change, the Church has begun to recognise the need to better support people with mental health needs in their congregations.” She said that churches wanted to support people with mental health problems, but did not know how. “This can often lead to isolation or people leaving the Church because they feel misunderstood or not catered for. I believe the Church is a key untapped local resource which can support people with mental health needs.”

This article first appeared on ‘Christian Today’ 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.