Centre for Youth Mental Health - Research Publications

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    Contribution of neurocognition to 18-month employment outcomes in first-episode psychosis
    Karambelas, GJ ; Cotton, SM ; Farhall, J ; Killackey, E ; Allott, KA (WILEY, 2019-06)
    AIM: To examine whether baseline neurocognition predicts vocational outcomes over 18 months in patients with first-episode psychosis enrolled in a randomized controlled trial of Individual Placement and Support or treatment as usual. METHODS: One-hundred and thirty-four first-episode psychosis participants completed an extensive neurocognitive battery. Principal axis factor analysis using PROMAX rotation was used to determine the underlying structure of the battery. Setwise (hierarchical) multiple linear and logistic regressions were used to examine predictors of (1) total hours employed over 18 months and (2) employment status, respectively. Neurocognition factors were entered in the models after accounting for age, gender, premorbid IQ, negative symptoms, treatment group allocation and employment status at baseline. RESULTS: Five neurocognitive factors were extracted: (1) processing speed, (2) verbal learning and memory, (3) knowledge and reasoning, (4) attention and working memory and (5) visual organization and memory. Employment status over 18 months was not significantly predicted by any of the predictors in the final model. Total hours employed over 18 months were significantly predicted by gender (P = .027), negative symptoms (P = .032) and verbal learning and memory (P = .040). Every step of the regression model was a significant predictor of total hours worked overall (final model: P = .013). CONCLUSION: Verbal learning and memory, negative symptoms and gender were implicated in duration of employment in first-episode psychosis. The other neurocognitive domains did not significantly contribute to the prediction of vocational outcomes over 18 months. Interventions targeting verbal memory may improve vocational outcomes in early psychosis.
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    Social inclusion and its interrelationships with social cognition and social functioning in first-episode psychosis
    Gardner, A ; Cotton, SM ; Allott, K ; Filia, KM ; Hester, R ; Killackey, E (WILEY, 2019-06)
    AIM: People with psychosis are at risk of social exclusion. Research is needed in this area due to the lack of direct measurement of social inclusion, which becomes salient in adolescence and is relevant to first-episode psychosis (FEP; the onset of which typically occurs during or shortly after adolescence). Social inclusion may be impacted by impaired social cognition and social functioning, which are related features observed in psychosis. The aim of this study was to explore interrelationship(s) between social cognition, social functioning and social inclusion in FEP while controlling for symptomatology (positive, negative and depressive symptoms) and demographic characteristics. METHODS: A series of cross-sectional hierarchical multiple regressions were conducted to examine whether: social cognition (theory of mind, emotion recognition) predicted social functioning; social functioning predicted social inclusion, and whether social functioning mediated the relationship between social cognition and social inclusion in people aged 15 to 25 (M = 20.49, SD = 2.41) with FEP (N = 146). Age, sex, premorbid IQ, positive and negative psychotic symptoms and depression were control variables. RESULTS: Poor facial emotion recognition (β = -.22, P < .05) and negative symptoms (β = -.45, P < .001) predicted lower social functioning. Role-specific social functioning (ie, current employment) predicted greater social inclusion (β = .17, P < .05). Higher depression symptomatology predicted lower social inclusion (β = -.43, P < .001). Social functioning did not mediate the relationship between social cognition and inclusion. Psychotic symptoms were unrelated to social inclusion. CONCLUSIONS: Employment and depression may influence social inclusion somewhat independently of psychotic symptomatology in FEP. Inferences should be viewed with caution given this study did not involve longitudinal data.
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    Evaluation of a professional development training programme for mental health clinicians specializing in early psychosis
    Macneil, C ; Foster, F ; Nicoll, A ; Osman, H ; Monfries, R ; Cotton, S (WILEY, 2018-06)
    The Early Psychosis Prevention and Intervention Centre Statewide Services (ESW) team provides training for multidisciplinary clinicians that specialise in early psychosis across the State of Victoria, Australia. The aim of this paper is to describe the 4-phase approach utilised by ESW to prepare for and deliver workshops, to report on participants' ratings of the ESW workshops, and to make recommendations for other trainers of early psychosis clinicians. Between March 2009 and September 2014, ESW provided 85 training workshops that had a strong focus on evidence-based approaches and international guidelines, and utilized clinical examples of early psychosis interventions. At the conclusion of each workshop, participants were asked to complete a questionnaire that comprised qualitative and quantitative elements. These assessed perceived trainer knowledge, learning, interactivity and specific topic feedback. The focus of this paper will be on describing the quantitative data resulting from these questionnaires. A total of 1708 clinicians provided feedback on the 85 workshops. There was a high level of compliance, with 83.0% of workshop participants completing the questionnaires. Feedback was positive across all areas, with the 2 areas that were most highly endorsed being that presenters "appeared to know their subject matter well" (endorsed by 98.4% of participants) and that "topics were explained well" (endorsed by 96.8% of participants). Training for early psychosis clinicians that focusses on core clinical topics, is well planned, incorporates feedback from previous training, and is based on adult learning principles, is likely to be effective and well received by early psychosis clinicians.
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    Relationships between the frequency and severity of non-suicidal self-injury and suicide attempts in youth with borderline personality disorder
    Andrewes, HE ; Hulbert, C ; Cotton, SM ; Betts, J ; Chanen, AM (WILEY, 2019-04)
    AIM: Non-suicidal self-injury (NSSI) is a recognized indicator of suicide risk. Yet, the ubiquity of this behaviour in borderline personality disorder (BPD) limits its utility as a predictor of risk. Consequently, this study aimed to elucidate the relationship between other features of NSSI, including frequency and severity, and suicide attempts. METHOD: Participants included 107 youth (15 to 25 year olds) with BPD who were assessed for BPD severity, depressive symptoms, 12-month frequency of NSSI and suicide attempts, as well as the levels of treatment sought following each self-harm event. RESULTS: Three-quarters (75.7%) of youth with BPD reported NSSI and two-thirds (66.4%) reported a suicide attempt over the previous 12 months. The frequency of NSSI over the previous 12 months did not show a linear or quadratic relationship with the number of suicide attempts when adjusting for severity of depression, impulsivity and interpersonal problems. NSSI severity was not associated with more frequent suicide attempts. Only impulsivity and depression were uniquely predictive of suicide attempt frequency. A relative increase in the frequency and severity of NSSI occurred in the months prior to a suicide attempt. CONCLUSION: The prevalence of NSSI and suicide attempts among youth presenting for their first treatment of BPD appear to be perilously high, considerably higher than rates reported by adults with BPD. Findings suggest that clinicians should give more weight to average levels of impulsivity and depression, rather than the absolute frequency and severity of NSSI, when assessing for risk of suicide attempts. Notwithstanding this, a relative increase in the frequency and severity of NSSI appears to be predictive of a forthcoming suicide attempt.
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    Does co-occurring borderline personality disorder influence acute phase treatment for first-episode psychosis?
    Francey, SM ; Jovev, M ; Phassouliotis, C ; Cotton, SM ; Chanen, AM (WILEY, 2018-12)
    BACKGROUND: This aims of this study were: (1) to determine the prevalence of co-occurring borderline personality disorder (BPD) in a first-episode psychosis (FEP) sample; (2) to determine differences between patients with and without BPD on demographics, comorbidities and clinical risks and other variables; and (3) to examine whether BPD comorbidity influenced treatment received by patients for FEP during their first 3 months after service entry to a specialist early psychosis service. METHODS: A file audit was conducted for 100 consecutive admissions to an early psychosis service. Patients with a clinician-rated co-occurring diagnosis of BPD were compared with patients without clinician-rated BPD on a range of variables. RESULTS: Twenty-two percent of the FEP sample was diagnosed with co-occurring BPD by clinician ratings. The FEP group with co-occurring BPD was found to be younger, more likely to have other comorbidities, and were at higher risk of suicide and violent behaviour. Group differences were found in treatment received for FEP, whereby patients with co-occurring BPD had poorer access to standard treatment, including guideline concordant antipsychotic medication prescription. CONCLUSION: Young people with co-occurring clinician-rated BPD and FEP experienced greater difficulty accessing standard care for FEP and received relatively different treatment, including different pharmacotherapy, compared with those FEP patients without BPD. There is a need to develop new clinical guidelines and effective treatments for this specific subgroup with early psychosis and co-occurring BPD that take into account interpersonal and "premorbid" aspects of their presenting problems.
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    A systematic review and meta-analysis of prospective transition from major depression to bipolar disorder
    Ratheesh, A ; Davey, C ; Hetrick, S ; Alvarez-Jimenez, M ; Voutier, C ; Bechdolf, A ; McGorry, PD ; Scott, J ; Berk, M ; Cotton, SM (WILEY, 2017-04)
    OBJECTIVE: Some people with major depressive disorder (MDD) may be at a pre-onset stage for bipolar disorder (BD), where early identification or prevention efforts may be feasible. We aimed to identify rates and characteristics predictive of transition to BD in prospective follow-up studies of people with MDD. METHODS: Using a systematic search strategy, we identified studies with a diagnostic ascertainment of MDD and BD of an adequate standard, and where the minimum length of follow-up was 6 months. We examined the incidence and point prevalence of BD and the pooled odds ratios (OR) for baseline predictors. RESULTS: From 5554 unique publications, 56 were included. Nearly a quarter of adults (22.5%) and adolescents with MDD followed up for a mean length of 12-18 years developed BD, with the greatest risk of transition being in the first 5 years. The meta-analysis identified that transition from MDD to BD was predicted by family history of BD (OR = 2.89, 95% CI: 2.01-4.14, N = 7), earlier age of onset of depression (g = -0.33, SE = 0.05, N = 6) and presence of psychotic symptoms (OR = 4.76, 95% CI: 1.79-12.66, N = 5). CONCLUSIONS: Participants with the identified risk factors merit closer observation and may benefit from prevention efforts, especially if outcomes broader than BD are considered.
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    Ethical considerations in preventive interventions for bipolar disorder
    Ratheesh, A ; Cotton, SM ; Davey, CG ; Adams, S ; Bechdolf, A ; Macneil, C ; Berk, M ; McGorry, PD (WILEY, 2017-04)
    AIM: Early intervention and prevention of serious mental disorders such as bipolar disorder has the promise of decreasing the burden associated with these disorders. With increasing early and preventive intervention efforts among cohorts such as those with a familial risk for bipolar disorder, there is a need to examine the associated ethical concerns. The aim of this review was to examine the ethical issues underpinning the clinical research on pre-onset identification and preventive interventions for bipolar disorder. METHODS: We undertook a PubMed search updated to November 2014 incorporating search terms such as bipolar, mania, hypomania, ethic*(truncated), early intervention, prevention, genetic and family. RESULTS: Fifty-six articles that were identified by this method as well as other relevant articles were examined within a framework of ethical principles including beneficence, non-maleficence, respect for autonomy and justice. The primary risks associated with research and clinical interventions include stigma and labelling, especially among familial high-risk youth. Side effects from interventions are another concern. The benefits of preventive or early interventions were in the amelioration of symptoms as well as the possibility of minimizing disability, cognitive impairment and progression of the illness. Supporting the autonomy of individuals and improving access to stigma-free care may help moderate the potential challenges associated with the risks of interventions. CONCLUSIONS: Concerns about the risks of early identification and pre-onset interventions should be balanced against the potential benefits, the individuals' right to choice and by improving availability of services that balance such dilemmas.
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    Improving functional outcomes in early-stage bipolar disorder: The protocol for the REsearch into COgnitive and behavioural VERsatility trial
    Cotton, SM ; Berk, M ; Jackson, H ; Murray, G ; Filia, K ; Hasty, M ; Chanen, A ; Davey, C ; Nelson, B ; Ratheesh, A ; MacNeil, C (WILEY, 2019-12)
    AIM: Young people with bipolar disorder (BD) commonly experience reduced quality of life, persistent symptoms and impaired functional recovery despite often superior school performance. Compromised long-term functioning can ensue. There is evidence that psychological therapies alongside pharmacology may be more efficacious earlier in the course of the disorder. Intervention in the early stages may thus reduce the burden and risk associated with BD and mitigate the impact of the disorder on normal developmental trajectories. To date, however, the availability of evidence-based psychological therapies for young people with early BD is limited. Furthermore, there are no large-scale randomized controlled trials (RCTs) of such interventions. METHODS: The study is a prospective, single-blind, RCT examining the effectiveness of an adjunctive individualized and manualized psychological intervention, compared with treatment as usual within youth-specific early intervention services. The REsearch into COgnitive and behavioural VERsatility (RECOVER) intervention is delivered over a 6-month period. About 122 young people in the early stages of BD-I (at least one manic episode in the previous 2 years, with no more than five lifetime treated/untreated manic or hypomanic episodes) will be recruited. The assessments will occur at baseline, 3, 6 (primary endpoint, end of treatment), 9, 12, 15 and 18 months. RESULTS: Recruitment will commence in January 2019 and is anticipated to occur over a 3.5-year period. CONCLUSIONS: To date, there are no evidence-based psychological therapies tailored to young people with early BD. We will test whether early psychological intervention in the course of BD can reduce the symptomatic, psychological, vocational and social impacts that are seen in entrenched disorder.
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    Aripiprazole compared with placebo for auditory verbal hallucinations in youth with borderline personality disorder: Protocol for the VERBATIM randomized controlled trial
    Chanen, AM ; Betts, J ; Jackson, H ; McGorry, P ; Nelson, B ; Cotton, SM ; Bartholomeusz, C ; Jovev, M ; Ratheesh, A ; Davey, C ; Pantelis, C ; McCutcheon, L ; Francey, S ; Bhaduri, A ; Lowe, D ; Rayner, V ; Thompson, K (WILEY, 2019-12)
    AIM: Up to half of patients with borderline personality disorder report auditory verbal hallucinations that are phenomenologically indistinguishable from those in schizophrenia, occur early in the course of the disorder, and are enduring, distressing and disabling. In clinical practice, this symptom is widely assumed to be unresponsive to treatment with antipsychotic medication and early intervention is rarely offered. The Verbal Experiences Response in Borderline personality disorder to Aripiprazole TrIal Medication (VERBATIM) study aims to be the first controlled trial to investigate the effectiveness of conventional pharmacotherapy for this symptom in this patient group. METHOD: VERBATIM is a 12-week, triple-blind, single-centre, parallel groups randomised controlled trial, with a 27-week follow-up period. Participants between the ages of 15 and 25 years receive either aripiprazole or placebo daily, commencing at 2 mg and increasing to 10 mg by day 15. Further dose escalations (up to 30 mg) may occur, as clinically indicated. This trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry ACTRN12616001192471 on 30/08/2016. RESULTS: The primary outcome is severity of auditory verbal hallucinations assessed using the Psychotic Symptom Rating Scale. Secondary outcomes include the severity of general psychopathology, borderline personality pathology, social and occupational functioning and change in brain resting state connectivity. The primary endpoint is week 12 and secondary endpoint is week 39. CONCLUSION: The results will inform treatment decisions for individuals with borderline personality disorder who present with auditory verbal hallucinations.
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    Effectiveness of a professional development training program in increasing knowledge of mental health clinicians specializing in early psychosis
    Macneil, C ; Foster, F ; Nicoll, A ; Monfries, R ; Coulson, L ; Osnnan, H ; Grainger, M ; Cotton, S (WILEY, 2019-08)
    AIM: For early psychosis services to be effective, it is essential to have staff that are trained in evidence-based interventions in this area. In this paper, we report on research undertaken by The Early Psychosis Prevention and Intervention Centre's Statewide Services (ESW) team. The focus was on assessing knowledge acquisition in early psychosis clinicians that had attended ESW's specialist training. METHODS: Between October 2012 and October 2017, data were collected from a large cohort of clinicians that had attended 46 ESW workshops covering topics identified in international guidelines as key components of early psychosis service provision. Participants were asked to complete between 3 and 11 pre- and post-workshop short answer and/or multiple choice questions that related to learning outcomes for the workshop. The percentage of correct responses before and after the workshop was compared for each participant, with a cumulative measure taken to provide information regarding knowledge acquisition across each workshop. RESULTS: Participant compliance was high (89.7%) with 962 completed questionnaires being collected from 1073 attendees across the workshops. Results showed that the ESW training led to a statistically significant increase in clinician knowledge from pre-training scores of 47.2% correct, to 83.5% correct answers at the conclusion of training (pre M = 47.2%, SD = 28.8; post M = 83.5%, SD = 23.7; t[890] = -35.66, P < 0.001). CONCLUSIONS: Training that utilized adult learning principles had a strong focus on evidence-based interventions, and used clinical examples to embed core principles, led to a statistically significant increase in early intervention clinician knowledge.