Melbourne School of Psychological Sciences - Theses
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ItemThe SENSE Study (Sleep and Education: learning New Skills Early): long-term outcomes of a randomised controlled trial of a cognitive-behavioural and mindfulness-based group sleep intervention to prevent depression and improve anxiety in at-risk adolescents( 2019)Objective: Depression is one of the most common and debilitating mental health problems and its incidence dramatically increases during adolescence. Accumulating evidence suggests that adolescent depression can be prevented with psychosocial interventions, but there is still insufficient evidence to support their widespread implementation. Notably, there is a need for randomised controlled trials of novel interventions that are delivered to community-based adolescents identified to be at-risk for developing depression (i.e., targeted prevention) rather than the general adolescent population (i.e., universal prevention). Improving sleep represents a promising and innovative therapeutic target for the prevention of adolescent depression. Not only are sleep problems, including insufficient and poor-quality sleep, common during adolescence, they also tend to precipitate the onset of depression. Further, sleep interventions may be especially effective if they are delivered to adolescents experiencing anxiety. Anxiety, particularly generalised anxiety, and sleep problems often co-occur, and anxiety is also a risk factor for the development of depression. Evidence from a small but growing number of studies indicates that multicomponent cognitive-behavioural and mindfulness-based sleep interventions can improve sleep in adolescent samples. However, few studies have investigated depression and anxiety outcomes, particularly using randomised controlled designs, active control comparison conditions, extended follow-up periods, a multi-method assessment of sleep (i.e., subjective and objective measures) and mental health (i.e., diagnosis and symptoms) outcomes, and in community-based samples. Notably, no randomised controlled trial has investigated whether a sleep intervention can prevent the first onset of major depressive disorder (MDD) in adolescents. The current study was designed to address these gaps in the literature. The primary aim of the study was to investigate the long-term efficacy of a seven-week cognitive-behavioural and mindfulness-based group sleep intervention for the targeted prevention of first onset MDD and improvement of depressive symptoms over a two-year follow-up period in community-based adolescents experiencing concurrent high levels of anxiety symptoms and sleep problems (i.e., ‘at-risk’ for depression). Given the association between sleep and anxiety, notably generalised anxiety disorder (GAD), and dearth of adolescent sleep intervention studies investigating anxiety outcomes, the secondary and exploratory aim of the study was to investigate the long-term efficacy of the sleep intervention for preventing the incidence of GAD and improving anxiety symptoms over a two-year follow-up period. Importantly, the study aimed to demonstrate that any beneficial effects to depression and/or anxiety outcomes occurred via the putative mechanism of improvements to subjective and objective indices of sleep. As best can be determined, the research reported in this thesis represents the only attempt to date to prevent first onset MDD by improving sleep in an adolescent sample, and the only randomised controlled trial of an adolescent sleep intervention to examine anxiety outcomes over a two-year follow-up period. It was predicted that, compared to adolescents allocated to the active control (study skills) intervention, adolescents allocated to the sleep treatment intervention would: show greater improvements in subjective and objective indices of sleep (i.e., reduced sleep onset latency, increased total sleep time, better overall sleep quality, and reduced weekday bedtime intra-individual variability and weekday-to-weekend bedtime shift) immediately following the intervention and over the two-year follow-up period; be less likely to develop first onset MDD during, and would report lower levels of depressive symptoms at, the two-year follow-up (primary outcomes); and would be less likely to develop new onset GAD during, and would report lower levels of anxiety symptoms at, the two-year follow-up (secondary outcomes). Further, it was predicted that any beneficial long-term effects for depression and anxiety outcomes (i.e., lower incidence of MDD or GAD and/or reduction in depressive and anxiety symptoms) would be significantly mediated by improvements in sleep associated with the sleep treatment intervention (i.e., sleep improvements immediately post-intervention and/or over the two-year follow-up period). Methods: Participant recruitment and eligibility assessments occurred from January 2013 to June 2014. A school-based screening (n = 1491) was conducted at 23 secondary schools (14 Government, 4 Catholic, 5 Independent) in metropolitan Melbourne, Australia, to identify community-based adolescents with high levels of self-reported sleeping problems (score > 4 on the Pittsburgh Sleep Quality Index; PSQI) and anxiety symptoms (score > 32 males/ > 38 female on the Spence Children’s Anxiety Scale; SCAS). Consenting participants who met screening criteria (n = 218) completed semi-structured diagnostic clinical interview (Kiddie-Schedule for Affective Disorders and Schizophrenia for school-age children-Present and Lifetime version; K-SADS-PL) at the University of Melbourne, primarily to exclude individuals (n = 30) with a lifetime history of MDD, consistent with the study’s aim to prevent first onset depression. Eligible participants (n = 144) were randomised (1:1 allocation on an individual basis, and conditions were balanced for age, gender and presence or absence of current anxiety disorder at baseline) to either a seven-week, face-to-face, multicomponent cognitive-behavioural and mindfulness-based group sleep improvement treatment intervention (Sleep SENSE; n = 71) or an attention-matched active control study skills intervention (Study SENSE; n = 73). The Sleep SENSE intervention aimed to address common sleep problems including insufficient sleep duration, prolonged sleep onset, and variability in sleep timing, and included anxiety management components to assist with managing anxiety during the pre-sleep period. Mental health and sleep were assessed using: the K-SADS-PL (for MDD and GAD diagnosis); the Center for Epidemiologic Studies-Depression scale (CES-D; depressive symptoms); the SCAS (anxiety symptoms); the PSQI (self-reported sleep onset latency, total sleep time, overall sleep quality); and week-long actigraphy with sleep diary (objective sleep onset latency, total sleep time, weekday bedtime intra-individual variability, and weekday-to-weekend bedtime shift). Assessments occurred on three occasions–pre-intervention, post-intervention, and two-years after the completion of the intervention. All outcome assessments were administered by researchers who were blind to participants’ intervention assignment. Statistical analyses: All analyses used a modified intention-to-treat approach. Specifically, the final analysed sample (n = 122, sleep treatment n = 62, control intervention n = 60; 60% female; M age = 14.5 years, SD = 0.95, range 12.04 to 16.31 years) included participants who were eligible for and started the interventions, including those who dropped out of the interventions or were lost to follow-up (n = 13) but excluded participants who were identified as ineligible after randomisation (n = 2) and those who were randomised but never started the interventions (sleep treatment n = 10, control intervention n = 10). Latent growth curve modelling with multiple mediation analysis was used to test the effect of condition (i.e., sleep treatment or control intervention) on the long-term depression (i.e., presence or absence of MDD diagnosis, and severity of depressive symptoms) and anxiety (i.e., presence or absence of GAD diagnosis, and severity of anxiety symptoms) outcomes via improvements in the seven sleep variables immediately post-intervention (i.e., ‘initial status’ which was centred at the post-intervention time point) and over the two-year follow-up period (i.e., average linear ‘rate of change’ scaled to represent change per year). That is, the latent growth process of a sleep variable (i.e., the latent variables of initial status and rate of change) was used the mediator in the tested models. In total, 28 separate models were estimated using Mplus (Version 7) software using maximum likelihood estimation with robust standard errors. Results: Regarding the primary outcomes, there was no statistical evidence that the sleep treatment intervention improved subjective or objective indices of sleep immediately post-intervention or over the two-year follow-up period, or significantly predicted the presence or absence of major depressive disorder during, or reductions in depressive symptoms at, the two-year follow-up, relative to the active control intervention. Regarding the secondary outcome, the sleep treatment intervention did not significantly predict reductions on anxiety symptoms at two-year follow-up. However, the sleep treatment intervention significantly reduced the conditional odds of having GAD during the two-year follow-up period by a factor of seven on average, relative to the active control intervention, although confidence intervals suggested a small effect. There were no statistically significant indirect effects in any of the model investigated. Regardless of condition, participants’ subjective (B = -1.77, 95% CI [-3.47, -0.07]) and objective (B = -4.53, 95% CI [-7.96, -1.10]) sleep onset latency and subjective total sleep time (B = -0.18, 95% CI [-0.31, -0.05]) decreased over time, and weekday bedtime intra-individual variability increased over time (B = 7.99, 95% CI [2.11, 13.86]). In addition, poorer subjective sleep quality (B = 1.46, 95% CI [0.38, 2.54]) and less objective total sleep time (B = -3.31, 95% CI [-6.33, -0.28]) immediately post-intervention predicted depressive symptoms at two-year follow-up, and reductions in weekday bedtime intra-individual variability over time were associated with a decreased likelihood of GAD during the two-year follow-up (B = -0.52, 95% CI [-0.86, -0.18]). Conclusions: Together, the findings do not support the long-term efficacy of a targeted multicomponent cognitive-behavioural and mindfulness-based group sleep intervention for the improvement of sleep problems and prevention of first onset major depressive disorder in a community-based sample of at-risk adolescents. However, they tentatively suggest that anxiety may be more responsive to the sleep intervention than depression. In the context of a robust study design, the findings are hypothesis-generating and raise important considerations for the design of future clinical trials investigating the role of adolescent sleep interventions on emerging psychopathology. Funding: Australian National Health and Medical Research Council Grant (APP1027076). Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12612001177842; prospectively registered on 6th November 2012).
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ItemFatigue after child brain injury( 2016)Objective: Traumatic brain injury (TBI) is one of the most frequent causes of childhood disability. Fatigue is commonly reported during the acute and chronic phases of TBI recovery. Fatigue is defined as reduced performance in response to prolonged or unusual exertion and leads to reduced quality of life and school participation in children. Despite the prevalence of fatigue following TBI, there is little examining its nature and course. In particular, patterns of fatigue over time and predictors of longitudinal outcome after child TBI are unclear. The aim of this thesis is to address identified gaps in the existing research within the field of fatigue after child TBI. Throughout, we adopt a model of fatigue that is developmentally sensitive and multidimensional – including physical, sleep/rest, and cognitive elements. First, through systematic review of the literature we identify a psychometrically robust fatigue assessment instrument for use in child TBI. We then use this multidimensional fatigue measure to assess fatigue at three time-points after child TBI: 6 weeks, 6- and 12-months in order to meet the following study aims. First, we aim to compare fatigue in our TBI sample to published control data (at 6-weeks and 12-months post-injury), by TBI severity. Second, we examine fatigue over time (6- to 12-months post-injury) within our sample. Fourth, we explore factors predictive of worse fatigue on the fatigue measure at 6-weeks (child and parent perspectives) and 12-months (parent perspectives) post-injury. Our hypotheses were that fatigue following child TBI (a) would be higher than reported in published healthy children control data, (b) would reduce over time post-injury and (c) would be associated with more severe TBI and other hypothesised risk factors (such as sociodemographic characteristics). Method: Phase 1: A systematic review of fatigue assessment instruments used in children was conducted using key academic databases. Study quality and the psychometric properties of the instruments were assessed. Phase 2: We included participants already recruited to a larger prospective longitudinal study comprising 159 children (0-17 years at injury) with mild, moderate or severe TBI, presenting to one of three participating sites (two Canadian, one Australia). From the larger cohort, a subsample of 47 adolescents (8-18 years at injury) also participated in follow-up- 6-weeks post-injury. As part of the larger study protocol, at the time of child TBI, parents provided pre-injury child data based on retrospective report, including report of pre-injury fatigue and sleep difficulties. Healthy control data published from an American sample of children age 2-19 years was used for group comparisons (Panepinto et al., 2014). Results: Phase 1: Systematic Review identified twenty fatigue instruments, and two demonstrated strong measurement properties. Phase 2: Fatigue was rated by 35 participants (parents and adolescents) 6-weeks post-injury. At 6-weeks post-injury, fatigue in child TBI was significantly worse relative to control data (47 per cent and 29 per cent rated severe fatigue respectively). Between 6- and 12-months post-injury there was no detectable improvement in fatigue. Rather, cognitive fatigue worsened over time. Fatigue 12-months post-injury was again worse relative to control data (parent ratings). Fatigue was predicted by multiple variables, including pre-injury sociodemographic factors (female sex), psychological well-being (general fatigue) and pre-injury fatigue (sleep/rest fatigue). Symptoms after injury in multiple domains (physical/motor, pain, sleep psychological or inattention) additionally predicted fatigue 12 months post-injury. Conclusions: Fatigue is a complex, severe and persistent complaint after child TBI. Interventions are required to help reduce fatigue after child TBI.
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ItemSleep, mood, and cognitive vulnerability in adolescents: a naturalistic study over restricted and extended sleep opportunities( 2013)Introduction: It is well established that for adolescents, school days are associated with sleep restriction, and that insufficient sleep has been linked to mood disturbances. This longitudinal study assessed sleep, mood, and life stress over the school term and vacation periods with restricted and extended sleep opportunities. The relationships between objective and subjective sleep, as well as between sleep and mood were examined. A cognitive model was proposed and tested to assess whether sleep-specific (i.e., dysfunctional beliefs and attitudes about sleep) and global (i.e., dysfunctional attitudes) cognitive vulnerabilities played a role in these relationships. Methods: One-hundred and forty-six adolescents (47.3% male) aged 16.2+/-1.0 years (M+/-SD) from the general community wore an actigraph continuously for four weeks: the last week of a school term (Time-E), the following two-week vacation (Time-V), and the first week of the next term (Time-S). Social demographic information, chronotype, and cognitive vulnerabilities were assessed at Time-E. Subjective sleep, symptoms of depression, anxiety, and life stress were repeatedly measured at Time-E, Time-V, Time-S, and the middle of the subsequent school term. Regression analyses were used to explore the relationship between sleep and mood, and structural equation modelling was used to examine changes of variables over time, as well as the moderating roles of cognitive vulnerabilities. Results: Compared with school days, sleep during the vacation was characterized by later timing, longer duration, lower quality and greater variability. Daily changes in actigraphy- measured sleep over the vacation period showed linear delays in sleep timing throughout the vacation, while changes in time-in-bed were non-significant. The first vacation week was characterized by a linear decrease in total sleep time and sleep quality, and these changes stabilized during the second vacation week. Compared to vacations, school terms were associated with higher symptoms of depression, anxiety, and life stress. Poorer sleep quality, particularly poorer subjective perception of sleep quality, was significantly associated with higher symptoms of depression and anxiety. Sleep- specific cognitive vulnerability moderated the relationship between objective and subjective sleep onset latency during extended but not restricted sleep opportunity. After controlling for life stress, global cognitive vulnerability played different moderating roles in the relationship between subjective sleep and mood over school term and vacation periods. Higher global cognitive vulnerability was associated with a stronger relationship between subjective sleep and symptoms of anxiety (but not depression) during the school term, as well as with a stronger relationship between subjective sleep and symptoms of depression (but not anxiety) during the vacation period. Conclusion: Sleep, mood, and life stress changed markedly over the school term and vacation periods. Changes in sleep over the vacation suggested that the recovery from school- related sleep restriction was completed within two weeks’ extended sleep opportunity, and the average sleep duration over this period suggested that sleep requirements in adolescence may be less than conventionally described in the media and in the scientific literature. Cognitive vulnerabilities played important roles in the relationship between sleep and mood. Adolescents with higher cognitive vulnerability might be more emotionally vulnerable towards school-related sleep restriction. These findings have important implications for future studies, as well as practical implications for policies and interventions designed to improve adolescents’ wellbeing.
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ItemA study of group psychotherapy: an empirical study of the whole group( 2001)The view regarding social units as entities in their own right disappeared from scientific consideration in the mid-twentieth century as much for political and ideological reasons as scientific ones. Yet group psychotherapy rediscovered these ideas. The problem to re-establish them scientifically is lack of empirical methodology for investigating whole groups. The study integrated theories of groups as psychic entities from sociology, social psychology and group psychotherapy to form hypotheses about therapeutic groups" functioning. Four dimensions of whole-group function were derived: Structure, Cognitive Organisation, Affect, and Action Coherence. An observational instrument, the "Group Function Record," was developed, categories defined for each dimension and a procedure established to rate minute-by-minute group function from videotaped psychotherapy groups. Therapists" Interventions were also recorded. The instrument treats the group as the object of study and quality of collective functioning is rated irrespective of members present or their roles. Reliability was established and ratings were made of one latency and four adolescent yearlong groups. Results substantiated an eight-phase developmental sequence derived from the group development literature and outlined a theory of group formation. The most challenging, but creative state was found to be when the group is whole with all members in communication, though it is unstable and often managed by breaking into subgroups. A linear relation existed showing that the smaller the group, the better it functions. Groups also function best with one or two members missing, but more absentees threaten the group’s existence. More highly organized groups are more stable, but tend to destabilize when they become self-reflective. Homeostatic self-correcting tendencies and a close relationship between affective and action changes were evident. Change towards unpleasurable affect is associated with change from cooperation to conflict and vice versa. Crises tend to be precipitated by affective change, but correct themselves within the next minute or two. The effects of Therapists" Interventions towards members, the group or both were analyzed. Group interventions initially tend to reduce functionality, followed by improvement after several minutes; member interventions have inconsistent effects; interventions to group and members in the same minute tend to produce immediate improved function. The findings and their implications for therapeutic goals and technique with adolescents are discussed in relation to the theoretical background. Considerable merit is found in the collective mentality theories, many of whose postulates are validated. Indications for therapeutic technique are outlined from the findings. The method provides a different view of group process posing new questions and suggesting simple techniques are therapeutically potent. Further avenues of research are suggested.