Centre for Youth Mental Health - Theses
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ItemPsychological Interventions for Interpersonal Trauma in Young People with symptoms of Posttraumatic Stress, Anxiety and Depression( 2022-08)Worldwide exposure to potentially traumatic events is highly prevalent among young people aged 12 to 25 years, with international data indicating that approximately two-thirds of adolescents experience exposure to a traumatic event before age 16. In addition to interpersonal trauma inflicted by a caregiver, such as abuse (sexual, physical, and emotional), neglect, and maltreatment, young people are often exposed to family violence, physically assaulted or intimidated by siblings or peers, and are bullied. Unfortunately, subsequent exposure to a different interpersonal trauma type is not uncommon, with nearly 65% of young people experiencing multiple exposures once exposed to one interpersonal trauma. Exposure to interpersonal trauma during this developmentally sensitive period is associated with pervasive and long-lasting psychological, physical, behavioural, social, and economic costs accounting for between 28% and 45% of the population attributable risk for the early onset of youth psychological disorders. In addition to posttraumatic stress, anxiety, depression, problematic substance use, emotional dysregulation, lack of impulse control, poor interpersonal relationships, dissociation, as well as attention and cognition, dysfunctions are highly prevalent and associated with increased incidents of self-harming behaviours and suicidal thoughts and behaviours. Although evidence-based interventions and guideline recommendations exist for the treatment of PTSD in children/adolescents and adults, none of the recommended interventions has been developmentally adapted for transitional-aged youth aged 15 to 25 years exposed to interpersonal trauma, and it remains unclear what the most effective and safe treatment is for these young people. This thesis sought to address this significant gap in the literature with the ultimate aim of evaluating the evidence for psychological interventions for posttraumatic stress disorder (PTSD) and comorbidities in young people exposed to interpersonal trauma and understanding if trauma-focused cognitive behavioural therapy ([TF-CBT]; Cohen et al., 2017), specifically are potentially suitable for this group of young people. The research reported in this thesis had three main aims. Aim 1: To collect, interpret and synthesise quantitative research about the efficacy of psychological interventions for treating anxiety, depression, and substance use in addition to posttraumatic stress symptoms in young people exposed to interpersonal trauma. Aim 2: To understand if trauma-focused cognitive behavioural therapy (TF-CBT) is feasible, acceptable, and potentially clinically effective for young people impacted by interpersonal trauma and symptoms of posttraumatic stress disorder (PTSD). Aim 3: To understand if TF-CBT is safe and tolerable, with a specific focus on determining whether the exposure component of TF-CBT (known as trauma narration) is associated with an elevation in distress or an increase in self-harming behaviours or suicidal thoughts and behaviours. Three studies were conducted to address these aims. Study 1: To achieve the first aim, Study 1 used a meta-analytical approach to evaluate the efficacy of psychological interventions in reducing PTSD, anxiety, depression, and substance use symptoms in young people exposed to interpersonal trauma. Until now, the largest meta-analysis of young people is the study conducted by Gutermann et al. (2016). Unfortunately, the results of this study were affected by incomplete age-data (i.e., no mean age or age range) and poorly reported trauma data (i.e., reported mixed types, not specific types). I was interested in overcoming these two issues in order to provide specific evidence of treatment effects for young people (aged 12–25 years) and those exposed to a wide range of interpersonal trauma types (i.e., beyond physical and sexual abuse). Therefore, I conducted a new review, selecting only those studies where participants’ mean age fell between 12 and 25 years, with at least 80% of the sample exposed to one or more interpersonal traumas. Large significant effect sizes were observed for psychological interventions versus controls for outcomes of PTSD, and there were small significant effect sizes for anxiety and small trend-level non-significant effect sizes for depression. TF-CBT outperformed other treatments in the sub-group analysis for PTSD. However, results need to be interpreted within the context of the small sample size and heterogeneity. Study 2: To achieve the second aim, Study 2 employed a single-arm pre vs post study design, with two additional assessment points at the start and end of the trauma narration phase of TF-CBT for transitional-aged young people aged 15- 25. The sample included 20 young people (65% female, n = 13) who participated in up to 20 sessions of TF-CBT over 30 weeks. Two female participants dropped out of treatment (one after the first session and the other before the start of trauma narration. The remaining participants attended a mean of 15 sessions of TF-CBT over 25 weeks. TF-CBT was implemented with fidelity, and young people reported that they would recommend the intervention to a friend experiencing a similar issue. Quantitative data supported the relative clinical efficacy of TF-CBT. At the end of treatment, only one of the 16 participants with a baseline PTSD diagnosis met the diagnostic criteria. Significant improvements were also noted in self-reported PTSD, anxiety, and depression outcomes. Study 3: To achieve the third aim, distress, self-harm and suicide from Study 2 were analysed and interrogated to investigate if TF-CBT was safe and tolerable. The young people enrolled in Study 2 completed the Subjective Units of Distress Scale (SUDS) at the start and end of each session and were also asked question 6 of the C-SSRS, which inquired about their suicidal thoughts and behaviours in the week between therapy sessions. In addition, data from the Deliberate Self Harm Inventory (DSHI) and Adult Suicide Ideation Questionnaire (ASIQ) were also analysed. Across the 279 sessions of TF-CBT (M = 15.5 sessions), there were 16 incidents of elevated distress in seven participants, 15 incidents of self-harming behaviour in seven participants, and one of both elevated distress and suicide ideation. Results indicated there might be a relationship between distress and self-harming behaviours. Conclusion: This thesis used quantitative methods to understand the relative efficacy of psychological interventions for PTSD, anxiety, and depression in transitional-aged young people exposed to interpersonal trauma. The results of the meta-analysis and data from the pilot study demonstrated the potential safety and efficacy of TF-CBT for transitional-aged young people. This new knowledge is timely given the expansion in specialised mental health service delivery and the need to better accommodate the needs of transitional-aged young people with a history of trauma exposure.
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ItemCharacteristics and Predictors of Suicidality in Young People with Depressive Disorders( 2023)Depression is one of the most prevalent and disabling mental health conditions among young people worldwide. Suicidality and depression are closely intertwined, yet the specific factors that contribute to the nature and severity of suicidality, or changes in suicidality over time, are not perfectly understood. Factors other than depressive symptom severity, such as comorbid psychopathology and personality traits, might be important contributors. In order to reduce the burden of suicidality in young people with depression, we need to improve our understanding of its underlying constructs and contributory elements. This has the potential to contribute to improved prevention and early intervention efforts across multiple stages of suicidality, in addition to informing more targeted clinical treatment approaches. Aims and Objectives The broad aim of this research program was to contribute towards an improved understanding of suicidal thoughts and behaviours in young people with clinically diagnosed depressive disorders. More specifically, the aim was to identify modifiable intervention targets, which could inform clinical treatment approaches, and suicide prevention and early intervention efforts more broadly. Methods This research program comprises four studies each addressing different research questions. Study 1 is a comprehensive systematic review of contributors to suicidality in young people with unipolar and bipolar depression. Study 2 is an analysis of the dimensionality of a widely used measure of suicidal ideation, including associations between this measure’s latent factors and actual suicidal behaviour in young people with major depressive disorder (MDD). Study 3 is an investigation of how different dimensions of social support are associated with suicidal ideation in a treatment seeking cohort of young people with MDD; and Study 4 is a longitudinal analysis of associations between a range of psychosocial correlates and suicidal ideation severity in this same cohort of young people MDD, assessed over a 12-week period. Main Results Several key themes can be drawn from the findings of this research program. First, there is a lack of consensus regarding how the construct of suicidality should be defined, highlighting the need for international collaboration in the development of a standardised, validated classification system for suicidal ideation and suicidal behaviours. The second key finding is that suicidality in young people with depressive disorders is multidimensional in nature. That is, the way in which suicidality manifests in an individual is multifaceted. Suicidality is comprised of multiple constructs encompassing both active and passive ideation, intrapersonal cognitions such as hopelessness and lack of self-worth, and interpersonal factors such as perceived burdensomeness. The third key finding is that there are multiple determinants of suicidality in young people with depressive disorders; in addition to depressive symptoms, there are numerous other predictors of the nature and severity of suicidality. Notably, familial support is an important protective factor, while psychopathological features such as state and trait anxiety contribute to suicidality severity. Discussion Outcomes of this research program reinforce the notion that suicidality is complex and multideterminant in nature. Depression symptomatology is an important contributor, suggesting that regular monitoring of depression symptom severity should be a core aspect of the clinical management of suicidality in young people with depressive disorders. Suicidality is not driven by depression symptomatology alone and it is clear that suicide prevention and intervention efforts need to go beyond simply reducing depression severity. Psychiatric comorbidity with depression, particularly comorbid anxiety, is an important determinant of suicidality. Anxiety and depression, in particular, share many clinical features and risk factors. Interventions targeting transdiagnostic features could have clinical utility in reducing the burden of suicide in young people. In addition, methodological assessment of personality features and carefully targeted intervention approaches such as dialectal behaviour therapy, or mentalization-based therapy, could be a beneficial component of the clinical management of depression and suicidality in young people. An important clinical implication of this research program is that there is likely substantial variability underlying the mechanisms for suicidality from one depressed young person to the next. This suggests that there is perhaps a similarly high degree of variability with respect to potentially effective treatment targets for suicidality. It raises the question of how useful it is to consider a diagnosis of depression as a specific risk factor for suicidality in young people. Alternative approaches to identifying aetiological mechanisms of suicidality, such as a specific symptom approach, could be warranted. It is crucial to develop and employ early intervention approaches for suicidality in young people which focus on the earliest stage of suicidality. Potential targets for early intervention, such as increasing adaptive social support to reduce severity of suicidal ideation, are likely to be beneficial in preventing transition to suicidal behaviour. This highlights the need to assess and monitor suicidality early in young people presenting with mental health symptoms, irrespective of the specific diagnosis. This requires the use of age-appropriate suicidality assessment tools designed for use in young people. Given the fluctuating nature of suicidality, real-time symptom monitoring could perhaps be implemented as part of routine clinical care. The use of transdiagnostic interventions aimed at modifying common cognitive processes underlying depression, anxiety, and suicidality could be an effective treatment approach. Although suicidality is a complex phenomenon and no single approach to prevention or intervention is likely to be universally effective, the findings of this research program do have the potential to help reduce the suicidality-related health burden in this particularly vulnerable population.