Centre for Youth Mental Health - Theses
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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.
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Item“It Was a Nice Place to Be.” A Phenomenological Exploration of Young People’s Experience of Moderated Online Social Therapy (MOST) For First-Episode Psychosis( 2021)First-episode psychosis (FEP) is a serious mental health condition that can effect a person’s thoughts, perception, mood, and behaviour (American Psychiatric Association, 2013) and is often characterised by a “loss of contact with reality (Bosnjak Kuharic, Kekin, Hew, Rojnic Kuzman, & Puljak, 2019).” As it typically emerges in late adolescence and early adulthood (Alvarez-Jimenez et al., 2019), psychosis can significantly disrupt a young person’s confidence and interrupt their social, emotional, and vocational life trajectories (Alvarez-Jimenez et al., 2013; Bucci et al., 2018). While the introduction of early intervention services has improved the short term outcomes for people experiencing psychosis (Cotton et al., 2016; A. Malla et al., 2017), overtime, psychotic disorders are still associated with poor long-term outcomes in regard to education, housing, physical health, employment, social inclusion, and poverty (Alvarez-Jimenez et al., 2012; Cotton et al., 2017). Evidence suggests that long-term maintenance care is required to prevent relapse and to preserve the clinical and functional gains achieved during early intervention (Alvarez-Jimenez et al., 2021; A. Malla et al., 2017). Digital mental health intervention has been identified as one possible way to provide long term maintenance support to young people with first episode psychosis. The use of digital mental health interventions in the treatment, management, and support of first-episode psychosis is a burgeoning area of interest in the mental health field as it presents an opportunity to provide lower intensity treatment over an extended period of time (Alvarez-Jimenez et al., 2019; Bell & AlvarezJimenez, 2019; Gumley et al., 2020). However, while digital mental health interventions have been trialled in first-episode psychosis populations, there is limited research exploring young people’s experiences of using digital technology and engagement with such interventions have tended to vary substantially. A better understanding of the subjective experience of the user is valuable in and of itself and can be used to improve interventions and identify facilitators and barriers to use. Thus, the knowledge gained via an in-depth exploration of young people’s experience could be harnessed to increase engagement levels of digital mental health interventions for first-episode psychosis. Aim: The primary aim of this thesis was to examine young people's experiences of the therapeutic and social network components of a long-term digital mental health intervention for first-episode psychosis. The secondary aim was to investigate young people's perspectives on the development of blended models of treatment for FEP. Two qualitative studies were conducted to achieve these aims. Study One: Study One used an interpretative phenomenological analysis approach to explore young people's subjective experiences of a long-term digital mental health platform, Horyzons, for FEP, with a particular focus on the experience of online therapy and the social network components. Twelve in-depth phenomenological interviews were conducted with young people who used the Horyzons platform to varying degrees. The data was split meaningfully into two sub-studies during the analysis process due to the breadth of information collected. Sub-study one became an exploration of young people's experience of social connection on the Horyzons platform. We found that the social network nurtured a sense of connection among community members. The platform became an embodied experience that gave young people a sense of self-recognition and belonging. This research also identified significant barriers to engagement, including social anxiety, paranoia, internalised stigma, lack of autonomy, and social protocol confusion. Sub-study two explored young people's experience of online therapy and found that the self-directed nature of the platform was beneficial and motivating to some and overwhelming for others. Moreover, the online therapy experience was idiosyncratic and took on different meanings for different young people. The online therapeutic content led to on-demand help-seeking, positive distraction, revision, generalisation and translation, and normalisation. On-demand help-seeking and positive distraction were identified as two ways in which online therapy was experienced differently from face-to-face therapy and spoke to the unique contribution that online therapy can make to a therapeutic intervention. Study Two: Study two used an end-user design approach combined with thematic analysis to explore young people's perspective of blended models of face-to-face and digital treatment in first-episode psychosis. The sample included ten participants. We found that young people strongly endorsed the use of blended models of care, in so far, as it enhances their treatment experience but does not replace the face-to-face care altogether. Increased accessibility to, and continuity of, care, a channel to access posttherapy support from peers, consolidation of psychoeducation and a way to strengthen the bond between a young person and clinician were identified as benefits of blended models of care. Conclusions: This thesis used two qualitative approaches to better understand young people's experience of digital mental health intervention for first-episode psychosis and young people's perspectives on blended models of mental health care for first-episode psychosis. By exploring experience and perspective, this research was able to shed light on different aspects of a digital mental health interventions for first-episode psychosis and identify facilitators and barriers to young people's engagement that has not been previously identified. This new knowledge constitutes a timely and relevant contribution to the field of digital mental health literature.
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ItemDesign and refinement of the MATE program: Mindful Awareness Training and Education: how do young people understand and practise mindfulness?( 2012)Background and aims: Young people (aged 15-24) often experience difficulties regulating their emotions. This is thought to be a key mediator of distress and ill health. Improving emotion regulation is an important target for mental health promotion in this age group. Mindfulness practice includes cultivating awareness of emotions and developing skilful ways to deal with them. Mindfulness training has been shown to improve mental health in adults. Preliminary investigations have also been reported in children and adolescents. Few studies specific to young people are available and none have reported engaging young people themselves in the design process. Very little research has been reported into online delivery, and all of this work so far has involved adults. Using the Internet to provide mindfulness training has the potential to improve accessibility for young people. Very little research, all of which has involved adults, has been reported into online delivery. The aim in this project was to use a participatory, mixed methods approach to the design and preliminary evaluation of a mindfulness training program for young people in live and online editions. Methods: Initial design of the Mindful Awareness Training and Education program, MATE version 1, was informed by a review of the literature and discussion with experts. MATE v.2 was created after consultation with 13 mindfulness-naïve young people. The live edition of MATE v.2 was trialled with 11 participants. Evaluation included qualitative interviews, a focus group, written and online feedback, and quantitative measurement. The latter was conducted at commencement, immediately after the program and at six weeks’ follow-up. Qualitative data collection and analysis were informed by grounded theory. Results: Consultees on MATE v.1 described mindfulness training as a desirable activity for young people and offered valuable suggestions regarding program structure and content. Recruitment of participants for the pilot trial of MATE v.2 was difficult. Those enrolled showed a high level of engagement with both the program content and evaluation process: 73% completed all program stages, 88% of whom also attended either a focus group or interview. Benefits, in terms of improved emotion regulation and well-being, and reduction in symptoms of stress, anxiety and depression were suggested by qualitative and quantitative data. An explanatory model of participants’ experience was devised indicating that: (1) key initial benefits were a calmer mind and greater sense of agency; and (2) that with ongoing practice, additional benefits may occur. Greater understanding of their minds helped participants develop enhanced confidence and perceived competence in managing day-to-day challenges. Some participants reported transient increased distress in the middle weeks of the program. MATE v.3, the final version of the program, in live and online editions, resulted from an integration of findings. Conclusions: Mindfulness training appears to be acceptable to young people and a feasible strategy to enhance mental health and well-being in this age group. Participants in the live trial were able, within a short time, to develop a sophisticated understanding and application of mindfulness. The MATE program, as devised and refined in this project, is ready for large-scale face to face trial and for website development in its online edition.
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ItemLabelling of mental disorders and help-seeking in young people( 2012)BACKGROUND: Mental disorders are the most common health problem affecting young people, yet their rates of help-seeking are amongst the lowest. Improving help-seeking rates amongst young people is vital. The labels used to describe emerging physical health problems have been found to influence the effectiveness of help-seeking choices. In regard to mental health, accurate psychiatric labelling of mental disorders is promoted in community awareness campaigns designed to increase help-seeking rates. However, research examining the association between labelling of mental disorders and help-seeking is scarce, particularly with young people. Indeed, it has been contended that the use of psychiatric labels to describe mental disorders may be coupled with stigmatizing beliefs and thus inhibit help-seeking, in which case lay mental health or non-specific labels may be less harmful. Motivated by these factors, the aim of this thesis was to examine the range of labels young people use to describe mental disorders, the association between label use and help-seeking intentions and beliefs, and the association between label use and stigmatising beliefs. METHOD: A national telephone survey was conducted with 2802 Australian young people aged 12-25 years and 1528 co-resident parents from June to August 2006. Respondents were randomly assigned a vignette describing a young person experiencing symptoms of depression, psychosis or social phobia. This was followed by a series of questions relating to the vignette that examined the label used to describe the problem, help-seeking intentions and beliefs, and stigmatizing beliefs. The range of labels used was examined using percent frequencies. Factors associated with label use and the association between label use and help-seeking choices and label use and stigma were examined using binary logistic regression analyses. RESULTS: Depression was accurately labelled twice as frequently as was psychosis, whereas social phobia was rarely accurately labelled and was most commonly labelled using lay terms. Use of accurate labels increased with age and females were more likely to use them. For all vignettes, likelihood of using an accurate label was associated with exposure to mental health community awareness campaigns and accuracy of label used by a parent. Accurate labelling was associated with a preference for professionally recommended sources of help with greater consistency than any other labels commonly used. Stigma was not commonly associated with label use. Most mental health labels were associated with seeing the person as “sick” rather than “weak”, and accurate psychiatric labels had the strongest effect sizes. However, for the psychosis vignette, the “dangerous/unpredictable” component of stigma was associated with mental health labels, and the accurate psychiatric label showed the strongest association. DISCUSSION: It can be broadly concluded that accurate psychiatric labels are linked to mental health specific sources of help while generic lay labels are linked to more general sources of help. Using an accurate label may act as a schematic hub for conceptualizing an emerging mental disorder that enables effective selection of recommended sources of help. Stigma is not commonly associated with use of an accurate label and is therefore unlikely to be a barrier to help-seeking in most instances. These findings can help to inform and improve the effectiveness of community awareness strategies designed to increase help-seeking rates for mental disorders in young people.