Centre for Youth Mental Health - Research Publications
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A Comparison of Vocational Engagement Among Young People with Psychosis, Depression and Borderline Personality Pathology
Poor vocational engagement is well documented among young people experiencing first-episode psychosis (FEP). The aim of the present study was to establish and compare rates of vocational engagement across young people with first-episode psychosis, depression, and borderline personality pathology. A file audit was used to collect vocational data of young people aged 15-25 entering tertiary mental health treatment in 2011. Rates of vocational engagement were similar across groups, indicating that like those with FEP, young people with depression and borderline personality pathology experience impaired vocational engagement and are in need of targeted vocational interventions. Post hoc analysis indicated that that the depression group had significantly more people who were partially vocationally engaged compared with the psychosis group, suggesting that vocational interventions might need to be targeted differently across different diagnostic groups. Future research should explore risk factors for vocational disengagement across diagnostic groups in order to inform intervention development.
Integration of Digital Tools Into Community Mental Health Care Settings That Serve Young People: Focus Group Study.
(JMIR Publications Inc., 2021-08-19)
BACKGROUND: Digital mental health tools have substantial potential to be easily integrated into people's lives and fundamentally impact public health. Such tools can extend the reach and maximize the impact of mental health interventions. Before implementing digital tools in new settings, it is critical to understand what is important to organizations and individuals who will implement and use these tools. Given that young people are highly familiar with technology and many mental health concerns emerge in childhood and adolescence, it is especially crucial to understand how digital tools can be integrated into settings that serve young people. OBJECTIVE: This study aims to learn about considerations and perspectives of community behavioral health care providers on incorporating digital tools into their clinical care for children and adolescents. METHODS: Data were analyzed from 5 focus groups conducted with clinicians (n=37) who work with young people at a large community service organization in the United States. This organization provides care to more than 27,000 people annually, most of whom are of low socioeconomic status. The transcripts were coded using thematic analysis. RESULTS: Clinicians first provided insight into the digital tools they were currently using in their treatment sessions with young people, such as web-based videos and mood-tracking apps. They explained that their main goals in using these tools were to help young people build skills, facilitate learning, and monitor symptoms. Benefits were expressed, such as engagement of adolescents in treatment, along with potential challenges (eg, accessibility and limited content) and developmental considerations (eg, digital devices getting taken away as punishment). Clinicians discussed their desire for a centralized digital platform that securely connects the clinician, young person, and caregivers. Finally, they offered several considerations for integrating digital tools into mental health care, such as setting up expectations with clients and the importance of human support. CONCLUSIONS: Young people have unique considerations related to complex accessibility patterns and technology expectations that may not be observed when adults are the intended users of mental health technologies. Therefore, these findings provide critical insights to inform the development of future tools, specifically regarding connectivity, conditional restraints (eg, devices taken away as punishment and school restrictions), expectations of users from different generations, and the blended nature in which digital tools can support young people.
Why Depressed Mood is Adaptive: A Numerical Proof of Principle for an Evolutionary Systems Theory of Depression.
(Ubiquity Press, Ltd., 2021)
We provide a proof of principle for an evolutionary systems theory (EST) of depression. This theory suggests that normative depressive symptoms counter socioenvironmental volatility by increasing interpersonal support via social signalling and that this response depends upon the encoding of uncertainty about social contingencies, which can be targeted by neuromodulatory antidepressants. We simulated agents that committed to a series of decisions in a social two-arm bandit task before and after social adversity, which precipitated depressive symptoms. Responses to social adversity were modelled under various combinations of social support and pharmacotherapy. The normative depressive phenotype responded positively to social support and simulated treatments with antidepressants. Attracting social support and administering antidepressants also alleviated anhedonia and social withdrawal, speaking to improvements in interpersonal relationships. These results support the EST of depression by demonstrating that following adversity, normative depressed mood preserved social inclusion with appropriate interpersonal support or pharmacotherapy.
Basic self-disturbance in subjects at clinical high risk for psychosis: Relationship with clinical and functional outcomes at one year follow-up
(ELSEVIER IRELAND LTD, 2021-06-01)
Basic self-disturbance (BSD) is assumed to drive symptom development in schizophrenia spectrum disorders and in clinical high-risk (CHR) for psychosis. We investigated the relationship between BSD at baseline, assessed with the Examination of Anomalous Self-Experience (EASE), and symptoms and functional outcome after one year in 32 patients, including 26 CHR and six with non-progressive attenuated psychotic symptoms. Correlations between baseline BSD levels and positive, negative and disorganization symptoms, and global functioning level at follow-up were significant. Hierarchical regression analyses revealed that higher levels of baseline BSD predicted more severe positive symptoms and lower global functioning at follow-up, after adjusting for baseline positive symptoms and functioning. Subjects who were not in symptomatic and functional remission after one year had higher levels of BSD and negative symptoms, and lower functioning level, at baseline. Baseline BSD in participants with schizophrenia spectrum diagnoses at follow-up (9 of 12 were schizotypal personality disorder) were at the levels seen in schizotypal disorders in previous studies, but not significantly different from the other participants. Early identification and assessment of BSD may constitute a useful prognostic tool and a signal for therapeutic targets in CHR conditions. Further CHR studies investigating these relationships with larger samples are recommended.
Exploring the clinical relevance of a dichotomy between affective and non-affective psychosis: Results from a first-episode psychosis cohort study
AIM: Defining diagnosis is complex in early psychosis, which may delay the introduction of an appropriate treatment. The dichotomy of affective and non-affective psychosis is used in clinical setting but remains questioned on a scientific basis. In this study, we explore the clinical relevance of this dichotomy on the basis of clinical variables in a sample of first-episode psychosis patients. METHOD: We conducted a prospective study in a sample of 330 first-episode psychosis treated at an early intervention program. Affective and non-affective psychosis patients were compared on premorbid history, baseline data, outcomes and course of symptoms over the 3 years of treatment. RESULTS: Affective psychosis patients (22.42%) were more likely to be female, and had a shorter duration of untreated psychosis. The longitudinal analyses revealed that positive symptoms remained higher over the entire follow-up in the non-affective sub-group. A higher degree of variability of manic symptoms and a significantly better insight after 6 months were observed in the affective sub-group. No difference was observed regarding depressive and negative symptoms. At discharge, only the environmental quality of life and insight recovery were better in affective psychosis. CONCLUSIONS: Our study suggests that despite marginal differences at baseline presentation, these sub-groups differ regarding outcome, which may require differentiation of treatment and supports the utility of this dichotomy.
Personality disorder among youth with first episode psychotic mania: An important target for specific treatment?
AIM: Personality disorder is a common co-occurrence ('comorbidity') among patients with bipolar disorder and appears to affect outcome negatively. However, there is little knowledge about the impact of this comorbidity in the early phases of bipolar disorder. We examined the prevalence and effect of personality disorder co-occurrence on outcome in a cohort of youth with first episode mania with psychotic features. METHODS: Seventy-one first episode mania patients, aged 15-29, were assessed at baseline, 6, 12, and 18 months as part of a randomized controlled trial of olanzapine and chlorpromazine as add-on to lithium in first episode mania with psychotic features. The current study involved secondary analysis of trial data. RESULTS: A co-occurring clinical personality disorder diagnosis was present in 16.9% of patients. Antisocial and narcissistic personality disorders were the most common diagnoses. Patients with co-occurring personality disorder had higher rates of readmission to hospital, lower rates of symptomatic recovery and poorer functional levels at 6 months, but these differences disappeared after 12 and 18 months. CONCLUSIONS: In the early phase of bipolar disorder, patients with personality disorder comorbidity display delayed symptomatic and functional recovery and increased likelihood to need hospital readmissions. These observations suggest that routine assessment for personality disorder and specific interventions are important in order to improve short-term treatment efficacy in this subgroup.
Characterization and Prediction of Clinical Pathways of Vulnerability to Psychosis through Graph Signal Processing
Abstract There is a growing recognition that psychiatric symptoms have the potential to causally interact with one another. Particularly in the earliest stages of psychopathology dynamic interactions between symptoms could contribute heterogeneous and cross-diagnostic clinical evolutions. Current clinical approaches attempt to merge clinical manifestations that co-occur across subjects and could therefore significantly hinder our understanding of clinical pathways connecting individual symptoms. Network approaches have the potential to shed light on the complex dynamics of early psychopathology. In the present manuscript we attempt to address 2 main limitations that have in our opinion hindered the application of network approaches in the clinical setting. The first limitation is that network analyses have mostly been applied to cross-sectional data, yielding results that often lack the intuitive interpretability of simpler categorical or dimensional approaches. Here we propose an approach based on multi-layer network analysis that offers an intuitive low-dimensional characterization of longitudinal pathways involved in the evolution of psychopathology, while conserving high-dimensional information on the role of specific symptoms. The second limitation is that network analyses typically characterize symptom connectivity at the level of a population, whereas clinical practice deals with symptom severity at the level of the individual. Here we propose an approach based on graph signal processing that exploits knowledge of network interactions between symptoms to predict longitudinal clinical evolution at the level of the individual. We test our approaches in two independent samples of individuals with genetic and clinical vulnerability for developing psychosis.
Psychosocial interventions for self-harm in adults.
BACKGROUND: Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults. OBJECTIVES: To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020). SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide. DATA COLLECTION AND ANALYSIS: We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach. MAIN RESULTS: We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions. AUTHORS' CONCLUSIONS: Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.
The making of men program: A mixed-methods evaluation of a gender-sensitive rite of passage program for adolescent males
(Dougmar Publishing Group, Inc., 2021-02-12)
IntroductionCurrent gendered health disparities impacting the wellbeing of boys and young men require new early intervention-focussed approaches. Health promotion programs developed with young men’s health needs and preferences in mind commonly report positive outcomes. Male-specific rite of passage programs aim to formally acknowledge the life-stage transition from boyhood to manhood through a holistic focus on identity, community, and social responsibility. While these programs are growing in popularity, there is limited data available on their effectiveness.
MethodsThis study undertook a pilot evaluation of the Making of Men rite of passage program in a sample of second-ary school boys (n=61, age M=16.0, SD=0.5) and their accompanying fathers or male mentors (n=47, age M=52.1, SD=5.8 years) providing non-matched pre-test, post-test, alongside follow-up data for participating boys. Qualitative interviews were also undertaken with 15 individuals (5 mothers, 6 staff members, 4 fathers).
ResultsQuantitative program feedback indicated acceptability, with most respondents providing positive feedback, particularly from participating fathers. Exploratory quantitative effects indicated potential improvements in subjective social support and open communication among boys. Fathers appeared to report lower confor-mity to traditional masculine norms post-program, in addition to more open communication. Qualitative interviews identified three main themes: enabling relational bonds, creating a men-specific context, and supporting developmental transitions.
ConclusionsPositive program acceptability and promising outcome effects highlighted the present rite of passage program as a promising mechanism for supporting healthy masculine identity development among adolescent males.
Can a social media intervention improve online communication about suicide? A feasibility study examining the acceptability and potential impact of the #chatsafe campaign
(PUBLIC LIBRARY SCIENCE, 2021-06-15)
There is a need for effective and youth-friendly approaches to suicide prevention, and social media presents a unique opportunity to reach young people. Although there is some evidence to support the delivery of population-wide suicide prevention campaigns, little is known about their capacity to change behaviour, particularly among young people and in the context of social media. Even less is known about the safety and feasibility of using social media for the purpose of suicide prevention. Based on the #chatsafe guidelines, this study examines the acceptability, safety and feasibility of a co-designed social media campaign. It also examines its impact on young people's willingness to intervene against suicide and their perceived self-efficacy, confidence and safety when communicating on social media platforms about suicide. A sample of 189 young people aged 16-25 years completed three questionnaires across a 20-week period (4 weeks pre-intervention, immediately post-intervention, and at 4-week follow up). The intervention took the form of a 12-week social media campaign delivered to participants via direct message. Participants reported finding the intervention acceptable and they also reported improvements in their willingness to intervene against suicide, and their perceived self-efficacy, confidence and safety when communicating on social media about suicide. Findings from this study present a promising picture for the acceptability and potential impact of a universal suicide prevention campaign delivered through social media, and suggest that it can be safe to utilize social media for the purpose of suicide prevention.
Psychosocial work exposures and health outcomes: a meta-review of 72 literature reviews with meta-analysis.
(Scandinavian Journal of Work, Environment and Health, 2021-05-27)
Objective This meta-review aimed to present all available quantitative pooled estimates for the associations between psychosocial work exposures and health outcomes using a systematic literature review of literature reviews with meta-analysis. Methods A systematic review of the literature from 2000 to 2020 was conducted using PubMed, Web of Science, Scopus, and PsycINFO databases following the PRISMA guidelines. All literature reviews and Individual-Participant Data (IPD)-Work consortium studies exploring an association between psychosocial work exposures and health outcomes and providing pooled estimates using meta-analysis were included. All types of psychosocial work exposures and health outcomes were studied. The quality of each included review was assessed. Results A total of 72 reviews and IPD-Work consortium studies were included. These mainly focused on job strain as exposure and cardiovascular diseases and mental disorders as outcomes. The associations between psychosocial work factors and cardiovascular diseases and mental disorders were in general significant, and the magnitude of these associations was stronger for mental disorders than for cardiovascular diseases. Based on high-quality reviews, significant associations were found between job/high strain and long working hours as exposures and coronary heart diseases, (ischemic) stroke, and depression as outcomes. A few additional significant associations involved other exposures and health outcomes. Conclusions The included reviews brought convincing findings on the associations of some psychosocial work factors with mental disorders and cardiovascular diseases. More research may be needed to explain these associations, explore other exposures and outcomes, and make progress towards determining the causality of the associations.
Transition from child and adolescent MHS to adult MHS: what happens to young people with personality disorder?
(CAMBRIDGE UNIV PRESS, 2021-06-01)
Aims Hypothesis: Personality Disorder (PD) adolescents, compared to non-PD case, have a worse experience at transition. Aims: To describe the outcomes of referrals of adolescents for transition to adult services and compare PD and non-PD populations to identify potential improvements to allow for better transition experience of the PD patients. Background Borderline PD is prevalent in adolescents - although there is a reluctance to make the diagnosis. When patients reach graduation from CAMHS, many fall through the ‘gap’ in services during the transition. Consequently, adding the paucity in research about the transition experience of PD patients, it is important to evaluate what happens to these patients during the transition process to help better understand their experience, and how it can be improved. Method Patient's clinical records from Tower Hamlet CAMHS, East London NHS Foundation Trust, were reviewed retrospectively from July 2018 to November 2019, assessing whether optimal transition standards were met. A total of 41 cases that transitioned from CAMHS to AMHS were identified. Transition standards compared were: information sharing – case and risk, parallel care, transition planning and continuity. PD diagnosis was identified based on the recording of this diagnosis or meeting DSM5 criteria from the notes. PD and non-PD transition experience was compared. Result 36 were given a diagnosis by the CAMHS clinician at transition and 5 had no diagnosis assigned. No cases had a PD diagnosis made by the CAMHS clinician, however 1 case mentioned ‘PD traits’, 1 mentioned ‘EUPD’ as a possible differential and 2 cases were labelled as ‘emotional dysregulation’. The research team found 17 cases that met DSM5 criteria for PD diagnosis. Comparing transition experience of PD vs non-PD patients, the PD patients had a less optimal transition process. Statistical analysis using Chi Square Tests, showed significantly less optimal transition planning (X2 = 5.103, p < 0.05) and continuity (Fisher's exact test p = 0.049). Cohens W indicated a medium effect for transition planning and continuity. Conclusion Adolescents with a diagnosis of PD transition less well to Adult MHS than those without the PD diagnosis. Implications of our findings point to 1) the importance of considering a diagnosis of PD 2) if the diagnosis of PD is made, to anticipate greater difficulties in transition 3) the need to identify specific reasons for transition difficulties related to patient, clinician and system factors and their interrelation.