Centre for Youth Mental Health - Theses
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The medium-term course and outcome of Major Depressive Disorder in a youth-aged clinical sample
Abstract Background Youth (age 15-25) with Major Depressive Disorder who present for treatment have a complex range of psychopathology, and multiple areas of functional impairment. The medium-term outcome of this group, over the transition to adulthood, is yet to be prospectively studied. Prospective studies enable the identification of baseline predictors of poor outcome that can then be targets of future interventions. In prospective studies of clinical samples of adults with Major Depressive Disorder, personality disorders and high levels of neuroticism are among the most consistent predictors of poor outcome. Objectives This study aimed to describe the medium-term symptomatic and functional course of a clinical sample of youth with Major Depressive Disorder. It also aimed to investigate the predictors of the course of Major Depressive Disorder, with a focus on personality variables, particularly borderline personality disorder pathology and neuroticism. Borderline personality pathology was of specific interest due to its high prevalence in clinical populations of young people, and its established association with functional impairment. It was hypothesized that dimensional measures of borderline personality disorder pathology and neuroticism would be independent predictors of the symptomatic and functional course of Major Depressive Disorder of the study sample. Methods The study followed-up 90 young people who had received treatment for Major Depressive Disorder at a specialist psychiatric outpatient service, after an interval of between 6 and 15 years (mean=9.4 years). At baseline, a detailed assessment of psychopathology and personality had been performed, using semi-structured interviews for mental state and personality disorders and the NEO-PI. The longitudinal symptomatic course of the sample was charted with the Longitudinal Interval Follow-up Evaluation (LIFE). Longitudinal functioning was assessed with the LIFE-Range of Impaired Functioning Tool (LIFE-RIFT), and the Social Adjustment Scale-Self Report was used to measure functioning at follow-up. The instruments used in the baseline assessment were repeated at follow-up to assess mental state disorders and the degree of change in personality and personality pathology over the follow-up period. Results Results indicated that participants experienced a significant symptomatic and functional burden over the medium-term. The mean time to recovery of the presenting Major Depressive Episode was 32 months. The study participants were found to be in an Major Depressive Episode for a mean of 42 percent of the follow-up period, this high proportion contributed to by a recurrence rate of 76 percent after recovery from the presenting Major Depressive Episode. 81 percent of the sample also experienced a mental state disorder other than an Major Depressive Episode during the follow-up period. The mean annual level of functioning of the sample was in the mild impairment range, with Interpersonal Relations the LIFE-RIFT domain recording the greatest impairment. At follow-up, average functioning was in the mildly atypical range. Both borderline personality pathology (r=0.25, p=0.03) and neuroticism (r=0.23, p=0.02) were found to be predictive of the time to recovery of the presenting Major Depressive Episode, and borderline personality pathology was also predictive of mean annual functioning (r=0.24, p=0.03) over the follow-up period. Neither though were retained as significant predictors in multiple predictor regression analyses. In regression analyses, a co-occurring anxiety disorder at baseline and baseline functioning (measured by the SOFAS) were the most consistent predictors of the course outcomes. Both of these variables predicted the time to recovery of the presenting Major Depressive Episode (Anxiety disorder: Beta =0.25, p=0.03; SOFAS: Beta =-0.24, p=0.03) and the cumulative duration of time in an Major Depressive Episode over the follow-up period (Anxiety: Beta=0.21, p=0.04; SOFAS: Beta=-0.36, p=0.001). The baseline SOFAS also predicted the overall longitudinal functioning of the sample (LIFE-RIFT mean annual total score)(Beta=-0.43, p=0.002) and overall functioning at follow-up (Social Adjustment Scale-Self Report overall mean) (Beta=-0.28, p=0.03). A co-occurring anxiety disorder predicted the Interpersonal Relations domain of the LIFE-RIFT (Beta=0.30, p=0.004). Other significant baseline predictors in the multiple predictor analyses were a personality disorder and having had a previous Major Depressive Episode at baseline, Both were predictive of the LIFE-RIFT mean annual total score (Personality disorder: Beta=0.28, p=0.02; Previous Major Depressive Episode: Beta =0.29, p=0.02). Baseline Cluster A personality pathology predicted the overall mean of the Social Adjustment Scale-Self Report at follow-up (Beta=0.26, p=0.04). Conclusions This study describes the significant and enduring symptomatic and functional burden experienced by a clinical sample of youth with Major Depressive Disorder over the course of the transition to adulthood. The symptomatic burden consisted of both Major Depressive Disorder and a high prevalence of other mental state disorders. This study identified both functional impairment, and the presence of a co-occurring anxiety disorder at presentation as independently contributing to the symptomatic and functional burden of Major Depressive Disorder. Personality pathology in the form of personality disorder or Cluster A pathology independently contributed to the functional burden, as did having had a previous Major Depressive Episode at presentation. The findings in regard to the course of Major Depressive Disorder indicate the need to take a longitudinal perspective in planning for treatment for this population. This would aim to ensure timely and appropriate intervention for recurrent episodes, and for the frequently co-occurring mental state disorders. In its findings on predictors of course, this study presents a diversity of influential factors. Ideally, these factors would be able to be addressed in an integrated treatment program. Such a program would have the potential to lead to much improved longitudinal outcomes.
“It levels you out again but you're not dealing with the trauma”: An exploration into how people with a history of interpersonal childhood trauma and psychosis subjectively experience antipsychotic medications
Among people diagnosed with psychotic disorders, those with a history of interpersonal childhood trauma (ICT) present with a more complex clinical profile. In addition to experiencing hallucinations/delusions, these individuals can experience a range of post-traumatic stress/trauma-related symptoms and, more specifically, the distress associated with remembering/re-experiencing traumatic events. There is also a high likelihood that people with trauma and psychosis will experience dissociation, depression, anxiety, suicidality, substance use and cognitive impairment. Irrespective of their symptomatic profile, these individuals are often prescribed an antipsychotic medication. Little is known about how these individuals experience the emotional, cognitive and physical effects of antipsychotics or how antipsychotics influence their trauma-related and other non-psychotic symptoms. Thus, this study aimed to explore how people with psychosis and a history of ICT subjectively experience the wide-ranging psychological and physical effects of antipsychotic medications. An embedded mixed-methods research design with a qualitative phenomenological priority was implemented. Nineteen people who were diagnosed with psychosis and had experienced ICT participated in semi-structured interviews. Participants were specifically asked about how antipsychotics influenced their 1) general emotional, cognitive and physical states, 2) trauma-related thoughts, emotions and physical responses and 3) dissociative symptoms (depersonalisation and derealisation). Participants’ interview transcripts were analysed using interpretative phenomenological analysis. The results demonstrated that, for most participants, antipsychotic medications altered the way they experienced their memories of childhood trauma. There were differences between participants in how antipsychotics altered their trauma memories. Some participants indicated that their medication alleviated the frequency and/or intensity of distressing trauma-related thoughts, emotions and/or physical symptoms, while others mentioned that their flashbacks and thoughts of past traumatic events intensified. Participants also reported that, by supressing trauma-related thoughts and emotions, antipsychotics prevented them from confronting or processing their childhood trauma. While participants considered this beneficial in the short term, they recognised that they would need to confront their trauma to heal. As such, having trauma memories supressed by the emotional and cognitive effects of antipsychotics was not considered beneficial in the long term by these participants. There was also a mixed response from participants about whether antipsychotic medications altered their dissociative symptoms. Many participants reported that antipsychotics supressed their emotions and/or impaired their cognitive functioning, while a few mentioned that they were able to think more clearly and concentrate for longer. Many participants also described varying adverse physical effects of antipsychotic medications. The most common were weight gain and movement difficulties. Participants reported that they had tried many different antipsychotics before finding a medication that was somewhat effective in alleviating their psychotic symptoms. This study’s findings suggest that the cognitive, emotional and physiological effects of antipsychotic medications can be experienced as beneficial or detrimental depending, in part, on how they influence trauma-related thoughts/emotions/physical responses and dissociative symptoms. These findings highlight the need for intervention studies that evaluate the effect of antipsychotic medication on the trauma-related/post-traumatic stress and dissociative symptoms of people with a history of childhood trauma and psychosis.
Non-Psychotic Outcomes and Personality Disorders in Young People at Ultra-High Risk of Developing a Psychotic Disorder: A Long-Term Follow-Up Study
Background: Despite there being a large body of research available on the precursors of psychosis (the “prodromal” phase), there is a paucity of literature available on pre or comorbid mental and personality disorders in the ultra-high risk (UHR) for psychosis population. Most research thus far has been cross-sectional, with only a few long-term follow-ups, limiting the ability to investigate the long-term pattern and outcomes of comorbidity. Aims: The current study investigated comorbidity of non-psychotic mental and personality disorders in the UHR population - specifically, the prevalence of these disorders at entry and follow-up and their association with clinical and functional outcomes over the long-term (6 to 12 years). In addition, this study investigated the issue of whether UHR status is specific to psychosis outcomes or for a range of non-psychotic mental disorders, including major depressive disorder, anxiety disorder and personality disorders. The current study also aimed to identify baseline clinical predictors of the long-term trajectories of mental disorder. Method: The sample comprised 172 young people from the Personal Assessment & Crisis Evaluation (PACE) Clinic considered to be at UHR of developing a psychotic disorder. The majority of the original sample (n=125, 72.7%) presented for follow-up assessment (mean=8.8 years, range = 6.8 to 12.1 years since baseline assessment). Comorbid non-psychotic mental and personality disorders were assessed using the Structured Clinical Interview for DSM-IV (SCID I and II). Global functioning was assessed using the global assessment of functioning (GAF) scale, the Social and Occupational Functioning Assessment Scale (SOFAS) and the Quality of Life Scale (QLS). Results: Only 13% of participants did not meet criteria for a non-psychotic mental disorder diagnosis at baseline. The remaining 87% of participants were diagnosed with mental disorders, the majority of which were mood disorders (79%), followed by anxiety disorders (48%) and substance use disorders (18%). The pattern of disorder prevalence present at baseline continued at follow-up, though at a reduced rate, with 48.8% not meeting criteria for non-psychotic mental disorder. The disorder that proved to be most persistent for participants over time was mood disorder, with 45% of the sample experiencing this continuously. Baseline clinical predictor variables were unable to predict remission of a non-psychotic mental disorder. However, meeting Trait Vulnerability UHR criteria predicted incidence of a non-psychotic disorder and high scores on baseline psychopathology predicted continuous non-psychotic disorder over time. Presence of a continuous non-psychotic mental disorder was also associated with lower functional outcomes on multiple measures at follow-up. Baseline mental disorder was not significantly associated with transition to psychosis. Persistence of attenuated psychotic symptoms was experienced by 30% of the sample at follow up assessment and this was significantly associated with impairment in social and occupational functioning. Personality disorders were reported by 19% of the sample at follow-up. The most prevalent disorder was borderline personality disorder (11%). Personality disorders were associated with poorer clinical and functional outcomes: presence of personality disorders (compared to no personality disorder) was associated with an increased rate of transition to psychosis, and was associated with presence of comorbid non-psychotic mental disorder and poorer social and functional outcomes. Conclusions: Most (84%) participants meeting UHR criteria at baseline did not go on to develop psychosis. The majority did, however, present with persisting non-psychotic mental disorders that were associated with poorer functional outcomes at follow-up. The course of non-psychotic mental disorders in UHR participants over time was able to be predicted for continuous and incident disorders using baseline clinical variables, though the strength of the predictions was modest. Therefore, the link between baseline clinical predictors and long-term mental health outcomes would benefit from further investigation. Almost one-third of UHR participants continued to experience attenuated psychotic symptoms over the longer term. Those who also met criteria for personality disorders at follow-up were also more likely to be experiencing comorbid non-psychotic mental disorders, poorer functional outcomes and an increased risk of transition to psychosis than those who did not have a personality disorder. This research indicates that people meeting criteria for UHR are at risk of experiencing a range of other non-psychotic psychiatric problems over time.
Application of joint modelling to the analysis of transition to psychosis
Background and Aims: Psychosis is a mental condition that is associated with serious adverse effects on people's personal lives and a huge economic burden on society. Criteria for identifying people at high risk of developing psychosis, referred to as clinical high risk (CHR) criteria, were established during the 1990s and 2000s. These criteria have given hope that treatments can be provided at an early stage to delay or prevent the onset of psychosis. However, while individuals satisfying these criteria, called CHR individuals, certainly have a much higher risk of developing psychosis than the general population, a considerable proportion of them do not transition from an at-risk state to psychosis. Therefore, much research has been conducted in the past twenty years or so seeking predictors of transition to psychosis among CHR individuals. Such research work has almost entirely been based on fixed predictors, which are predictors whose values do not change or pertain to only the baseline time point, i.e. at study entry. Even though longitudinal data, i.e. repeated measurements over time, can be obtained and are common in transition to psychosis studies, they are rarely utilised in the analysis. Predictors with longitudinal measurements are called time-dependent predictors (TDPs). TDPs carry information about the progression of the illness and they can provide continuous updates of the transition risk prediction over time according to the changes in their values. Such updating of prediction is called dynamic prediction and could contribute to the provision of timely and personalized treatment to the patients concerned. This doctoral work has two aims: (1) to examine the inclusion of TDPs in the analysis of transition to psychosis among CHR individuals and (2) to examine the implementation of dynamic prediction in predicting transition to psychosis among CHR individuals. Method: The relatively new statistical methodology, joint modelling, was used to incorporate TDPs into the analysis of transition to psychosis data. Both simulated data and real data were used to assess the performance of joint modelling and the potential benefit of the inclusion of longitudinal data in the analysis and prediction of the risk of transition. Results: Compared to the conventional approach of using only baseline values, the inclusion of longitudinal data via joint modelling was shown to provide better statistical inference in the estimation of the effect of the predictors on the risk of transition. Moreover, dynamic prediction through the use of TDPs was shown to have the potential to provide better prediction of the risk of transition than the use of fixed predictors only. Conclusion: The inclusion of longitudinal data in the form of TDPs via joint modelling in the analysis of transition to psychosis is certainly a worthwhile endeavour. Dynamic prediction of transition through the incorporation of TDPs in prediction models has great potential in improving the prediction of transition and enabling the provision of personalized treatment.
Antecedents of incident bipolar disorder in youth
Background: Bipolar disorder (BD) is a serious mental illness characterised by episodes of mania and depression. The disability associated with this disorder and the observation that at least a sub-proportion have a progressive course suggests that early or preventive interventions may be an effective strategy to minimise the disability. However, prevention efforts for BD require characterisation of targets for such interventions. Aims and objectives: Thus, the overall aim of this research program was to describe the pre-onset illness stages related to the development of incident (hypo)manic episodes and their associated functional impairment. Specifically, we aimed to examine clinical populations where preventive efforts may be more feasible. The objectives included identification of i) baseline characteristics associated with later BD among non-bipolar help-seeking youth; ii) rates and predictors of transition from major depressive disorder (MDD) to BD in previously published studies; iii) instruments that have prospective predictive validity in identifying BD and iv) the precursors of functional impairment in the post-illness period. Methods: This thesis comprises five studies that have examined these issues using diverse methodologies – using systematic review, meta-analyses and longitudinal cohort designs. Three studies involved examining baseline characteristics associated with the development of later BD from non-bipolar states. One study identified the instruments that have been used to predict the later onset of BD using a systematic review, while the final study examined the pre-onset predictors of later functioning among young people with first episode BD. Main results: The characteristics associated with later BD in the two cohort studies included subthreshold manic symptoms, comorbid substance use, severity of depression, antidepressant use and lower functioning. Meta-analyses identified that family history of BD, comorbid psychotic symptoms and lower age of onset of depression was predictive of transition from MDD to BD. The systematic review identified few instruments with prospective validity for predicting BD onset that had been replicated in clinical cohorts. However, instruments with validity in non-clinical cohorts, or those without replication were described. Across the first four studies, combinations of risk factors were associated with a greater risk of transition to BD. Poor premorbid adjustment in the pre-onset phase was predictive of later functioning among youth with first episode mania. Discussion: The findings of these studies point to the need to use combinations of risk factors identified using validated instruments, particularly in young people to predict the onset of BD. This may then help develop preventive interventions that may be tested in studies that are feasible and have adequate statistical power. Incorporating functional precursors into pre-illness stages may help with prevention of functional impairments. A putative instrument which may decrease measurement bias is also proposed. The primary limitation of the included studies was in the post-hoc nature of analyses and the associated lack of availability of all possible baseline confounders. Additionally, low statistical power limited the ability to examine certain associations. Future studies should examine multiple confounding variables in longitudinal cohorts of youth and young adults. Larger cohorts that are enriched for multiple risk factors may help improve statistical power.
Early psychosis workforce: development of core competencies for mental health professionals working in the early psychosis field
Background: Evidence for early intervention in psychosis has steadily grown over the last 20 years leading to increasing investment in early psychosis service development and a rapidly expanding workforce. Although training of staff has been identified as critical to early psychosis model fidelity and the effective delivery of early psychosis services, to date there has been limited peer-reviewed research in this area. The development and use of competency standards has been identified as useful in supporting health professionals’ education and training, and in health workforce development. Currently the most common approach to competency standards development in healthcare is expert consensus. The overall aim of this thesis was to identify the core competencies required of mental health professionals working in the early psychosis field, which could function as an evidence-based tool to support the early psychosis workforce, strengthen early psychosis model fidelity and in turn assist early psychosis service implementation. The Delphi method was used to establish expert consensus on the core competencies Method: A two-stage Delphi method was used to establish expert consensus on the core competencies. In the first stage, a systematic literature search was conducted to generate competency items. A Delphi Reference Group consisting of 5 clinicians and researchers further reviewed these competency statements for overlap and redundancy. In the second stage, an expert panel consisting of expert early psychosis clinicians from around the world was formed. Panel members then rated each of the competency items on how essential they are to the clinical practice of all early psychosis clinicians. A comparison group of experts in adult severe mental illness was also formed. Data from the comparison group was not included in the primary study. Post-hoc comparisons were made to determine whether there were any differences or similarities in response patterns between the two different panels. Results: In total, 1023 pieces of literature, including textbooks, journal articles and grey literature were reviewed, from which 4667 competency statements were extracted for potential inclusion in the study. After review by the Delphi Reference Group, a final 542 competency statements were identified for inclusion in the questionnaire. 63 early psychosis experts participated in three questionnaire rating rounds. The overall retention rate was 93.6% across all three rating rounds. Of the 542 competency items, 242 competency statements were rated as ‘Essential’ or ‘Important’ by 90% or more of the expert panel and are thus identified as the required core competencies of an early psychosis clinician. Twenty-nine of these competency statements were endorsed by 62 or more of the 63 early psychosis experts. Due to the very high level of consensus achieved, these highest-rated competency statements may be considered the foundational competencies for early psychosis practice. A comparison group of 15 experts in adult severe mental illness participated in one rating round. There were few notable differences between the two expert groups. However the differences identified indicate that there may be important philosophical differences between mainstream mental health services and an early intervention approach to early psychosis care. Conclusion: The study generated a set of core competencies required of clinicians working in the early psychosis field. The core competencies provide a common language for early psychosis clinicians across professional disciplines and regardless of country of practice. The findings thus provide a useful resource to support early psychosis workforce development and early psychosis service reform.
An examination on cognitive functioning following a first episode of mania in people treated with lithium and quetiapine monotherapy: a 12-month follow-up study
Cognitive impairments that persist during remission in bipolar disorder have received intensive investigation over the past couple of decades. Nevertheless, the onset and extent of cognitive deficits that occur either prior to, or following, a first episode of mania (FEM), and the trajectory of cognitive functioning in the early stages of illness remain unclear. Moreover, the effect of treatment medication on cognitive functioning in people with bipolar disorder warrants systematic investigation. Specifically, lithium carbonate and quetiapine fumurate have shown to be effective in the treatment of mania and bipolar depression and are both postulated to have neuroprotective properties. The aims of this research program were to: (i) examine cognitive functioning in people following FEM; (ii) assess cognitive changes following FEM over a 12-month period; and (iii) compare the effects of lithium and quetiapine monotherapy on cognitive functioning over the same 12-months. A systematic review of all peer-reviewed studies on cognitive functioning in people with FEM during both the acute and remission phases of the illness was conducted. This involved a systematic search of the literature from three electronic databases from 1980 to 2014. The search identified seven studies on cognitive functioning in people with FEM. The limited studies in the acute phase focussed only on aspects of executive functioning, with findings of impairment in cognitive flexibility, but not in response inhibition or verbal fluency. Although deficits in several cognitive domains were identified during the remission phase, the findings between studies were largely inconsistent. Nevertheless, the most consistent finding during remission was a deficit in working memory, and that verbal fluency and nonverbal memory were not affected. The systematic review highlighted the need for further studies and clarification on the extent of cognitive impairment following FEM, and assisted in the formation of the hypotheses of the empirical studies. For the empirical studies, a total of 61 participants with FEM randomised to lithium or quetiapine monotherapy, and 21 demographically matched healthy controls (HCs) were recruited. FEM participants and HCs were compared on cognitive functioning using an extensive cognitive battery over a 12-month follow-up period. FEM participants were assessed on cognitive functioning at baseline, 3-months, and 12-months, whereas, cognitive functioning of HCs was assessed at baseline and 12-months. The cognitive assessment included measurements of processing speed, attention, sustained attention, verbal learning and memory, nonverbal memory, working memory, verbal fluency, executive functioning, and intelligence. The first empirical study involved a cross-sectional analysis comparing cognitive functioning in FEM participants following stabilisation relative to HCs. Although the groups were matched in age, sex and premorbid intelligence, the findings revealed that FEM participants had significantly lower full-scale IQ (FSIQ) and education level than HCs. However, the difference between groups in FSIQ was no longer significant after controlling for premorbid intelligence. FEM participants displayed cognitive deficits of medium to large effect in processing speed, verbal learning and memory, and working memory compared to HCs. There were no significant differences between groups on other measures of cognition after controlling for FSIQ, education and premorbid intelligence. The second empirical paper involved a longitudinal analysis that assessed the trajectory of cognitive functioning in the FEM participants relative to HCs over 12-months. The findings revealed a significant group by time interaction in one measure of processing speed (Trail Making Test – Part A), and immediate verbal recall (Rey Auditory Verbal Learning Test – trial 1), with a significant improvement observed in the FEM group relative to HCs over time. On the contrary, a significant group by time interaction was observed in a processing speed measure of focussed reaction time (CogstateTM Detection), with FEM participants showing a slower performance relative to HCs over time. A significant group by time interaction was also observed in one aspect of executive functioning - effortful inhibitory control (Stroop effect), revealing that HCs improved in performance over 12-months, whereas the FEM participants did not. There were no other group by time interactions for other measures of cognition. The final empirical study was a randomised-controlled trial, which examined the effects of lithium and quetiapine monotherapy in people following FEM over a 12-month period. The results showed a significant group by time interaction in phonemic verbal fluency, with an improved performance in lithium-treated participants compared to quetiapine-treated participants over time. There were no other significant group by time interactions after controlling for multiple comparisons. In conclusion, the findings from this research program revealed that FEM participants had poorer global intelligence relative to HCs, as well as impairments in some but not all cognitive domains following stabilisation from FEM. There appears to be stability in cognitive functioning for most domains over the 12-month period following FEM. However, an improvement was observed in immediate verbal memory and one measure of processing speed over time in FEM participants relative to HCs, although FEM participants performed slower over time on a simple processing speed test of focused reaction time. In addition, there may be a developmental arrest in effortful inhibitory control, as HCs showed an improvement in this function over the 12-month period that was not evident in the FEM group. There were no significant differences between lithium-treated and quetiapine-treated participants on most cognitive domains, apart from phonemic verbal fluency, in which lithium-treated participants showed a significant improvement relative to quetiapine-treated participants over the 12-month period. These findings suggest that neuroprotective properties of lithium may benefit aspects of cognitive functioning when commenced in the early stages of illness. The presence of cognitive deficits in FEM signifies that cognitive changes may occur very early in the illness course. The findings from this research program did not provide evidence for a progressive deterioration in cognitive functioning following FEM, although more rigorous longitudinal studies involving subgroup analysis are warranted. Future studies should examine the relationship between brain abnormalities and cognitive functioning in people following FEM, as well as assess the effects of lithium and quetiapine monotherapy on clinical and neuroanatomical changes over time.
Suicide prevention in young people
Suicide-related behaviour is a significant problem among young people in Australia. Although the reduction of youth suicide is a national priority there remains a lack of intervention research upon which to base preventative efforts. This thesis argues that there is the need for a greater number of intervention studies in suicide prevention, including brief, innovative interventions across a number of settings. The thesis begins by systematically reviewing the literature in the field of youth suicide prevention with an in-depth focus on suicide-related behaviour in school and clinical settings. The empirical component comprises four sequentially conducted studies that together aimed to examine the status quo with regard to suicide prevention research among young people in Australia and specifically examined the safety, acceptability and efficacy of two novel interventions designed to reduce suicide risk among youth in both a clinical and an educational setting. The studies employed a range of methodologies, and together sought to address some of the gaps in current research. Study One reported on the extent of suicide research that was conducted in Australia during the period 2007–2011, via an examination of published journal articles and funded grants. Study Two was a randomised controlled trial that tested the effects of a brief postcard intervention among 165 at-risk young people who had sought help from a specialist mental health service (the Postcard Study). Study Three was a cross-sectional survey administered to a random sample of school wellbeing staff across Victoria, Australia. The survey sought specific information regarding their views on approaches to suicide prevention in school settings, and in particular, with regard to using the Internet for the delivery of suicide prevention programs. The final study, Study Four, was a pilot study that employed a pre-test/post-test design to examine the efficacy, safety and acceptability of a cognitive behavioural therapy program (Reframe-IT), delivered via the Internet to 21 secondary school students at risk of suicide. Together, these studies demonstrated a lack of intervention research in the field of youth suicide prevention, as evidenced by a lack of both published papers and funded grants. They also showed that although schools are considered to be an appropriate setting for suicide prevention programs, school staff feel under-skilled when working with at-risk youth. That said a raft of approaches were reported as being required in schools, including information and awareness programs, specific suicide prevention training, screening programs and greater access to clinical services. The study also identified that school staff consider schools to be an appropriate and acceptable setting for conducting suicide prevention activities. The two intervention studies demonstrated that it is feasible and safe to conduct intervention research, including randomised controlled trials, with suicidal young people. Although the Postcard Study demonstrated no differences between the treatment and control groups, the intervention was considered to be acceptable and appeared to have no iatrogenic effects. Participants in the Reframe-IT Program all demonstrated reduced suicidal ideation, reduced depressive symptoms and reduced hopelessness at the end of the program. In addition, no iatrogenic effects were evident, indicating that there are safe ways of talking with young people about suicide via the Internet. As with much suicide research, each of these studies suffered from some methodological limitations. Despite this, these findings add to a growing body of evidence that is arguing for greater intervention research in this field. Indeed, it appears that it is feasible, safe and acceptable to test novel interventions with suicidal young people in both clinical and school settings and that interventions do exist that hold promise with this population. Hence, there is no reason for the continued exclusion of suicidal young people from research studies. The thesis concludes by outlining a number of opportunities for the future of suicide prevention research, and specifically articulates the need for a more collaborative and strategic approach to suicide research in Australia. This would enable many of the methodological limitations that frequently hamper suicide research to be overcome, and some of the pessimism that exists with regard to our ability to prevent youth suicide to be challenged.
Social inclusion and mental illness
Background: Social inclusion is increasingly recognised as an important contributor to good mental health and greater mental health outcomes, in particular for people with mental illness. Despite increased understanding of the positive impact that social inclusion can have, the potential to make progress has been slowed by some key limitations. The key, underlying problem regarding social inclusion, is the lack of a specific operationalised definition, with only some consensus regarding what it means to be socially included. This lack of specificity has made it difficult to accurately measure the impact of initiatives designed to improve social inclusion. Nonetheless, several attempts at developing measures of social inclusion have been made, in particular for use with people with mental illness. Psychometric testing has been conducted on some, but not all of the measures, and has not been completed on any of them. The overall aim of this thesis was to develop a measure of social inclusion for use with people with mental illness. The measure was designed in a series of studies ensuring the representative input of people with a lived experience of mental illness. The measure was titled the SIMI-LE, an abbreviation of a measure of Social Inclusion for people with Mental Illness – Long Edition. Method: The development of the SIMI-LE took place over three sequential studies. The first study involved a thematic analysis of literature regarding social inclusion to obtain the opinions of professionals regarding key contributors of social inclusion. Seventy-one pieces of literature were reviewed (academic literature regarding social inclusion in general n=25, academic literature regarding social inclusion and mental illness n=26, and organisational reports n=20). The second was a Delphi study, conducted to obtain a consensus between three groups regarding the importance or relevance of contributors identified in the first study. Participants included 32 consumers of a mental health service, 32 carers of a person with mental illness and 40 community members. The third study involved the construction of the measure, and preliminary testing with a sample of ninety participants (30 consumers, 30 family members of a person with mental illness and 30 community members). Results: A comprehensive list of contributors was compiled during the first study. A consensus across three groups regarding how important or relevant each of these contributors were, was obtained during the second study. Finally, the SIMI-LE was constructed and preliminary testing conducted. The measure was seen to have good face validity and was highly acceptable to participants. Preliminary findings demonstrated poorer outcomes for people with mental illness as compared to those without, with differences seen in each of the five categories. Discussion: Overall, the aim of developing a measure of social inclusion for use with people with mental illness was achieved. In the process of developing the measure, a greater understanding of social inclusion from the perspective of people with mental illness was obtained. The measure has demonstrated excellent preliminary psychometric properties and has displayed the ability to differentiate between groups, as expected. Implications for use and suggestions for future research are detailed.
Affective processes and alcohol use in mid-adolescence
The aim of this thesis was to prospectively examine the role of affective processes in driving mid-adolescent drinking behaviour across multiple stages of use. While previous studies have provided considerable evidence that affective processes are related to adolescent alcohol use, there have been few prospective, longitudinal studies that have comprehensively examined how different components and dimensions of affect contribute to various stages of drinking. Methods: This thesis draws on data from the Orygen Adolescent Development Study, an ongoing longitudinal research project that has obtained multi-method assessments of affective processes from approximately 250 adolescents since 2004. Incorporated into analyses were four measures of affect, gathered at age 12: (i) self-report measures of clinical symptoms; (ii) self-report measures of affective temperament; (iii) observation of adolescent affective behaviours during a parent-child conflict resolution task; and (iv) structural magnetic resonance imaging (MRI) of key brain regions implicated in affective processes. These measures were used to prospectively predict the onset of use, heavy drinking, and the experience of alcohol-related problems four years later, at age 16. Results: Few variables predicted early onset and heavy drinking, although the results indicated that adolescents who have a tendency to seek out pleasurable experiences are at greater risk of early initiation of alcohol use. In contrast, the experience of alcohol-related problems was consistently predicted by variables associated with higher levels of negative affect and poorer behavioural and affective self-regulation. This relationship was evident across all four domains of affect examined. Conclusions: Among Australian adolescents, the initiation of alcohol use during mid-adolescence and tendency to drink heavily by age 16 may be not be strongly motivated by individual differences in affect. In contrast, affective dysregulation appears to be a robust predictor of alcohol-related problems during this period, and can impart risk over and above the influence of heavy use. These findings suggest a number of avenues for prevention and intervention efforts aimed to reduce the prevalence of underage drinking and its associated harms.
Design and refinement of the MATE program: Mindful Awareness Training and Education: how do young people understand and practise mindfulness?
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.
The development and evaluation of guidelines and an information website for adult caregivers of adults with bipolar disorder
Background and aim: Bipolar disorder is a challenging and usually chronic illness associated with occupational and social consequences that affect the lives of both the person and those who care for them. Family members and friends with a primary role in supporting an adult with bipolar disorder (caregivers) are at risk of caregiver burden, depression and health problems. However, there is little evidence-based information to guide caregivers in ways to provide helpful support and maintain their own wellbeing. Thus, the aim of this project was to develop an easily accessible resource with relevant and useful information and suggestions for caregivers. Methods: The project was divided into two phases. In the first phase a Delphi consensus study was conducted with expert clinician, caregiver and consumer panel members to establish what information and suggestions to include in guidelines for adult caregivers of adults with bipolar disorder (N=143). In the second phase of the project, a web-based version of the guidelines www.bipolarcaregivers.org was developed to make this information easily accessible over the Internet. A formative evaluation of the website was conducted to establish the relevance and usefulness of the information to caregivers and how it could be improved. This involved an initial online survey for visitors to the website (N=536) and a more detailed follow-up email feedback survey, sent to interested caregivers of adults with bipolar disorder a month later (N=121). Results: There was mostly high consensus about what to include in the guidelines between the different Delphi panels. Out of a total of 626 survey items rated by the Delphi panels over three survey rounds, 537 (86%) were included in the guidelines. In the evaluation study, the majority of caregiver visitors who completed the initial feedback survey (97%) reported thinking that the information on www.bipolarcaregivers.org was “very useful” or “useful”. Similarly, between 86.4%-97.4% of caregivers who responded to the follow-up survey rated the information they read as “very useful" or “useful”. Nearly 93% found the information relevant and all participants said it gave them the impression that others were going through similar experiences. Over two thirds reported using the sections on providing support and working with the person to manage the illness and gave concrete examples of how they implemented the guidelines. Nevertheless, despite the overall positive results, qualitative feedback suggested practical ways the website could be further refined. Discussion: This project resulted in a publicly accessible information resource www.bipolarcaregivers.org that was reported to be relevant and useful by most of the users in the evaluation study. The website includes brief information summaries and a PDF of the guidelines that can easily be printed. The guidelines have been translated into booklets in Portugal and Brazil. According to Google Analytics, traffic to the website continues to increase. Www.bipolarcaregivers.org may form an initial step in providing basic information to caregivers caring for an adult with bipolar disorder. Those who care for people with more severe and complex illness presentations might benefit from additional support and training to cope with their caregiving role. Similarly, more detailed or tailored information and support may be suitable for caregivers who are already very experienced or well informed. A strength of this project is its consideration of the views of stakeholders and careful comparison and integration with the research literature. Future studies could combine stakeholder involvement with more rigorous evaluation of www.bipolarcaregivers.org and its long-term effect on caregiver and consumer outcomes. If funds become available, the website could be made more interactive to enhance learning of information and skills, and offer more tangible and tailored support. Background and aim: Bipolar disorder is a challenging and usually chronic illness associated with occupational and social consequences that affect the lives of both the person and those who care for them. Family members and friends with a primary role in supporting an adult with bipolar disorder (caregivers) are at risk of caregiver burden, depression and health problems. However, there is little evidence-based information to guide caregivers in ways to provide helpful support and maintain their own wellbeing. Thus, the aim of this project was to develop an easily accessible resource with relevant and useful information and suggestions for caregivers. Methods: The project was divided into two phases. In the first phase a Delphi consensus study was conducted with expert clinician, caregiver and consumer panel members to establish what information and suggestions to include in guidelines for adult caregivers of adults with bipolar disorder (N=143). In the second phase of the project, a web-based version of the guidelines www.bipolarcaregivers.org was developed to make this information easily accessible over the Internet. A formative evaluation of the website was conducted to establish the relevance and usefulness of the information to caregivers and how it could be improved. This involved an initial online survey for visitors to the website (N=536) and a more detailed follow-up email feedback survey, sent to interested caregivers of adults with bipolar disorder a month later (N=121). Results: There was mostly high consensus about what to include in the guidelines between the different Delphi panels. Out of a total of 626 survey items rated by the Delphi panels over three survey rounds, 537 (86%) were included in the guidelines. In the evaluation study, the majority of caregiver visitors who completed the initial feedback survey (97%) reported thinking that the information on www.bipolarcaregivers.org was “very useful” or “useful”. Similarly, between 86.4%-97.4% of caregivers who responded to the follow-up survey rated the information they read as “very useful" or “useful”. Nearly 93% found the information relevant and all participants said it gave them the impression that others were going through similar experiences. Over two thirds reported using the sections on providing support and working with the person to manage the illness and gave concrete examples of how they implemented the guidelines. Nevertheless, despite the overall positive results, qualitative feedback suggested practical ways the website could be further refined. Discussion: This project resulted in a publicly accessible information resource www.bipolarcaregivers.org that was reported to be relevant and useful by most of the users in the evaluation study. The website includes brief information summaries and a PDF of the guidelines that can easily be printed. The guidelines have been translated into booklets in Portugal and Brazil. According to Google Analytics, traffic to the website continues to increase. Www.bipolarcaregivers.org may form an initial step in providing basic information to caregivers caring for an adult with bipolar disorder. Those who care for people with more severe and complex illness presentations might benefit from additional support and training to cope with their caregiving role. Similarly, more detailed or tailored information and support may be suitable for caregivers who are already very experienced or well informed. A strength of this project is its consideration of the views of stakeholders and careful comparison and integration with the research literature. Future studies could combine stakeholder involvement with more rigorous evaluation of www.bipolarcaregivers.org and its long-term effect on caregiver and consumer outcomes. If funds become available, the website could be made more interactive to enhance learning of information and skills, and offer more tangible and tailored support.