The Sources of Strength Australia project: A cluster randomised controlled trial of a peer-connectedness school-based program to promote help-seeking in adolescents

BACKGROUND

Suicide is a significant public health problem and there is a clear need for interventions to improve help seeking for suicide and psychological distress in young people. This trial aimed to assess the effectiveness of the school-based Sources of Strength program in increasing help-seeking intentions and behaviours in adolescents.

METHODS

A cluster, randomised controlled trial was conducted in 13 Australian secondary schools (N = 1633), with each school randomly allocated to the intervention (n = 7) or wait-list control condition (n = 6). Participants in the intervention condition received the Sources of Strength program over two years and all participants completed self-report measures of help-seeking intentions and behaviour at four time-points. Staff and students in the intervention condition also provided qualitative feedback on the perceived impact of the program.

RESULTS

Mixed model repeated measures analyses demonstrated no significant effect of the Sources of Strength program on help-seeking intentions or behaviour at post-intervention or 6- or 18-month follow-up. Staff and students reported, through qualitative feedback, that the program increased awareness of and openness to help seeking and promoted a common language and school community.

LIMITATIONS

The current study only included self-report measures that may have been influenced by situational factors or biases.

CONCLUSIONS

Although the Sources of Strength program may have increased awareness of help seeking, there was no evidence that it is effective in increasing help-seeking intentions or behaviours in this cohort. The program may be more suitable for schools in disadvantaged areas where there may be limited existing connections to trusted adults.

People Who Die by Suicide Without Receiving Mental Health Services: A Systematic Review

Introduction

The majority of people who die by suicide have never seen a mental health professional or been diagnosed with a mental illness. To date, this majority group has largely been ignored, with most existing research focusing on predictors of suicide such as past suicide attempts. Identifying the characteristics of people who die by suicide without receiving services, often with a fatal first attempt, is crucial to reduce suicide rates through guiding improvements to service pathways and “just in time” interventions.

Methods

In this systematic review, PsycInfo, PubMed, CINAHL, and Web of Science were searched for peer-reviewed articles published from 1980 to 1st March 2021. Included studies examined predictors of non-receipt of formal mental health services among people who died by suicide. Data were extracted from published reports and the quality of included studies was assessed using a modified version of the Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies. This review was registered with PROSPERO, CRD 42021226543.

Results

Sixty-seven studies met inclusion criteria, with sample sizes ranging from 39 to 193,152 individuals. Male sex, younger or older age, and rural location were consistently associated with non-receipt of mental health services. People not receiving mental health services were also less likely to have a psychiatric diagnosis, past suicidal behavior or contact with general health services, and more likely to use violent means of suicide. There was some evidence that minority ethnicity and psychosocial stressors were associated with service non-receipt.

Conclusion

People who die by suicide without receiving mental health services are likely to have diverse profiles, indicating the need for multifaceted approaches to effectively support people at risk of suicide. Identifying the needs and preferences of individuals who are at risk of suicide is crucial in developing new support pathways and services, and improving the quality of existing services.

Systematic Review Registration

http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42021226543.

Psychosocial impacts of home-schooling on parents and caregivers during the COVID-19 pandemic

Background

The COVID-19 pandemic has been highly disruptive, with the closure of schools causing sudden shifts for students, educators and parents/caregivers to remote learning from home (home-schooling). Limited research has focused on home-schooling during the COVID-19 pandemic, with most research to date being descriptive in nature. The aim of the current study was to comprehensively quantify the psychosocial impacts of home-schooling on parents and other caregivers, and identify factors associated with better outcomes.

Methods

A nationally representative sample of 1,296 Australian adults was recruited at the beginning of Australian COVID-19 restrictions in late-March 2020, and followed up every two weeks. Data for the current study were drawn from waves two and three. Surveys assessed psychosocial outcomes of psychological distress, work and social impairment, and wellbeing, as well as a range of home-schooling factors.

Results

Parents and caregivers who were home-schooling during the COVID-19 pandemic experienced significantly higher levels of psychological distress and work/social impairment compared to those who were not home-schooling or had no school-aged children. A current mental health diagnosis or lower levels of perceived support from their child’s school negatively affected levels of psychological distress, work and social impairment, and wellbeing in parents and caregivers involved in home-schooling.

Conclusions

The mental health impacts of home-schooling were high and may rise as periods of home-schooling increase in frequency and duration. Recognising and acknowledging the challenges of home-schooling is important, and should be included in psychosocial assessments of wellbeing during periods of school closure. Emotional and instrumental support is needed for those involved in home-schooling, as perceived levels of support is associated with improved outcomes. Proactive planning by schools to support parents may promote better outcomes and improved home-schooling experiences for students.

What could we do differently next time? Australian parents' experiences of the short-term and long-term impacts of home schooling during the COVID-19 pandemic

BACKGROUND

COVID-19 lockdowns have resulted in school closures worldwide, requiring curriculum to be delivered to children remotely (home schooling). Qualitative evidence is needed to provide important context to the positive and negative impacts of home schooling and inform strategies to support caregivers and children as the pandemic continues. This study aimed to explore the experiences of home schooling caregivers at multiple time-points during the pandemic.

METHODS

Data were obtained from a longitudinal survey of a representative Australian sample conducted over 8 waves during 2020 and 2021. Participants who had home schooled at least one child during COVID-19 completed open-ended questions at Wave 4 (May 2020; n = 176), Wave 7 (June 2020; n = 145), and Wave 8 (March 2021; n = 57). Participants were asked to describe what they found positive and challenging about home schooling (Wave 4), what they would do differently if they home schooled their children again (Wave 7), and the longer-term impacts of home schooling on caregivers and children (Wave 8).

RESULTS

91% of participants at Wave 4 reported at least one positive and/or negative aspect of home schooling. At Wave 8, 32% and 29% of participants reported no long-term positive or negative impacts of home schooling respectively. Using a qualitative content analysis approach, six themes were developed from the data, encompassing the impacts of home schooling on parents, and the perceived impacts on children. Impacts on parents included connecting with children, managing the work-life-school balance, and the challenge of home schooling when parents are not teachers. Perceived impacts on children included: quieter and safer learning at home, and the negatives of managing schoolwork load and social isolation. At Wave 7, 56 participants (44%) identified at least one thing they would do differently.

CONCLUSIONS

Despite some participants reporting positive experiences associated with home schooling, it remains challenging for many parents and their children. Supports for parents and children engaged in home schooling should provide clear and flexible guidance on how to balance schoolwork with other competing demands, assist parents who lack confidence in supporting their children's remote learning, and address risks associated with social isolation.

Physical and Mental Health Effects of Bushfire and Smoke in the Australian Capital Territory 2019-20

The 2019–20 bushfire season in south-eastern Australia was one of the most severe in recorded history. Bushfire smoke-related air pollution reached hazardous levels in major metropolitan areas, including the Australian Capital Territory (ACT), for prolonged periods of time. Bushfire smoke directly challenges human health through effects on respiratory and cardiac function, but can also indirectly affect health, wellbeing and quality of life. Few studies have examined the specific health effects of bushfire smoke, separate from direct effects of fire, and looked beyond physical health symptoms to consider effects on mental health and lifestyle in Australian communities. This paper describes an assessment of the health impacts of this prolonged exposure to hazardous levels of bushfire smoke in the ACT and surrounding area during the 2019–20 bushfire season. An online survey captured information on demographics, health (physical and mental health, sleep) and medical advice seeking from 2,084 adult participants (40% male, median age 45 years). Almost all participants (97%) experienced at least one physical health symptom that they attributed to smoke, most commonly eye or throat irritation, and cough. Over half of responders self-reported symptoms of anxiety and/or feeling depressed and approximately half reported poorer sleep. Women reported all symptoms more frequently than men. Participants with existing medical conditions or poorer self-rated health, parents and those directly affected by fire (in either the current or previous fire seasons) also experienced poorer physical, mental health and/or sleep symptoms. Approximately 17% of people sought advice from a medical health practitioner, most commonly a general practitioner, to manage their symptoms. This study demonstrated that prolonged exposure to bushfire smoke can have substantial effects on health. Holistic approaches to understanding, preventing and mitigating the effects of smoke, not just on physical health but on mental health, and the intersection of these, is important. Improved public health messaging is needed to address uncertainty about how individuals can protect their and their families health for future events. This should be informed by identifying subgroups of the population, such as those with existing health conditions, parents, or those directly exposed to fire who may be at a greater risk.

The Youth Aware of Mental Health program in Australian Secondary Schools: 3- and 6-month outcomes

OBJECTIVE

The evidence base for suicide prevention programs in Australian schools is limited. The aim of this study was to examine the impact of a universal, mental health promotion and suicide prevention program-Youth Aware of Mental Health (YAM)-on suicidal ideation, mental health, and help-seeking in Australian secondary school students from baseline to post-intervention and 6-month follow up.

METHODS

Using a single-arm design, the YAM program was delivered to Year 9 students (13-16 years) in secondary schools located within four regions across New South Wales, Australia. A structured self-report questionnaire using validated scales was administered at each time point. Linear mixed-effects modelling was used to examine differences in suicidal ideation scores across time, while accounting for random effects of individual schools.

RESULTS

Suicidal ideation reduced significantly from baseline to post, and from baseline to follow-up (p < 0.001). Depression severity declined (p < 0.001) and help-seeking intentions increased (p < 0.001) at post-intervention and 6- months following the intervention period. No suicide deaths were reported for any study participants.

CONCLUSION

The current findings provide preliminary evidence that the YAM program is a promising preventive intervention for Australian schools, particularly for reducing suicidal ideation, depression and increasing help-seeking intentions in young people. The implementation of YAM in a large number of schools across New South Wales demonstrates the feasibility, and acceptability by schools, of implementing this program at scale.

TRIAL REGISTRATION

ANZCTR, ACTRN12619000338167. Registered 5 March 2019-Retrospectively registered, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376989&isReview=true .

Cause or symptom? A longitudinal test of bidirectional relationships between emotion regulation strategies and mental health symptoms

Previous work has generally conceptualized emotion regulation as contributing to mental health outcomes, and not vice versa. The present study challenges this assumption by using a prospective design to investigate the directionality of underlying relationships between emotion regulation and mental health in the context of a major population-level stressor. We surveyed a large nationally representative sample of adults (18-91 years, N = 704) at three 1-month intervals across the acute lockdown phase of the COVID-19 pandemic in Australia, using standardized measures of depression and anxiety symptoms. At each time point, we also measured the use of two emotion regulation strategies-cognitive reappraisal and emotional suppression-previously associated with adaptive and maladaptive mental health outcomes, respectively. We found cognitive reappraisal was unrelated to mental health symptoms. In contrast, greater emotional suppression was robustly associated with higher symptom levels for both depression and anxiety. Longitudinal analyses revealed this association reflected bidirectional relationships. Higher symptoms of depression and anxiety each predicted greater subsequent use of emotional suppression, and greater use of emotional suppression predicted higher subsequent symptoms. This bidirectionality suggests emotional suppression is both symptomatic and predictive of psychological distress. The lack of a relationship for cognitive reappraisal is discussed with respect to the pandemic context and evidence that high stress might reduce people's ability to use this strategy effectively. Given the strong emphasis on reappraisal in clinical practice, there is a critical need to understand for whom, what and when this strategy is helpful. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Associations of loneliness, belongingness and health behaviors with psychological distress and wellbeing during COVID-19

Background

The aim of this study was to assess the effects of loneliness, belongingness and other modifiable factors on psychological distress and wellbeing and whether the effects of COVID-19 modulated these relationships.

Methods

The current study reported on 1217 participants aged 18 years or older who completed an online survey from 28 to 31 March 2020. Survey measures included demographic characteristics; exposure to COVID-19; impact of COVID-19 on employment, finance, and work and social adjustment; loneliness, thwarted belongingness, and health behavior changes as modifiable factors. Outcome measures were psychological distress and wellbeing.

Results

Linear regression models revealed that COVID-19 related work and social adjustment difficulties, financial distress, loneliness, thwarted belongingness, eating a less healthy diet poorer sleep and being female were all associated with increased psychological distress and reduced wellbeing (p < 0.05). Psychological distress was more elevated for those with high difficulties adjusting to COVID-19 and high levels of thwarted belongingness (p < 0.005). Similarly, as COVID-19 related work and social adjustment difficulties increased, wellbeing reduced. This was more pronounced in those who felt lower levels of loneliness (p < 0.0001). Other interactions between COVID-19 impacts were observed with gender and poorer diet for psychological distress and cigarette use, age and gender for wellbeing (p < 0.05).

Limitations

The study was cross-sectional, preventing causal interpretation of the relationships.

Conclusion

Modifiable factors, age and gender had significant impacts on psychological distress and wellbeing. Public health and policy approaches to improving social, economic and lifestyle factors may mitigate the negative mental health effects of the pandemic and its restrictions.

A Brief Intervention to Increase Uptake and Adherence of an Internet-Based Program for Depression and Anxiety (Enhancing Engagement With Psychosocial Interventions): Randomized Controlled Trial

BACKGROUND

Psychosocial, self-guided, internet-based programs are effective in treating depression and anxiety. However, the community uptake of these programs is poor. Recent approaches to increasing engagement (defined as both uptake and adherence) in internet-based programs include brief engagement facilitation interventions (EFIs). However, these programs require evaluation to assess their efficacy.

OBJECTIVE

The aims of this hybrid implementation effectiveness trial are to examine the effects of a brief internet-based EFI presented before an internet-based cognitive behavioral therapy self-help program (myCompass 2) in improving engagement (uptake and adherence) with that program (primary aim), assess the relative efficacy of the myCompass 2 program, and determine whether greater engagement was associated with improved efficacy (greater reduction in depression or anxiety symptoms) relative to the control (secondary aim).

METHODS

A 3-arm randomized controlled trial (N=849; recruited via social media) assessed the independent efficacy of the EFI and myCompass 2. The myCompass 2 program was delivered with or without the EFI; both conditions were compared with an attention control condition. The EFI comprised brief (5 minutes), tailored audio-visual content on a series of click-through linear webpages.

RESULTS

Uptake was high in all groups; 82.8% (703/849) of participants clicked through the intervention following the pretest survey. However, the difference in uptake between the EFI + myCompass 2 condition (234/280, 83.6%) and the myCompass 2 alone condition (222/285, 77.9%) was not significant (n=565; χ²₁=29.2; P=.09). In addition, there was no significant difference in the proportion of participants who started any number of modules (1-14 modules) versus those who started none between the EFI + myCompass 2 (214/565, 37.9%) and the myCompass 2 alone (210/565, 37.2%) conditions (n=565; χ²₁<0.1; P=.87). Finally, there was no significant difference between the EFI + myCompass 2 and the myCompass 2 alone conditions in the number of modules started (U=39366.50; z=-0.32; P=.75) or completed (U=39494.0; z=-0.29; P=.77). The myCompass 2 program was not found to be efficacious over time for symptoms of depression (F_4,349.97=1.16; P=.33) or anxiety (F_4,445.99=0.12; P=.98). However, planned contrasts suggested that myCompass 2 may have been effective for participants with elevated generalized anxiety disorder symptoms (F_4,332.80=3.50; P=.01).

CONCLUSIONS

This brief internet-based EFI did not increase the uptake of or adherence to an existing internet-based program for depression and anxiety. Individuals' motivation to initiate and complete internet-based self-guided interventions is complex and remains a significant challenge for self-guided interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618001565235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375839.

Trajectories of Change in an Open-access Internet-Based Cognitive Behavior Program for Childhood and Adolescent Anxiety: Open Trial

BACKGROUND

Although evidence bolstering the efficacy of internet-based cognitive behavioral therapy (iCBT) for treating childhood anxiety has been growing continuously, there is scant empirical research investigating the timing of benefits made in iCBT programs (eg, early or delayed).

OBJECTIVE

This study aims to examine the patterns of symptom trajectories (changes in anxiety) across an iCBT program for anxiety (BRAVE Self-Help).

METHODS

This study's participants included 10,366 Australian youth aged 7 to 17 years (4140 children aged 7-12 years; 6226 adolescents aged 12-17 years) with elevated anxiety who registered for the BRAVE Self-Help program. Participants self-reported their anxiety symptoms at baseline or session 1 and then at the commencement of each subsequent session.

RESULTS

The results show that young people completing the BRAVE Self-Help program tend to fall into two trajectory classes that can be reliably identified in terms of high versus moderate baseline levels of anxiety and subsequent reduction in symptoms. Both high and moderate anxiety severity trajectory classes showed significant reductions in anxiety, with the greatest level of change being achieved within the first six sessions for both classes. However, those in the moderate anxiety severity class tended to show reductions in anxiety symptoms to levels below the elevated range, whereas those in the high symptom group tended to remain in the elevated range despite improvements.

CONCLUSIONS

These findings suggest that those in the high severity group who do not respond well to iCBT on a self-help basis may benefit from the additional support provided alongside the program or a stepped-care approach where progress is monitored and support can be provided as necessary.

The Literacy of Suicide Scale

Background: Until recently, little was known about the public's knowledge of suicide or its association with help-seeking. Aims: In this article we describe the development, validation, and application of the Literacy of Suicide Scale (LOSS). Method: A total of 658 people participated in the development of the LOSS, while 191 participated in a validation study. Item response theory was used to identify LOSS items. A systematic review of the literature was conducted to ascertain the breadth of use and application of the LOSS. Results: Overall, 26 items were selected for the final version of the LOSS, with 12 items identified for a short form of the scale. The LOSS has been included in 25 studies across nine countries with general community, student, and clinical populations. The LOSS has demonstrated change in response to psychoeducation interventions and is associated with suicide stigma and help-seeking in select studies. Limitations: Further validation of the LOSS in clinical populations is needed. Conclusion: The LOSS is a comprehensive measure of suicide literacy that may be used to identify knowledge gaps, inform awareness-raising activities, and assess the effectiveness of interventions to improve suicide literacy. The LOSS has been used in a broad range of settings, demonstrating application to diverse populations and cultural contexts.

Incorporating psychopathology into the interpersonal-psychological theory of suicidal behavior (IPTS)

BACKGROUND

The interpersonal-psychological theory of suicidal behavior (IPTS) posits that the joint presence of perceived burdensomeness (PB), thwarted belongingness (TB), and capability for suicide (CS) is necessary for suicide attempt. Emerging evidence demonstrates these effects are not consistently observed. Psychopathology may independently impact on the explanatory power of the IPTS constructs.

AIMS

The aims of the current study were to assess whether the inclusion of psychopathology indicators into the IPTS explains additional variance in recent suicide attempt and to assess the relative influence of interpersonal-psychological constructs versus mental illness on suicide attempt.

METHOD

Australian adults (N = 1,323; 77% female) who reported suicidal ideation in the past year were recruited using social media advertising to complete an online cross-sectional survey.

RESULTS

None of the predicted IPTS interactions was significantly associated with recent suicide attempt, although PB and CS had significant independent associations. The addition of psychopathology indicators to the IPTS model explained significant additional variation in suicide attempt (18% vs. 14%).

CONCLUSIONS

The influence of psychopathology on suicide attempt may be insufficiently explained by interpersonal-psychological constructs. The IPTS may have greater explanatory power to identify transitions from suicidal ideation to suicide attempt after accounting for mental illness.

Delivering A Digital Mental Health Service in Australian Secondary Schools: Understanding School Counsellors' and Parents' Experiences

This study examined school counsellors’ and parents’ experiences of a school-based digital mental health service (Smooth Sailing) that screened students’ mental health and provided automated psychological care. The Smooth Sailing service was offered to 4 secondary schools in New South Wales, Australia, for a 6-week trial period with 59 students taking part. The participating school counsellors (n = 4) completed a semi-structured interview to explore their experiences. Parents of students who had consented to being contacted (n = 37/59) were invited to complete an anonymous online survey about their child’s participation. Six parents completed the survey. The school counsellors expressed overall support for the service and cited the ease of service use, its ability to identify students at-risk, and the provision of psychoeducation to students as clear benefits. They identified some barriers to the service, such as parental consent and suggested strategies to improve uptake and engagement, such as incentives, more frequent screening and use with older students. Parents also reported positive experiences with the service, expressing appreciation for mental health screening in schools and a new system to connect them and their child to school counselling services. Taken together, these findings provide initial support for delivering the Smooth Sailing service in secondary schools.

Predictors of acceptability and engagement in a self-guided online program for depression and anxiety

BACKGROUND

Low engagement with self-guided online programs limits the potential of these programs to provide effective and low-cost treatment of mild to moderate depression and anxiety at scale. Identifying factors that increase uptake and adherence in self-guided online programs may facilitate the development of targeted implementation strategies to increase engagement with these programs in the community. Using data from a randomized controlled trial of a self-guided online program for depression and anxiety, the aim of this study was to identify predictors of the acceptability of internet-based psychological programs, and engagement (uptake and adherence) with the online program tested in the trial.

METHODS

A total of 556 community members with elevated symptoms of depression or anxiety were recruited via social media into the two active conditions of a three-arm randomized controlled trial. This trial tested the effectiveness of a 7-week self-guided online program for depression and anxiety called myCompass 2, delivered with or without an Engagement-Facilitation Intervention. Predictors of uptake (accessing at least one therapeutic module of the program), adherence (modules completed), and acceptability of internet-based psychological programs (Unified Theory of Acceptance and Use of Technology, UTAUT scale) were examined, including demographics, mental health status, help-seeking attitudes, stigma, acceptability of internet programs, and personality factors.

RESULTS

Logistic regression demonstrated that higher levels of conscientiousness (OR = 1.06, p = .026, 95% CI =1.01-1.12), and acceptability of internet-based psychological programs (OR = 1.09, p = .005, 95% CI =1.03-1.16) predicted greater uptake, and that failing to complete a module was predicted by lower levels of acceptability (OR = 0.88, p = .027, 95% CI =0.78-0.99). Linear regression showed that higher levels of agreeableness (t = 4.66, p < .001), lower levels of stigma (t = -2.28, p = .023) and more positive help-seeking attitudes (t = 2.05, p = .041) predicted higher acceptability attitudes.

DISCUSSION

Acceptability of internet-based psychological programs was identified as a factor that increased both uptake and adherence to the myCompass 2 program. Efforts to increase the acceptability of these programs may improve engagement with these programs in the community. It may also be useful to consider personality traits and clinical profiles when considering the appropriate audience for self-guided internet interventions.

Physical, mental, and social wellbeing and their association with death by suicide and self-harm in older adults: a community-based cohort study

OBJECTIVE

To assess associations between physical, mental, and social well-being and suicide and self-harm in a community-based sample of older adults.

METHODS

Using a cohort design, questionnaire data from 102,880 individuals aged 65 years or older living in New South Wales, Australia during 2006-2009 were linked to hospital and cause-of-death databases until 2017. Poisson regressions obtained adjusted incidence rate ratios (IRRs).

RESULTS

One hundred nine suicides and 191 deliberate self-harm (DSH) events occurred. Compared to those reporting excellent/good overall health, older adults reporting fair overall health had higher suicide rates (IRR = 2.8, 95% confidence interval: 1.8-4.4). Also, suffering from physical limitations was associated with higher rates of suicide. A fair versus excellent/good memory was associated with higher rates of suicide (IRR = 2.0, 1.3-3.3). Male erectile dysfunction was linked to self-harm (IRR = 2.8, 1.0-7.7). Suicide rates were elevated with baseline Kessler-10 scores of 20-50 versus 10-15 (IRR = 5.0, 2.9-8.9); the corresponding IRR for DSH was 2.9 (1.8-4.8). Elevated rates were observed for both self-reported depression and anxiety. Poor versus excellent/good quality of life was associated with suicide (IRR = 4.3, 1.7-10.7) and achieving less than desired to due to emotional problems was linked to self-harm (IRR = 1.8 1.3-2.4). Rates of suicide ande DSH were lower in those with ≥5 people to depend on versus one (suicide: IRR = 0.5, 0.3-0.9; DSH: IRR = 0.5, 0.3-0.7).

CONCLUSIONS

Older adults experiencing health problems, including those relating to overall health or memory, and those with psychological distress had elevated rates of suicidal behavior. Rates of subsequent self-harm and/or death by suicide were elevated in participants with small social networks.

Trajectories of depression and anxiety symptoms during the COVID-19 pandemic in a representative Australian adult cohort

Objectives

To estimate initial levels of symptoms of depression and anxiety, and their changes during the early months of the COVID‐19 pandemic in Australia; to identify trajectories of symptoms of depression and anxiety; to identify factors associated with these trajectories.

Design, setting, participants

Longitudinal cohort study; seven fortnightly online surveys of a representative sample of 1296 Australian adults from the beginning of COVID‐19‐related restrictions in late March 2020 to mid‐June 2020.

Main outcome measures

Symptoms of depression and anxiety, measured with the Patient Health Questionnaire (PHQ‐9) depression and Generalised Anxiety Disorder (GAD‐7) scales; trajectories of symptom change.

Results

Younger age, being female, greater COVID‐19‐related work and social impairment, COVID‐19‐related financial distress, having a neurological or mental illness diagnosis, and recent adversity were each significantly associated with higher baseline depression and anxiety scores. Growth mixture models identified three latent trajectories for depression symptoms (low throughout the study, 81% of participants; moderate throughout the study, 10%; initially severe then declining, 9%) and four for anxiety symptoms (low throughout the study, 77%; initially moderate then increasing, 10%; initially moderate then declining, 5%; initially mild then increasing before again declining, 8%). Factors statistically associated with not having a low symptom trajectory included mental disorder diagnoses, COVID‐19‐related financial distress and social and work impairment, and bushfire exposure.

Conclusion

Our longitudinal data enabled identification of distinct symptom trajectories during the first three months of the COVID‐19 pandemic in Australia. Early intervention to ensure that vulnerable people are clinically and socially supported during a pandemic should be a priority.

Silence is Deadly: A controlled trial of a public health intervention to promote help-seeking in adolescent males

OBJECTIVE

To test the effectiveness of a male-targeted upstream public health intervention in increasing help-seeking intentions for mental disorders and suicide in an adolescent population.

METHOD

A two-arm controlled trial was conducted with 10 schools in the Australian Capital Territory. A total of 594 male adolescents aged between 16 and 18 years participated in the study. Participants in the intervention condition received the single session Silence is Deadly program, while participants in the control condition completed usual classes. All participants completed a pre-intervention, post-intervention, and a 6- to 12-week follow-up survey assessing help-seeking intentions, attitudes, and behaviors.

RESULTS

At follow-up, the Silence is Deadly program was found to significantly increase help-seeking intentions from friends, which was in line with the program's messaging to seek help from and provide support to friends in times of distress or suicide risk. The program did not have an effect on help-seeking intentions for other sources of help or on help-seeking attitudes and behavior.

CONCLUSIONS

The present study provides preliminary support for male-targeted public health interventions for suicide that use male-focused norming and role modeling to improve help-seeking in this population.

A detailed hierarchical model of psychopathology: From individual symptoms up to the general factor of psychopathology

Much of our knowledge about the relationships among domains of psychopathology is built on the diagnostic categories described in the Diagnostic and Statistical Manual of Mental Disorders (DSM), with relatively little research examining the symptom-level structure of psychopathology. The aim of this study was to delineate a detailed hierarchical model of psychopathology-from individual symptoms up to a general factor of psychopathology-allowing both higher- and lower-order dimensions to depart from the structure of the DSM. We explored the hierarchical structure of hundreds of symptoms spanning 18 DSM disorders, in two large samples-one from the general population in Australia (n = 3175), and the other a treatment-seeking clinical sample from the USA (n = 1775). There was marked convergence between the two samples, offering new perspectives on higher-order dimensions of psychopathology. We also found several noteworthy departures from the structure of the DSM in the symptom-level data.

Specific aspects of sleep disturbance associated with suicidal thoughts and attempts

OBJECTIVE

Previous research suggests that sleep disturbance is associated with suicidal ideation and suicide attempt. However, few studies have accounted for the presence of multiple mental disorders and interpersonal factors associated with suicide risk. Furthermore, limited research has examined which aspects of sleep disturbance are most strongly associated with suicidal thoughts and attempts.

METHOD

A large community-based sample of Australian adults (n = 3,618; 81% female; 37% reporting ideation) completed a comprehensive survey assessing suicidal thoughts and behaviours, sleep disturbance, common mental disorders and interpersonal risk factors. Sleep disturbance was assessed using the 6-item PROMIS sleep disturbance scale and suicidality was measured using the Psychiatric Symptom Frequency Scale. Analyses were adjusted for age, sex, perceived burdensomeness, thwarted belongingness, and clinical caseness for six mental disorders, including major depression.

RESULTS

After accounting for mental health, demographic and interpersonal characteristics, increasing sleep disturbance was significantly associated with higher odds of both suicidal ideation (OR=1.17 for one-SD increase in PROMIS-SD), and suicide attempt (OR=1.33 for one-SD increase in PROMIS-SD). Of the specific indicators of sleep disturbance, only sleep onset (difficulties falling asleep) had a significant independent association with both suicidal ideation (p < 0.001) and suicide attempt (p = 0.047).

CONCLUSIONS

Sleep disturbance is independently associated with greater risk of suicidal thoughts and behaviours. Sleep disturbance is highly modifiable, so sleep interventions for people with suicide risk and sleep problems may provide an effective and efficient approach to suicide prevention in the community.

Exposure-Based Writing Therapies for Subthreshold and Clinical Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis

We undertook a systematic review to assess the efficacy of exposure-based writing therapies (WTs) for trauma-exposed adults with subthreshold or clinical levels of posttraumatic stress disorder. Four databases (PsycINFO, Medline, Wiley Online, PILOTS) were searched for randomized controlled trials (RCTs) of exposure-based WTs. A total of 13 RCTs that reported on results from 17 WT versus control comparisons were included. The primary outcomes were posttraumatic stress symptom severity at posttreatment and/or clinical response. An overall unclear or high risk of bias was identified in 84.6% of studies. In comparison to both waitlist k = 3, Hedges' g = -0.97, 95% CI [-1.20, -0.73], and placebo writing conditions, k = 9, Hedges' g = -0.48, 95% CI [-0.87, -0.08], WTs were more beneficial to participants. There was no evidence of a difference between WTs that were longer in duration compared to other psychotherapy, k = 2; pooled OR = 1.42; 95% CI [0.83, 2.43]. These findings indicate that exposure-based WTs are effective when compared to waitlist and placebo writing control conditions. The evidence needs to be considered in the context of the modest number of studies conducted to date, the high methodological heterogeneity between the studies, and the high or unclear risk of bias across many studies. Further research is needed to increase the evidence base regarding the efficacy of WTs for posttraumatic stress. Future research should also measure the mediators and predictors of outcomes to further develop protocols and understand which variants of WTs work for different populations or individuals.

Help-seeking attitudes and intentions for generalised anxiety disorder in adolescents: the role of anxiety literacy and stigma

Help seeking for anxiety tends to be low in adolescents. Identifying modifiable factors that may facilitate help seeking is important. The aim of the current study is to test the effects of generalized anxiety disorder (GAD) literacy and stigma (personal and perceived) on attitudes and intentions toward seeking help from professionals and key adult sources. 1767 adolescents aged 12-18 years participated in the current study and completed measures of GAD literacy, GAD stigma, professional help-seeking attitudes, and intentions to seek help from a range of sources. The results of the study found that participants had limited GAD literacy and up to 20% personally agreed with stigmatising statements about GAD. Participants reported greater intentions to seek help from parents than from formal sources. More positive attitudes toward seeking help were associated with higher levels of GAD literacy (p < 0.001) and lower personal GAD stigma (p < 0.001). Lower perceived GAD stigma was associated with increased intentions to seek help from their mothers (p < 0.05) or fathers (p < 0.01), while lower personal GAD stigma was also associated with help-seeking intentions from their mothers (p < 0.05). Higher perceived GAD stigma was associated with intentions to seek help from nobody (p < 0.001). Overall, the current study highlights the important role that parents can play in the help-seeking process for adolescents, with parents often the most accessible source of help. Improving parent and adolescent knowledge and attitudes towards GAD may help to improve early help seeking in young people.

Measures of mental, physical, and social wellbeing and their association with death by suicide and self-harm in a cohort of 266,324 persons aged 45 years and over

PURPOSE

The aim of this study was to examine the relation of mental, physical, and social wellbeing measures to death by suicide and self-harm (SH).

METHODS

Using a cohort design, questionnaire data on 266,324 responders aged ≥ 45 years, living in NSW, Australia were linked to hospital and death databases during 2006-2017. Adjusted incidence rate ratios (IRR) were calculated.

RESULTS

Overall, 212 suicides and 723 SH episodes were observed. A dose-response relationship with suicidal behaviour was found for Kessler-10 Psychological Distress Scale; IRRs of 4.5 (95% CI 2.4-8.3) for suicide and 8.3 (95% CI 6.5-10.7) for SH were observed for scores of high versus low distress. Elevated rates were also observed for those reporting poor versus good or excellent health (suicide, IRR: 3.8, 95% CI 2.2-6.9; SH, IRR: 4.5 95% CI 3.4-6.1); being dependent versus not dependent on help with daily tasks (suicide, IRR: 2.4 95% CI 1.5-3.7; SH, IRR: 2.6 95% CI 2.0-3.3); being a current smoker (suicide, IRR: 1.8, 95% CI 1.1-2.9; SH, IRR: 2.9 95% CI 2.3-3.5) having versus not having male erectile problems (SH, IRR: 1.9 95% CI 1.4-2.5). Participants with ≥ 5 people versus one person to depend on had reduced suicidal behaviour (suicide, IRR: 0.5 95% CI 0.3-0.7, SH, IRR: 0.5 95% CI 0.4-0.6).

CONCLUSIONS

An active social network was linked to lower rates of suicide and self-harm. Adverse health, dependence on help, psychological distress were associated with higher rates of suicide and self-harm, while erectile problems were linked to an elevated rate of self-harm.

The Emerging Literature on Exposure-Based Writing Therapies for Subthreshold and Clinical Posttraumatic Stress Disorder: A Response to Thompson-Hollands et al.'s (2020) Commentary on Dawson et al. (2020)

Thompson-Hollands et al.'s (2020) commentary on our systematic review of exposure-based writing therapies for subthreshold and clinical posttraumatic stress symptoms (Dawson et al., 2020) emphasizes important questions about the impact of heterogeneity in drawing inferences from evidence reviews. In this reply, we discuss (a) our rationale for undertaking a systematic review that was broad rather than narrow in scope and (b) provide clarifications on how heterogeneity was considered in the meta-analyses that were conducted. We also strongly agree with Thompson-Hollands et al.'s recommendation that future research should focus on better understanding the mechanisms by which exposure-based writing therapies help reduce posttraumatic stress symptoms.

Efficacy of a Transdiagnostic Self-Help Internet Intervention for Reducing Depression, Anxiety, and Suicidal Ideation in Adults: Randomized Controlled Trial

Background

Low-intensity self-guided mental health interventions that are delivered on the web may meet the needs and preferences of adults with mild to moderate symptoms. However, few clinical trials have examined the effectiveness of self-guided transdiagnostic interventions within a naturalistic setting.

Objective

This randomized controlled trial (RCT) tests the effectiveness of the video-based transdiagnostic intervention FitMindKit in reducing depression symptoms (primary outcome), anxiety symptoms, disability, and suicidal ideation, relative to an attention-matched control condition called HealthWatch.

Methods

The RCT was conducted with adults living in the Australian Capital Territory, Australia. Participants (n=1986) were recruited through the web using social media advertisements, screened for psychological distress, and then randomized to receive one of two 4-week programs: FitMindKit (12-module psychotherapy intervention) or HealthWatch (12-module program providing general health information). Participants were assessed at baseline and at 4 weeks postbaseline. To maintain the ecological validity of the trial, participants completed brief assessments and interventions without direct researcher contact or incentives.

Results

Mixed model repeated-measures analyses of variance demonstrated that FitMindKit significantly improved depression symptoms (F_1,701.7=3.97; P=.047), along with panic symptoms (F_1,706.5=5.59; P=.02) and social anxiety symptoms (F_1,680.0=12.37; P<.001), relative to the attention control condition. There were no significant effects on other outcomes.

Conclusions

Self-guided transdiagnostic interventions can be beneficial when delivered directly to end users through the internet. Despite low adherence and small effect sizes, the availability of such interventions is likely to fill a critical gap in the accessibility of mental health services for the community.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618001688279; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376113.

International Registered Report Identifier (IRRID)

RR2-10.1016/j.conctc.2019.100341

Effects of previous exposure to psychotherapeutic strategies on depression and anxiety symptoms during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has seen an increase in depression and anxiety among those with and without a history of mental illness. Commonly used forms of psychological therapy improve mental health by teaching psychotherapeutic strategies that assist people to better manage their symptoms and cope with life stressors. Minimal research to date has explored their application or value in managing mental health during significant broad-scale public health crises.

AIMS

To determine which psychotherapeutic strategies people who have previously received therapy use to manage their distress during the COVID-19 pandemic, and whether the use and perceived helpfulness of these strategies has an effect on symptoms of depression and anxiety.

METHOD

Data (N = 857) was drawn from multiple waves of a representative longitudinal study of the effects of COVID-19 on the mental health of Australian adults, which includes measures of anxiety, depression and experiences with psychotherapy and psychotherapeutic strategies.

RESULTS

Previous engagement in therapy with psychotherapeutic strategies had a protective effect on depressive but not anxiety symptoms. Common and helpful strategies used by respondents were exercise, mindfulness and breathing exercises. Using mindfulness and perceiving it to be helpful was associated with lower levels of depression and anxiety symptoms. No other strategies were associated with improved mental health.

CONCLUSIONS

Prior knowledge of psychotherapeutic strategies may play a role in managing mental health during unprecedented public health events such as a global pandemic. There may be value in promoting these techniques more widely in the community to manage general distress during such times.