Age of onset of mental disorders and use of mental health services: needs, opportunities and obstacles

A Systematic Review of the Effect of Early Interventions for Psychosis on the Usage of Inpatient Services

OBJECTIVES

To review and synthesize the currently available research on whether early intervention for psychosis programs reduce the use of inpatient services.

METHODS

A systematic review was conducted using keywords searches on PubMed, Embase (Ovid), PsycINFO (ProQuest), Scopus, CINAHL (EBSCO), Social Work Abstracts (EBSCO), Social Science Citations Index (Web of Science), Sociological Abstracts (ProQuest), and Child Development & Adolescent Studies (EBSCO). To be included, studies had to be peer-reviewed publications in English, examining early intervention programs using a variant of assertive community treatment, with a control/comparison group, and reporting inpatient service use outcomes. The primary outcome extracted number hospitalized and total N. Secondary outcome extracted means and standard deviations. Data were pooled using random effects models. Primary outcome was the occurrence of any hospitalization during treatment. A secondary outcome was the average bed-days used during treatment period.

RESULTS

Fifteen projects were identified and included in the study. Results of meta-analysis supported the occurrence of a positive effect for intervention for both outcome measures (any hospitalization OR: 0.33; 95% CI 0.18-0.63, bed-days usage SMD: -0.38, 95% CI -0.53 to -0.24). There was significant heterogeneity of effect across the studies. This heterogeneity is due to a handful of studies with unusually positive responses.

CONCLUSION

These results suggest that early intervention programs are superior to standard of care, with respect to reducing inpatient service usage. Wider use of these programs may prevent the occurrence of admission for patients experiencing the onset of psychotic symptoms.

Juvenile Justice, Mental Health, and the Transition to Adulthood: A Review of Service System Involvement and Unmet Needs in the U.S

Although adolescents are the primary focus of juvenile justice, a significant number of young people involved with this system are considered transition age youth (i.e., 16-25 years of age). The aim of this review is to summarize the specific needs of transition age youth with mental health conditions involved with the juvenile justice system, identify the multiple service systems relevant to this group, and offer recommendations for policies and practice. A comprehensive search strategy was used to identify and synthesize the literature. Findings highlight the paucity of research specific to transition age youth. Thus, we also summarized relevant research on justice-involved adolescents, with a focus evaluating its potential relevance in the context of the unique milestones of the transition age, including finishing one's education, setting and working towards vocational goals, and transitioning from ones' family of origin to more independent living situations. Existing programs and initiatives relevant to transition age youth with mental health conditions are highlighted, and nine specific recommendations for policy and practice are offered.

Demographic correlates of attenuated positive psychotic symptoms

It is now well established that the utilization of standardized clinical criteria can enhance prediction of psychosis. These criteria are primarily concerned with the presence and severity of attenuated positive symptoms. Because these symptom criteria are used to derive algorithms for designating clinical high risk (CHR) status and for maximizing prediction of psychosis risk, it is important to know whether the symptom ratings vary as a function of demographic factors that have previously been linked with symptoms in diagnosed psychotic patients. Using a sample of 356 CHR individuals from the NAPLS-II multi-site study, we examined the relation of three sex, age, and educational level, with the severity of attenuated positive symptom scores from the Scale of Prodromal Symptoms (SOPS). Demographic factors accounted for little of the variance in symptom ratings (5-6%). Older CHR individuals manifested more severe suspiciousness, and female CHR participants reported more unusual perceptual experiences than male participants. Contrary to prediction, higher educational level was associated with more severe ratings of unusual thought content, but less severe perceptual abnormalities. Overall, sex, age and education were modestly related to unusual thought content and perceptual abnormalities, only, suggesting minimal implication for designating CHR status and predicting psychosis-risk.

Mental health service use by young people: the role of caregiver characteristics

AIMS

Many children and adolescents experiencing mental health problems do not receive appropriate care. Strategies to encourage appropriate access to services might be improved by a more detailed understanding of service use determinants within this group. In view of caregivers' key role in young people's pathways to care, this study aimed to advance understanding of caregiver-related characteristics that influence service use among young people.

METHODS

We interviewed 407 primary caregivers of young people aged 9-18 years, recruited from a Greater London (United Kingdom) community sample. Caregivers reported on young people's service use in health care sector and/or education settings, and caregivers' intended stigmatising behaviours, help-seeking attitudes, and personal service use. Logistic regression analyses examined the relationship between these caregiver characteristics and young people's service use, controlling for young people's clinical and socio-demographic factors.

RESULTS

Caregivers' intended stigmatising behaviours in particular exerted a strong influence on young people's service use within each service setting. The impact of this characteristic interacted with caregivers' service use in influencing young people's service use across health care and education settings and health care settings specifically. For young people's service use within education settings, caregivers' intended stigmatising behaviours score had a main effect.

CONCLUSIONS

This study highlights the key role caregivers' attitudes and experiences hold in young people's service use. The findings indicate that strategies aiming to bridge the gap between young people's service needs and utilisation might be improved by targeting stigma amongst caregivers.

Predictors of outcome in early-onset psychosis: a systematic review

Given the global burden of psychotic disorders, the identification of patients with early-onset psychosis (EOP; that is, onset before the age of 18) at higher risk of adverse outcome should be a priority. A systematic search of Pubmed, Embase, and PsycInfo (1980 through August 2014) was performed to identify longitudinal observational studies assessing correlates and/or predictors of clinical, functional, cognitive, and biological outcomes in EOP. Seventy-five studies were included in the review. Using multivariate models, the most replicated predictors of worse clinical, functional, cognitive, and biological outcomes in EOP were premorbid difficulties and symptom severity (especially of negative symptoms) at baseline. Longer duration of untreated psychosis (DUP) predicted worse clinical, functional, and cognitive outcomes. Higher risk of attempting suicide was predicted by greater severity of psychotic illness and of depressive symptoms at the first episode of psychosis. Age at onset and sex were not found to be relevant predictors of outcome in most multivariate models, whereas studies using bivariate analyses yielded inconsistent results. Lower intelligence quotient at baseline predicted lower insight at follow-up, worse functional outcomes, and a diagnostic outcome of schizophrenia. Biological predictors of outcome in EOP have been little studied and have not been replicated. Lower levels of antioxidants at baseline predicted greater brain volume changes and worse cognitive functioning at follow-up, whereas neuroimaging markers such as regional cortical thickness and gray matter volume at baseline predicted remission and better insight at follow-up, respectively. EOP patients with poorer premorbid adjustment and prominent negative symptoms at initial presentation are at risk of poor outcome. They should therefore be the target of careful monitoring and more intensive interventions to address whether the disease course can be modified in this especially severely affected group. Early intervention strategies to reduce DUP may also improve outcome in EOP.

Children with mental versus physical health problems: differences in perceived disease severity, health care service utilization and parental health literacy

PURPOSE

To compare children with mental and physical health problems regarding (1) perceived disease severity; (2) the impact of their condition on their families; (3) their utilization of health care services (including satisfaction with care); and (4) parents' health literacy about their child's condition and its treatment. Furthermore, we examined whether parents' health literacy differs between types of mental health condition.

METHODS

Parental reports about their 9- to 14-year-old children with mental (n = 785) or physical health problems (n = 475) were analyzed from the population-based National Survey of Children with Special Health Care Needs in Switzerland.

RESULTS

Mental health problems were perceived as being more severe (p < 0.001) and exerting a larger impact upon the family (e.g., financial impact) than physical health problems. Furthermore, fewer parents of children with a mental health problem mentioned having a particular person or place to contact if they needed information or advice regarding the child's condition (p = 0.004) and were satisfied with the health care services their child received (p < 0.001). The odds of low health literacy was higher among parents with children suffering from mental health problems vs. parents of children with physical health problems (OR in the adjusted model = 1.92; 95 % CI 1.47-2.50; p < 0.001); this finding held generally for mental health problem (although only a trend was observable for internalizing problems).

CONCLUSIONS

The large impact of children's mental health conditions on themselves and their families might be reduced by adapting the provision of health care and by increasing parents' health literacy.

EPA guidance on the early detection of clinical high risk states of psychoses

The aim of this guidance paper of the European Psychiatric Association is to provide evidence-based recommendations on the early detection of a clinical high risk (CHR) for psychosis in patients with mental problems. To this aim, we conducted a meta-analysis of studies reporting on conversion rates to psychosis in non-overlapping samples meeting any at least any one of the main CHR criteria: ultra-high risk (UHR) and/or basic symptoms criteria. Further, effects of potential moderators (different UHR criteria definitions, single UHR criteria and age) on conversion rates were examined. Conversion rates in the identified 42 samples with altogether more than 4000 CHR patients who had mainly been identified by UHR criteria and/or the basic symptom criterion 'cognitive disturbances' (COGDIS) showed considerable heterogeneity. While UHR criteria and COGDIS were related to similar conversion rates until 2-year follow-up, conversion rates of COGDIS were significantly higher thereafter. Differences in onset and frequency requirements of symptomatic UHR criteria or in their different consideration of functional decline, substance use and co-morbidity did not seem to impact on conversion rates. The 'genetic risk and functional decline' UHR criterion was rarely met and only showed an insignificant pooled sample effect. However, age significantly affected UHR conversion rates with lower rates in children and adolescents. Although more research into potential sources of heterogeneity in conversion rates is needed to facilitate improvement of CHR criteria, six evidence-based recommendations for an early detection of psychosis were developed as a basis for the EPA guidance on early intervention in CHR states.

Is the use of accurate psychiatric labels associated with intentions and beliefs about responses to mental illness in a friend? Findings from two national surveys of Australian youth

Aims. An inherent prerequisite to mental health first-aid (MHFA) is the ability to identify that there is a mental health problem, but little is known about the association between psychiatric labelling and MHFA. This study examined this association using data from two national surveys of Australian young people. Methods. This study involved a national telephonic survey of 3746 Australian youth aged 12-25 years in 2006, and a similar survey in 2011 with 3021 youth aged 15-25 years. In both surveys, respondents were presented with a vignette portraying depression, psychosis or social phobia in a young person. The 2011 survey also included depression with suicidal thoughts and post-traumatic stress disorder. Respondents were asked what they thought was wrong with the person, and reported on their first-aid intentions and beliefs, which were scored for quality of the responses. Results. Accurate labelling of the mental disorder was associated with more helpful first-aid intentions and beliefs across vignettes, except for the intention to listen non-judgementally in the psychosis vignette. Conclusions. Findings suggest that community education programmes that improve accurate psychiatric label use may have the potential to improve the first-aid responses young people provide to their peers, although caution is required in the case of psychosis.

Young People's Views on Electronic Mental Health Assessment: Prefer to Type than Talk?

For mental health professionals to provide personalized early interventions, young people need to disclose sensitive information to a clinician they are unlikely to have yet formed a relationship with. We conducted in-depth qualitative interviews with 129 young people aged 12-25 years from several sites across Australia to gauge views on whether young people thought that an electronic psychosocial assessment tool could help them initially disclose personal information. Additionally, we were interested in whether young people from different demographic groups held similar views around using the e-tool. Results provided support for the use of an e-tool, with most young people stating that it could help in the disclosure of particularly embarrassing problems. The main advantages reported were that the e-tool would support disclosure without fear of judgment by health professionals, and would enable young people greater input in deciding what to focus on. Young people who held a preference to simply talk were most concerned about the clinician missing non-verbal cues. These findings highlight the value of incorporating electronic options within clinical practice, but also the need for health professionals to work within a flexible framework guided by the individual preferences of each of their clients.

Lifetime prevalence of DSM-IV mental disorders among new soldiers in the U.S. Army: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

BACKGROUND

The prevalence of 30-day mental disorders with retrospectively reported early onsets is significantly higher in the U.S. Army than among socio-demographically matched civilians. This difference could reflect high prevalence of preenlistment disorders and/or high persistence of these disorders in the context of the stresses associated with military service. These alternatives can to some extent be distinguished by estimating lifetime disorder prevalence among new Army recruits.

METHODS

The New Soldier Study (NSS) in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully structured measures to estimate lifetime prevalence of 10 DSM-IV disorders in new soldiers reporting for Basic Combat Training in 2011-2012 (n = 38,507). Prevalence was compared to estimates from a matched civilian sample. Multivariate regression models examined socio-demographic correlates of disorder prevalence and persistence among new soldiers.

RESULTS

Lifetime prevalence of having at least one internalizing, externalizing, or either type of disorder did not differ significantly between new soldiers and civilians, although three specific disorders (generalized anxiety, posttraumatic stress, and conduct disorders) and multimorbidity were significantly more common among new soldiers than civilians. Although several socio-demographic characteristics were significantly associated with disorder prevalence and persistence, these associations were uniformly weak.

CONCLUSIONS

New soldiers differ somewhat, but not consistently, from civilians in lifetime preenlistment mental disorders. This suggests that prior findings of higher prevalence of current disorders with preenlistment onsets among soldiers than civilians are likely due primarily to a more persistent course of early-onset disorders in the context of the special stresses experienced by Army personnel.

The film festival “AUSNAHME|ZUSTAND” (State of Emergency)--do feature films and documentaries on mental health reduce stigma and influence help-seeking attitudes?

The study aims at evaluating the impact of the Germany-wide film festival “AUSNAHME|ZUSTAND” on social distance and help-seeking attitudes of the adolescent audience. The festival, on the subject of mental health, was staged for the second time, aiming to give a podium to the topic mental health and to inform and entertain an adolescent audience that has not been in close contact with the subject before. A pre-post test was carried out to look for the effect of feature films and documentaries on social distance of the audience towards people with mental illness and on the change in help-seeking attitudes. A total of 532 young people with a mean age of 15.6 were questioned during the film festival in Leipzig. As the results show, the effect on the viewers׳ social distance and their help-seeking attitudes strongly depend on the content of the feature films and documentaries. Two films improved attitudes – one both social distance and help-seeking, one only help-seeking. One film increased social distance, and two films did not affect either outcome. Age, gender, and knowing someone with mental health problems also turned out to be decisive factors influencing the development of social distance and help-seeking attitudes. Feature films or documentaries about mental illness can reduce social distance or influence help-seeking attitudes, but effects strongly depend on the particular film.

Cenesthopathy in adolescence: an appraisal of diagnostic overlaps along the anxiety-hypochondriasis-psychosis spectrum

OBJECTIVE

To discuss the diagnostic validity of unusual bodily perceptions along the spectrum from age-specific, often transitory and normal, to pathological phenomena in adolescence to hypochondriasis and finally to psychosis.

METHODS

Critical literature review of the cornerstone diagnostic groups along the spectrum embracing anxiety and cenesthopathy in adolescence, hypochondriasis, and cenesthopathy and psychosis, followed by a discussion of the diagnostic overlaps along this spectrum.

RESULTS

The review highlights significant overlaps between the diagnostic cornerstones. It is apparent that adolescents with unusual bodily perceptions may conceptually qualify for more than one diagnostic group along the spectrum. To determine whether cenesthopathies in adolescence mirror emerging psychosis, a number of issues need to be considered, i.e. age and mode of onset, gender, level of functioning and drug use. The role of overvalued ideas at the border between hypochondriasis and psychosis must be considered.

CONCLUSION

As unusual bodily symptoms may in some instances meet formal psychosis risk criteria, a narrow understanding of these symptoms may lead to both inappropriate application of the new DSM-5 attenuated psychosis syndrome and of treatment selection. On the other hand, the possibility of a psychotic dimension of unusual bodily symptoms in adolescents must always be considered as most severe expression of the cenesthopathy spectrum.

Stress sensitivity mediates the relationship between traumatic life events and attenuated positive psychotic symptoms differentially by gender in a college population sample

The purpose of this study was to investigate whether stress sensitivity mediates the relationship between traumatic life events and total attenuated positive psychotic symptoms, as well as the relationship between traumatic life events and endorsement of 8 or more attenuated positive psychotic symptoms as distressing (a threshold that has been associated with higher risk for psychosis in clinical groups). Participants (n = 671, aged 17-35, 29% male) were college students who were administered the Prodromal Questionnaire, the Perceived Stress Scale and the Life Events Checklist. Bootstrapping results indicated that stress sensitivity significantly mediated the relationships between traumatic life events and the number of attenuated positive psychotic symptoms endorsed and between traumatic life events and those who endorsed 8 or more distressing attenuated positive psychotic symptoms. Stratified gender analyses indicated the findings were specific to females. Results suggest that stress sensitivity may represent a specific vulnerability factor for risk of attenuated psychotic symptoms in those previously exposed to traumatic life events and that this liability appears stronger in females.

Shame, perceived knowledge and satisfaction associated with mental health as predictors of attitude patterns towards help-seeking

Aims. To examine stigma- and knowledge-related barriers to help-seeking among members of the general population. Methods. In a representative survey of young to middle-aged Swiss adults (n = 8875), shame about a potential own mental illness, perceived knowledge about and satisfaction with one's mental health, psychiatric symptoms and attitudes towards help-seeking were assessed. Results. A latent profile analysis of all participants yielded two groups with different attitudes towards help-seeking. Relative to the majority, a one-in-four subgroup endorsed more negative attitudes towards seeking professional help, including psychiatric medication, and was characterized by more shame, less perceived knowledge, higher satisfaction with their mental health, younger age, male gender and lower education. Among participants with high symptom levels (n = 855), a third subgroup was reluctant to seek help in their private environment and characterized by high symptoms as well as low satisfaction with their mental health. Conclusions. Shame as an emotional proxy of self-stigma as well as poor subjective mental health literacy may be independent barriers to help-seeking. Interventions to increase mental health service use could focus on both variables and on those individuals with more negative views about professional help, in the general public as well as among people with a current mental illness.

Thirty-day prevalence of DSM-IV mental disorders among nondeployed soldiers in the US Army: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

IMPORTANCE

Although high rates of current mental disorder are known to exist in the US Army, little is known about the proportions of these disorders that had onsets prior to enlistment.

OBJECTIVE

To estimate the proportions of 30-day DSM-IV mental disorders among nondeployed US Army personnel with first onsets prior to enlistment and the extent which role impairments associated with 30-day disorders differ depending on whether the disorders had pre- vs post-enlistment onsets.

DESIGN, SETTING, AND PARTICIPANTS

A representative sample of 5428 soldiers participating in the Army Study to Assess Risk and Resilience in Servicemembers completed self-administered questionnaires and consented to linkage of questionnaire responses with administrative records.

MAIN OUTCOMES AND MEASURES

Thirty-day DSM-IV internalizing (major depressive, bipolar, generalized anxiety, panic, and posttraumatic stress) and externalizing (attention-deficit/hyperactivity, intermittent explosive, alcohol/drug) disorders were assessed with validated self-report scales. Age at onset was assessed retrospectively. Role impairment was assessed with a modified Sheehan Disability Scale.

RESULTS

A total of 25.1% of respondents met criteria for any 30-day disorder (15.0% internalizing; 18.4% externalizing) and 11.1% for multiple disorders. A total of 76.6% of cases reported pre-enlistment age at onset of at least one 30-day disorder (49.6% internalizing; 81.7% externalizing). Also, 12.8% of respondents reported severe role impairment. Controlling for sociodemographic and Army career correlates, which were broadly consistent with other studies, 30-day disorders with pre-enlistment (χ₈² = 131.8, P < .001) and post-enlistment (χ₇² = 123.8, P < .001) ages at onset both significantly predicted severe role impairment, although pre-enlistment disorders were more consistent powerful predictors (7 of 8 disorders significant; odds ratios, 1.6-11.4) than post-enlistment disorders (5 of 7 disorders significant; odds ratios, 1.5-7.7). Population-attributable risk proportions of severe role impairment were 21.7% for pre-enlistment disorders, 24.3% for post-enlistment disorders, and 43.4% for all disorders.

CONCLUSIONS AND RELEVANCE

Interventions to limit accession or increase resilience of new soldiers with pre-enlistment mental disorders might reduce prevalence and impairments of mental disorders in the US Army.

Risk factors for mental disorders in patients with hypertensive intracerebral hemorrhage following neurosurgical treatment

BACKGROUND

Mental disorders are commonly observed among surgically treated patients with hypertensive intracerebral hemorrhage (HICH), leading to serious negative impacts on the patient's treatment, rehabilitation, and prognosis. The study aimed to establish the prevalence rates and risk factors for mental disorders following the surgical treatment of HICH.

METHODS

This was a prospective study. Surgically treated patients with HICH were assessed 6 months following surgical treatment. The sociodemographic data were obtained from each subject, and clinical characteristics were collected for each patient from his or her hospital records. Mental disorder-related risk factors were examined using unpaired t-tests for continuous variables and χ(2) for categorical data, respectively, followed by multiple logistic regression analysis.

RESULTS

A total of 96 patients were recruited for this study. The incidence of mental disorders following surgical treatment of HICH was 32.3%. Univariate analysis revealed that the occurrence of postoperative mental disorders was correlated with gender, income, social interaction, relationship between family members, hematoma localization, hematoma volume, preoperative Glasgow Coma Scale (GCS) score, surgical approach, Barthel Index, hospitalization time, and discharged patients' caregivers. Multivariate logistic regression analysis indicated that female patients, social barriers, surgical treatment with a craniotomy, and bad relationship between family members were the independent risk factors for mental disorders following surgical treatment of HICH.

CONCLUSIONS

Postoperative mental disorders in patients with HICH were more likely to occur in female patients and patients who faced social barriers, those who were treated with a craniotomy, and those who experienced bad relationships between their family members. More attention and supports should be provided to this group of patients.

The associations between psychiatric label use and young people's help-seeking preferences: results from an Australian national survey

Aims. Emerging evidence suggests that psychiatric labels may facilitate help seeking in young people. This study examined whether young people's use of accurate labels for five disorders would predict their help-seeking preferences. Methods. Young people's help-seeking intentions were assessed by a national telephone survey of 3021 Australian youths aged 15-25. Respondents were presented with a vignette of a young person portraying depression, depression with suicidal thoughts, psychosis, social phobia or post-traumatic stress disorder (PTSD). They were then asked what they thought was wrong with the person, and where they would go for help if they had a similar problem. Results. Accurate psychiatric label use was associated with a preference to seek help from a general practitioner or mental health specialist. Accurately labelling the psychosis vignette was also associated with a preference to not seek help from family or friends. Conclusions. Findings add to the emerging evidence that accurate psychiatric labelling may facilitate help seeking for various mental disorders in young people, and support the promise of community awareness campaigns designed to improve young people's ability to accurately identify mental disorders.

Prevalence and comorbidity of psychiatric disorders among 6-year-old children: 2004 Pelotas Birth Cohort

PURPOSE

Most studies published on the prevalence of psychiatric disorders in children were conducted in high-income countries despite the fact that nearly 90 % of the world's population aged under 18 live in low- and middle-income countries. The study aimed to assess the prevalence of psychiatric disorders among children of 6 years of age, to examine the distribution of psychiatric disorders by gender and socioeconomic status and to evaluate the occurrence of psychiatric comorbidities.

METHODS

The 2004 Pelotas Birth Cohort originally comprised 4,231 live births from Pelotas, southern Brazil. A total of 3,585 (84.7 % of 4,231 births) children aged 6 years were assessed using the Development and Well-Being Assessment (DAWBA).

RESULTS

Nearly 13 % of the children presented a psychiatric diagnosis according to DSM-IV, being more prevalent among males than females (14.7 and 11.7 %, respectively, p = 0.009). Anxiety disorders were the most prevalent of all disorders (8.8 %) and specific phobias (5.4 %) and separation anxiety disorder (3.2 %) were the most common subtypes. Attention deficit hyperactivity disorder (2.6 %), oppositional defiant disorder/conduct disorder (2.6 %), and depression (1.3 %) were also diagnosed. More than one psychiatric disorder was presented by 17 % of children. Socioeconomically disadvantaged children had a higher prevalence of psychiatric disorders.

CONCLUSION

Our findings underline the early onset of psychiatric disorders among children and the frequent occurrence of psychiatric comorbidity. Early prevention is needed in the field of mental health in Brazil and should start during infancy.

Does depression experienced by mothers leads to a decline in marital quality: a 21-year longitudinal study

PURPOSE

Marital conflict and/or marital breakdown are known pathways to the onset of depression. Few studies however have examined the possibility that depression can lead to a decrease in marital quality and an increase in marital breakdown. Depression may be an important pathway to a decline in martial quality.

METHODS

A birth cohort study with women (mothers) recruited early in pregnancy and followed for 21 years. Using repeated measures analysis for four waves of data collection we use GEE to examine the extent to which symptoms of depression predict subsequent poor martial quality in women and poor marital quality predicts subsequent depression.

RESULTS

A bidirectional association between poor marital quality and depression is observed. After removing those who had pre-existing poor marital quality we note that depression predicts subsequent poor martial quality. Similarly, we note that poor marital quality predicts subsequent depression. These associations are all statistically significant and of a similar magnitude.

CONCLUSION

Over the maternal reproductive life course there is a long-term trajectory of reduced marital quality and increased depression. Maternal depression is as likely to lead to a decline in marital quality as poor martial quality is likely to lead to increased levels of depression. There may be a need to develop intervention programmes to reduce this long-term pattern of change.

Associations between stigma and help-seeking intentions and beliefs: findings from an Australian national survey of young people

To reduce stigma and improve help seeking by young people for mental illness, we need a better understanding of the associations between various dimensions of stigma and young people's help-seeking intentions and helpfulness beliefs for various sources of help and for different disorders. This study assessed stigmatizing attitudes and help-seeking intentions and helpfulness beliefs via a national telephone survey of 3021 youths aged 15-25. Five stigma scales were used: social distance, personally held weak-not-sick and dangerousness beliefs, and weak-not-sick and dangerousness beliefs perceived in others. Respondents were presented with a vignette of a young person portraying depression, depression with suicidal thoughts, depression with alcohol abuse, post-traumatic stress disorder, social phobia, or psychosis. Beliefs that mental illness is a sign of personal weakness and preference for social distance were associated with less intention to seek professional help and less endorsement of their helpfulness. In contrast, dangerousness/unpredictability beliefs were associated with more intention to seek professional help and more endorsement of their helpfulness. Findings highlight the importance of examining the associations between different dimensions of stigma with different sources of help, specifically for various mental disorders, to better inform future efforts to reduce stigma and increase help seeking in young people.

Prediction of community mental health service utilization by individual and ecological level socio-economic factors

Individuals with a more deprived socioeconomic status (SES) are more likely to have higher rates of psychiatric morbidity and use of psychiatric services. Such service use is also influenced by socioeconomic factors at the ecological level. The aim of this article is to investigate the influence of these variables on service utilization. All patients in contact with three Italian community psychiatric services (CPS) were included. Community and hospital contacts over 6 months were investigated. Socio-economic characteristics were described using a SES Index and two new Resources Accessibility Indexes. Low SES was found to be associated with more community service contacts. When other individual and ecological variables were controlled for, SES was negatively associated only with the number of home visits, which was about half the rate in deprived areas. An association between service utilization and the resources of the catchment area was also detected. The economic crisis in Europe is increasing inequality of access, so paying attention to SES characteristics at both the individual and the ecological levels is likely to become increasingly important in understanding patterns of psychiatric service utilization and planning care accordingly.

Personality Stability from Childhood to Midlife: Relating Teachers' Assessments in Elementary School to Observer- and Self-Ratings 40 Years Later

We report on the longitudinal stability of personality traits across an average 40 years in the Hawaii Personality and Health Cohort relating childhood teacher assessments of personality to adult self- and observer- reports. Stabilities based on self-ratings in adulthood were compared to those measured by the Structured Interview for the Five-Factor Model (SIFFM; Trull & Widiger, 1997), and trait ratings completed by interviewers. Although convergence between self-reports and observer-ratings was modest, childhood traits demonstrated similar levels of stability across methods in adulthood. Extraversion and Conscientiousness generally showed higher stabilities, whereas Neuroticism showed none. For Agreeableness and Intellect/Openness, stability was highest when assessed with observer-ratings. These findings are discussed in terms of differences in trait evaluativeness and observability across measurement methods.

The enigmatic persistence of anorexia nervosa

OBJECTIVE

In this review, based on recent advances in cognitive neuroscience, the author presents a formulation in which the marked persistence of anorexia nervosa can be usefully understood as a well-ingrained maladaptive habit.

METHOD

The author reviewed the relevant literature on the development and course of anorexia nervosa and interpreted critical features in light of developments in cognitive neuroscience.

RESULTS

Anorexia nervosa is a well characterized disorder with remarkable persistence both across history and among affected individuals. Food restriction, the salient behavioral feature of the disorder, often begins innocently but gradually takes on a life of its own. Over time, it becomes highly entrenched and resistant to change through either psychological or pharmacological treatment. Cognitive neuroscience has described two related but distinct processes that underlie the acquisition of new patterns of behavior, namely, action-outcome and stimulus-response learning. It is likely that both processes are engaged in the development of anorexia nervosa and that stimulus-response learning (that is, habit formation) is critical to the persistence of the dieting behavior.

CONCLUSIONS

The formulation of the dieting behavior characteristic of anorexia nervosa as a well-entrenched habit provides a basis for understanding the striking persistence of this disorder. This model helps explain the resistance of anorexia nervosa to interventions that have established efficacy in related disorders and implies that addressing the dieting behavior is critical, especially early in the course of the illness, before it has become ingrained.

Where would young people seek help for mental disorders and what stops them? Findings from an Australian national survey

BACKGROUND

In order to improve help seeking by young people for mental illness, a better understanding is required of their help-seeking intentions and barriers to their help seeking from various different sources and for different disorders.

METHODS

Young people's help-seeking intentions and perceived barriers to help seeking were assessed by a national telephone survey of 3021 youths aged 15-25 years. Respondents were presented with a vignette of a young person portraying depression, depression with suicidal thoughts, depression with alcohol abuse, post-traumatic stress disorder, social phobia, or psychosis.

RESULTS

Embarrassment or shyness was the most frequently mentioned barrier to seeking help from most sources. However, different barriers featured prominently depending on the disorder and the helper. Age, sex, and knowing a family member or friend who had received professional help for mental illness predicted some barriers.

LIMITATIONS

Help-seeking intentions and barriers were assessed with reference to a vignette character and may not reflect actual experience or behaviors.

CONCLUSIONS

Findings can facilitate the targeting of future efforts to improve young people's help seeking for mental disorders by highlighting the barriers that are more relevant for specific disorders, sources of help and personal characteristics.

The impact of cannabis use on age of onset and clinical characteristics in first-episode psychotic patients. Data from the Psychosis Incident Cohort Outcome Study (PICOS)

Cannabis use is frequent among first-episode psychosis (FEP) patients and has been associated with several clinical features. This study aimed in an FEP sample to determine whether cannabis use is associated with (1) a higher level of positive symptoms, a lower level of depression and a better premorbid adjustment, (2) an earlier age of onset, and a better premorbid IQ. The study was conducted within the framework of the Psychosis Incident Cohort Outcome Study (PICOS), a multisite collaborative research on FEP patients who attended the psychiatric services in Veneto Region, Italy. Standardized instruments were used to collect sociodemographic, clinical, and drug use data. A total of 555 FEP patients met the inclusion criteria, 517 of whom received an ICD-10 diagnosis of psychosis; 397 (55% males; mean age: 32 yrs ± 9.5) were assessed. Out of these, 311 patients agreed to be interviewed on drug and alcohol misuse; 20.3% was positive for drug misuse: cannabis (19.0%), cocaine (3.9%), and hallucinogens (3.9%). Cannabis use was not associated with a higher level of positive symptoms, but correlated with less severe depressive symptoms. No relationship was observed between premorbid adjustment or IQ and cannabis use. FEP patients who used cannabis had an earlier age of onset than abstinent patients, even after adjusting for gender and diagnosis. Our results suggest a possible causal role of cannabis in triggering psychosis in certain vulnerable subjects. Particular attention must be paid to this behaviour, because reducing cannabis use can delay or prevent some cases of psychosis.

Role of Long-Chain Omega-3 Fatty Acids in Psychiatric Practice

Nutrition plays a minor role in psychiatric practice which is currently dominated by a pharmacological treatment algorithm. An accumulating body of evidence has implicated deficits in the dietary essential long-chain omega-3 (LCn-3) fatty acids, eicosapenaenoic acid (EPA) and docosahexaenoic acid (DHA), in the pathophysiology of several major psychiatric disorders. LCn-3 fatty acids have an established long-term safety record in the general population, and existing evidence suggests that increasing LCn-3 fatty acid status may reduce the risk for cardiovascular disease morbidity and mortality. LCn-3 fatty acid supplementation has been shown to augment the therapeutic efficacy of antidepressant, mood-stabilizer, and second generation antipsychotic medications, and may additionally mitigate adverse cardiometabolic side-effects. Preliminary evidence also suggests that LCn-3 fatty acid supplementation may be efficacious as monotherapy for primary and early secondary prevention and for perinatal symptoms. The overall cost-benefit ratio endorses the incorporation of LCn-3 fatty acids into psychiatric treatment algorithms. The recent availability of laboratory facilities that specialize in determining blood LCn-3 fatty acid status and emerging evidence-based consensus guidelines regarding safe and efficacious LCn-3 fatty acid dose ranges provide the infrastructure necessary for implementation. This article outlines the rationale for incorporating LCn-3 fatty acid treatment into psychiatric practice.

The balanced care model for global mental health

BACKGROUND

For too long there have been heated debates between those who believe that mental health care should be largely or solely provided from hospitals and those who adhere to the view that community care should fully replace hospitals. The aim of this study was to propose a conceptual model relevant for mental health service development in low-, medium- and high-resource settings worldwide. Method We conducted a review of the relevant peer-reviewed evidence and a series of surveys including more than 170 individual experts with direct experience of mental health system change worldwide. We integrated data from these multiple sources to develop the balanced care model (BCM), framed in three sequential steps relevant to different resource settings.

RESULTS

Low-resource settings need to focus on improving the recognition and treatment of people with mental illnesses in primary care. Medium-resource settings in addition can develop 'general adult mental health services', namely (i) out-patient clinics, (ii) community mental health teams (CMHTs), (iii) acute in-patient services, (iv) community residential care and (v) work/occupation. High-resource settings, in addition to primary care and general adult mental health services, can also provide specialized services in these same five categories.

CONCLUSIONS

The BCM refers both to a balance between hospital and community care and to a balance between all of the service components (e.g. clinical teams) that are present in any system, whether this is in low-, medium- or high-resource settings. The BCM therefore indicates that a comprehensive mental health system includes both community- and hospital-based components of care.

Psychopathology and adversities from early- to late-adolescence: a general population follow-up study with the CBCL DSM-Oriented Scales

Aims. Adolescence is a critical transition phase between childhood and adulthood, when the burden of mental disorder may still be prevented. The aim of this study was to evaluate the continuity and discontinuity of behavioural problems in adolescence while taking into account the multiple co-variation of psychopathological traits and the complex role of recent stressful life events (SLEs). Methods. This is a 5-year follow-up investigation of emotional and behavioural problems assessed by the newly developed Child Behavior Checklist (CBCL) DSM-Oriented Scales (DOSs) in 420 general population subjects aged 15-19 years. Results. The DOSs showed good stability, even when multiple co-variation was taken into account. Longitudinal data showed that homotypic evolution of psychopathology was to be expected in the first place. Equifinality and multifinality were also found. Oppositional Defiant Problems emerged to be polyvalent predictors of both internalizing and externalizing problems. Furthermore, Oppositional Defiant Problems predicted more SLEs, which in turn predicted more Depression, Anxiety and Oppositional Defiant Problems. Mediational analyses confirmed the role of SLEs in partially accounting for the continuity of Oppositional Defiant Problems and for the heterotypic progression towards Affective Problems. Conclusions. These data underscore early adolescence behavioural problems as an important focus for primary and secondary intervention.

Ontogeny of contextual fear memory formation, specificity, and persistence in mice

Pinpointing the precise age when young animals begin to form memories of aversive events is valuable for understanding the onset of anxiety and mood disorders and for detecting early cognitive impairment in models of childhood-onset disorders. Although these disorders are most commonly modeled in mice, we know little regarding the development of learning and memory in this species because most previous studies have been restricted to rats. Therefore, in the present study, we constructed an ontogenetic timeline of contextual fear memory ranging from infancy to adulthood in mice. We found that the ability of mice to form long-term context-shock associations emerged ∼13-14 d of age, which is several days earlier than previously reported for rats. Although the ability to form contextual fear memories remained stable from infancy into adulthood, infant mice had shorter-lasting memories than adolescent and adult mice. Furthermore, we found that mice subjected to fetal alcohol exposure showed a delay in the developmental emergence of contextual fear memory, illustrating the utility of this ontogenetic approach in detecting developmental delays in cognitive function stemming from maladaptive early life experience.