The underlying neurobiology of key functional domains in young people with mood and anxiety disorders: a systematic review

Genetics, epigenetics, and neurobiology of childhood-onset depression: an umbrella review

Depression is a serious and persistent psychiatric disorder that commonly first manifests during childhood. Depression that starts in childhood is increasing in frequency, likely due both to evolutionary trends and to increased recognition of the disorder. In this umbrella review, we systematically searched the extant literature for genetic, epigenetic, and neurobiological factors that contribute to a childhood onset of depression. We searched PubMed, EMBASE, OVID/PsychInfo, and Google Scholar with the following inclusion criteria: (1) systematic review or meta-analysis from a peer-reviewed journal; (2) inclusion of a measure assessing early age of onset of depression; and (3) assessment of neurobiological, genetic, environmental, and epigenetic predictors of early onset depression. Findings from 89 systematic reviews of moderate to high quality suggest that childhood-onset depressive disorders have neurobiological, genetic, environmental, and epigenetic roots consistent with a diathesis-stress theory of depression. This review identified key putative markers that may be targeted for personalized clinical decision-making and provide important insights concerning candidate mechanisms that might underpin the early onset of depression.

Neurocognitive abilities associated with antisocial behavior with and without callous-unemotional traits in a community sample

OBJECTIVE

Antisocial behavior (aggression, rule breaking) is associated with lower intelligence and executive function deficits. Research has not clarified whether these associations differ with the presence of callous-unemotional (CU) traits, particularly within levels of antisocial behavior observed in the community.

METHOD

We examined whether antisocial behavior and CU traits were differentially associated with intelligence and executive function metrics in 474 adolescent twins (Mean age = 14.18; SD = 2.20) sampled from birth records to represent youth in the community living in neighborhoods with above average levels of poverty. Intelligence was assessed using standardized scores from the Shipley-2. Executive function was assessed using Go/No-Go and Stop Signal tasks.

RESULTS

Neither antisocial behavior, nor CU traits alone, were associated with cognitive functioning when accounting for demographic factors. However, antisocial behavior and CU traits interacted to predict reaction time variability. At low levels of CU traits, antisocial behavior was associated with higher reaction time variability (traditionally thought to reflect worse sustained attention). At high levels of CU traits, antisocial behavior was associated with lower reaction time variability (thought to reflect better sustained attention).

CONCLUSION

Elevated antisocial behavior and CU traits may be characterized by a distinct neurocognitive profile compared to elevated antisocial behavior in isolation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Neural activation of anxiety and depression in children and young people: A systematic meta-analysis of fMRI studies

Functional magnetic resonance imaging (fMRI) studies consistently demonstrate altered neural activation in youth experiencing anxiety and depression in a way that is distinct from adult-onset disorders. However, there is a paucity of research systematically reviewing this, and no meta-analyses have been conducted using Activation Likelihood Estimation (ALE). The present study conducted a systematic literature search to identify fMRI studies in youth (age 4-18) with depression or anxiety disorders. 48 studies with over 2000 participants were identified that met the inclusion criteria. Significant foci were extracted. Five ALE meta-analyses were conducted: a) activation for both anxiety disorders and depression; b) activation for anxiety disorders only; c) activation for depression only; d) deactivation for both anxiety disorders and depression; e) deactivation for depression. Results indicated significant clusters of increased activation in the bilateral amygdala for youth with internalising disorders, and specifically for those with anxiety disorders. Significant increased activation extended into the dorsal anterior cingulate, entorhinal cortex, the putamen, and the medial and lateral globus pallidus in youth with anxiety disorders. These findings help to detail the nature of anxiety being an amygdala hyperactivity disorder, whilst also defining the distinction between neural activation patterns in anxiety and depression.

Neurocognitive functioning predicts suicidal behaviour in young people with affective disorders

BACKGROUND

Neurocognitive impairment is recognised as a risk factor for suicidal behaviour in adults. The current study aims to determine whether neurocognitive deficits also predict ongoing or emergent suicidal behaviour in young people with affective disorders.

METHODS

Participants were aged 12-30 years and presented to early intervention youth mental health clinics between 2008 and 2018. In addition to clinical assessment a standardised neurocognitive assessment was conducted at baseline. Clinical data was extracted from subsequent visits using a standardised proforma.

RESULTS

Of the 635 participants who met inclusion criteria (mean age 19.6 years, 59% female, average follow up 476 days) 104 (16%) reported suicidal behaviour during care. In 5 of the 10 neurocognitive domains tested (cognitive flexibility, processing speed, working memory, verbal memory and visuospatial memory) those with suicidal behaviour during care were superior to clinical controls. Better general neurocognitive function remained a significant predictor (OR=1.94, 95% CI 1.29- 2.94) of suicidal behaviour in care after controlling for other risk factors.

LIMITATIONS

The neurocognitive battery used was designed for use with affective and psychotic disorders and may not have detected some deficits more specific to suicidal behaviour.

CONCLUSION

Contrary to expectations, better neurocognitive functioning predicts suicidal behaviour during care in young people with affective disorders. While other populations with suicidal behaviour, such as adults with affective disorders or young people with psychotic disorders, tend to experience neurocognitive deficits which may limit their capacity to engage in some interventions, this does not appear to be the case for young people with affective disorders.

Protocol for a young adult mental health (Uspace) cohort: personalising multidimensional care in young people admitted to hospital

INTRODUCTION

Currently, the literature on personalised and measurement-based mental healthcare is inadequate with major gaps in the development and evaluation of 21st century service models. Clinical presentations of mental ill health in young people are heterogeneous, and clinical and functional outcomes are often suboptimal. Thus, treatments provided in a person-centred and responsive fashion are critical to meet the unique needs of young people and improve individual outcomes. Personalised care also requires concurrent assessment of factors relating to outcomes and underlying neurobiology. This study builds on a completed feasibility study and will be the first to incorporate clinical, cognitive, circadian, metabolic and hormonal profiling with personalised and measurement-based care in a cohort of young people admitted to hospital.

METHODS AND ANALYSIS

This prospective, transdiagnostic, observational study will be offered to all young people between the ages of 16 and 30 years admitted to the inpatient unit of the participating centre. In total, 400 participants will be recruited. On admission to hospital, young people will undergo clinical and diagnostic assessment, cognitive testing, self-report questionnaires, metabolic and hormonal data collection, and anthropomorphic measurements. Participants will wear an actigraphy watch for at least 1 week during admission to measure circadian patterns and sleep-wake cycles. A feedback session between clinician and participant will occur after clinical and other laboratory assessments to tailor individual treatment plans, explain the ongoing process of measurement-based care, and provide participant and family education. Associations between cognitive impairments, disturbed sleep-wake behaviours, circadian rhythms, clinical symptoms and functional impairments will be evaluated to improve the understanding of parameters affecting clinical outcomes.

ETHICS AND DISSEMINATION

This study protocol was approved by the Human Research Ethics Committees of the University of Sydney (HREC USYD 2015/867) and St Vincent's Hospital (HREC SVH 17/045). This study will be published on completion in a peer-reviewed journal.

Differential effects of GABAA receptor activation in the prelimbic and orbitofrontal cortices on anxiety

RATIONALE

The development of effective anxiety treatments has been hindered by limited understanding of the neurobiological mechanisms involved in anxiety regulation. Whilst gamma-aminobutyric acid (GABA) neurotransmission in the prefrontal cortex (PFC) is one mechanism consistently implicated in anxiety regulation, PFC subregions may contribute uniquely.

OBJECTIVES

The present study examined the effects of inactivating the PFC subregions of the prelimbic cortex (PrL) or orbitofrontal cortex (OFC) through GABA_A receptor (GABA_AR) activation, on anxiety behaviours in male Wistar rats.

METHODS

Sixty-six male Wistar rats were surgically implanted with bilateral cannulae into the PrL (n = 33) or the OFC (n = 33). Rats then received a microinjection of either the GABA_A receptor agonist muscimol or vehicle prior to each experiment, conducted 1 week apart. Measures of anxiety were examined using the elevated plus maze (EPM) and the emergence test (ET). The effect on locomotor activity (baseline or methamphetamine-induced) was also tested.

RESULTS

Differential effects of brain region inactivation on anxiety-like behaviour were shown by measures in the EPM and ET; muscimol infused into the PrL-reduced anxiety-like behaviour, yet had no significant effect when infused into the OFC, compared with control treated rats. No effects on locomotor activity at baseline or following methamphetamine treatment were found.

CONCLUSIONS

This study highlights that activation of GABA_ARs specifically within the PrL, but not OFC, reduces anxiety behaviours in male rats. This suggests that activity of the PrL plays a more important role than the OFC in the neurobiological mechanisms of unconditioned anxiety and should be targeted for future therapies.

Youth Mental Health Tracker: protocol to establish a longitudinal cohort and research database for young people attending Australian mental health services

INTRODUCTION

Mental disorders are a leading cause of long-term disability worldwide. Much of the burden of mental ill-health is mediated by early onset, comorbidities with physical health conditions and chronicity of the illnesses. This study aims to track the early period of mental disorders among young people presenting to Australian mental health services to facilitate more streamlined transdiagnostic processes, highly personalised and measurement-based care, secondary prevention and enhanced long-term outcomes.

METHODS AND ANALYSIS

Recruitment to this large-scale, multisite, prospective, transdiagnostic, longitudinal clinical cohort study ('Youth Mental Health Tracker') will be offered to all young people between the ages of 12 and 30 years presenting to participating services with proficiency in English and no history of intellectual disability. Young people will be tracked over 3 years with standardised assessments at baseline and 3, 6, 12, 24 and 36 months. Assessments will include self-report and clinician-administered measures, covering five key domains including: (1) social and occupational function; (2) self-harm, suicidal thoughts and behaviour; (3) alcohol or other substance misuse; (4) physical health; and (5) illness type, clinical stage and trajectory. Data collection will be facilitated by the use of health information technology. The data will be used to: (1) determine prospectively the course of multidimensional functional outcomes, based on the differential impact of demographics, medication, psychological interventions and other key potentially modifiable moderator variables and (2) map pathophysiological mechanisms and clinical illness trajectories to determine transition rates of young people to more severe illness forms.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Human Research Ethics Committee of the Sydney Local Health District (2019/ETH00469). All data will be non-identifiable, and research findings will be disseminated through peer-reviewed journals and scientific conference presentations.

Non-invasive Neurophysiology in Learning and Training: Mechanisms and a SWOT Analysis

Although many scholars deem non-invasive measures of neurophysiology to have promise in assessing learning, these measures are currently not widely applied, neither in educational settings nor in training. How can non-invasive neurophysiology provide insight into learning and how should research on this topic move forward to ensure valid applications? The current article addresses these questions by discussing the mechanisms underlying neurophysiological changes during learning followed by a SWOT (strengths, weaknesses, opportunities, and threats) analysis of non-invasive neurophysiology in learning and training. This type of analysis can provide a structured examination of factors relevant to the current state and future of a field. The findings of the SWOT analysis indicate that the field of neurophysiology in learning and training is developing rapidly. By leveraging the opportunities of neurophysiology in learning and training (while bearing in mind weaknesses, threats, and strengths) the field can move forward in promising directions. Suggestions for opportunities for future work are provided to ensure valid and effective application of non-invasive neurophysiology in a wide range of learning and training settings.

Cohort profile: the Brain and Mind Centre Optymise cohort: tracking multidimensional outcomes in young people presenting for mental healthcare

PURPOSE

The Brain and Mind Centre (BMC) Optymise cohort assesses multiple clinical and functional domains longitudinally in young people presenting for mental health care and treatment. Longitudinal tracking of this cohort will allow investigation of the relationships between multiple outcome domains across the course of care. Subsets of Optymise have completed detailed neuropsychological and neurobiological assessments, permitting investigation of associations between these measures and longitudinal course.

PARTICIPANTS

Young people (aged 12-30) presenting to clinics coordinated by the BMC were recruited to a research register (n=6743) progressively between June 2008 and July 2018. To date, 2767 individuals have been included in Optymise based on the availability of at least one detailed clinical assessment.

MEASURES

Trained researchers use a clinical research proforma to extract key data from clinical files to detail social and occupational functioning, clinical presentation, self-harm and suicidal thoughts and behaviours, alcohol and other substance use, physical health comorbidities, personal and family history of mental illness, and treatment utilisation at the following time points: baseline, 3, 6, 12, 24, 36, 48, and 60 months, and time last seen.

FINDINGS TO DATE

There is moderate to substantial agreement between raters for data collected via the proforma. While wide variations in individual illness course are clear, social and occupational outcomes suggest that the majority of cohort members show no improvement in functioning over time. Differential rates of longitudinal transition are reported between early and late stages of illness, with a number of baseline factors associated with these transitions. Furthermore, there are longitudinal associations between prior suicide attempts and inferior clinical and functional outcomes.

FUTURE PLANS

Future reports will detail the longitudinal course of each outcome domain and examine multidirectional relationships between these domains both cross-sectionally and longitudinally, and explore in subsets the associations between detailed neurobiological measures and clinical, social and functional outcomes.

Right care, first time: a highly personalised and measurement-based care model to manage youth mental health

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people.

Impulsivity in the self-harm and suicidal behavior of young people: A systematic review and meta-analysis

BACKGROUND

Impulsivity is considered a possible phenotype underlying the expression of self-harm and suicidal behaviors. Yet impulsivity is a not a unitary construct and there is evidence that different facets of impulsivity follow different neurodevelopmental trajectories and that some facets may be more strongly associated with such behaviors than others. Moreover, it is unclear whether impulsivity is a useful predictor of self-harm or suicidal behavior in young people, a population already considered to display heightened impulsive behavior.

METHODS

A systematic review and meta-analysis of studies published in Medline, PubMed, PsychInfo or Embase between 1970 and 2017 that used a neurocognitive measure to assess the independent variable of impulsivity and the dependent variable of self-harm and/or suicidal behavior among young people (mean age < 30 years old).

RESULTS

6183 titles were identified, 141 full texts were reviewed, and 18 studies were included, with 902 young people with a self-harm or suicidal behavior and 1591 controls without a history of these behaviors. Deficits in inhibitory control (13 studies, SMD 0.21, p-value = 0.002, 95% confidence interval (CI) (0.08-0.34), prediction interval (PI) = 0.06-0.35) and impulsive decision-making (14 studies, SMD 0.17, p-value = 0.008, 95% CI (0.045-0.3), PI = 0.03-0.31) were associated with self-harm or suicidal behavior. There were no significant differences between measures of different facets of impulsivity (ie. delay discounting, risky decision-making, cognitive or response inhibition) and self-harm or suicidal behavior.

CONCLUSION

Multiple facets of impulsivity are associated with suicidal behavior in young people. Future suicide research should be designed to capture impulsive states and investigate the impact on different subtypes of impulsivity.

Impairment in planning tasks of children and adolescents with anxiety disorders

Anxiety disorders are associated with poor neuropsychological performance in attention and memory. However, little is known about the impact of these difficulties on other cognitive functions, such as planning. The ability to plan, including attention, working memory and set-shifting components, can be assessed by the Tower of Hanoi task (ToH). This study evaluated seventy-one participants, aged from 7-17 years. Thirty-seven subjects met DSM-IV diagnostic criteria for at least one anxiety disorder and 34 individuals comprised the controls. The neuropsychological tests used were: the ToH, a problem-solving task, involves planning ability and other executive functions (working memory, attentional control and cognitive flexibility); for the assessment of processing speed and problem-solving, the Vocabulary/Matrix Reasoning subtests of the Wechsler Abbreviated Scale of Intelligence was used to measure for estimated-IQ in both groups. The groups were compared with a generalized linear model controlling for age, IQ and ADHD comorbidity. Compared with controls, anxiety disorders subjects made more errors and required more time to complete the ToH. Children and adolescents with anxiety disorders have poorer planning ability compared to subjects without anxiety disorders, and the difficulty in planning is affected by interference from other cognitive functions, such as attention, working memory, cognitive flexibility and problems-solutions.

Clinical, neurocognitive and demographic factors associated with functional impairment in the Australian Brain and Mind Youth Cohort Study (2008-2016)

OBJECTIVES

We sought to determine the unique and shared contributions of clinical, neurocognitive and demographic factors to functional impairment in a large, transdiagnostic, clinical cohort of adolescents and young adults.

DESIGN

Cross-sectional baseline data from a prospective, cohort study.

SETTING

Help-seeking youth referred from outpatient services were recruited to the Brain and Mind Youth Cohort (2008-2016) in Sydney, Australia.

PARTICIPANTS

In total, 1003 outpatients were recruited, aged between 12 and 36 years (mean= 20.4 years, 54% female), with baseline diagnoses of affective, psychotic, developmental or behavioural disorders.

INTERVENTIONS

Treatment as usual.

PRIMARY OUTCOME MEASURES

Social and occupational functioning was used to index level of functional impairment. Structural equation modelling was used to examine associations between neurocognition, core clinical symptoms and alcohol and substance use, and clinician-rated and researcher-rated functional impairment. Moderator analyses were conducted to determine the potential influence of demographic and clinical factors (eg, medication exposure).

RESULTS

Independent of diagnosis, we found that neurocognitive impairments, and depressive, anxiety and negative symptoms, were significantly associated with functioning. The association of neurocognition with social and occupational functioning remained significant even when constraining for age (15-25-year-olds only) or diagnosis (affective disorders only) in the final model.

CONCLUSIONS

This study demonstrated that, in a clinically representative sample of youth, the key determinants of functioning may not be disorder specific. Further, evidence of neurocognitive dysfunction suggests that interventions that target cognition and functioning should not necessarily be reserved just for older adults with established illness.

A Neuroscience-Oriented Research Approach to Borderline Personality Disorder

Traditionally, the study of personality disorders had been based on psychoanalytic or behavioral models. Over the past two decades, there has been an emerging neuroscience model of borderline personality disorder (BPD) grounded in the concept of BPD as a condition in which dysfunctional neural circuits underlie its pathological dimensions, some of which include emotion dysregulation (broadly encompassing affective instability, negative affectivity, and hyperarousal), abnormal interpersonal functioning, and impulsive aggression. This article, initiated at a joint Columbia University- Cornell University Think Tank on BPD with representation from the Icahn School of Medicine at Mount Sinai, suggests how to advance research in BPD by studying the dimensions that underlie BPD in addition to studying the disorder as a unitary diagnostic entity. We suggest that linking the underlying neurobiological abnormalities to behavioral symptoms of the disorder can inform a research agenda to better understand BPD with its multiple presentations.

Prior suicide attempts predict worse clinical and functional outcomes in young people attending a mental health service

BACKGROUND

Mental disorders and suicidal thoughts and behaviours are common in help-seeking youth. Few studies report the longitudinal associations between these phenomena and clinical and functional outcomes. This study examined whether prior suicide attempts predict poorer outcomes in mental health service attendees.

METHODS

Clinical and functional data from 1143 individuals (aged 12-30) attending a primary care-based mental health service in Australia were collected over 3-60 months (median = 21 months). Odds ratios (OR) with 95% confidence intervals for the effect of a prior suicide attempt on follow-up outcomes were estimated (adjusted for confounders).

RESULTS

Prior suicide attempts were common (n = 164; 14%) and prospectively associated with suicidal thoughts (OR = 1.71), suicide attempts (OR = 2.59), self-harm (OR = 1.71), an increased likelihood of being diagnosed with bipolar disorder (OR = 2.99), and the onset of an alcohol/substance use disorder (OR = 2.87). Over the course of care, no suicide attempts were reported in 1052 (92%) individuals, but 25 (2%) had recurrent attempts, and 66 (6%) had new onset of an attempt. New onset was associated with being female and previous suicidal ideation or self-harm; recurrent attempts were associated with being older and comorbid alcohol/substance use disorder.

LIMITATIONS

The cohort includes only individuals who remained in clinical contact, and the consistency of their documentation varied (across clinicians and over time).

CONCLUSIONS

Young people with prior suicide attempts are vulnerable to ongoing suicidal behaviours, and poorer clinical and functional outcomes. More intensive management strategies may be needed to directly address these behaviours and the long-term risks they confer. These behaviours also emerge over the course of care among those with no previous history, which has important implications for active service-level strategies that target these behaviours for all of those who present to such services.

Elevated striatal γ-aminobutyric acid in youth with major depressive disorder

BACKGROUND

Alterations in γ-aminobutyric acid (GABA) have been hypothesized to play a role in the pathogenesis of psychiatric illness. Our previous work has specifically linked anterior cingulate cortex (ACC) GABA deficits with anhedonia in youth with major depressive disorder (MDD). As anhedonia reflects alterations within the reward circuitry, we sought to extend this investigation and examine GABA levels in another key reward-related region, the striatum, in the same adolescent population.

METHODS

Thirty-six youth [20 with MDD and 16 healthy controls; (HC)], ages 12 to 21 years old, underwent J-edited proton magnetic resonance spectroscopy (¹H MRS) whereby GABA levels were measured in striatal and ACC voxels. GABA levels were compared between groups and between voxel positions and were examined in relation to clinical symptomatology, such as depression severity, anhedonia, anxiety, and suicidality.

RESULTS

Depressed youth had unexpectedly higher GABA levels in the striatum compared to HC. In both depressed and healthy youth, GABA levels were higher in the striatum than in the ACC, while the differences in depressed youth were greater. Moreover, in depressed youth, higher striatal GABA above the mean of HCs was correlated with lower ACC GABA below the mean of HCs. Striatal GABA was not correlated with clinical symptomatology in this small sample.

CONCLUSIONS

Together, these findings suggest that higher striatal GABA levels may serve some compensatory function as a result of lower ACC GABA in depressed adolescents. It is also possible that, like lower ACC GABA, higher striatal GABA might simply be another pathological feature of adolescent depression.

Delineating the trajectories of social and occupational functioning of young people attending early intervention mental health services in Australia: a longitudinal study

OBJECTIVES

Mental disorders typically emerge during adolescence and young adulthood and put young people at risk for prolonged socioeconomic difficulties. This study describes the longitudinal course of social and occupational functioning of young people attending primary care-based, early intervention services.

DESIGN

A longitudinal study of young people receiving mental healthcare.

SETTING

Data were collected between January 2005 and August 2017 from a designated primary care-based mental health service.

PARTICIPANTS

554 young people (54% women) aged 12-32 years.

MEASURES

A systematic medical file audit collected clinical and functional information at predetermined time intervals (ie, 3 months to 5+ years) using a clinical pro forma. Group-based trajectory modelling (GBTM) was used to identify distinct trajectories of social and occupational functioning over time (median number of observations per person=4; median follow-up time=23 months).

RESULTS

Between first clinical contact and time last seen, 15% of young people had reliably deteriorated, 23% improved and 62% did not demonstrate substantive change in function. Of the whole cohort, 69% had functional scores less than 70 at time last seen, indicative of ongoing and substantive impairment. GBTM identified six distinct functional trajectories whereby over 60% had moderate-to-serious functional impairment at entry and remained chronically impaired over time; 7% entered with serious impairment and deteriorated further; a quarter were mildly impaired at entry and functionally recovered and only a small minority (4%) presented with serious impairments and functionally improved over time. Not being in education, employment or training, previous hospitalisation and a younger age at baseline emerged as significant predictors of these functional trajectories.

CONCLUSION

Young people with emerging mental disorders have significant functional impairment at presentation for care, and for the majority, it persists over the course of clinical care. In addition to providing clinical care earlier in the course of illness, these data suggest that more sophisticated and more intensive individual-level and organisational strategies may be required to achieve significant and sustained functional improvements.

Prevalence and Associated Features of Anxiety Disorder Comorbidity in Bipolar Disorder: A Meta-Analysis and Meta-Regression Study

Objective: Bipolar disorder is highly comorbid with anxiety disorders, however current and lifetime comorbidity patterns of each anxiety disorder and their associated features are not well studied. Here, we aimed to conduct a meta-analysis and meta-regression study of current evidence. Method: We searched PubMed to access relevant articles published until September 2015, using the keywords "Bipolar disorder" or "Affective Psychosis" or "manic depressive" separately with "generalized anxiety," "panic disorder," "social phobia," "obsessive compulsive," and "anxiety." Variables for associated features and prevalence of anxiety disorders were carefully extracted. Results: Lifetime any anxiety disorder comorbidity in BD was 40.5%; panic disorder (PD) 18.1%, generalized anxiety disorder (GAD) 13.3%, social anxiety disorder (SAD) 13.5% and obsessive compulsive disorder (OCD) 9.7%. Current any anxiety disorder comorbidity in BD is 38.2%; GAD is 15.2%, PD 13.3%, SAD 11.7%, and OCD 9.9%. When studies reporting data about comorbidities in BDI or BDII were analyzed separately, lifetime any anxiety disorder comorbidity in BDI and BDII were 38% and 34%, PD was 15% and 15%, GAD was 14% and 16.6%, SAD was 8% and 13%, OCD was 8% and 10%, respectively. Current any DSM anxiety disorder comorbidity in BDI or BDII were 31% and 37%, PD was 9% and 13%, GAD was 8% and 12%, SAD was 7% and 11%, and OCD was 8% and 7%, respectively. The percentage of manic patients and age of onset of BD tended to have a significant impact on anxiety disorders. Percentage of BD I patients significantly decreased the prevalence of panic disorder and social anxiety disorder. A higher rate of substance use disorder was associated with greater BD-SAD comorbidity. History of psychotic features significantly affected current PD and GAD. Conclusions: Anxiety disorder comorbidity is high in BD with somewhat lower rates in BDI vs BDII. Age of onset, substance use disorders, and percentage of patients in a manic episode or with psychotic features influences anxiety disorder comorbidity.

The Influence of Myelin Oligodendrocyte Glycoprotein on White Matter Abnormalities in Different Onset Age of Drug-Naïve Depression

Neurophysiological mechanisms of white matter abnormalities in the earlier onset major depressive disorder (eoMDD, onset age ≤25 years old) differ from that in the later onset MDD (loMDD, onset age >25 years old). Myelin oligodendrocyte glycoprotein (MOG) is an important factor influencing white matter development. The influence of MOG on white matter in MDD of different age onset need to be explored. We compared MOG plasma concentrations and diffusion tensor imaging (DTI) data in 35 first-episode medication-naïve MDD patients (23 eoMDD, 12 loMDD), and 32 healthy controls (HC, 17 younger, 15 older). MOG was significantly higher in eoMDD and lower in loMDD compared with HC. Mean diffusivity (MD) values were significantly increased in inferior fronto-occipital fasciculus (IFOF) in eoMDD, and decreased in loMDD. In both younger and older groups, MOG correlated positively with IFOF MD values. Abnormal MOG has different influence in MDD of different age onset, which is linked to MOG's overly active effect on abnormal white matter in eoMDD and markedly weak effect in loMDD cases. Abnormal MOG would be an important factor in white matter damage in MDD; the influence of MOG differs with onset age.

Social functioning in patients with depressive and anxiety disorders

OBJECTIVE

Adaptive social functioning is severely impeded in depressive and anxiety disorders, even after remission. However, a comprehensive overview is still lacking.

METHOD

Using data from the Netherlands Study of Depression and Anxiety (NESDA), behavioural (network size, social activities, social support) and affective (loneliness, affiliation, perceived social disability) indicators of social functioning were analyzed in patients with anxiety (N = 540), depressive (N = 393), comorbid anxiety and depressive disorders ('comorbid', N = 748), remitted participants (N = 621), and healthy control subjects (N = 650).

RESULTS

Analyses revealed an increasing trend of social dysfunction among patient groups, in patients with comorbid anxiety and depressive disorders, showing the most severe impairments, followed by depressed and anxious patients (P's < 0.001 for all social functioning indicators). Affective indicators showed the largest effect sizes (Cohen's d range from 0.13 to 1.76). We also found impairments in social functioning among remitted patients. Furthermore, perceived social disability among patients was predictive of still having a depressive and/or anxiety diagnosis 2 years later (P < 0.01).

CONCLUSIONS

Behavioural but especially affective indicators of social functioning are impaired in patients with anxiety or depressive disorders and most in patients with comorbid disorders. After remission of affective psychopathology, residual impairments tend to remain, while social dysfunction in patients seems predictive of future psychopathology.