Predictors of suicidal ideation severity among treatment-seeking young people with major depressive disorder: The role of state and trait anxiety

OBJECTIVE

Depression and suicidal ideation are closely intertwined. Yet, among young people with depression, the specific factors that contribute to changes in suicidal ideation over time are uncertain. Factors other than depressive symptom severity, such as comorbid psychopathology and personality traits, might be important contributors. Our aim was to identify contributors to fluctuations in suicidal ideation severity over a 12-week period in young people with major depressive disorder receiving cognitive behavioural therapy.

METHODS

Data were drawn from two 12-week randomised, placebo-controlled treatment trials. Participants (N = 283) were 15-25 years old, with moderate to severe major depressive disorder. The primary outcome measure was the Suicidal Ideation Questionnaire, administered at baseline and weeks 4, 8 and 12. A series of linear mixed models was conducted to examine the relationship between Suicidal Ideation Questionnaire score and demographic characteristics, comorbid psychopathology, personality traits and alcohol use.

RESULTS

Depression and anxiety symptom severity, and trait anxiety, independently predicted higher suicidal ideation, after adjusting for the effects of time, demographics, affective instability, non-suicidal self-injury and alcohol use.

CONCLUSIONS

Both state and trait anxiety are important longitudinal correlates of suicidal ideation in depressed young people receiving cognitive behavioural therapy, independent of depression severity. Reducing acute psychological distress, through reducing depression and anxiety symptom severity, is important, but interventions aimed at treating trait anxiety could also potentially be an effective intervention approach for suicidal ideation in young people with depression.

Assessing Suicidal Ideation in Young People With Depression: Factor Structure of the Suicidal Ideation Questionnaire

Evaluating suicidal ideation in young people seeking mental health treatment is an important component of clinical assessment and treatment planning. To reduce the burden of youth suicide, we need to improve our understanding of suicidal ideation, its underlying constructs, and how ideation translates into suicidal behaviour. Using exploratory factor analysis, we investigated the dimensionality of the Suicidal Ideation Questionnaire (SIQ) among 273 participants aged 15-25 with Major Depressive Disorder. Area under the receiver operating characteristic curve (AUROC) analysis was used to explore associations between latent factors and actual suicidal behaviour. Findings suggested that the SIQ assesses multiple factors underlying suicidal ideation. AUROC analyses demonstrated that latent factors relating to both active and passive suicidal ideation predicted past-month suicidal behaviour and suicide attempt. These findings contribute to an improved understanding of the complexities of suicidal ideation and relationships with suicidal behaviour in young people with depression.

Correlates of suicidality in young people with depressive disorders: A systematic review

OBJECTIVE

Depression is one of the most prevalent and disabling mental health conditions among young people worldwide. The health and economic burdens associated with depressive illness are substantial. Suicide and depression are closely intertwined, yet a diagnosis of depression itself lacks predictive specificity for suicidal behaviour. To better inform suicide prevention and early intervention strategies for young people, improved identification of modifiable intervention targets is needed. The objective of this review was to identify clinical, psychosocial and biological correlates of suicidality in young people diagnosed with a broad range of unipolar and bipolar depressive disorders.

METHOD

Systematic searches were conducted across MEDLINE, Embase and PsycINFO to identify studies of young people aged 15-25 years diagnosed with unipolar or bipolar depressive disorders. An assessment of suicidality was required for inclusion. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 and Synthesis Without Meta-analysis guidelines.

RESULTS

We integrated findings from 71 studies including approximately 24,670 young people with clinically diagnosed depression. We identified 26 clinical, psychosocial and biological correlates of suicidality. Depression characteristics (type and severity), psychiatric comorbidity (particularly anxiety and substance use disorders) and neurological characteristics emerged as having the most evidence for being associated with suicidal outcomes. Our ability to pool data and conduct meaningful quantitative synthesis was hampered by substantial heterogeneity across studies and incomplete reporting; thus, meta-analysis was not possible.

CONCLUSION

Findings of this review reinforce the notion that suicidality is a complex phenomenon arising from the interplay of multiple contributing factors. Our findings question the utility of considering a diagnosis of depression as a specific risk factor for suicidality in young people. Suicidality itself is transdiagnostic; adoption of a transdiagnostic approach to investigating its aetiology and treatment is perhaps warranted. Future research investigating specific symptoms, or symptom networks, might help to further our understanding of suicidality among young people experiencing mental illness.

Why Depressed Mood is Adaptive: A Numerical Proof of Principle for an Evolutionary Systems Theory of Depression

We provide a proof of principle for an evolutionary systems theory (EST) of depression. This theory suggests that normative depressive symptoms counter socioenvironmental volatility by increasing interpersonal support via social signalling and that this response depends upon the encoding of uncertainty about social contingencies, which can be targeted by neuromodulatory antidepressants. We simulated agents that committed to a series of decisions in a social two-arm bandit task before and after social adversity, which precipitated depressive symptoms. Responses to social adversity were modelled under various combinations of social support and pharmacotherapy. The normative depressive phenotype responded positively to social support and simulated treatments with antidepressants. Attracting social support and administering antidepressants also alleviated anhedonia and social withdrawal, speaking to improvements in interpersonal relationships. These results support the EST of depression by demonstrating that following adversity, normative depressed mood preserved social inclusion with appropriate interpersonal support or pharmacotherapy.

New generation antidepressants for depression in children and adolescents: a network meta-analysis

BACKGROUND

Major depressive disorders have a significant impact on children and adolescents, including on educational and vocational outcomes, interpersonal relationships, and physical and mental health and well-being. There is an association between major depressive disorder and suicidal ideation, suicide attempts, and suicide. Antidepressant medication is used in moderate to severe depression; there is now a range of newer generations of these medications.

OBJECTIVES

To investigate, via network meta-analysis (NMA), the comparative effectiveness and safety of different newer generation antidepressants in children and adolescents with a diagnosed major depressive disorder (MDD) in terms of depression, functioning, suicide-related outcomes and other adverse outcomes. The impact of age, treatment duration, baseline severity, and pharmaceutical industry funding was investigated on clinician-rated depression (CDRS-R) and suicide-related outcomes.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR)), together with Ovid Embase, MEDLINE and PsycINFO till March 2020.

SELECTION CRITERIA

Randomised trials of six to 18 year olds of either sex and any ethnicity with clinically diagnosed major depressive disorder were included. Trials that compared the effectiveness of newer generation antidepressants with each other or with a placebo were included. Newer generation antidepressants included: selective serotonin reuptake inhibitors; selective norepinephrine reuptake inhibitors (SNRIs); norepinephrine reuptake inhibitors; norepinephrine dopamine reuptake inhibitors; norepinephrine dopamine disinhibitors (NDDIs); and tetracyclic antidepressants (TeCAs).

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened titles/abstracts and full texts, extracted data, and assessed risk of bias. We analysed dichotomous data as Odds Ratios (ORs), and continuous data as Mean Difference (MD) for the following outcomes: depression symptom severity (clinician rated), response or remission of depression symptoms, depression symptom severity (self-rated), functioning, suicide related outcomes and overall adverse outcomes. Random-effects network meta-analyses were conducted in a frequentist framework using multivariate meta-analysis. Certainty of evidence was assessed using Confidence in Network Meta-analysis (CINeMA). We used "informative statements" to standardise the interpretation and description of the results.

MAIN RESULTS

Twenty-six studies were included. There were no data for the two primary outcomes (depressive disorder established via clinical diagnostic interview and suicide), therefore, the results comprise only secondary outcomes. Most antidepressants may be associated with a "small and unimportant" reduction in depression symptoms on the CDRS-R scale (range 17 to 113) compared with placebo (high certainty evidence: paroxetine: MD -1.43, 95% CI -3.90, 1.04; vilazodone: MD -0.84, 95% CI -3.03, 1.35; desvenlafaxine MD -0.07, 95% CI -3.51, 3.36; moderate certainty evidence: sertraline: MD -3.51, 95% CI -6.99, -0.04; fluoxetine: MD -2.84, 95% CI -4.12, -1.56; escitalopram: MD -2.62, 95% CI -5.29, 0.04; low certainty evidence: duloxetine: MD -2.70, 95% CI -5.03, -0.37; vortioxetine: MD 0.60, 95% CI -2.52, 3.72; very low certainty evidence for comparisons between other antidepressants and placebo). There were "small and unimportant" differences between most antidepressants in reduction of depression symptoms (high- or moderate-certainty evidence). Results were similar across other outcomes of benefit. In most studies risk of self-harm or suicide was an exclusion criterion for the study. Proportions of suicide-related outcomes were low for most included studies and 95% confidence intervals were wide for all comparisons. The evidence is very uncertain about the effects of mirtazapine (OR 0.50, 95% CI 0.03, 8.04), duloxetine (OR 1.15, 95% CI 0.72, 1.82), vilazodone (OR 1.01, 95% CI 0.68, 1.48), desvenlafaxine (OR 0.94, 95% CI 0.59, 1.52), citalopram (OR 1.72, 95% CI 0.76, 3.87) or vortioxetine (OR 1.58, 95% CI 0.29, 8.60) on suicide-related outcomes compared with placebo. There is low certainty evidence that escitalopram may "at least slightly" reduce odds of suicide-related outcomes compared with placebo (OR 0.89, 95% CI 0.43, 1.84). There is low certainty evidence that fluoxetine (OR 1.27, 95% CI 0.87, 1.86), paroxetine (OR 1.81, 95% CI 0.85, 3.86), sertraline (OR 3.03, 95% CI 0.60, 15.22), and venlafaxine (OR 13.84, 95% CI 1.79, 106.90) may "at least slightly" increase odds of suicide-related outcomes compared with placebo. There is moderate certainty evidence that venlafaxine probably results in an "at least slightly" increased odds of suicide-related outcomes compared with desvenlafaxine (OR 0.07, 95% CI 0.01, 0.56) and escitalopram (OR 0.06, 95% CI 0.01, 0.56). There was very low certainty evidence regarding other comparisons between antidepressants.

AUTHORS' CONCLUSIONS

Overall, methodological shortcomings of the randomised trials make it difficult to interpret the findings with regard to the efficacy and safety of newer antidepressant medications. Findings suggest that most newer antidepressants may reduce depression symptoms in a small and unimportant way compared with placebo. Furthermore, there are likely to be small and unimportant differences in the reduction of depression symptoms between the majority of antidepressants. However, our findings reflect the average effects of the antidepressants, and given depression is a heterogeneous condition, some individuals may experience a greater response. Guideline developers and others making recommendations might therefore consider whether a recommendation for the use of newer generation antidepressants is warranted for some individuals in some circumstances. Our findings suggest sertraline, escitalopram, duloxetine, as well as fluoxetine (which is currently the only treatment recommended for first-line prescribing) could be considered as a first option. Children and adolescents considered at risk of suicide were frequently excluded from trials, so that we cannot be confident about the effects of these medications for these individuals. If an antidepressant is being considered for an individual, this should be done in consultation with the child/adolescent and their family/caregivers and it remains critical to ensure close monitoring of treatment effects and suicide-related outcomes (combined suicidal ideation and suicide attempt) in those treated with newer generation antidepressants, given findings that some of these medications may be associated with greater odds of these events. Consideration of psychotherapy, particularly cognitive behavioural therapy, as per guideline recommendations, remains important.

Relationships Between Different Dimensions of Social Support and Suicidal Ideation in Young People with Major Depressive Disorder

BACKGROUND

Suicidal ideation (SI) is a common feature of depression and is closely associated with suicidal behaviour. Social support is implicated as an important determinant of suicide, but it is unclear how different social support dimensions influence SI in young people with depression. This study examines relationships between social support dimensions and SI in young people with major depressive disorder (MDD).

METHODS

283 Australians aged 15-25, diagnosed with MDD, were recruited from two clinical trials conducted in youth-specific outpatient mental health services. The Multidimensional Scale of Perceived Social Support (MSPSS) was used to evaluate perceived support from Family, Friends, and a Significant Other. Suicidal ideation was assessed using the Suicidal Ideation Questionnaire (SIQ). Hierarchical regression was used to explore associations between social support and SI, controlling for demographics and depression severity.

RESULTS

A hierarchical regression model predicted 9% of the variability in SI, with depression severity being the most significant predictor. Family Support was inversely related to SI and uniquely contributed 2% of the variance; β = -0.15 (95% CI -0.27 - -0.02) p < .05. Demographics and support from Friends or a Significant Other were not significantly associated with SI.

LIMITATIONS

Findings are correlational; it cannot be determined that increasing family support would decrease SI severity.

CONCLUSION

Perceived Family Support was negatively associated with SI in young people with MDD. This suggests that family members might play important roles in suicide prevention efforts. More work is needed exploring ways to empower families to develop adaptive family functioning and support.

Characteristics and predictors of suicidality in young people with clinical depression: a systematic review protocol

OBJECTIVE

The objective of this review is to examine clinical, psychosocial, and biological factors associated with suicidality in young people diagnosed with depression. This review will describe risk and protective factors, focusing on modifiable attributes, in order to inform suicide prevention and early intervention strategies.

INTRODUCTION

Suicide is the world's second-leading cause of death among young people. Depression is closely associated with suicide; however, it lacks specificity as a predictor of suicidal behavior. There is a clear need to improve our understanding of both risk and protective factors associated with the full spectrum of suicidality in young people, across a range of depressive disorders.

INCLUSION CRITERIA

Studies that include young people 15 to 25 years of age with a diagnosis of depression made in accordance with a diagnostic classification standard will be considered. Diagnosis must be made using a structured clinical interview or be received through standard clinical practice. Analytical cross-sectional studies, prospective and retrospective cohort studies, and case-control studies will be included. Studies must include an assessment of suicidality made using standardized or non-standardized tools. A broad range of inpatient and outpatient settings will be considered.

METHODS

MEDLINE, Embase, and PsycINFO will be searched for studies published in English, with no date limitation. Two independent reviewers will conduct study screening, assess methodological quality, and extract data using standardized tools. If there is sufficient homogeneity across studies, meta-analyses using a random-effects model will be conducted. If quantitative meta-analysis is not possible, a narrative synthesis will be undertaken.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020151612.

A World Unto Itself: Human Communication as Active Inference

Recent theoretical work in developmental psychology suggests that humans are predisposed to align their mental states with those of other individuals. One way this manifests is in cooperative communication; that is, intentional communication aimed at aligning individuals' mental states with respect to events in their shared environment. This idea has received strong empirical support. The purpose of this paper is to extend this account by proposing an integrative model of the biobehavioral dynamics of cooperative communication. Our formulation is based on active inference. Active inference suggests that action-perception cycles operate to minimize uncertainty and optimize an individual's internal model of the world. We propose that humans are characterized by an evolved adaptive prior belief that their mental states are aligned with, or similar to, those of conspecifics (i.e., that 'we are the same sort of creature, inhabiting the same sort of niche'). The use of cooperative communication emerges as the principal means to gather evidence for this belief, allowing for the development of a shared narrative that is used to disambiguate interactants' (hidden and inferred) mental states. Thus, by using cooperative communication, individuals effectively attune to a hermeneutic niche composed, in part, of others' mental states; and, reciprocally, attune the niche to their own ends via epistemic niche construction. This means that niche construction enables features of the niche to encode precise, reliable cues about the deontic or shared value of certain action policies (e.g., the utility of using communicative constructions to disambiguate mental states, given expectations about shared prior beliefs). In turn, the alignment of mental states (prior beliefs) enables the emergence of a novel, contextualizing scale of cultural dynamics that encompasses the actions and mental states of the ensemble of interactants and their shared environment. The dynamics of this contextualizing layer of cultural organization feedback, across scales, to constrain the variability of the prior expectations of the individuals who constitute it. Our theory additionally builds upon the active inference literature by introducing a new set of neurobiologically plausible computational hypotheses for cooperative communication. We conclude with directions for future research.

Variational ecology and the physics of sentient systems

This paper addresses the challenges faced by multiscale formulations of the variational (free energy) approach to dynamics that obtain for large-scale ensembles. We review a framework for modelling complex adaptive control systems for multiscale free energy bounding organism-niche dynamics, thereby integrating the modelling strategies and heuristics of variational neuroethology with a broader perspective on the ecological nestedness of biotic systems. We extend the multiscale variational formulation beyond the action-perception loops of individual organisms by appealing to the variational approach to niche construction to explain the dynamics of coupled systems constituted by organisms and their ecological niche. We suggest that the statistical robustness of living systems is inherited, in part, from their eco-niches, as niches help coordinate dynamical patterns across larger spatiotemporal scales. We call this approach variational ecology. We argue that, when applied to cultural animals such as humans, variational ecology enables us to formulate not just a physics of individual minds, but also a physics of interacting minds across spatial and temporal scales - a physics of sentient systems that range from cells to societies.

The hierarchically mechanistic mind: an evolutionary systems theory of the human brain, cognition, and behavior

The purpose of this review was to integrate leading paradigms in psychology and neuroscience with a theory of the embodied, situated human brain, called the Hierarchically Mechanistic Mind (HMM). The HMM describes the brain as a complex adaptive system that functions to minimize the entropy of our sensory and physical states via action-perception cycles generated by hierarchical neural dynamics. First, we review the extant literature on the hierarchical structure of the brain. Next, we derive the HMM from a broader evolutionary systems theory that explains neural structure and function in terms of dynamic interactions across four nested levels of biological causation (i.e., adaptation, phylogeny, ontogeny, and mechanism). We then describe how the HMM aligns with a global brain theory in neuroscience called the free-energy principle, leveraging this theory to mathematically formulate neural dynamics across hierarchical spatiotemporal scales. We conclude by exploring the implications of the HMM for psychological inquiry.

The hierarchically mechanistic mind: A free-energy formulation of the human psyche

This article presents a unifying theory of the embodied, situated human brain called the Hierarchically Mechanistic Mind (HMM). The HMM describes the brain as a complex adaptive system that actively minimises the decay of our sensory and physical states by producing self-fulfilling action-perception cycles via dynamical interactions between hierarchically organised neurocognitive mechanisms. This theory synthesises the free-energy principle (FEP) in neuroscience with an evolutionary systems theory of psychology that explains our brains, minds, and behaviour by appealing to Tinbergen's four questions: adaptation, phylogeny, ontogeny, and mechanism. After leveraging the FEP to formally define the HMM across different spatiotemporal scales, we conclude by exploring its implications for theorising and research in the sciences of the mind and behaviour.

Differences Between Landline and Mobile Phone Users in Sexual Behavior Research

This study investigated differences between the demographic characteristics, participation rates (i.e., agreeing to respond to questions about sexual behavior), and sexual behaviors of landline and mobile phone samples in Australia. A nationally representative sample of Australians aged 18 years and over was recruited via random digit dialing in December 2011 to collect data via computer-assisted telephone interviews. A total of 1012 people (370 men, 642 women) completed a landline interview and 1002 (524 men, 478 women) completed a mobile phone interview. Results revealed that telephone user status was significantly related to all demographic variables: gender, age, educational attainment, area of residence, country of birth, household composition, and current ongoing relationship status. In unadjusted analyses, telephone status was also associated with women's participation rates, participants' number of other-sex sexual partners in the previous year, and women's lifetime sexual experience. However, after controlling for significant demographic factors, telephone status was only independently related to women's participation rates. Post hoc analyses showed that significant, between-group differences for all other sexual behavior outcomes could be explained by demographic covariates. Results also suggested that telephone status may be associated with participation bias in research on sexual behavior. Taken together, these findings highlight the importance of sampling both landline and mobile phone users to improve the representativeness of sexual behavior data collected via telephone interviews.

Self-reported parenting style is associated with children's inflammation and immune activation

Family environments and parenting have been associated with inflammation and immune activation in children and adolescents; however, it remains unclear which specific aspects of parenting drive this association. In this study, we cross-sectionally examined the association between 5 discrete parenting styles and inflammation and immune activation in late childhood. Data were drawn from 102 families (55 with female children, mean age 9.50 years, SD = 0.34) participating in the Imaging Brain Development in the Childhood to Adolescence Transition Study. Children provided saliva samples from which inflammation (C-reactive protein) and immune competence/activation (secretory immunoglobulin A) were measured. Parents completed the Alabama Parenting Questionnaire, which measures 5 aspects of parenting style-positive parental involvement, positive disciplinary techniques, consistency in disciplinary techniques, corporal punishment, and monitoring and supervision. Results showed that higher scores on the poor parental monitoring scale were associated with higher levels of both inflammation and immune activation in children. This study highlights parental monitoring and supervision as a specific aspect of parenting behavior that may be important for children's physical and mental health. (PsycINFO Database Record

The lifetime experience of traumatic events is associated with hair cortisol concentrations in community-based children

Adversity early in life can disrupt the functioning of the hypothalamic-pituitary-adrenal axis (HPAA) and increase risk for negative health outcomes. Recent research suggests that cortisol in scalp hair represents a promising measure of HPAA function. However, little is known about the relationship between early exposure to traumatic events and hair cortisol concentrations (HCC) in childhood, a critical period of HPAA development. The current study measured HCC in scalp hair samples collected from 70 community-based children (14 males, mean age=9.50) participating in the Imaging Brain Development in the Childhood to Adolescence Transition Study (iCATS). Data were also collected on lifetime exposure to traumatic events and current depressive symptoms. Lifetime exposure to trauma was associated with elevated HCC; however, HCC was not associated with current depressive symptoms. Consistent with some prior work, males were found to have higher HCC than females, although results should be treated with caution due to the small number of males who took part. Our findings suggest that hair cortisol may represent a biomarker of exposure to trauma in this age group; however, further study is necessary with a particular focus on the characterization of trauma and other forms of adversity.

Corrigendum to: Heterosexual experience and recent heterosexual encounters among Australian adults: The Second Australian Study of Health and Relationships

Background Current information about numbers of other-sex partners, experiences of different heterosexual behaviours and the recent heterosexual experiences among a representative sample of Australian adults is needed. It is not known whether these practices have changed between 2001–02 and 2012–13. Methods: Computer-assisted telephone interviews were completed by a representative sample of 9963 men and 10 131 women aged 16–69 years from all states and territories. The overall participation rate among eligible people was 66.2%. Results: Men reported more sexual partners than women, although the lifetime number of heterosexual partners reported by women increased significantly between 2001–02 and 2012–13. In 2012–13, 14.7% of men and 8.6% of women reported two or more sexual partners in the last year. Reporting multiple partners was significantly associated with being younger, being bisexual, living in major cities, having a lower income, having a blue-collar occupation and not being married. The proportion of respondents reporting ever having had oral sex or anal intercourse increased significantly since the last survey. At the last heterosexual encounter, 91.9% of men and 66.2% of women had an orgasm, oral sex was reported in only approximately one in four encounters and anal intercourse was uncommon. Conclusion: There were increases between 2001–02 and 2012–13 in partner numbers among women and in the lifetime experience of oral and anal sex. The patterns of heterosexual experience in Australia are similar to those found in studies of representative samples in other countries.

Corrigendum to: Knowledge about and experience of sexually transmissible infections in a representative sample of adults: the Second Australian Study of Health and Relationships

Background Sexually transmissible infections (STIs) present a substantial public health burden, and are related to modifiable sexual behaviours. Methods: Computer-assisted telephone interviews were completed by a population-representative sample of 20 094 men and women aged 16–69 years. The overall participation rate among eligible people was 66.2%. Respondents were asked questions regarding their knowledge about, self-reported history of, and testing for STIs. Results: STI knowledge was better in women, the young, people of higher socioeconomic status, those with a variety of indicators of being at high STI risk and those with a history of receiving sex education in school. Approximately one in six men and women reported a lifetime history of an STI. A history of STI testing in the last year was reported by ~one in six (17%) women and one in eight men (13%) and higher rates of testing in women were reported in most high-risk groups. The highest rates of STI testing (61%) and HIV testing (89%) were reported in homosexual men. Conclusion: Knowledge of STI-related health consequences and transmission is improving in Australians, and rates of STI testing were relatively high but were higher in women than in men. Further increases in testing rates in both sexes will be required to facilitate the early diagnosis and treatment of STIs, which is a cornerstone of STI control.

Heterosexual experience and recent heterosexual encounters among Australian adults: the Second Australian Study of Health and Relationships

Background Current information about numbers of other-sex partners, experiences of different heterosexual behaviours and the recent heterosexual experiences among a representative sample of Australian adults is needed. It is not known whether these practices have changed between 2001-02 and 2012-13.

METHODS

Computer-assisted telephone interviews were completed by a representative sample of 9963 men and 10131 women aged 16-69 years from all states and territories. The overall participation rate among eligible people was 66.2%.

RESULTS

Men reported more sexual partners than women, although the lifetime number of heterosexual partners reported by women increased significantly between 2001-02 and 2012-13. In 2012-13, 14.7% of men and 8.6% of women reported two or more sexual partners in the last year. Reporting multiple partners was significantly associated with being younger, being bisexual, living in major cities, having a lower income, having a blue-collar occupation and not being married. The proportion of respondents reporting ever having had oral sex or anal intercourse increased significantly since the last survey. At the last heterosexual encounter, 91.9% of men and 66.2% of women had an orgasm, oral sex was reported in only approximately one in four encounters and anal intercourse was uncommon.

CONCLUSION

There were increases between 2001-02 and 2012-13 in partner numbers among women and in the lifetime experience of oral and anal sex. The patterns of heterosexual experience in Australia are similar to those found in studies of representative samples in other countries.

Change and stasis in sexual health and relationships: comparisons between the First and Second Australian Studies of Health and Relationships

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Masturbation, paying for sex, and other sexual activities: the Second Australian Study of Health and Relationships

Background This study describes the prevalence of (solo) masturbation, paying for sex and a range of other sexual practices among Australians. Methods: A representative sample of 20 094 men and women aged 16–69 years (participation rate among eligible people, 66.2%) were recruited by landline and mobile phone random-digit dialling and computer-assisted telephone interviews in 2012–13. Results: Many respondents (men, 72%; women, 42%) had masturbated in the past year. Half (51%) of the men and 24% of women had masturbated in the past 4 weeks. In the past year, more than two-fifths of respondents (men, 63%; women, 20%) had looked at pornography in any medium. Approximately 15% of men and 21% of women had used a sex toy. Digital-anal stimulation with a partner was practised by 19% of men and 15% of women, and oral-anal stimulation by 7% of men and 4% of women. Sexual role playing or dressing up were engaged in by 7–8%. Online sex, swinging, group sex, BDSM (bondage and discipline, ‘sadomasochism’ or dominance and submission) and fisting (rectal or vaginal) were each engaged in by less than 3% of the sample. Seventeen per cent of men said they had ever paid for sex; 2% had done so in the past year. Conclusion: Most of the solo practices studied were engaged in by more men than women, but women were more likely to have used a sex toy. Autoerotic activities are both substitutes for partnered sex and additional sources of pleasure for people with sexual partners.

Attitudes toward sex and relationships: the Second Australian Study of Health and Relationships

Background Attitudes towards sex and relationships influence laws about what is and is not permissible and social sanctions against behaviours considered unacceptable. They are an important focus for research given their links to sexual behaviour. The aim of the present study was to describe attitudes towards sex and relationships, to identify correlates of scores on a scale of sexual liberalism and to examine responses to jealousy-evoking scenarios among Australian adults. Methods: Computer-assisted landline and mobile telephone interviews were completed by a population-representative sample of 20 094 men and women aged 16–69 years. The overall participation rate among eligible people was 66.2%. Respondents expressed their agreement with 11 attitude statements, five of which formed a valid scale of liberalism, and also responded to a jealousy-evoking scenario. Results: There was general agreement that premarital sex was acceptable (87%), that sex was important for wellbeing (83%) and that sex outside a committed relationship was unacceptable (83%). Respondents were accepting of homosexual behaviour and abortion and few believed that sex education encouraged earlier sexual activity. More liberal attitudes were associated with: being female; speaking English at home; homosexual or bisexual identity; not being religious; greater education; and higher incomes. Respondents who expressed more liberal attitudes had more diverse patterns of sexual experience. Predicted sex differences were found in response to the jealousy-evoking scenario — men were more jealous of a partner having sex with someone else and women were more jealous of a partner forming an emotional attachment — but responses varied with age. Conclusion: Sexual attitudes of Australians largely support a permissive but monogamous paradigm. Since 2002, there has been a shift to less tolerance of sex outside a committed relationship, but greater acceptance of homosexual behaviour.

First vaginal intercourse and oral sex among a representative sample of Australian adults: the Second Australian Study of Health and Relationships

Background Current information about the characteristics of Australian adults' first vaginal intercourse and contraception or precautions used on that occasion is needed, as well as whether these characteristics have changed between 2001-02 and 2012-13.

METHODS

Computer-assisted telephone interviews were completed by a representative sample of 20094 men and women aged 16-69 years. The overall participation rate among eligible people was 66.2%. Respondents indicated their age at first vaginal intercourse and first oral sex. Those who reported vaginal intercourse were asked the age of their partner, their relationship to their partner, the duration of this relationship, and what contraception or precautions (if any) were used.

RESULTS

There was a significant decline in the median age of first vaginal intercourse for both men and women among those born between the 1940s and the 1960s, but no further decline since. There has also been a significant increase in the use of protection at first vaginal intercourse, from less than 20% of men and women in the 1950s to over 90% in the 2000s. For men and women, first vaginal sex before age 16 years was significantly associated with a greater number of lifetime and recent sexual partners, and a greater likelihood of having had a sexually transmitted infection.

CONCLUSION

Given the earlier age at first vaginal intercourse, sex education should begin earlier so that all young people have information about contraception and disease prevention before they begin their sexual careers.

Design and methods of the Second Australian Study of Health and Relationships

Background This paper describes the methods and process of the Second Australian Study of Health and Relationships.

METHODS

A representative sample of the Australian population was contacted by landline and mobile phone modified random-digit dialling in 2012-13. Computer-assisted telephone interviews elicited sociodemographic and health details as well as sexual behaviour and attitudes. For analysis, the sample was weighted to reflect the study design and further weighted to reflect the location, age and sex distribution of the population at the 2011 Census.

RESULTS

Interviews were completed with 9963 men and 10131 women aged 16-69 years from all states and territories. The overall participation rate among eligible people was 66.2% (63.9% for landline men, 67.9% for landline women and 66.5% for mobile respondents). Accounting for the survey design and adjusting to match the 2011 Census resulted in a weighted sample of 20094 people (10056 men and 10038 women). The sample was broadly representative of the Australian population, although as in most surveys, people with higher education and higher status occupations were over-represented. Data quality was high, with the great majority saying they were not at all or only slightly embarrassed by the questionnaire and almost all saying they were 90-100% honest in their answers.

CONCLUSIONS

The combination of methods and design in the Second Australian Study of Health and Relationships, together with the high participation rate, strongly suggests that the results of the study are robust and broadly representative of the Australian population.

Homosexual experience and recent homosexual encounters: the Second Australian Study of Health and Relationships

Background The aim of this study is to describe homosexual experience and characteristics of recent homosexual encounters among Australian adults and identify changes between 2001–02 and 2012–13. Methods: Computer-assisted telephone interviews were completed by a representative sample of 20 094 men and women aged 16–69 years and the participation rate among eligible people was 66.2%. Respondents indicated the number of same-sex partners they had had in their lifetime and in the last 12 months. Those who reported any homosexual experience were asked the age at which this first occurred and about characteristics of the first and most recent homosexual encounter. Results: Reporting ever having same-sex experience was more common in women (13.5%) than in men (6.5%, P < 0.001). Among these people, men reported more lifetime and recent same-sex partners than women (P < 0.001). Same-sex experience was associated with some but not all indices of higher socioeconomic status. In men, it was associated with living in a major city (P = 0.02) and in women, it was associated with younger (<30 years) age and with very low income (P < 0.001). Men were younger than women at their first homosexual encounter (P = 0.005). Women were more likely than men to have their first same-sex encounter with a regular partner. For women but not men, there was a significant increase in the proportion reporting same-sex experience since 2001–02. Conclusion: Same-sex experience is not uncommon and is increasing in prevalence in young Australian women. The high number of same-sex partners among homosexual and bisexual men places them at greater risk of sexually transmissible infection.

Knowledge about and experience of sexually transmissible infections in a representative sample of adults: the Second Australian Study of Health and Relationships

Background Sexually transmissible infections (STIs) present a substantial public health burden, and are related to modifiable sexual behaviours.

METHODS

Computer-assisted telephone interviews were completed by a population-representative sample of 20 094 men and women aged 16-69 years. The overall participation rate among eligible people was 66.2%. Respondents were asked questions regarding their knowledge about, self-reported history of, and testing for STIs.

RESULTS

STI knowledge was better in women, the young, people of higher socioeconomic status, those with a variety of indicators of being at high STI risk and those with a history of receiving sex education in school. Approximately one in six men and women reported a lifetime history of an STI. A history of STI testing in the last year was reported by ~one in six (17%) women and one in eight men (13%) and higher rates of testing in women were reported in most high-risk groups. The highest rates of STI testing (61%) and HIV testing (89%) were reported in homosexual men.

CONCLUSION

Knowledge of STI-related health consequences and transmission is improving in Australians, and rates of STI testing were relatively high but were higher in women than in men. Further increases in testing rates in both sexes will be required to facilitate the early diagnosis and treatment of STIs, which is a cornerstone of STI control.

Safer sex and condom use: findings from the Second Australian Study of Health and Relationships

Background It is important to have current and reliable estimates of the frequency and correlates of condom use among Australian adults. Methods: A representative sample of 20 094 men and women aged 16–69 years, from all states and territories, completed computer-assisted telephone interviews. The overall participation rate among eligible people was 66.2%. Results: Although most respondents had used a condom at some time in their lives, fewer than half of those who were sexually active in the year before being interviewed had used a condom in that year. Condom use in the last year was associated with youth, speaking a language other than English at home, bisexual identity, greater education, residence in major cities, lower income and having multiple sexual partners in the last year. One-quarter of respondents used a condom the last time they had vaginal intercourse and one-sixth of these were put on after genital contact. Condom use during most recent vaginal sex was associated with youth, lower income, having sex with a non-regular partner and not using another form of contraception. Condom use appears to have increased between 2001–02 and 2012–13. Conclusion: Consistent with other research, this study showed that condom use was strongly associated with partner type and use of other contraception. There may be a need to highlight among people with multiple sexual partners the fact that non-barrier methods of contraception do not offer protection against sexually transmissible infections. The finding that many condoms were applied after genital contact suggests a need to promote both use and correct use of condoms.

Sexual identity, sexual attraction and sexual experience: the Second Australian Study of Health and Relationships

Background Behavioural and other aspects of sexuality are not always consistent. This study describes the prevalence and overlap of same-sex and other-sex attraction and experience and of different sexual identities in Australia. Methods: Computer-assisted telephone interviews were completed by a representative sample of 20 094 men and women aged 16–69 years recruited by landline and mobile phone random-digit dialling with a response rate (participation rate among eligible people) of 66.2%. Respondents were asked about their sexual identity (‘Do you think of yourself as’ heterosexual/straight, homosexual/gay, bisexual, etc.) and the sex of people with whom they had ever had sexual contact and to whom they had felt sexually attracted. Results: Men and women had different patterns of sexual identity. Although the majority of people identified as heterosexual (97% men, 96% women), women were more likely than men to identify as bisexual. Women were less likely than men to report exclusively other-sex or same-sex attraction and experience; 9% of men and 19% of women had some history of same-sex attraction and/or experience. Sexual attraction and experience did not necessarily correspond. Homosexual/gay identity was more common among men with tertiary education and living in cities and less common among men with blue-collar jobs. Many gay men (53%) and lesbians (76%) had some experience with an other-sex partner. More women identified as lesbian or bisexual than in 2001–02. Similarly, more women reported same-sex experience and same-sex attraction. Conclusion: In Australia, men are more likely than women to report exclusive same-sex attraction and experience, although women are more likely than men to report any non-heterosexual identity, experience and attraction. Whether this is a feature of the plasticity of female sexuality or due to lesser stigma than for men is unknown.

Experiences of sexual coercion in a representative sample of adults: the Second Australian Study of Health and Relationships

Background It is important to have current reliable estimates of the prevalence, correlates and consequences of sexual coercion among a representative sample of Australian adults and to identify changes over time in prevalence and consequences.

METHODS

Computer-assisted telephone interviews were completed by a representative sample of 20094 Australian men and women aged 16-69 years. The participation rate among eligible people was 66.2%.

RESULTS

Sexual coercion (i.e. being forced or frightened into sexual activity) was reported by 4.2% of men and 22.4% of women. Sexual coercion when aged ≤16 years was reported by 2.0% of men and 11.5% of women. Correlates of sexual coercion were similar for men and women. Those who had been coerced reported greater psychosocial distress, were more likely to smoke, were more anxious about sex and more likely to have acquired a sexually transmissible infection. Few people had talked to others about their experiences of sexual coercion and fewer had talked to a professional. There were no significant differences between the First and Second Australian Study of Health and Relationships in whether men or women had experienced coercion, talked to anyone about this or talked to a counsellor or psychologist.

CONCLUSION

Sexual coercion has detrimental effects on various aspects of people's lives. It usually occurs at the ages at which people become sexually active. There is a need to reduce the incidence of sexual coercion, better identify experiences of sexual coercion, and provide accessible services to minimise the detrimental effects of sexual coercion.

Characteristics of heterosexual regular relationships among a representative sample of adults: the Second Australian Study of Health and Relationships

Background The aim of this study was to describe important characteristics of Australian adults' heterosexual regular sexual relationships and examine how these characteristics have changed since 2002.

METHODS

Computer-assisted landline and mobile telephone interviews were completed by a representative sample of 20 094 Australian residents aged 16-69 years. The participation rate among eligible people was 66.2%. Data were collected on respondents' social and demographic characteristics, relationship status and duration, cohabitation status, partner's age, contraception use, expectations about sexual exclusivity, sexual partners in the previous year, actual and ideal frequencies of sex and levels of physical pleasure and emotional satisfaction in their relationships.

RESULTS

Most sexually active respondents 89%; 74% of all respondents, were in a heterosexual regular relationship. Most (97%) expected sexual exclusivity in their relationships, with 3% reporting extradyadic sex in the previous year. Respondents reported an average frequency of sex of 1.44 times per week, with most reporting very high levels of physical pleasure (men, 88%; women, 76%) and emotional satisfaction (men, 86%; women, 84%) in their relationships. Comparisons with data from the First Australian Study of Health and Relationships revealed that significantly more sexually active men were in a relationship in the current survey; that respondents' average frequency of sex was significantly lower; and that women's reports of extreme emotional satisfaction had risen. Otherwise, results were consistent with those of the first study.

CONCLUSIONS

In general, results suggested that the characteristics of Australians' heterosexual relationships changed little between 2002 and 2013. Despite a decline in respondents' average weekly frequency of sex, the majority of respondents reported being in a highly satisfying, sexually exclusive relationship.