Development of best practice guidelines for clinical and community service providers to prevent suicide in LGBTQA+ young people: A Delphi expert consensus study

OBJECTIVE

The aim of this study was to develop best practice guidelines for preventing suicide and reducing suicidal thoughts and behaviours in LGBTQA+ young people (lesbian, gay, bisexual, trans, queer/questioning, asexual, and those of other diverse sexualities and genders) within clinical and community service settings in Australia.

METHODS

We conducted a Delphi expert consensus study. A systematic literature search and interviews with key informants informed an initial 270-item questionnaire. Two expert panels completed the questionnaire, delivered over two rounds: (1) Australian professionals with expertise in LGBTQA+ mental health/suicide prevention and (2) Australian LGBTQA+ young people aged 14-25 with lived experience of suicidal thoughts and/or behaviours. Items endorsed as 'essential' or 'important' by >80% of both expert panels were included in the guidelines.

RESULTS

A total of 115 people participated in the Delphi process; n = 52 professionals completed Round 1, and n = 42 completed Round 2; n = 63 LGBTQA+ young people completed Round 1, and n = 50 completed Round 2. A total of 290 items were included in the guidelines and grouped into: (1) general principles for creating an affirming and inclusive environment for LGBTQA+ young people; (2) assessing suicide risk and working with suicidal LGBTQA+ young people; (3) considerations for specific LGBTQA+ populations; and (4) advocating for LGBTQA+ young people.

CONCLUSION

These guidelines are the first of their kind in Australia. They provide practical support to service providers regardless of prior training in LGBTQ+ identities or mental health, with the aim of reducing suicidal thoughts and behaviours, and preventing suicide, in LGBTQA+ young people.

It's time for change: inequities and determinants of health-related quality of life among gender and sexually diverse young people in Australia

PURPOSE

This study was guided by three research aims: firstly, to examine the longitudinal trends of health-related quality of life (HR-QoL) among gender and sexuality diverse (LGBTQA2S+) young people through adolescence (ages 14-19); secondly, to assess longitudinal associations between poor mental health and HR-QoL among LGBTQA2S+ young people through adolescence; and thirdly, to examine differences in HR-QoL among LGBTQA2S+ young people during early adolescence (ages 14 and 15) depending on select school-, peer-, and parent-level factors.

METHODS

This study used three of nine available waves of data from a large population-level, probability sample-based, longitudinal cohort study, namely the K' cohort: children aged 4-5 years old at time of study enrolment followed-up biennially (~ 61% retention rate). HR-QoL weighted means and standard deviations were calculated using Child Health Utility 9D (CHU-9D) scores for LGBTQA2S+ participants at ages 14 and 15 (Wave 6), ages 16 and 17 (Wave 7), and ages 18 and 19 (Wave 8). To strategically identify policy-relevant modifiable behavioural factors suitable for prevention and early intervention, non-parametric Wilcoxon signed-rank tests tested differences in mean CHU-9D ranks at ages 14 and 15 (Wave 6) between groups (gender identity: trans vs. cis; identity-level sexuality: gay, lesbian, bisexual, or other diverse sexuality vs. heterosexual; group-level sexuality: sexually diverse vs. not sexually diverse) and selected school factors (school acceptance, belonging, freedom of expression), peer factors (peer relationship quality, trust, respect), and family factors (parental acceptance, understanding, trust), with Hedge's g correction statistics computed for effect sizes. Longitudinal associations between gender, sexuality, and poor mental health (depressive symptoms, anxiety, symptoms, self-harm thoughts/behaviour, and suicidal thoughts/behaviour) and HR-QoL were tested using mixed-effects models with random intercepts and random slopes for nested clustering (participants within postcodes).

RESULTS

HR-QoL disparities disproportionately affecting LGBTQA2S+ groups relative to their cisgender, heterosexual peers, were well-established by age 14 to 15 relatively steeper reductions in HR-QoL were observed throughout adolescence among all LGBTQA2S+ groups, with HR-QoL widening the most for trans participants. Poor mental health was significantly associated with HR-QoL declines. LGBTQA2S+ participants with positive school- and parent factors related to feelings of acceptance, belonging, and freedom of self-expression, reported significantly higher HR-QoL during early adolescence.

CONCLUSION

Evidence-based public health policy responses are required to address the dire HR-QoL inequities among LGBTQA2S+ young people, particularly trans young people. Prioritising the promotion of school- and family-based interventions which foster LGBTQA2S+ inclusivity, acceptance, and a sense of belonging from early adolescence through young adulthood, represents a feasible, evidence-based, and cost-effective response to address these HR-QoL disparities.

Mental ill-health and substance use among sexuality diverse adolescents: The critical role of school climate and teacher self-efficacy

INTRODUCTION

Mental ill-health, substance use and their co-occurrence among sexuality diverse young people during earlier adolescence is relatively understudied. The preventive utility of positive school climate for sexuality diverse adolescents' mental health is also unclear, as well as the role of teachers in conferring this benefit.

METHOD

Using Wave 8 'B Cohort' data from the Longitudinal Study of Australian children (N = 3127, Mage = 14.3), prevalence ratios and odds ratios were used to assess prevalence and disparities in mental ill-health and substance use, and multinomial logistic regression for co-occurring outcomes, among sexuality diverse adolescents relative to heterosexual peers. Logistic regression was used to assess associations between school climate and teacher self-efficacy with sexuality diverse adolescents' mental health.

RESULTS

Mental ill-health prevalence ranged from 22% (suicidal thoughts/behaviour) to 46% (probable depressive disorders) and substance use between 66% (cigarette use) and 97% (alcohol use). Sexuality diverse participants were significantly more likely to report self-harm and high levels of emotional symptoms in co-occurrence with cigarette, alcohol and/or cannabis use. For each 1-point increase in school climate scores as measured by the Psychological Sense of School Membership scale, there was 10% reduction in sexuality diverse adolescents reporting high levels of emotional symptoms, probable depressive disorder, self-harm thoughts/behaviour and suicidal thoughts/behaviour. For each 1-point increase in lower perceived (worse) teacher self-efficacy scores as measured by four bespoke teacher self-efficacy items, odds of sexuality diverse adolescent-reported suicidal thoughts/behaviour increased by 80%.

DISCUSSION

Mental ill-health, substance use and especially their co-occurrence, are highly prevalent and pose significant and inequitable health and well-being risks. Schools represent a potential site for focusing future prevention efforts and educating and training teachers on sexuality diversity is a promising pathway towards optimising these.

Minority stressors, traumatic events, and associations with mental health and school climate among gender and sexuality diverse young people in Australia: Findings from a nationally representative cohort study

INTRODUCTION

Population-level, nationally representative data on the prevalence of minority stressors and traumatic events, mental ill-health effects, and the preventative utility of school climate, among gender and sexuality diverse young people in Australia, is significantly lacking. In this study, we estimated the prevalence and distribution of minority stressors and traumatic events among young people by sexuality identity (gay/lesbian, bisexual, other sexuality, heterosexual), sexuality diversity (sexuality diverse, not sexuality diverse), and gender identity (transgender, cisgender) and assessed associations with mental ill-health and the moderating role of school climate factors.

METHODS

Using Wave 8 (2018) follow-up data from a population-level, nationally representative longitudinal cohort study, the sample comprised 3037 young people aged 17-19 years in Australia. Prevalence ratios for minority stressors and traumatic events were calculated for gender and sexuality diverse categories using logistic regression models. Linear regression models were used to test associations between traumatic events and minority stressors, and mental ill-health. Multivariate linear regression tested school climate factors as effect modifier between minority stressors and mental ill-health among sexuality diverse young people.

RESULTS

Rates of traumatic events and minority stressors were highest among bisexual and gay/lesbian young people and were significantly associated with mental ill-health among all gender and sexuality diverse young people. Highest mental ill-health effects were observed among trans young people. Among sexuality diverse young people, positive and negative feelings toward school climate were associated with decreased and increased mental ill-health, respectively. After accounting for sexuality diversity, positive overall school climate appeared protective of mental ill-health effects of sexuality-based discrimination.

DISCUSSION

Minority stressors, traumatic events, and associated mental ill-health are prevalent among gender and sexuality diverse young people in Australia, especially trans, bisexual, and gay/lesbian young people. Promotion of affirmative, safe, and inclusive school climate demonstrates significant promise for the prevention and early intervention of mental ill-health among gender and sexuality diverse young people.

Gender non-conformity in childhood and adolescence and mental health through to adulthood: a longitudinal cohort study, 1995-2018

BACKGROUND

Few studies have examined associations between gender non-conformity (GNC) in childhood or adolescence and mental health outcomes later in life. This study examined associations between (1) GNC and mental health over multiple time points in childhood and adolescence, and (2) GNC in childhood and/or adolescence and mental health in adulthood.

METHOD

Second generation participants from the Raine Study, a longitudinal cohort from Perth, Western Australia. Data were collected between 1995 and 2018, comprising seven waves: ages 5 (N = 2236), 8 (N = 2140), 10 (N = 2048), 14 (N = 1864), 17 (N = 1726), 22 (N = 1236) and 27 (N = 1190) years. History of GNC, v. absence of this history, was based on responses to item 110 from the Child Behaviour Checklist (CBCL)/Youth Self Report (YSR) ('wishes to be of opposite sex'). The CBCL/YSR were used to measure internalising and externalising symptoms. Items 18 ('deliberate self-harm [DSH] or attempts suicide') and 91 ('talks/thinks about killing self') were used as measures of suicidal ideation (SI) and DSH. For adults, Depression, Anxiety and Stress Subscales and Kessler Psychological Distress Scale assessed mental health.

RESULTS

Child and adolescent GNC was associated with elevated internalising and externalising behaviours and increased odds of DSH. A history of GNC was also associated with vulnerability for severe psychological distress in adulthood in some symptom scales.

CONCLUSION

GNC over the child and adolescent period is associated with significant emotional and behavioural difficulties, and psychological distress. A history of GNC in childhood and/or adolescence also predicts poorer mental health in adulthood on multiple symptom domains.

Association between mental health workforce supply and clusters of high and low rates of youth suicide: An Australian study using suicide mortality data from 2016 to 2020

OBJECTIVE

To examine the association between mental health workforce supply and spatial clusters of high versus low incidence of youth suicide.

METHODS

A cross-sectional analysis of spatial suicide clusters in young Australians (aged 10-25) from 2016 to 2020 was conducted using the scan statistic and suicide data from the National Coronial Information System. Mental health workforce was extracted from the 2020 National Health Workforce Dataset by local government areas. The Geographic Index of Relative Supply was used to estimate low and moderate-to-high mental health workforce supply for clusters characterised by a high and low incidence of suicide (termed suicide hotspots and coldspots, respectively). Univariate and multivariate logistic regression was used to determine the association between suicide clusters and a range of sociodemographic characteristics including mental health workforce supply.

RESULTS

Eight suicide hotspots and two suicide coldspots were identified. The multivariate analysis showed low mental health workforce supply was associated with increased odds of being involved in a suicide hotspot (adjusted odds ratio = 8.29; 95% confidence interval = 5.20-13.60), followed by residential remoteness (adjusted odds ratio = 2.85; 95% confidence interval = 1.68-4.89), and illicit drug consumption (adjusted odds ratio = 1.97; 1.24-3.11). Both coldspot clusters occurred in areas with moderate-to-high mental health workforce supply.

CONCLUSION

Findings highlight the potential risk and protective roles that mental health workforce supply may play in the spatial distributions of youth suicide clusters. These findings have important implications for the provision of postvention and the prevention of suicide clusters.

Trauma-informed prevention programmes for depression, anxiety, and substance use among young people: protocol for a mixed-methods systematic review

BACKGROUND

Mental ill-health and substance use bear a substantial burden and harm on young people and often arise from co-occurring and compounding risk factors, such as traumatic stress. Trauma-informed prevention of mental ill-health and substance use demonstrates significant promise in reducing this burden. A systematic literature review is required to identify and summarise the effectiveness, feasibility, acceptability, and design principles underpinning existing trauma-informed mental ill-health and/or substance use prevention programmes for young people aged 12-24 years.

METHODS

MEDLINE, Embase, CINAHL, PsychINFO, and Cochrane Library will be searched from 2012 through September 2022. Reference lists of included articles will be citation-chained. Title and abstracts will be screened and two reviewers will review articles full-text. One reviewer will extract data from eligible articles using a piloted data extraction form, and 20% of the data will be verified by a second reviewer. Risk of bias will be assessed using the Cochrane risk-of-bias tool for randomised trials (RoB 2), Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I), and The Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies and The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research (CASP), depending on the study type. Characteristics of existing trauma-informed mental ill-health and/or substance use prevention programmes for young people will be summarised narratively. Effectiveness, feasibility, and acceptability will be qualitatively described and summarised, with proportions and effect sizes quantitatively synthesised, where possible.

DISCUSSION

Trauma-informed approaches to prevention demonstrate significant promise, yet to date, no study has systematically summarised and synthesised the available literature. To fill this gap, the present review will systematically identify and summarise the effectiveness, feasibility, acceptability, and design principles underpinning existing trauma-informed mental health and/or substance use prevention programmes for young people aged 12-24. This review will inform the development, adaptation, evaluation, and implementation of future trauma-informed mental ill-health and substance use prevention programmes for young people. Findings will inform critical efforts to interrupt and prevent already elevated trajectories of mental ill-health, substance use, and related harms among those young people exposed to adversity.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022353883.

Web-Based Self-Compassion Training to Improve the Well-Being of Youth With Chronic Medical Conditions: Randomized Controlled Trial

BACKGROUND

Up to one-third of young people live with chronic physical conditions (eg, diabetes, asthma, and autoimmune disease) that frequently involve recurrent pain, fatigue, activity limitations, stigma, and isolation. These issues may be exacerbated as young people transition through adolescence. Accordingly, young people with chronic illness are at a high risk of psychological distress. Accessible, evidence-based interventions for young people with chronic illnesses are urgently needed to improve well-being, support adaptation, and enhance daily functioning. Self-compassion, which is an adaptive means of relating to oneself during times of difficulty, is a promising intervention target for this population.

OBJECTIVE

This study aims to test the efficacy of a 4-week, self-guided, web-based self-compassion training program for improving well-being among young Australians (aged 16-25 years) living with a chronic medical condition. The primary outcomes were self-compassion, emotion regulation difficulties, and coping; the secondary outcomes were well-being, distress, and quality of life. We also sought to test whether changes in primary outcomes mediated changes in secondary outcomes and gather feedback about the strengths and limitations of the program.

METHODS

We conducted a single-blind, parallel-group, randomized controlled trial comparing a 4-week, fully automated, web-based self-compassion training program with a waitlist control. Participants were recruited via the internet, and outcomes were self-assessed at 4 (T1) and 12 weeks (T2) after the baseline time point via a web-based survey. A mixed methods approach was used to evaluate the program feedback.

RESULTS

Overall, 151 patients (age: mean 21.15, SD 2.77 years; female patients: n=132, 87.4%) were randomized to the intervention (n=76, 50.3%) and control (n=75, 49.7%) groups. The loss-to-follow-up rate was 47.4%, and program use statistics indicated that only 29% (22/76) of young people in the experimental group completed 100% of the program. The main reported barrier to completion was a lack of time. As anticipated, treatment effects were observed for self-compassion (P=.01; partial η2=0.05; small effect); well-being (P≤.001; partial η2=0.07; medium effect); and distress (P=.003; partial η2=0.054; small-medium effect) at the posttest time point and maintained at follow-up. Contrary to our hypotheses, no intervention effects were observed for emotion regulation difficulties or maladaptive coping strategies. Improvements in adaptive coping were observed at the posttest time point but were not maintained at follow-up. Self-compassion, but not emotion regulation difficulties or coping, mediated the improvements in well-being.

CONCLUSIONS

Minimal-contact, web-based self-compassion training can confer mental health benefits on young people with chronic conditions. This group experiences substantial challenges to participation in mental health supports, and program engagement and retention in this trial were suboptimal. Future work should focus on refining the program content, engagement, and delivery to optimize engagement and treatment outcomes for the target group.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry 12619000572167; https://tinyurl.com/5n6hevt.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-020-8226-7.

Moderated Online Social Therapy for Carers of Early Psychosis Clients in Real-World Settings: Cluster Randomized Controlled Trial

BACKGROUND

Family carers of youth recovering from early psychosis experience significant stress; however, access to effective family interventions is poor. Digital interventions provide a promising solution.

OBJECTIVE

Our objective was to evaluate across multiple Australian early psychosis services the effectiveness of a novel, web-based early psychosis intervention for carers.

METHODS

In this cluster randomized controlled trial conducted across multiple Australian early psychosis services, our digital moderated online social therapy for carers (Altitudes) plus enhanced family treatment as usual (TAU) was compared with TAU alone on the primary outcome of perceived stress and secondary outcomes including mental health symptoms and family variables at the 6-month follow-up.

RESULTS

Eighty-six caregivers were randomized and data were available for 74 young people in their care. Our primary hypothesis that carers randomized to Altitudes+TAU would report greater improvements in perceived stress at follow-up compared with carers randomized to TAU alone was not supported, with the TAU alone group showing more improvement. For secondary outcomes, the TAU alone group showed improved mindfulness over time. Regardless of group assignment, we observed improvements in satisfaction with life, quality of life, emotional overinvolvement, and burden of care. In contrast, hair cortisol concentration increased. Post hoc analyses revealed more contact with early psychosis services in the intervention group compared to TAU alone and that improvements in perceived stress and social support were associated with use of the intervention in the Altitudes+TAU group. In this study, 80% (12/15) reported a positive experience with Altitudes and 93% (14/15) would recommend it to others.

CONCLUSIONS

Our trial did not show a treatment effect for Altitudes in perceived stress. However, our post hoc analysis indicated that the amount of use of Altitudes related to improvements in stress and social support. Additional design work is indicated to continue users' engagement and to significantly improve outcomes in problem-solving, communication, and self-care.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12617000942358; https://trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12617000942358.

The Future Proofing Study: Design, methods and baseline characteristics of a prospective cohort study of the mental health of Australian adolescents

OBJECTIVES

The Future Proofing Study (FPS) was established to examine factors associated with the onset and course of mental health conditions during adolescence. This paper describes the design, methods, and baseline characteristics of the FPS cohort.

METHODS

The FPS is an Australian school-based prospective cohort study with an embedded cluster-randomized controlled trial examining the effects of digital prevention programs on mental health. Data sources include self-report questionnaires, cognitive functioning, linkage to health and education records, and smartphone sensor data. Participants are assessed annually for 5 years.

RESULTS

The baseline cohort (N = 6388, M = 13.9 years) is broadly representative of the Australian adolescent population. The clinical profile of participants is comparable to other population estimates. Overall, 15.1% of the cohort met the clinical threshold for depression, 18.6% for anxiety, 31.6% for psychological distress, and 4.9% for suicidal ideation. These rates were significantly higher in adolescents who identified as female, gender diverse, sexuality diverse, or Aboriginal and/or Torres Strait Islander (all ps < 0.05).

CONCLUSIONS

This paper provides current and comprehensive data about the status of adolescent mental health in Australia. The FPS cohort is expected to provide significant insights into the risk, protective, and mediating factors associated with development of mental health conditions during adolescence.

Evidence that infant and early childhood developmental impairments are associated with hallucinatory experiences: results from a large, population-based cohort study

BACKGROUND

Cognitive and motor dysfunction are hallmark features of the psychosis continuum, and have been detected during late childhood and adolescence in youth who report psychotic experiences (PE). However, previous investigations have not explored infancy and early childhood development. It remains unclear whether such deficits emerge much earlier in life, and whether they are associated with psychotic, specifically hallucinatory, experiences (HE).

METHODS

This study included data from Gen2 participants of The Raine Study (n = 1101), a population-based longitudinal cohort study in Western Australia. Five areas of childhood development comprising: communication; fine motor; gross motor; adaptive (problem-solving); and personal-social skills, were assessed serially at ages 1, 2 and 3 years. Information on HE, depression and anxiety at ages 10, 14 and 17 years was obtained. HE were further subdivided into those with transient or recurrent experiences. Mixed effects logistic regression models and cumulative risk analyses based on multiple domain delays were performed.

RESULTS

Early poorer development in multiple areas was noted from ages 1, 2 and 3 years among youth who reported HE. Early developmental delays significantly increased the risk for later HE. This association was particularly marked in the recurrent HE group, with over 40% having early developmental delays in multiple domains. There was no significant association between early childhood development and later anxiety/depression apart from lower gross motor scores at age 3.

CONCLUSIONS

The findings suggest that early pan-developmental deficits are associated with later HE, with the effect strongest for young people who report recurrent HE throughout childhood and adolescence.

Reach and perceived effectiveness of a community-led active outreach postvention intervention for people bereaved by suicide

Background

Postvention is a core component of suicide prevention strategies, internationally. However, the types of supports provided to people impacted by suicide vary widely. This study examines the perceived effectiveness of the Primary Care Navigator (PCN) model for people bereaved by suicide. The PCN model was implemented in response to a suicide cluster. It is an active outreach postvention intervention, initiated by police in response to a suspected suicide and links individuals to support in the immediate aftermath of their loss.

Methods

A retrospective cross-sectional mixed methods approach was used to (1) identify the reach of the PCN model, (2) describe the type of support provided to people bereaved by a suspected suicide and (3) identify the perceived effectiveness of the PCN model from the perspective of WA police, postvention stakeholders and individuals bereaved by suicide. Quantitative data was used to examine the characteristics of suicide in the region, the characteristics of people who received bereavement support, and the types of support that were provided. Interviews with police, postvention stakeholders, and people bereaved by a suspected suicide were conducted to identify the perceived effectiveness of the intervention.

Results

Between 1 January 2019 and 31 March 2021 there were 80 suspected suicides. Active outreach was provided to 347 bereaved individuals via the PCN model. Just under half of those who were offered outreach accepted further support (N = 164) in the form of suicide bereavement information (98%), mental health or clinical support (49.6%), specialized postvention counseling (38.4%), financial assistance (16%) and assistance with meals (16%), followed by housing assistance (14%) and referral to community services (11%). Police, stakeholders, and people with lived experience of a suspected suicide perceived the PCN model to be effective at connecting them to the community, linking people to support, and preventing suicide.

Conclusion

The results provide evidence supporting the perceived effectiveness of an active outreach approach to postvention that provides acute support to people bereaved by suicide. Findings highlight important practical areas of support such as providing referral pathways and information on grief and suicide loss in the immediate aftermath of a suicide loss.

Enhancing functional recovery for young people recovering from first episode psychosis via sport-based life skills training: outcomes of a feasibility and pilot study

Early intervention within First Episode Psychosis (FEP) recovery efforts support functional recovery in several ways, including increasing levels of (1) physical activity (2) life skills, and (3) social connectivity. Sport has been proposed as an ideal platform to target these three goals simultaneously. The primary aims were to assess the feasibility of utilising sport-based life skills within FEP recovery efforts and test intervention components. The secondary aim was to evaluate the potential recovery benefits. Seven young people (aged 15-25 years) with FEP participated in a six-week sport programme alongside their support workers (community and peer workers) from the service, including peer workers with a lived experience of psychosis. The programme consisted of various sporting activities, which were designed to promote physical activity, maximise social connectivity, and teach life-skills (e.g. motivation, emotional regulation, and goal-setting) that are relevant and transferrable to other contexts (e.g. school, employment, independent living). The support participants engaged with the programme at the same level as the young people, with the role of providing support and normalising/modelling engagement. The young and support participants provided feedback during and after the programme via questionnaires and interviews. Young participants self-reported physical activity levels, psychological needs, recovery dimensions, and life skills pre- and post- intervention using established psychometric tools. We used thematic analysis to analyse the qualitative data and compared this information with other data collected (e.g. attendance, feedback, quantitative measurements). The study culminated with a process evaluation. The results indicated that, despite challenges with engagement for young people with FEP, sport-based life skills programming may be a feasible and useful recovery outlet. In addition, the results highlighted specific intervention components that were useful to promote engagement and recovery benefits. This study serves as a critical foundation for future sport-based work within FEP recovery.

Working with Young People at Risk of Suicidal Behaviour and Self-Harm: A Qualitative Study of Australian General Practitioners' Perspectives

General Practitioners (GPs) play a crucial role in the identification and support of young people at risk of suicidal behaviour and self-harm; however, no studies have explored GPs' perspectives, approaches, challenges, and resource needs when working with this cohort in an Australian setting. This was a qualitative study where fifteen GPs (Mage = 45.25 years) from multiple clinics in Western Australia took part in semi-structured interviews, and data were analysed thematically. Seven main themes were identified: (1) working with young people has its unique challenges; (2) screening and assessment tools can help to manage uncertainty and discomfort; (3) going beyond tools-the dialogue and relationship are most important; (4) there are limits to what we can offer in the time available; (5) the service access and referral pathways lack clarity and coordination; (6) the provision of mental health support should not fall on GPs alone; and (7) more comprehensive training in suicide and self-harm is needed. The findings highlight a number of opportunities to enhance care and better assist GPs working with young people who present with suicidal behaviour and self-harm, including considerations for conducting assessments, targeted resources such as training, and system and service improvements.

Computerized cognitive behavioural therapy for gender minority adolescents: Analysis of the real-world implementation of SPARX in New Zealand

OBJECTIVE

SPARX is a form of computerized cognitive behavioural therapy in serious game format funded via the Ministry of Health to be freely available in New Zealand. At registration users identify themselves as male, female, transgender or intersex. We aimed to establish whether adolescent transgender users of SPARX, compared to adolescent male and female users, were more likely to have high mental health needs at baseline and were more likely to complete SPARX. We also sought to determine changes in transgender adolescents' depressive symptoms after using SPARX.

METHODS

Quantitative analysis of 5 years of usage data from the nation-wide delivery of SPARX in New Zealand.

RESULTS

There were 9079 adolescents who completed the registration process and used SPARX, 2.3% (n = 207) identified as transgender. The majority of transgender registrants (69.0%) completing a baseline Patient Health Questionnaire - modified for Adolescents were categorized as having high mental health needs, significantly more so than male and female registrants (p < 0.001). Over half of all SPARX registrants completed the first module of the program, with subsequently lower proportions of transgender registrants completing Module 4 (p = 0.005) and Module 7 (i.e. the last module, p = 0.048). Of those registrants completing a baseline and subsequent Patient Health Questionnaire - modified for Adolescents, both male (n = 247) and female (n = 630) registrants, on average, had improvements in their scores (2.68 and 3.15, respectively), whereas transgender registrants (n = 14) did not (-0.43) (p = 0.048).

CONCLUSION

This is the first study describing the impact of an e-therapy on transgender young people. The analysis of data from this free self-help intervention suggests that transgender adolescents seeking treatment for depression have particularly high mental health needs, and an existing well tested tool may be less effective for them than it is for others. Taken together the results appear to suggest targeted efforts may be required for transgender adolescents.

Intersex adolescents seeking help for their depression: the case study of SPARX in New Zealand

OBJECTIVE

SPARX is a computerized cognitive behavioral therapy self-help program for adolescent depression that is freely available in New Zealand. At registration, users identify themselves as either male, female, intersex, or transgender. We aimed to describe the mental health of adolescent intersex users.

METHOD

A secondary analysis of SPARX usage data over 5 years.

RESULTS

Of the 8922 adolescents users, 0.6% (n = 50) identified as intersex. Based on Patient Health Questionnaire 9 - modified for Adolescents (PHQ-A) results, 78.3% of intersex users had high levels of depression and/or self-harm and suicidal ideation. The mean PHQ-A scores for intersex users were significantly higher than for males and females (p < .001). As only three intersex users completed SPARX Level 4 or more (of the seven-level program), we were unable to meaningfully investigate any reductions in their depressive symptoms over time.

CONCLUSIONS

There is a dearth of empirical data on the mental health of intersex adolescents. These results suggest that intersex adolescents seeking help from an online resource have high mental health needs compared with other young people, possibly because they defer seeking help.

Group mindful self-compassion training to improve mental health outcomes for LGBTQIA+ young adults: Rationale and protocol for a randomised controlled trial

BACKGROUND

Young adults who are lesbian, gay, bisexual, trans, queer or questioning, intersex, asexual and other diverse genders and sexualities (LGBTQIA+) are more likely to experience mental health difficulties and are at significantly elevated risk of substance abuse, self-harm and suicide, relative to their heterosexual, endosex and cisgender peers. There is a need for effective mental health interventions for LGBTQIA+ young adults. Mindful Self-Compassion training is a promising approach; among LGBTQIA+ individuals, self-compassion accounts for more variation in mental health outcomes than bullying, victimization, and adverse childhood experiences combined. Furthermore, LGBTQIA+ individuals with high self-compassion report more positive identity and happiness, less self-stigma, and lower suicidality than those with low self-compassion.

METHOD

This paper outlines the rationale and protocol for a single-blind CONSORT-compliant randomised controlled trial, comparing group Mindful Self-Compassion to a delayed-treatment waitlist control group, for improving mental health, decreasing self-criticism and increasing self-compassion in LGBTQIA+ young adults (age 18-25 years). Mindful Self-Compassion training is an 8-week group program that focuses on cultivating self-compassion and mindfulness. While typically delivered as a face-to-face program, the proposed trial will investigate efficacy of the program when provided via videoconferencing.

DISCUSSION

Videoconference Mindful Self-Compassion training has the potential to improve the mental health of Australian LGBTQIA+ young adults and provide a possible cost-effective, scalable intervention for this population. The proposed trial will be the first to determine its efficacy for LGBTQIA+ young adults and will provide the first data on the delivery of the program via videoconferencing.

Effectiveness, Acceptability, and Feasibility of Digital Health Interventions for LGBTIQ+ Young People: Systematic Review

BACKGROUND

Young people (aged 12-25 years) with diverse sexuality, gender, or bodily characteristics, such as those who identify as lesbian, gay, bisexual, transgender, intersex, or queer (LGBTIQ+), are at substantially greater risk of a range of mental, physical, and sexual health difficulties compared with their peers. Digital health interventions have been identified as a potential way to reduce these health disparities.

OBJECTIVE

This review aims to summarize the characteristics of existing evidence-based digital health interventions for LGBTIQ+ young people and to describe the evidence for their effectiveness, acceptability, and feasibility.

METHODS

A systematic literature search was conducted using internet databases and gray literature sources, and the results were screened for inclusion. The included studies were synthesized qualitatively.

RESULTS

The search identified 38 studies of 24 unique interventions seeking to address mental, physical, or sexual health-related concerns in LGBTIQ+ young people. Substantially more evidence-based interventions existed for gay and bisexual men than for any other population group, and there were more interventions related to risk reduction of sexually transmitted infections than to any other health concern. There was some evidence for the effectiveness, feasibility, and acceptability of these interventions overall; however, the quality of evidence is often lacking.

CONCLUSIONS

There is sufficient evidence to suggest that targeted digital health interventions are an important focus for future research aimed at addressing health difficulties in LGBTIQ+ young people. Additional digital health interventions are needed for a wider range of health difficulties, particularly in terms of mental and physical health concerns, as well as more targeted interventions for same gender-attracted women, trans and gender-diverse people, and people with intersex variations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020128164; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=128164.

The Role of the Avatar in Gaming for Trans and Gender Diverse Young People

A significant proportion of trans and gender diverse (TGD) young people report membership of the gaming community and resultant benefits to wellbeing. To date their experiences and needs regarding a key feature of games, the avatar, are largely unexplored, despite increasing interest in the therapeutic role of avatars in the general population. The aim of this study was to better understand the role of the avatar in gaming, its impact on TGD young people’s mental health, and their unique needs regarding avatar design. N = 17 TGD young people aged 11–22 years (M = 16.3 years) participated in four focus groups. A general inductive approach was used to thematically analyze the transcribed data. TGD young people report considerable therapeutic benefits of using avatars with positive mental health implications. Importantly, TGD young people use avatars to explore, develop and rehearse their experienced gender identities, often as a precursor to coming out in the offline world. They also report negative experiences of feeling excluded due to the constraints of conventional notions of gender that are widely reflected in game design. Participants described simple design features to better reflect gender diversity, such as increased customization. Such changes would facilitate the positive gains reported by participants and better reflect the diversity of young people who use games. The findings have important implications for both recreational and serious or therapeutic game design.

Retrograde signaling by a mtDNA-encoded non-coding RNA preserves mitochondrial bioenergetics

Alveolar epithelial type II (AETII) cells are important for lung epithelium maintenance and function. We demonstrate that AETII cells from mouse lungs exposed to cigarette smoke (CS) increase the levels of the mitochondria-encoded non-coding RNA, mito-RNA-805, generated by the control region of the mitochondrial genome. The protective effects of mito-ncR-805 are associated with positive regulation of mitochondrial energy metabolism, and respiration. Levels of mito-ncR-805 do not relate to steady-state transcription or replication of the mitochondrial genome. Instead, CS-exposure causes the redistribution of mito-ncR-805 from mitochondria to the nucleus, which correlated with the increased expression of nuclear-encoded genes involved in mitochondrial function. These studies reveal an unrecognized mitochondria stress associated retrograde signaling, and put forward the idea that mito-ncRNA-805 represents a subtype of small non coding RNAs that are regulated in a tissue- or cell-type specific manner to protect cells under physiological stress.

Best practice when working with suicidal behaviour and self-harm in primary care: a qualitative exploration of young people's perspectives

OBJECTIVES

General practitioners (GPs) have a key role in supporting young people who present with suicidal behaviour/self-harm. However, little is known about young people's opinions and experiences related to GPs' practices for such presentations, and their decisions to disclose suicidal behaviour/self-harm to GPs. Additionally, existing guidelines for the management of suicide risk and/or self-harm have not incorporated young people's perspectives. This study aimed to explore young people's views and experiences related to the identification, assessment and care of suicidal behaviour and self-harm in primary care settings with GPs.

DESIGN, SETTING AND PARTICIPANTS

Two qualitative focus groups were conducted in Perth, Western Australia, with 10 young people in total (Mage = 20.67 years; range: 16-24). Data were collected using a semistructured, open-ended interview schedule and analysed using thematic analysis.

RESULTS

Five major themes were identified from the focus groups. (1) Young people wanted a collaborative dialogue with GPs, which included being asked about suicidal behaviour/self-harm, informed of treatment processes and having autonomy in decision making; (2) young people were concerned with a loss of privacy when disclosing suicidal behaviour/self-harm; (3) young people viewed labels and assessments as problematic and reductionist-disliking the terms 'risk' and 'risk assessment', and assessment approaches that are binary and non-holistic; (4) young people highlighted the importance of GPs' attitudes, with a genuine connection, attentiveness and a non-judgemental demeanour seen as paramount; and (5) young people wanted to be provided with practical support and resources, followed-up, and for GPs to be competent when working with suicidal behaviour/self-harm presentations.

CONCLUSIONS

Our study identified several concerns and recommendations young people have regarding the identification, assessment and care of suicidal behaviour/self-harm in primary care settings. Taken together, these findings may inform the development of resources for GPs, and support progress in youth-oriented best practice.

Parents' Experience and Psychoeducation Needs When Supporting a Young Person Who Self-Harms

BACKGROUND

Self-harm in young people can have a substantial negative impact on the well-being and functioning of parents and other carers. The "Coping with Self-Harm" booklet was originally developed in the UK as a resource for parents and carers of young people who self-harm, and an adaptation study of this resource was conducted in Australia. This paper presents qualitative analysis of interviews with parents about their experiences and psychoeducational needs when supporting a young person who engages in self harm.

METHODS

The qualitative study drew on semi-structured individual and group interviews with parents (n = 19 participants) of young people who self-harm. Data were analysed using Thematic Analysis.

RESULTS

The analysis identified six themes: (1) the discovery of self-harm, (2) challenges in the parent-young person relationship, (3) parents' need to understand self-harm, (4) parents' emotional reactions to self-harm, (5) the importance of self-care and help-seeking among parents, and (6) the need for psychoeducational resources.

CONCLUSION

The study highlights the need for support for parents and carers of young people who engage in self-harm, including development and adaptation of resources, such as the "Coping with Self-Harm" booklet, of which an Australian version has now been developed.

Online self-compassion training to improve the wellbeing of youth with chronic medical conditions: protocol for a randomised control trial

BACKGROUND

Chronic medical conditions (CMCs) affect up to 35% of children and adolescents. Youth with chronic medical conditions are at an increased risk of psychological distress and reduced health-related quality of life, and report rates of mental illness up to double that of their physically healthy peers. Accessible, evidence-based interventions for young people with chronic illness are urgently required to improve their mental health and daily functioning. Self-compassion involves taking a mindful, accepting approach to difficult experiences, being aware that one is not alone in one's suffering, and being kind and understanding with oneself during challenging times. Self-compassion shares strong associations with mental health outcomes among young people and preliminary work indicates that interventions that build self-compassion have the potential to substantially improve youth mental health. Self-compassion is also associated with better physical and mental health outcomes among individuals living with CMCs. While face-to-face self-compassion training is available, there are several barriers to access for youth with CMCs. Online self-compassion training potentially offers an accessible alternative for this high-risk group.

METHODS

Self-Compassion Online (SCO) is a self-compassion program that has been tested with a non-clinical adult group. For the proposed trial, a reference group of youth (16-25 years) with chronic illness reviewed the program and proposed adaptations to improve its suitability for youth with chronic illness. In alignment with the SPIRIT Checklist, this paper outlines the protocol for a CONSORT-compliant, single-blind randomised controlled trial to test the efficacy of the adapted program, relative to a waitlist control, for improving self-compassion, wellbeing, distress, emotion regulation, coping and quality of life among young Australians with CMCs. Mechanisms of action and feasibility of SCO will be analysed using quantitative data and participant interviews, respectively. Finally, cost-utility will be analysed using health-related quality of life data.

DISCUSSION

The SCO program could provide a scalable solution for improving psychological outcomes and quality of life among youth with chronic illness. The proposed trial will be the first to determine its efficacy for improving these outcomes, relative to waitlist control.

TRIAL REGISTRATION

The trial was registered on the Australian New Zealand Clinical Trials Registry on the 11th April 2019, ACTRN12619000572167. Protocol version: Version 2, 21 December 2019.

Trans and gender diverse young people's attitudes towards game-based digital mental health interventions: A qualitative investigation

BACKGROUND

Trans and gender diverse (TGD) young people are at high risk for mental health difficulties. Previous research has shown that three in four TGD young people have been diagnosed with an anxiety disorder and/or depression and almost one in two have attempted suicide. TGD young people experience barriers to traditional mental health services, commonly faced with inexperienced providers and discrimination. Video and computer games, as well as online spaces, are sources of resilience for TGD young people. Digital mental health interventions are a feasible, but understudied, approach to consider for this population.

METHODS

N = 14 TGD young people aged 11-18 years were recruited to take part in focus groups as part of a multistage project. The focus groups were transcribed verbatim and analysed using a general inductive thematic analysis approach. This paper reports on their attitudes towards digital games and game-based digital mental health interventions.

DISCUSSION

Aspects of game-based digital mental health interventions should be inclusive of diverse genders and sexuality, moderated appropriately and include content such as storylines and characters who are of diverse sexualities and/or gender. Participants were of the opinion that games should be preventative rather than treatment-focused; however, considering the high rate of mental health difficulties in this population, interventions should ideally address symptoms along the continuum from sub-clinical to clinical.

Decision analysis supports the use of drain amylase-based enhanced recovery method after esophagectomy

Postesophagectomy anastomotic leak is a common postsurgical complication. The current standard method of detecting leak is esophagram usually late in the postoperative period. Perianastomotic drain amylase level had shown promising results in early detection anastomosis leak. Previous studies have shown that postoperative day 4 amylase level is more specific and sensitive than esophagram. The purpose of this study is to determine if implementing a drain amylase-based screening method for anastomotic leak can reduce length of stay and hospital cost relative to a traditional esophagram-based pathway. The drain amylase protocol we propose uses postoperative day 4 drain amylase level to direct the initiation of PO intake and discharge. We designed a decision analysis tree using TreeAge Pro software to compare the drain amylase-based screening method to the standard of care, the esophagram. We performed a retrospective review of postesophagectomy patients from a tertiary academic medical center (University hospital Cleveland medical center) where amylase level was measured routinely postoperatively. The patients were separated into amylase-based pathway group and the standard of care group based on their postop management. The length of stay, costs, complications, and leak rate of these two groups were used to inform the decision analysis tree. In the base-case analysis, the decision analysis demonstrated that an amylase-based screening method can reduce the hospital stay by one day and reduced costs by ∼$3,000 compared to esophagram group. To take the variability of the data into consideration, we performed a Monte Carlo simulation. The result showed again a median saving of 0.71 days and ∼$2,500 per patient in hospital cost. A ballistic sensitivity analysis was performed to show that the sensitivity of postoperative day 4 amylase level in detecting a leak was the most important factor in the model. We conclude that implementing an amylase-based screening method for anastomotic leak in postesophagectomy patient can significantly reduce hospital cost and length of stay. This study demonstrates a novel protocol to improve postesophagectomy care. Based on this result, we believe a prospective multicenter study is appropriate.

Adolescents' Perspectives on a Mobile App for Relationships: Cross-Sectional Survey

Background

Adolescence can be a fertile time for relationship issues, with interpersonal conflict being a risk factor for poor mental health. Mobile app interventions may have a significant appeal to young people in assisting with relationship distress. However, currently available apps have not been formally evaluated. Youths’ perspectives on engaging with mobile technology to assist with relationships are also unknown.

Objective

This study aimed to examine adolescents’ attitudes toward the concept of a mobile phone app for relationship help and support, and whether they would be likely to use such an intervention.

Methods

A cross-sectional Web survey consisting of 42 questions, including 13 free responses, was delivered. The proposed app, including character vignettes, was presented, and participants were asked to indicate whether they had experienced the same relationship issues, whether their peers would relate to the issues, and how helpful they found the proposed advice. Participants were also asked to provide their own suggestions for help, which were analyzed using thematic analyses.

Results

A total of 150 adolescents (aged 15 to 18) participated. Overall, 60.7% (91/150) were likely to use an app for relationship problems, and this was not associated with demographics or social support (all P values >.05). Likelihood of app usage was found to be influenced by perceived need for help, personal beliefs about app effectiveness, and whether the app is engaging and easy to use. Overall, adolescents were receptive of the proposed content with an average of 99.3% (149/150), rating the strategies provided as somewhat to very helpful.

Conclusions

Adolescents were likely to use a mobile phone app for relationship support, and use was not influenced by gender, age, social support, or any other background characteristic. Instead, likely use was influenced by need, personal beliefs, usability, and the appropriateness of app content. App developers must address these factors if the app is to have a wide-scale uptake.

Preventing Depression in Final Year Secondary Students: School-Based Randomized Controlled Trial

Background

Depression often emerges for the first time during adolescence. There is accumulating evidence that universal depression prevention programs may have the capacity to reduce the impact of depression when delivered in the school environment.

Objective

This trial investigated the effectiveness of SPARX-R, a gamified online cognitive behavior therapy intervention for the prevention of depression relative to an attention-matched control intervention delivered to students prior to facing a significant stressor—final secondary school exams. It was hypothesized that delivering a prevention intervention in advance of a stressor would reduce depressive symptoms relative to the control group.

Methods

A cluster randomized controlled trial was conducted in 10 government schools in Sydney, Australia. Participants were 540 final year secondary students (mean 16.7 [SD 0.51] years), and clusters at the school level were randomly allocated to SPARX-R or the control intervention. Interventions were delivered weekly in 7 modules, each taking approximately 20 to 30 minutes to complete. The primary outcome was symptoms of depression as measured by the Major Depression Inventory. Intention-to-treat analyses were performed.

Results

Compared to controls, participants in the SPARX-R condition (n=242) showed significantly reduced depression symptoms relative to the control (n=298) at post-intervention (Cohen d=0.29) and 6 months post-baseline (d=0.21) but not at 18 months post-baseline (d=0.33).

Conclusions

This is the first trial to demonstrate a preventive effect on depressive symptoms prior to a significant and universal stressor in adolescents. It demonstrates that an online intervention delivered in advance of a stressful experience can reduce the impact of such an event on the potential development or exacerbation of depression.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12614000316606; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365986 (Archived by WebCite at http://www.webcitation.org/ 6u7ou1aI9)

Web-Based and Mobile Suicide Prevention Interventions for Young People: A Systematic Review

OBJECTIVE

Suicide is a significant public health issue, and is especially concerning in adolescents and young adults, who are over-represented both in attempts and completed suicide. Emerging technologies represent a promising new approach to deliver suicide prevention interventions to these populations. The current systematic review aims to identify online and mobile psychosocial suicide prevention interventions for young people, and evaluate the effectiveness of these interventions.

METHOD

PsycINFO, Medline, Embase and The Cochrane Library were electronically searched for all articles published between January, 2000 and May, 2015. Peer-reviewed journal articles reporting on interventions for young people aged 12-25 years with suicidality as a primary outcome were eligible for inclusion. No exclusions were placed on study design.

RESULTS

One study met inclusion criteria, and found significant reductions in the primary outcome of suicidal ideation, as well as depression and hopelessness. Two relevant protocol papers of studies currently underway were also identified.

CONCLUSIONS

There is a paucity of current evidence for online and mobile interventions for suicide prevention in youth. More high quality empirical evidence is required to determine the effectiveness of these novel approaches to improving suicide outcomes in young people.

An Australian Example of Translating Psychological Research into Practice and Policy: Where We are and Where We Need to Go

Research findings from psychological science have identified interventions that will benefit human health. However, these findings are not often incorporated into practice-based settings or used to inform policy, in part, due to methodological and contextual limitations. A strategic approach is required if we are to find a way to facilitate the translation of these findings into areas that will offer genuine impact on health. There is an overwhelming focus on conducting more clinical trials, without consideration of how to ensure that findings from such trials make it to the patients or populations for whom they were intended. The aim of this paper is to outline how the Black Dog Institute, an Australian medical research institute, has created a framework designed to facilitate the translation of research findings into practice-based community settings, and how these findings can be used to inform policy. We propose that the core strategies adopted at the Black Dog Institute to prioritize and implement a translational program will be useful to institutes and organizations worldwide to augment the impact of their work. We provide several examples of how our research has been implemented in practice-based settings at a community-level, and how we have used research in psychology as a platform to inform policy change.

Trial for the Prevention of Depression (TriPoD) in final-year secondary students: study protocol for a cluster randomised controlled trial

BACKGROUND

Evidence suggests that current treatments cannot fully alleviate the burden of disease associated with depression but that prevention approaches offer a promising opportunity to further reduce this burden. Adolescence is a critical period in the development of mental illness, and final school examinations are a significant and nearly universal stressor that may act as a trigger for mental health difficulties such as depression. The aim of the present trial is to investigate the impact of SPARX-R, an online, gamified intervention based on cognitive behavioural principles, on the prevention of depression in secondary school students before their final examinations.

METHODS/DESIGN

Government, independent and Catholic secondary schools in New South Wales, Australia, will be recruited to participate in the trial. All students enrolled in their final year of high school (year 12) in participating schools will be invited to participate. To account for possible attrition, the target sample size was set at 1600 participants across 30 schools. Participating schools will be cluster randomised at the school level to receive either SPARX-R or lifeSTYLE, an attention-controlled placebo comparator. The control intervention is an online program aimed at maintaining a healthy lifestyle. The primary outcome will be symptoms of depression, and secondary outcomes will include symptoms of anxiety, suicidal ideation and behaviours, stigma and academic performance. Additional measures of cost-effectiveness, as well as process variables (e.g., adherence, acceptability) and potential predictors of response to treatment, will be collected. Consenting parents will be invited to complete measures regarding their own mental health and expectations for their child. Assessments will be conducted pre- and post-intervention and at 6- and 18-month follow-up. Primary analyses will compare changes in levels of depressive symptomatology for the intervention group relative to the attention control condition using mixed-effects model repeated-measures analyses to account for clustering within schools.

DISCUSSION

This is the first trial of a universal depression prevention intervention delivered to school students in advance of a specific, significant stressor. If found to be effective, this program may offer schools a new approach to preparing students for their final year of schooling.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry identifier: ACTRN12614000316606 . Registered 25 March 2014.

The development and implementation of a pilot CBT for early psychosis service: achievements and challenges

AIM

Cognitive behaviour therapy (CBT) is a clinically indicated treatment for first-episode psychosis. Despite this, CBT for early psychosis is not routinely available as part of standard mental health services in Australia. The aim of this pilot project was to develop a CBT for early psychosis service to be provided as an adjunct to existing community mental health services. This study examined the feasibility of this service model, delivered in a real-world setting. A secondary aim was to explore the effectiveness of this service, as measured by clinical and functional outcomes.

METHODS

Participants living in northern Sydney, Australia, and who had recently experienced a first episode of psychosis, were offered up to 20 sessions of individual CBT. Service feasibility was measured via attrition rates, therapy attendance and referrer feedback. Measures of psychosis, depression, anxiety and psychosocial functioning, were assessed pretreatment, after six and 12 sessions, and at 3 months post-treatment.

RESULTS

Nineteen clients attended treatment to completion. Survey feedback from referrers affirmed the positive impact of the service on clients' recovery. Additionally, clients showed improvements in symptoms of psychosis over the first three time points. Psychosocial functioning also shifted from the moderately to mildly impaired range by the end of treatment.

CONCLUSIONS

The CBT for early psychosis service has been successfully integrated into the mental health landscape of northern Sydney. Outcomes of this pilot project are discussed with reference to the achievements of the service, as well as the obstacles encountered, and how they were overcome.

Regulation of negative affect in schizophrenia: the effectiveness of acceptance versus reappraisal and suppression

Although general emotion coping difficulties are well documented in schizophrenia, there has been limited study of specific regulatory strategies such as suppression, reappraisal, and acceptance. In the present study, clinical and control participants were asked to watch video clips selected to elicit negative affect while engaging in one of these three different emotion regulation strategies (counterbalanced), versus a passive viewing condition. The experiential and expressive components of emotion were quantified using self-report and facial electromyography, respectively. A major finding was that, in contrast to control participants, individuals with schizophrenia did not report a greater willingness to reexperience negative emotion after engaging in acceptance. These data are discussed in the context of evidence highlighting the potentially important role of acceptance in understanding affective abnormalities in clinical conditions such as schizophrenia.

The habitual use of emotion regulation strategies in schizophrenia

OBJECTIVES. Although emotion dysregulation is regarded as a core feature of schizophrenia, the use of specific regulatory strategies remains poorly understood. The aim of this study, therefore, was to investigate the habitual use of suppression, reappraisal, and acceptance in this population. METHODS. Thirty-three individuals with schizophrenia and 36 matched controls completed self-report measures examining emotion regulation and psychosocial functioning. RESULTS. No group differences were found in terms of use of suppression or reappraisal, but clinical participants reported using less acceptance. Further, greater use of acceptance was associated with better psychosocial outcomes. CONCLUSIONS. Results highlight the potential utility of acceptance-based interventions for comorbid psychopathology in schizophrenia.

The influence of growth hormone replacement on peripheral inflammatory and cardiovascular risk markers in adults with severe growth hormone deficiency

BACKGROUND

Adult GHD syndrome is associated with clustering of adverse cardiovascular (CV) risk factors such as abnormal body composition, dyslipidemia, insulin resistance and abnormal haemostatic factors. There is a wealth of evidence linking CV events with elevated levels of inflammatory markers (hs-CRP and IL-6) in the general population; however data on their abnormalities in GHD and specially the effects of GH replacement (GHR) on these inflammatory markers are limited.

OBJECTIVE

To study the effects of GHR on inflammatory markers, glucose homeostasis and body composition in a cohort of adults with recently diagnosed severe GHD due to hypothalamic pituitary disease.

DESIGN

Fifteen hypopituitary adults (11 males, mean age 48.5 years) with recently diagnosed, severe GHD were recruited. Patients received GHR (in addition to other pituitary hormone replacements) titrated to clinical response and to normalize age and gender adjusted IGF-1 levels. Weight, waist hip ratio (WHR), body composition, fasting plasma glucose and insulin, insulin resistance index (HOMA-IR), fasting serum lipid levels, hs-CRP, IL-6 and TNF-alpha were measured at baseline and following a minimum 6 months of stable maintenance GHR.

RESULTS

GHR resulted in a physiological increase in IGF-1 SDS [median -0.6 to +0.39, P<0.0001], improved quality of life (mean pre-treatment AGHDA score 16 vs. post-treatment score 7, P<0.0001) and reduction in WHR (0.94 vs. 0.92, P=0.01). There were no significant changes in body weight and composition. Levels of hs-CRP (log transformed, mean (SD)) were significantly reduced following GHR (pre 1.21 (0.9) vs. post 0.27 (0.9), P<0.0001) but TNF-alpha and IL-6 levels remained unchanged. Fasting glucose (mmol/L) [4.6 (0.1) vs. 5.1 (0.1), P=0.003], fasting insulin (muU/mL) [9.4 (8.1) vs. 12.1 (9.2), P=0.03] and HOMA-IR [1.2 (1.0) vs. 1.5 (1.1) P=0.02] (all pre-GHR vs. post-GHR and mean (SD)) significantly increased following GHR indicating increased insulin resistance. Significant improvements were noted in fasting LDL-cholesterol (LDL-C) and HDL-cholesterol (HDL-C) levels following GHR [3.4 (0.9) vs. 2.9 (0.7), P=0.03 and 1.2 (0.2) vs. 1.3 (0.2), P=0.02, respectively] (all pre-GHR vs. post-GHR and mean (SD)). Levels of total cholesterol and triglycerides did not change following GHR.

CONCLUSIONS

Physiological GHR for at least 6 months in hypopituitary adults with recently diagnosed severe GHD resulted in favourable changes in hs-CRP, WHR, fasting LDL-C and HDL-C levels all of which are recognised CV risk markers. However, there remains a high prevalence of obesity in this population and given the worsening of insulin sensitivity in the short term with GHR, monitoring and aggressive treatment of established CV risk factors is essential to reduce premature atherosclerotic CVD in this patient population.

Attention to the eyes and fear-recognition deficits in child psychopathy

The ability to recognise fear is impaired in people with damage to the amygdala and, interestingly, in adult psychopathy. Here we confirm that deficits in recognising fear exist in children with psychopathic traits. We show for the first time that, as with patients with amygdala damage, this deficit can be temporarily corrected by simply asking them to focus on the eyes of other people. These data support models of psychopathy that emphasise specific dysfunction of the amygdala and suggest an innovative approach for intervening early in the development of psychopathy.

Outcomes of minimally invasive esophagectomy (MIE) for high-grade dysplasia of the esophagus

OBJECTIVE

The management of high-grade dysplasia (HGD) of the esophagus is controversial with some clinicians advocating non-operative ablation or surveillance. Minimally invasive esophagectomy (MIE) allows re-section of the esophagus and may minimize morbidity. This report summarizes our experience with MIE for HGD.

METHODS

A retrospective review of 28 patients who underwent MIE for a pre-operative diagnosis of HGD. MIE initially involved a laparoscopic transhiatal approach (n=1), but subsequently evolved to laparoscopy with VATS mobilization (n=27) of the esophagus.

RESULTS

From August 1996 to March 2001, 28 patients underwent MIE. There were 23 males and five females; median age was 61 (40-78) years. Median hospital stay was 5 (3-20) days and ICU stay was 1 (1-20) day. One patient required conversion to laparotomy because of dense adhesions. There were ten other patients who had successful MIE despite prior laparotomy. Median operating time was 8 (5.8-13) h. One death occurred from sepsis, pneumonia and multi-system organ failure. Complications occurred in 15 patients. In addition to the patient who died, five re-operations were required for: small bowel perforation (n=1), jejunostomy leak (n=1), pyloric dilation for gastric outlet obstruction (n=1), cholecystectomy (n=1), incision and drainage of an abdominal abscess (n=1). Final pathologies were HGD (n=17), in situ cancer (n=6) and invasive cancer (n=5). At a median follow-up of 13 (2-41) months all hospital survivors are alive and free of disease.

CONCLUSIONS

This report confirms the risk of occult cancer in patients with HGD (39% in this series) supporting the recommendation for esophagectomy. MIE can be performed with acceptable results and may minimize morbidity compared to previous reports of open esophagectomy for HGD.

Laparoscopic cholecystectomy: what does affect the outcome? A retrospective multifactorial regression analysis

BACKGROUND

The association between various factors and the postoperative outcome has not been thoroughly studied in laparoscopic cholecystectomy (LC). The aim of this retrospective study was to determine which factors significantly affect patients outcome after LC.

METHODS

The medical and operative records of all consecutive patients who underwent LC at our institution from 1991 to 1996 were reviewed. The effect of age, medical and surgical history, duration of procedure, and setup (urgent or elective) on the postoperative complication rate and on the length of postoperative hospital stay (LOS) were analyzed using multiple linear regression and logistic regression analysis. Overall, 601 patients were included in the study.

RESULTS

The factors that significantly prolonged LOS were age (p = 0.0145), acute cholecystitis (p = 0.0006), history of ischemic heart disease (p = 0.0332), and duration of procedure (p < 0.0001). A significantly higher postoperative morbidity rate was noted in patients who had a procedure longer then 2 h than in patients whose surgery required less the 2 h (13.6% vs 3.6%, respectively; p < 0.0001). Similarly, higher morbidity was noted in elderly patients than in younger patients (16% vs 6.1%; p = 0.0005). Other factors that significantly increased postoperative morbidity included acute cholecystitis (p = 0.023), a history of cholangitis (p = 0.018), and diabetes (p = 0.05).

CONCLUSIONS

According to this study, advanced age, longer duration of procedure, and acute cholecystitis significantly increase both the postoperative morbidity and the LOS. History of ischemic heart disease significantly increases LOS, but does not increase morbidity after LC.