The Health4Life e-health intervention for modifying lifestyle risk behaviours of adolescents: secondary outcomes of a cluster randomised controlled trial

OBJECTIVES

To investigate the effectiveness of a school-based multiple health behaviour change e-health intervention for modifying risk factors for chronic disease (secondary outcomes).

STUDY DESIGN

Cluster randomised controlled trial.

SETTING, PARTICIPANTS

Students (at baseline [2019]: year 7, 11-14 years old) at 71 Australian public, independent, and Catholic schools.

INTERVENTION

Health4Life: an e-health school-based multiple health behaviour change intervention for reducing increases in the six major behavioural risk factors for chronic disease: physical inactivity, poor diet, excessive recreational screen time, poor sleep, and use of alcohol and tobacco. It comprises six online video modules during health education class and a smartphone app.

MAIN OUTCOME MEASURES

Comparison of Health4Life and usual health education with respect to their impact on changes in twelve secondary outcomes related to the six behavioural risk factors, assessed in surveys at baseline, immediately after the intervention, and 12 and 24 months after the intervention: binge drinking, discretionary food consumption risk, inadequate fruit and vegetable intake, difficulty falling asleep, and light physical activity frequency (categorical); tobacco smoking frequency, alcohol drinking frequency, alcohol-related harm, daytime sleepiness, and time spent watching television and using electronic devices (continuous).

RESULTS

A total of 6640 year 7 students completed the baseline survey (Health4Life: 3610; control: 3030); 6454 (97.2%) completed at least one follow-up survey, 5698 (85.8%) two or more follow-up surveys. Health4Life was not statistically more effective than usual school health education for influencing changes in any of the twelve outcomes over 24 months; for example: fruit intake inadequate: odds ratio [OR], 1.08 (95% confidence interval [CI], 0.57-2.05); vegetable intake inadequate: OR, 0.97 (95% CI, 0.64-1.47); increased light physical activity: OR, 1.00 (95% CI, 0.72-1.38); tobacco use frequency: relative difference, 0.03 (95% CI, -0.58 to 0.64) days per 30 days; alcohol use frequency: relative difference, -0.34 (95% CI, -1.16 to 0.49) days per 30 days; device use time: relative difference, -0.07 (95% CI, -0.29 to 0.16) hours per day.

CONCLUSIONS

Health4Life was not more effective than usual school year 7 health education for modifying adolescent risk factors for chronic disease. Future e-health multiple health behaviour change intervention research should examine the timing and length of the intervention, as well as increasing the number of engagement strategies (eg, goal setting) during the intervention.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12619000431123 (prospective).

Is low-level alcohol consumption really health-protective? A critical review of approaches to promote causal inference and recent applications

Heavy and disordered alcohol consumption is a known risk factor for several health conditions and is associated with considerable disease burden. However, at low-to-moderate levels, evidence suggests that drinking is associated with reduced risk for certain health outcomes. Whether these findings represent genuine protective effects or mere methodological artifacts remains unclear, but has substantial consequences for policy and practice. This critical review introduces methodological advances capable of enhancing causal inference from observational research, focusing on the 'G-methods' and Mendelian Randomization. We also present and evaluate recent research applying these methods and compare findings to the existing evidence base. Future directions are proposed for improving our causal understanding of the relationships between alcohol and long-term health outcomes.

Dynamic Associations Between Anxiety Symptoms and Drinking Behavior From Early Adolescence to Young Adulthood

PURPOSE

Research is inconclusive with respect to the possible risk-increasing effect of anxiety symptoms on heavy drinking behavior among adolescents and young adults. Adult role transitions and changes in the social context from early adolescence into young adulthood may impact the association between anxiety symptoms and alcohol use.

METHODS

The TRacking Adolescents' Individual Lives Survey, including 2,229 individuals at baseline, was used to evaluate the bi-directional and longitudinal associations between anxiety symptoms and alcohol use, using data at 14, 16, 19, 22, and 25 years of age.

RESULTS

Cross-lagged models revealed a relatively stable negative association at 14, 16, and 19 years, showing that relatively higher anxiety symptoms were associated with relatively lower drinking levels three years later. This effect was absent in young adulthood. There was no evidence for significant associations between alcohol use and subsequent anxiety symptoms, with the exception of alcohol use at age 19, which predicted relatively lower levels of anxiety symptoms at age 22.

DISCUSSION

Overall, the results indicated that anxiety symptoms may withhold adolescents from (heavy) drinking, although this protective effect disappeared in young adulthood. Transitions in social contexts as well as autonomy and adult responsibilities could underlie the changing association between alcohol use and anxiety symptoms throughout adolescence and young adulthood.

Age at first drink and its influence on alcohol use behaviours in young adulthood: Evidence from an Australian household-based panel study

BACKGROUND

Public health guidelines recommend delaying the initiation age for alcohol. However, the causal link between age-at-first-drink (AFD) and future alcohol use in young adulthood is uncertain. This study examined the association between AFD and alcohol-related outcomes at age 20 years using an Australian sample.

METHODS

Data were obtained from Waves 1-19 (years 2001-2019) of the Household, Income and Labour Dynamics in Australia Survey on 20-year-olds with responses across ≥3 consecutive waves (n = 2278). The AFD for each respondent (between 15 and 20 years) was analysed relative to Australian legal drinking age (18 years). Inverse probability treatment weighting was used to evaluate associations between AFD and four outcomes at age 20 years: risk of current alcohol use; quantity of weekly alcohol consumption; risk of binge drinking; and frequency of binge drinking. Adjustments were made for confounders (e.g., heavy drinking by parents). Robustness of study findings was evaluated using several diagnostic tests/sensitivity analyses.

RESULTS

Among 20-year-olds, those with an AFD of 15-16 years consumed significantly more alcohol per week compared to an AFD of 18 years. Additionally, 20-year-old drinkers with an AFD of 16 years were significantly more likely to binge drink (though this association was likely confounded). An inverse dose-response relationship was observed between AFD and weekly alcohol consumption at 20 years, where a higher AFD led to lower alcohol consumption.

CONCLUSION

Study findings indicate an association between a higher AFD and consuming less alcohol in young adulthood, which could potentially support the scale-up of prevention programs to delay AFD among Australian adolescents.

The InterSECT framework: A proposed model for explaining population-level trends in substance use and emotional concerns

Across high-income countries, adolescent emotional concerns have been increasing in prevalence over the past two decades and it is unclear why this is occurring, including if and how substance use relates to these changing trends. On the other hand, substance use has been generally declining, and little is known about the role of emotional concerns in these trends. Several studies have explored the changes in co-occurring substance use and emotional concerns among adolescents over time, with mixed results and inconsistent messaging about the implications of the findings. In response, we developed a theoretical framework for exploring the intersection between trends in substance use and emotional health (InterSECT Framework). This framework includes a discussion and related examples for three core hypotheses: 1) strengthening of co-occurrence or the "hardening" hypothesis, 2) co-occurrence staying the same or the "consistency" hypothesis, and 3) weakening of co-occurrence or the "decoupling" hypothesis. This framework seeks to guide the conceptualization, evaluation, and understanding of changes in the co-occurrence of substance use and emotional concerns over time, including outlining a research agenda informed by pre-existing research and youth perspectives.

Examining temporal trends in psychological distress and the co-occurrence of common substance use in a population-based sample of grade 7-12 students from 2013 to 2019

PURPOSE

Characterizing trends and correlates of adolescent psychological distress is important due to observed global increases over the last 20 years. Substance use is a commonly discussed correlate, though we lack an understanding about how co-occurrence of these concerns has been changing over time.

METHODS

Data came from repeated, representative, cross-sectional surveys of grade 7-12 students across Ontario, Canada conducted biennially from 2013 to 2019. Poisson regression with robust standard errors was used to examine changes in the joint association between psychological distress (operationalized as Kessler-6 [K6] scores ≥ 13) and substance use over time. Weighted prevalence ratios (PR) and their 99% confidence intervals were estimated, where p < 0.01 denotes statistical significance.

RESULTS

The prevalence of psychological distress doubled between 2013 and 2019, with adjusted increases of about 1.2 times each survey year. This biennial increase did not differ based on sex, perceived social standing, school level, or any substance use. Students using substances consistently reported a higher prevalence of psychological distress (between 1.2 times and 2.7 times higher). There were similarly no differential temporal trends based on substance use for very high distress (K6 ≥ 19) or K6 items explored individually.

CONCLUSION

Psychological distress steeply increased among adolescents and substance use remains important to assess and address alongside distress. However, the magnitude of temporal increases appears to be similar for adolescents reporting and not reporting substance use.

The Long-Term Relationship Between Cannabis and Heroin Use: An 18- to 20-year Follow-Up of the Australian Treatment Outcome Study (ATOS)

OBJECTIVE

Cannabis use is common among individuals with opioid use disorder, but it remains unclear whether cannabis use is associated with an increase or a reduction in illicit opioid use. To overcome limitations identified in previous longitudinal studies with limited follow-ups, the authors examined a within-person reciprocal relationship between cannabis and heroin use at several follow-ups over 18 to 20 years.

METHODS

The Australian Treatment Outcome Study (ATOS) recruited 615 people with heroin dependence in 2001 and 2002 and reinterviewed them at 3, 12, 24, and 36 months as well as 11 and 18-20 years after baseline. Heroin and cannabis use were assessed at each time point using the Opiate Treatment Index. A random-intercept cross-lagged panel model analysis was conducted to identify within-person relationships between cannabis use and heroin use at subsequent follow-ups.

RESULTS

After accounting for a range of demographic variables, other substance use, and mental and physical health measures, an increase in cannabis use 24 months after baseline was significantly associated with an increase in heroin use at 36 months (estimate=0.21, SE=0.10). Additionally, an increase in heroin use at 3 months and 24 months was significantly associated with a decrease in cannabis use at 12 months (estimate=-0.27, SE=0.09) and 36 months (estimate=-0.22, SE=0.08). All other cross-lagged associations were not significant.

CONCLUSIONS

Although there was some evidence of a significant relationship between cannabis and heroin use at earlier follow-ups, this was sparse and inconsistent across time points. Overall, there was insufficient evidence to suggest a unidirectional or bidirectional relationship between the use of these substances.

Structure of psychopathology in adolescents and its association with high-risk personality traits

The present study examined high-risk personality traits and associations with psychopathology across multiple levels of a hierarchical-dimensional model of psychopathology in a large adolescent, general population sample. Confirmatory factor analyses were run using data from two randomized controlled trials of Australian adolescents (N = 8,654, mean age = 13.01 years, 52% female). A higher-order model - comprised of general psychopathology, fear, distress, alcohol use/harms, and conduct/inattention dimensions - was selected based on model fit, reliability, and replicability. Indirect-effects models were estimated to examine the unique associations between high-risk personality traits (anxiety sensitivity, negative thinking, impulsivity, and sensation seeking) and general and specific dimensions and symptoms of psychopathology. All personality traits were positively associated with general psychopathology. After accounting for general psychopathology, anxiety sensitivity was positively associated with fear; negative thinking was positively associated with distress; impulsivity was positively associated with conduct/inattention; and sensation seeking was positively associated with alcohol use/harms and conduct/inattention, and negatively associated with fear. Several significant associations between personality traits and individual symptoms remained after accounting for general and specific psychopathology. These findings contribute to our understanding of the underlying structure of psychopathology among adolescents and have implications for the development of personality-based prevention and early intervention programs.

Potential Mediators of a School-Based Digital Intervention Targeting Six Lifestyle Risk Behaviours in a Cluster Randomised Controlled Trial of Australian Adolescents

Lifestyle risk behaviours-physical inactivity, poor diet, poor sleep, recreational screen time, and alcohol and tobacco use-collectively known as the "Big 6" emerge during adolescence and significantly contribute to chronic disease development into adulthood. To address this issue, the Health4Life program targeted the Big 6 risk behaviours simultaneously via a co-designed eHealth school-based multiple health behaviour change (MHBC) intervention. This study used multiple causal mediation analysis to investigate some potential mediators of Health4Life's effects on the Big 6 primary outcomes from a cluster randomised controlled trial of Health4Life among Australian school children. Mediators of knowledge, behavioural intentions, self-efficacy, and self-control were assessed. The results revealed a complex pattern of mediation effects across different outcomes. Whilst there was a direct effect of the intervention on reducing moderate-to-vigorous physical activity risk, the impact on sleep duration appeared to occur indirectly through the hypothesised mediators. Conversely, for alcohol and tobacco use, both direct and indirect effects were observed in opposite directions cancelling out the total effect (competitive partial mediation). The intervention's effects on alcohol and tobacco use highlighted complexities, suggesting the involvement of additional undetected mediators. However, little evidence supported mediation for screen time and sugar-sweetened beverage intake risk. These findings emphasise the need for tailored approaches when addressing different risk behaviours and designing effective interventions to target multiple health risk behaviours. The trial was pre-registered with the Australian and New Zealand Clinical Trials Registry: ACTRN12619000431123.

Playing for more than winning: Exploring sports participation, physical activity, and belongingness and their relationship with patterns of adolescent substance use and mental health

BACKGROUND

Promoting adolescent sports participation and physical activity may be effective low-barrier prevention strategies for co-occurring adolescent substance use (SU) and mental health symptoms (MH). The objectives of this study were to: 1) explore associations between profiles of SU/MH and sports participation; and 2) determine whether physical activity and belongingness account for these associations.

METHODS

Data came from a representative sample of 11,994 grade 9-12 Ontarian students (ages ~14-18) previously grouped into five SU/MH profiles based on patterns of use and symptoms. A series of multinomial logistic regressions, adjusted for socio-demographics and school clustering, were used to predict the risks of students belonging to SU/MH profiles based on: 1) school sports participation (>=weekly), 2) sports and physical activity (>=60minutes; 0-7 days), and 3) sports, physical activity, and school belongingness.

RESULTS

Greater school sports participation, physical activity, and belongingness were each associated with reduced risks of belonging to most profiles with elevations in SU and/or MH symptoms relative to the low SU/MH profile (Relative Risk Ratios: sports=0.62-0.87, physical activity=0.78-0.98, belonging=0.75-0.83). Frequency of physical activity accounted for ~32-60% of the associations between sports and SU/MH profiles, while school belongingness accounted for the remaining associations. Physical activity and belongingness remained independently associated with SU/MH profiles.

CONCLUSIONS

Findings suggest possible indirect associations between school sports participation and SU/MH profiles through physical activity and school belongingness, which may be promising prevention targets that have independent associations over and above sports. School sports participation may be one of a number of ways to achieve these goals.

Longitudinal relationships between lifestyle risk factors and neurodevelopment in early adolescence

OBJECTIVE

The goal of this study is to investigate the cross-sectional and longitudinal relationships between clustered lifestyle risk factors (sleep, physical activity, body mass index [BMI], and screen time) and neurodevelopment over the early adolescent period.

METHOD

Data from the ABCD Study Data Release 3.0 consisted of 11,878 participants (aged 9-10 years) at baseline and 6,571 participants (aged 11-12 years) at 2-year follow-up. The interrelationships between lifestyle risk factors and brain structure were analyzed using bivariate multiple indicator latent change score models. Using confirmatory factor analysis, a single lifestyle risk factor domain (measured by sleep, physical activity, BMI, and screen time) was shown to fit the data well. Using exploratory and confirmatory factor analysis, seven brain structure domains were extracted and labeled as temporal-parietal, frontotemporal, occipital, orbitofrontal, temporal, cingulate, parietal, and cuneus domains. All bivariate latent change score models accounted for age, sex at birth, race/ethnicity, parental education, and marital status.

RESULTS

Higher lifestyle risk was associated with smaller brain volume at baseline. Higher baseline lifestyle risk was also associated with a greater rate of change (i.e., greater decreases) in brain volume for the temporal-parietal, frontotemporal, orbitofrontal, parietal, and cuneus domains. Effects were not reciprocal; baseline brain volume did not predict changes in lifestyle behaviors over time.

CONCLUSION

These findings are important for understanding the biological mechanisms underpinning health risk factors and can be used to target interventions and improve brain health during this critical developmental phase. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Understanding suicidal transitions in Australian adults: protocol for the LifeTrack prospective longitudinal cohort study

BACKGROUND

The factors that influence transition from suicidal ideation to a suicide attempt or remission of suicidal thoughts are poorly understood. Despite an abundance of research on risk factors for suicidal ideation, no large-scale longitudinal population-based studies have specifically recruited people with suicidal ideation to examine the mechanisms underlying critical transitions to either suicide attempt or recovery from suicidal ideation. Without longitudinal data on the psychological, behavioural, and social determinants of suicide attempt and the remission of suicidal ideation, we are unlikely to see major gains in the prevention of suicide.

AIM

The LifeTrack Project is a population-based longitudinal cohort study that aims to identify key modifiable risk and protective factors that predict the transition from suicidal ideation to suicide attempt or remission of suicidal ideation. We will assess theory-informed risk and protective factors using validated and efficient measures to identify distinct trajectories reflecting changes in severity of suicidal ideation and transition to suicide attempt over three years.

METHODS

A three-year prospective population-based longitudinal cohort study will be conducted with adults from the general Australian population who initially report suicidal ideation (n = 842). Eligibility criteria include recent suicidal ideation (past 30 days), aged 18 years or older, living in Australia and fluent in English. Those with a suicide attempt in past 30 days or who are unable to participate in a long-term study will be excluded. Participants will be asked to complete online assessments related to psychopathology, cognition, psychological factors, social factors, mental health treatment use, and environmental exposures at baseline and every six months during this three-year period. One week of daily measurement bursts (ecological momentary assessments) at yearly intervals will also capture short-term fluctuations in suicidal ideation, perceived burdensomeness, thwarted belongingness, capability for suicide, and distress.

CONCLUSION

This study is intended to identify potential targets for novel and tailored therapies for people experiencing suicidal ideation and improve targeting of suicide prevention programs. Even modest improvements in current treatments may lead to important reductions in suicide attempts and deaths.

STUDY REGISTRATION

Australian New Zealand Clinical Trials Registry identifier: ACTRN12623000433606.

Long-term patterns of treatment use for opioid use disorder (OUD): Findings from the 18-20-year Australian Treatment Outcome Study

BACKGROUND

Opioid-related deaths continue to increase to unprecedented rates in many regions of the world. While long-term stable treatment has been shown to reduce associated morbidity and mortality, discontinuation and numerous treatment episodes are common, limiting our understanding of the common course of treatment and associated characteristics. Therefore, using an 18-20-year follow-up of people with heroin dependence, we aimed to identify i) distinct trajectories of treatment use, ii) whether baseline characteristics predict treatment trajectory group membership, and ii) if group membership is associated with characteristics at 18-20-years post-baseline.

METHODS

A total of 615 people with heroin dependence were recruited from maintenance therapy, detoxification, residential rehabilitation, or needle and syringe programs as part of the Australian Treatment Outcome Study (ATOS), a longitudinal cohort followed up on seven occasions over 18-20-years between 2001 and 2021. Of those who had complete data (n = 393), group-based trajectory modelling and a series of multinomial logistical regressions were conducted.

RESULTS

Five trajectories of treatment use were identified: i) 'long-term low treatment' (17.2%), ii) 'rapid increase with gradual decrease' (13.9%), iii) 'late increase' (17.8%), (iv) 'long-term treatment' (27.7%), and (v) 'reduced treatment' (23.5%). Entering maintenance treatment at baseline predicted trajectory group membership, while trajectory group membership was associated with demographics and the use of heroin, methamphetamine, alcohol, and benzodiazepines at 18-20-years.

CONCLUSIONS

In one of the longest cohort studies of its kind, we characterised distinct trajectories of treatment use in people with heroin dependence over 18-20-years. Clinicians should be aware of the potential impact of demographics and substance use on long-term treatment use. Despite the well-documented benefits of long-term treatment, some patients may be able to achieve abstinence from opioids without engaging in treatment over the life-course.

Association of maternal and paternal perinatal depression and anxiety with infant development: A longitudinal study

BACKGROUND

Maternal and paternal perinatal depression and anxiety are theorised to adversely impact infant development. Yet, few studies have assessed both mental health symptoms and clinical diagnoses within the one study. Moreover, research on fathers is limited. This study therefore aimed to examine the association between symptoms and diagnoses of maternal and paternal perinatal depression and anxiety with infant development.

METHOD

Data were from the Triple B Pregnancy Cohort Study. Participants included 1539 mothers and 793 partners. Depressive and anxiety symptoms were assessed using the Edinburgh Postnatal Depression Scale and Depression Anxiety Stress Scales. Major depressive disorder, generalized anxiety disorder, social anxiety disorder, panic disorder, and agoraphobia were assessed using the Composite International Diagnostic Interview in trimester three. Infant development was assessed at 12-months using the Bayley Scales of Infant and Toddler Development.

RESULTS

Antepartum, maternal depressive and anxiety symptoms were associated with poorer infant social-emotional (d = -0.11, p = .025) and language development (d = -0.16, p = .001). At 8-weeks postpartum, maternal anxiety symptoms were associated with poorer overall development (d = -0.11, p = .030). No association was observed for clinical diagnoses in mothers, nor paternal depressive and anxiety symptoms or clinical diagnoses; albeit risk estimates were largely in the expected direction of adverse effects on infant development.

CONCLUSIONS

Evidence suggests that maternal perinatal depression and anxiety symptoms may adversely impact infant development. Effects were small but findings underscore the importance of prevention, early screening and intervention, alongside consideration of other risk factors during early critical periods.

Development and psychometric evaluation of the mental readiness for military transition scale (MT-Ready)

BACKGROUND

The transition to civilian life following separation from military service is associated with increased risk of mental health disorders, suicide, and poor adjustment. No measure currently enables pre-separation screening to assess mental readiness for transition and identify personnel most at risk of poor outcomes. The Mental Readiness for Military Transition Scale (MT-Ready) was developed to identify psychosocial factors predictive of post-separation psychological adjustment and mental health.

METHODS

Phase I was a qualitative study including transitioned veterans (n = 60), partners of transitioned veterans (n = 20) and mental health clinicians (n = 20) which enabled development of candidate items that were subsequently piloted with a current serving Australian Defence Force (ADF) sample (n = 19). Phase II included evaluation of the factor structure, psychometric properties, and scale refinement of the initial pool of 50 items with a convenience sample of transitioning ADF personnel (n = 345). Analyses included exploratory factor analysis, evaluation of test-retest reliability, internal consistency, convergent, divergent, discriminant and predictive validity. Receiver Operating Characteristic Curve Analysis was also conducted to determine an optimal cut-off score.

RESULTS

Exploratory factor analysis resulted in a 15-item, three-factor solution that explained 62.2% of the variance: Future focus and optimism; Anger and perceived failure; Civilian connections and social support. Reliability and convergent, divergent, and discriminant validity was established. Receiver Operating Characteristic Curve Analysis determined a cut-off score of 55. MT-Ready scores significantly differentiated those reporting adjusting versus not adjusting to civilian life 3.7 months post-separation, and predicted post-separation outcomes including symptoms of Posttraumatic Stress Disorder, depression, anxiety, psychological adjustment and quality of life.

CONCLUSIONS

This evaluation provides promising evidence the MT-Ready is a valid, reliable measure of mental readiness for transition, with predictive capability and considerable potential to assist prevention of poor post-separation outcomes among military personnel.

The 3-year effects of a personality-targeted prevention program on general and specific dimensions of psychopathology

This study aimed to examine the effect of a personality-targeted prevention program (Preventure) on trajectories of general and specific dimensions of psychopathology from early- to mid-adolescence. Australian adolescents (N = 2190) from 26 schools participated in a cluster randomized controlled substance use prevention trial. This study compared schools allocated to deliver Preventure (n = 13 schools; n = 466 students; Mage = 13.42 years), a personality-targeted selective intervention, with a control group (n = 7 schools; n = 235 students, Mage = 13.47 years). All participants were assessed for psychopathology symptoms at baseline, 6-, 12-, 24- and 36-months post-baseline. Outcomes were a general psychopathology factor and four specific factors: fear, distress, alcohol use/harms and conduct/inattention), extracted from a higher-order model. Participants who screened as 'high-risk' on at least one of four personality traits (negative thinking, anxiety sensitivity, impulsivity and sensation seeking) were included in intention-to-treat analyses. Intervention effects were examined using multi-level mixed models accounting for school-level clustering. Among high-risk adolescents, growth in general psychopathology was slower in the Preventure group compared to the control group (b = -0.07, p = 0.038) across the three years. After controlling for effects on general psychopathology, there were no significant, additional effects on the lower order factors. This study provides evidence for the effectiveness of a selective personality-targeted intervention in altering trajectories of general psychopathology during adolescence. This finding represents impacts on multiple symptom domains and highlights the potential for general psychopathology as an intervention target.

Is the association between psychological distress and risky alcohol consumption shifting over time? An age-period-cohort analysis of the Australian population

This study explored age, period, and cohort effects associated with trends in psychological distress and risky alcohol consumption. Data came from 108,536 Australians aged 14-79 years old from birth cohorts between 1925-2005, endorsing past year alcohol use in the 2004-2019 Australian National Drug Strategy Household Surveys. Risky alcohol consumption was split into exceeding weekly national drinking limits (>10 drinks per week) or daily limits (>4 drinks per day). An extended hierarchical age-period-cohort model was used to investigate differential effects on trends in psychological distress. Psychological distress showed an inverse U-shape throughout the lifespan with a peak in distress at age 60. Exceeding weekly alcohol limits was positively related to psychological distress prior to age 40 while exceeding daily alcohol limits remained positively related across the lifespan. There were relatively flat period effects, with no alcohol-related changes in psychological distress across years. Lastly, psychological distress gradually increased across birth cohorts until a notable spike among Australians born from 1980-2005 alongside weakening alcohol-related cohort effects. Overall, the recent increases in psychological distress did not appear to be meaningfully explained by risky alcohol consumption though risky alcohol consumption remained an important factor to consider alongside psychological distress.

Associations Between Personality Traits and Energy Balance Behaviors in Emerging Adulthood: Cross-Sectional Study

BACKGROUND

Internalizing and externalizing personality traits are robust risk factors for substance use and mental health, and personality-targeted interventions are effective in preventing substance use and mental health problems in youth. However, there is limited evidence for how personality relates to other lifestyle risk factors, such as energy balance-related behaviors, and how this might inform prevention efforts.

OBJECTIVE

This study aimed to examine concurrent cross-sectional associations between personality traits (ie, hopelessness, anxiety sensitivity, impulsivity, and sensation seeking) and sleep, diet, physical activity (PA), and sedentary behaviors (SB), 4 of the leading risk factors for chronic disease, among emerging adults.

METHODS

Data were drawn from a cohort of young Australians who completed a web-based, self-report survey in 2019 during early adulthood. A series of Poisson and logistic regressions were conducted to examine the concurrent associations between the risk behaviors (sleep, diet, PA, and sitting and screen time) and personality traits (hopelessness, anxiety sensitivity, impulsivity, and sensation seeking) among emerging adults in Australia.

RESULTS

A total of 978 participants (mean age 20.4, SD 0.5 years) completed the web-based survey. The results indicated that higher scores on hopelessness were associated with a greater daily screen (risk ratio [RR] 1.12, 95% CI 1.10-1.15) and sitting time (RR 1.05, 95% CI 1.0-1.08). Similarly, higher scores on anxiety sensitivity were associated with a greater screen (RR 1.04, 95% CI 1.02-1.07) and sitting time (RR 1.04, 95% CI 1.02-1.07). Higher impulsivity was associated with greater PA (RR 1.14, 95% CI 1.08-1.21) and screen time (RR 1.06, 95% CI 1.03-1.08). Finally, higher scores on sensation seeking were associated with greater PA (RR 1.08, 95% CI 1.02-1.14) and lower screen time (RR 0.96, 95% CI 0.94-0.99).

CONCLUSIONS

The results suggest that personality should be considered when designing preventive interventions for lifestyle risk behaviors, particularly in relation to SB, such as sitting and screen time.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612000026820; https://tinyurl.com/ykwcxspr.

Different Tokes for Different Folks: Use of Cannabis Products Among a Longitudinal Cohort of People with Heroin Dependence

Co-occurring cannabis use is common among those with opioid use disorder (OUD), but the extent to which it is harmful may be due to its preparation and concentration of various cannabinoids. The current study aimed to examine the prevalence of, and long-term associations with, the use of varying cannabis products among a naturalistic longitudinal cohort of people with heroin dependence. A total of 615 people, most of whom were entering treatment, were recruited to the Australian Treatment Outcome Study (ATOS) in 2001-2002. This analysis focuses on the 401 participants followed up at 18-20 years post baseline. Structured interviews assessed the use of cannabis products, as well as demographic and health covariates. High-potency/indoor-grown cannabis was the most common type ever used (68.8%), and in the past 12 months (80.4%), followed by low potency/outdoor grown (22.4%; 14.4%), and less so for other types of cannabis. After controlling for covariates, older age at baseline was associated with lower odds of high-potency cannabis being used as the primary type in the past 12 months. In contrast to studies of non-opioid dependent populations, common use of high-potency cannabis was not associated with more severe health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11469-023-01071-5.

A comprehensive evaluation of the longitudinal association between alcohol consumption and a measure of inflammation: Multiverse and vibration of effects analyses

BACKGROUND

Moderate alcohol consumption appears to be associated with reduced inflammation. Determining whether this association is robust to common variations in research parameters has wide-reaching implications for our understanding of disease aetiology and public health policy. We aimed to conduct comprehensive multiverse and vibration of effects analyses evaluating the associations between alcohol consumption and a measure of inflammation.

METHODS

A secondary analysis of the 1970 British Birth Cohort Study was performed, using data from 1970 through 2016. Measurements of alcohol consumption were taken in early/mid-adulthood (ages 34 and 42), and level of inflammation marker high-sensitivity C-reactive protein (hsCRP) at age 46. Multiverse analyses were applied to comparisons of low-to-moderate consumption and consumption above various international drinking guidelines with an 'abstinent' reference. Research parameters of interest related to: definitions of drinking and reference groups; alcohol consumption measurement year; outcome variable transformation; and breadth of covariate adjustment. After identifying various analytic options within these parameters and running the analysis over each unique option combination, specification curve plots, volcano plots, effect ranges, and variance decomposition metrics were used to assess consistency of results.

RESULTS

A total of 3101 individuals were included in the final analyses, with primary analyses limited to those where occasional consumers served as reference. All combinations of research specifications resulted in lower levels of inflammation amongst low-to-moderate consumers compared to occasional consumers (1st percentile effect: -0.21; 99th percentile effect: -0.04). Estimates comparing above-guidelines drinking with occasional consumers were less definitive (1st percentile effect: -0.26; 99th percentile effect: 0.43).

CONCLUSIONS

The association between low-to-moderate drinking and lower hsCRP levels is largely robust to common variations in researcher-defined parameters, warranting further research to establish whether this relationship is causal. The association between above-guidelines drinking and hsCRP levels is less definitive.

Study protocol of the Our Futures Vaping Trial: a cluster randomised controlled trial of a school-based eHealth intervention to prevent e-cigarette use among adolescents

BACKGROUND

Effective and scalable prevention approaches are urgently needed to address the rapidly increasing rates of e-cigarette use among adolescents. School-based eHealth interventions can be an efficient, effective, and economical approach, yet there are none targeting e-cigarettes within Australia. This paper describes the protocol of the OurFutures Vaping Trial which aims to evaluate the efficacy and cost-effectiveness of the first school-based eHealth intervention targeting e-cigarettes in Australia.

METHODS

A two-arm cluster randomised controlled trial will be conducted among Year 7 and 8 students (aged 12-14 years) in 42 secondary schools across New South Wales, Western Australia and Queensland, Australia. Using stratified block randomisation, schools will be assigned to either the OurFutures Vaping Program intervention group or an active control group (health education as usual). The intervention consists of four web-based cartoon lessons and accompanying activities delivered during health education over a four-week period. Whilst primarily focused on e-cigarette use, the program simultaneously addresses tobacco cigarette use. Students will complete online self-report surveys at baseline, post-intervention, 6-, 12-, 24-, and 36-months after baseline. The primary outcome is the uptake of e-cigarette use at 12-month follow-up. Secondary outcomes include the uptake of tobacco smoking, frequency/quantity of e-cigarettes use and tobacco smoking, intentions to use e-cigarettes/tobacco cigarettes, knowledge about e-cigarettes/tobacco cigarettes, motives and attitudes relating to e-cigarettes, self-efficacy to resist peer pressure and refuse e-cigarettes, mental health, quality of life, and resource utilisation. Generalized mixed effects regression will investigate whether receiving the intervention reduces the likelihood of primary and secondary outcomes. Cost-effectiveness and the effect on primary and secondary outcomes will also be examined over the longer-term.

DISCUSSION

If effective, the intervention will be readily accessible to schools via the OurFutures platform and has the potential to make substantial health and economic impact. Without such intervention, young Australians will be the first generation to use nicotine at higher rates than previous generations, thereby undoing decades of effective tobacco control.

TRIAL REGISTRATION

The trial has been prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12623000022662; date registered: 10/01/2023).

Health4Life eHealth intervention to modify multiple lifestyle risk behaviours among adolescent students in Australia: a cluster-randomised controlled trial

BACKGROUND

Lifestyle risk behaviours are prevalent among adolescents and commonly co-occur, but current intervention approaches tend to focus on single risk behaviours. This study aimed to evaluate the efficacy of the eHealth intervention Health4Life in modifying six key lifestyle risk behaviours (ie, alcohol use, tobacco smoking, recreational screen time, physical inactivity, poor diet, and poor sleep, known as the Big 6) among adolescents.

METHODS

We conducted a cluster-randomised controlled trial in secondary schools that had a minimum of 30 year 7 students, in three Australian states. A biostatistician randomly allocated schools (1:1) to Health4Life (a six-module, web-based programme and accompanying smartphone app) or an active control group (usual health education) with the Blockrand function in R, stratified by site and school gender composition. All students aged 11-13 years who were fluent in English and attended participating schools were eligible. Teachers, students, and researchers were not masked to allocation. Primary outcomes were alcohol use, tobacco use, recreational screen time, moderate to vigorous physical activity (MVPA), sugar-sweetened beverage intake, and sleep duration at 24 months, measured by self-report surveys, and analysed in all students who were eligible at baseline. Latent growth models estimated between-group change over time. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619000431123).

FINDINGS

Between April 1, 2019, and Sept 27, 2019, we recruited 85 schools (9280 students), of which 71 schools with 6640 eligible students (36 schools [3610 students] assigned to the intervention and 35 [3030 students] to the control) completed the baseline survey. 14 schools were excluded from the final analysis or withdrew, mostly due to a lack of time. We found no between-group differences for alcohol use (odds ratio 1·24, 95% CI 0·58-2·64), smoking (1·68, 0·76-3·72), screen time (0·79, 0·59-1·06), MVPA (0·82, 0·62-1·09), sugar-sweetened beverage intake (1·02, 0·82-1·26), or sleep (0·91, 0·72-1·14) at 24 months. No adverse events were reported during this trial.

INTERPRETATION

Health4Life was not effective in modifying risk behaviours. Our results provide new knowledge about eHealth multiple health behaviour change interventions. However, further research is needed to improve efficacy.

FUNDING

Paul Ramsay Foundation, the Australian National Health and Medical Research Council, the Australian Government Department of Health and Aged Care, and the US National Institutes of Health.

The relationship between alcohol use and dementia in adults aged more than 60 years: a combined analysis of prospective, individual-participant data from 15 international studies

AIM

To synthesize international findings on the alcohol-dementia relationship, including representation from low- and middle-income countries.

METHODS

Individual participant data meta-analysis of 15 prospective epidemiological cohort studies from countries situated in six continents. Cox regression investigated the dementia risk associated with alcohol use in older adults aged over 60 years. Additional analyses assessed the alcohol-dementia relationship in the sample stratified by sex and by continent. Participants included 24 478 community dwelling individuals without a history of dementia at baseline and at least one follow-up dementia assessment. The main outcome measure was all-cause dementia as determined by clinical interview.

RESULTS

At baseline, the mean age across studies was 71.8 (standard deviation = 7.5, range = 60-102 years), 14 260 (58.3%) were female and 13 269 (54.2%) were current drinkers. During 151 636 person-years of follow-up, there were 2124 incident cases of dementia (14.0 per 1000 person-years). When compared with abstainers, the risk for dementia was lower in occasional [hazard ratio (HR) = 0.78; 95% confidence interval (CI) = 0.68-0.89], light-moderate (HR = 0.78; 95% CI = 0.70-0.87) and moderate-heavy drinkers (HR = 0.62; 95% CI = 0.51-0.77). There was no evidence of differences between life-time abstainers and former drinkers in terms of dementia risk (HR = 0.98; 95% CI = 0.81-1.18). In dose-response analyses, moderate drinking up to 40 g/day was associated with a lower risk of dementia when compared with lif-time abstaining. Among current drinkers, there was no consistent evidence for differences in terms of dementia risk. Results were similar when the sample was stratified by sex. When analysed at the continent level, there was considerable heterogeneity in the alcohol-dementia relationship.

CONCLUSIONS

Abstinence from alcohol appears to be associated with an increased risk for all-cause dementia. Among current drinkers, there appears to be no consistent evidence to suggest that the amount of alcohol consumed in later life is associated with dementia risk.

Moderate Alcohol Consumption and Depression: A Marginal Structural Model Approach Promoting Causal Inference

OBJECTIVE

Moderate alcohol consumption is associated with decreased risk for depression, but it remains unclear whether this is a causal relationship or a methodological artifact. To compare the effects of consistent abstinence and occasional, moderate, and above-guideline alcohol consumption throughout early to middle adulthood on depression at age 50, the authors conducted a secondary analysis of the National Longitudinal Survey of Youth 1979 cohort and employed a marginal structural model (MSM) approach.

METHODS

Baseline was set at 1994, when individuals were ages 29-37. The MSM incorporated measurements of alcohol consumption in 1994, 2002, and 2006, baseline and time-varying covariates, and repeated measurements with the Center for Epidemiologic Studies Depression Scale-Short Form (CES-D-SF). A total of 5,667 eligible participants provided valid data at baseline, 3,593 of whom provided valid outcome data. The authors used all observed data to predict CES-D-SF means and rates of probable depression for hypothetical trajectories of consistent alcohol consumption.

RESULTS

The results approximated J-curve relationships. Specifically, both consistent occasional and consistent moderate drinkers were predicted to have reduced CES-D-SF scores and rates of probable depression at age 50 compared with consistent abstainers (CES-D-SF scores: b=-0.84, 95% CI=-1.47, -0.11; probable depression: odds ratio=0.58, 95% CI=0.36, 0.88 for consistent occasional drinkers vs. abstainers; CES-D-SF scores: b=-1.08, 95% CI=-1.88, -0.20; probable depression: odds ratio=0.59, 95% CI=0.26, 1.13 for consistent moderate drinkers vs. consistent abstainers). Consistent above-guideline drinkers were predicted to have slightly increased risk compared with consistent abstainers, but this was not significant. In sex-stratified analyses, results were similar for females and males.

CONCLUSIONS

This study contributes preliminary evidence that associations between moderate alcohol consumption and reduced risk for depression may reflect genuine causal effects. Further research using diverse methodologies that promote causal inference is required.

Media reporting on alcohol and other drugs in Australia and the Mindframe guidelines: Baseline data

INTRODUCTION

The aim of this study was to generate a baseline database of print media reporting on alcohol and other drug (AOD) issues prior to the release of the Mindframe guidelines in March 2019. Specifically, to: (i) describe the content associated with media entries that focus on AOD use in Australian news media; (ii) determine how the media entries compare to several domains associated with recently developed Mindframe guidelines for publicly reporting on AOD; and (iii) identify content factors associated with different scores.

METHODS

Media entries between July 2016 and June 2017 were searched for key AOD-related terms using the Australian and New Zealand Newsstream database. Two coding schemes were developed to rate a stratified sample of 50% of the media entries against the Mindframe guidelines. Associations between content and total comparison scores were determined using linear regression models.

RESULTS

Detailed coding of the 2007 articles identified as relevant for the current study indicated that a majority (67%) were focused on one of three substances: alcohol, cannabis or methamphetamine. Most of the entries were either law enforcement (22%) or criminal justice related (19%). Entries that focused on methamphetamine scored significantly lower than entries on alcohol when compared to the Mindframe guidelines, similarly entries focused on crime/justice-related topics scored significantly lower than entries focused on positive outcomes.

DISCUSSION AND CONCLUSIONS

A disproportionate number of print media entries, particularly those related methamphetamine use, focused on crime or justice-related topics, potentially further contributing to stigma, and emphasising the legal consequences of AOD use.

Factors Influencing Community Participation in Internet Interventions Compared With Research Trials: Observational Study in a Nationally Representative Adult Cohort

BACKGROUND

Digital mental health (DMH) programs can be effective in treating and preventing mental health problems. However, community engagement with these programs can be poor. Understanding the barriers and enablers of DMH program use may assist in identifying ways to increase the uptake of these programs, which have the potential to provide broad-scale prevention and treatment in the community.

OBJECTIVE

In this study, we aimed to identify and compare factors that may influence participation in DMH programs in practice and research trials, identify any respondent characteristics that are associated with these factors, and assess the relationship between intentions to use DMH programs and actual uptake.

METHODS

Australian adults aged ≥18 years were recruited from market research panels to participate in the study. The sample was representative of the Australian adult population based on age, gender, and location. Participants completed a cross-sectional web-based survey assessing demographic characteristics, mental health symptom measures, attitudes and use of DMH programs in practice and in research studies, and the factors influencing their use in both settings.

RESULTS

Across both research and practice, trust in the organization delivering the service or trial was the top-ranked factor influencing participation, followed by anonymity or privacy and adequate information. There was little variation in rankings across demographic groups, including intentions to use DMH programs or mental health status. Intentions to use DMH programs were a strong predictor of both current (odds ratio 2.50, 99% CI 1.41-4.43; P<.001) and past (odds ratio 2.98, 99% CI 1.71-5.19; P<.001) use behaviors.

CONCLUSIONS

Efforts to increase the uptake of DMH programs or participation in research trials should focus on clearly communicating the following to users: the legitimacy of the organization delivering the program, security and use of participant data, and effectiveness of DMH programs.

Multiple lifestyle risk behaviours and hierarchical dimensions of psychopathology in 6640 Australian adolescents

OBJECTIVE

Physical inactivity, sugar sweetened beverage consumption, alcohol use, smoking, poor sleep and excessive recreational screen time (the 'Big 6' lifestyle risk behaviours) often co-occur and are key risk factors for psychopathology. However, the best fitting latent structure of the Big 6 is unknown and links between multiple lifestyle risk behaviours and hierarchical dimensions of psychopathology have not been explored among adolescents. This study aimed to address these gaps in the literature.

METHODS

Confirmatory factor analysis, latent class analysis and factor mixture models were conducted among 6640 students (M_age = 12.7 years) to identify the latent structure of the Big 6 lifestyle risk behaviours. Structural equation models were then used to examine associations with psychopathology.

RESULTS

A mixture model with three classes, capturing mean differences in a single latent factor indexing overall risk behaviours, emerged as the best fitting model. This included relatively low-risk (Class 1: 30%), moderate-risk (Class 2: 67%) and high-risk (Class 3: 3%) classes. Students high on externalizing demonstrated significantly greater odds of membership to the high-risk class (odds ratio = 8.75, 99% confidence interval = [3.30, 23.26]) and moderate-risk class (odds ratio = 2.93, 99% confidence interval = [1.43, 5.97]) in comparison to the low-risk class. Similarly, students high on internalizing demonstrated significantly higher odds of membership to the high-risk class (odds ratio = 1.89, 99% confidence interval = [1.06, 3.37]) and the moderate-risk class (odds ratio = 1.66, 99% confidence interval = [1.03, 2.67]) in comparison to the low-risk class. Associations between lower order factors of psychopathology and lifestyle risk behaviours were mostly accounted for by the more parsimonious higher order factors.

CONCLUSION

Classes representing differences in probabilities of the Big 6 lifestyle risk behaviours relate to varying levels of hierarchical dimensions of psychopathology, suggesting multiple health behaviour change and transdiagnostic intervention approaches may be valuable for reducing risk of psychopathology.

Factors associated with the time to transition from suicidal ideation to suicide plans and attempts in the Australian general population

BACKGROUND

Suicide plans and attempts rarely occur without prior suicidal ideation but are hard to predict. Early intervention efforts need to focus on subgroups of the population who are more likely to transition from ideation to suicidal plans and attempts. The current study utilised data from a large nationally representative sample to investigate the time taken to transition and the demographic and mental health correlates of transitioning to suicidal plans and attempts among those with suicidal ideation.

METHODS

Data were from 1237 Australians aged 16-85 years who reported suicidal thoughts at some point in their life. Discrete time survival analysis was used to retrospectively examine the time in years and correlates of transitioning from suicidal ideation to suicide plans and suicide attempt.

RESULTS

The majority of those who transitioned to suicide plans or attempts typically did so within 2 years of first experiencing suicidal ideation. Several factors were independently associated with increased speed to transition, including alcohol use disorder, drug use disorder, major depressive episode, obsessive compulsive disorder, sexual minority status, and non-urban location. Older age, being male, older age of first ideation and greater family support were associated with a slower transition.

CONCLUSION

The current study suggests that pre-existing mental or substance use disorders, particularly drug use disorder, as well as sexual minority status, sex and greater family support play an important role in the transition from suicidal ideation to plans or attempts. These results highlight the potential importance of suicide prevention programs that aim to improve social connectedness.

Systematic review of the efficacy, effectiveness, and cost-effectiveness of stepped-care interventions for the prevention and treatment of problematic substance use

BACKGROUND

Stepped-care is a commonly recommended and implemented care model across health care domains, including substance use. Despite their presumed efficient allocation of treatment resources, a current and robust evidence synthesis is needed on the efficacy, effectiveness and cost-effectiveness of stepped-care for substance use.

METHODS

This systematic review analyzed articles describing evaluations of stepped-care models that measured the use of acutely psychoactive substances (i.e., alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, and stimulants) as a primary or secondary outcome, in participants over 18 years old. The analysis investigated model and participant characteristics associated with treatment outcomes.

RESULTS

The study team conducted a search of five databases of literature (PsychINFO, MEDLINE, Embase, Cochrane Library and Scopus) published between January 1, 2010, and November 1, 2020. The search yielded 1051 unique articles, 19 of which were included in the analysis. The studies had considerable variability in sample sizes (n = 18-2310), time to follow-up (4.5 months to 3 years), and retention rates (35.1-100 %). Studies examined outcomes for either alcohol alone (n = 9), alcohol and other drug use (n = 9), or drug use alone (n = 1). Most studies (n = 13;) were rated as good quality. Three (15.8 %) were rated as fair and three (15.8 %) were rated as poor quality. The evidence regarding the efficacy, effectiveness and cost-effectiveness of stepped-care approaches is limited, but four of seven studies found that adaptive-care interventions delivered in the context of other systemic interventions produced greater benefit than control conditions in relation to at least one alcohol-related outcome. We have insufficient evidence to determine whether the modes or intensity of interventions included in the models, or decision rules used to step people up or down to differing levels of care, have an impact on outcome.

CONCLUSION

Heterogeneity between studies with regard to model and evaluation design limited the degree to which the analysis could draw robust conclusions. Sample recruitment and statistical power are particular challenges, and the field needs more innovative evaluation designs to assess the efficacy, effectiveness, and cost-effectiveness of stepped-care models.

Association of adolescent and young adult depression and anxiety with perinatal mental health in fathers: Findings from an Australian longitudinal study

The current study examined associations between preconception diagnoses of major depressive disorder (MDD) and anxiety disorders in adolescence and young adulthood and perinatal depression and anxiety symptoms in early fatherhood. In an Australian community cohort study of health and development, earlier history of MDD and anxiety disorders (extending back to adolescence) were assessed retrospectively in the third trimester of pregnancy via the Composite International Diagnostic Interview. Paternal perinatal depression and anxiety were then assessed prospectively over three timepoints (third trimester of pregnancy, 8 weeks and 12 months postpartum), using established cut-points on the Edinburgh Postnatal Depression Scale and the Depression Anxiety Stress Scales (anxiety subscale). Mixed-effects regression models examined risk associations between preconception diagnoses of MDD and anxiety disorders, and perinatal depression and anxiety symptoms at each timepoint, adjusting for socio-demographic factors and concurrent maternal mental health difficulties. The odds of clinically concerning levels of paternal perinatal depression and anxiety were 6-fold and 4-fold higher, respectively, in men with a preconception history of MDD. The odds of perinatal depression were 3-fold higher in men with a preconception history of an anxiety disorder. Less evidence was found for an association between preconception diagnoses of an anxiety disorder and perinatal anxiety in fathers. Interventions aimed at improving mental health in men during adolescence and young adulthood may promote continued psychological health in men during early fatherhood.

A systematic review of the efficacy, effectiveness and cost-effectiveness of workplace-based interventions for the prevention and treatment of problematic substance use

Employee alcohol and other drug use can negatively impact the workplace, resulting in absenteeism, reduced productivity, high turnover, and worksite safety issues. As the workplace can influence employee substance use through environmental and cultural factors, it also presents a key opportunity to deliver interventions, particularly to employees who may not otherwise seek help. This is a systematic review of workplace-based interventions for the prevention and treatment of problematic substance use. Five databases were searched for efficacy, effectiveness and/or cost-effectiveness studies and reviews published since 2010 that measured use of psychoactive substances (i.e., alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, and stimulants) as a primary or secondary outcome, in employees aged over 18. Thirty-nine articles were identified, 28 describing primary research and 11 reviews, most of which focused solely on alcohol use. Heterogeneity between studies with respect to intervention and evaluation design limited the degree to which findings could be synthesized, however, there is some promising evidence for workplace-based universal health promotion interventions, targeted brief interventions, and universal substance use screening. The few studies that examined implementation in the workplace revealed specific barriers including lack of engagement with e-health interventions, heavy use and reluctance to seek help amongst male employees, and confidentiality concerns. Tailoring interventions to each workplace, and ease of implementation and employee engagement emerged as facilitators. Further high-quality research is needed to examine the effectiveness of workplace substance use testing, Employee Assistance Programs, and strategies targeting the use of substances other than alcohol in the workplace.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=227598, PROSPERO [CRD42021227598].

Effect of Selective Personality-Targeted Alcohol Use Prevention on 7-Year Alcohol-Related Outcomes Among High-risk Adolescents: A Secondary Analysis of a Cluster Randomized Clinical Trial

IMPORTANCE

Alcohol consumption is one of the leading preventable causes of burden of disease worldwide. Selective prevention of alcohol use can be effective in delaying the uptake and reducing harmful use of alcohol during the school years; however, little is known about the durability of these effects across the significant transition from early adolescence into late adolescence and early adulthood.

OBJECTIVE

To examine the sustained effects of a selective personality-targeted alcohol use prevention program on alcohol outcomes among adolescents who report high levels of 1 of 4 personality traits associated with substance use.

DESIGN, SETTING, AND PARTICIPANTS

A cluster randomized clinical trial was conducted to assess the effectiveness of the selective personality-targeted PreVenture program on reducing the growth of risky alcohol use and related harms from early to late adolescence and early adulthood. Participants included grade 8 students attending 14 secondary schools across New South Wales and Victoria, Australia, in 2012 who screened as having high levels of anxiety sensitivity, negative thinking, impulsivity, and/or sensation seeking. Schools were block randomized to either the PreVenture group (7 schools) or the control group (7 schools). The primary end point of the original trial was 2 years post baseline; the present study extends the follow-up period from July 1, 2017, to December 1, 2019, 7 years post baseline. Data were analyzed from July 22, 2021, to August 2, 2022.

INTERVENTIONS

The PreVenture program is a 2-session, personality-targeted intervention designed to upskill adolescents to better cope with their emotions and behaviors.

MAIN OUTCOMES AND MEASURES

Self-reported monthly binge drinking, alcohol-related harms, and hazardous alcohol use measured by the Alcohol Use Disorders Identification Test-Concise consumption screener.

RESULTS

Of 438 participants (249 male [56.8%]; mean [SD] age, 13.4 [0.5] years) from 14 schools, 377 (86.2%) provided follow-up data on at least 2 occasions, and among those eligible, 216 (54.0%) participated in the long-term follow-up. Compared with the control condition, the PreVenture intervention was associated with reduced odds of any alcohol-related harm (odds ratio [OR], 0.81 [95% CI, 0.70-0.94]) and a greater mean reduction in the frequency of alcohol-related harms (β = -0.22 [95% CI, -0.44 to -0.003]) at the 7.0-year follow-up. There were no differences in the odds of monthly binge drinking (OR, 0.80 [95% CI, 0.56-1.13]) or hazardous alcohol use (OR, 0.87 [95% CI, 0.59-1.27]) at the 7.0-year follow-up. Exploratory analyses at the 5.5-year follow-up showed that compared with the control condition, the PreVenture intervention was also associated with reduced odds of monthly binge drinking (OR, 0.87, [95% CI, 0.77-0.99]) and hazardous alcohol use (OR, 0.91 [95% CI, 0.84-0.99]), but this was not sustained.

CONCLUSIONS AND RELEVANCE

This study demonstrated that a brief selective personality-targeted alcohol use prevention intervention delivered in the middle school years can have sustained effects into early adulthood.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12612000026820.

The relationship between brain structure and general psychopathology in preadolescents

BACKGROUND

An emerging body of literature has indicated that broad, transdiagnostic dimensions of psychopathology are associated with alterations in brain structure across the life span. The current study aimed to investigate the relationship between brain structure and broad dimensions of psychopathology in the critical preadolescent period when psychopathology is emerging.

METHODS

This study included baseline data from the Adolescent Brain and Cognitive Development (ABCD) Study^® (n = 11,875; age range = 9-10 years; male = 52.2%). General psychopathology, externalizing, internalizing, and thought disorder dimensions were based on a higher-order model of psychopathology and estimated using Bayesian plausible values. Outcome variables included global and regional cortical volume, thickness, and surface area.

RESULTS

Higher levels of psychopathology across all dimensions were associated with lower volume and surface area globally, as well as widespread and pervasive alterations across the majority of cortical and subcortical regions studied, after adjusting for sex, race/ethnicity, parental education, income, and maternal psychopathology. The relationships between general psychopathology and brain structure were attenuated when adjusting for cognitive functioning. There were no statistically significant relationships between psychopathology and cortical thickness in this sample of preadolescents.

CONCLUSIONS

The current study identified lower cortical volume and surface area as transdiagnostic biomarkers for general psychopathology in preadolescence. Future research may focus on whether the widespread and pervasive relationships between general psychopathology and brain structure reflect cognitive dysfunction that is a feature across a range of mental illnesses.

Measurement properties of smartphone approaches to assess physical activity in healthy young people: A systematic review (Preprint)

Background

Physical inactivity is a preventable risk factor for several chronic diseases and one of the driving forces behind the growing global burden of disease. Recent evidence has shown that interventions using mobile smartphone apps can promote a significant increase in physical activity (PA) levels. However, the accuracy and reliability of using apps is unknown.

Objective

The aim of our review was to determine the accuracy and reliability of using mobile apps to measure PA levels in young people. We conducted a systematic review guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

Methods

Studies published from 2007 to 2020 were sourced from 8 databases—Ovid MEDLINE, Embase (Elsevier), Cochrane Library (Wiley), PsychINFO (EBSCOhost), CINAHL (EBSCOhost), Web of Science (Clarivate), SPORTDiscus (EBSCOhost), and IEEE Xplore Digital Library database. Studies were conducted in young people aged 10-24 years and without chronic illnesses, who evaluated a mobile app’s ability to measure PA. Primary outcomes included validity, reliability, and responsiveness of the measurement approach. Duplicate screening was conducted for eligibility, data extraction, and assessing the risk of bias. Results were reported as a systematic review. The main physical activity measures evaluated for each study were the following: total PA time (min/day or min/week), total moderate to vigorous PA per week, daily step count, intensity measure (heart rate), and frequency measure (days per week).

Results

Of the 149 identified studies, 5 met the inclusion criteria (322 participants, 176 female; mean age 14, SD 3 years). A total of 3 studies measured criterion validity and compared PA measured via apps against PA measured via an Actigraph accelerometer. The 2 studies that reported on construct validity identified a significant difference between self-reported PA and the objective measure. Only 1 of the 5 apps examined was available to the public, and although this app was highly accepted by young people, the app recorded PA to be significantly different to participants’ self-reported PA.

Conclusions

Overall, few studies assess the reliability, validity, and responsiveness of mobile apps to measure PA in healthy young people, with studies typically only reporting on one measurement property. Of the 3 studies that measured validity, all concluded that mobile phones were acceptable and valid tools. More research is needed into the validity and reliability of smartphone apps to measure PA levels in this population as well as in populations with other characteristics, including other age groups and those with chronic diseases.

Trial Registration

PROSPERO CRD42019122242; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=122242

The 7-Year Effectiveness of School-Based Alcohol Use Prevention From Adolescence to Early Adulthood: A Randomized Controlled Trial of Universal, Selective, and Combined Interventions

OBJECTIVE

Alcohol use is a leading cause of burden of disease among young people. Prevention strategies can be effective in the short-term; however little is known about their longer-term effectiveness. The aim of this study was to examine the sustainability of universal, selective, and combined alcohol use prevention across the critical transition period from adolescence into early adulthood.

METHOD

In 2012, a total of 2190 students (mean age, 13.3 years) from 26 Australian high schools participated in a cluster randomized controlled trial and were followed up for 3 years post baseline. Schools were randomly assigned to deliver the following: (1) universal Web-based prevention for all students (Climate Schools); (2) selective prevention for high-risk students (Preventure); (3) combined universal and selective prevention (Climate Schools and Preventure [CAP]); or (4) health education as usual (control). This study extends the follow-up period to 7-years post baseline. Primary outcomes were self-reported frequency of alcohol consumption and binge drinking, alcohol-related harms, and hazardous alcohol use, at the 7-year follow-up.

RESULTS

At 7-year follow-up, students in all 3 intervention groups reported reduced odds of alcohol-related harms compared to the control group (odds ratios [ORs] = 0.13-0.33), and the Climate (OR = 0.04) and Preventure (OR = 0.17) groups reported lower odds of hazardous alcohol use. The Preventure group also reported lower odds of weekly alcohol use compared to the control group (OR = 0.17), and the Climate group reported lower odds of binge drinking (OR = 0.12), holding mean baseline levels constant.

CONCLUSION

This study demonstrated that both universal and selective preventive interventions delivered in schools can have long-lasting effects and reduce risky drinking and related harms into adulthood. No added benefit was observed by delivering the combined interventions.

CLINICAL TRIAL REGISTRATION INFORMATION

The CAP Study: Evaluating a Comprehensive Universal and Targeted Intervention Designed to Prevent Substance Use and Related Harms in Australian Adolescents; https://www.anzctr.org.au/; ACTRN12612000026820.

Rethink My Drink: study protocol for a 12-month randomised controlled trial comparing a brief internet-delivered intervention to an online patient information booklet in reducing risky alcohol consumption among older adults in Australia

BACKGROUND AND AIMS

Alcohol consumption is increasing among older adults. Rethink My Drink is a brief internet-delivered intervention to reduce alcohol consumption and related harms, adapted specifically for older adults. This protocol for a large-scale randomised controlled trial will evaluate whether Rethink My Drink is effective in reducing alcohol consumption and cognitive decline in a sample of older risky drinkers, compared with an active control.

DESIGN

1:1 parallel group, randomised controlled trial.

SETTING

Online trial in Australia.

PARTICIPANTS

Hazardous or harmful drinkers (defined as those scoring ≥5 on the Alcohol Use Disorders Identification Test [AUDIT]) age 60 to 75 years old (n = 842). Participants will be recruited from August 2021 to August 2022 through online social media advertisements and community networks.

INTERVENTION AND COMPARATOR

Participants will be randomly allocated to receive access to Rethink My Drink (intervention) or Alcohol: The Facts (comparator), an online patient information booklet provided by New South Wales (NSW) Health.

MEASUREMENTS

Primary outcomes include (i) average weekly standard drinks and (ii) rate of cognitive decline. Secondary outcomes include (i) typical quantity of drinks per drinking day; (ii) heavy episodic drinking; (iii) age-specific risky drinking; (iv) alcohol-related harms; (v) subjective cognitive complaints; and (vi) quality of life. All primary and secondary outcomes will be assessed at baseline, post-intervention (4 weeks) and 12 months. Effectiveness will be evaluated using multilevel linear regression, adjusting for baseline demographic differences. Bonferroni adjustments will be used to control for multiple comparisons. Multiple imputation, regression weighting and sensitivity analyses will assess the effect of attrition.

COMMENTS

This will be the first large-scale trial, internationally, to examine whether a brief internet-delivered intervention is effective in reducing alcohol consumption and cognitive decline among older adults. If successful, the intervention will provide an accessible and highly scalable treatment to reduce risky alcohol consumption in older adulthood.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): III. Emotional dysfunction superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a quantitative nosological system that addresses shortcomings of traditional mental disorder diagnoses, including arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, substantial heterogeneity within disorders, and diagnostic unreliability over time and across clinicians. This paper reviews evidence on the validity and utility of the internalizing and somatoform spectra of HiTOP, which together provide support for an emotional dysfunction superspectrum. These spectra are composed of homogeneous symptom and maladaptive trait dimensions currently subsumed within multiple diagnostic classes, including depressive, anxiety, trauma-related, eating, bipolar, and somatic symptom disorders, as well as sexual dysfunction and aspects of personality disorders. Dimensions falling within the emotional dysfunction superspectrum are broadly linked to individual differences in negative affect/neuroticism. Extensive evidence establishes that dimensions falling within the superspectrum share genetic diatheses, environmental risk factors, cognitive and affective difficulties, neural substrates and biomarkers, childhood temperamental antecedents, and treatment response. The structure of these validators mirrors the quantitative structure of the superspectrum, with some correlates more specific to internalizing or somatoform conditions, and others common to both, thereby underlining the hierarchical structure of the domain. Compared to traditional diagnoses, the internalizing and somatoform spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and greater clinical applicability. Validated measures are currently available to implement the HiTOP system in practice, which can make diagnostic classification more useful, both in research and in the clinic.

Weeding out the truth: a systematic review and meta-analysis on the transition from cannabis use to opioid use and opioid use disorders, abuse or dependence

BACKGROUND AND AIMS

The idea that cannabis is a 'gateway drug' to more harmful substances such as opioids is highly controversial, yet has substantially impacted policy, education and how we conceptualize substance use. Given a rise in access to cannabis products and opioid-related harm, the current study aimed to conduct the first systematic review and meta-analysis on the likelihood of transitioning from cannabis use to subsequent first-time opioid use, opioid use disorders (OUD), dependence or abuse.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, pubMed/MEDLINE, Scopus, EMBASE, PsychINFO, Cochrane Central Register of Controlled Trials and Informit Health Collection were searched for full-text articles assessing the likelihood of transitioning from cannabis to subsequent opioid use, and from opioid use to OUD, abuse or dependence given prior cannabis use. Analysis of subpopulations within studies were discussed narratively, and E-values were calculated to assess the potential influence of unmeasured confounding.

FINDINGS

Six studies provided relevant data from the United States, Australia and New Zealand between 1977 and 2017, a total sample of 102 461 participants. Random-effects analysis of the adjusted pooled effect size indicates that the likelihood of transitioning from cannabis to opioid use, relative to non-cannabis users, is odds ratio (OR) = 2.76, 95% confidence interval (CI) = 2.26-3.36, whereas the likelihood of transitioning from opioid use to OUD, abuse or dependence given prior cannabis use is OR = 2.52, 95% CI = 1.65-3.84. While the evidence was determined to be of low quality with moderate risk of bias, E-values suggest that these findings are robust against unmeasured confounding.

CONCLUSION

A systematic review and meta-analysis found that while people who use cannabis are disproportionately more likely to initiate opioid use and engage in problematic patterns of use than people who do not use cannabis, the low quality of the evidence must be considered when interpreting these findings.

Are there non-linear relationships between alcohol consumption and long-term health?: a systematic review of observational studies employing approaches to improve causal inference

Background

Research has long found ‘J-shaped’ relationships between alcohol consumption and certain health outcomes, indicating a protective effect of moderate consumption. However, methodological limitations in most studies hinder causal inference. This review aimed to identify all observational studies employing improved approaches to mitigate confounding in characterizing alcohol–long-term health relationships, and to qualitatively synthesize their findings.

Methods

Eligible studies met the above description, were longitudinal (with pre-defined exceptions), discretized alcohol consumption, and were conducted with human populations. MEDLINE, PsycINFO, Embase and SCOPUS were searched in May 2020, yielding 16 published manuscripts reporting on cancer, diabetes, dementia, mental health, cardiovascular health, mortality, HIV seroconversion, and musculoskeletal health. Risk of bias of cohort studies was evaluated using the Newcastle-Ottawa Scale, and a recently developed tool was used for Mendelian Randomization studies.

Results

A variety of functional forms were found, including reverse J/J-shaped relationships for prostate cancer and related mortality, dementia risk, mental health, and certain lipids. However, most outcomes were only evaluated by a single study, and few studies provided information on the role of alcohol consumption pattern.

Conclusions

More research employing enhanced causal inference methods is urgently required to accurately characterize alcohol–long-term health relationships. Those studies that have been conducted find a variety of linear and non-linear functional forms, with results tending to be discrepant even within specific health outcomes.

Trial registration

PROSPERO registration number CRD42020185861.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01486-5.

436Food addiction, mental health and substance-use during a transition period: Data from 6,700 Australian 12/13-year-olds

Background

Early adolescence is a challenging transition period where mental ill-health and experimentation with alcohol and tobacco often increases. Some foods and eating behaviours can be addictive in a way that is comparable to addictive substances. Few studies have examined the prevalence of food addiction in young people, and none have measured it with mental ill-health and substance-use.

Methods

6,700 Year 7 students across NSW, WA and QLD completed the baseline questionnaire for “Health4Life” (Mage=12.7±0.5, 49%F). The prevalence of, and associations between, food addiction (YFAS-C), anxiety (PROMIS-A), depression (PHQ-A), psychological distress (K6), discretionary food/drink intake (SPANS) and alcohol and tobacco use were examined.

Results

Respondents who met diagnostic criteria for food addiction (5.2%, n = 272) were significantly more likely to screen positively for anxiety (X23=315.4, P &lt; 0.001), probable major depression (X21=299.9, P &lt; 0.001) and psychological distress at levels of serious mental illness (X21=238.885, P &lt; 0.001). They were also significantly more likely to have consumed a full standard drink and smoked tobacco in the past 6-months (X21=53.8, P &lt; 0.001 and X21=29.7, P &lt; 0.001, respectively) and to consume high amounts of sugar-sweetened beverages (X21=15.2, P &lt; 0.001), discretionary foods (X22=26.4, P &lt; 0.001) and energy drinks (X25=28.4, P &lt; 0.001). Relative risks ranged 1.29-4.35.

Conclusions

Findings suggest a strong link between food addiction, substance use, discretionary food and drink consumption and mental ill-health in early adolescence. Further analysis will model multivariable relationships whilst controlling for affluence, BMI and gender.

Key messages

Links between food addiction, substance use and mental ill-health are found in the largest sample of adolescents screened for these variables worldwide.

195The Health4Life Initiative: An eHealth intervention targeting multiple lifestyle risk behaviours among Australian adolescents

Background

Physical inactivity, poor diet, sedentary recreational screen time, poor sleep, alcohol use and smoking (the “Big 6”) are key lifestyle risk factors for chronic disease. The Big 6 typically emerge during adolescence, co-occur and continue into adulthood. To improve short- and long-term health, early and effective prevention is critical.

Methods

A cluster randomised controlled trial (ACTRN12619000431123) is being conducted in 71 schools across NSW, QLD and WA. Schools are randomised to the Health4life intervention or health education as usual. The intervention has three components: 1) An online, school-based program delivered to all Year 7 students; 2) An accompanying smartphone application (all students); 3) Booster content, delivered to at-risk students in Years 8 and 9. Students complete questionnaires on five occasions over three years.

Results

Preliminary analyses including 6716 students (49% female) indicated that 22% of participants met national guidelines for physical activity, 27% reported drinking 2+ cups of sugar-sweetened beverages/week, 3% had consumed a standard alcoholic drink in the prior 6 months, 2% had tried smoking, 86% engaged in excessive recreational screen time, and 32% had inadequate sleep. The final dataset will be analysed for the conference.

Conclusions

Many Australian adolescents are engaging in lifestyle behaviours that put them at risk of chronic disease. Effective and scalable preventive interventions that simultaneously target these behaviours are needed.

Key messages

This is the first trial of an eHealth intervention to concurrently target the Big 6 among adolescents. Health4Life has the potential to improve physical and mental health in adolescence and beyond.

1168Are there non-linear alcohol–health relationships?: Review of observational studies employing enhanced causal methods

Focus of Presentation

Research has long found ‘J-shaped’ relationships between alcohol consumption and certain health outcomes, indicating a protective effect of moderate consumption. However, methodological limitations in most studies hinder causal inference. While enhanced methods for data analysis (e.g. G-methods) and alternative observational designs (e.g. Mendelian Randomisation) have been developed, they are not commonly applied to alcohol–health research. This presentation will report on a systematic review of observational studies that employ improved approaches to mitigate confounding in characterising alcohol–long-term health relationships (PROSPERO registration: CRD42020185861).

Findings

MEDLINE, PsycINFO, Embase and SCOPUS were searched in May 2020, yielding 16 published manuscripts reporting on cancer, diabetes, dementia, mental health, cardiovascular health, mortality, HIV seroconversion, and musculoskeletal health. Study findings were qualitatively synthesised. A variety of functional forms were found, including reverse J/J-shaped relationships for prostate cancer and related mortality, dementia risk, mental health, and certain lipids. However, most outcomes were only evaluated by a single study, and few studies provided information on the role of alcohol consumption pattern.

Conclusions/Implications

More research employing enhanced causal inference methods is urgently required to accurately characterise alcohol–long-term health relationships. Those studies that have been conducted find a variety of linear and non-linear functional forms, with results tending to be discrepant even within specific health outcomes.

Key messages

A systematic review found that those studies of alcohol–long-term health relationships employing enhanced causal methods are too few and inconsistent to establish whether non-linear alcohol–health relationships exist.

272Transdiagnostic Risk and Protective Factors for Psychopathology in Young People: A systematic review

Focus of Presentation

Mental health and substance use disorders are among the leading causes of burden of disease worldwide. These disorders often emerge during adolescence, with risk of onset peaking between the ages 13 and 24. Despite decades of research, the underlying causes of mental health disorders remain unclear. This in part may be due to limitations of existing, categorical diagnostic systems, such as low specificity demonstrated by the high rates of co-occurring mental health disorders. A growing body of research supports a move towards dimensional, empirically derived models of psychopathology, such as the Hierarchical Taxonomy of Psychopathology (Hi-TOP) model. The present systematic review seeks to identify risk and protective factors for psychopathology in young people that occur across traditional diagnostic categories by synthesising and evaluating findings from research investigating empirically based models of psychopathology.

Findings

Findings will be summarised in a narrative synthesis and grouped by broad research domain, such as genetic, neurobiological, cognitive social and environmental.

Conclusions/Implications

The implications of these findings for the development of prevention and early intervention programs will be discussed.

Key messages

Empirically based models of psychopathology provide a vital opportunity to advance our knowledge of the risk and protective factors for mental health and substance use disorders, and in turn lead to the development or enhancement of prevention programs.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): II. Externalizing superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is an empirical effort to address limitations of traditional mental disorder diagnoses. These include arbitrary boundaries between disorder and normality, disorder co-occurrence in the modal case, heterogeneity of presentation within dis-orders, and instability of diagnosis within patients. This paper reviews the evidence on the validity and utility of the disinhibited externalizing and antagonistic externalizing spectra of HiTOP, which together constitute a broad externalizing superspectrum. These spectra are composed of elements subsumed within a variety of mental disorders described in recent DSM nosologies, including most notably substance use disorders and "Cluster B" personality disorders. The externalizing superspectrum ranges from normative levels of impulse control and self-assertion, to maladaptive disinhibition and antagonism, to extensive polysubstance involvement and personality psychopathology. A rich literature supports the validity of the externalizing superspectrum, and the disinhibited and antagonistic spectra. This evidence encompasses common genetic influences, environmental risk factors, childhood antecedents, cognitive abnormalities, neural alterations, and treatment response. The structure of these validators mirrors the structure of the phenotypic externalizing superspectrum, with some correlates more specific to disinhibited or antagonistic spectra, and others relevant to the entire externalizing superspectrum, underlining the hierarchical structure of the domain. Compared with traditional diagnostic categories, the externalizing superspectrum conceptualization shows improved utility, reliability, explanatory capacity, and clinical applicability. The externalizing superspectrum is one aspect of the general approach to psychopathology offered by HiTOP and can make diagnostic classification more useful in both research and the clinic.

A systematic review of transdiagnostic risk and protective factors for general and specific psychopathology in young people

A large body of research has emerged over the last decade examining empirical models of general and specific psychopathology, which take into account comorbidity among psychiatric disorders and enable investigation of risk and protective factors that are common across disorders. This systematic review presents findings from studies of empirical models of psychopathology and transdiagnostic risk and protective factors for psychopathology among young people (10-24 years). PsycInfo, Medline and EMBASE were searched from inception to November 2020, and 41 studies were identified that examined at least one risk or protective factor in relation to broad, empirically derived, psychopathology outcomes. Results revealed several biological (executive functioning deficits, earlier pubertal timing, genetic risk for ADHD and schizophrenia, reduced gray matter volume), socio-environmental (stressful life events, maternal depression) and psychological (low effortful control, high neuroticism, negative affectivity) transdiagnostic risk factors for broad psychopathology outcomes, including general psychopathology, internalising and externalising. Methodological complexities are discussed and recommendations for future studies of empirical models of psychopathology are presented. These results contribute to a growing body of support for transdiagnostic approaches to prevention and intervention for psychiatric disorders and highlight several promising avenues for future research.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

The Development of Preliminary HiTOP Internalizing Spectrum Scales

As part of a broader project to create a comprehensive self-report measure for the Hierarchical Taxonomy of Psychopathology consortium, we developed preliminary scales to assess internalizing symptoms. The item pool was created in four steps: (a) clarifying the range of content to be assessed, (b) identifying target constructs to guide item writing, (c) developing formal definitions for each construct, and (d) writing multiple items for each construct. This yielded 430 items assessing 57 target constructs. Responses from a heterogeneous scale development sample (N = 1,870) were subjected to item-level factor analyses based on polychoric correlations. This resulted in 39 scales representing a total of 213 items. The psychometric properties of these scales replicated well across the development sample and an independent validation sample (N = 496 adults). Internal consistency analyses established that most scales assess relatively narrow forms of psychopathology. Structural analyses demonstrated the presence of a strong general factor. Additional analyses of the 35 nonsexual dysfunction scales revealed a replicable four-factor structure with dimensions we labeled Distress, Fear, Body Dysmorphia, and Mania. A final set of analyses established that the internalizing scales varied widely-and consistently-in the strength of their associations with neuroticism and extraversion.