Ethical issues when conducting health research with military personnel: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to understand the scope and nature of evidence in relation to the ethical issues that arise when conducting health research with military personnel.

INTRODUCTION

Ethical obligations in human research have been debated for centuries. Historically, research conducted with military personnel has led to ethical controversies regarding autonomy, harm, and informed consent. In particular, the power dynamics, hierarchical nature, and culture that are inherent in military structures may compromise the voluntary nature of research participation.

INCLUSION CRITERIA

This scoping review will include all sources of evidence that identify ethical issues, such as autonomy, beneficence, non-maleficence, and justice, within health research with military personnel, including reservists. This review will exclude sources of evidence on health research conducted during combat or on new technologies for fighting in wars.

METHODS

This scoping review will be conducted in accordance with the JBI methodology for scoping reviews. A 3-step search strategy will be used to obtain both published and unpublished sources of evidence. Two independent reviewers will screen sources of evidence against the inclusion and exclusion criteria. No limits on language will be applied; we will use Google Translate to translate sources of evidence in languages other than English. Sources of evidence published since 1964 will be included. Data will be extracted using a purpose-designed spreadsheet and the results will be summarized descriptively and presented in tabular format.

REVIEW REGISTRATION

Open Science Framework https://osf.io/db85p.

Adolescent self-harm: Parents' experiences of supporting their child and help-seeking

Self-harm in children and adolescents is a growing public health issue. Parents are forefront in identifying, responding to and supporting their child to seek help. A sequential mixed-method study which included an online survey (N = 37) and a semi-structured interview (n = 10) was conducted to understand parents' experiences of supporting and accessing help for their child. Parents (M = 45.70 years, SD = 6.18) with a child who has engaged in self-harm behaviours (M = 16.89 years, SD = 3.91) participated. Parents sought help from a range of services and perceived psychiatrists, private psychologists and friends as the most helpful and school psychologists, paediatricians, Emergency Department (ED) and the national youth mental health organisation as the least helpful. Two themes were interpreted from the qualitative data: (1) An emotional journey into the dark unknown, and (2) The promise of psychological help. A series of recommendations for other parents in similar situations, as well as health professionals were made. Parents want health professionals to provide appropriate referrals, work collaboratively with families, meaningfully connect with and validate parents, provide practical and psychological support for families and establish parent support groups. There remains a need for widely available evidence-informed resources, information and support for parents.

Mind-mindedness and preschool children's behavioral difficulties: The moderating role of maternal parenting distress

Mind-mindedness (MM) is a caregiver's tendency to appreciate their infant's internal mental states. This longitudinal study investigated whether maternal MM (10 months) was linked with children's later behavioral problems (51 months) and the moderating role of maternal parenting distress (PD; 36 months) in a sample of 91 mother-infant dyads. Appropriate MM comments were coded from video-recorded, semi-structured play interactions between mothers and their infants; PD was obtained from maternal completion of the PD subscale of the Parenting Stress Index - Short Form (PSI-SF); and child internalizing and externalizing behavior problems were gathered from maternal report on the Strengths and Difficulties Questionnaire (SDQ). Moderated regression analyses revealed higher early appropriate MM was associated with significantly fewer internalizing emotional problems at 51 months among mothers with lower PD at 36 months, and higher early appropriate MM was associated with lower conduct problems at 51 months in mothers with higher PD at 36 months. Findings demonstrated the importance of considering nuanced contexts such as at-risk mothers and differential presentations of child difficulties in the analysis of the relationship between MM and child behavioral difficulties and the development of MM interventions.

Antenatal mind-mindedness and its relationship to maternal-fetal attachment in pregnant women

In this study, researchers aimed to investigate whether a relationship exists between maternal-fetal attachment (MFA) and antenatal mind-mindedness in a sample of Australian pregnant women (n = 43). Participants completed the Maternal Fetal Attachment Scale (MFAS) in their second and third trimester, and a modified 'describe your baby' interview with the inclusion of general prompts as a measure of antenatal mind-mindedness in their third trimester. Positive correlations were observed between mental comments, but not total predictions, made by women during the modified antenatal mind-mindedness task and MFAS scores at the second and third trimesters. An average of 6.07 total predictions and 1.30 mental predictions were made before prompts, increasing to 17.65 total comments and 6.58 mental comments after prompts. Prompts within the mind-mindedness task resulted in 42 participants making at least one mental prediction (M = 6.58). Our findings provide the first evidence for a relationship between MFA and antenatal mind-mindedness, and highlight the importance of considering mind-mindedness during pregnancy in the developing bond from mother to baby.

Salivary testosterone and cortisol levels in borderline personality disorder before and after a 12-week group dialectical behavior therapy intervention

Background

Borderline Personality Disorder (BPD) is a chronic, debilitating, and difficult to treat condition. BPD has recently been linked to steroid hormone dysregulation and medical conditions characterized by disturbed androgen metabolism. This study aimed to investigate cortisol and testosterone levels in BPD, and changes in hormones following psychological treatment.

Methods

Participants with BPD (n = 33) completed a 12-week Dialectical Behavior Therapy group program. Pre and post salivary testosterone and cortisol were analyzed. Baseline hormones in the BPD group were compared to age-and-sex matched controls (n = 33). Non-parametric tests were utilized to investigate group differences, pre-post treatment hormone and symptom changes, and associations between symptoms and hormone levels.

Results

Participants with BPD had significantly higher testosterone levels than controls. Mean testosterone levels in females with BPD were double that of female controls. Testosterone and cortisol levels were related, and some BPD symptoms were associated with with hormone levels. BPD symptoms reduced significantly with treatment, however pre to post hormone levels did not change.

Conclusions

This study supports an association between BPD symptoms and neuroendocrine dysfunction at baseline, however we found no reduction in hormone dysfunction post treatment. Further research into relationships between stress signaling and neuroendocrine disturbances in BPD may inform aetiological and treatment models.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12618000477224. Registered on 3 April 2018.

The social and emotional wellbeing needs of Aboriginal staff in out of home care: Walking in two worlds

BACKGROUND

There is a disproportionate representation of Aboriginal children in the Australian Out of Home Care system. An important strategy to ensure Aboriginal children experience trauma informed care that is culturally situated is to have access to Aboriginal practitioners. The experiences of Aboriginal practitioners working in Aboriginal Out of Home Care have not been explored thoroughly.

PARTICIPANTS AND SETTING

This community led research was undertaken on Dharawal Country on the South Coast of the Illawarra region, Australia with an Out of Home Care program managed by an Aboriginal Community Controlled Organisation. The study included Aboriginal (n = 50) and non-Aboriginal (n = 3) participants connected through employment or community membership to the organisation.

OBJECTIVE

We aimed to explore the wellbeing needs of Aboriginal practitioners working with Aboriginal children in Aboriginal Out of Home Care.

METHODS

This co-designed qualitative research project used yarning sessions (individual and group), co-analysis with co-researchers, document analysis and reflexive writing.

FINDINGS

Aboriginal practitioners are required to bring their cultural expertise to their work and with this, there is an expectation of cultural leadership and the fulfilling of cultural responsibilities. These elements bring with them emotional labour that must be acknowledged and accounted for in working in the Out of Home Care sector.

CONCLUSION

The findings point to the importance of establishing an organisational social and emotional wellbeing framework in recognition of Aboriginal practitioner's specific needs, centring cultural participation as a key wellbeing and trauma informed strategy.

Patient perspectives on non-response to psychotherapy for borderline personality disorder: a qualitative study

BACKGROUND

Despite increasing evidence for the effectiveness of psychotherapy for Borderline Personality Disorder (BPD), estimates show that approximately half of those in treatment do not clinically improve or reach reliable change criteria. There are limited qualitative descriptions of treatment factors associated with non-response from the perspectives of those struggling to improve.

METHOD

Eighteen people (72.2% female, mean age 29.4 (SD = 8)) with experience of receiving psychotherapeutic treatment for BPD were interviewed to obtain their perspectives on hindering factors in treatment and what may be helpful to reduce non-response. The data in this qualitative study was analysed thematically.

RESULTS

Four domains were created from the insights patients shared on non-response and what may be needed to mitigate it. The focus of Domain 1 was that therapy cannot be effective until two factors are in place. First, the patient needs sufficient safety and stability in their environment in order to face the challenges of therapy. Second, they need to be able to access therapy. Domain 2 described factors the patients themselves contribute. The themes in this domain were described as phases that need to be progressed through before therapy can be effective. These phases were ceasing denial that help is warranted and deserved, taking responsibility for behaviours that contribute to unwellness, and committing to the hard work that is required for change. Domain 3 described how the lack of a safe alliance and ruptures in the safety of the relationship with the therapist can contribute to non-response. Domain 4 was comprised of factors that patients identified as supportive of moving through the barriers to response. The first theme in this domain was prioritising the safety of the therapy relationship. The second theme was giving a clear diagnosis and taking a collaborative approach in sessions. The final theme described the importance of focusing on practical goals with the patient to create tangible life changes.

CONCLUSION

This study found that non-response is complex and multifaceted. First, it is clear that systems need to be in place to support access to adequate care and foster life stability. Second, considerable effort may be needed at the engagement phase of therapy to clarify expectations. Third, attention to specific interpersonal challenges between patients and therapists is an important focus. Finally, structured work to improve relationships and vocational outcomes is indicated.

A Systematic Review of Child to Parent Violence Interventions

Objective: To identify, appraise and synthesize research on the interventions used in child to parent violence. Method: A systematic literature review was conducted using the electronic databases of PsycINFO, Scopus, Web of Science and CINAHL Full Text. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, three authors conducted the screening process which was implemented in two stages including screening the title and abstract, followed by screening the full text. Papers were assessed for quality using the Mixed Methods Assessment Tool. The search identified 727 studies which met the inclusion criteria, deduplication resulted in 525 number for review, with 8 articles included in the review. Results: This review identifies six themes from the six unique interventions included to address the research questions: How do practitioners effectively support families experiencing child-to-parent violence? The six themes are: Conceptualising the violence; Assessment of needs and risks; Intervention types and settings; Program techniques and components of interventions; Intervention outcomes and effectiveness; and Research design and methods. Three narratives were iteratively developed from these themes which highlight the main findings of the review: importance of the practitioner and their skills; conceptual clarity of CPV; and CPV interventions. Conclusions: The findings from this systematic review identifies the need for further research into child to parent violence including what makes interventions effective, what needs and outcomes the interventions are addressing, and the implications of classifications of this violence.

What aspects of mindfulness and emotion regulation underpin self-harm in individuals with borderline personality disorder?

BACKGROUND

Self-harm presents significant risk for individuals with borderline personality disorder (BPD). Both self-harm and BPD are associated with deficits in mindfulness and emotion dysregulation. Previous research suggests that thought suppression and emotional inexpressivity may underpin self-harm in people with BPD, suggesting potential links to self-harm functions common for those with BPD. More research is needed to strengthen our understanding of this relationship.

AIMS

This study examines how BPD symptoms, mindfulness, emotion dysregulation and self-harm functions are related.

METHODS

Australian community outpatients diagnosed with BPD (N = 110) completed measures of mindfulness, emotion dysregulation and self-harm functions. Serial mediation analyses were conducted to examine relationships between variables.

RESULTS

BPD symptoms, chronic emptiness, mindfulness skills, describing and non-reacting, emotion dysregulation areas of emotion regulation strategies and poor emotional clarity were associated with recent self-harm. Various combinations of describing, strategies and clarity mediated the path between emptiness and self-harm functions more likely to be endorsed by individuals with a diagnosis of BPD. Describing was associated with all but anti-suicide function, while strategies was associated with all but anti-dissociation.

CONCLUSION

The study highlights how individuals with BPD experiencing chronic emptiness may benefit from treatment targeting describing skills and adaptive emotion regulation strategies.

Sex differences in borderline personality disorder: A scoping review

Borderline Personality Disorder (BPD) is often perceived to be a female-predominant disorder in both research and clinical contexts. Although there is growing recognition of possible sex differences, the current literature remains fragmented and inconclusive. This scoping review aimed to synthesize available research evidence on potential sex differences in BPD. PsycINFO, PubMed, Scopus and Web-of-Science were searched from January 1982 to July 2022 surrounding the key concepts of sex and BPD. Data searching and screening processes followed the Joanna Briggs Institute methodology involving two independent reviewers, and a third reviewer if necessary, and identified 118 papers. Data regarding BPD symptoms, comorbid disorders, developmental factors, biological markers, and treatment were extracted. Data was summarized using the vote counting method or narrative synthesis depending on the availability of literature. Males with BPD were more likely to present externalizing symptoms (e.g., aggressiveness) and comorbid disorders (e.g., substance use), while females with BPD were more likely to present internalizing symptoms (e.g., affective instability) and comorbid disorders (e.g., mood and eating disorders). This review also revealed that substantially more research attention has been given to overall sex differences in baseline BPD symptoms and comorbid disorders. In contrast, there is a dearth of sex-related research pertaining to treatment outcomes, developmental factors, and possible biological markers of BPD. The present scoping review synthesized current studies on sex differences in BPD, with males more likely to present with externalizing symptoms in contrast to females. However, how this might change the prognosis of the disorder or lead to modifications of treatment has not been investigated. Most studies were conducted on western populations, mainly North American (55%) or European (33%), and there is a need for future research to also take into consideration genetic, cultural, and environmental concomitants. As the biological construct of 'sex' was employed in the present review, future research could also investigate the social construct 'gender'. Longitudinal research designs are needed to understand any longer-term sex influence on the course of the disorder.

'He's out of control, I'm out of control, it's just - I've got to do something': a narrative inquiry of child to parent violence

Families globally experience child to parent violence (CPV). Stories of CPV have been considered at an individual and collective level to ascertain themes in parents' accounts to identify enabling and restraining factors for CPV. However, understanding the societal narratives, defined as discourses, which have a multi-directional and entangled relationship with individual recounts of CPV have yet to be investigated. This research utilizes Narrative Inquiry with participatory approaches to explicate the societal narratives within mothers' recounts of CPV. This analysis, guided by the interactional and discursive view of violence, and response-based practice, identifies societal narratives which set the conditions for what is possible and impossible in relation to CPV. The analysis contributes to understanding the attitudes of minimization and concealment of violence within parents' accounts of CPV. The mothers' recounts were constrained and made possible by the 'good' mother narrative and narratives of adolescence and gender. This research examines the intra-actions mothers' recounts have with the societal narratives, and the performance of their roles as (en)actors of the subject positions 'mother' and 'child'. Implications for practice and research include: consideration to practitioner's views of power and subject positions in a parent and child relationship when working with CPV; and practitioners to be critical of essentialism and gender in working with CPV. This study posits a practical demonstration for using the response-based practice approach in research; and a way of viewing stories which can be incorporated in working with families experiencing CPV.

Pathological narcissism: An analysis of interpersonal dysfunction within intimate relationships

Pathological narcissism is marked by deficits in psychosocial functioning. Difficulties in relationships include instances of aggression, devaluation and control; however, few studies have examined these relationships from the perspective of partners and family members. We studied participants who were in relationships with relatives high in narcissistic traits (N = 436; current romantic partners [57.3%]; former romantic partners [21.1%]; family members [15.4%]). Participant responses were analysed thematically, and their underlying mental health problems were also measured. Thematic analysis of participant responses indicated themes of abuse from the relative with narcissism (physical, verbal, emotional and sexual) as well as the relative imposing challenging financial and sexual behaviours. There were complex interpersonal themes of mutual idealization but also devaluation. In response, participants reported high levels of anxiety, depression, self-aggression, sickness and somatic concerns. Further, participants expressed overt outward hostility towards their relative with narcissism, but also dependency strivings and frustrated dependency themes. Partners and their relative with narcissism appeared locked into interpersonal and intrapersonal dynamic conflicts. Clinical implications include specific attendance to alliance issues, dependency themes, and a focus on limit setting to establish personal safety.

To love and work: A longitudinal study of everyday life factors in recovery from borderline personality disorder

Although recovery from borderline personality disorder (BPD) is common, not all individuals improve over time. This study sought to examine the features that contribute to response or non-response for individuals at different stages of recovery from BPD over a longitudinal follow-up. Participants were individuals with a diagnosis of BPD that were followed up after 1 year of receiving psychological treatment. There were no significant differences between participants at intake across key indices; however, at 1-year follow-up, two groups were distinguishable as either 'functioning well' (n = 23) or 'functioning poorly' (n = 25) based on symptomatology and functional impairment. Participant qualitative responses were analysed thematically and via Leximancer content analysis. Thematic analysis indicated three key themes: (1) love of self and others, (2) making a contribution through work and study and (3) stability in daily life. Participants who were 'functioning well' described meaningful relationships with others, enjoyment in vocation, and described less frequent or manageable life crises. The 'functioning poorly' group described relationship conflicts, vocational challenges, feelings of aimlessness and purposelessness, instability in daily living and frequent crises. Leximancer content analysis visually depicted these divergent thematic nomological networks. Corroborating quantitative analyses indicated significant differences between these groups for social, occupational and symptom profiles. These findings highlight the centrality of achieving the capacity to 'love and work' in fostering a sense of personal recovery. Treatments may need specific focus on these factors, as they appeared to reinforce symptomatic trajectories of either improvement or poor non-response to therapy.

The role of pregnancy acceptability in maternal mental health and bonding during pregnancy

BACKGROUND

Pregnancy is an important time for women's mental health and marks the foundations of the emerging bond between mother and baby. This study aimed to investigate the role of pregnancy acceptability and intendedness in maternal mental health and bonding during pregnancy.

METHODS

Data were collected from a community sample of 116 Australian pregnant women (M = 29.54, SD = 5.31) through a series of self-report questionnaires pertaining to mental health and antenatal bonding.

RESULTS

Lower pregnancy acceptability was correlated with higher depression, anxiety and total distress, lower physical and environmental quality of life and lower antenatal bonding. Women who reported their pregnancy was intended reported higher physical quality of life than those who reported their pregnancy was unintended. The relationship between total distress and antenatal bonding was moderated by women's degree of pregnancy acceptability (low versus high). For women with low acceptability, higher distress was associated with lower bonding, but there was no such association for women with high pregnancy acceptability. The moderation model examining associations between distress and pregnancy acceptability explained 15% of the variance in antenatal bonding scores.

CONCLUSION

Consideration of women's appraisal of their pregnancy acceptability may provide a valuable framework for identifying individuals who may be at risk for mental health and bonding difficulties.

Prevalence, Response and Management of Self-harm in School Children Under 13 Years of Age: A Qualitative Study

Research suggests that the incidents of self-harm among young people are increasing and age of onset of self-harm is decreasing. There is limited understanding of how widespread the problem of self-harm among younger school students is, and how schools respond to these incidents. This study used an in-depth qualitative approach to understand self-harm in children under 13, and how elementary schools respond including typical actions, support for the child and parental involvement. School psychologists in New South Wales, Australia (n = 17; 78% females), completed in-depth interviews detailing types of self-harm, prevalence and frequency, and how these incidents were managed, including student intervention approaches and participation of parents. Thematic analysis of interviews was conducted. Psychologists estimated the prevalence of self-harm in their schools was 6.5% and was increasing, with an average age of onset of 10.8 years. Self-harm was most often understood as a coping mechanism associated with anxiety, stress and being bullied. Six themes emerged from the interviews. School psychologists reported that self-harm occurs less frequently in primary school children than high school children, but noted these behaviours still require early intervention. Participants felt they were limited in the support they can provide students who self-harm, and wanted more training for all school staff and parents in identifying and responding to student self-harm. School psychologists are important in identification and management of self-harm, and they report they need further support in helping children who are engaging in self-harm behaviours. Upskilling teachers and parents may assist in reducing rates of self-harm among children.

Parental Response Style to Adolescent Self-Harm: Psychological, Social and Functional Impacts

Adolescent self-harm is a significant public health issue. We aimed to understand how parent stress response styles to their child's self-harm affects their wellbeing and functioning and the wider family. Thirty-seven participants in Australia (parents; 92% female) completed a mixed methods survey regarding their adolescent child's self-harm. We conducted Pearson zero-order correlations and independent t-tests to examine the impact of parent response style on their quality of life, health satisfaction, daily functioning, and mental health. We also used thematic analysis to identify patterns of meaning in the data. Two-thirds of participants reported mental ill health and reduced functional capacity due to their adolescent's self-harm. Parents with a more adaptive response style to stress had better mental health. Qualitative analyses revealed parents experienced sustained feelings of distress and fear, which resulted in behavioural reactions including hypervigilance and parental mental health symptoms. In the wider family there was a change in dynamics and parents reported both functional and social impacts. There is a need to develop psychological support for the adolescent affected and parents, to support more adaptive response styles, and decrease the negative effects and facilitate the wellbeing of the family unit.

Understanding chronic feelings of emptiness in borderline personality disorder: a qualitative study

BACKGROUND

Chronic feelings of emptiness are significant in the lives of people with Borderline Personality Disorder (BPD). Feelings of emptiness have been linked to impulsivity, self-harm, suicidal behaviour and impaired psychosocial function. This study aimed to understand the experience of chronic emptiness, the cognitions, emotions and behaviours linked to emptiness, and clarify the differences between chronic emptiness and hopelessness, loneliness and depression.

METHODS

This study interviewed people (n = 15) with BPD and used a template analysis qualitative approach to understand their experiences of chronic feelings of emptiness.

RESULTS

Chronic feelings of emptiness were experienced as a feeling of disconnection from both self and others, and a sense of numbness and nothingness which was frequent and reduced functional capacity. Feelings of purposelessness and unfulfillment were closely associated with emptiness, and most participants experienced emptiness as distressing. Responses to feelings of emptiness varied, with participants largely engaging in either impulsive strategies to tolerate feelings of emptiness or distracting by using adaptive behaviours. Most participants distinguished chronic feelings of emptiness from loneliness, hopelessness, dissociation, and depression.

CONCLUSIONS

Feelings of chronic emptiness are an important and challenging symptom of BPD which require clinical intervention. Strengthening identity, sense of purpose and vocational and relationship functioning may reduce the intensity of emptiness.

Searching in the dark: Shining a light on some predictors of non-response to psychotherapy for borderline personality disorder

BACKGROUND

Borderline Personality Disorder (BPD) is a prevalent and serious mental health condition. People can experience recovery or remission after receiving psychotherapy for BPD; however, it is estimated that about 45% of people in well conducted treatment trials do not respond adequately to current psychological treatments.

AIM

To further advance psychotherapies for BPD by identifying the factors that contribute to the problem of non-response.

METHOD

184 consecutive participants with BPD in community treatment were naturalistically followed up over 12 months and measures of personality and social functioning were examined. Logistic regressions were used to determine which baseline factors were associated with the likelihood of being a non-responder after 12 months of psychotherapy. After 12 months, 48.4% of participants were classed as non-responders due to a lack of reduction in BPD symptoms according to the Reliable Change Index (RCI) method.

RESULTS

At baseline intake, patients who endorsed an adult preoccupied attachment relationship style and increased anger were more likely to be a non-responder regarding BPD symptoms at 12 months. In addition, those with preoccupied attachment patterns in their adult relationships were more likely to be non-responders regarding general psychological distress at follow up. Higher baseline levels of paranoia and endorsement of a dismissive adult relationship style was associated with being a non-responder in regard to global functioning.

CONCLUSIONS

Consistent with previous research, almost half of the sample did not achieve reliable change at 12-month follow up. A relationship style characterised by preoccupied insecurity and high anger seemed to be particularly challenging in being able to benefit from psychotherapy. This style may have affected both relationships outside, but also inside therapy, complicating treatment engagement and alliance with the therapist. Early identification and modification of treatment based on challenges from these relationship styles may be one way to improve psychotherapy outcomes for BPD.

Now and then: a ten-year comparison of young people in residential substance use disorder treatment receiving group dialectical behaviour therapy

BACKGROUND

Reducing substance use in youth is a global health priority. We compared two cohorts from the same 12-week residential substance use disorder (SUD) facility over a 10 year period: Cohort A (2008-2009) and Cohort B (2018-2020). The essential components of the program remained the same with the primary treatment being dialectical behaviour therapy (DBT) plus residential milieu.

METHODS

Young people in the current Cohort B (N = 100) versus historical Cohort A (N = 102) had a similar ratio of males (74 vs. 70%) but were slightly older (mean 20.6 vs. 19.5 years). Linear mixed models were used to model outcome measures (global psychiatric symptoms, substance use severity, and quality of life) longitudinally up to 12 months later.

RESULTS

Baseline to end-of-treatment comparisons showed that the current Cohort B had overall higher levels of global psychiatric symptoms (d = 0.70), but both groups reduced psychiatric symptoms (Cohort A: d = 1.05; Cohort B: d = 0.61), and had comparable increases in confidence to resist substance use (d = 0.95). Longitudinal data from the current Cohort B showed significant decreases in substance use severity from baseline to 6-month follow-up (d = 1.83), which were sustained at 12-month follow-up (d = 0.94), and increases in quality of life from baseline to end-of-treatment (d = 0.83).

CONCLUSIONS

We demonstrate how DBT plus milieu residential care for young people continues to show positive effects in a 10-year comparison. However, youth seeking treatment today compared to 10 years ago evidenced higher acuity of psychiatric symptoms reinforcing the importance of continuous improvement of psychological treatments.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: trial ID ACTRN12618000866202 , retrospectively registered on 22/05/2018, .

Assessing the efficacy of a stepped-care group treatment programme for borderline personality disorder: study protocol for a pragmatic trial

Background

Borderline personality disorder (BPD) is a high prevalence and serious mental health disorder that has historically challenged the finite resources of health services. Despite empirical evidence supporting structured psychological therapy as the first line of treatment, there remains significant barriers in providing timely access to evidence-based treatment for this population. The primary aim of this study is to evaluate the effectiveness of providing a stepped-care structured psychological group treatment to individuals with BPD within local mental health services. The secondary aims of the study are to identify the variables that predict the need to step up or down in care and the effectiveness of treatment on psychosocial functioning.

Methods

Participants seeking treatment at two community mental health services will be invited to participate. Randomised controlled trial assignment will be to either (i) group skills treatment or (ii) treatment as usual. Group treatment will be offered via a stepped-care pathway with participants initially attending a 12-week group with the option of a subsequent 16-week group. The criteria for inclusion in continuing treatment includes meeting > 4 BPD diagnostic criteria or severity on GAF (< 65) at the completion of the 12-week group. Data will be collected at baseline and at five follow-up time points over a 12-month period.

Discussion

This pragmatic trial will provide valuable information regarding the effectiveness of a progressive stepped-care group treatment for individuals with BPD in the real-world setting of a community mental health service. It will further the current understanding of variables that predict treatment dose and duration.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12618000477224. Registered on 3 April 2018

The relationship between digital media use during pregnancy, maternal psychological wellbeing, and maternal-fetal attachment

The widespread accessibility and use of the internet provides numerous opportunities for women to independently seek out pregnancy-related information and social and emotional support during the antenatal period. Given the heightened psychological vulnerability of the pregnancy period there is a critical need to examine digital media use within the context of the feelings that women have about themselves and towards their fetus. The current study examined the relationship between digital media use during pregnancy, psychological wellbeing and their maternal-fetal attachment using an online survey. Forty-eight pregnant women completed a self-report questionnaire on their reasons for using digital media, and standardised measures of self-criticism, negative affect, social quality of life (QOL), and maternal-fetal attachment. The mean age of participants was 29.4 years (SD = 5.26), with a mean of 24.3 weeks gestation (SD = 9.95). Information seeking, emotional support and social support were highly endorsed reasons for digital media use (85.42%, 66.67%, 62.5% respectively). However, digital media use was positively correlated with negative affect (p = .003) and self-criticism (p < .001). Digital media use was also negatively correlated with QOL (p = .007). There was no evidence of a relationship between digital media use and maternal-fetal attachment (p = .330). Digital environments may be an important social context within which a pregnant woman develops her own maternal identity and knowledge. There are a number of benefits and limitations of this medium for providing information and support for women during pregnancy. Enhancing the opportunities to promote pregnant women's wellbeing in this context is an important avenue for further research and practice.

Pathological Narcissism: A Study of Burden on Partners and Family

Pathological narcissism is characterized by impaired interpersonal functioning, but few studies have examined the impact of the disorder on those living in a close relationship. Participants (N = 683; comprising romantic partners [77.8%], mothers [8.5%] or other family members [10%]) in a close relationship with a relative with pathological narcissism completed measures assessing levels of grief, burden, mental health, and coping style. Participants' reported burden was over 1.5 standard deviations above comparison carers of people with mood, neurotic, or psychotic disorders, and higher than carers of people with borderline personality disorder. Similarly, caseness for depression (69% of sample) or anxiety disorders (82%) in the sample was high. Relationship type, subtype expression (vulnerable/grandiose), and coping style were all found to significantly relate to experienced psychopathology. Although limitations exist regarding sample selection that may influence interpretation of results, these findings quantify the significant interpersonal impact of pathological narcissism in this sample.

Priorities for service improvement in personality disorder in Australia: Perspectives of consumers, carers and clinicians

BACKGROUND

Improvements to service provision for personality disorder has been predominately explored through the perspectives of clinicians, with limited understanding of the views of consumers and carers. The aim of the present study was to understand the priorities for service improvement through multiple perspectives.

METHOD

Twelve roundtables, with a total of 53 consumers, clinicians and carers, discussed how organizations could improve service provision for people with personality disorder and completed a questionnaire on current and optimal service provision. Inductive thematic analysis was used to identify the priorities for service improvement, and we aimed to identify differences between what participants currently receive and what they believe to be optimal.

RESULTS

Four priorities were identified: (1) increasing consumer, carer and peer involvement in care, (2) re-orienting approaches to service provision, (3) improving access and accessibility of treatment and (4) building the capacity of services. Participants were more likely to receive individual or group treatment alone, yet believed combined individual and group treatment to be optimal. Significantly, more participants believed that long-term treatment was optimal.

CONCLUSION

A shift in focus from establishing a consistent approach to servicing, to focusing on holistic care that involves consumers and carers in care, is required. © 2020 The Authors Personality and Mental Health Published by John Wiley & Sons Ltd.

Measuring the shadows: A systematic review of chronic emptiness in borderline personality disorder

BACKGROUND

Chronic feelings of emptiness is an under-researched symptom of borderline personality disorder (BPD), despite indications it may be central to the conceptualisation, course, and outcome of BPD treatment. This systematic review aimed to provide a comprehensive overview of chronic feelings of emptiness in BPD, identify key findings, and clarify differences between chronic feelings of emptiness and related constructs like depression, hopelessness, and loneliness.

METHOD

A PRISMA guided systematic search of the literature identified empirical studies with a focus on BPD or BPD symptoms that discussed chronic feelings of emptiness or a related construct.

RESULTS

Ninety-nine studies met criteria for inclusion in the review. Key findings identified there were significant difficulties in defining and measuring chronic emptiness. However, based on the studies reviewed, chronic emptiness is a sense of disconnection from both self and others. When experienced at frequent and severe levels, it is associated with low remission for people with BPD. Emptiness as a construct can be separated from hopelessness, loneliness and intolerance of aloneness, however more research is needed to explicitly investigate these experiences. Chronic emptiness may be related to depressive experiences unique to people with BPD, and was associated with self-harm, suicidality, and lower social and vocational function.

CONCLUSIONS AND IMPLICATIONS

We conclude that understanding chronic feelings of emptiness is central to the experience of people with BPD and treatment focusing on connecting with self and others may help alleviate a sense of emptiness. Further research is required to provide a better understanding of the nature of chronic emptiness in BPD in order to develop ways to quantify the experience and target treatment. Systematic review registration number: CRD42018075602.

Childbirth satisfaction and perceptions of control: postnatal psychological implications

Background

Satisfaction with childbirth is associated with a number of factors prior to and during birth, including perceived control during labour, and has implications for postnatal psychological health.

Methods

A total of 38 pregnant women recruited prior to 20-weeks gestation completed questionnaires regarding perceptions of control during, and satisfaction with, childbirth, mental health and maternal attachment at two-months postpartum. Birth details and breastfeeding difficulties were obtained from hospital records.

Results

Satisfaction with childbirth was associated with perceived control and a physiological birth, and perceived control was associated with a physiological birth and midwife-led continuity of care. At two-months postpartum, satisfaction with childbirth was associated with fewer depressive symptoms, while perceived control was associated with fewer anxiety symptoms.

Discussion

It is important for healthcare providers to implement practices that support birthing satisfaction, such as provision of midwife-led continuity of care. Healthcare provision should also provide psychological support to mothers whose birthing experience was unsatisfactory and tailor additional support during early breastfeeding for these women.

Parenting stress and competence in borderline personality disorder is associated with mental health, trauma history, attachment and reflective capacity

BACKGROUND

Individuals with borderline personality disorder (BPD) may experience additional challenges in their parenting role, including increased stress and lower self-efficacy and satisfaction. These difficulties have been shown to impact their children, and may be implicated in the potential intergenerational transmission of personality vulnerabilities.

METHODS

Parental stress and competence variables were examined in a cross-sectional study of 284 parents (94.72% female, M = 37.37, SD = 8.04 years), of which 69 (24.30%) met caseness for BPD criteria. We completed a multivariate analysis of variance to test how parents with 'high BPD features' (meeting caseness for BPD) compared to those with 'low BPD features' on a range of parenting and mental health variables. Multivariate linear regression modelling was then utilised to explore whether these parenting variables were associated with personality and psychological wellbeing, recalled trauma history, orientation to attachment relationships and reflective capacity.

RESULTS

Individuals high in BPD features experienced more stress and lower competence in their parenting role than those low in BPD features. These parents also reported more personality vulnerabilities, poorer psychological wellbeing, recalled more traumatic experiences in their childhood, were more likely to endorse insecure attachment styles and had poorer reflective capacity. In the regression model, parenting stress and competence was associated with personality traits, general psychological wellbeing, recalled trauma history, attachment style and reflective capacity variables. Parental reflective capacity had the strongest association with parenting stress, satisfaction, efficacy, the perception of having a difficult child and a difficult parent-child relationship, and psychological wellbeing had the greatest association with parenting distress.

CONCLUSIONS

Parents who were able to imaginatively enter the subjective world of the child and hold the child's mind in mind with less certainty, reported reduced parenting stress and greater parenting satisfaction and efficacy. Helping to improve personality and mental health functioning, increasing parental reflective capacity and strengthening parent-child attachment relationships, may reduce parenting stress and increase parenting competence in individuals with BPD.

Living with personality disorder and seeking mental health treatment: patients and family members reflect on their experiences

BACKGROUND

Despite effective treatments for personality disorders being developed, consumers and carers often report negative experiences of mental health services, including challenges accessing these treatments.

METHODS

This qualitative study used separate focus groups to compare the unique perspectives of consumer and carers, and to investigate how to improve services for individuals with personality disorders. Reflexive thematic analysis was used to analyze the data.

RESULTS

Both consumers and carers (N = 15) discussed the value of providing appropriate information to consumers when they are diagnosed with personality disorder. Consumers and carers described the importance of creating a safe environment for consumers when they present to the emergency department. Both groups discussed experiencing positive and negative treatment from mental health professionals, and suggested that professionals should be trained to understand personality disorder. Limited accessibility and quality of services, and offering peer support to consumers were also described by consumers and carers. Consumers and carers also had perspectives which were unique to their group. Consumers identified the importance of psychological treatment, having a strong therapeutic relationship with a mental health professional, and the benefit of long term psychotherapy with the same professional. Broadening the scope of psychotherapies including creative, animal-assisted, and physical therapies was recommended by consumers. Carers described the importance of assessing for personality disorder and intervening early. Involvement in the assessment, diagnosis, and intervention process was important to carers. The desire to be recognized and supported by mental health professionals was discussed by carers.

CONCLUSIONS

This research contributes to the concern that consumers with personality disorder and their carers experience stigma and low quality care within mental health services. In line with these findings, we recommend guidelines for health professionals who work with consumers with personality disorder.

Using peer workers with lived experience to support the treatment of borderline personality disorder: a qualitative study of consumer, carer and clinician perspectives

BACKGROUND

Peer support is a recovery oriented approach where consumers and carers are introduced to people with lived experience of the disorder who have recovered. Paid roles within health services for such consumer peer workers and carer peer workers (or 'specialists') are increasingly common. To date specific studies on such peer support for consumers with borderline personality disorder (BPD) and their carers has not been conducted.

METHODS

This qualitative study used interviews to explore perceptions and models of peer support for BPD from the perspectives of 12 consumers, 12 carers, and 12 mental health professionals. Participant responses were analyzed using reflexive thematic analysis within a phenomenological methodology.

RESULTS

All groups described how consumer peer workers may provide hope, connection, and validation to a consumer's lived experience. Offering both traditional mental health treatment plus peer support, and giving consumers choice regarding a consumer peer worker was welcomed. Differences in opinion were found regarding the consumer peer worker's role in relation to the mental health team, including whether consumer peer workers should access medical records. Perspectives differed regarding the consumer peer worker and carer peer worker positions, highlighting potential role confusion. Carers discussed the value of receiving support from carer peer workers and consumer peer workers. Mental health professionals described how consumer peer workers can experience workplace stigma and problems with boundary setting, and acknowledged a need for peer workers to be valued by having a duty of care and confidentiality code to follow and be offered supervision.

CONCLUSIONS

Two models of peer support for BPD emerged: an integrated model where consumer peer workers work within the mental health team, and a complementary model where consumer peer workers are separate from the mental health team. Based on these findings we provide recommendations for services to help support such peer work for consumers with BPD and their carers.

Nutrition information in pregnancy: Where do women seek advice and has this changed over time?

AIM

Nutrition during pregnancy is fundamental to both the health of the mother and her baby. Sources of nutrition-related information are available via many sources but their accuracy is unknown. The present study aimed to (a) identify where women source their nutrition information during pregnancy and (2) assess the accuracy of nutrition information for pregnancy that is available on the internet.

METHODS

A survey instrument that identified the main sources of nutrition information was administered to 68 pregnant women recruited online. Data from this survey were compared to previous similar surveys conducted with pregnant mothers across years 2008, 2011 and 2014. A content analysis of websites was simultaneously conducted to assess the accuracy of available information.

RESULTS

The main source of nutrition information for a variety of topics was verbal communication from health professionals (% responses affirmative for that source ranged from 6.6% to 69% across survey years). There was an increasing trend in internet sourced information for most nutrition topics, but this source remained low for iodine across all years (range: 7.3%-15.9%). The internet was the main source of information for listeria/food safety (15.3%-32.4%) and healthy eating (25%-42%). Of the n = 165 websites identified by the content analysis, 82.4% (n = 136) were rated as accurate, with government (96.9%) and business/company (100%) sites having the highest accuracy.

CONCLUSION

Verbal communication from health professionals remains the most important source of nutrition information for pregnancy. The high credibility of websites indicates this to be an additional resource. Further study into health literacy levels among women visiting these sites is needed to assess impact on dietary behaviour.

Evaluation of a brief intervention within a stepped care whole of service model for personality disorder

BACKGROUND

Although there is growing evidence that stepped models of care are useful for providing appropriate, person centered care, there are very few studies applied to personality disorders. A brief, four session, psychological treatment intervention for personality disorder within a whole of service stepped care model was evaluated. The intervention stepped between acute emergency crisis mental health services and longer-term outpatient treatments.

METHODS

Study 1 used service utilization data from 191 individuals referred to the brief intervention at a single community health site in a metropolitan health service. Proportions of individuals retained across the intervention and the referral pathways accessed following the intervention were examined. Study 2 examined 67 individuals referred to the brief intervention across 4 different sites in metropolitan health services. A range of measures of symptoms and quality of life were administered at the first and last session of the intervention. Effect sizes were calculated to examine mean changes across the course of the intervention.

RESULTS

Study 1 found that 84.29% of individuals referred to the intervention attended at least 1 session, 60.21% attended 2 sessions or more and 41.89% attended 3 or more sessions. 13.61% of the sample required their care to be "stepped up" within the service, whereas 29.31% were referred to other treatment providers following referral to the intervention. Study 2 found a significant reduction in borderline personality disorder symptom severity and distress following the intervention, and an increase in quality of life. The largest reduction was found for suicidal ideation (d = 1.01).

CONCLUSIONS

Brief psychological intervention was a useful step between acute services and longer-term treatments in this stepped model of care for personality disorder. Suicide risk and symptom severity reduced and quality of life improved, with only a small proportion of individuals requiring ongoing support from the health service following the intervention.

Parenting and personality disorder: An overview and meta-synthesis of systematic reviews

BACKGROUND/OBJECTIVES

Maladaptive parenting (including childhood maltreatment, abuse and neglect) has been implicated in the scientific literature exploring the aetiology of personality disorder, particularly borderline personality disorder (BPD). Our primary objective was to summarise the evidence on the relationship between parenting and personality disorder, assisting clinical decision-makers to translate this research into clinical policy and practice.

METHODS

We conducted an overview of systematic reviews that assessed individuals with personality disorder pathology for experiences of maladaptive parenting, compared to psychiatric or healthy comparisons/controls, and the impact on psychopathological and relational outcomes. Systematic literature searches were conducted in Scopus, Web of Science, MEDLINE, PsycINFO, and by hand in August 2018. Methodological quality was assessed using the CASP systematic review checklist, and results were qualitatively synthesised. A pre-determined protocol was registered in Prospective Register of Systematic Reviews (PROSPERO 2019:CRD42018096177).

RESULTS

Of the 312 identified records, 293 abstracts were screened, 36 full-text articles were retrieved and eight systematic reviews met pre-determined criteria for qualitative synthesises. The majority of studies reported outcomes related to BPD (n = 7), and study design, methodology and quality varied. Within the eight systematic reviews there were 211 primary studies, of which 140 (66.35%) met eligibility criteria for inclusion in this overview. Eligible primary studies reported on 121,895 adult, child/adolescent and parent-offspring participants, with most studies focused on borderline personality pathology (n = 100, 71.43%). Study design and methodology also varied for these studies. Overall, five systematic reviews overwhelming found that maladaptive parenting was a psychosocial risk factor for the development of borderline personality pathology, and three studies found that borderline personality pathology was associated with maladaptive parenting, and negative offspring and parenting-offspring outcomes.

CONCLUSIONS

In light of these findings, we recommend greater emphasis on parenting in clinical practice and the development of parenting interventions for individuals with personality disorder. However, our understanding is limited by the heterogeneity and varying quality of the evidence, and as such, future research utilising more rigorous research methodology is needed.

The residential status of children whose parents are in treatment for methamphetamine use

INTRODUCTION AND AIMS

Methamphetamine (MA) use has increased markedly over the past decade, during which time there has been an increase in children in out of home care. This study explores whether MA use in parents attending residential treatment services for substance use issues is associated with higher proportions of children living out of the home.

DESIGN AND METHODS

Data were collected from individuals attending residential treatment centres provided by the Australian Salvation Army between 2009 and 2016. Centres provide residential alcohol and other substance use treatment in a modified therapeutic community. Trained staff administered sections of the Addiction Severity Index measuring substance use, legal and parenting status, and the Mental Health Screening Form-III at intake. Data were limited to those who had at least one child under 18 years; final sample size was 2964.

RESULTS

Of the 2964 parents, 36.3% nominated MAs use as a primary or secondary substance of use. Between 2011 and 2016, a significantly greater proportion of parents using MAs (86.1%), had at least one child not living at home compared to those using other substances (81.3%; χ² =7.95, P = 0.005). The proportion of female parents increased significantly 14.7% (2009) to 37.9% (2016; χ² = 51.54, P < 0.001). Also, more males (83.7%) than females (79.6%) had a child living out of home (χ² = 11.23, P = 0.01).

DISCUSSION AND CONCLUSIONS

Given that MA use can result in increased risks of violence and neglect the increase in parents using the substance is concerning. The growing number of mothers in treatment warrants further investigation, particularly as women face inherent difficulties in seeking treatment with dependent children.

Illawarra Born cross-generational health study: feasibility of a multi-generational birth cohort study

Background

There is a strong interest in the concept of developmental origins of health and disease and their influence on various factors “from cradle to grave”. Despite the increasing appreciation of this lifelong legacy across the human life course, many gaps remain in the scientific understanding of mechanisms influencing these formative phases. Cross-generational susceptibility to health problems is emerging as a focus of research in the context of birth cohort studies.

The primary aim of the Illawarra Born study is to make scientific discoveries associated with improving health and wellbeing across the lifespan, with a particular focus on preventable chronic diseases, especially mental health. This birth cohort study will follow and collect data from three cohorts representing different stages across the lifespan: infants, adults (parents) and older adults (grandparents). The multi-generational, cross-sectional and longitudinal design of this birth cohort study supports a focus on the contributions of genetics, environment and lifestyle on health and wellbeing. The feasibility of conducting a multi-generational longitudinal birth cohort project was conducted through a small pilot study.

Methods/design

The purpose of this paper is to report on the feasibility and acceptability of the research protocol for a collaborative cross-generation health study in the community and test recruitment and outcome measures for the main study. This feasibility study included pregnant women who were intending to give birth in the Illawarra-Shoalhaven region in Eastern Australia. The area includes a large, regional referral hospital, with capacity to treat specialist and complex cases. Pregnant women were asked to participate in five data collection waves beginning at 22 weeks gestation and ending with a 6-month post-partum appointment. Recruitment was then extended, via the pregnant women, to also include fathers and maternal grandmothers.

Discussion

This feasibility study focused on the perinatal period and collected data across three multi-disciplinary domains including mental health, diet, exposures to toxins and the role of these in maternal and infant outcomes. Forty-one families participated in extensive data collection from 22 weeks gestation to 6-months post-partum. Factors impacting on viability and feasibility including recruitment solutions provide the basis for a large-scale study.

The lived experience of recovery in borderline personality disorder: a qualitative study

BACKGROUND

The concept of recovery in borderline personality disorder (BPD) is not well defined. Whilst clinical approaches emphasise symptom reduction and functioning, consumers advocate for a holistic approach. The consumer perspective on recovery and comparisons of individuals at varying stages have been minimally explored.

METHOD

Fourteen narratives of a community sample of adult women with a self-reported diagnosis of BPD, were analysed using qualitative interpretative phenomenological analysis to understand recovery experiences. Individuals were at opposite ends of the recovery continuum (seven recovered and seven not recovered).

RESULTS

Recovery in BPD occurred across three stages and involved four processes. Stages included; 1) being stuck, 2) diagnosis, and 3) improving experience. Processes included; 1) hope, 2) active engagement in the recovery journey, 3) engagement with treatment services, and 4) engaging in meaningful activities and relationships. Differences between individuals in the recovered and not recovered group were prevalent in the improving experience stage.

CONCLUSION

Recovery in BPD is a non-linear, ongoing process, facilitated by the interaction between stages and processes. Whilst clinical aspects are targets of specialist interventions, greater emphasis on fostering individual motivation, hope, engagement in relationships, activities, and treatment, may be required within clinical practice for a holistic recovery approach.

A 1-year follow-up study of capacity to love and work: What components of borderline personality disorder most impair interpersonal and vocational functioning?

BACKGROUND

For individuals with borderline personality disorder (BPD), both the reduction in symptoms and the improvement of vocational and interpersonal function (psychosocial function) are important for recovery. Research suggests that some components of BPD make it harder to achieve functional recovery; however, findings are varied and inconclusive. The present study assesses recovery over time in BPD, investigates which symptoms make it harder to function and explores the relationships between these symptoms.

METHOD

One hundred ninety-nine consecutively recruited individuals in psychological treatment for personality disorder were studied over 12 months. Measures of BPD symptom severity at intake were used to predict improvements in social and vocational function at follow-up. Exploratory modelling was conducted to understand the relationships between symptoms and function.

RESULTS

Following 12 months of treatment, symptoms and functioning improved. Those who experienced more severe emptiness, impulsivity and self-harm had worse outcomes. A relationship between chronic emptiness at intake and impaired vocational outcome (days out of work) at follow-up was found, mediated by severity of impulsivity and frequency of self-harm.

CONCLUSION

Chronic emptiness is associated with dysfunctional behaviours such as impulsivity and self-harm, and poor psychosocial improvement. Interventions targeting chronic emptiness in those most vulnerable may improve functional outcomes. © 2018 John Wiley & Sons, Ltd.

A whole of school intervention for personality disorder and self-harm in youth: a pilot study of changes in teachers' attitudes, knowledge and skills

BACKGROUND

The school environment offers an ideal opportunity for early identification and intervention for youth with self-harm and complex mental health issues, such as borderline personality disorder (BPD). Yet, class teachers often report minimal knowledge, feeling ill-equipped to respond, and experience high levels of stress when exposed to such challenges. Research is required to understand how training and development activities led by school counsellors may enhance teacher attitudes, confidence and knowledge of self-harm and complex mental health issues, such as BPD. We aimed to explore the extent that a whole of school initiative might enhance capacity for early identification and intervention.

METHOD

18 secondary schools implemented a manualised program, Project Air Strategy for Schools. N = 400 class teachers (71.3% female, mean age 42 years) across city and rural locations were evaluated before and after program implementation on attitudes, knowledge and skills.

RESULTS

Providing class teachers with additional training on complex mental health issues and associated behaviours such as self-harm was well received. Participants reported post-program improvements in their optimism (d = .35), confidence (d = .63), knowledge (d = .73) and skills (d = 0.67) in working with young people with complex mental health issues, such as BPD.

CONCLUSIONS

Providing school counsellor led structured approaches, to help class teachers identify and respond to youth in distress, closed identified gaps. Results indicated improvements in class teachers' knowledge and attitudes towards self-harm and BPD. The intervention also improved the capacity of schools to plan and implement strategies to reduce the impact of mental health problems on the young person and their peers. A stay-at-school psychological care approach was fostered by enhancing partnerships between class teachers and school counsellors.

Personality disorder: A mental health priority area

Personality disorders have received limited recognition as a public health priority, despite the publication of treatment guidelines and reviews showing effective treatments are available. Inclusive approaches to understanding and servicing personality disorder are required that integrate different service providers. This viewpoint paper identifies pertinent issues surrounding early intervention, treatment needs, consumer and carer experiences, and the need for accurate and representative data collection in personality disorder as starting points in mental health care reform.

Longitudinal Intergenerational Birth Cohort Designs: A Systematic Review of Australian and New Zealand Studies

Background

The longitudinal birth cohort design has yielded a substantial contribution to knowledge of child health and development. The last full review in New Zealand and Australia in 2004 identified 13 studies. Since then, birth cohort designs continue to be an important tool in understanding how intrauterine, infant and childhood development affect long-term health and well-being. This updated review in a defined geographical area was conducted to better understand the factors associated with successful quality and productivity, and greater scientific and policy contribution and scope.

Methods

We adopted the preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach, searching PubMed, Scopus, Cinahl, Medline, Science Direct and ProQuest between 1963 and 2013. Experts were consulted regarding further studies. Five inclusion criteria were used: (1) have longitudinally tracked a birth cohort, (2) have collected data on the child and at least one parent or caregiver (3) be based in Australia or New Zealand, (4) be empirical in design, and (5) have been published in English.

Results

10665 records were initially retrieved from which 23 birth cohort studies met the selection criteria. Together these studies recruited 91,196 participants, with 38,600 mothers, 14,206 fathers and 38,390 live births. Seventeen studies were located in Australia and six in New Zealand. Research questions initially focused on the perinatal period, but as studies matured, longer-term effects and outcomes were examined.

Conclusions

This review demonstrates the significant yield from this effort both in terms of scientific discovery and social policy impact. Further opportunities have been recognised with cross-study collaboration and pooling of data between established and newer studies and international studies to investigate global health determinants.

Tigecycline: a new glycylcycline antimicrobial

Tigecycline is a new glycyclcycline antimicrobial recently approved for use in the USA, Europe and elsewhere. While related to the tetracyclines, tigecycline overcomes many of the mechanisms responsible for resistance to this class. It demonstrates favourable in vitro potency against a variety of aerobic and anaerobic Gram-positive and Gram-negative pathogens, including those frequently demonstrating resistance to multiple classes of antimicrobials. This includes methicillin-resistant Staphylococcus aureus, penicillin-resistant S. pneumoniae, vancomycin-resistant enterococci, Acinetobacter baumannii, beta-lactamase producing strains of Haemophilis influenzae and Moraxella catarrhalis, and extended-spectrum beta-lactamase producing strains of Escherichia coli and Klebsiella pneumoniae. In contrast, minimum inhibitory concentrations for Pseudomonas and Proteus spp. are markedly elevated. Tigecycline is administered parenterally twice daily. Randomised, controlled trials have demonstrated that tigecycline is non-inferior to the comparators for the treatment of complicated skin and skin structure infections, as well as complicated intra-abdominal infections. The most frequent and problematic side effect associated with its administration to date has been nausea and/or vomiting.

Germ-line splicing mutation of the p53 gene in a cancer-prone family

Li-Fraumeni syndrome is a rare autosomal dominant susceptibility to a variety of cancers including carcinomas of the breast and the adrenal cortex, tumors of brain and muscle tissue, and leukemias. Affected individuals develop cancer at a young age and often at multiple primary sites. A study has been conducted into the genetic basis of cancer in a particular Li-Fraumeni syndrome family. Examination of p53 as a candidate susceptibility gene revealed that, in two affected individuals, there was an aberrant larger transcript of 3.6 kilobases present in both tumor and constitutional material in addition to the normal-sized 2.8-kilobase transcript. The additional transcript was not found in three unaffected family members. S1 nuclease mapping localized the insertion toward the 5' end of the p53 transcript near exons 4 and 5, and sequencing revealed a point mutation in the splice donor site of intron 4 in the germ-line of the two affected individuals, which accounted for the presence of the larger transcript. The same splicing mutation was also detected in two obligate carriers and was not found in two unaffected individuals. As no mutations were detected in exons 5-8 in either tumor examined, the second p53 allele was most likely lost during tumorigenesis in both tumors. The demonstration of a germ-line splicing mutation in affected individuals from a Li-Fraumeni syndrome family provides for a novel mechanism of p53 inactivation not seen previously in other affected families, in whom the mutations have all been missense.(ABSTRACT TRUNCATED AT 250 WORDS)