Predicting the emergence of full-threshold bipolar I, bipolar II and psychotic disorders in young people presenting to early intervention mental health services.

BACKGROUND: Predictors of new-onset bipolar disorder (BD) or psychotic disorder (PD) have been proposed on the basis of retrospective or prospective studies of 'at-risk' cohorts. Few studies have compared concurrently or longitudinally factors associated with the onset of BD or PDs in youth presenting to early intervention services. We aimed to identify clinical predictors of the onset of full-threshold (FT) BD or PD in this population. METHOD: Multi-state Markov modelling was used to assess the relationships between baseline characteristics and the likelihood of the onset of FT BD or PD in youth (aged 12-30) presenting to mental health services. RESULTS: Of 2330 individuals assessed longitudinally, 4.3% (n = 100) met criteria for new-onset FT BD and 2.2% (n = 51) met criteria for a new-onset FT PD. The emergence of FT BD was associated with older age, lower social and occupational functioning, mania-like experiences (MLE), suicide attempts, reduced incidence of physical illness, childhood-onset depression, and childhood-onset anxiety. The emergence of a PD was associated with older age, male sex, psychosis-like experiences (PLE), suicide attempts, stimulant use, and childhood-onset depression. CONCLUSIONS: Identifying risk factors for the onset of either BD or PDs in young people presenting to early intervention services is assisted not only by the increased focus on MLE and PLE, but also by recognising the predictive significance of poorer social function, childhood-onset anxiety and mood disorders, and suicide attempts prior to the time of entry to services. Secondary prevention may be enhanced by greater attention to those risk factors that are modifiable or shared by both illness trajectories.

Transdiagnostic clinical staging in youth mental health: a first international consensus statement.

Recognizing that current frameworks for classification and treatment in psychiatry are inadequate, particularly for use in young people and early intervention services, transdiagnostic clinical staging models have gained prominence. These models aim to identify where individuals lie along a continuum of illness, to improve treatment selection and to better understand patterns of illness continuity, discontinuity and aetiopathogenesis. All of these factors are particularly relevant to help-seeking and mental health needs experienced during the peak age range of onset, namely the adolescent and young adult developmental periods (i.e., ages 12-25 years). To date, progressive stages in transdiagnostic models have typically been defined by traditional symptom sets that distinguish "sub-threshold" from "threshold-level" disorders, even though both require clinical assessment and potential interventions. Here, we argue that staging models must go beyond illness progression to capture additional dimensions of illness extension as evidenced by emergence of mental or physical comorbidity/complexity or a marked change in a linked biological construct. To develop further consensus in this nascent field, we articulate principles and assumptions underpinning transdiagnostic clinical staging in youth mental health, how these models can be operationalized, and the implications of these arguments for research and development of new service systems. We then propose an agenda for the coming decade, including knowledge gaps, the need for multi-stakeholder input, and a collaborative international process for advancing both science and implementation.

What is the prevalence, and what are the clinical correlates, of insulin resistance in young people presenting for mental health care? A cross-sectional study.

OBJECTIVES: To report the distribution and predictors of insulin resistance (IR) in young people presenting to primary care-based mental health services. DESIGN: Cross-sectional. SETTING: Headspace-linked clinics operated by the Brain and Mind Centre of the University of Sydney. PARTICIPANTS: 768 young people (66% female, mean age 19.7±3.5, range 12-30 years). MAIN OUTCOME MEASURES: IR was estimated using the updated homeostatic model assessment (HOMA2-IR). Height and weight were collected from direct measurement or self-report for body mass index (BMI). RESULTS: For BMI, 20.6% of the cohort were overweight and 10.2% were obese. However, <1% had an abnormally high fasting blood glucose (>6.9 mmol/L). By contrast, 9.9% had a HOMA2-IR score >2.0 (suggesting development of IR) and 11.7% (n=90) had a score between 1.5 and 2. Further, there was a positive correlation between BMI and HOMA2-IR (r=0.44, p<0.001). Participants in the upper third of HOMA2-IR scores are characterised by younger age, higher BMIs and depression as a primary diagnosis. HOMA2-IR was predicted by younger age (ß=0.19, p<0.001) and higher BMI (ß=0.49, p<0.001), together explaining 22% of the variance (F(2,361)=52.1, p<0.001). CONCLUSIONS: Emerging IR is evident in a significant subgroup of young people presenting to primary care-based mental health services. While the major modifiable risk factor is BMI, a large proportion of the variance is not accounted for by other demographic, clinical or treatment factors. Given the early emergence of IR, secondary prevention interventions may need to commence prior to the development of full-threshold or major mood or psychotic disorders.

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

BACKGROUND: Mental disorders and suicidal thoughts and behaviours are common in help-seeking youth. Few studies report the longitudinal associations between these phenomena and clinical and functional outcomes. This study examined whether prior suicide attempts predict poorer outcomes in mental health service attendees. METHODS: Clinical and functional data from 1143 individuals (aged 12-30) attending a primary care-based mental health service in Australia were collected over 3-60 months (median = 21 months). Odds ratios (OR) with 95% confidence intervals for the effect of a prior suicide attempt on follow-up outcomes were estimated (adjusted for confounders). RESULTS: Prior suicide attempts were common (n = 164; 14%) and prospectively associated with suicidal thoughts (OR = 1.71), suicide attempts (OR = 2.59), self-harm (OR = 1.71), an increased likelihood of being diagnosed with bipolar disorder (OR = 2.99), and the onset of an alcohol/substance use disorder (OR = 2.87). Over the course of care, no suicide attempts were reported in 1052 (92%) individuals, but 25 (2%) had recurrent attempts, and 66 (6%) had new onset of an attempt. New onset was associated with being female and previous suicidal ideation or self-harm; recurrent attempts were associated with being older and comorbid alcohol/substance use disorder. LIMITATIONS: The cohort includes only individuals who remained in clinical contact, and the consistency of their documentation varied (across clinicians and over time). CONCLUSIONS: Young people with prior suicide attempts are vulnerable to ongoing suicidal behaviours, and poorer clinical and functional outcomes. More intensive management strategies may be needed to directly address these behaviours and the long-term risks they confer. These behaviours also emerge over the course of care among those with no previous history, which has important implications for active service-level strategies that target these behaviours for all of those who present to such services.

Predicting early transition from sub-syndromal presentations to major mental disorders.

BACKGROUND: Transition from at-risk state to full syndromal mental disorders is underexplored for unipolar and bipolar disorders compared with psychosis. AIMS: Prospective, trans-diagnostic study of rates and predictors of early transition from sub-threshold to full syndromal mental disorder. METHOD: One-year outcome of 243 consenting youth aged 15-25 years with a sub-syndromal presentation of a potentially severe mental disorder. Survival analysis and odds ratio (OR) for predictors of transition identified from baseline clinical and demographic ratings. RESULTS: About 17% (n=36) experienced transition to a major mental disorder. Independent of syndromal diagnosis, transition was significantly more likely in individuals who were NEET (not in education, employment or training), in females and in those with more negative psychological symptoms (e.g. social withdrawal). CONCLUSIONS: NEET status and negative symptoms are modifiable predictors of illness trajectory across diagnostic categories and are not specific to transition to psychosis. DECLARATION OF INTEREST: I.B.H. has been a Commissioner in Australia's National Mental Health Commission since 2012. He was a board member of headspace: National Youth Mental Health Foundation until January 2012. He has led a range of community-based and pharmaceutical industry-supported depression awareness and education and training programmes. He has led projects for health professionals and the community supported by governmental, community agency and pharmaceutical industry partners (Wyeth, Eli Lilly, Servier, Pfizer, AstraZeneca) for the identification and management of depression and anxiety. He has received honoraria for presentations of his own work at educational seminars supported by a number of non-government organisations and the pharmaceutical industry (including Servier, Pfizer, AstraZeneca and Eli Lilly). He is a member of the Medical Advisory Panel for Medibank Private and also a board member of Psychosis Australia Trust. He leads an investigator-initiated study of the effects of agomelatine on circadian parameters (supported in part by Servier) and has participated in a multicentre clinical trial of the effects of agomelatine on sleep architecture in depression and a Servier-supported study of major depression and sleep disturbance in primary care settings. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Differential impact of current diagnosis and clinical stage on attendance at a youth mental health service.

AIM: To examine whether clinical stage of illness and current diagnosis influence appointment behaviour in a specialized primary-level youth mental health service. METHODS: Factors associated with attendance at 8697 appointments made by 828 young people (females = 497) aged 12-25 years over a 1-year period were analysed. RESULTS: The number of appointments made did not correlate with the rates of attendance. However, those with more severe psychiatric morbidity made significantly more appointments and missed significantly more appointments than those with less severe presentations. Impaired social functioning was the best predictor of female attendance rates, whereas age and clinical stage of illness best predicted male attendance rates. Current diagnosis rather than functional impairment appeared to influence the level of input offered by clinicians. CONCLUSIONS: Age, gender, severity of illness, functioning and psychological distress had differential associations with both planned treatment intensity and attendance rates. These differences are likely to have implications for service provision in this youth population.

Treatment patterns and short-term outcomes in an early intervention youth mental health service.

AIM: Early intervention mental health services tailored for young people are being developed across the world, yet reports on service use patterns and short-term clinical outcomes for the clinically diverse group accessing these services are very limited. The current study employed the clinical staging model to examine whether young people within the two clinical stages that precede full-threshold disorder (stage 1a and stage 1b) differed in terms of treatments received and short-term symptomatic and functional outcomes. METHODS: Eight hundred ninety young people aged 12-25 years seeking mental healthcare within a 12-month period were analysed in this study. RESULTS: Attenuated syndrome (stage 1b) patients used significantly more services than help-seeking (stage 1a) patients, including significantly higher rates of psychotropic medication prescription (9.3% vs. 43.6%). Stage 1a patients started with significantly lower levels of psychological distress and significantly higher levels of functioning at service entry and showed improvement only in psychological distress over 10 sessions. Despite using significantly more services, stage 1b patients remained impaired on both measures after 10 sessions; however, they showed some modest improvements in their levels of psychological distress and functioning over this time. CONCLUSION: Patients with attenuated syndromes have treatment patterns and clinical outcomes not dissimilar to those with more severe mental disorders and therefore require more intensive interventions provided over a longer time period in order to achieve recovery. The staging model allows services to selectively allocate their limited resources towards those patients with greater care needs. More research into the unique treatment needs and longer term outcomes of this diverse patient group is supported.

A clinical staging model for early intervention youth mental health services.

Transformational reforms in mental health services are providing more young Australians who experience mental health problems with access to high-quality care. However, the current diagnostic approach has low utility in the early stages of illness, causing uncertainty among clinicians in regard to matching clients' needs with safe and effective interventions. The authors propose a clinical staging model that has the potential to better match illness stage to intervention. The model allows clinicians to provide more personalized and responsive care, especially to young people with attenuated syndromes (subthreshold disorders) who have a clear need for mental health care but who may not otherwise receive it. This approach can also assist clinicians in considering the potential trajectory of illness. Recent research using this framework has demonstrated the model's prospective utility. The authors describe application of the model in an early intervention youth mental health service in Australia.