Comparison of accredited person and medical officer discharge decisions under the Mental Health Act of NSW: A cohort study of deliberate self-poisoning patients.

BACKGROUND: The Accredited Persons Programme was introduced in 2003. The relevant Mental Health Acts (NSW) authorised reviews by appropriately credentialed non-medical health professionals as part of the process of detaining and treating a person without consent: an authority previously held by medical officers. Evaluations of the Programme are needed. OBJECTIVE: To compare discharge decisions for hospital-treated deliberate self-poisoning patients made by an Accredited Person and Medical Officers. METHODS: For a 10-year cohort (2003-2012) of index hospital-treated deliberate self-poisoning admissions at the Calvary Mater Newcastle, we compared Accredited Person and Medical Officer discharge decisions from the general hospital. We specifically examined discharges to the psychiatric hospital under a Mental Health Act certificate (used as an index of the Accredited Person's use of the authority under the Accredited Persons Programme) compared to any other discharge destination. Unadjusted and adjusted logistic regression models and a propensity score analysis were used to explore the relationship between clinician type and discharge destination. RESULTS: There were 2237 index assessments (Accredited Person = 884; Medical Officer = 1443). One-quarter (27%) were referred for assessment under the Act at the psychiatric hospital, with the Accredited Person significantly more likely (32%) to require this compared to the Medical Officers (24%); Risk Difference: 8.3% (4.5 to 12.1). However, after adjusting for patient characteristics; Risk Difference: -3.0% (-5.9 to -0.1) and for propensity score, Risk Difference: -3.3% (-6.7 to 0.1), the Accredited Person and Medical Officer likelihood of discharging for an assessment under the Act was similar. CONCLUSIONS: The Accredited Person assessed more clinically complex patients than the Medical Officers. After adjusting for clinical complexity and propensity score, the likelihood of referral for involuntary psychiatric hospital care was similar for Accredited Person and Medical Officers. Our evaluation of the Accredited Person programme in the general hospital was favourable, and wider implementation and evaluation is warranted.

Hospital-treated deliberate self-poisoning patients: Drug-induced delirium and clinical outcomes.

OBJECTIVE: Drug-induced delirium has been attributed to opioid, benzodiazepine, antipsychotic, antihistaminic and anticholinergic drug groups at therapeutic doses. Delirium also occurs in hospital-treated self-poisoning (at supra-therapeutic doses), although the causative drug classes are not well established and co-ingestion is common. We tested the magnitude and direction of association of five major drug groups with incident cases of delirium. METHODS: A retrospective longitudinal cohort (n = 5131) study was undertaken of deliberate and recreational/chronic misuse poisoning cases from a regional sentinel toxicology unit. We described ingestion and co-ingestion patterns and estimated the unadjusted and adjusted odds for developing a drug-induced delirium. We also estimated the odds of drug-induced delirium being associated with three outcomes: intensive care unit admission, general hospital length of stay and discharge to home. RESULTS: Drug-induced delirium occurred in 3.9% of cases (n = 200). The unadjusted odds ratios for development of delirium were increased for anticholinergics 10.79 (5.43-21.48), antihistamines 6.10 (4.20-8.84) and antipsychotics 2.99 (2.20-4.06); non-significant for opioids 1.31 (95% confidence interval = [0.81, 2.13]); and reduced for benzodiazepines 0.37 (0.24-0.58); with little change after adjustment for age, gender and co-ingestion. Delirium was associated with intensive care unit admission, longer length of stay and discharge destination. CONCLUSION: Drug-induced delirium was uncommon in this population. Co-ingestion was common but did not alter the risk. In contrast to drug-induced delirium at therapeutic doses in older populations, opioids were not associated with delirium and benzodiazepines were protective. Drug-induced delirium required increased clinical services. Clinical services should be funded and prepared to provide additional supportive care for these deliriogenic drug group ingestions.

Employment and retirement impacts on health and wellbeing among a sample of rural Australians.

BACKGROUND: In Australia, it is projected that one in four individuals will be at the nominal retirement age of 65 or over by 2056; this effect is expected to be especially pronounced in rural areas. Previous findings on the effects of retirement on wellbeing have been mixed. The present study explores the effects of employment and retirement on health and wellbeing among a sample of rural Australians. METHODS: Australian Rural Mental Health Study participants who were aged 45 or over (N = 2013) were included in a series of analyses to compare the health and wellbeing of individuals with differing employment and retirement circumstances. Self-reported outcome variables included perceived physical health and everyday functioning, financial wellbeing, mental health, relationships, and satisfaction with life. RESULTS: Across the outcomes, participants who were employed or retired generally reported better health and wellbeing than those not in the workforce. Retired participants rated more highly than employed participants on mental health, relationships, and satisfaction with life. There was also a short-term benefit for perceived financial status for retired participants compared to employed participants, but this effect diminished over time. CONCLUSIONS: While retirement is a significant life transition that may affect multiple facets of an individual's life, the direction and magnitude of these effects vary depending on the retirement context, namely the pre-retirement and concurrent circumstances within which an individual is retiring. Personal perceptions of status changes may also contribute to an individual's wellbeing more so than objective factors such as income. Policies that promote rural work/retirement opportunities and diversity and address rural disadvantage are needed.

Improvements in Hope, Engagement and Functioning Following a Recovery-Focused Sub-Acute Inpatient Intervention: a Six-Month Evaluation.

Few studies have examined the post-discharge benefits associated with recover-oriented programs delivered in inpatient and sub-acute mental health settings. The aim of this study was to evaluate the medium-term outcomes of a 6-week sub-acute inpatient intervention program for 27 service users with a diagnosis of serious mental illness (mean age = 33.22 years, 70.4% with a psychosis diagnosis). Recovery data were collected on admission, at discharge, and at 3- and 6-months post-discharge using self-report, collaborative and clinical measures. The three clinician-rated measures (assessing therapeutic engagement, functioning, and life skills) revealed linear improvements from admission to 6-month follow-up (with mean z-change ranging from 0.72 to 1.35), as did the self-reported social connection measure (Mental Health Recovery Star, MHRS; mean z-change: 1.05). There were also curvilinear improvements in self-determination and self-reported MHRS symptom management and functioning scores; however, only modest changes were detected in hope (Herth Hope Index) and MHRS self-belief scores. Change scores based on self-reported and clinician-rated measures tended to be uncorrelated. An exploration of client-level outcomes revealed three recovery trajectory subgroups: transient (21.7%), gradual (34.8%), or sustained (43.5%) improvement; with members of the latter group tending to have longer illness durations. The study's findings are encouraging, to the extent that they demonstrate recovery-focused sub-acute inpatient programs can promote clinical recovery and aspects of personal recovery. However, they also suggest that recovery perspectives differ between clients and clinicians, and that far more work is required to understand the psychological factors that generate and sustain the hope that recovery is possible.

A randomised trial of dialectical behaviour therapy and the conversational model for the treatment of borderline personality disorder with recent suicidal and/or non-suicidal self-injury: An effectiveness study in an Australian public mental health service.

OBJECTIVES: Borderline personality disorder is a complex mental disorder that is associated with a high degree of suffering for the individual. Dialectical behaviour therapy has been studied in the largest number of controlled trials for treatment of individuals with borderline personality disorder. The conversational model is a psychodynamic treatment also developed specifically for treatment of borderline personality disorder. We report on the outcomes of a randomised trial comparing dialectical behaviour therapy and conversational model for treatment of borderline personality disorder in a routine clinical setting. METHOD: Participants had a diagnosis of borderline personality disorder and a minimum of three suicidal and/or non-suicidal self-injurious episodes in the previous 12 months. Consenting individuals were randomised to either dialectical behaviour therapy or conversational model and contracted for 14 months of treatment (n = 162 commenced therapy). Dialectical behaviour therapy involved participants attending weekly individual therapy, weekly group skills training and having access to after-hours phone coaching. Conversational model involved twice weekly individual therapy. Assessments occurred at baseline, mid-treatment (7 months) and post-treatment (14 months). Assessments were conducted by a research assistant blind to treatment condition. Primary outcomes were change in suicidal and non-suicidal self-injurious episodes and severity of depression. We hypothesised that dialectical behaviour therapy would be more effective in reducing suicidal and non-suicidal self-injurious behaviour and that conversational model would be more effective in reducing depression. RESULTS: Both treatments showed significant improvement over time across the 14 months duration of therapy in suicidal and non-suicidal self-injury and depression scores. There were no significant differences between treatment models in reduction of suicidal and non-suicidal self-injury. However, dialectical behaviour therapy was associated with significantly greater reductions in depression scores compared to conversational model. CONCLUSION: This research adds to the accumulating body of knowledge of psychotherapeutic treatment of borderline personality disorder and supports the use of both dialectical behaviour therapy and conversational model as effective treatments in routine clinical settings, with some additional benefits for dialectical behaviour therapy for persons with co-morbid depression.

Hospital-treated deliberate self-poisoning in the older adult: Identifying specific clinical assessment needs.

BACKGROUND: Hospital-treated deliberate self-poisoning is common, with a median patient age of around 33 years. Clinicians are less familiar with assessing older adults with self-poisoning and little is known about their specific clinical requirements. OBJECTIVE: To identify clinically important factors in the older-age population by comparing older adults (65+ years) with middle-aged adults (45-64 years) during an index episode of hospital-treated deliberate self-poisoning. METHODS: A prospective, longitudinal, cohort study of people presenting to a regional referral centre for deliberate self-poisoning (Calvary Mater Newcastle, Australia) over a 10-year period (2003-2013). We compared older-aged adults with middle-aged adults on demographic, toxicological and psychiatric variables and modelled independent predictors of referral for psychiatric hospitalisation on discharge with logistic regression. RESULTS: There were (n = 157) older-aged and (n = 925) middle-aged adults. The older-aged group was similar to the middle-aged group in several ways: proportion living alone, reporting suicidal ideation/planning, prescribed antidepressant and antipsychotic drugs, and with a psychiatric diagnosis. However, the older-aged group were also different in several ways: greater proportion with cognitive impairment, higher medical morbidity, longer length of stay, and greater prescription and ingestion of benzodiazepines in the deliberate self-poisoning event. Older age was not a predictor of referral for psychiatric hospitalisation in the multivariate model. CONCLUSION: Older-aged patients treated for deliberate self-poisoning have a range of clinical needs including ones that are both similar to and different from middle-aged patients. Individual clinical assessment to identify these needs should be followed by targeted interventions, including reduced exposure to benzodiazepines.

Motivational Interviewing: Reconciling Recovery-Focused Care and Mental Health Nursing Practice.

Motivational interviewing (MI) is a long-established evidenced-based intervention aimed at guiding people to implement change. Originally developed by William Miller from the United States and Stephen Rollnick from the United Kingdom, a strong emphasis for MI is the underlying 'spirit', rather than merely the specific techniques within the model. The 'spirit' of MI consists of four key components: acceptance, partnership, evocation and compassion. These have direct overlap with concepts within the personal recovery model recognised as a critical framework in delivery of contemporary mental health services for consumers. Despite this recognition, recovery concepts have struggled to gain consistent traction, particularly within inpatient mental health units. This paper proposes that MI presents one strategy for integrating recovery-focused principles within routine mental health nursing (MHN) practice. An overview of MI and its relationship with recovery principles is discussed in the context of contemporary MHN practice. Evaluation results of a locally developed MI workshop for MHNs within a regional area of New South Wales (NSW) in Australia are presented to highlight the emerging evidence for this potential. Following the workshop, MHN participants showed key improvements in knowledge and confidence scores, as well as in understanding of key MI processes and strategies. The consolidation of these skills through training and a supervision framework is outlined.

Is the reported increase in young female hospital-treated intentional self-harm real or artefactual?

BACKGROUND: The Australian Institute of Health and Welfare has reported an increased rate of hospital-treated intentional self-harm in young females (2000-2012) in Australia. These reported increases arise from institutional data that are acknowledged to underestimate the true rate, although the degree of underestimation is not known. OBJECTIVE: To consider whether the reported increase in young females' hospital-treated intentional self-harm is real or artefactual and specify the degree of institutional underestimation. METHODS: Averages for age- and gender-standardised event rates for hospital-treated intentional self-harm (national: Australian Institute of Health and Welfare; state: New South Wales Ministry of Health) were compared with sentinel hospital event rates for intentional self-poisoning (Hunter Area Toxicology Service, Calvary Mater Newcastle) in young people (15-24 years) for the period 2000-2012. A time series analysis of the event rates for the sentinel hospital was conducted. RESULTS: The sentinel hospital event rates for young females of 444 per 100,000 were higher than the state (378 per 100,000) and national (331 per 100,000) rates. There was little difference in young male event rates - sentinel unit: 166; state: 166 and national: 153 per 100,000. The sentinel hospital rates showed no change over time for either gender. CONCLUSION: There was no indication from the sentinel unit data of any increase in rates of intentional self-poisoning for young females. The sentinel and state rates were higher than the national rates, demonstrating the possible magnitude of underestimation of the national data. The reported increases in national rates of hospital-treated self-harm among young females might be due to artefactual factors, such as changes in clinical practice (greater proportion admitted), improved administrative coding of suicidal behaviours or possibly increased hospital presentations of community self-injury cases, but not intentional self-poisoning. A national system of sentinel units is needed for the accurate and timely monitoring of all hospital-treated self-harm.

The predictors of depression in a longitudinal cohort of community dwelling rural adults in Australia.

PURPOSE: Many major studies of depression in Australia are under-representative of rural and remote residents, limiting the generalizability of their findings. This study explores the contributions of a range of individual, social, and community factors to the trajectory of depressive symptoms among a cohort of rural and remote residents. METHODS: Data from four waves of the Australian Rural Mental Health Study (baseline n = 2639), a 5 year longitudinal study of rural community residents, were examined within generalized linear mixed models to predict depressive symptoms. Depression was measured using the PHQ-9, with key correlates including social support, employment status, financial wellbeing, neuroticism, and rural community factors. RESULTS: Moderate-to-severe depression was reported by 6.3% of the baseline sample. Being permanently unable to work resulted in over a threefold increase in the odds of depression at the following survey wave. Self-rated financial hardship was associated with a fourfold increase in the odds of future depression, as was a high level of community concerns. Neuroticism and tobacco use also made a significant independent contribution to future depressive symptoms. Interpersonal support was a protective factor, reducing the odds of next-wave depression by 64%. CONCLUSION: Financial and employment-related difficulties appear to be important risk factors for depression, and targeting individuals experiencing such difficulties may be an effective means of reducing depression among certain sub-groups. Strategies to prevent depression in rural and remote Australia may benefit from a focus on interpersonal and community-level support, as the effects of this support are lasting and contribute to a reduced likelihood of depressive episodes in future years.

Drought-related stress among farmers: findings from the Australian Rural Mental Health Study.

OBJECTIVES: To investigate general and drought-related stress experienced by farmers at both the personal and community levels, and whether socio-demographic and community factors influence this stress. DESIGN: Multivariate analysis of data from the Australian Rural Mental Health Study (ARMHS), a longitudinal cohort study (2007-2013). SETTING: Non-metropolitan New South Wales. PARTICIPANTS: Subset of 664 ARMHS participants (at baseline) who identified as living or working on a farm. MAIN OUTCOME MEASURES: Personal drought-related stress (PDS), community drought-related stress (CDS), and general psychological distress (K10 score). RESULTS: Farmers who were under 35, both lived and worked on a farm, experienced greater financial hardship, and were in outer regional, remote or very remote NSW reported PDS particularly frequently. Of these factors, only being under 35 and increased remoteness were associated with higher incidence of CDS. Mild wet weather during the prior 12 months reduced PDS and CDS but increased general distress. Moderate or extreme wet weather did not affect PDS or general distress, but moderate wet weather was associated with increased CDS. Drought-related stress and general psychological distress were influenced by different socio-demographic and community factors. CONCLUSIONS: Farmers in NSW experience significant stress about the effects of drought on themselves, their families, and their communities. Farmers who are younger, live and work on a farm, experience financial hardship, or are isolated are at particular risk of drought-related stress. Medical practitioners who provide assistance to farmers and farming communities can contribute to initiatives that relieve stress about drought.

Randomised controlled trial of a healthy lifestyle intervention among smokers with psychotic disorders: Outcomes to 36 months.

OBJECTIVE: People living with psychotic disorders (schizophrenia spectrum and bipolar disorders) have high rates of cardiovascular disease risk behaviours, including smoking, physical inactivity and poor diet. We report cardiovascular disease risk, smoking cessation and other risk behaviour outcomes over 36 months following recruitment into a two-arm randomised controlled trial among smokers with psychotic disorders. METHODS: Participants ( N = 235) drawn from three sites were randomised to receive nicotine replacement therapy plus (1) a Healthy Lifestyles intervention delivered over approximately 9 months or (2) a largely telephone-delivered intervention (designed to control for nicotine replacement therapy provision, session frequency and other monitoring). The primary outcome variables were 10-year cardiovascular disease risk and smoking status, while the secondary outcomes included weekly physical activity, unhealthy eating, waist circumference, psychiatric symptomatology, depression and global functioning. RESULTS: Significant reductions in cardiovascular disease risk and smoking were detected across the 36-month follow-up period in both intervention conditions, with no significant differences between conditions. One-quarter (25.5%) of participants reported reducing cigarettes per day by 50% or more at multiple post-treatment assessments; however, few (8.9%) managed to sustain this across the majority of time points. Changes in other health behaviours or lifestyle factors were modest; however, significant improvements in depression and global functioning were detected over time in both conditions. Participants experiencing worse 'social discomfort' at baseline (e.g. anxiety, mania, poor self-esteem and social disability) had on average significantly worse global functioning, lower scores on the 12-Item Short Form Health Survey physical scale and significantly greater waist circumference. CONCLUSION: Although the telephone-delivered intervention was designed as a comparison condition, it achieved excellent retention and comparable outcomes. Telephone-delivered smoking cessation support may potentially help to reduce smoking rates among people with psychotic disorders. Discomfort in social situations may also be a useful target for future health interventions, addressing confidence and social skills, and promoting social networks that reduce inactivity.

Addiction Vulnerability: Exploring Relationships Among Cigarette Smoking, Substance Misuse, and Early Psychosis.

OBJECTIVE: Smoking rates in adolescents at risk for psychosis are significantly greater than in those who are not at risk. Recent research suggests that cigarette smoking in adolescence may be a potential marker of transition to psychosis, although the exact relationship between the two remains unclear. Our aim was to examine whether tobacco smoking is a potential marker of transition to psychosis or subsequent episodes of psychosis, independently of other substance use, or alternatively whether smoking is essentially a general marker of later mental illness episodes. METHODS: This substudy was conducted as part of an audit of a specialized early psychosis community mental health service, the Psychological Assistance Service (PAS). A multilayered audit over 10 years (January 1997 to December 2007) of PAS presentations was conducted (N = 1997), which documented baseline sociodemographic and clinical characteristics and subsequent illness episodes and service usage. Among clients with baseline smoking status information (n = 421, mean age = 18.3 years), this study examined predictors of transition to or subsequent episodes of psychosis, substance misuse, and affective disorder. RESULTS: A recent psychosis episode at baseline and receiving ongoing treatment from PAS predicted transition to or subsequent psychosis episodes; however, baseline ultra-high-risk status was not predictive. In addition, baseline smoking/substance misuse status was a significant predictor, with smokers being twice as likely to experience a subsequent episode of psychosis, even after controlling for other baseline comorbidity. Baseline smoking status also independently predicted subsequent substance misuse episodes, but not subsequent affective disorder. Among clients experiencing post-PAS comorbid substance misuse and psychosis, the majority (80.3%) reported smoking at baseline. CONCLUSIONS: Smoking status at service presentation appeared to function as a general proxy for addiction vulnerability among young help seekers and thereby as a potential marker for the development of severe mental illness (including psychosis) and associated health problems. Routine evaluations of presenting problems need to incorporate comprehensive assessments of early substance misuse and tobacco smoking. Adjunctive lifestyle interventions promoting smoking cessation, physical health, and well-being need to be offered in conjunction with conventional mental health interventions tailored to key presenting problems, recovery, and psychological strengthening.

Self-recognition of mental health problems in a rural Australian sample.

OBJECTIVE: Although mental health literacy has increased in recent years, mental illness is often under-recognised. There has been little research conducted on mental illness in rural areas; however, this can be most prominent in rural areas due to factors such as greater stigma and stoicism. The aim of this study is to create a profile of those who are most and least likely to self-identify mental health problems among rural residents with moderate- to-high psychological distress. DESIGN: Secondary analysis of a longitudinal postal survey. SETTING: Rural and remote New South Wales, Australia. PARTICIPANTS: Four-hundred-and-seventy-two community residents. MAIN OUTCOME MEASURE: Participants completed the K10 Psychological Distress Scale, as well as the question 'In the past 12 months have you experienced any mental health problems?' The characteristics of those who reported moderate/high distress scores were explored by comparing those who did and did not experience mental health problems recently. RESULTS: Of the 472 participants, 319 (68%) with moderate/high distress reported a mental health problem. Reporting a mental health problem was higher among those with recent adverse life events or who perceived more stress from life events while lower among those who attributed their symptoms to a physical cause. CONCLUSIONS: Among a rural sample with moderate/high distress, one-third did not report a mental health problem. Results suggest a threshold effect, whereby mental health problems are more likely to be acknowledged in the context of additional life events. Ongoing public health campaigns are necessary to ensure that symptoms of mental illness are recognised in the multiple forms that they take.

Alcohol consumption in the Australian coal mining industry.

OBJECTIVES: To investigate patterns of alcohol use within the coal mining industry, and associations with the personal, social, workplace and employment characteristics. DESIGN: 8 mine sites across 3 eastern Australian states were surveyed, selected to encompass key geographic characteristics (accessibility and remoteness) and mine type (open cut and underground). Problematic alcohol use was measured using the Alcohol Use Disorders Identification Test (AUDIT) to determine: (1) overall risky or hazardous drinking behaviour; and (2) frequency of single-occasion drinking (6 or more drinks on 1 occasion). RESULTS: A total of 1457 employees completed the survey, of which 45.7% of male and 17.0% of female participants reported levels of alcohol use within the range considered as risky or hazardous, considerably higher than the national average. Hierarchical linear regression revealed a significant contribution of many individual level factors associated with AUDIT scores: younger age, male, current smoking status; illicit substance use; previous alcohol and other drug use (AOD) problems; and higher psychological distress. Workplace factors associated with alcohol use included working in mining primarily for the high remuneration, and the type of mining, with underground miners reporting higher alcohol use than open-cut miners. CONCLUSIONS: Our findings provide support for the need to address alcohol use in the coal mining industry over and above routine on-site testing for alcohol use.

An Integrated Recovery-oriented Model (IRM) for mental health services: evolution and challenges.

BACKGROUND: Over past decades, improvements in longer-term clinical and personal outcomes for individuals experiencing serious mental illness (SMI) have been moderate, although recovery has clearly been shown to be possible. Recovery experiences are inherently personal, and recovery can be complex and non-linear; however, there are a broad range of potential recovery contexts and contributors, both non-professional and professional. Ongoing refinement of recovery-oriented models for mental health (MH) services needs to be fostered. DISCUSSION: This descriptive paper outlines a service-wide Integrated Recovery-oriented Model (IRM) for MH services, designed to enhance personally valued health, wellbeing and social inclusion outcomes by increasing access to evidenced-based psychosocial interventions (EBIs) within a service context that supports recovery as both a process and an outcome. Evolution of the IRM is characterised as a series of five broad challenges, which draw together: relevant recovery perspectives; overall service delivery frameworks; psychiatric and psychosocial rehabilitation approaches and literature; our own clinical and service delivery experience; and implementation, evaluation and review strategies. The model revolves around the person's changing recovery needs, focusing on underlying processes and the service frameworks to support and reinforce hope as a primary catalyst for symptomatic and functional recovery. Within the IRM, clinical rehabilitation (CR) practices, processes and partnerships facilitate access to psychosocial EBIs to promote hope, recovery, self-agency and social inclusion. Core IRM components are detailed (remediation of functioning; collaborative restoration of skills and competencies; and active community reconnection), together with associated phases, processes, evaluation strategies, and an illustrative IRM scenario. The achievement of these goals requires ongoing collaboration with community organisations. CONCLUSIONS: Improved outcomes are achievable for people with a SMI. It is anticipated that the IRM will afford MH services an opportunity to validate hope, as a critical element for people with SMI in assuming responsibility and developing skills in self-agency and advocacy. Strengthening recovery-oriented practices and policies within MH services needs to occur in tandem with wide-ranging service evaluation strategies.

Pilot Study of an Exercise Intervention for Depressive Symptoms and Associated Cognitive-Behavioral Factors in Young Adults With Major Depression.

This study assesses the feasibility of integrating motivational interviewing (MI) with an exercise intervention. It also explores patterns of depressive symptom changes (cognitive, affective, and somatic subscales) and their relationship to cognitive, behavioral, and immunological factors (interleukin 6, IL-6, a marker for inflammation) across the exercise intervention. Twelve young adults (20.8 ± 1.7 years) meeting DSM-IV criteria for major depressive disorder received a brief MI intervention followed by a 12-week exercise intervention. Assessments were conducted preintervention, postintervention, throughout the intervention, and at follow-up. Preliminary results show differential effects of exercise, with the largest standardized mean improvements for the affective subscale (-1.71), followed by cognitive (-1.56) and somatic (-1.39) subscales. A significant relationship was observed between increased behavioral activation and lower levels of IL-6. Despite study limitations, the magnitude of changes suggests that natural remission of depressive symptoms is an unlikely explanation for the findings. A randomized controlled trial has commenced to evaluate effectiveness of the intervention.

Therapeutic Alliance, Client Need for Approval, and Perfectionism as Differential Moderators of Response to eHealth and Traditionally Delivered Treatments for Comorbid Depression and Substance Use Problems.

PURPOSE: This study sought to undertake an exploratory analysis of the impact of therapeutic alliance and dysfunctional attitudes (perfectionism and need for approval) on outcomes for participants receiving therapist-delivered and eHealth interventions for comorbid depression and alcohol/cannabis use problems. These factors have been shown in previous research to moderate response to psychological treatment for depression and related disorders. METHOD: Participants (N = 274) with concurrent depression and alcohol/cannabis misuse were randomized to 10 sessions of therapist-delivered cognitive behavior therapy/motivational interviewing (CBT/MI), computer-delivered CBT/MI with brief therapist assistance (SHADE CBT/MI), or supportive counseling (PCT). Follow-up occurred at 3, 6, and 12 months post-baseline. Exploratory moderator analyses examined changes in depression, alcohol use, and cannabis use over the 3-12-month follow-up timepoints, adjusting for baseline, as a function of treatment allocation, and the hypothesized moderators of therapeutic alliance, perfectionism, and need for approval. RESULTS: The sample size and number of comparisons in the analysis mean that the results are considered preliminary and need replication in larger trials. The analysis revealed that "client initiative," a subscale of therapeutic alliance, moderated change in depression scores between 3- and 12-month follow-up for the PCT group, with higher scores associated with decreases in depression over time. Higher therapeutic "bond" early in treatment for SHADE CBT/MI participants was associated with reduced cannabis use over time. Participants with higher "perfectionism" scores at baseline who received therapist CBT/MI reported increases in depression over the follow-up period, but reductions in depression if they received SHADE CBT/MI. Therapist CBT/MI participants high on "need for approval" at baseline reported better alcohol use outcomes over time. CONCLUSION: The preliminary nature of these results do not justify firm conclusions. However, the specific variables of perfectionism, need for approval, and client initiative show promise as moderators of treatment efficacy for comorbid depression and alcohol/cannabis use problems. Further research is justified to determine whether these factors can assist in tailoring the modality and strategies offered in the delivery of psychotherapy to this population.

Implementation of a recovery-oriented model in a sub-acute Intermediate Stay Mental Health Unit (ISMHU).

BACKGROUND: An ongoing service evaluation project was initiated following the establishment of a new, purpose-built, 20-bed sub-acute Intermediate Stay Mental Health Unit (ISMHU). This paper: provides an overview of the targeted 6-week program, operating within an Integrated Recovery-oriented Model (IRM); characterises the clients admitted during the first 16 months; and documents their recovery needs and any changes. METHODS: A brief description of the unit's establishment and programs is initially provided. Client needs and priorities were identified collaboratively using the Mental Health Recovery Star (MHRS) and addressed through a range of in-situ, individual and group interventions. Extracted client and service data were analysed using descriptive statistics, paired t-tests examining change from admission to discharge, and selected correlations. RESULTS: The initial 154 clients (165 admissions, average stay = 47.86 days) were predominately male (72.1%), transferred from acute care (75.3%), with schizophrenia or related disorders (74.0%). Readmission rates within 6-months were 16.2% for acute and 3.2% for sub-acute care. Three MHRS subscales were derived, together with stage-of-change categories. Marked improvements in MHRS Symptom management and functioning were identified (z-change = -1.15), followed by Social-connection (z-change = -0.82) and Self-belief (z-change = -0.76). This was accompanied by a mean reduction of 2.59 in the number of pre-action MHRS items from admission to discharge (z-change = 0.98). Clinician-rated Health of the Nation Outcome Scales (HoNOS) improvements were smaller (z-change = 0.41), indicative of illness chronicity. Staff valued the elements of client choice, the holistic and team approach, program quality, review processes and opportunities for client change. Addressing high-levels of need in the 6-week timeframe was raised as a concern. CONCLUSIONS: This paper demonstrates that a recovery-oriented model can be successfully implemented at the intermediate level of care. It is hoped that ongoing evaluations support the enthusiasm, commitment and feedback evident from staff, clients and carers.

Effectiveness of a 10-week group program based on Dialectical Behaviour Therapy skills among patients with personality and mood disorders: findings from a pilot study.

OBJECTIVES: Community mental health services are often required to manage people experiencing repeated crises. Personality disorders are not uncommon, accounting for up to one-third of such presentations. These patients are often difficult to treat, leading to a revolving-door phenomenon. This study evaluated the effectiveness of a pilot intervention in reducing psychological symptoms and distress, and examined the impact of the intervention on mental health service utilization. METHODS: A pre- versus post-treatment evaluation was conducted of the effectiveness of a 10-week group psychological intervention based on Dialectical Behaviour Therapy skills, conducted in a regional Australian community mental health service with patients diagnosed with either Cluster B personality disorder or a mood disorder. RESULTS: Of those who completed the program ( N = 38 patients), 84% were female, with an average age of 35.13 years. Participants were active clients of the service for an average of 58.3 weeks prior to the program. They demonstrated significant improvements in quality of life and self-control, and a reduction in hopelessness, cognitive instability and dependence on mental health services. CONCLUSIONS: Limiting the Dialectical Behaviour Therapy program to a short-term skills-based group component was successful with the targeted patient group; however, more research is required to establish the generalizability of these results.

Associations between personality disorder characteristics and treatment outcomes in people with co-occurring alcohol misuse and depression.

BACKGROUND: Personality disorders are highly comorbid with alcohol misuse and depressive symptomatology; however, few studies have investigated treatment outcomes in this population. The aim of this study was to examine relationships between baseline personality disorder cluster profiles and overall and treatment-related changes for those with co-occurring alcohol misuse and depression. METHODS: Secondary analysis was conducted using a subset of data (N = 290) from two randomised controlled trials of psychological interventions for co-occurring alcohol misuse and depression, which did not specifically target personality disorders. Baseline dimensional personality disorder cluster scores were derived from the International Personality Disorder Examination Questionnaire (IPDEQ). Four treatment conditions were compared: a brief integrated intervention, followed by no further treatment, or nine further sessions of integrated-, alcohol-, or depression-focused treatment. Associations between IPDEQ scores and changes in alcohol use, depressive symptoms and functioning from baseline to the 6- and the 12-month follow-ups were of primary interest. RESULTS: Personality disorder cluster scores moderately negatively impacted on overall change (primarily Cluster C), as well as treatment-related outcomes (primarily Cluster A), particularly changes in depressive symptoms and psychosocial functioning. Longer interventions appeared to be more effective in the longer-term (e.g., at 12-month follow-up), with integrated interventions relatively more effective than single-focused ones for individuals with higher personality disorder cluster scores. CONCLUSIONS: Greater attention needs to be paid to particular personality disorder clusters during the assessment and treatment of individuals with co-occurring alcohol misuse and depression. Integrated interventions, incorporating motivational interviewing and cognitive behaviour therapy, may provide a useful therapeutic framework. Integrated interventions also provide opportunities for adjunctive components focussing on other issues and coping strategies (e.g., to offset negative affective states), potentially tailored to the characteristics and needs of individual participants.