Late effects of prematurity: Psychiatric outcomes of 17-year-olds born very preterm.

AIM: Very preterm (VPT) birth is a known early vulnerability factor, impacting both physical and mental health over the life-span. The additional burden of psychiatric illness in VPT adolescents is likely to adversely affect critical developmental tasks and personal, social and academic/vocational trajectories. Our aim was to examine the magnitude and extent of the risk of psychological burden by determining the prevalence of psychiatric disorders in our prospectively followed-up VPT and full-term (FT) control cohorts, in this period of developmental transition at age 17 years. METHODS: Rates of psychiatric disorder in the VPT and FT control cohorts were ascertained at clinical interview of the adolescents and their care giver(s) by an adolescent psychiatrist. RESULTS: VPT birth was associated with a greater risk of generalised anxiety disorder (VPT vs. FT risk ratio (RR) 2.33; 95% confidence interval (CI): 1.16, 4.67, P = 0.02), as well as attentional problems (VPT vs. FT RR 3.46; 95% CI: 1.01, 11.88, P = 0.03). Although care givers of VPT adolescents reported many social and communication difficulties, and observation at clinical interview supported this, our data did not reach clinical threshold for group differences in autistic spectrum disorder. For all other psychiatric disorders, there was no difference between VPT and FT control adolescents. CONCLUSION: Our longitudinal cohort follow-up study examining the late effects of VPT birth has demonstrated increased rates of clinically significant psychiatric disorder in this period of important developmental transition. Families and health professionals need to be aware of the increased risk so they can monitor for symptoms and seek effective mental health treatments and support.

Exploring the Acceptability, Feasibility, and Effectiveness of a Digital Parenting Program to Improve Parental Well-being After the Christchurch Earthquakes: Cluster-Randomized Trial.

BACKGROUND: Up to 6 years after the 2011 Christchurch earthquakes, approximately one-third of parents in the Christchurch region reported difficulties managing the continuously high levels of distress their children were experiencing. In response, an app named Kakano was co-designed with parents to help them better support their children's mental health. OBJECTIVE: The objective of this study was to evaluate the acceptability, feasibility, and effectiveness of Kakano, a mobile parenting app to increase parental confidence in supporting children struggling with their mental health. METHODS: A cluster-randomized delayed access controlled trial was carried out in the Christchurch region between July 2019 and January 2020. Parents were recruited through schools and block randomized to receive immediate or delayed access to Kakano. Participants were given access to the Kakano app for 4 weeks and encouraged to use it weekly. Web-based pre- and postintervention measurements were undertaken. RESULTS: A total of 231 participants enrolled in the Kakano trial, with 205 (88.7%) participants completing baseline measures and being randomized (101 in the intervention group and 104 in the delayed access control group). Of these, 41 (20%) provided full outcome data, of which 19 (18.2%) were for delayed access and 21 (20.8%) were for the immediate Kakano intervention. Among those retained in the trial, there was a significant difference in the mean change between groups favoring Kakano in the brief parenting assessment (F1,39=7, P=.012) but not in the Short Warwick-Edinburgh Mental Well-being Scale (F1,39=2.9, P=.099), parenting self-efficacy (F1,39=0.1, P=.805), family cohesion (F1,39=0.4, P=.538), or parenting sense of confidence (F1,40=0.6, P=.457). Waitlisted participants who completed the app after the waitlist period showed similar trends for the outcome measures with significant changes in the brief assessment of parenting and the Short Warwick-Edinburgh Mental Well-being Scale. No relationship between the level of app usage and outcome was found. Although the app was designed with parents, the low rate of completion of the trial was disappointing. CONCLUSIONS: Kakano is an app co-designed with parents to help manage their children's mental health. There was a high rate of attrition, as is often seen in digital health interventions. However, for those who did complete the intervention, there was some indication of improved parental well-being and self-assessed parenting. Preliminary indications from this trial show that Kakano has promising acceptability, feasibility, and effectiveness, but further investigation is warranted. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12619001040156; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377824&isReview=true.

Cardiac structure and function in very preterm-born adolescents compared to term-born controls: A longitudinal cohort study.

BACKGROUND: There is emerging evidence of differences in cardiac structure and function in preterm-born adults and increased risk of heart failure. However, there is a paucity of data in populations who have been exposed to modern intensive care and the impact of perinatal factors is unclear. AIMS: To compare echocardiographic measures of cardiac structure and function in a regional cohort of 17-year-olds born very preterm compared to term-born peers and the influence of perinatal factors. STUDY DESIGN: Observational longitudinal cohort study. SUBJECTS: A regional cohort of ninety-one 17-year-olds born at <32 weeks gestation compared to sixty-two term-born controls. OUTCOME MEASURES: Echocardiographic measures of cardiac structure and function. RESULTS: Left ventricular and right atrial volume and left ventricular mass, indexed to body surface area, were significantly smaller in preterm-born adolescents compared to term-born controls even when adjusted for sex. There were no between group differences in cardiac function. Within those born preterm we found a significant association between gestational age and birthweight z-score and measures of cardiac function at 17 years. Within the preterm group, those with a diagnosis of bronchopulmonary dysplasia had higher left ventricular posterior wall thickness, higher mitral deceleration time and lower left atrial area and tricuspid annular plane of systolic excursion. CONCLUSIONS: Adolescents born very prematurely, who have received modern intensive care, have measurable differences in heart structure compared to their term-born peers but heart function is preserved. For those born preterm, gestational age, birthweight and bronchopulmonary dysplasia are associated with differences in cardiac function.

Same proof, different pudding: comparative views of New Zealand child psychiatrists, child psychologists and child psychotherapists regarding a proposed national child and adolescent research network.

OBJECTIVES: This study was undertaken to evaluate the views of New Zealand clinicians regarding a proposed national child and adolescent mental health research network. METHODS: Child psychiatrists, child psychologists and child psychotherapists were invited to participate in an electronic survey describing their previous experience of research, current interest in research, barriers to undertaking research and interest in a national research network. RESULTS: Responses were received from child psychiatrists (N = 33), child psychologists (N = 58) and child psychotherapists (N = 8), many of whom were clinicians and few of whom were researchers. Although most clinicians were interested in participating in future research, areas of interest differed between clinical groups. Clinician barriers to research included lack of time, lack of confidence and lack of research skills. Researcher barriers included lack of funding, time and administrative support. All groups were supportive of the development of a national research network. CONCLUSIONS: Despite some different areas of interest, there appears to be sufficient combined support from New Zealand child psychiatrists, child psychologists and child psychotherapists to pursue the establishment of a national child and adolescent mental health research network.

Impact of the Canterbury earthquakes on dispensing of psychiatric medication for children and adolescents: longitudinal quantitative study.

BACKGROUND: Natural disasters are increasing in frequency and impact; they cause widespread disruption and adversity throughout the world. The Canterbury earthquakes of 2010-2011 were devastating for the people of Christchurch, New Zealand. It is important to understand the impact of this disaster on the mental health of children and adolescents. AIMS: To report psychiatric medication use for children and adolescents following the Canterbury earthquakes. METHOD: Dispensing data from community pharmacies for the medication classes antidepressants, antipsychotics, anxiolytics, sedatives/hypnotics and methylphenidate are routinely recorded in a national database. Longitudinal data are available for residents of the Canterbury District Health Board (DHB) and nationally. We compared dispensing data for children and adolescents residing in Canterbury DHB with national dispensing data to assess the impact of the Canterbury earthquakes on psychotropic prescribing for children and adolescents. RESULTS: After longer-term trends and population adjustments are considered, a subtle adverse effect of the Canterbury earthquakes on dispensing of antidepressants was detected. However, the Canterbury earthquakes were not associated with higher dispensing rates for antipsychotics, anxiolytics, sedatives/hypnotics or methylphenidate. CONCLUSIONS: Mental disorders or psychological distress of a sufficient severity to result in treatment of children and adolescents with psychiatric medication were not substantially affected by the Canterbury earthquakes.

Improvement in cognitive function in young people with bipolar disorder: Results from participants in an 18-month randomised controlled trial of adjunctive psychotherapy.

OBJECTIVE: To examine the effects of 18 months of intensive stabilisation with medication management and Interpersonal and Social Rhythm Therapy or Non-specific Supportive Clinical Management on cognitive function in young people with bipolar disorder. Determinants of change in cognitive function over the 18 months of the trial were also examined. METHOD: Patients aged 15-36 years with Bipolar I Disorder, Bipolar II Disorder and Bipolar Not Otherwise Specified were recruited. From a battery of cognitive tests, change scores for pre-defined domains of cognitive function were created based on performance at baseline and follow-up. Change was compared between the two therapy groups. Regression analysis was used to determine the impact of a range of clinical variables on change in cognitive performance between baseline and follow-up. RESULTS: One hundred participants were randomised to Interpersonal and Social Rhythm Therapy (n = 49) or Non-specific Supportive Clinical Management (n = 51). Seventy-eight patients underwent cognitive testing at baseline and 18 months. Across both groups, there were significant improvements in a Global Cognitive Composite score, Executive Function and Psychomotor Speed domains from baseline to 18 months. Lower scores at baseline on all domains were associated with greater improvement over 18 months. Overall, there was no difference between therapies in change in cognitive function, either in a global composite score or change in domains. CONCLUSION: While there was no difference between therapy groups, intensive stabilisation with psychological therapy was associated with improved cognitive function, particularly in those patients with poorer cognitive function at baseline. However, this was not compared with treatment as usual so cannot be attributed necessarily to the therapies.

'E' therapy in the community: Examination of the uptake and effectiveness of BRAVE (a self-help computer programme for anxiety in children and adolescents) in primary care.

OBJECTIVE: Recognizing and treating anxiety early is an important public mental health objective. There is clinical trial evidence that 'e' therapies are appealing, engaging and effective and have the potential to improve access to treatment. However, their implementation and effectiveness in real world settings is still emerging. Following a major natural disaster in NZ, an online therapist assisted CBT programme for children with anxiety, (BRAVE_TA) was made available in primary care. METHODS: Uptake and feasibility of BRAVE_TA delivery was assessed by examining referral patterns, non-engagement rates and programme progression within a geographic region of NZ (Canterbury population of around 500,000). Effectiveness of BRAVE_TA was measured by the extent of change in the primary outcome measure of anxiety, the CAS8, between baseline and last completed session. RESULTS: There were 1361 referrals to BRAVE_TA over 2014-2018, mostly from primary care doctors and nurses in primary schools. After attrition due to triage and family withdrawal, 75% (N = 1026) were enrolled. Around half of children/adolescents completed 4 sessions with moderate effect sizes achieved Children/adolescents who completed more sessions, had lower anxiety after their last session, with most of the improvement occurring within the first three to four sessions. CONCLUSION: BRAVE_TA has shown to be an acceptable and effective 'e' therapy tool in a 'real world' primary care setting for children/adolescents with anxiety. This study supports the role of 'e' therapy as part of a stepped-care model within primary care in improving access to treatment and thus improving public mental health in children.Trial registry: ACTRN12612000063819.

Rural youth in distress? Youth self-harm presentations to a rural hospital over 10 years.

Introduction Despite growing awareness of increasing rates of youth suicide and self-harm in New Zealand, there is still little known about self-harm among rural youth. Aim This study compared: (1) rates of youth self-harm presentations between a rural emergency department (ED) and nationally available rates; and (2) local and national youth suicide rates over the decade from January 2008 to December 2017. Methods Data were requested on all presentations to Ashburton Hospital ED coded for 'self-harm' for patients aged 15-24 years. Comparative data were obtained from the coroner, Ministry of Health and the 2013 census. Analyses were conducted of the effects of age, time, repetition, method, ethnicity and contact with mental health services on corresponding suicide rates. Results Self-harm rates in Ashburton rose in the post-earthquake period (2013-17). During the peri-earthquake period (2008-12), non-Maori rates of self-harm were higher than for Maori (527 vs 116 per 100000 youth respectively), reflecting the national trend. In the post-earthquake period, although non-Maori rates of self-harm stayed stable (595 per 100000), there was a significant increase in Maori rates of self-harm to 1106 per 100000 (Chi-squared = 14.0, P < 0.001). Youth living within the Ashburton township showed higher rates than youth living more rurally. Discussion Youth self-harm behaviours, especially self-poisoning, have increased since the Canterbury earthquakes in the Ashburton rural community. Of most concern was the almost ninefold increase in Maori self-harm presentations in recent years, along with the increasing prevalence among teenagers and females. Possible explanations and further exploratory investigation strategies are discussed.

Three-year follow-up after psychotherapy for young people with bipolar disorder.

OBJECTIVES: (1) To examine the differences between interpersonal and social rhythm therapy (IPSRT) and specialist supportive care (SSC) in the longer term impacts of IPSRT and SSC on cumulative depression and mania symptoms over a further 78-week follow-up period post treatment. (2) To calculate the survival time before recurrence of a new mood episode over the 3-year period. METHODS: One hundred young people with bipolar disorder aged between 15 and 36 years who had been randomized to treatment with either IPSRT or SSC for 78 weeks were followed up for a subsequent 78 weeks. The Longitudinal Interval Follow-up Evaluation was completed at 26-week intervals. A Mann-Whitney U test was used to determine if there were significant differences between therapy types and a Kaplan-Meier survival analysis was used to determine time to recurrence. Cox regression was used to assess the association between time to relapse and therapy type. RESULTS: There were no significant differences between therapies at each of the data points for either depression or mania scores. The mean change in depression and mania in both groups was significantly different for all three follow-up data points. The actuarial cumulative recurrence rates were 53% for IPSRT and 49% for SSC. There was no significant difference between the groups in time to recurrence. CONCLUSIONS: While there were no significant differences between the two therapies, there was an overall reduction in symptoms in both therapies. There may be sustained benefits in providing intensive psychotherapies in conjunction with pharmacotherapy for young people with bipolar disorder.

The impact of the Canterbury earthquakes on successful school leaving for adolescents.

OBJECTIVE: To examine the impact of the Canterbury earthquakes on the important adolescent transition period of school leaving. METHOD: Local and national data on school leaving age, attainment of National Certificate of Educational Achievement (NCEA) standards, and school rolls (total registered students for schools) were examined to clarify long-term trends and delineate these from any impacts of the Canterbury earthquakes.  Results: Despite concerns about negative impacts, there was no evidence for increased school disengagement or poorer academic performance by students as a consequence of the earthquakes. CONCLUSION: Although there may have been negative effects for a minority, the possibility of post-disaster growth and resilience being the norm for the majority meant that negative effects on school leaving were not observed following the earthquakes. A range of post-disaster responses may have mitigated adverse effects on the adolescent population. Implications for Public Health: Overall long-term negative effects are unlikely for the affected adolescent population. The results also indicate that similar populations exposed to disasters in other settings are likely to do well in the presence of a comprehensive post-disaster response.

Sequential population study of the impact of earthquakes on the emotional and behavioural well-being of 4-year-olds in Canterbury, New Zealand.

AIM: Exposure to a large natural disaster can lead to behavioural disturbances, developmental delay and anxiety among young children. Although most children are resilient, some will develop mental health problems. Major earthquakes occurred in Canterbury, New Zealand, in September 2010 and February 2011. A community screening tool assessing behavioural and emotional problems in children, the Strengths and Difficulties Questionnaire, has been reported by parents (SDQ-P) and teachers (SDQ-T) of all 4-year-olds in the region since 2008. METHODS: Mean total and subtest scores for the SDQ-P and SDQ-T were compared across periods before, during and after the earthquakes in sequential population cohorts of children. Comparisons across the periods were made in relation to the proportions of children defined by New Zealand norms as 'abnormal'. Results were also compared between zones considered to have been exposed to higher or lower impact from the earthquakes. RESULTS: Parent mean total SDQ scores did not change between periods before, during and after the earthquakes. Teacher mean SDQ total scores significantly reduced (improved) when compared between baseline and post-earthquake periods. Mean SDQ pro-social scores from both teachers and parents increased (strengthened) when compared between baseline and post-earthquake periods. Results did not significantly vary according to a measure of impact from the earthquakes. CONCLUSION: The main finding that a population-based measure of behavioural and emotional problems among children was not deleteriously impacted by the earthquakes is surprising and is not consistent with other research findings. Further work is needed to explore the health needs of children in Canterbury based on methodological improvements.

Prospective rates of suicide attempts and nonsuicidal self-injury by young people with bipolar disorder participating in a psychotherapy study.

OBJECTIVE: Bipolar disorder is a chronic relapsing disorder associated with high rates of suicide, suicide attempts and nonsuicidal self-injury. The study aimed to prospectively identify the rates of suicide attempts and nonsuicidal self-injury in young people participating in an adjunctive randomised controlled psychotherapy for bipolar disorder and to identify differences in individuals who engaged in nonsuicidal self-injury, made suicide attempts or did both. METHOD: In all, 100 participants aged 15-36 years with bipolar disorder received 78 weeks of psychotherapy and were followed up for a further 78 weeks. Data were collected using the Longitudinal Interval Follow-up Evaluation. RESULTS: Suicide attempts reduced from 11% at baseline to 1% at the end of follow-up (week 156). Similarly, self-harm reduced from 15% at baseline to 7% at the end of follow-up. Individuals who engaged in both nonsuicidal self-injury and made suicide attempts differed from those with who only made suicide attempts, engaged in nonsuicidal self-injury or did neither. They were characterised by a younger age of illness onset and higher comorbidity. CONCLUSION: Adjunctive intensive psychotherapy may be effective in reducing suicide attempts and nonsuicidal self-injury and warrants further attention. Particular attention needs to be paid to individuals with early age of onset of bipolar disorder.

Randomized, controlled trial of Interpersonal and Social Rhythm Therapy for young people with bipolar disorder.

OBJECTIVE: This randomized, controlled clinical trial compared the effect of interpersonal and social rhythm therapy (IPSRT) to that of specialist supportive care (SSC) on depressive outcomes (primary), social functioning, and mania outcomes over 26-78 weeks in young people with bipolar disorder receiving psychopharmacological treatment. METHODS: Subjects were aged 15-36 years, recruited from a range of sources, and the patient groups included bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified. Exclusion criteria were minimal. Outcome measures were the Longitudinal Interval Follow-up Evaluation and the Social Adjustment Scale. Paired-sample t-tests were used to determine the significance of change from baseline to outcome period. Analyses of covariance were used to determine the impact of therapy, impact of lifetime and current comorbidity, interaction between comorbidity and therapy, and impact of age at study entry on depression. RESULTS: A group of 100 participants were randomized to IPSRT (n = 49) or SSC (n = 51). The majority had bipolar I disorder (78%) and were female (76%), with high levels of comorbidity. After treatment, both groups had improved depressive symptoms, social functioning, and manic symptoms. Contrary to our hypothesis, there was no significant difference between therapies. There was no impact of lifetime or current Axis I comorbidity or age at study entry. There was a relative impact of SSC for patients with current substance use disorder. CONCLUSIONS: IPSRT and SSC used as an adjunct to pharmacotherapy appear to be effective in reducing depressive and manic symptoms and improving social functioning in adolescents and young adults with bipolar disorder and high rates of comorbidity. Identifying effective treatments that particularly address depressive symptoms is important in reducing the burden of bipolar disorder.

Psychosocial characteristics and poly-drug use of pregnant women enrolled in methadone maintenance treatment.

Pregnant women with substance dependency are a high-risk psychiatric and obstetric population, with their infants also at elevated neonatal risk. This paper draws on prospective, longitudinal data from a regional cohort of 81 methadone-maintained (MM) and 107 comparison women and their infants to describe the obstetric, socio-familial and mental health needs of women in methadone maintenance treatment during pregnancy. Of particular interest was the extent and pattern of maternal licit and illicit drug use over the course of pregnancy. Results showed that MM women had complex reproductive histories, chronic health problems, and were subject to high rates of socioeconomic adversity and comorbid mental health problems. During pregnancy, more than half continued to use licit and illicit drugs, although there was a general trend for drug use to reduce over time. No differences were observed between women maintained on low (12.5-61.0mg/day) and high (61.1-195.0mg/day) doses of methadone, with the exception of opiate abuse which was higher in the low dose group (p=.07). Findings highlight that pregnant women enrolled in MMT and their infants represent a vulnerable group with complex, social, obstetric and psychiatric needs. They also reinforce the need for services that can provide on-going wrap-around, multidisciplinary and multiagency care for these high risk dyads, both during pregnancy and in the transition to parenthood.

Further evidence for slow binocular rivalry rate as a trait marker for bipolar disorder.

OBJECTIVE: Binocular rivalry refers to a situation where contradictory information is presented simultaneously to the same location of each eye. This leads to the alternation of images every few seconds. The rate of alternation between images has been shown to be slower in euthymic participants with bipolar disorder than in healthy controls. The alternation rate is not uniformly slowed in bipolar disorder patients and may be influenced by clinical variables. The present study examined whether bipolar disorder patients have slower alternation rates, examined the influence of depression and explored the role of clinical variables and cognitive functions on alternation rate. METHOD: Ninety-six patients with bipolar disorder and 24 control participants took part in the study. Current mood status and binocular rivalry performance were analysed with nonparametric tests. A slow and a normal alternation group were created by median split. We subsequently explored the distribution of several clinical variables across these groups. Further, we investigated associations between alternation rate and various cognitive functions, such as visual processing, memory, attention and general motor speed. RESULTS: The median alternation rate was significantly slower for participants with bipolar disorder type I (0.39 Hz) and for participants with bipolar spectrum disorder (0.43 Hz) than for control participants (0.47 Hz). Depression had no effect on alternation rate. There were no differences between participants with bipolar disorder type I and type II and in regard to medication regime and predominance of one rivalry image. There were also no differences in regard to the clinical variables and no significant associations between alternation rate and the cognitive functions explored. CONCLUSION: We replicated a slowing in alternation rate in some bipolar disorder participants. The alternation rate was not affected by depressed mood or any of the other factors explored, which supports views of binocular rivalry rates as a trait marker in bipolar disorder.

Effects of comorbidity and early age of onset in young people with Bipolar Disorder on self harming behaviour and suicide attempts.

BACKGROUND: The age of the first episode of illness in Bipolar Disorder has been shown to be an important predictor of outcome with early onset, particularly onset before puberty, associated with greater comorbidity, a poorer quality of life and greatest impairment in functioning. METHODS: Baseline data from a psychotherapy study was used to examine the prevalence of other comorbid psychiatric conditions and the impact of onset at an early age on both self harming behaviour and suicide attempts in young people with Bipolar Disorder. RESULTS: This study of 100 adolescents and young adults (aged 15-36 years) with Bipolar Disorder showed that comorbid conditions were very common, even at the start of their bipolar illness. Comorbidity increased as the age of onset decreased with very early onset (<13 years) patients bearing the greatest burden of disease. Greater comorbidity also significantly increased the risk of having self harmed and attempted suicide with high lethal intent. Self harming behaviour was predicted by having a lifetime diagnoses of Borderline Personality Disorder and Panic Disorder along with an early age of onset of Bipolar Disorder. In contrast, previous suicide attempts were predicted by greater comorbidity and not by very early (<13 years) age of onset.