Changes in Rates of Special Considerations in Higher Education Applications Pre- and During the COVID-19 Pandemic in Victoria, Australia.

BACKGROUND AND AIMS: Since the onset of the COVID-19 pandemic, a significant rise in mental ill health has been observed globally in young people, particularly those in their final years of secondary school. Students' negative experiences coincide with a critical transitional period which can disrupt milestones in social and educational development. This study aimed to use innovative population-level data to map the impact of the pandemic on students entering higher education. METHODS: Pre-pandemic (2019/2020) and pandemic (2020/2021) tertiary education application data were obtained from the Victorian Tertiary Admissions Centre. Prevalence of applications for special consideration related to mental ill health were compared between cohorts across various geographical areas and applicant demographic subgroups. Relative risk regression models were used to understand the role of different risk factors. RESULTS: Rates of mental health-related special consideration applications increased by 38% among all applications (pre-pandemic: 7.8%, n = 56 916; pandemic: 10.8%, n = 58 260). Highest increases were observed among students in areas with both extended and close-quarter lockdown experiences, and areas impacted by 2019/2020 black summer bushfires. The increases were higher among Year 12 students and students with other special consideration needs (e.g., physical condition, learning disability). Slightly higher increases were observed in areas with higher socio-economic status, which may potentially be related to inequality in mental health service access. CONCLUSION: As consequences of mental health difficulties and academic disruption in youth can be long lasting, it is critical to establish a mental health support framework both in and outside of higher education to facilitate young people's recovery from the pandemic.

The liminal space of first-episode psychosis and its treatment: A qualitative study exploring the experience of young people participating in an antipsychotic dose reduction randomized controlled trial.

OBJECTIVE: The current guidelines recommend continuation of antipsychotic medication for a minimum of at least 1 year following a first episode of psychosis (FEP). There have been several trials investigating whether early dose reduction or cessation leads to improved functional outcomes. The aim of this study was to explore the experience of consenting to and participating in a randomized controlled trial (RCT) of antipsychotic medication cessation. METHOD: Five participants in the Reduce trial-an RCT evaluating early antipsychotic medication dose reduction/cessation following FEP-aged 22-24 years completed a semistructured qualitative interview following the RCT. Interpretive phenomenological analysis was undertaken to understand the key themes. RESULTS: A superordinate theme was derived from interviews: the Liminal Space of FEP and treatment. Themes within the Liminal Space included: rejection versus identification with psychosis, medication as symbolic of illness versus wellness, embodiment of wellness and illness with medication, medication as symbolic of independence versus dependence, discovery of independence when autonomously choosing medication, the Reduce trial offered safety to navigate the liminal space, and self-exploration versus altruism. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The experience and treatment of FEP involves young people feeling torn between multiple, competing perspectives, demands, and priorities. Participation in an RCT exploring dose reduction provided additional supports contributing to the perception of greater safety to navigate their own experiences of treatment that was appropriate for them. When treatment is experienced as collaborative, involves shared decision making and support, other than medication, young people feel more equipped to navigate the liminal space. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Inequitable access to mental healthcare for socially excluded adolescents.

BACKGROUND: Adolescence is a critical period for mental health and social exclusion, a key social determinant of mental health. Early intervention approaches are key to mitigating the impact of mental ill-health during adolescence, however social exclusion can create additional barriers to accessing care. AIM: We aimed to better understand help-seeking experiences of adolescents facing co-occurring social exclusion and mental ill-health, including sources of support, barriers and preferences for service provision. METHOD: Cross-sectional data were analysed, from the 2022 Mission Australia Youth Survey (N = 18,800). Adolescents aged 15 to 19 years were recruited from around Australia, through schools, community organisations and digital platforms. Indices of four domains of social exclusion (housing, finances, relational and education/employment) were created using existing Youth Survey variables, and supplemented with demographic characteristics, psychological distress and help-seeking behaviours (perceived need, mental health supports, barriers to access and preferences). Relationships between social exclusion domains, mental health concerns and help-seeking behaviours were explored using logistic regression models. RESULTS: A total of 9,743 young people reported having needed mental health support, yet only 58.1% reportedly sought support (n = 5,565). Social exclusion domains were associated with different help-seeking behaviours: housing challenges with higher help-seeking (OR = 1.28; 95% CI [1.15, 1.42]); relational difficulties and edu-employment issues with lower (OR = 0.75; 95% CI [0.68, 0.83] and OR = 0.82; 95% CI [0.75, 0.89]). Stigma, confidentiality concerns, cost and not knowing where to seek help were common barriers to help-seeking; those experiencing social exclusion more likely to report these. Participants reported a strong preference for face-to-face support. CONCLUSIONS: This study highlights the additional needs and challenges faced by adolescents dealing with both social exclusion and mental ill-health. With greater barriers to help-seeking, concerted efforts are needed to reduce stigma, improve mental health literacy and increase access to trusted information sources. Further initiatives should focus on structural factors that socially exclude young people and exacerbate inequitable access to mental healthcare.

An ethics analysis of antipsychotic dose reduction and discontinuation: Principles for supporting recovery from psychosis.

OBJECTIVE: To examine the evidence and practice of antipsychotic dose reduction from the lens of biomedical ethics (specifically principlism) to support evidence-based practice and patient choice and self-determination. METHODS: An overview of the evidence from randomized controlled trials of antipsychotic dose reduction versus maintenance is presented. This is followed by a theoretical examination of the four key biomedical ethical principles of autonomy, nonmaleficence, beneficence, and justice and how they apply in the case of antipsychotic dose reduction. RESULTS: Existing clinical trial research is dominated by relapse as the primary outcome, with dose reduction associated with a higher risk of relapse than maintenance. Few studies have measured other patient-centered outcomes but have shown preliminary evidence for superior cognitive functioning, lower negative symptoms, and better functioning following dose reduction. Respect for autonomy is a cornerstone of psychiatric rehabilitation, and this includes the right of people to choose to reduce or discontinue antipsychotic medication. Reduced capacity for treatment decision making can be supported. Autonomy and appraisal of nonmaleficence and beneficence associated with dose reduction can be facilitated through shared or supported decision making. Clinicians should continue to strive for justice through the fair allocation of resources to support all people who request antipsychotic dose reduction. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Clinicians have a responsibility to balance the four core ethical principles to the best of their ability when supporting a person in their recovery journey. Exploring, trialing, and supporting antipsychotic dose reduction may be part of this process if that is the patient's choice. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Vocational functioning in young people accessing services for first-episode psychosis and ultra-high risk of psychosis: A longitudinal naturalistic cohort study.

AIMS: Young people with first-episode psychosis (FEP) or at ultra-high risk (UHR) of psychosis often have lower vocational engagement than their peers. This study examines the effect of treatment in early intervention for psychosis services in Australia on engagement in education and employment. METHODS: This is a naturalistic sample of young people aged 12-25 with FEP (n = 1574) and UHR (n = 1515), accessing treatment in the headspace Early Psychosis (hEP) programme. Engagement in education and employment was assessed at baseline and every 90 days in treatment. Mixed effects logistic regression were used to analyse changes over time. RESULTS: On entering the hEP programme, approximately 49% of the young people with FEP and 28% of the young people at UHR status identified as Not in Education, Employment or Training (NEET). The odds of being NEET were reduced by 27% (95% confidence interval = [14, 39]) for every 6 months treatment for the FEP group, but no change in NEET status was observed in the UHR group. In both groups, absence from daily activities was significantly reduced during time in treatment. CONCLUSION: While there are methodological challenges analysing real-world non-control group cohort data, the findings indicate positive effects of the hEP programme on vocational and daily activity engagement for young people with FEP and at UHR status. A large proportion of the young people still identified as NEET after receiving treatment services, suggesting further refinement to ensure targeted and consistent vocational support throughout care.

A supported education programme implemented in youth mental health services: Outcomes and lessons from the first year of COVID-disrupted delivery.

AIM: Educational attainment is consistently highly valued by young people with mental ill health, yet maintenance and completion of education is a challenge. This paper reports on the implementation of a supported education programme for youth mental health. METHODS: Between 10 October 2019 and 10 October 2020, a supported education programme was delivered within primary and tertiary youth mental health services. A description of the programme, context, and adjustments required due to COVID-19 is presented, and the educational outcomes of young people referred to the programme were explored. Two case studies are also presented. RESULTS: The programme received 71 referrals over this period, of which 70.4% had not yet completed secondary school and 68% were experiencing multiple mental health conditions. Overall outcomes were positive, with 47.5% of the 40 young people who chose to engage with the programme maintaining or re-engaging with education. However, the remainder of those who engaged withdrew from the programme, often reporting challenges due to COVID-19 such as social isolation or increased uncertainty. Additionally, a number of young people declined or disengaged from the programme to focus on employment. CONCLUSION: This report of the experience of integrating a supported employment programme in Australian youth mental health services reinforces the need for such support, and provides preliminary evidence for its successful implementation as part of routine care. The disengagement in response to COVID-19 highlights the real-world challenges of the pandemic, while young people's voicing of employment goals indicates the need for combined educational and vocational support-to assist transition and progression between these goals.

The societal impact of individual placement and support implementation on employment outcomes for young adults receiving temporary health-related welfare benefits: a difference-in-differences study.

BACKGROUND: Individual placement and support (IPS) is an evidence-based practice that helps individuals with mental illness gain and retain employment. IPS was implemented for young adults at a municipality level through a cross-sectoral collaboration between specialist mental healthcare, primary mental healthcare, and the government funded employment service (NAV). We investigated whether IPS implementation had a causal effect on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation (work assessment allowance, WAA) welfare benefit, measured at the societal level compared to municipalities that did not implement IPS. METHOD: We used a difference in differences design to estimate the effects of IPS implementation on the outcome of workdays per year using longitudinal registry data. We estimate the average effect of being exposed to IPS implementation during four-years of implementation compared to ten control municipalities without IPS for all WAA recipients. RESULTS: We found a significant, positive, causal effect on societal level employment outcomes of 5.6 (p = 0.001, 95% CI 2.7-8.4) increased workdays per year per individual, equivalent to 12.7 years of increased work in the municipality where IPS was implemented compared to municipalities without IPS. Three years after initial exposure to IPS implementation individuals worked, on average, 10.5 more days per year equating to 23.8 years of increased work. CONCLUSIONS: Implementing IPS as a cross sectoral collaboration at a municipality level has a significant, positive, causal, societal impact on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation welfare benefit.

The prevalence of vitamin D deficiency and associated factors in first-episode psychosis.

AIM: Vitamin D deficiency is prevalent in people with established psychotic disorders, but less is known about vitamin D levels in people with first-episode psychosis (FEP). This study aimed to determine the prevalence of vitamin D deficiency in people with FEP and identify the factors associated with vitamin D status. METHODS: This was a prospective cohort study nested within a randomized controlled trial, which included 37 young people with an FEP with minimal antipsychotic medication exposure. RESULTS: Twenty-four percent of participants were vitamin D deficient, and a further 30% were vitamin D insufficient. There was no association between vitamin D and demographic factors or clinical symptoms (positive, negative, general psychopathology and depressive symptoms) or cognition and functioning. However, vitamin D levels were associated with season of sampling. CONCLUSIONS: Considering the longer-term adverse effects associated with vitamin D deficiency, it is warranted to ensure this clinical population receives supplementation if indicated.

The Cost-Effectiveness of a Novel Online Social Therapy to Maintain Treatment Effects From First-Episode Psychosis Services: Results From the Horyzons Randomized Controlled Trial.

BACKGROUND: Digital interventions have potential applications in promoting long-term recovery and improving outcomes in first-episode psychosis (FEP). This study aimed to evaluate the cost-effectiveness of Horyzons, a novel online social therapy to support young people aged 16-27 years following discharge from FEP services, compared with treatment as usual (TAU) from a healthcare sector and a societal perspective. STUDY DESIGN: A cost-effectiveness analysis (CEA), based on the change in social functioning, and a cost-utility analysis (CUA) using quality-adjusted life years were undertaken alongside a randomized controlled trial. Intervention costs were determined from study records; resources used by patients were collected from a resource-use questionnaire and administrative data. Mean costs and outcomes were compared at 18 months and incremental cost-effectiveness ratios were calculated. Uncertainty analysis using bootstrapping and sensitivity analyses was conducted. STUDY RESULTS: The sample included 170 participants: Horyzons intervention group (n = 86) and TAU (n = 84). Total costs were significantly lower in the Horyzons group compared with TAU from both the healthcare sector (-AU$4789.59; P < .001) and the societal perspective (-AU$5131.14; P < .001). In the CEA, Horyzons was dominant, meaning it was less costly and resulted in better social functioning. In the CUA, the Horyzons intervention resulted in fewer costs but also yielded fewer QALYs. However, group differences in outcomes were not statistically significant. When young people engaged more with the platform, costs were shown to decrease and outcomes improved. CONCLUSIONS: The Horyzons intervention offers a cost-effective approach for improving social functioning in young people with FEP after discharge from early intervention services.

EMPOWERED trial: protocol for a randomised control trial of digitally supported, highly personalised and measurement-based care to improve functional outcomes in young people with mood disorders.

OBJECTIVES: Many adolescents and young adults with emerging mood disorders do not achieve substantial improvements in education, employment, or social function after receiving standard youth mental health care. We have developed a new model of care referred to as 'highly personalised and measurement-based care' (HP&MBC). HP&MBC involves repeated assessment of multidimensional domains of morbidity to enable continuous and personalised clinical decision-making. Although measurement-based care is common in medical disease management, it is not a standard practice in mental health. This clinical effectiveness trial tests whether HP&MBC, supported by continuous digital feedback, delivers better functional improvements than standard care and digital support. METHOD AND ANALYSIS: This controlled implementation trial is a PROBE study (Prospective, Randomised, Open, Blinded End-point) that comprises a multisite 24-month, assessor-blinded, follow-up study of 1500 individuals aged 15-25 years who present for mental health treatment. Eligible participants will be individually randomised (1:1) to 12 months of HP&MBC or standardised clinical care. The primary outcome measure is social and occupational functioning 12 months after trial entry, assessed by the Social and Occupational Functioning Assessment Scale. Clinical and social outcomes for all participants will be monitored for a further 12 months after cessation of active care. ETHICS AND DISSEMINATION: This clinical trial has been reviewed and approved by the Human Research Ethics Committee of the Sydney Local Health District (HREC Approval Number: X22-0042 & 2022/ETH00725, Protocol ID: BMC-YMH-003-2018, protocol version: V.3, 03/08/2022). Research findings will be disseminated through peer-reviewed journals, presentations at scientific conferences, and to user and advocacy groups. Participant data will be deidentified. TRIAL REGISTRATION NUMBER: ACTRN12622000882729.

Impact of rural settings on the interpersonal and personal processes associated with young people supporting a peer who experienced a traumatic event.

INTRODUCTION: There is limited research into informal support processes amongst young people supporting a peer through a traumatic event and how this process occurs specifically within a rural setting. OBJECTIVE: The aim of this research was to understand how the contextual environment impacts on the personal and interpersonal processes of rural-based young people supporting a peer who experienced a traumatic event. DESIGN: Qualitative interviews were conducted with 22 young people (aged 14-19), who resided in Gippsland, Victoria, Australia. A substantive theory was developed using Charmaz's (1) Constructivist grounded theory methodology. FINDINGS: Young people who shared responsibility for supporting their peer went back to life as normal and felt connected to their community, whereas young people who maintained sole responsibility, experienced mental health problems, disconnected from their community and felt like an outsider. The contextual environmental factors (i.e., service accessibility, limited transport, and internet blackspots) impacted both negatively and positively on young people's ability to provide support as well as influenced whether they felt safe share responsibility. DISCUSSION: This theory implies that providing pathways to reconnecting with place and community, are essential in guiding young people back to their foundations of support. CONCLUSION: Integrating these insights can create new service models in rural areas, whilst also creating opportunities to form healthy foundations of support.

Foundations of support: Processes associated with adolescents supporting a peer who experienced a traumatic event.

BACKGROUND: There is limited research on how supporting a peer through a traumatic event is experienced by adolescents. The aim of this research was to understand the personal and interpersonal processes of adolescents supporting a peer who experienced a traumatic event based on youth definitions. METHOD: In-depth qualitative interviews were conducted with 22 adolescents aged 14-19, residing in Gippsland, Victoria, Australia. A constructivist grounded theory methodology was used to develop a substantive theory. RESULTS: The substantive theory 'Foundations of Support' was developed which explained the support process phenomena. Specifically, adolescents who had shared responsibility for supporting their peers went back to life as normal, whereas adolescents who maintained sole responsibility experienced mental health problems. DISCUSSION: The 'Foundations of Support' grounded theory highlights the importance of adolescents having strong connections to their trusted others, such as family, friends and community. This theory implies that facilitating connections with positive supports such as place and community are essential in guiding adolescents back to their foundations of support. Without strong connections, adolescents are at risk of maintaining sole responsibility, losing their sense of identity and feeling alienated within their community.

Long term outcomes and causal modelling of compulsory inpatient and outpatient mental health care using Norwegian registry data: Protocol for a controversies in psychiatry research project.

OBJECTIVES: Compulsory mental health care includes compulsory hospitalisation and outpatient commitment with medication treatment without consent. Uncertain evidence of the effects of compulsory care contributes to large geographical variations and a controversy on its use. Some argue that compulsion can rarely be justified and should be reduced to an absolute minimum, while others claim compulsion can more frequently be justified. The limited evidence base has contributed to variations in care that raise issues about the quality/appropriateness of care as well as ethical concerns. To address the question whether compulsory mental health care results in superior, worse or equivalent outcomes for patients, this project will utilise registry-based longitudinal data to examine the effect of compulsory inpatient and outpatient care on multiple outcomes, including suicide and overall mortality; emergency care/injuries; crime and victimisation; and participation in the labour force and welfare dependency. METHODS: By using the natural variation in health providers' preference for compulsory care as a source of quasi-randomisation we will estimate causal effects of compulsory care on short- and long-term trajectories. CONCLUSIONS: This project will provide valuable insights for service providers and policy makers in facilitating high quality clinical care pathways for a high risk population group.

The Australian Early Psychosis Collaborative Consortium (AEPCC): Improving Clinical Care in Early Psychosis.

OBJECTIVES: The field of early psychosis has undergone considerable expansion over the last few decades and has a strong evidence base of effectiveness. Like all areas of healthcare, however, early psychosis services need to more consistently deliver higher quality care to achieve better outcomes for patients and families. A national clinical research infrastructure is urgently required to enable the sector to deliver the highest quality care and expand and translate evidence more quickly and efficiently. This paper describes the establishment of the Australian Early Psychosis Collaborative Consortium (AEPCC) that aims to achieve this. CONCLUSION: AEPCC is the first of its kind in Australia (and internationally). It will deliver the required clinical research infrastructure through the implementation of a clinical quality registry, clinical trials and translation network, and lived experience network. AEPCC will provide a critical resource to better understand the state of early psychosis care, and trial new interventions on a scale that has not previously been possible in Australia.

Eating disorders in young people.

OBJECTIVE: Eating disorders (EDs) have their onset most frequently in adolescence and young adulthood. Treatment for EDs lack efficacy, and we have made little progress in improving outcomes for patients over the course of the last several decades. As with other mental health conditions, early intervention may greatly improve outcomes, yet, little research exists in this area. CONCLUSIONS: More effective evidence-based treatments are sorely needed for EDs, particularly for early stages of the illness to minimise the potential harms of treatment and long-standing illness. Treatment service models would also benefit from taking an approach that ensures continuation of care from adolescence to young adulthood.

Implementing a combined individual placement and support and vocational peer work program in integrated youth mental health settings.

AIM: To describe the implementation and outcomes of a combined individual placement and support (IPS) and vocational peer work program for young people with mental ill-health. METHODS: This uncontrolled pilot study co-located IPS workers and vocational peer workers within two integrated youth mental health services (provided to clients aged 15-25 years old). Employment outcomes included job placements (working 15 hours or more per week in a paid competitive job in the open employment market) and sustained employment (employed for at least 26 weeks). Participants who required additional assistance also received peer work. RESULTS: Of the 326 young people enrolled, 195 (59.8%) achieved competitive employment, including 157 (48.2%) in funder-approved placements. Among those in approved placements, 87 (55.4%) achieved sustained employment. For the 116 participants additionally receiving vocational peer work, 54 (46.6%) worked in funder-approved placements, of whom 27 (50.0%) achieved sustained employment. Among 210 participants who did not receive peer work, 103 (49.0%) worked in funder-approved placements, of whom 60 (58.3%) achieved sustained employment. CONCLUSIONS: The program achieved positive vocational outcomes and good fidelity to the IPS model. Approximately half of young people had employment placements, with a relatively high proportion maintained over time. The similar proportion of placements for those who did and did not receive peer work was encouraging given the IPS team determined that the former group needed additional support. Recommendations include upskilling the workforce, a data linkage system to obtain placement evidence, and using implementation science methodologies to understand how IPS programs are successfully embedded. This demands a coordinated effort between governments and funders, policymakers, services, and professional bodies.