Patterns, predictors, and patient-reported reasons for antidepressant discontinuation in the WHO World Mental Health Surveys.

BACKGROUND: Despite their documented efficacy, substantial proportions of patients discontinue antidepressant medication (ADM) without a doctor's recommendation. The current report integrates data on patient-reported reasons into an investigation of patterns and predictors of ADM discontinuation. METHODS: Face-to-face interviews with community samples from 13 countries (n = 30 697) in the World Mental Health (WMH) Surveys included n = 1890 respondents who used ADMs within the past 12 months. RESULTS: 10.9% of 12-month ADM users reported discontinuation-based on recommendation of the prescriber while 15.7% discontinued in the absence of prescriber recommendation. The main patient-reported reason for discontinuation was feeling better (46.6%), which was reported by a higher proportion of patients who discontinued within the first 2 weeks of treatment than later. Perceived ineffectiveness (18.5%), predisposing factors (e.g. fear of dependence) (20.0%), and enabling factors (e.g. inability to afford treatment cost) (5.0%) were much less commonly reported reasons. Discontinuation in the absence of prescriber recommendation was associated with low country income level, being employed, and having above average personal income. Age, prior history of psychotropic medication use, and being prescribed treatment from a psychiatrist rather than from a general medical practitioner, in comparison, were associated with a lower probability of this type of discontinuation. However, these predictors varied substantially depending on patient-reported reasons for discontinuation. CONCLUSION: Dropping out early is not necessarily negative with almost half of individuals noting they felt better. The study underscores the diverse reasons given for dropping out and the need to evaluate how and whether dropping out influences short- or long-term functioning.

Suicidal ideation, suicide plans and suicide attempts among Australian adults: Findings from the 2020-2022 National Study of Mental Health and Wellbeing.

OBJECTIVE: This study aimed to describe the epidemiology of suicidal ideation, suicide plans and suicide attempts, examine services received for suicide attempts, and explore the relationship between suicide attempts and self-harm without suicidal intent. METHODS: We used survey data from the 2020-2022 National Study of Mental Health and Wellbeing, which involved a nationally representative sample of Australian adults aged 16-85 (n = 15,893). Comparisons were made with the 2007 National Study of Mental Health and Wellbeing (n = 8841). RESULTS: In 2020-2022, the proportions of adults who had experienced suicidal ideation, suicide plans and suicide attempts during their lifetime were 16.6%, 7.5% and 4.9%, respectively. The proportions who had experienced these in the past 12 months were 3.3%, 1.1% and 0.3%. The odds of experiencing suicidal ideation and making a suicide plan were significantly higher in 2020-2022 than in 2007. Groups at heightened risk of suicidal ideation, suicide plans and/or suicide attempts in the previous 12 months were males, young people, people who were gay, lesbian, or bisexual or used some other term to describe their sexual identity, people outside the labour force, people from disadvantaged areas and people with mental disorders. Two-fifths of those who attempted suicide during the previous 12 months did not use health services following their attempt, and two-thirds also self-harmed without suicidal intent. CONCLUSION: The implications of these findings for the forthcoming National Suicide Prevention Strategy are discussed. Suicidal thoughts and behaviours confer risk for suicide and are significant problems in their own right. Their prevention requires a strong whole-of-government response.

Co-occurring mental and substance use disorders in Australia 2020-2022: Prevalence, patterns, conditional probabilities and correlates in the general population.

BACKGROUND: Previous estimates from 2007 found that co-occurring mental and/or substance use disorders were a pervasive feature of Australia's mental health. Since that time there have been shifts and improvements in the conceptualisation and incorporation of co-occurring disorders in research and treatment settings. The current study provides up-to-date estimates on the prevalence of co-occurring mental and/or substance use disorders, highlights common patterns of co-occurrence, identifies significant correlates and examines any changes in the extent of co-occurring disorders since 2007. METHODS: Data were from the two Australian National Surveys of Mental Health and Wellbeing conducted in 2020-2022 (N = 15,893) and 2007 (N = 8841). Descriptive statistics were estimated for the number of co-occurring conditions, correlations and pairwise conditional probabilities. Multinomial logistic and robust Poisson regressions were used to identify significant correlates and compare changes in co-occurring conditions across surveys. RESULTS: Approximately 46% of people with a mental or substance use disorder in the past 12 months experienced two or more diagnosable conditions. There was little evidence to suggest that the prevalence of co-occurring disorders has changed since 2007 (Prevalence Ratio (PR) = 1.08, 95% CI = 0.98-1.18). Subgroup analysis indicated that those aged 16-24 years were significantly more likely to experience any co-occurrence in 2020-2022 compared with those aged 16-24 years in 2007 (PR = 1.44, 95% CI = 1.17-1.77). CONCLUSIONS: Co-occurring mental and substance use disorders remain endemic in Australia. Indeed, they appear to be increasingly problematic in younger, more recent cohorts. The results suggest that continued effort is needed to develop and implement transdiagnostic interventions that target broad contextual and/or societal factors.

The epidemiology of mental and substance use disorders in Australia 2020-22: Prevalence, socio-demographic correlates, severity, impairment and changes over time.

OBJECTIVE: Mental and substance use disorders are the leading causes of disability worldwide. Contemporary estimates of prevalence, severity and impairment are essential for service planning. This study provides estimates of prevalence, severity, impairment and demographic correlates of mental and substance use disorders in 2020-22 and changes in prevalence since 2007. METHODS: Data were from the two Australian National Surveys of Mental Health and Wellbeing conducted in 2020-22 (N = 15,893) and 2007 (N = 8841). Descriptive statistics report prevalence of lifetime and 12-month mental and substance use disorder by sex and age, proportion of people with each mental disorder by levels of severity (mild, moderate and severe) and mean days out of role by mental disorder class (mood, anxiety, substance use). Logistic regression analyses examined demographic correlates of mental disorder class and assessed changes over time. RESULTS: The lifetime prevalence of any mental or substance use disorder in 2020-22 was 40.2%. The 12-month prevalence was 20.2% (mood disorder - 7.4%, anxiety disorder - 15.7% and substance use disorder - 3.1%). Mood disorders were associated with significant impairment. The prevalence of mental disorders has changed over time, with mood and anxiety disorders increasing and substance use disorders decreasing. These changes were most evident among young adults. CONCLUSION: Mental disorders are common in Australia. Impairment associated with mental disorders remains significant. Particular focus should be paid to young adults aged 16-24 years who have shown the largest increases in anxiety and mood disorder prevalence over the past 13 years.

Persons with mental disorders and suicidality in crisis or high-risk situations involving police negotiation: a systematic review.

Police negotiators respond to crisis and high-risk situations including mental health crises, but little is known about the nature, frequency and characteristics of these events. This systematic review examined literature about mental disorder and suicidality prevalence in negotiation events from peer-reviewed articles published within the last 20 years. Of 1455 articles identified, 11 met study inclusion criteria. Most contributed only indirect evidence using data on fatal police encounters, case reviews and analysis of communication techniques. Reliable prevalence estimates were not found, though findings suggest suicidality was a precipitating factor in more than half of events and was present during most events. Mental disorder (primarily substance use, mood and psychotic disorders) was also identified as a significant factor prior to and during events. Few articles described frequency or characteristics of these critical events. Further research is needed to inform frontline responses, resourcing and support pathways for police providing this crucial service.

Antidepressant use in low- middle- and high-income countries: a World Mental Health Surveys report.

BACKGROUND: The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries. METHODS: Face-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents. RESULTS: 3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2-4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness. CONCLUSION: ADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.

Determinants of effective treatment coverage for posttraumatic stress disorder: findings from the World Mental Health Surveys.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with significant morbidity, but efficacious pharmacotherapy and psychotherapy are available. Data from the World Mental Health Surveys were used to investigate extent and predictors of treatment coverage for PTSD in high-income countries (HICs) as well as in low- and middle-income countries (LMICs). METHODS: Seventeen surveys were conducted across 15 countries (9 HICs, 6 LMICs) by the World Health Organization (WHO) World Mental Health Surveys. Of 35,012 respondents, 914 met DSM-IV criteria for 12-month PTSD. Components of treatment coverage analyzed were: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) effective treatment coverage. Regression models investigated predictors of treatment coverage. RESULTS: 12-month PTSD prevalence in trauma exposed individuals was 1.49 (S.E., 0.08). A total of 43.0% (S.E., 2.2) received any mental health services, with fewer receiving adequate pharmacotherapy (13.5%), adequate psychotherapy (17.2%), or effective treatment coverage (14.4%), and with all components of treatment coverage lower in LMICs than HICs. In a multivariable model having insurance (OR = 2.31, 95 CI 1.17, 4.57) and severity of symptoms (OR = .35, 95% CI 0.18, 0.70) were predictive of effective treatment coverage. CONCLUSION: There is a clear need to improve pharmacotherapy and psychotherapy coverage for PTSD, particularly in those with mild symptoms, and especially in LMICs. Universal health care insurance can be expected to increase effective treatment coverage and therefore improve outcomes.

Early impacts of the 'National Suicide Prevention Trial' on trends in suicide and hospital admissions for self-harm in Australia.

OBJECTIVES: The National Suicide Prevention Trial was announced by the Australian Government in 2016 and aimed to prevent suicidal behaviour in 12 trial sites (representing a population of ~8 million). This study investigated the early population-level impact of the National Suicide Prevention Trial activity on rates of suicide and hospital admissions for self-harm in comparison to control areas. METHODS: Relative and absolute differences in monthly rates of suicide and hospital admissions for self-harm were compared in the period after the National Suicide Prevention Trial implementation (July 2017-November 2020) to the period prior to implementation (January 2010-June 2017) in (1) 'National Suicide Prevention Trial areas' and (2) 'Control areas', using a difference-in-difference method in a series of negative binomial models. Analyses also investigated whether associations for suicide and self-harm rates differed by key socio-demographic factors, namely sex, age group, area socio-economic status and urban-rural residence. RESULTS: There were no substantial differences between 'National Suicide Prevention Trial areas' and 'Control areas' in rates of suicide (2% relative decrease, relative risk = 0.98, 95% confidence interval = [0.91, 1.06]) or self-harm (1% relative decrease, relative risk = 0.99, 95% confidence interval = [0.96, 1.02]), adjusting for sex, age group and socio-economic status. Stronger relative decreases in self-harm only were evident for those aged 50-64 years, high socio-economic status areas, metropolitan and remote geographic areas. CONCLUSION: There was limited evidence that the National Suicide Prevention Trial resulted in reductions in suicide or hospital admissions for self-harm during the first 4 years of implementation. Continued monitoring of trends with timely data is imperative over the next 2-3 years to ascertain whether there are any subsequent impacts of National Suicide Prevention Trial activities.

Perceived helpfulness of treatment for social anxiety disorder: findings from the WHO World Mental Health Surveys.

PURPOSE: To investigate the prevalence and predictors of perceived helpfulness of treatment in persons with a history of DSM-IV social anxiety disorder (SAD), using a worldwide population-based sample. METHODS: The World Health Organization World Mental Health Surveys is a coordinated series of community epidemiological surveys of non-institutionalized adults; 27 surveys in 24 countries (16 in high-income; 11 in low/middle-income countries; N = 117,856) included people with a lifetime history of treated SAD. RESULTS: In respondents with lifetime SAD, approximately one in five ever obtained treatment. Among these (n = 1322), cumulative probability of receiving treatment they regarded as helpful after seeing up to seven professionals was 92.2%. However, only 30.2% persisted this long, resulting in 65.1% ever receiving treatment perceived as helpful. Perceiving treatment as helpful was more common in female respondents, those currently married, more highly educated, and treated in non-formal health-care settings. Persistence in seeking treatment for SAD was higher among those with shorter delays in seeking treatment, in those receiving medication from a mental health specialist, and those with more than two lifetime anxiety disorders. CONCLUSIONS: The vast majority of individuals with SAD do not receive any treatment. Among those who do, the probability that people treated for SAD obtain treatment they consider helpful increases considerably if they persisted in help-seeking after earlier unhelpful treatments.

Hypervitaminosis A in Pediatric Patients With Advanced Chronic Kidney Disease.

OBJECTIVE: Hypervitaminosis A is well-described but overlooked in chronic kidney disease (CKD) and has been associated with hypercalcemia, contributing to mineral bone disease. Our objective is to assess prevalence of hypervitaminosis A and its association with bone health in an advanced-CKD population. METHODS: We performed a retrospective review of 58 children with CKD 4-5 to examine the association between vitamin A levels and bone health and compared these values between a primarily formula-fed (FF) and nonprimarily formula-fed cohort (NFF). RESULTS: Fifty-six of 58 patients (97%) had hypervitaminosis A with a mean vitamin A level of 1,475 ± 597 mcg/dL. When compared with the upper limit of normal vitamin A level for age, the FF group's vitamin A level was 2.9x upper limit of normal and the NFF group's vitamin A level was 2.2x upper limit of normal (P = .02). The mean calcium level was 10.3 mg/dL in the FF group and 9.8 mg/dL in the NFF group (P = .057). Percent of patients lower than, within, or greater than goal parathyroid hormone range was statistically significant with 15 (62%) of the FF group lower than goal and 16 (72%) of the NFF cohort greater than goal (P = .006). CONCLUSIONS: We concluded vitamin A and calcium levels are higher in the FF versus the NFF population. FF patients are more likely to have parathyroid hormone levels lower than the goal range, placing them at risk for adynamic bone disease. We recommend monitoring vitamin A levels as part of routine nutritional assessments and dietary interventions to prevent hypervitaminosis A to improve bone health in late CKD.

Perceived helpfulness of bipolar disorder treatment: Findings from the World Health Organization World Mental Health Surveys.

OBJECTIVES: To examine patterns and predictors of perceived treatment helpfulness for mania/hypomania and associated depression in the WHO World Mental Health Surveys. METHODS: Face-to-face interviews with community samples across 15 countries found n = 2,178 who received lifetime mania/hypomania treatment and n = 624 with lifetime mania/hypomania who received lifetime major depression treatment. These respondents were asked whether treatment was ever helpful and, if so, the number of professionals seen before receiving helpful treatment. Patterns and predictors of treatment helpfulness were examined separately for mania/hypomania and depression. RESULTS: 63.1% (mania/hypomania) and 65.1% (depression) of patients reported ever receiving helpful treatment. However, only 24.5-22.5% were helped by the first professional seen, which means that the others needed to persist in help seeking after initial unhelpful treatments in order to find helpful treatment. Projections find only 22.9% (mania/hypomania) and 43.3% (depression) would persist through a series of unhelpful treatments but that the proportion helped would increase substantially if persistence increased. Few patient-level significant predictors of helpful treatment emerged and none consistently either across the two components (i.e., provider-level helpfulness and persistence after earlier unhelpful treatment) or for both mania/hypomania and depression. Although prevalence of treatment was higher in high-income than low/middle-income countries, proportional helpfulness among treated cases was nearly identical in the two groups of countries. CONCLUSIONS: Probability of patients with mania/hypomania and associated depression obtaining helpful treatment might increase substantially if persistence in help-seeking increased after initially unhelpful treatments, although this could require seeing numerous additional treatment providers. In addition to investigating reasons for initial treatments not being helpful, messages reinforcing the importance of persistence should be emphasized to patients.

Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report.

BACKGROUND: Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment. METHODS: Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment. RESULTS: The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness. CONCLUSIONS: The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.

Quantifying the size of the informal care sector for Australian adults with mental illness: caring hours and replacement cost.

PURPOSE: To quantify and value the total informal support provided by family and friends to Australian adults with mental illness in 2018. METHODS: The number of mental health carers was drawn from the 2015 Survey of Disability, Ageing and Carers (SDAC), adjusted to the 2018 population. Annual caring hours by type of assistance were estimated using the SDAC, 2007 National Survey of Mental Health and Wellbeing and an online carer survey. Caring hours for each task were assigned an hourly replacement cost from the National Disability Insurance Scheme. Informal caring was valued as the sum of these costs minus expenditure on carer income support payments, estimating how much it would hypothetically cost governments to replace this care with formal support services. RESULTS: An estimated 354,000 (95% uncertainty interval (UI): 327,000-383,000) Australian mental health carers provided 186 million (95% UI: 159-215) hours of support in 2018. The estimated replacement cost was AU$8.4 billion (95% UI: 7.0-10.0), excluding AU$1.3 billion in income support. Univariate sensitivity analyses demonstrated that results were robust to variation in model inputs, with total caring hours the most influential parameter. Using an alternative estimate of mean caring hours, the replacement cost could be as high as AU$13.2 billion (95% UI: 11.2-15.4). CONCLUSION: Informal carers provide substantial support to people with mental illness, highlighting their important contribution to the mental health system and reinforcing the need for carer support services. Future valuation studies would benefit from refinement of available data collections, particularly on hours and types of care provided.

Service demand for psychological interventions among Australian adults: a population perspective.

BACKGROUND: Psychological interventions (PIs) are good practice treatment for both subthreshold and diagnosed mental disorders. Australia has implemented major reforms to expand the provision of subsidised psychological services for individuals with a diagnosed mental disorder. But there are gaps in knowledge about demand for PIs (i.e., use of and perceived need for PIs) across the population. This study uses nationally representative survey data from the 2007 Australian National Survey of Mental Health and Wellbeing to analyse demand for PIs. It also provides a method for analysing survey data to estimate demand for PIs when new survey data becomes available, along with suggestions to inform future survey development. METHODS: Nationally representative community survey respondents (n = 8841, 16-85 years) indicated their perceived need for nine types of help for mental health problems in the past 12 months, including three PIs (cognitive behavioural therapy, psychotherapy, and counselling), and whether these needs were unmet, partially met, or fully met. Types of help were grouped as: PIs only; PIs plus other; and other only. Chi-square analyses were used to examine the association between type of intervention, sociodemographic and clinical factors, and type of professional consulted; multinomial logistic regression models were used to examine predictors of type of intervention(s) received. RESULTS: 7.9% (95%CI: 7.2-8.6) received PIs. Receipt of PIs was positively associated with higher education and consulting a mental health specialist. Twice as many respondents received PIs plus medication as compared to PIs only (4.2% vs. 2.0%). Almost half (45.4, 95%CI 36.5-54.6) incurred out-of-pocket costs for treatment. The most common reason for partially met need for PIs was cost (24.8, 95%CI 17.2-34.3); for unmet need, it was preference for self-management (33.9, 95%CI 21.2-49.5). Perceived unmet need for PIs only (3.1, 95%CI 2.1-4.6) or PIs plus other interventions (5.2, 95%CI 3.9-6.9%) was lower than for other interventions only (22.8, 95%CI 18.7-27.6). CONCLUSIONS: Continued reforms in Australia means that on-going monitoring of demand for PIs, using nationally representative data, is required. This study provides a baseline for comparison of the long-term effects of these reforms; this comparison may be undertaken using data from the third iteration of Australia's NSMHWB, due for completion in 2021-22.

Predictors of unplanned discharge from community-based residential mental health rehabilitation for people affected by severe and persistent mental illness.

BACKGROUND: Little is known about what predicts disengagement from rehabilitation treatment for people affected by severe and persistent mental illness (SPMI). AIMS: To identify predictors of unplanned discharge among consumers admitted to community-based residential rehabilitation units in Australia. METHOD: Secondary analysis of data from a prospective cohort study of consumers admitted to three Community Care Units (CCUs) between 2014 and 2017 (n = 139). CCUs provide transitional residential rehabilitation support to people affected by SPMI. Demographic, treatment-related and clinical predictors of unplanned discharge were identified using binomial regression models controlling for site-level variability. Factors associated with self- vs staff-initiated unplanned discharge were also examined. RESULTS: 38.8% of consumers experienced unplanned discharge. Significant predictors of unplanned discharge were younger age, higher alcohol consumption and disability associated with mental illness, as well as recovery stage indicating a sense of growth and higher competence in daily task performance. 63.0% of unplanned discharges were initiated by staff, mostly for substance-related reasons (55.9%). History of trauma was more likely among consumers with self-initiated discharge than those with staff-initiated unplanned and planned discharge. CONCLUSIONS: Assertive intervention to address alcohol-use, and ensuring care is trauma-informed, may assist in reducing rates of unplanned discharge from rehabilitation care.

Perceived helpfulness of treatment for posttraumatic stress disorder: Findings from the World Mental Health Surveys.

BACKGROUND: Perceived helpfulness of treatment is an important healthcare quality indicator in the era of patient-centered care. We examine probability and predictors of two key components of this indicator for posttraumatic stress disorder (PTSD). METHODS: Data come from World Mental Health surveys in 16 countries. Respondents who ever sought PTSD treatment (n = 779) were asked if treatment was ever helpful and, if so, the number of professionals they had to see to obtain helpful treatment. Patients whose treatment was never helpful were asked how many professionals they saw. Parallel survival models were estimated for obtaining helpful treatment in a specific encounter and persisting in help-seeking after earlier unhelpful encounters. RESULTS: Fifty seven percent of patients eventually received helpful treatment, but survival analysis suggests that it would have been 85.7% if all patients had persisted in help-seeking with up to six professionals after earlier unhelpful treatment. Survival analysis suggests that only 23.6% of patients would persist to that extent. Odds of ever receiving helpful treatment were positively associated with receiving treatment from a mental health professional, short delays in initiating help-seeking after onset, absence of prior comorbid anxiety disorders and childhood adversities, and initiating treatment before 2000. Some of these variables predicted helpfulness of specific treatment encounters and others predicted persistence after earlier unhelpful encounters. CONCLUSIONS: The great majority of patients with PTSD would receive treatment they considered helpful if they persisted in help-seeking after initial unhelpful encounters, but most patients whose initial treatment is unhelpful give up before receiving helpful treatment.

Barriers to mental health care for Australian children and adolescents in 1998 and 2013-2014.

OBJECTIVE: To assess changes in barriers to mental health care for children and adolescents over 16 years. METHODS: We used data from two nationally representative surveys of Australian children and adolescents (4-17 years old), conducted in 1998 (N = 4509) and 2013-2014 (N = 6310). Barriers to care were assessed among parents who had reported a perceived partially met or unmet need for their child in the past 6 months in 1998, and the past 12 months in 2013-2014; barriers were similarly assessed among adolescents in relation to themselves. We addressed measurement inconsistencies between surveys by harmonising barriers to accommodate differences in wording and performing sensitivity analyses among those with a 1-month disorder to equalise the timeframes in which barriers were assessed. To assess change, we examined whether the rank order of the three most commonly endorsed barriers changed and whether the 95% confidence intervals (CI) around their estimates overlapped. RESULTS: Similar proportions of parents reported a partially met or unmet need in 1998 (12.9%, 95% CI = [11.7, 14.0]) as in 2013-2014 (14.3%, 95% CI = [13.2, 15.3]), but the ratio of unmet to partially met need decreased from 3:1 in 1998 to 1:1 in 2013-2014. Top three parent-endorsed barriers ('self-reliance', 'unsure where to get help', and 'cost') were the same at both time points; 'self-reliance' decreased from 65.9% (95% CI = [61.1%, 70.7%]) to 34.9% (95% CI = [31.5%, 38.3%]). Top two adolescent-endorsed barriers ('self-reliance' and 'concerned what others might think') were the same at both time points, the third differed, but none of them decreased. CONCLUSION: Perceived unmet need for mental health care for children and adolescents may have decreased between 1998 and 2013-2014, but the gap in receiving sufficient care may have increased. Despite investments in community awareness and treatment during this period, key barriers seemed largely unchanged. For parents, the decrease in self-reliance may reflect a positive shift in beliefs about the potential benefits of treatment.

Disordered eating among Australian adolescents: Prevalence, functioning, and help received.

OBJECTIVE: To estimate the prevalence of disordered eating (DE) among Australian adolescents and examine associations with clinical mental health problems, problems with functioning, and help received. METHOD: We analyzed data from the Young Minds Matter survey (n = 2,298, 13-17 years). We derived an index of DE severity with four levels: (1) no DE; (2) subclinical DE; (3) suspected eating disorder; and (4) lifetime eating disorder diagnosis. RESULTS: In 2013-2014, 31.6% (95%CI 35.5-39.9) of Australian adolescents experienced DE, comprising 25.7% (95%CI 23.9-37.6) with subclinical DE, 11.0% (95%CI 9.7-12.6) with a suspected eating disorder, and 0.9% (95%CI 0.6-1.3) with a lifetime eating disorder diagnosis. DE was more common among girls (41.4%, 95%CI 37.9-44.4) than boys (34.0%, 95%CI 31.1-37.0; p = .002). Adolescents with DE, compared to those without, were more likely to experience clinical mental health problems and problems with functioning. Most adolescents with DE reported help-seeking in the past year, commonly self-help; around 40% used school-based, primary care or specialist services (i.e., formal services). In multivariate analyses, the use of more specialized and intensive services was associated with more severe DE, greater problems with functioning, female gender, and 12-month mental disorder or subthreshold mental disorder symptoms. DISCUSSION: The implementation of mental health promotion and prevention efforts for DE, and screening for DE in school and primary care settings, may facilitate detection and appropriate help-seeking among adolescents with DE.

A systematic review of service models and evidence relating to the clinically operated community-based residential mental health rehabilitation for adults with severe and persisting mental illness in Australia.

BACKGROUND: Clinically operated community-based residential rehabilitation units (Community Rehabilitation Units) are resource intensive services supporting a small proportion of the people with severe and persisting mental illness who experience difficulties living in the community. Most consumers who engage with these services will be diagnosed with schizophrenia or a related disorder. This review seeks to: generate a typology of service models, describe the characteristics of the consumers accessing these services, and synthesise available evidence about consumers' service experiences and outcomes. METHOD: A systematic review was undertaken to identify studies describing Community Rehabilitation Units in Australia, consumer characteristics, and evidence about consumer experiences and outcomes. Search strings were applied to multiple databases; additional records were identified through snowballing. Records presenting unique empirical research were subject to quality appraisal. RESULTS: The typology defined two service types, Community-Based Residential Care (C-BRC), which emerged in the context of de-institutionalisation, and the more recent Transitional Residential Rehabilitation (TRR) approach. Key differentiating features were the focus on transitional care and 'recovery' under TRR. Schizophrenia spectrum disorders were the most common primary diagnosis under both service types. TRR consumers were more likely to be male, referred from community settings, and less likely to be subject to involuntary treatment. Regarding outcomes, the limited quantitative evidence (4 records, 2 poor quality) indicated C-BRC was successful in supporting the majority of consumers transferred from long-term inpatient care to remain out of hospital. All qualitative research conducted in C-BRC settings was assessed to be of poor quality (3 records). No methodologically sound quantitative evidence on the outcomes of TRR was identified. Qualitative research undertaken in these settings was of mixed quality (9 records), and the four records exploring consumer perspectives identified them as valuing the service provided. CONCLUSIONS: While there is qualitative evidence to suggest consumers value the support provided by Community Rehabilitation Units, there is an absence of methodologically sound quantitative research about the consumer outcomes achieved by these services. Given the ongoing and increasing investment in these facilities within the Australian context, there is an urgent need for high-quality research examining their efficiency and effectiveness. TRIAL REGISTRATION: PROSPERO ( CRD42018097326 ).

Employment disadvantage and associated factors for informal carers of adults with mental illness: are they like other disability carers?

BACKGROUND: Providing unpaid support to family and friends with disabling health conditions can limit a carer's capacity to participate in employment. The emotional support needs and unpredictability of caring for people with mental illness may be particularly demanding. While previous research suggests variable employment rates across carers for different conditions, there are limited data on mental health carers specifically. METHODS: This study analysed employment patterns for working-age, co-resident carers of adults with mental illness in an Australian cross-sectional household survey, the 2015 Survey of Disability, Ageing and Carers. RESULTS: Significantly more mental health carers were not employed (42.3%, 95% CI: 36.6-48.1) compared to non-carers (24.0%, 95% CI: 23.5-24.6). Employed mental health carers were more likely to work fewer than 16 h per week (carers: 17.2%, 95% CI: 12.8-22.8, vs. non-carers: 11.7%, 95% CI: 11.3-12.1) and in lower skilled occupations (carers: 22.6, 95% CI: 17.5-28.7, vs. non-carers: 15.7, 95% CI: 15.1-16.2). Among the sub-group of primary mental health carers, 25.8% (95% CI: 15.6-39.5) had reduced their working hours to care and a further 26.4% (95% CI: 17.2-38.2) stopped working altogether. In corresponding comparisons between mental health carers and carers for people with other cognitive/behavioural conditions, and physical conditions with or without secondary mental illness, there were no differences except that mental health carers were more likely to be working in a lower skilled occupation than other cognitive/behavioural condition carers (14.8% of the latter, 95% CI 10.1-21.2). Multivariate logistic regression analyses revealed that female mental health carers were less likely to be employed if they were aged 35-54, had no post-secondary education, had a disability, or cared for someone with severe activity limitations. For male mental health carers, having a disability or caring for someone with severe limitations or who did not receive paid assistance were significantly associated with not being employed. CONCLUSIONS: These results highlight the employment disadvantage experienced by mental health carers compared to non-carers, and similarities in employment patterns across carers for different conditions. Improving the availability of paid support services for people with mental illness may be an important target to assist carers to maintain their own employment.