Individual placement and support for vocational recovery in first-episode psychosis: randomised controlled trial.

BACKGROUND: High unemployment is a hallmark of psychotic illness. Individual placement and support (IPS) may be effective at assisting the vocational recoveries of young people with first-episode psychosis (FEP).AimsTo examine the effectiveness of IPS at assisting young people with FEP to gain employment (Australian and Clinical Trials Registry ACTRN12608000094370). METHOD: Young people with FEP (n = 146) who were interested in vocational recovery were randomised using computer-generated random permuted blocks on a 1:1 ratio to: (a) 6 months of IPS in addition to treatment as usual (TAU) or (b) TAU alone. Assessments were conducted at baseline, 6 months (end of intervention), 12 months and 18 months post-baseline by research assistants who were masked to the treatment allocations. RESULTS: At the end of the intervention the IPS group had a significantly higher rate of having been employed (71.2%) than the TAU group (48.0%), odds ratio 3.40 (95% CI 1.17-9.91, z = 2.25, P = 0.025). However, this difference was not seen at 12- and 18-month follow-up points. There was no difference at any time point on educational outcomes. CONCLUSIONS: This is the largest trial to our knowledge on the effectiveness of IPS in FEP. The IPS group achieved a very high employment rate during the 6 months of the intervention. However, the advantage of IPS was not maintained in the long term. This seems to be related more to an unusually high rate of employment being achieved in the control group rather than a gross reduction in employment among the IPS group.Declaration of interestNone.

Evaluation of a Database for Tracking Cases of Child Sexual Abuse.

Administrative databases are used by criminal justice professionals to guide specialist responses to crimes of child sexual abuse. Assumptions might be made that the database will be accurate, contemporaneous, complete, and meaningful; however, this may not be the case. The main aim of the current study was to critically evaluate a database used by practitioners for tracking cases of child sexual abuse, in order to identify evidence that may justify investment in improved data gathering and centralised information management systems. Three data quality dimensions were examined: (1) completeness, measured as data that were not missing and were of adequate breadth and depth, (2) accuracy, namely that the data are correct, and (3) believability, where the data may be regarded as credible or plausible. Results indicated that data quality was of concern for all three dimensions, with missing and inaccurate data found across a range of variables, and issues with believability found on two variables. The implications of these results for development of new data documentation methods are discussed.

Predictors of vocational recovery among young people with first-episode psychosis: findings from a randomized controlled trial.

OBJECTIVE: The current study sought to examine demographic and clinical predictors of vocational recovery among young people with first-episode psychosis who participated in a randomized controlled trial (RCT) investigating the effectiveness of the supported employment model among this population. METHOD: Our original RCT compared Individual Placement and Support + treatment as usual (n = 20) with treatment as usual alone (n = 21) (Killackey, Jackson, & McGorry, 2008). A series of logistic regression analyses were conducted to assess the predictive power of demographic and clinical factors on the vocational recovery of young people with first-episode psychosis. RESULTS: Vocational recovery (defined as securing a position in competitive employment or attending a course of education at any point during the 6-month follow-up period) was predicted by participating in the vocational intervention (OR = 14.17, p = .001), having never been married (compared to those married/de facto: OR = 6.56, p = .044), and the instrumental role functioning subscale from the Quality of Life scale (OR = 1.21, p = .037). When considered together, only treatment group remained significant: Participants randomized to the vocational intervention were 16.26 times more likely to obtain work or study during the follow-up period compared to participants randomized to treatment as usual. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: It is critical that vocational services are introduced as part of an evidence-based, multidisciplinary approach in routine clinical care at early psychosis services. Further replication of these findings is indicated with a larger sample, particularly with the addition of cognitive training interventions to further improve vocational outcomes for young people with first-episode psychosis.

Validity of the 12-item General Health Questionnaire (GHQ-12) in detecting depressive and anxiety disorders among high school students.

Despite the common use of the 12-item General Health Questionnaire (GHQ-12) with adolescents, there is limited data supporting its validity with this population. The aims of the study were to investigate the psychometric properties of the GHQ-12 among high school students, to validate the GHQ-12 against the gold standard of a diagnostic interview, and to suggest a threshold score for detecting depressive and anxiety disorders. Six hundred and fifty-four high school students from years 10 to 12 (ages 15-18) completed the GHQ-12 (Likert scored) and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV-Test Revision (DSM-IV-TR). Receiver operating characteristic (ROC) curves were plotted. The mean GHQ-12 score for the total sample was 9.9 (S.D.=5.4). Results from the ROC curve indicated that the GHQ-12 performed better than chance at identifying depressive and anxiety disorders (area under the curve (AUC)=0.781). A GHQ-12 threshold score of 9/10 for males and 10/11 for females was found to be optimal. Given the significant proportion of mental illness among high school students, there may be a need to introduce screening for mental illnesses as part of the school curriculum. This can assist with the early identification and enable low stigma preventive intervention within the school environment.

Using internet enabled mobile devices and social networking technologies to promote exercise as an intervention for young first episode psychosis patients.

BACKGROUND: Young people with first episode psychosis are at an increased risk for a range of poor health outcomes. In contrast to the growing body of evidence that suggests that exercise therapy may benefit the physical and mental health of people diagnosed with schizophrenia, there are no studies to date that have sought to extend the use of exercise therapy among patients with first episode psychosis. The aim of the study is to test the feasibility and acceptability of an exercise program that will be delivered via internet enabled mobile devices and social networking technologies among young people with first episode psychosis. METHODS/DESIGN: This study is a qualitative pilot study being conducted at Orygen Youth Health Research Centre in Melbourne, Australia. Participants are young people aged 15-24 who are receiving clinical care at a specialist first episode psychosis treatment centre. Participants will also comprise young people from the general population. The exercise intervention is a 9-week running program, designed to gradually build a person's level of fitness to be able to run 5 kilometres (3 miles) towards the end of the program. The program will be delivered via an internet enabled mobile device. Participants will be asked to post messages about their running experiences on the social networking website, and will also be asked to attend three face-to-face interviews. DISCUSSION: This paper describes the development of a qualitative study to pilot a running program coupled with the use of internet enabled mobile devices among young people with first episode psychosis. If the program is found to be feasible and acceptable to patients, it is hoped that further rigorous evaluations will ultimately lead to the introduction of exercise therapy as part of an evidence-based, multidisciplinary approach in routine clinical care.

Psychiatric disorders and unmet needs in Australian police cells.

OBJECTIVE: To determine the prevalence of current psychiatric disorders and unmet needs in a sample of police cell detainees in Victoria. METHOD: A cross-sectional descriptive study was conducted, including data linkage with the Victoria Police database and the Victorian Psychiatric Case Register. In Melbourne, Australia, 150 detainees were recruited from two busy metropolitan police stations. Outcome measures included estimated rates of psychiatric disorders, using the Structured Clinical Interview for DSM-IV-TR, and individual needs, using the Camberwell Assessment of Need - Forensic Version. RESULTS: One quarter (n = 32, 25.4%) of detainees had a prior admission to a psychiatric hospital, and three quarters met current criteria for a diagnosable mental disorder. The most common disorders were substance dependence (n = 81, 54%) and mood disorders (n = 60, 40%). A third met diagnostic criteria for both a mental illness and a substance use disorder. The odds of being classified with mood (OR = 10.1), anxiety (OR = 2.2), psychotic (OR = 15.4) and substance use disorders (OR = 26.3) were all significantly higher in the current sample as compared with the general population. Detainees with a mental illness identified significantly more needs and significantly more unmet needs (e.g. psychological distress) than those who did not rate as having a current mental illness. CONCLUSIONS: There remains a pressing need to evaluate standardized screening tools for mental illnesses in police cells to provide timely access to assessment and treatment services. The need for functional interagency collaborations are highlighted and discussed.

Psychotic-like experiences in a community sample of adolescents: implications for the continuum model of psychosis and prediction of schizophrenia.

OBJECTIVE: Studies conducted in community samples suggest that psychotic-like experiences are common in the general population, leading to suggestions that they are either variations of normal personality or are different expressions of underlying vulnerability to psychotic disorder. Different types of psychotic symptoms may exist, some being normal variants and some having implications for mental health and functioning. The aim of the present study was to determine if different subtypes of psychotic-like experiences could be identified in a community sample of adolescents and to investigate if particular subtypes were more likely to be associated with psychosocial difficulties, that is, distress, depression and poor functioning, than other subtypes. METHOD: Eight hundred and seventy-five Year 10 students from 34 schools participated in a cross-sectional survey that measured psychotic-like experiences using the Community Assessment of Psychic Experiences; depression using the Centre for Epidemiologic Studies Depression Scale; and psychosocial functioning using the Revised Multidimensional Assessment of Functioning Scale. Factor analysis was conducted to identify any subtypes of psychotic experiences. RESULTS: Four subtypes of psychotic-like experiences were identified: Bizarre Experiences, Perceptual Abnormalities, Persecutory Ideas, and Magical Thinking. Intermittent, infrequent psychotic experiences were common, but frequent experiences were not. Bizarre Experiences, Perceptual Abnormalities and Persecutory Ideas were strongly associated with distress, depression and poor functioning. Magical Thinking was only weakly associated with these variables. Overall these findings may suggest that infrequent psychotic-like experiences are unlikely to be a specific risk factor for onset of a psychotic disorder in community samples. CONCLUSIONS: Given that the different subtypes had varying associations with current difficulties it is suggested that not all subtypes confer the same risk for onset of psychotic disorder and poor outcome. Bizarre Experiences, Perceptual Abnormalities and Persecutory Ideas may represent expressions of underlying vulnerability to psychotic disorder, but Magical Thinking may be a normal personality variant.

Stability of retrospective self-reports of childhood trauma in first-episode psychosis.

AIM: Childhood trauma (CT), abuse and neglect are commonly reported by individuals experiencing psychosis. However, there are concerns that acute psychotic symptoms, in particular delusions, may contribute to inaccurate reporting of CT. As a result, individuals experiencing psychosis may not be asked about their experiences of abuse when they are being seen in psychiatric settings. This lack of attention can directly impact on the tailoring of their clinical care. This study aimed to investigate the stability of reports of CT by young people experiencing a first psychotic episode (FEP) compared to healthy comparison subjects. METHODS: Responses of 24 young people during the acute FEP and 3 months later to items on the Childhood Trauma Questionnaire (CTQ) were compared to 30 non-psychiatric controls. All participants were aged 15 to 25 years. RESULTS: FEP participants reported higher CT than controls at both time points. Reliability analyses (interclass correlation coefficients [ICCs]) suggested strong agreement between CT reports at baseline and follow-up for FEP participants (.81) and controls (.91). Positive psychotic symptoms were unrelated to CT reports. Although the severity of CT reports fluctuated between assessments, complete retractions of severe abuse claims occurred rarely. CONCLUSIONS: The results suggest that retrospective self-report can be used to reliably assess CT in young people experiencing acute psychosis.

A descriptive study of juvenile family violence: data from intervention order applications in a Childrens Court.

There is increasing recognition that family violence may be perpetrated by juveniles against their parents and siblings, however empirical research regarding the nature and causes of such violence is relatively limited. This study examines juvenile family violence in the context of an Intervention Order (IO) being sought against a relative aged 18years or less. All cases over a 3-year period involving an IO application in a major metropolitan Children's Court in Australia were analysed (n=438). The majority of applicants/victims were parents (78%) and to a lesser extent siblings (11%) and other relatives (9%). Most parents who sought applications were mothers (63%) and one-parent households were over-represented (66%). The majority of defendants/perpetrators were male (69%), though juvenile females constituted a significant minority (31%). Intervention orders were sought to prohibit property damage (61%), physical assaults (59%) and/or threats (53%). According to the victim reports, these behaviours emerged in the context of prolonged behavioural problems (49%), a desire to intimidate the victim (12%) or retaliation (8%). While 44% of IO applications were granted, the majority were not (56%) due to the victim discontinuing the application prior to a formal hearing. Of the orders that were granted, a third (32%) were subsequently reported as having been breached. Juvenile family violence is a serious social problem that requires more systematic research to identify the correlates of this behaviour and effective interventions to prevent or reduce its occurrence.

Validation of a short adaptation of the Mood and Anxiety Symptoms Questionnaire (MASQ) in adolescents and young adults.

The Mood and Anxiety Symptoms Questionnaire (MASQ) was developed to measure the symptom-dimensions of the tripartite model of anxiety and depression. A 30-item short adaptation of the MASQ (MASQ-D30) was previously developed and validated in adult psychiatric outpatients. The aim of the present study was to evaluate the validity and reliability of the MASQ-D30 in a sample of adolescents and young adults. Help-seeking adolescents from Australia (N=147; mean age: 17.7 years; 58.8% female) completed the original, 90-item MASQ. Confirmatory Factor Analysis (CFA) was used to evaluate the construct validity (a 3-factor structure) of the original MASQ and the MASQ-D30. Internal consistencies and correlations with other instruments were calculated and compared between versions. CFA showed that the intended 3-factor structure fit adequately to the MASQ-D30 data (CFI=0.95; RMSEA=0.08). Internal consistencies ranged from 0.85 to 0.92 across the scales and patterns of correlations with the Center for Epidemiological Studies-Depression (CES-D) indicated adequate convergent/divergent properties. Importantly, the observed psychometric characteristics were comparable with the original MASQ and alternative short-forms. Results indicated that the MASQ-D30 is a valid and reliable instrument in young people, allowing for quick assessment of the tripartite dimensions of depression and anxiety.

Development and validation of a new measure of everyday adolescent functioning: the multidimensional adolescent functioning scale.

PURPOSE: Everyday functioning is an important outcome for studies of the developmental psychopathology of adolescence. An unbiased, well-validated, and easy-to-use instrument to specifically assess normal adolescent functioning is not yet available. The current study aimed to introduce and validate the Multidimensional Adolescent Functioning Scale (MAFS). METHODS: The MAFS was developed by clinical consensus, resulting in a 23-item self-report questionnaire with three distinct subscales: general functioning, family-related functioning, and peer-related functioning. MAFS data were collected in a general population sample (N = 842; mean age = 15.0 years [standard deviation = .4]) at baseline and again at 1- and 3-year follow-up. Psychometric analyses included confirmatory factor analysis, calculations of internal consistency, scale correlations, and correlations with the abridged General Health Questionnaire. RESULTS: Confirmatory factor analysis showed that the hypothesized 3-factor structure fits well to the MAFS data. All scales showed adequate internal consistency (greatest lower bound: .75-.91) and sufficient discriminative ability (scale intercorrelations: ρ = .15-.52). Of the scales, general functioning was most strongly correlated with the General Health Questionnaire, whereas family- and peer-related functioning showed weaker correlations with this general measure. The results were stable across repeated measurements and gender groups. CONCLUSIONS: The MAFS is an easy-to-use instrument with good psychometric characteristics, which could be suitable for a broad range of future research applications, especially when a multidimensional and unbiased indication of normal adolescent functioning is required.

The relative contribution of neurocognition and social cognition to 6-month vocational outcomes following Individual Placement and Support in first-episode psychosis.

AIMS: To examine whether baseline neurocognition and social cognition predict vocational outcomes over 6 months in patients with first-episode psychosis (FEP) enrolled in a randomised controlled trial of Individual Placement and Support (IPS) versus treatment as usual (TAU). METHODS: 135 FEP participants (IPS n=69; TAU n=66) completed a comprehensive neurocognitive and social cognitive battery. Principal axis factor analysis using PROMAX rotation was used to determine the underlying cognitive structure of the battery. Setwise (hierarchical) logistic and multivariate linear regressions were used to examine predictors of: (a) enrolment in education and employment; and (b) hours of employment over 6 months. Neurocognition and social cognition factors were entered into the models after accounting for premorbid IQ, baseline functioning and treatment group. RESULTS: Six cognitive factors were extracted: (i) social cognition; (ii) information processing speed; (iii) verbal learning and memory; (iv) attention and working memory; (v) visual organisation and memory; and (vi) verbal comprehension. Enrolment in education over 6 months was predicted by enrolment in education at baseline (p=.002) and poorer visual organisation and memory (p=.024). Employment over 6 months was predicted by employment at baseline (p=.041) and receiving IPS (p=.020). Better visual organisation and memory predicted total hours of paid work over 6 months (p<.001). CONCLUSIONS: Visual organisation and memory predicted the enrolment in education and duration of employment, after accounting for premorbid IQ, baseline functioning and treatment. Social cognition did not contribute to the prediction of vocational outcomes. Neurocognitive interventions may enhance employment duration in FEP.

A randomized controlled trial of vocational intervention for young people with first-episode psychosis: method.

AIM: Young people who are experiencing first-episode psychosis (FEP) are at increased risk of being unemployed compared to either their same age peers in the general population, or those with other mental illnesses. Significant research has been conducted examining employment interventions for those with chronic psychotic illness. This has yielded strong results in favour of an intervention called individual placement and support (IPS). However, significantly less work has examined the benefit of this approach to those in FEP when the potential for vocational rehabilitation is perhaps greater. This study adds to the knowledge of vocational intervention in first-episode psychotic illness. Additionally, it expands this work into the areas of cognition, social cognition, social inclusion and economics. METHODS: The study is a single-blind, randomized controlled trial comparing receiving high-quality FEP treatment as usual plus IPS (IPS + TAU) to a FEP treatment as usual (TAU) intervention alone within a specialized FEP service. RESULTS: The study recruited 146 people attending a first-episode psychosis service over 2 years. They were assessed at baseline, 6 months (end of intervention) 12 and 18 months with a battery covering psychopathology, economic, demographic, social cognitive, cognitive and diagnostic variables. CONCLUSIONS: This paper describes the methodology for the largest attempted study of IPS in FEP. This study has the capacity to answer questions about the benefits on illness and economic impacts of vocational recovery in FEP. Further, it has the capacity to extend knowledge about the contribution of cognitive and social cognitive factors to recovery in this domain.

Managing risks of violence in a youth mental health service: a service model description.

AIM: There is a significant relationship between experiencing a severe mental illness, particularly psychosis, and exhibiting violent or offending behaviour. Reducing, if not preventing, the risks of violence among patients of mental health services is clinically warranted, but models to address this are limited. METHODS: We provide a rationale for, and service description of, a pilot forensic satellite clinic embedded within an early intervention service for patients with emerging psychosis, mood disorder and/or personality disorders. The core elements of the programme and its implementation are described, and demographic, clinical and risk data are presented for the patients assessed during the clinic's pilot phase. RESULTS: A total of 54 patients were referred, 45 of whom were subsequently assessed via primary or secondary consultation. The majority of patients were male, with psychosis (40%) or major depressive disorder (31%) as the most common diagnoses. Illicit substance use in the sample was common, as was previous aggression (81%) and prior criminal offences (51%). Most referrals related to assessing and managing violent behaviour (64%) and violent/homicidal ideation (38%). On the basis of the risk assessments, 71% of patients were rated as medium to high risk of offending. CONCLUSION: Assessing and managing risks of violent offending among young patients are both clinically indicated for a proportion of patients and feasible via a forensic outreach model. Given the proliferation of early psychosis services worldwide, the issue of managing, and ideally preventing, patient risk of violence will almost certainly have wide application. However, a comprehensive evaluation of this model is required to ultimately determine the effectiveness of this approach for improving patient outcomes.

Does screening high school students for psychological distress, deliberate self-harm, or suicidal ideation cause distress--and is it acceptable? An Australian-based study.

BACKGROUND: Programs designed to detect students at risk of depression and suicidality have shown success (Shaffer et al., 2004). AIMS: The current study sought to examine whether or not such a program was acceptable to participants and whether or not it caused distress. METHODS: Participants were boys aged 14 to 16. Participants were assessed using an on-line questionnaire; acceptability was measured via postal questionnaire. RESULTS: Of 272 participants, 31 (11.4%) were considered at-risk; 13 required ongoing support, 8 of whom had not previously sought help. Overall screening did not appear to cause significant undue distress, although some differences were evident between at-risk and not at-risk students. All participants found the program acceptable. CONCLUSIONS: When conducted carefully, early detection programs can be an effective and acceptable method of identifying at-risk adolescents.

Impact of co-occurring substance use on 6 month outcomes for young people seeking mental health treatment.

OBJECTIVE: Co-occurring substance use and mental health disorders are highly prevalent among young people attending services, yet few studies have examined the effect of such comorbidity among those referred for treatment. The aim of the current study was to examine the impact of co-occurring substance use disorders (SUDs) on 6 month outcomes for young people seeking mental health treatment. METHOD: One hundred and six young people (aged 15-24 years) with a non-psychotic DSM-IV Axis I disorder were assessed following referral to a specialist youth public mental health service. Participants were given a structured interview, as well as questionnaires assessing drug use, psychopathology, psychosocial functioning and self-esteem at baseline and 6 month follow up. RESULTS: At baseline, 23 participants met criteria for a co-occurring SUD and 83 had a non-psychotic Axis I disorder. Both the non-SUD and the co-occurring SUD groups had high levels of psychopathology, serious impairments in functioning and moderate levels of suicidal ideation, although those with co-occurring SUD had significantly poorer levels of functioning. At 6 month follow up the co-occurring SUD group continued to experience substantial problems with symptoms and functioning whereas the non-SUD group had significant improvement in both of these domains. CONCLUSIONS: The present findings are consistent with studies examining the impact of co-occurring substance use and mental health issues across different treatment settings, and reinforce recommendations that young people with co-occurring disorders require more intensive and integrated interventions. The present findings also highlight the need for routine assessment and management of substance use issues within youth mental health settings.