Perceived need and barriers to adolescent mental health care: agreement between adolescents and their parents.

AIMS: Mental disorders cause high burden in adolescents, but adolescents often underutilise potentially beneficial treatments. Perceived need for and barriers to care may influence whether adolescents utilise services and which treatments they receive. Adolescents and parents are stakeholders in adolescent mental health care, but their perceptions regarding need for and barriers to care might differ. Understanding patterns of adolescent-parent agreement might help identify gaps in adolescent mental health care. METHODS: A nationally representative sample of Australian adolescents aged 13-17 and their parents (N = 2310), recruited between 2013-2014, were asked about perceived need for four types of adolescent mental health care (counselling, medication, information and skill training) and barriers to care. Perceived need was categorised as fully met, partially met, unmet, or no need. Cohen's kappa was used to assess adolescent-parent agreement. Multinomial logistic regressions were used to model variables associated with patterns of agreement. RESULTS: Almost half (46.5% (s.e. = 1.21)) of either adolescents or parents reported a perceived need for any type of care. For both groups, perceived need was greatest for counselling and lowest for medication. Identified needs were fully met for a third of adolescents. Adolescent-parent agreement on perceived need was fair (kappa = 0.25 (s.e. = 0.01)), but poor regarding the extent to which needs were met (kappa = -0.10 (s.e. = 0.02)). The lack of parental knowledge about adolescents' feelings was positively associated with adolescent-parent agreement that needs were partially met or unmet and disagreement about perceived need, compared to agreement that needs were fully met (relative risk ratio (RRR) = 1.91 (95% CI = 1.19-3.04) to RRR = 4.69 (95% CI = 2.38-9.28)). Having a probable disorder was positively associated with adolescent-parent agreement that needs were partially met or unmet (RRR = 2.86 (95% CI = 1.46-5.61)), and negatively with adolescent-parent disagreement on perceived need (RRR = 0.50 (95% CI = 0.30-0.82)). Adolescents reported most frequently attitudinal barriers to care (e.g. self-reliance: 55.1% (s.e. = 2.39)); parents most frequently reported that their child refused help (38.7% (s.e. = 2.69)). Adolescent-parent agreement was poor for attitudinal (kappa = -0.03 (s.e. = 0.06)) and slight for structural barriers (kappa = 0.02 (s.e. = 0.09)). CONCLUSIONS: There are gaps in the extent to which adolescent mental health care is meeting the needs of adolescents and their parents. It seems important to align adolescents' and parents' needs at the beginning and throughout treatment and to improve communication between adolescents and their parents. Both might provide opportunities to increase the likelihood that needs will be fully met. Campaigns directed towards adolescents and parents need to address different barriers to care. For adolescents, attitudinal barriers such as stigma and mental health literacy require attention.

Threats to kill: a follow-up study.

BACKGROUND: Mental health clinicians are frequently asked to assess the risks presented by patients making threats to kill, but there are almost no data to guide such an evaluation. METHOD: This data linkage study examined serious violence following making threats to kill and the potential role of mental disorder. A total of 613 individuals convicted of threats to kill had their prior contact with public mental health services established at the time of the index offence. The group's subsequent criminal convictions were established 10 years later using the police database. Death from suicidal or homicidal violence was also established. RESULTS: Within 10 years, 44% of threateners were convicted of further violent offending, including 19 (3%) homicides. Those with histories of psychiatric contact (40%) had a higher rate (58%) of subsequent violence. The highest risks were in substance misusers, mentally disordered, young, and those without prior criminal convictions. Homicidal violence was most frequent among threateners with a schizophrenic illness. Sixteen threateners (2.6%) killed themselves, and three were murdered. CONCLUSIONS: In contrast to the claims in the literature that threats are not predictive of subsequent violence, this study revealed high rates of assault and even homicide following threats to kill. The mentally disordered were over-represented among threat offenders and among those at high risk of subsequent violence. The mentally disordered threateners at highest risk of violence were young, substance abusing, but not necessarily with prior convictions. Those who threaten others were also found to be at greater risk of killing themselves or being killed.

Substance misuse in first-episode psychosis: 15-month prospective follow-up study.

BACKGROUND: Well-designed prospective studies of substance misuse in first-episode psychosis can improve our understanding of the risks associated with comorbid substance misuse and psychosis. AIMS: To examine the potential effects of substance misuse on in-patient admission and remission and relapse of positive symptoms in first-episode psychosis. METHOD: The study was a prospective 15-month follow-up investigation of 103 patients with first-episode psychosis recruited from three mental health services. RESULTS: Substance misuse was independently associated with increased risk of in-patient admission, relapse of positive symptoms and shorter time to relapse of positive symptoms after controlling for potential confounding factors. Substance misuse was not associated with remission or time to remission of positive symptoms. Heavy substance misuse was associated with increased risk of in-patient admission, relapse and shorter time to relapse. CONCLUSIONS: Substance misuse is an independent risk factor for a problematic recovery from first-episode psychosis.

Suicidal ideation and suicide attempts as predictors of mental health service use.

OBJECTIVE: To examine the extent to which suicidal ideation and suicide attempts are predictive of service use. DESIGN AND SETTING: The National Survey of Mental Health and Wellbeing considered service utilisation in relation to self-reported mental health problems. Service utilisation was inquired of in relation to hospital-based care (including both specialist mental health and general care settings), as well as consultations with a range of health professionals (both specialist and non-specialist mental health professionals, including psychiatrists, psychologists and general practitioners) on an outpatient basis. PARTICIPANTS: Secondary analysis of self-report data from 10,641 randomly selected Australian adults who participated in the National Survey of Mental Health and Wellbeing in 1997. The key predictor variables were reported suicidal ideation and suicide attempts over the past 12 months. MAIN OUTCOME MEASURES: Use of services for mental health problems (past 12 months). RESULTS: When considered in isolation, individuals reporting suicidal ideation were more likely to make use of at least one type of service for mental health problems than non-suicidal individuals (OR, 17.3; 95% CI, 13.2-22.6), and individuals reporting suicide attempts were even more likely to do so (OR, 32.3; 95% CI, 9.0-115.4). In the case of suicidal ideation, this effect remained significant after controlling for a range of potential confounders. For suicide attempts, the effect of mental health service use was no longer significant after other variables were taken into account. CONCLUSIONS: Suicidal individuals are likely to make use of services, and a high proportion of suicides may be preventable through appropriate healthcare system responses.

Personality disorders in the community: a report from the Australian National Survey of Mental Health and Wellbeing.

BACKGROUND: The first set of aims of the present study was to determine the prevalence of personality disorders (PDs) in a nation, and gender differences in the types and numbers of PDs endorsed. The second set of aims was to establish the relationship of PD to other, non-PD disorders, physical conditions, and disability. METHOD: Data were obtained from the Australian National Survey of Mental Health and Wellbeing, conducted between May and August 1997. A stratified random sample of households was generated, from which all those aged 18 or over were considered potential interviewees. There were 10,641 respondents to the survey, and this represented a response rate of 78%. Each interviewee was asked 59 questions indexing specific ICD-10 PD criteria. RESULTS: Of the total survey sample, 704 persons had at least one PD. Using weighted replicate weights, it was estimated that approximately 6.5% of the adult population of Australia have one or more PDs (lifetime prevalence). Persons with PD were more likely to be younger, male, and not married, and to have an anxiety disorder, an affective disorder, a substance use disorder, or a physical condition. They were also more likely to have greater disability than those without PD. CONCLUSION: The study is the first nationwide survey of mental disorders conducted within Australia. It provides an estimate of the prevalence of the various types of PD. The survey has considerable limitations, however, and these are discussed.

Measurement of the severity of amphetamine dependence.

A Severity of Amphetamine Dependence Questionnaire (SAmDQ) was administered to 101 subjects attending an Australian drug dependency treatment centre. The SAmDQ was adapted from the Severity of Opiate and Alcohol Dependence Questionnaires (SODQ & SADQ). The structural characteristics of the SAmDQ were examined and compared with previous findings reported on samples of opiate addicts with the SODQ. A high degree of consistency was found between the results obtained with the SAmDQ and previous findings with the SODQ. The relationship between the SAmDQ and the Severity of Dependence Scale (SDS) was also examined. The findings suggest that further development of amphetamine dependence measurement is required.

Social indicators and the prediction of psychiatric inpatient service utilisation.

The relationship between social variables and psychiatric service use in Victoria was investigated using a social indicators approach. Indicators were developed separately for the urban and rural areas of the state using 1986 census data. Principal components analysis was employed to reduce the data. Simple, unit weight indicators were developed and explained a considerable proportion of the variation in the rate of persons admitted to psychiatric facilities, the rate of admission episodes and the rate of occupied bed days for urban areas; a moderate amount of variation for these measures was accounted for by indicators developed for rural areas. The findings were considered in relation to both methodological issues and the role of other factors (e.g., accessibility and availability of psychiatric services) which may contribute to service use.

The implementation of community-based crisis services for people with acute psychiatric illness.

This article describes three recently established community-based crisis services for people with acute psychiatric illness. Data were obtained from local information systems developed in the early phase of service operation. Patterns of service were found to vary among the teams in terms of the frequency of contact with the client, the period of contact with the client and the overall numbers of contacts. Such diversification of services reflects, at least in part, the differences in the service networks within which the new services were Such diversification of services is inevitable and creative, and the evaluation of these services must consider not only the short-term impact of crisis services, but also the impact of the network of care services on longer term outcomes for the client.

Alfentanil pharmacokinetics in patients undergoing abdominal aortic surgery.

The pharmacokinetics of alfentanil, 300 micrograms.kg-1 IV, were determined in patients undergoing elective abdominal aortic reconstruction. The mean age (+/- SD) of the patients was 64.3 +/- 7.4 yr; their mean weight was 74.7 +/- 13.8 kg. Five patients underwent aneurysm repair and six had aortobifemoral grafting. Serum alfentanil concentrations were measured by gas-liquid chromatography in samples drawn at increasing intervals over a 24-hr period. A three-compartment model was fitted to the concentration versus time data. The volume of the central compartment and the volume of distribution at steady state (Vdss) were 0.44 +/- 0.022 and 0.63 +/- 0.32 L.kg-1, respectively. Total drug clearance was 6.4 = 1.9 ml.min-1.kg-1. The elimination half-time was 3.7 +/- 2.6 hr. Patient age was positively correlated with both Vdss and elimination half-time. There were no significant correlations between the pharmacokinetic variables and the duration of aortic cross-clamping, the duration of surgery, or the rate or total volume of IV fluids infused intraoperatively. In general surgical patients, the elimination half-time of alfentanil has been reported to be 1.2-2.0 hr. Although the elimination half-time of alfentanil was longer in patients undergoing abdominal aortic surgery, alfentanil was eliminated much faster than either fentanyl or sufentanil in this patient population.

Depression, negative and positive symptoms, and the DST in schizophrenia.

It has been suggested that the presence of depression is a major determinant of abnormal dexamethasone suppression in patients with schizophrenia. It has been reported that negative symptoms in patients with schizophrenia are associated with increased rates of nonsuppression. In this study of schizophrenic inpatients, the Dexamethasone Suppression Test (DST), depression and negative and positive symptom ratings were carried out in two phases of the acute episode, in the second week after administration to, and in the week prior to discharge from, hospital. There was no association between depression and cortisol nonsuppression or between negative and positive symptoms and cortisol nonsuppression either early or late in the acute episode. It is concluded that the DST has no clinical utility in identifying the non-melancholic depression which occurs commonly in schizophrenia.

An evaluation of the psychoactive substance dependence syndrome in its application to opiate users.

The Psychoactive Substance Abuse and Dependence (PSDA) section of the revised, 3rd edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-III-R) bears a close correspondence to the conceptualization of a dependence syndrome as posited by Edwards, Arif & Hodgson (1981). Further, DSM-III-R represents a major shift in psychodiagnostics. The present study investigated hypothesized properties of the dependence syndrome and examined the characteristics of DSM-III-R criteria with a sample of opiate users. Findings indicated general support for the unidimensional postulate of the dependence syndrome but did not support the weighting of syndrome elements within DSM-III-R. The implications of such findings for the proposed DSM-IV are discussed.

Psychometric properties of the Manchester Scale.

This article reports a preliminary investigation of the psychometric properties of the Manchester Scale (MS). Fifty-three patients were assessed on the instrument, 33 at time 1 (7-10 days after admission) and 53 at time 2 (during the week prior to discharge). Interrater reliabilities were generally good at time 2. The factor analyses conducted on the 8 MS items at times 1 and 2 suggest that MS contains a heterogeneous group of items: only the MS negative symptoms were related to one another. The MS positive and negative symptoms were strongly correlated with their counterpart items on the Schedules for the Assessment of Positive Symptoms and Negative Symptoms, suggesting that the MS items have good concurrent validity.

Assessment of articulated thoughts in social anxiety: modification of the ATSS procedure.

In the present study an assessment strategy was developed which adapted the Articulated Thoughts during Simulated Situations (ATSS) paradigm devised by Davison, Robins & Johnson (1983). That strategy was applied to the assessment of social anxiety. Responses of 10 socially anxious and 10 non-anxious males were compared as they imagined themselves participating in videotaped simulations of heterosocial interactions. Each time the subject was aware of a reaction to the events depicted, he stopped the videotape, and then articulated his thoughts. Consistent with cognitive conceptualizations of social anxiety, the articulated thoughts of anxious males were distinguished by a greater focus upon the self in general and by a concentration upon irrational concerns in particular. In contrast, non-anxious males provided larger proportions of thoughts directed towards the environment and in particular, provided more positive thoughts both about other persons and their interactions in general. The theoretical and methodological implications of the data are discussed.

Methadone: old problems for new programmes.

The present paper is concerned with factors which compromise the effective delivery of programmes incorporating methadone. Current clinical practices and programme characteristics are reviewed and policy issues regarding the role of methadone are considered, especially within the context of containing the spread of HIV infection. These issues are discussed in relation to empirical outcome studies, local prescribing trends and clinical case material. The authors conclude that there is an urgent need for: (1) an evaluation of the outcome of private practitioner methadone dispensation versus comprehensive agency-based therapy; (2) the accreditation of staff in all programmes incorporating methadone; and (3) the development of monitoring mechanisms, including on-site clinical audits of programmes.

Severity of opiate dependence in an Australian sample: further validation of the SODQ.

The Severity of Opiate Dependence Questionnaire (SODQ) was administered to 114 subjects attending an Australian drug dependency treatment centre. The psychometric properties of the SODQ were examined and compared with previous findings reported on American and British samples of opiate addicts. Severity of opiate dependence was assessed independently using a structured clinical interview based on DSM-III-R criteria (i.e. SCID-R). Together those analyses suggested (i) measurement difficulties with some aspects of the opiate dependence syndrome and (ii) only a modest relationship between subjects' self-report and clinicians' judgements of severity of opiate dependence.

Negative symptoms and social skills performance in schizophrenia.

The present study aimed to determine whether the negative symptoms of patients with schizophrenia were better predictors of social competence than a range of other variables pertaining to demographics, illness, hospitalization, and premorbid functioning. Independent raters assessed social skills performance on a video-taped role-play test and 5 min conversation in 53 inpatients with a DSM-III diagnosis of schizophrenia. Patients' social skills were also assessed by ward nurses. Project clinicians assessed depression, medication side effects and positive and negative symptoms. Multiple-regression analyses demonstrated that, generally, negative symptoms were the best predictors of social skills performance.

Which employment interview skills best predict the employability of schizophrenic patients?

To examine the effects of verbal and nonverbal interview microbehaviors and interview characteristics on employability, Simulated Employment Interviews were conducted with 46 psychiatric inpatients who each met the DSM-III criteria for a diagnosis of schizophrenia. Each interview was videotaped and shown to two raters, who generated independent ratings for six microbehaviors (eye-contact, facial gestures, body posture, verbal content, voice volume, and length of speech) and six subject characteristics (motivation, self-confidence, ability to communicate, manifest adjustment, manifest intelligence and overall interview skill). A panel of three Commonwealth Employment Service psychologists viewed the same videotaped interviews and generated employability ratings. Verbal and nonverbal microbehaviors were relatively independent while subject characteristics were highly interdependent. Microbehaviors and characteristics correlated at a high level. Of the 12 interview microbehaviors and characteristics, manifest adjustment and ability to communicate accounted for 64% of the total variance in predicting employability. Interviewees who were perceived as behaving in an adjusted manner and as being good communicators were rated as more employable.

Is social skills performance a correlate of schizophrenia subtypes?

53 inpatients with a DSM-III diagnosis of schizophrenia were assessed in the week prior to discharge from hospital on measures of social skills performance and on severity of positive and negative symptoms. A cluster analysis based on the total positive and negative symptom scores resulted in three groups. The group with the least negative symptoms exhibited the best social skills performance. The findings add a further dimension to the validity of the subtyping of schizophrenia on the basis of positive and negative symptoms.

Persistent psychotic symptoms at discharge in patients with schizophrenia.

A sample of patients with DSM-III schizophrenia was examined and rated using Andreasen's Schedule for the Assessment of Positive Symptoms (SAPS) and the Schedule for the Assessment of Negative Symptoms (SANS), soon after admission and in the week prior to discharge. A high proportion of the sample had persistent positive and negative symptoms at discharge. This finding is discussed in relation to the service demands placed on the hospital, changing government policies concerning hospital and community care, and the possible consequences of early discharge policies in the absence of adequate community services.

Discriminant validity of the Crown-Crisp Experiential Index.

The discriminative power of the CCEI subscales was examined. Several approaches were undertaken on the responses from subjects in three neurotically disturbed groups and a normal control group. Analyses indicated that simple cut-off points could discriminate effectively an 'adjusted-neurotic' dimension; simple cut-off points were relatively more difficult to develop for discrimination among the three neurotically disturbed groups. Discriminant analysis of the CCEI subscales indicated that approximately 74 per cent of all subjects could be classified correctly. The OBS and HYS subscales were not found to be effective discriminators among the four groups. While that finding may question the utility of those scales, an alternative explanation was proposed in terms of the characteristics of the present samples.