Sarah Hetrick

Monitoring depressive symptoms and suicidality is essential in the management of depression in young people, yet routine monitoring is rare. This qualitative study sought to explore the experiences and beliefs of general practitioners about factors associated with monitoring youth depression in primary care settings. Two focus groups with general practitioners (n = 12) were audio-recorded, transcribed verbatim and analysed using thematic analysis. A semi-structured interview schedule was used. In the primary care setting, monitoring was perceived as part of a continuum of care that begins with screening and diagnosis and as beneficial mostly in regards to informing treatment planning. Benefits and risks were reported, along with challenges and facilitators. Monitoring youth depression in primary care settings is perceived as both beneficial and potentially risky. Monitoring tools need to inform treatment planning, be brief and fit within existing electronic software used by general ...

In the context of controversy and uncertainty about the role of selective serotonin reuptake inhibitors (SSRIs) for the treatment of depressive disorders in children and adolescents, we consider the evidence of the benefits and risks of this class of medication and the possible role of shared decision-making as a practical way to guide clinicians, young people and their families through treatment decisions. We suggest that there is an imperative for clinicians to engage young people in a process of shared decision-making, given the uncertainties about SSRI medication in this age group. Shared decision-making provides a way for clinicians to engage young people and ensure they receive the treatment required for this disorder, the potential outcomes of which are severe.

To investigate sociodemographic variation in antidepressant utilisation. Cross-sectional analysis of antidepressant prescription under the Pharmaceutical Benefits Scheme in Australia, 2003-2005. Antidepressant utilisation (defined daily dose/1000/day) by sex, age, socioeconomic status (SES) and geographical area. Total antidepressant utilisation increased with age. Among those aged > or = 15 years, female utilisation was about double that of males. About half of antidepressant utilisation was accounted for by sertraline, venlafaxine, citalopram, and paroxetine. SES differentials in antidepressant utilisation changed across age groups for males and females: among those aged < or = 19 years, total antidepressant utilisation was significantly less in lower SES groups (P < 0.001); there was no relationship to SES among 20-29-year-olds; and among those aged > or = 30 years, antidepressant utilisation was significantly higher in lower SES groups (P < 0.001). SES differences were attenuated after adjusting for urban or rural residence, but remained statistically significant. Antidepressant utilisation rates were highest in regional centres. Antidepressant utilisation in Australia partially reflects sociodemographic differences in the prevalence of affective disorder. Discrepancies between treatment provision and treatment need suggest that not all social strata in Australia have equal access to these treatments.

Monitoring depressive symptoms and suicidality is essential in the management of depression in young people, yet routine monitoring is rare. This qualitative study sought to explore the experiences and beliefs of general practitioners about factors associated with monitoring youth depression in primary care settings. Two focus groups with general practitioners (n = 12) were audio-recorded, transcribed verbatim and analysed using thematic analysis. A semi-structured interview schedule was used. In the primary care setting, monitoring was perceived as part of a continuum of care that begins with screening and diagnosis and as beneficial mostly in regards to informing treatment planning. Benefits and risks were reported, along with challenges and facilitators. Monitoring youth depression in primary care settings is perceived as both beneficial and potentially risky. Monitoring tools need to inform treatment planning, be brief and fit within existing electronic software used by general practitioners.

Given the high prevalence of mental health and/or substance use problems in young people, an assessment interview that assists clinicians to engage with young people and assess their psychosocial needs is essential. Currently, there are few assessment tools for this purpose. To describe the rationale and process of extending a psychosocial assessment interview to assist clinicians in assessing the full range of mental health disorders common in young people. The 'headspace' assessment interview is designed to assist engagement while assessing psychosocial and mental health problems. It can be used by a range of clinicians in primary care settings for the purposes of developing treatment or referral options. To date, as part of a national clinical service platform, the interview has been used with over 2000 young people. A preliminary process evaluation indicated that the interview is perceived to have utility and acceptability among the clinicians who are using it in their practice to assess young people's mental health problems and psychosocial functioning.

Antipsychotic-induced weight gain is an important issue in the treatment of psychotic illnesses, and affects 80% of individuals being treated with antipsychotic drugs. However, the true dimension of weight gain and many accepted 'facts' in this area remain unclear as most research has been conducted in short-term trials and has included individuals receiving prolonged antipsychotic treatment. This review aims to systematically and critically review the evidence on weight gain induced by the two leading second-generation antipsychotics (olanzapine and risperidone) and the most widely researched first-generation antipsychotic (haloperidol) in patients with chronic and first-episode psychotic disorders. Weight gain was 3- to 4-fold greater in studies that included young patients with limited previous exposure to antipsychotic agents in both short-term studies (7.1-9.2 kg for olanzapine, 4.0-5.6 kg for risperidone and 2.6-3.8 kg for haloperidol vs 1.8-5.4 kg, 1.0-2.3 kg and 0.01-1.4 kg, respectively, in studies that included patients with chronic psychotic disorders) and long-term trials (10.2-15.4 kg for olanzapine, 6.6-8.9 kg for risperidone and 4.0-9.7 kg for haloperidol vs 2.0-6.2 kg, 0.4-3.9 kg and -0.7 to 0.4 kg, respectively). The same disparity was observed regarding the proportion of patients increasing their baseline weight by > or =7% (the cut-off for clinically significant weight gain). Recent studies carried out in young patients with first-episode psychosis (FEP), along with methodological artefacts in studies of chronic populations, suggest that the magnitude of weight gain reported by much of the literature could in fact be an underestimation of the true magnitude of this adverse effect. Although antipsychotics present idiosyncratic patterns of weight gain, they may also generate similar absolute gains.

Objectives: There is a lack of clear guidance regarding the management of ongoing suicidality in young people experiencing major depressive disorder. This study utilised an expert consensus approach in identifying practice principles to complement relevant clinical guidelines for the treatment of major depressive disorder in young people. The study also sought to outline a broad treatment framework for clinical intervention with young people experiencing ongoing suicidal ideation. Methods: In-depth focus groups were undertaken with a specialist multidisciplinary clinical team (the Youth Mood Clinic at Orygen Youth Health Clinical Program, Melbourne) working with young people aged 15–25 years experiencing ongoing suicidal ideation. Each focus group was audio recorded and transcribed verbatim using orthographic conventions. Principles of grounded theory and thematic analysis were used to analyse and code the resultant data. Results: The identified codes were subsequently synthesised i...

Clinicians are increasingly being asked to implement guideline recommendations into their practice, but are given little practical guidance on this complex task. In this paper we outline a promising theory-driven approach we took to implementing guideline recommendations about routine monitoring of weight gain and metabolic disturbance in our first-episode psychosis clinic. While there is significant psychological and physical morbidity associated with weight gain and metabolic disturbance, routine monitoring was not being undertaken according to guideline recommendations. We examined the factors that make it difficult to undertake routine monitoring by interviewing psychiatrists. This barrier analysis allowed us to develop and introduce feasible and acceptable strategies to address these barriers, increasing the likelihood that routine monitoring would take place. This paper advocates for undertaking an analysis of the barriers clinicians face to undertaking evidence-based practice...

Introduction. Depression in adolescents and young people is associated with reduced social, occupational, and interpersonal functioning, increases in suicide and self-harm behaviours, and problematic substance use. Age-appropriate, evidence-based treatments are required to provide optimal care. Methods. "Evidence mapping" methodology was used to quantify the nature and distribution of the extant high-quality research into the prevention and treatment of depression in young people across psychological, medical, and other treatment domains. Results. Prevention research is dominated by cognitive-behavioral- (CBT-) based interventions. Treatment studies predominantly consist of CBT and SSRI medication trials, with few trials of other psychological interventions or complementary/alternative treatments. Quality studies on relapse prevention and treatment for persistent depression are distinctly lacking. Conclusions. This map demonstrates opportunities for future research to addr...

US authorities have recommended 'black-box' warnings for antidepressants because of the increased risk of suicidality for individuals up to age 25. There is thus a clinical and ethical imperative to provide effective treatment for youth depression with an acceptable risk-benefit balance. Long-chain omega-3 polyunsaturated fatty acids (PUFAs) play an important role in a range of physiological processes in living organisms. Supplementation with omega-3 PUFAs has been shown to have a range of beneficial effects on both physical and mental health, and results of previous trials suggest that omega-3 PUFAs may be a safe and effective treatment for depression. However, conclusions from these trials have been limited by their relatively small sample sizes. This trial will test the effectiveness of a 12-week parallel group, double-blind, randomized, placebo-controlled trial of 1.4 g day(-1) omega-3 PUFAs in help seeking 15- to 25-year-olds (N = 400) presenting with major depressive disorder. The primary hypothesis is that young people will show greater improvement of depressive symptoms after 12 weeks of treatment with omega-3 PUFAs plus cognitive behavioural case management compared with treatment with placebo plus cognitive behavioural case management. Because of using a large sample, results from this study will provide the strongest evidence to date to inform the use of omega-3 PUFAs as first-line therapy in young people presenting with major depressive disorder. The study also heralds an important step towards indicated prevention of persistent depression, which may reduce the burden, stigmatization, disability and economic consequences of this disorder.

Major depression accounts for the greatest burden of all diseases globally. The peak onset of depression occurs between adolescence and young adulthood, and for many individuals, depression displays a relapse-remitting and increasingly severe course. Given this, the development of cost-effective, acceptable, and population-focused interventions for depression is critical. A number of online interventions (both prevention and acute phase) have been tested in young people with promising results. As these interventions differ in content, clinician input, and modality, it is important to identify key features (or unhelpful functions) associated with treatment outcomes. A systematic review of the research literature was undertaken. The review was designed to focus on two aspects of online intervention: (1) standard approaches evaluating online intervention content in randomized controlled designs (Section 1), and (2) second-generation online interventions and services using social networking (eg, social networking sites and online support groups) in any type of research design (Section 2). Two specific literature searches were undertaken. There was no date range specified. The Section 1 search, which focused on randomized controlled trials, included only young people (12-25 years) and yielded 101 study abstracts, of which 15 met the review inclusion criteria. The Section 2 search, which included all study design types and was not restricted in terms of age, yielded 358 abstracts, of which 22 studies met the inclusion criteria. Information about the studies and their findings were extracted and tabulated for review. The 15 studies identified in Section 1 described 10 trials testing eight different online interventions, all of which were based on a cognitive behavioral framework. All but one of the eight identified studies reported positive results; however, only five of the 15 studies used blinded interviewer administered outcomes with most trials using self-report data. Studies varied significantly in presentation of intervention content, treatment dose, and dropout. Only two studies included moderator or clinician input. Results for Section 2 were less consistent. None of the Section 2 studies reported controlled or randomized designs. With the exception of four studies, all included participants were younger than 25 years of age. Eight of the 16 social networking studies reported positive results for depression-related outcomes. The remaining studies were either mixed or negative. Findings for online support groups tended to be more positive; however, noteworthy risks were identified. Online interventions with a broad cognitive behavioral focus appear to be promising in reducing depression symptomology in young people. Further research is required into the effectiveness of online interventions delivering cognitive behavioral subcomponents, such as problem-solving therapy. Evidence for the use of social networking is less compelling, although limited by a lack of well-designed studies and social networking interventions. A range of future social networking therapeutic opportunities are highlighted.

Depressive disorders are common in young people and are associated with significant negative impacts. Newer generation antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), are often used, however evidence of their effectiveness in children and adolescents is not clear. Furthermore, there have been warnings against their use in this population due to concerns about increased risk of suicidal ideation and behaviour. To determine the efficacy and adverse outcomes, including definitive suicidal behaviour and suicidal ideation, of newer generation antidepressants compared with placebo in the treatment of depressive disorders in children and adolescents. For this update of the review, we searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to October 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We searched clinical trial registries and pharmaceutical company websites. We checked reference lists of included trials and other reviews, and sent letters to key researchers and the pharmaceutical companies of included trials from January to August 2011. Published and unpublished randomised controlled trials (RCTs), cross-over trials and cluster trials comparing a newer generation antidepressant with a placebo in children and adolescents aged 6 to 18 years old and diagnosed with a depressive disorder were eligible for inclusion. In this update, we amended the selection criteria to include newer generation antidepressants rather than SSRIs only. Two or three review authors selected the trials, assessed their quality, and extracted trial and outcome data. We used a random-effects meta-analysis. We used risk ratio (RR) to summarise dichotomous outcomes and mean difference (MD) to summarise continuous measures. Nineteen trials of a range of newer antidepressants compared with placebo, containing 3335 participants, were included. The trials excluded young people at high risk of suicide and many co-morbid conditions and the participants are likely to be less unwell than those seen in clinical practice. We judged none of these trials to be at low risk of bias, with limited information about many aspects of risk of bias, high drop out rates and issues regarding measurement instruments and the clinical usefulness of outcomes, which were often variously defined across trials. Overall, there was evidence that those treated with an antidepressant had lower depression severity scores and higher rates of response/remission than those on placebo. However, the size of these effects was small with a reduction in depression symptoms of 3.51 on a scale from 17 to 113 (14 trials; N = 2490; MD -3.51; 95% confidence interval (CI) -4.55 to -2.47). Remission rates increased from 380 per 1000 to 448 per 1000 for those treated with an antidepressant. There was evidence of an increased risk (58%) of suicide-related outcome for those on antidepressants compared with a placebo (17 trials; N = 3229; RR 1.58; 95% CI 1.02 to 2.45). This equates to an increased risk in a group with a median baseline risk from 25 in 1000 to 40 in 1000. Where rates of adverse events were reported, this was higher for those prescribed an antidepressant. There was no evidence that the magnitude of intervention effects (compared with placebo) were modified by individual drug class. Caution is required in interpreting the results given the methodological limitations of the included trials in terms of internal and external validity. Further, the size and clinical meaningfulness of statistically significant results are uncertain. However, given the risks of untreated depression in terms of completed suicide and impacts on functioning, if a decision to use medication is agreed, then fluoxetine might be the medication of first choice given guideline recommendations. Clinicians need to keep in mind that there is evidence of an increased risk of suicide-related outcomes in those treated with antidepressant medications.

In mental health services, the past several decades has seen a slow but steady trend towards employment of past or present consumers of the service to work alongside mental health professionals in providing services. However the effects of this employment on clients (service recipients) and services has remained unclear.We conducted a systematic review of randomised trials assessing the effects of employing consumers of mental health services as providers of statutory mental health services to clients. In this review this role is called 'consumer-provider' and the term 'statutory mental health services' refers to public services, those required by statute or law, or public services involving statutory duties. The consumer-provider's role can encompass peer support, coaching, advocacy, case management or outreach, crisis worker or assertive community treatment worker, or providing social support programmes. To assess the effects of employing current or past adult consumers of mental health services as providers of statutory mental health services. We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2012, Issue 3), MEDLINE (OvidSP) (1950 to March 2012), EMBASE (OvidSP) (1988 to March 2012), PsycINFO (OvidSP) (1806 to March 2012), CINAHL (EBSCOhost) (1981 to March 2009), Current Contents (OvidSP) (1993 to March 2012), and reference lists of relevant articles. Randomised controlled trials of current or past consumers of mental health services employed as providers ('consumer-providers') in statutory mental health services, comparing either: 1) consumers versus professionals employed to do the same role within a mental health service, or 2) mental health services with and without consumer-providers as an adjunct to the service. Two review authors independently selected studies and extracted data. We contacted trialists for additional information. We conducted analyses using a random-effects model, pooling studies that measured the same outcome to provide a summary estimate of the effect across studies. We describe findings for each outcome in the text of the review with considerations of the potential impact of bias and the clinical importance of results, with input from a clinical expert. We included 11 randomised controlled trials involving 2796 people. The quality of these studies was moderate to low, with most of the studies at unclear risk of bias in terms of random sequence generation and allocation concealment, and high risk of bias for blinded outcome assessment and selective outcome reporting.Five trials involving 581 people compared consumer-providers to professionals in similar roles within mental health services (case management roles (4 trials), facilitating group therapy (1 trial)). There were no significant differences in client quality of life (mean difference (MD) -0.30, 95% confidence interval (CI) -0.80 to 0.20); depression (data not pooled), general mental health symptoms (standardised mean difference (SMD) -0.24, 95% CI -0.52 to 0.05); client satisfaction with treatment (SMD -0.22, 95% CI -0.69 to 0.25), client or professional ratings of client-manager relationship; use of mental health services, hospital admissions and length of stay; or attrition (risk ratio 0.80, 95% CI 0.58 to 1.09) between mental health teams involving consumer-providers or professional staff in similar roles.There was a small reduction in crisis and emergency service use for clients receiving care involving consumer-providers (SMD -0.34 (95%CI -0.60 to -0.07). Past or present consumers who provided mental health services did so differently than professionals; they spent more time face-to-face with clients, and less time in the office, on the telephone, with clients' friends and family, or at provider agencies.Six trials involving 2215 people compared mental health services with or without the addition of consumer-providers. There were no…

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Suicide-related behaviour is a major problem among adolescents. Yet relatively few studies have tested the efficacy, acceptability and safety of interventions for this population. We developed and pilot tested an online intervention for at-risk school students, which has led to reduced suicidal ideation, hopelessness and depressive symptoms. The aims of this study were to examine the safety and acceptability of the programme, and to determine which components were found to be most helpful and enjoyable. This pilot study employed a pre-test/post-test design, with an 8-week intervention phase. Participants were assessed immediately before, and immediately after the intervention. Participants were also asked to complete a weekly questionnaire immediately after the intervention, and again 2 days later assessing suicidal ideation and distress. Twenty-one young people completed the intervention. Overall, the intervention did not lead to increases in suicidal ideation or distress. Participants reported enjoying the programme, in particular watching the video diaries and completing the activities, and said they would recommend the programme to a friend. Overall, the cognitive components of the programme were found to be most helpful. Overall, the programme appeared to be a safe and acceptable intervention for at-risk adolescents. This was a small, pilot study so we need to interpret the results with caution. However, the findings are promising and suggest that young people at risk of suicide can safely be included in trials as long as adequate safety procedures are in place. The programme is now being tested in a randomized controlled trial.

To develop and examine the feasibility of an online monitoring tool of depressive symptoms, suicidality and side effects. The online tool was developed based on guideline recommendations, and employed already validated and widely used measures. Quantitative data about its use, and qualitative information on its functionality and usefulness were collected from surveys, a focus group and individual interviews. Fifteen young people completed the tool between 1 and 12 times, and reported it was easy to use. Clinicians suggested it was too long and could be completed in the waiting room to lessen impact on session time. Overall, clients and clinicians who used the tool found it useful. Results show that an online monitoring tool is potentially useful as a systematic means for monitoring symptoms, but further research is needed including how to embed the tool within clinical practice.