An open label pilot trial of low-dose lithium for young people at ultra-high risk for psychosis.

AIM: Lithium, even at low doses, appears to offer neuroprotection against a wide variety of insults. In this controlled pilot, we examined the safety (i.e., side-effect profile) of lithium in a sample of young people identified at ultra-high risk (UHR) for psychosis. The secondary aim was to explore whether lithium provided a signal of clinical efficacy in reducing transition to psychosis compared with treatment as usual (TAU). METHODS: Young people attending the PACE clinic at Orygen, Melbourne, were prescribed a fixed dose (450 mg) of lithium (n = 25) or received TAU (n = 78). The primary outcome examined side-effects, with transition to psychosis, functioning and measures of psychopathology assessed as secondary outcomes. RESULTS: Participants in both groups were functionally compromised (lithium group GAF = 56.6; monitoring group GAF = 56.9). Side-effect assessment indicated that lithium was well-tolerated. 64% (n = 16) of participants in the lithium group were lithium-adherent to week 12. Few cases transitioned to psychosis across the study period; lithium group 4% (n = 1); monitoring group 7.7% (n = 6). There was no difference in time to transition to psychosis between the groups. No group differences were observed in other functioning and symptom domains, although all outcomes improved over time. CONCLUSIONS: With a side-effect profile either comparable to, or better than UHR antipsychotic trials, lithium might be explored for further research with UHR young people. A definitive larger trial is needed to determine the efficacy of lithium in this cohort.

Involving Young People With Lived and Living Experience of Suicide in Suicide Research.

Background: Research into youth suicide prevention rarely involves young people with lived and living experiences as collaborators. Key barriers include a lack of guidelines or frameworks to inform collaboration, appropriate ethical approval processes, perceived risk, and recruitment. Aim: To develop guidelines for involving young people with lived and living experiences in suicide research as collaborators. Method: A Delphi expert consensus study was conducted with two expert panels: a youth lived and living experiences panel and a traditionally qualified researcher panel. Items rated as essential or important using a five-point Likert scale by more than 80% of both panels were included in the guidelines. Results: Forty-nine experts completed two consensus rounds. The guidelines are organized as follows: (1) preparation, (2) supporting safety and well-being, (3) evaluating involvement, and (4) tips for young people. Limitations: Participants were from English-speaking, Western countries only. Conclusion: These world-first guidelines address the unique challenges and opportunities for involving young people with lived and living experiences in suicide research.

The effectiveness of peer support from a person with lived experience of mental health challenges for young people with anxiety and depression: a systematic review.

BACKGROUND: Peer workers support individuals experiencing mental health challenges by drawing on their shared lived experience. Peer support has become increasingly popular for young people with anxiety and depression, but the evidence base is unclear. This systematic review aimed to understand the effectiveness of peer support for youth depression and anxiety (either primary or comorbid), and to understand in which contexts, for whom, and why peer support works. METHODS: A systematic search was conducted with the Orygen Evidence Finder, Embase, MEDLINE, and PsycInfo from January 1980 to July 2022. Controlled trials of interventions to improve mental health in young people (mean age 14-24), delivered by a peer worker with lived experienced of mental health challenges were included. Outcomes related to depression or anxiety were extracted and descriptive synthesis was undertaken due to the heterogeneity of studies. Study quality was rated using the Critical Appraisal Skills Programme; reporting adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: Nine randomised controlled trials with 2,003 participants were included, with seven undertaken in high income countries. One targeted depression and anxiety, two stigma-distress (any mental disorder), one first episode psychosis, four studies preventing eating disorders and one drug misuse. One study successfully reduced anxiety and depression, another reduced depression only, four reported reductions in negative affect, with the final three measuring, but not having a significant impact on depression. Study quality was rated as 'good' overall. DISCUSSION: Despite the uptake of youth peer support globally, there is limited evidence from controlled trials of the effect of peer support-related interventions on anxiety and depression. There is some effect on negative affect, especially for university students. Further rigorously designed trials of peer delivered interventions for young people need to be conducted with a focus on understanding the mechanisms of action underpinning peer support.

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

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

Peer-Facilitated Decision Making in Mental Health: Promises, Pitfalls, and Recommendations for Research and Practice.

Recognition has grown that peer support workers serve an important role in facilitating decision making about treatment and recovery among people with mental health conditions. This article provides examples of peer-facilitated decision support interventions in the literature, discusses promises and potential pitfalls associated with peers serving in decision support roles, and offers recommendations for research and practice. Examples were selected from the literature on decision support interventions for people with serious mental illnesses, such as schizophrenia, bipolar disorder, and major depression. Promises, pitfalls, and recommendations were informed by this research and by the literature on lived experience perspectives, the helper-therapy principle, and reported barriers to and facilitators of peers assisting with decision making. According to the included studies, peers may facilitate decision making in several ways (e.g., by asking service users about their goals or preferences, assisting them with using decision support tools, sharing stories, and facilitating access to information and resources). Peer-facilitated decision support may be associated with positive decision making and health outcomes for service users and peer support workers. However, providers need to carefully consider barriers to implementation of this support, such as inadequate resourcing, poor integration, and compromising of peer support values.

Decisional capacity in young people with first episode psychosis, major depressive disorder and no mental disorder.

We aimed to (1) examine decisional capacity for treatment in young people (aged 15 to 25 years) with first-episode psychosis (FEP), Major Depressive Disorder (MDD) and no mental disorder, and (2) determine which theoretically relevant factors are associated with, and predict decisional capacity. We assessed decisional capacity (using MacArthur Competence Assessment Tool-Treatment; MacCAT-T), cognitive abilities, insight and symptom severity in young people with no mental disorder (n = 38), MDD (n = 38) and FEP (n = 18) from inpatient and outpatient services. Most young people with MDD (84.2%) or no mental disorder (86.8%) had adequate decisional capacity to consent to treatment based on recommended cut-off scores, compared with fewer than half of the those with FEP (44.4%). Levels of capacity were not significantly different between young people with MDD and those with no mental disorder (p = .861). However, young people with FEP demonstrated significantly poorer decisional capacity than those with no mental disorder (p = .006) and MDD (p = .009). A hierarchical regression analysis suggested that differences may be better explained by variation in cognitive ability, especially thematic verbal recall. Greater symptom severity and poorer insight were associated with poorer decisional capacity for FEP (p = .008 and p < .001, respectively), but not MDD (p = .050 and p = .805, respectively). Cognitive performance (i.e., predicted IQ, processing speed, mental flexibility and thematic verbal memory) collectively explained 36.6% of the variance in decisional capacity (p < .001). Thematic verbal memory was the strongest predictor of decisional capacity (p < .001). Supports for memory should be implemented to facilitate involvement in treatment decisions during the early course of illness.

The youth online training and employment system: Study protocol for a randomized controlled trial of an online vocational intervention for young people with mental ill health.

AIM: People diagnosed with mental disorders experience higher rates of unemployment than those without. Career adaptability, defined as the ability to respond flexibly and make informed career decisions in work and throughout career transitions, is becoming increasingly important as the nature of work changes rapidly. Early vocational intervention may ameliorate poor education and employment outcomes experienced by young people with mental ill-health and promote transferable skills and adaptability. Online-based career support allows for ongoing access throughout different career stages. The current study combines mental health-informed digital career and peer motivation, to create a Youth Online Training and Employment System (YOTES) that supports young people with mental ill-health obtain and remain in education or employment. METHODS: This study is an unblinded randomized controlled trial for young people with mental ill-health, aged 16-25, who are seeking vocational support. Participants will be randomized to receive either YOTES, a moderated, online intervention with vocational, social, and peer motivation, or a control intervention, the headspace Digital Work and Study Service. Both groups will have access to in-person career support if seeking employment. The primary outcome will be career adaptability compared between the YOTES and control groups at 6-months post baseline. Secondary outcomes include number of hours worked in the past 7 days, hope, career confidence, psychological distress and health economic outcomes at 6- and 12-months post baseline. CONCLUSION: Results will demonstrate whether an online career intervention moderated by career practitioners with peer motivation can result in improved career adaptability in young people with mental ill-health.

Inside the black box of youth participation and engagement: Development and implementation of an organization-wide strategy for Orygen, a national youth mental health organization in Australia.

AIM: The involvement of young people in the development, implementation and evaluation of youth mental health services, policy and research programs is essential to ensure they are appropriate and responsive to the needs of young people. Despite the increasingly central role that youth engagement and participation plays internationally, such activities are rarely described in detail. This article aims to provide a thorough description of the development and implementation of an organization-wide, 3-year Youth Engagement and Participation Strategy for Orygen, a national youth mental health organization in Australia. METHODS: A descriptive account of the development and implementation of the Strategy, with detailed examples of programs and initiatives. RESULTS: The Strategy was developed based on available evidence, focus groups with key stakeholders and best practice principles. The implementation of the Strategy resulted in a number of programs being delivered that involved a range of young people from across Australia. Despite being successful overall, a number of challenges were experienced. Ongoing considerations include ensuring diversity of partnerships, 'raising the bar' of youth participation and creating meaningful pathways. CONCLUSIONS: Youth participation and engagement within a youth mental health context is best seen as an evolving ambition that must remain flexible to the needs of all stakeholders. Despite some challenges and ongoing fine-tuning, it is possible to successfully implement youth participation and engagement across all areas of youth mental health, including service design and delivery, research and translation, and policy.

What works for mental health problems in youth? Survey of real-world experiences of treatments and side effects.

AIM: Despite youth being the most common age group for onset of mental disorders, there is less knowledge on the benefits and harms of treatments in young people. In addition, efficacy data from randomized controlled trials may not generalize to how treatment works outside of research settings. This study aimed to investigate young people's perceived effectiveness of different treatments for mental health problems, the professionals who delivered these, and the experience of negative effects. METHODS: We developed a consumer report website where young people who were ever diagnosed with a mental disorder provided ratings on the helpfulness or harmfulness of different types of professionals, mental health treatments (medical, psychological complementary/alternative) and self-help strategies, and whether they had experienced particular negative effects. RESULTS: Here, 557 young people aged 12-25 years, who were recruited from English-speaking, high-income countries, provided 1258 ratings of treatments. All treatments showed varied perceptions of effectiveness. Medical and psychological treatments were rated moderately helpful on average with low rates of harmfulness. Self-help strategies were rated as being as helpful as professional treatments. Side effects related to the head or mind (e.g., concentration difficulties, inability to feel emotions, depression and irritability) were the most common across all types of medicines. For psychological treatments, treatment being too expensive and feeling worse at the end of a session were the most commonly reported negative effects. CONCLUSIONS: Study findings may be a useful guide to clinicians, researchers, young people and their families about what is likely to work in real-world settings.

The Experiences of Youth Mental Health Peer Workers over Time: A Qualitative Study with Longitudinal Analysis.

Peer work is a rapidly growing part of the mental health workforce, yet few studies explore the implementation of peer work in youth mental health. Qualitative focus groups were conducted with eight youth peer workers at the commencement of their employment, then at 3-months and 6-months after this time. Data were transcribed verbatim and analysed using thematic and trajectory analysis. The three main findings included: (1) there was a trajectory from fear to hope; (2) there was an improved understanding of benefits and role definition over time; and (3) there was an evolving concept of understanding shared experiences as a primary asset. Known barriers to implementing peer work are likely to occur in youth mental health settings as well. Ensuring that adequate training, change management and tailored support strategies are important to maximise the chances of successful youth peer work programs.

Physical health assistance in early recovery of psychosis: Study protocol for a randomized controlled trial.

AIM: Young people with psychotic disorders have poorer physical health compared to their healthy peers, a state compounded by the metabolic side-effects of antipsychotic medications. To address this, Orygen Youth Health has introduced physical health services including exercise physiologists and dieticians. These services are typically coordinated by the case manager and doctor. It is not yet known whether a treating team member dedicated to physical health will improve engagement, adherence and outcomes with these services. Hence, the protocol is presented here for a trial to evaluate the effect of including a physical health nurse in the care of young people with first-episode psychosis. METHODS: This will be a single-blind randomized controlled trial that includes 15- to 24-year-olds with first-episode psychosis who have just commenced (within 30 days) antipsychotic medication. The primary outcome will be the event of clinically significant weight gain (≥7% body weight). Participants will be assigned either a physical health nurse in their treating team (in addition to the case manager and doctor) for a 12-week period, or treatment as usual (case manager and doctor). Research assessments will be conducted at baseline, 12 and 26 weeks. Activity trackers worn by participants for the study's duration will measure sleep and physical activity. CONCLUSION: The present study will determine whether a physical health nurse will facilitate participants in attending and engaging in physical health interventions and whether this will be associated with physical health improvements or the prevention of worsening physical health.

Barriers and enablers to meaningful youth participation in mental health research: qualitative interviews with youth mental health researchers.

BACKGROUND: Involving young people in co-designing and conducting youth mental health research is essential to ensure research is relevant and responsive to the needs of young people. Despite this, many barriers exist to meaningful involvement. AIMS: To explore the experiences, barriers and enablers to partnering with young people for mental health research. METHODS: Semi-structured, qualitative interviews were conducted with 19 researchers employed at a youth mental health research institute in Australia. Thematic analysis was used to analyse these data. RESULTS: How researchers conceptualise youth participation was related to how confident and competent they felt engaging with young people. Attitudes and beliefs about the impact of youth participation on research quality were related to emotional factors, such as feelings of anxiety or excitement. Whether researchers engaged in youth participation was affected by resources, culture and the structures that their organisation had in place. CONCLUSION: Researchers generally want to engage young people in their work, but several factors can hinder this. By understanding the challenges facing researchers, and drawing on the factors that encourage and support those already engaging with young people, a framework to support genuine and meaningful youth participation in mental health research can be developed.

Essential ingredients of engagement when working alongside people after their first episode of psychosis: A qualitative meta-synthesis.

AIM: Early intervention services (EISs) for first-episode psychosis (FEP) have been established internationally, however, service disengagement is a recurrent concern resulting in unplanned treatment cessation. The implications of this are far-reaching due to the financial and personal costs associated with untreated symptoms. The aim of this meta-synthesis was to collect, interpret and synthesize qualitative research about how engagement is experienced within EISs for FEP. METHODS: A systematic search was conducted in PsycINFO, Ovid MEDLINE and Ovid Emcare from date of conception to November 2016. Following initial screening, 91 abstracts and 13 full texts were reviewed for eligibility. Nine studies were then critically appraised using the CASP tool for qualitative studies, data were systematically extracted and results were synthesized using constant comparison and reciprocal translational analysis. RESULTS: Nine qualitative studies explored engagement with EISs, from the perspectives of service users and their caregivers. No studies were found from the perspectives of clinicians or services. All 9 studies employed an inductive methodology, within an interpretivist epistemology. Five main themes were identified: experiences of finding help; factors promoting engagement; the therapeutic relationship; the role of caregivers in supporting engagement; and factors impacting ongoing engagement. CONCLUSIONS: There is a critical need to stimulate discussion around this multifaceted phenomenon, including a continued focus on the roles of key stakeholders and clinical models that may further facilitate collaboration in treatment plans and recovery.

Youth Codesign of a Mobile Phone App to Facilitate Self-Monitoring and Management of Mood Symptoms in Young People With Major Depression, Suicidal Ideation, and Self-Harm.

BACKGROUND: Effective treatment of depression in young people is critical, given its prevalence, impacts, and link to suicide. Clinical practice guidelines point to the need for regular monitoring of depression symptom severity and the emergence of suicidal ideation to track treatment progress and guide intervention delivery. Yet, this is seldom integrated in clinical practice. OBJECTIVE: The objective of this study was to address the gap between guidelines about monitoring and real-world practice by codesigning an app with young people that allows for self-monitoring of mood and communication of this monitoring with a clinician. METHODS: We engaged young people aged 18 to 25 years who had experienced depression, suicidal ideation including those who self-harm, as well as clinicians in a codesign process. We used a human-centered codesign design studio methodology where young people designed the features of the app first individually and then as a group. This resulted in a minimal viable product design, represented through low-fidelity hand-drawn wireframes. Clinicians were engaged throughout the process via focus groups. RESULTS: The app incorporated a mood monitoring feature with innovative design aspects that allowed customization, and was named a "well-being tracker" in response to the need for a positive approach to this function. Brief personalized interventions designed to support young people in the intervals between face-to-face appointments were embedded in the app and were immediately available via pop-ups generated by a back-end algorithm within the well-being tracker. Issues regarding the safe incorporation of alerts generated by the app into face-to-face clinical services were raised by clinicians (ie, responding in a timely manner) and will need to be addressed during the full implementation of the app into clinical services. CONCLUSIONS: The potential to improve outcomes for young people via technology-based enhancement to interventions is enormous. Enhancing communication between young people and their clinicians about symptoms and treatment progress and increasing access to timely and evidence-based interventions are desirable outcomes. To achieve positive outcomes for young people using technology- (app) based interventions, it is critical to understand and incorporate, in a meaningful way, the expectations and motivations of both young people and clinicians.

The CHOICE pilot project: Challenges of implementing a combined peer work and shared decision-making programme in an early intervention service.

AIM: Youth participation is central to early intervention policy and quality frameworks. There is good evidence for peer support (individuals with lived experience helping other consumers) and shared decision making (involving consumers in making decisions about their own care) in adult settings. However, youth programs are rarely tested or described in detail. This report aims to fill this gap by describing a consumer focused intervention in an early intervention service. METHODS: This paper describes the development process, intervention content and implementation challenges of the Choices about Healthcare Options Informed by Client Experiences and Expectations (CHOICE) Pilot Project. This highly novel and innovative project combined both youth peer work and youth shared decision making. RESULTS: Eight peer workers were employed to deliver an online shared decision-making tool at a youth mental health service in New South Wales, Australia. The intervention development involved best practice principles, including international standards and elements of co-design. The implementation of the peer workforce in the service involved a number of targeted strategies designed to support this new service model. However, several implementation challenges were experienced which resulted in critical learning about how best to deliver these types of interventions. CONCLUSIONS: Delivering peer work and shared decision making within an early intervention service is feasible, but not without challenges. Providing adequate detail about interventions and implementation strategies fills a critical gap in the literature. Understanding optimal youth involvement strategies assists others to deliver acceptable and effective services to young people who experience mental ill health.

Comprehensive Online Self-Monitoring to Support Clinicians Manage Risk of Suicide in Youth Depression.

BACKGROUND: Routine monitoring of depression symptoms and suicide risk is essential for appropriate treatment planning and risk management, but not well implemented by clinicians. We developed a brief online monitoring tool to address this issue. AIMS: To investigate whether the online tool can feasibly improve monitoring; whether it is acceptable and useful for young people and their clinicians; and to determine whether a shorter tool could be implemented. METHOD: In a naturalistic longitudinal cohort study, 101 young people with depression completed the online tool on a tablet, prior to their consultation. Their results were immediately available to their clinician. Clients and clinicians answered questionnaires about acceptability and usefulness. RESULTS: The tool was feasible to implement. Young people and clinicians found the tool acceptable and useful for understanding symptoms and risk. A brief three-item suicidal ideation screening measure correlated well with a validated measure of suicidal ideation. CONCLUSION: The online tool facilitates the quick exchange of key information about suicide risk, allowing clinicians to immediately address this. This level of responsiveness is likely to improve treatment outcomes. The brief version allows full integration into clinical practice to support clinicians managing those at risk of suicide.

Right choice, right time: Evaluation of an online decision aid for youth depression.

BACKGROUND: Appropriate treatment for youth depression is an important public health priority. Shared decision making has been recommended, yet no decision aids exist to facilitate this. OBJECTIVES: The main objective of this study was to evaluate an online decision aid for youth depression. DESIGN: An uncontrolled cohort study with pre-decision, immediately post-decision and follow-up measurements. SETTING AND PARTICIPANTS: Young people (n=66) aged 12-25 years with mild, mild-moderate or moderate-severe depression were recruited from two enhanced primary care services. INTERVENTION: Online decision aid with evidence communication, preference elicitation and decision support components. MAIN OUTCOME MEASURES: The main outcome measures were ability to make a decision; whether the decision was in line with clinical practice guidelines, personal preferences and values; decisional conflict; perceived involvement; satisfaction with decision; adherence; and depression scores at follow-up. RESULTS: After using the decision aid, clients were more likely to make a decision in line with guideline recommendations (93% vs 70%; P=.004), were more able to make a decision (97% vs 79%; P=.022), had significantly reduced decisional conflict (17.8 points lower (95% CI: 13.3-22.9 points lower) on the Decisional Conflict Scale (range 0-100)) and felt involved and satisfied with their decision. At follow-up, clients had significantly reduced depression symptoms (2.7 points lower (95% CI: 1.3-4.0 points lower) on the Patient Health Questionnaire nine-item scale (range 0-27)) and were adherent to 88% (95% CI: 82%-94%) of treatment courses. DISCUSSION AND CONCLUSIONS: A decision aid for youth depression can help ensure evidence-based, client-centred care, promoting collaboration in this often difficult to engage population.

Subjective ratings of neurocognitive functioning in depressed young people undergoing treatment: utility of a brief screening tool.

AIMS: To determine how young people with depression rate their neurocognitive functioning during treatment, and whether these ratings are affected by depression severity, age, suicidal ideation and antidepressant status. METHODS: Fifty young people (12-25 years) engaged in psychological therapy completed the Neuropsychological Symptoms Self-Report rating their neurocognitive functioning in a range of domains. RESULTS: In two domains, working memory/multitasking and motivation, more than 40% of the sample rated their functioning as improved, since commencing treatment. Ratings of neurocognitive functioning were affected by depression severity and suicidal ideation, particularly in the areas of wakefulness, attention and concentration, working memory/multitasking, and motivation. However, there were few differences related to age or antidepressant status. CONCLUSIONS: The Neuropsychological Symptoms Self-Report - a rapid measure of subjective neurocognitive functioning - can provide a snapshot of subjective changes in neurocognitive functioning during treatment for depression. This information may guide treatment approaches.

Development and pilot testing of an online monitoring tool of depression symptoms and side effects for young people being treated for depression.

AIM: To develop and examine the feasibility of an online monitoring tool of depressive symptoms, suicidality and side effects. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.