Helen Coughlan

Psychotic experiences in the population: association with functioning and mental distress

Psychotic experiences are far more common in the population than psychotic disorder. They are associated with a number of adverse outcomes but there has been little research on associations with functioning and distress. We wished to investigate functioning and distress in a community sample of adolescents with psychotic experiences. Two hundred and twelve school-going adolescents were assessed for psychotic experiences, mental distress associated with these experiences, global (social/occupational) functioning on the Childrens Global Assessment Scale, and a number of candidate mediator variables, including psychopathology, suicidality, trauma (physical and sexual abuse and exposure to domestic violence) and neurocognitive functioning. Seventy five percent of participants who reported psychotic experiences reported that they found these experiences distressing (mean score for severity of distress was 6.9 out of maximum 10). Participants who reported psychotic experiences had poorer functioning than participants who did not report psychotic experiences (respective means: 68.6, 81.9; OR=0.25, 95% CI=0.14-0.44). Similarly, participants with an Axis-1 psychiatric disorder who reported psychotic experiences had poorer functioning than participants with a disorder who did not report psychotic experiences (respective means: 61.8, 74.5; OR=0.28, 95% CI=0.12-0.63). Candidate mediator variables explained some but not all of the relationship between psychotic experiences and functioning (OR=0.48, 95% CI=0.22-1.05, P<0.07). Young people with psychotic experiences have poorer global functioning than those who do not, even when compared with other young people with psychopathology (but who do not report psychotic experiences). A disclosure of psychotic experiences should alert treating clinicians that the individual may have significantly more functional disability than suggested by the psychopathological diagnosis alone.

Towards a new paradigm of care: the International Declaration on Youth Mental Health

A recent and growing body of evidence on youngpeople’s mental health has pointed to the need foran international response to the increasing and con-cerning rates of mental ill-health among youngpeople.1,2The periods of adolescence and emergingadulthood3are considered the peak periods for theonset of mental ill-health4with 75% of all adult diag-noses of mental ill-health having had an onsetbefore the age of 25 years.5In an era when the physi-cal health of young people has never been better,6their psychological and mental health has neverbeen worse.7This leaves young people vulnerable todeveloping potentially intractable and enduringmental health difficulties with the inevitable per-sonal, familial, social and vocational consequencesthat accompany the experience of mentalill-health

White matter differences among adolescents reporting psychotic experiences : A population-based diffusion magnetic resonance imaging study

IMPORTANCE Abnormal brain connectivity is thought to have a key role in the pathophysiology of schizophrenia and other psychotic disorders. White matter (WM) abnormalities have been reported in patients with schizophrenia and patients with prodromal syndromes. To our knowledge, no studies have yet reported on WM differences among adolescents who report psychotic experiences, a known vulnerability group for later severe psychopathology, including psychotic illness. OBJECTIVE To study WM differences using diffusion-weighted imaging (whole-brain and tractography analyses) in adolescents who report psychotic experiences. DESIGN, SETTING, AND PARTICIPANTS A population-based case-control study of 28 adolescents 13 to 16 years old who reported psychotic experiences and a matched sample of 28 adolescents who did not report psychotic experiences drawn from a sample of 212 young people recruited from primary schools in North Dublin and Kildare, Ireland. The study dates were 2008 to 2011. INTERVENTIONS High-angular resolution diffusion-weighted imaging data were used to conduct whole-brain WM analysis using tract-based spatial statistics. Based on this exploratory analysis, a tractography-based approach with constrained spherical deconvolution was performed. RESULTS Compared with control group participants, adolescents who reported psychotic experiences showed WM differences bilaterally in striatal regions in proximity to the putamen (increased fractional anisotropy, P = .01, false discovery rate corrected), and tractography identified significant WM differences bilaterally in the uncinate fasciculus (increased fractional anisotropy in the right [P = .001] and axial diffusivity in the left [P = .01] uncinate fasciculus, respectively). Similar patterns of WM differences between groups survived adjustment for other psychopathology, indicating some specificity for psychotic experiences. Exploratory along-tract analyses showed WM differences between groups in the frontal projections of the right inferior fronto-occipital fasciculus (reduced radial diffusivity in approximately 32% of the tract segment [P ≤ .0001] and increased fractional anisotropy in approximately 16% of the tract segment [P ≤ .0009]). CONCLUSIONS AND RELEVANCE In a population-based study of adolescents reporting psychotic experiences, we found a number of WM differences in the region of the putamen located between the inferior fronto-occipital fasciculus and the uncinate fasciculus and in the left parietal regions that include the fiber bundle of the superior longitudinal fasciculus. These findings suggest that subtle structural changes to WM microstructure are not merely a consequence of disorder but may index vulnerability to psychosis even at a very early age.

From early intervention in psychosis to youth mental health reform: a review of the evolution and transformation of mental health services for young people

AbstractPurpose The objective of this review is to report on recent developments in youth mental health incorporating all levels of severity of mental disorders encouraged by progress in the field of early intervention in psychotic disorders, research in deficiencies in the current system and social advocacy.MethodsThe authors have briefly reviewed the relevant current state of knowledge, challenges and the service and research response across four countries (Australia, Ireland, the UK and Canada) currently active in the youth mental health field. ResultsHere we present information on response to principal challenges associated with improving youth mental services in each country. Australia has developed a model comprised of a distinct front-line youth mental health service (Headspace) to be implemented across the country and initially stimulated by success in early intervention in psychosis; in Ireland, Headstrong has been driven primarily through advocacy and philanthropy resulting in front-line services (Jigsaw) which are being implemented across different jurisdictions; in the UK, a limited regional response has addressed mostly problems with transition from child–adolescent to adult mental health services; and in Canada, a national multi-site research initiative involving transformation of youth mental health services has been launched with public and philanthropic funding, with the expectation that results of this study will inform implementation of a transformed model of service across the country including indigenous peoples.ConclusionsThere is evidence that several countries are now engaged in transformation of youth mental health services and in evaluation of these initiatives.

Prevalence of DSM-IV mental disorders, deliberate self-harm and suicidal ideation in early adolescence: an Irish population-based study.

BACKGROUND This study investigated the prevalence of DSM-IV Axis 1 mental disorders, deliberate self-harm and suicidal ideation in a sample of Irish adolescents aged 11-13 years. METHODS A total of 1131 students was surveyed for general psychopathology using the Strengths and Difficulties Questionnaire. Following this, a representative sample of 212 adolescents was assessed for mental disorders, deliberate self-harm and suicidal ideation using the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. RESULTS 14.6% of the sample met criteria for a borderline score and 6.9% for an abnormal score on the Strengths and Difficulties Questionnaire. Following clinical diagnostic interviews, 27.4% of participants received a current diagnosis of an Axis 1 disorder and 36.8% received a lifetime diagnosis, those rates falling to 15.4% and 31.2% respectively when specific phobias were excluded. CONCLUSIONS Findings from this study reveal that Irish adolescents aged 11-13 years are experiencing high levels of mental ill-health.

The impact of adolescent cannabis use, mood disorder and lack of education on attempted suicide in young adulthood

Suicide is one of the leading causes of death worldwide among young people. One of the strongest predictors of completed suicide is a previous suicide attempt (1). Suicide attempts are more frequent among young people, and a suicide attempt may be a marker of a lasting trajectory of adverse mental and physical problems into middle adulthood (1,2).There is limited evidence for factors during the adolescent period and the period of transition to young adulthood that increase the risk of attempted suicide. We used a prospective cohort study design incorporating clinical interviews to determine what factors measured at ages 12-15 years are associated with attempted suicide reported at ages 19-24 years. The methods for the baseline adolescent study have previously been described (3). Using a stratified random sampling technique, 743 students in eight mainstream schools were screened for psychopathology. Adolescents who scored above threshold on the screening instruments or who indicated the presence of significant suicidal ideation (N=140) were invited to attend for interview, along with a group of 174 controls matched for gender, school and school year. 84.3% adolescents from the “at risk” category and 54% of the control group attended for a semi-structured clinical interview, along with a parent or guardian. All 212 young people who were interviewed as young adolescents were invited to take part in a follow-up interview eight years later. Follow-up information was obtained on 168 participants (79% follow-up rate). There were no differences between responders and non-responders in age, gender, parental socio-economic status, “at-risk” status at baseline, or diagnosis of psychiatric disorder at baseline. We collected exposure information at interview on: family and childhood risk factors (family history of psychiatric illness and experience of childhood trauma, i.e. physical/sexual abuse or witnessing domestic violence); adolescent risk factors (psychopathology, cannabis use and alcohol use); young adult risk factors (psychopathology, cannabis use, self-harm, education level and employment status). The outcome measure was lifetime suicide attempts at 19-24 years old. Ten percent of participants had made a suicide attempt at some point in their lives up to age 19-24 years. The mean age of those attempting suicide was 20.6 years. Fifty-three percent of those who reported a suicide attempt were female. Hierarchical logistic regression models showed that adolescent mood disorder and adolescent cannabis use, young adult mood and anxiety disorders, and a low level of education were the most strongly predictive factors for making a suicide attempt when the effects of family psychiatric history, childhood trauma, alcohol use and other psychopathology were taken into account. Adolescent mood disorder and adolescent cannabis use both independently increased the odds of a suicide attempt 7-fold (OR=7.0, 95% CI: 1.4-34.3; OR=7.5, 95% CI: 1.2-43.8), while young adult mood and anxiety disorders both independently increased the odds of an attempt 11-fold (OR=11.7, 95% CI 1.8-73.9; OR=11.1, 95% CI: 21.0-57.9). Young adults with only secondary-level education had an 8-fold increase in the odds of a suicide attempt compared to those with third-level education (OR=8.0, 95% CI: 1.1-54.4). There is evidence that substance use disorders in adulthood increase the risk of suicidal behaviours. Here we show that any use of cannabis in the early adolescent period is a strong independent predictor of attempted suicide in young adulthood. We know that significant brain maturation continues to occur during adolescence, particularly in limbic structures such as the hippocampus; and within the prefrontal cortex important processes such as synaptic pruning, myelination and programming of neurotrophic levels are occurring at this time (4). Regular cannabis use can lead to grey matter volume reduction in a range of brain areas, including the medial temporal cortex, the parahippocampal gyrus, the insula and orbitofrontal regions (5). There is evidence of a linear association between the age at onset of cannabis use and both white matter integrity and grey matter volume, suggesting that the earlier the onset of use, the greater the toxic effects on the brain (5,6). Neuroimaging studies of people who have attempted suicide show structural and functional brain changes that are in keeping with those found in cannabis users (7). It is possible that cannabis use in early adolescence, at a vulnerable time for neurodevelopment, leads to or exacerbates ongoing dysfunctional brain changes that prime young people for a maladaptive trajectory towards young adulthood. Those most at risk for attempted suicide may have experienced accumulating risk exposures throughout childhood and adolescence and in young adulthood may lack adequate problem solving skills, as possibly indexed here by low levels of education. The increasing awareness among the mental health community that we need to focus on early clinical intervention to protect against the worst effects of emotional distress among our young people, both on a personal and an economic level (8), can only be acted on when we can reliably identify which young people are most at risk. The available evidence suggests that the specialist treatment of psychiatric disorder in adolescence alone is insufficient for the prevention of future suicide attempts (9). We need a more tailored approach to youth mental health and a greater awareness of the different contingencies involved in the pathway to suicidal behaviours such as accumulating risk from adolescent cannabis use, adolescent mood disorders and a lack of education.

The association between economic inactivity and mental health among young people: a longitudinal study of young adults who are not in employment, education or training

OBJECTIVES Increasing rates of young people not in education, employment or training (NEETs) are a cause of concern both in Ireland and internationally, but little longitudinal research has examined the link between psychiatric disorder in young people and NEET status. METHODS The Challenging Times (CT) Study is a longitudinal, population-based study of psychopathology among 212 young Irish people. Clinical interviews were performed at two time points: 12-15 years and 19-24 years. RESULTS NEET status in young adulthood was associated with a sevenfold increased risk of current suicidal ideation. This result was independent of prior adolescent mental disorder. NEET young people had a fourfold increased odds of being diagnosed with a mental disorder in childhood or early adolescence compared with their economically active peers. NEET young people were at an almost threefold increased risk of any mental health disorder a twofold increased risk of anxiety disorder and threefold increased odds of suicide attempts over their lifetime compared with economically active peers. CONCLUSIONS NEET young people are at increased risk for mental disorder and suicidal ideation. The association is bidirectional, as prior mental disorder in adolescence appeared to account for much of the association between NEET status and current mental health problems. However, economic inactivity conveys an increased risk for suicidal ideation over and above that due to prior disorder. Our findings provide a compelling economic and societal argument for early intervention and treatment of mental disorder and the importance of vocational interventions for reducing suicide risk in young adults.

Nonsuicidal self-injury, suicidal thoughts and suicide attempts among sexual minority youth in Ireland during their emerging adult years

This study aimed to examine whether or not sexual minority youth constitute an at‐risk group for nonsuicidal self‐injury, suicidal ideation or suicide attempts during their emerging adult years.

Youth mental health in Ireland: a lot done, more to do?

The emergence of a new youth mental health paradigm has challenged how we think about the provision of mental health care for adolescents and young adults. This editorial tracks the origins of this new paradigm within the field of mental health both internationally and in Ireland.

Prevalence of mental disorder among young adults in Ireland: a population based study

BACKGROUND There is a lack of epidemiological research on the mental health of young adults in Ireland. OBJECTIVES To determine prevalence of psychiatric disorders in a cohort of young Irish adults. METHODS The Challenging Times study was a landmark study of the prevalence of psychiatric disorders in adolescents in North Dublin, Ireland: 212 school children aged 12-15 years were recruited through schools and interviewed using the K-SADS semi-structured diagnostic instrument. This cohort was traced again at age 19-24 years (mean age 20.8 years) and interviewed using SCID I & II. Main outcome measures were current and lifetime Axis I and Axis II psychiatric disorders. RESULTS Follow-up rate was 80%. Using a weighted population prevalence analysis 19.8% of the cohort had a current mental disorder, 56.0% had a lifetime mental disorder of whom 28.4% had mood disorders, 27.1% had anxiety disorders, 22.7% had substance use disorders; 25.4% had lifetime multi-morbidity. Cluster A personality disorders were found in 2.3%. Lifetime prevalence of binge-drinking was 75.0%, cannabis use 65% and 17% of young adults had fulfilled criteria for an alcohol use disorder at sometime in their life. Lifetime prevalence of suicidal thoughts/behaviour was 21.1%. CONCLUSIONS Lifetime prevalence of psychiatric disorder and substance use were high in this sample of young Irish adults. Mental Health service provision for this age group is a priority. Larger studies of nationally representative samples are needed to inform service development.