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Aim The fluctuating symptoms of clinical high risk for psychosis hamper conversion prediction models. Exploring specific symptoms using machine-learning has proven fruitful in accommodating this challenge. The aim of this study is to explore specific predictors and generate atheoretical hypotheses of onset using a close-monitoring, machine-learning approach. Methods Study participants, N = 96, mean age 16.55 years, male to female ratio 46:54%, were recruited from the Prevention of Psychosis Study in Rogaland, Norway. Participants were assessed using the Structured Interview for Psychosis Risk Syndromes (SIPS) at 13 separate assessment time points across 2 years, yielding 247 specific scores. A machine-learning decision-tree analysis (i) examined potential SIPS predictors of psychosis conversion and (ii) hierarchically ranked predictors of psychosis conversion. Results Four out of 247 specific SIPS symptom scores were significant: (i) reduced expression of emotion at baseline, (ii) experience of emotions and self at 5 months, (iii) perceptual abnormalities/hallucinations at 3 months and (iv) ideational richness at 6 months. No SIPS symptom scores obtained after 6 months of follow-up predicted psychosis. Conclusions Study findings suggest that early negative symptoms, particularly those observable by peers and arguably a risk factor for social exclusion, were predictive of psychosis. Self-expression and social behaviour might prove relevant entry points for early intervention in psychosis and psychosis risk. Testing study results in larger samples and at other sites is warranted.

WHAT IS KNOWN ON THE SUBJECT?: Many carers report feeling unrecognized by professional healthcare teams. Carers often report difficulty accessing mental health services for relatives. Carers who are also mental health professionals may experience role conflict as found for General Practitioners. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Carers who are mental health professionals are often not recognized for their professional knowledge and face similar communication barriers as other carers. Difficulties for carers who are mental health professionals are concerned with information sharing, decision-making and continuity of care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Opportunity for services to learn from the experiences of mental health professional and carers to develop better communication and shared decision-making methods for carers Carers who are mental health professionals should be recognized by services for their dual role (and skills). Service development opportunity for training in supporting and engaging carers who are mental health professionals ABSTRACT: Introduction Around 60% of carers of relatives with mental health problems report feeling unrecognized by professional health care, and many report a lack of engagement, shared decision-making and information sharing. There is a paucity of research examining these issues for carers who are also mental health professionals. Aims This was an exploratory study to (a) explore the extent of this role among health service staff, (b) gather an indication of the issues faced by carers when interacting with the health system and (c) test the feasibility of conducting research. Methods Mental health professionals in mental health services completed an online survey that assessed the frequency, content and satisfaction of the experiences of carers. Results The sample comprised 453 mental health professionals (74% female), 52% being carers. Half of carers reported having therapist contact, and 25% were satisfied with the contact. Negative experiences were related to Information, Decision-making and Continuity of care. Discussion There was a high frequency of mental health professionals who were carers. The majority were dissatisfied, and this was primarily in relation to communication with services. Implications for practice Improving information sharing through training of staff and identification of the system barriers is likely to enhance experiences for service users and families.

Treatments to depression often take a latent modeling approach whereby depressive symptoms are a common cause of the disorder. However, such an approach is not without problems. For example, covariance amongst indicators are deemed spurious. Network modeling has been proposed as an alternative way of explaining depression. The purpose of this article is to introduce the network approach and outline how it can be used to foster the development of effective treatment packages. Viewing depression as a network may result in a reduction in the number of patients experiencing depressive episodes.

We examine psychological distress and mental health help-seeking in UK university students via an online survey of 461 students, of whom 273 reported having psychological distress. We examined the prevalence and predictors of help-seeking in students with psychological distress, with a focus on the role of adult attachment styles along with social support and perceived stigma. Overall, 22% of the sample reported severe psychological distress and 37% reported mild/moderate psychological distress. Of students reporting severe psychological distress, 58% sought help in the past year and 30% were receiving counselling or therapy. In the group with mild/moderate psychological distress, 30% reported help-seeking and 17% were receiving counselling or therapy. For students with psychological distress, being older, having more psychological distress, and higher anxious attachment predicted mental health help-seeking. Social support and perceived mental health stigma did not predict help-seeking in the regression model. There was some evidence that the relationship between avoidant attachment style and help-seeking may depend on level of psychological distress experienced (moderating role). Overall, the results point to considerable unmet mental health needs in the UK university environment. Targeted strategies to promote mental health help-seeking in younger students may be beneficial.

Background Longitudinal research into early intervention for youth at ultra high risk (UHR) for psychosis demonstrates beneficial outcomes including increased treatment compliance and greater participation in education and the workforce. Despite known barriers for rural youth accessing mental health services, research comparing urban and rural UHR youth is lacking. The study included an examination of the impact of substance use on functioning of UHR youth. Methods Youth aged 12 to 25 years were recruited from the urban area of Newcastle or the rural area of Orange, New South Wales, Australia, and identified as UHR by the Comprehensive Assessment of At Risk Mental States. Rural and urban youth were compared on clinical profiles, social and occupational functioning and substance use. Results The rural youth showed different help-seeking behaviours and had greater functional impairment than urban youth. Substance use was common across the sample of 57 youth (mean age 16.5 years, 56% female) and a history of hazardous substance use was associated with higher levels of depression. Rural youth (n = 32) were more likely than urban youth to be taking antidepressants at baseline (44% compared with 16%). Conclusion Different patterns of help seeking by rural UHR youth suggest a need for greater access to psychosis informed primary care early intervention services. Interventions should target functional decline to prevent adverse outcomes such as reduced community participation and unemployment. In addition, interventions for substance use should be a priority for UHR youth, who should also be screened and monitored for depressive symptoms and treated for depression if indicated.

Background: While the onset of many mental health problems occurs in adolescence, these problems are severely undertreated in this age group. To inform early intervention for adolescents, we investigated the effect of gender and education type on perception of barriers to help seeking, mental health literacy, and the awareness and use of mental health services. Method: A web-based survey using vignettes, open-ended and multiple choice items was administered to upper secondary school students in two counties in Norway. Results: The survey was completed by 1249 students (88% response rate) with an average age of 17.6 years and 56% were female. Compared to males, the females were better in identifying psychological problems of anxiety and trauma, awareness of mental health services (p < 0.001) and perceived more barriers for seeking help (cost and waiting time; p < 0.001). For use of all mental health services, the effect of education type was greater than the effect of gender. Conclusion: For adolescents, gender appears to play a significant, but not exclusive, role in the inclination to seek professional help for mental health problems. We hypothesise that the observed gender difference in use of services is related to the gender difference in awareness of referral pathway services and the influence of parents in help-seeking process.

ObjectivesEvidence from meta-analyses of randomised clinical trials shows interventions for young people at ultra-high risk (UHR) of developing psychosis are effective both clinically and economically. While research evidence has begun to be integrated into clinical guidelines, there is a lack of research on the implementation of these guidelines. This paper examines service provision for UHR individuals in accordance with current clinical guidelines within the National Health Service (NHS) in England.MethodA self-report online survey was completed by clinical leaders of Early Intervention in Psychosis (EIP) teams (n = 50) within the NHS across the UK.ResultsOf the 50 EIP teams responding (from 30 NHS Trusts), 53% reported inclusion of the UHR group in their service mandate, with age range predominantly 14–5 years (81%) and service provided for at least 12 months (53%). Provision of services according to NICE clinical guidelines showed 50% of services offered cognitive behavioural therapy (CBT) for psychosis, and 42% offered family intervention. Contrary to guidelines, 50% of services offered antipsychotic medication. Around half of services provided training in assessment by CAARMS, psycho-education, CBT for psychosis, family work and treatment for anxiety and depression.ConclusionsDespite clear evidence for the benefit of early intervention in this population, current provision for UHR within EIP services in England does not match clinical guidelines. While some argue this is due to a lack of allocated funding, it is important to note the similar variable adherence to clinical guidelines in the treatment of people with established schizophrenia.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Impairment in social functioning is a well-recognised feature of schizophrenia and other psychotic disorders. Early social functioning is a robust predictor of long-term outcomes in people with a psychotic disorder or at ultra high risk of developing psychosis. Thus, it is critical to assess strengths and weaknesses in social functioning. In this chapter, trainees will gain an overview of the evidence base and an appreciation of the need for social functioning assessment in the management of psychotic disorders across the different stages of illness. The reader will be introduced to objective and subjective aspects of social functioning, and their comparative influence on health and wellbeing. This chapter will compare the best available measures for the assessment of social and role functioning in psychosis; provide a critical review of the evidence for their reliability, validity, and utility in clinical settings; and suggest strategies to guide the clinician's choice of measurement tool.

Background Internationally, from 12.2–23.4% of youth (aged 16–24 years) are not in employment, education or training (NEET). These disengaged youth are more likely to experience social exclusion, increased psychological distress and poor quality of life. Youth at risk of disengagement are less likely to access traditional support services, requiring development of innovative interventions. Methods The trial is a single blind, three arm, randomised controlled trial evaluating the effectiveness of a telephone delivered psychological intervention for disengaged youth (12–25 years). Participants will be randomised to receive either (i) SWEL, (ii) Befriending, or (iii) Single Session Psycho-Education. Therapy will be over an 8 week period with a minimum of four and maximum of eight sessions for the SWEL or Befriending conditions, or a single session for the Psycho-Education condition. Outcomes will be assessed at baseline and at 2, 8 and 14-month follow-up with the primary outcome being re-engagement in education, training or employment. Discussion This large, multi-site, randomised controlled trial will inform the delivery of services for young people at risk of disengaging from education or training. The provision of psychological therapy by telephone increases access by youth – especially those in rural and remote areas - both to the trial and the treatment, if adopted by services. The outcomes of this trial could have meaningful societal impact for a vulnerable population. It is expected that recruitment, intervention and retention will present challenges for the trial given the focus on disengaged youth. Trial registration ANZCTR, ACTRN12614001212640, Registered 18 Nov 2014. Retrospectively registered. Ethics and dissemination Ethics approval has been obtained from the participating institutions. Results of the trial will be submitted for publication in peer reviewed journals and findings presented at scientific conferences and to key service providers and policy makers.

BACKGROUND Individuals with psychosis are heavy consumers of social media. It is unknown to what degree measures of social functioning include measures of online social activity. OBJECTIVE To examine the inclusion of social media activity in measures of social functioning in psychosis and ultrahigh risk (UHR) for psychosis. METHODS Two independent authors conducted a search using the following electronic databases: Epistemonikos, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE, Embase, and PsycINFO. The included articles were required to meet all of the following criteria: (1) an empirical study published in the English language in a peer-reviewed journal; (2) the study included a measure of objective or subjective offline (ie, non-Web-mediated contact) and/or online social functioning (ie, Web-mediated contact); (3) the social functioning measure had to be used in samples meeting criteria (ie, Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases) for a psychotic disorder or UHR for psychosis; and (4) the study was published between January 2004 and February 2019. Facebook was launched as the first large-scale social media platform in 2004 and, therefore, it is highly improbable that studies conducted prior to 2004 would have included measures of social media activity. RESULTS The electronic search resulted in 11,844 distinct articles. Full-text evaluation was conducted on 719 articles, of which 597 articles met inclusion criteria. A total of 58 social functioning measures were identified. With some exceptions, reports on reliability and validity were scarce, and only one measure integrated social media social activity. CONCLUSIONS The ecological validity of social functioning measures is challenged by the lack of assessment of social media activity, as it fails to reflect an important aspect of the current social reality of persons with psychosis. Measures should be revised to include social media activity and thus avoid the clinical consequences of inadequate assessment of social functioning. CLINICALTRIAL International Prospective Register of Systematic Reviews (PROSPERO) CRD42017058514; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017058514

Child abuse has been associated with risk of mental illness, including schizophrenia and other psychotic disorders and, among those with mental illness, with a more severe clinical profile. Using an extensively characterised and epidemiologically representative sample of 1825 Australians with a psychotic illness aged 18-64 years and in contact with mental health services, we estimated the proportion of individuals with psychotic disorders who self-reported child abuse and examined its relationship with clinical and other characteristics. The prevalence of child abuse in this nationally representative sample of people with psychotic illness was 30.6%. Women were almost three times more likely to report child abuse compared to males (OR, 2.8, 95% CI 2.3-3.4). When adjusted for age at interview and socio-economic status, there was no significant relationship between self-reported child abuse and type of psychosis or course of illness. Participants with child abuse were significantly more likely to have subjective thought disorder, lifetime suicide attempt and premorbid personality disorder (females only) and anxiety (males only). Our findings demonstrate that child abuse is relatively common across the range of psychotic disorders, with an elevated risk for women in particular, compounding the already high burden associated with psychotic illness. Clinicians need to inquire routinely about child abuse in order to develop appropriate treatment plans tailored to individual needs.

BACKGROUND: Neurocognitive deficits may be a risk factor for, but also a result of, psychosis. Non-remitting symptoms, premorbid functioning, level of education, and socioeconomic background are known associations. A possible confounder is substance use, which is common among patients with psychosis and often accompanied by worse clinical outcomes. The literature, however shows mixed results for the effect of substance use on neurocognitive outcomes. In this project, the long-term associations of substance use with neurocognition in a representative sample of first-episode psychosis patients were investigated. METHODS: The sample consisted of 195 patients who were assessed for symptom levels, function and neurocognition at 1, 2, 5 and 10 years after first treatment. Test scores were grouped into factor-analysis based indices: Motor speed, verbal learning, visuomotor processing, verbal fluency, and executive functioning. We also used a standardized composite score of all tests. Patients were divided into four groups based on substance use patterns during the first two years of treatment: persistent users, episodic users, stop-users and non-users. Data were analyzed using linear mixed effects modelling. RESULTS: Gender, premorbid academic functioning and previous education came out as the strongest predictors of neurocognitive trajectories. Patients who stopped using substances within the first two years of follow-up, improved over time on motor speed and verbal learning indices, whereas the other groups did not. Longitudinal course was parallel for all four groups with regards to verbal fluency, while patients who stopped using substances had better scores compared to non-users. Persistent users demonstrated impaired visuomotor processing speed compared to non-users. Within the stop- and episodic use groups, patients with narrow schizophrenia diagnoses had poorer scores compared to patients with other diagnoses on verbal learning and on the overall composite neurocognitive index. DISCUSSION: This study is one of very few long-term studies on neurocognitive impairments in first episode psychosis focusing specifically on substance use. Early cessation of substance use was associated with less neurocognitive deficits and some improvement over time on some cognitive measures, indicating a milder illness course and superior cognitive reserves to draw from in recovering from psychosis.

We aimed to examine and compare sex-differences in people receiving treatment for psychotic illnesses in community settings, based on long or short duration of illness; expecting association between longer illness-duration and worse outcomes in women and men. Clinical, demographic and service-use data from the Survey of High Impact Psychosis were analysed by sex and duration of illness (≤5 years; ≥6 years), using independent t-tests, chi-square tests, one-way ANOVA, and Cramer's V. Of the 1825 participants, 47% had schizophrenia, 17.5% bipolar and 16.1% schizo-affective disorders. More women than men had undertaken post-school education, maintained relationships, and been living in their own homes. Women with a shorter-illness-duration showed social functioning equivalent to non-ill women in the general population. Men tended to have an early illness onset, show premorbid dysfunction, be single, show severe disability, and to use illicit substances. Men with a longer-illness-duration were very socially disadvantaged and isolated, often experiencing homelessness and substance use. Men with a short-illness-duration were most likely to be in paid employment, but two-thirds earned less than $AUD500 per fortnight. Men with longer-illness-duration showed most disability, socially and globally. Interventions should be guided by diagnosis, but also by a person's sex and duration of illness.

Objective: The 2010 Survey of High Impact Psychosis (SHIP) is Australia’s second national psychosis survey. This paper provides an overview of its findings, including comparisons with the first psychosis survey and general population data. Methods: The survey covered 1.5 million people aged 18–64 years, approximately 10% of Australians in this age group. A two-phase design was used. In phase 1, screening for psychosis took place in public mental health services and non-government organizations supporting people with mental illness. In phase 2, 1825 of those screen-positive for psychosis were randomly selected and interviewed. Data collected included symptomatology, substance use, functioning, service utilization, medication use, education, employment, housing, and physical health including fasting blood samples. Results: The estimated 1-month treated prevalence of psychotic disorders in public treatment services was 3.1 people per 1000 population; the 12-month treated prevalence was 4.5 people per 1000. The majority (63.0%) of participants met ICD-10 criteria for schizophrenia/schizoaffective disorder. One-half (49.5%) reported attempting suicide in their lifetime and two-thirds (63.2%) were rated as impaired in their ability to socialize. Over half (54.8%) had metabolic syndrome. The proportion currently smoking was 66.1%. Educational achievement was low. Only 21.5% were currently employed. Key changes in the 12 years since the first survey included: a marked drop in psychiatric inpatient admissions; a large increase in the proportion attending community mental health clinics; increased use of rehabilitation services and non-government organizations supporting people with mental illness; a major shift from typical to atypical antipsychotics; and large increases in the proportions with lifetime alcohol or drug abuse/dependence. Conclusion: People with psychotic illness face multiple challenges. An integrated approach to service provision is needed to ensure that their living requirements and needs for social participation are met, in addition to their very considerable mental and physical health needs.

IntroductionWith most mental health disorders emerging in the later teenage years, university students are arguably an at-risk population with increased mental health support needs. This population is characterised by important, life-changing transitions (moving away from home, friends and family) and new potential stressors (including increased academic pressures and relational challenges). Research to examine determinants of mental health help-seeking behaviours in university students is needed to ensure emotional health needs are being met at this critical time.ObjectivesTo examine levels of psychological distress and mental health help-seeking behaviours in a sample of UK university students. By identifying factors associated with help seeking, we can better understand the mental health needs of this population and inform support provision.MethodsThis study draws on data from the social and emotional well-being in university students (SoWise) study, an online survey which aimed to examine risk and resilience for social and emotional well-being in young people attending a UK university.ResultsWhole sample analysis (n = 461) showed help seeking was significantly associated with psychological distress, current life stressors and anxious attachment and not associated with perceived mental health stigma. Sub-group analysis (n = 171) suggests being female and older significantly predicted help seeking in students with mild/moderate psychological distress.ConclusionsYounger males with mild/moderate psychological distress are less likely to seek mental health support and represent an “invisible” at risk group. Results also suggest that global anti-stigma campaigns in universities may not prove effective in encouraging help seeking.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Epidemiological research has revealed that the utilisation of professional mental health services is low among rural Australians, despite a similar prevalence of mental illness to urban communities. However, the extent of this unmet need and the length of delay to first seek treatment in rural communities remain unclear. The aim of this study was to investigate the delay among rural Australians in seeking treatment for anxiety and depressive disorders. A total of 124 participants with an anxiety or depressive disorder according to the Composite International Diagnostic Interview (CIDI) who were participants of the Australian Rural Mental Health Study (ARMHS) were included in this study. Multivariate methods examined the contribution of clinical (onset age, disorder type and comorbidity), attitudinal/demographic (perceived stigma and current age) and structural (rurality) variables to the delay to first seek help. The average length of the delay was 18.7 years across disorders (range 0–67). The shortest delays were in depressive disorders (10.41 years) and the longest for social phobia (28.02 years). Multivariate analysis indicated that younger onset age, older current age, diagnosis of panic disorder or depressive disorder, and living in a remote (R) or very remote area (VR) were associated with delays of more than one year. Delays to first seek treatment for anxiety and depressive disorders appear to be far more prolonged in rural compared to urban Australia. This is particularly the case for Australian residents living in R and VR areas. This is of particular concern due to the significant mental health needs of rural Australians.

Objective: Research regarding psychological distress has often underestimated the importance of contextual social factors. This research aims to investigate patterns of psychological distress within the family system (parent dyads) across rural and remote communities and the influence of remoteness on such distress. Design: Self‐report survey data from the Australian Rural Mental Health Study was used to examine the distress levels of cohabitating parental figures in rural and remote Australia. Setting: The survey was conducted across rural and remote communities within New South Wales. Participants: The sample consisted of 129 adult couples (mean age = 42.66 years, SD = 8.11), 43 from Inner Regional areas, 48 from Outer Regional areas, 24 from Remote areas and 14 from Very Remote areas. Main outcome measure: Distress levels (Kessler‐10). Results: A significant association was detected between the levels of psychological distress among parents within a household. The strength of this relationship increased with increasing remoteness of residence. Conclusions: Identifying the influence of spousal factors on mental health in rural and remote areas allows health services in such regions to be aware of the needs of rural couples and families. These results support the need to consider partner/spouse mental health in clinical assessment and support the importance of household factors especially in remote communities.

The individual and contextual factors influencing current mental health and well-being within rural communities are poorly understood.A stratified random sample of adults was drawn from non-metropolitan regions of NSW, Australia. One-quarter (27.7%) of the 2,639 respondents were from remote/very remote regions. An aggregate measure of current well-being was derived from levels of distress and related impairment (Kessler-10 LM), self-reported overall physical and mental health, functioning, satisfaction with relationships, and satisfaction with life. Multivariate methods investigated the contributions to current well-being of demographic/dispositional factors, recent events and social support, individual exposure to rural adversity, and district/neighbourhood level characteristics.Respondents from very remote regions tended to be younger and have lower education. Univariate associations were detected between well being and exposure to rural adversity (greater drought-related worry, lower perceived service and support availability, greater number of years living in the current district). Multivariate analysis (n = 2,462) accounted for 41% of the variance in well-being scores. The major contributing variables were dispositional factors (trait neuroticism, marital status), recent adverse events and indices of social support. However, no additional effects were detected for district-level variables (drought severity, regional socioeconomic categorisation, population change). Similar associations were detected using the K-10 alone as the outcome measure.The chief determinants of current well being were those reflecting individual level attributes and perceptions, rather than district-level rural characteristics. This has implications for strategies to promote well being within rural communities through enhancing community connectedness and combating social isolation in the face of major adversities such as drought.

Objective: This study investigates the relationship between levels of mental health and well‐being (in terms of self‐reported levels of distress) with employment and occupational status of rural residents, to better inform the provision of mental health services to those in greatest need in rural communities. Method: A stratified random sample of community residents in rural and remote New South Wales with over‐sampling of remote areas as first stage of a cohort study. Psychological distress was measured using Kessler‐10, inclusive of additional items addressing functional impairment (days out of role). Occupational data were classified using Australian and New Zealand Standard Classification of Occupations categories. Results: A total of 2639 adults participated in this baseline phase. Among them, 57% were in paid employment, 30% had retired from the workforce, 6% were permanently unable to work and 2% were unemployed. The highest levels of distress and functional impairment were reported in those permanently unable to work and the unemployed group with rates of ‘caseness’ (likely mental health disorder) varying from 57% to 69%, compared with 34% of farmers and farm managers and 29% of health workers (P 0.01). Conclusion: The rural unemployed suffer considerable psychological distress and ‘disability’, yet they are not the target of specific mental health promotion and prevention programs, which are often occasioned by rural adversity, such as drought, and delivered through work‐based pathways. Policy‐makers and health service providers need to consider the needs of the rural unemployed and those permanently unable to work and how they might be addressed.

Background: A 2004 study showed adolescents living in rural Australia were aware of the impact of drought on self, family and community, but did not report levels of emotional distress higher than adolescents of similar age and gender in the Australian community. It was proposed that the rural lifestyle had helped adolescents build resilience for managing this environmental adversity. Objective: To re sample adolescents from the same rural area and determine if this resilience remained after ongoing drought three years later. Design: A mixed methods approach using focus groups and a self-report questionnaire. Setting: Government Central Schools within the Riverina region of New South Wales. Participants: Male and female adolescents (n = 111) aged 11–17 years completed the self-report questionnaires, while some adolescents (n = 61) within this group also participated in focus groups. Main outcome measure: The Strengths and Difficulties Questionnaire and a Drought and Community Survey for Children comprised the self-report survey. Results: Adolescents reported significantly higher levels of emotional distress than those in the previous study (t (191) = 2.80, P

Objective: This paper outlines the methods and baseline data from a multisite cohort study of the determinants and outcomes of mental health and well-being within rural and remote communities. Methods: A stratified random sample of adults was drawn in non-metropolitan New South Wales using the Australian Electoral Roll, with the aim of recruiting all adult members of each household. Surveys assessed psychological symptoms, physical health and mental disorders, along with individual-, family/household- and community-level characteristics. A stratified subsample completed a telephone-administered World Mental Health-Composite International Diagnostic Interview (World Mental Health-3.0). Proxy measures of child health and well-being were obtained. Follow up of this sample will be undertaken at one, three and five years. Results: A total of 2639 individuals were recruited (1879 households), with 28% from remote/very remote regions. A significant relationship was found between recent distress (Kessler-10 scores), age and remoteness, with a linear reduction of Kessler-10 scores with age and the lowest mean scores in remote regions. Conclusions: Existing rurality categories cannot address the diverse socio-cultural, economic and environmental characteristics of non-metropolitan regions. While it has limitations, the dataset will enable a fine-grained examination of geographic, household and community factors and provide a unique longitudinal dataset over a five-year period.

Objective: The lack of consistent findings regarding comparisons of mental health between rural and urban areas has been attributed in part to methodological shortcomings, including poor conceptualisation of ‘rurality’. To address the diversity of rural and remote communities, an interdisciplinary collaboration sought to establish a database incorporating a range of domains hypothesised to be major influences on the mental health of individuals, families and communities. Design: The database domains included health (physical and mental), health service utilisation, sociodemographic characteristics, climate patterns, agricultural activity and primary industry. Important steps in the development of the database were addressing issues related to ethics, ownership, accessing data sources, sustainability of the database and integration of differing outcomes sought by the collaborators. Results: The paper describes the database while an illustrative example of analysis demonstrates its application. The potential for multilevel analyses between the database and other datasets is discussed as well as challenges for the future development of this valuable resource for rural mental health research. Conclusion: The Centre for Rural and Remote Mental Health database will be a valuable resource for rural mental health research.

Objective: The aim of this study was to investigate access to care and service delivery for first-episode psychosis (FEP) in rural, coastal and remote regions. Method: Routine clinical outcome data were analysed for patients aged 10–25 years who presented to mental health services in either a rural, coastal or remote region of New South Wales over a 3-year period. Results: The results showed rural region FEP patients travelled significantly further to access services than non-FEP patients. Remote region FEP patients were older and more likely to be male and Aboriginal than non-FEP patients. Alcohol and drug problems were significantly more likely for FEP than non-FEP patients across all regions. Utilization of mental health services was more frequent for FEP than non-FEP children and adolescents. Conclusion: The study highlights the importance of identification of FEP, particularly in the 10–18-year age group, where cognitive problems are likely to adversely affect schooling as well as be detrimental to social relationships. Service provision for FEP youth in rural areas requires innovation and coordination of limited resources, including better provision of training and ongoing clinical supervision.

Context and Purpose:Between 2002 and 2006 New South Wales was in the grip of the worst drought for more than 100 years. Financial hardships have led governments to declare “Exceptional Circumstances.” Little social research has investigated the impact of drought on children. For this study, children from rural and remote regions of New South Wales were asked for their interpretations of the impacts of drought on their lives.Methods:A multi-strategy approach combining qualitative and quantitative approaches was used to reveal deeper understanding of the impacts of drought. Students in Years 5 through 12 from six Central Schools in the rural southwest of New South Wales participated in focus groups and completed self-report questionnaires.Results:Quantitative self-reports indicated these students were not significantly more distressed than Australian norms. However, the themes that emerged from the students' statements indicated that the drought had been a very significant event for them. This qualitative information also indicated connections for these students to their families, schools, and communities.Conclusions:The emotional impacts of changes to family and community life appear to have been moderated by these students' positive attitudes toward their country lifestyle. These students have discussed the impact of drought on their environment, their livestock, financial resources, and their families. In the face of declining rural community networks, children should be supported through programs that maintain resilience in the face of recurring environmental stressors.

Objective: Solastalgia is a new concept developed to give greater meaning and clarity to environmentally induced distress. As opposed to nostalgia – the melancholia or homesickness experienced by individuals when separated from a loved home – solastalgia is the distress that is produced by environmental change impacting on people while they are directly connected to their home environment. The paper will focus on two contexts where collaborative research teams have found solastalgia to be evident: the experiences of persistent drought in rural NSW and the impact of large-scale open-cut coal mining on individuals in the Upper Hunter Valley of NSW. In both cases, people exposed to environmental change experienced negative affect that is exacerbated by a sense of powerlessness or lack of control over the unfolding change process. Methods: Qualitative (interviews and focus groups) and quantitative (community-based surveys) research has been conducted on the lived experience of drought and mining, and the findings relevant to solastalgia are presented. Results: The authors are exploring the potential uses and applications of the concept of solastalgia for understanding the psychological impact of the increasing incidence of environmental change worldwide. Conclusions: Worldwide, there is an increase in ecosystem distress syndromes matched by a corresponding increase in human distress syndromes. The specific role played by global-scale environmental challenges to ‘sense of place’ and identity will be explored in the future development of the concept of solastalgia.

Introduction: This paper reports on the development of a national recruitment and clinical assessment strategy by the Australian Schizophrenia Research Bank (ASRB). The aim of this strategy is to ensure a representative sample of people with schizophrenia and to collect comprehensive, cross-referenced clinical, cognitive, genetic, brain imaging and linked data. Method: The ASRB recruitment targets are 2000 people with schizophrenia and 2000 healthy, non-psychiatric controls. Using a three pronged approach, schizophrenia subjects will be recruited from various settings. To recruit people in the community, a successful TV and radio community service advertisement campaign was developed and a national 1800 telephone number established. The assessment battery includes the Diagnostic Interview for Psychosis (DIP: Castle et al, 2005), Neurological Evaluation Scale (Buchanan & Heinrichs, 1989), Wechsler Test of Adult Reading (WTAR-Wechsler, 2001), Wechsler Abbreviated Scale of Intelligence (WASI-Wechsler, 1999), Repeatable Battery for Assessment of Neuropsychological Status (RBANS Randolph et al, 1998), Letter Number Sequencing (Wechsler, 1997), Controlled Oral Word Association Test (Spreen & Benton, 1969), Global Assessment of Functioning (GAF-American Psychiatric Association, 2000), and the Schizotypal Personality Questionnaire (Raine et al., 1991). In addition, a blood sample and structural MRI scan are collected. Results: Over 2000 people have registered with the ASRB using the 1800 number. A proportion of these people have been assessed using the ASRB assessment battery. Conclusion: The ASRB is the first Australian research facility to develop a national recruitment and clinical assessment strategy in schizophrenia.

Longitudinal research into early intervention for youth at ultra high risk (UHR) for psychosis demonstrates beneficial outcomes including increased treatment compliance and greater participation in education and the workforce. Despite known barriers for rural youth accessing mental health services, research comparing urban and rural UHR youth is lacking. The study included an examination of the impact of substance use on functioning of UHR youth.Youth aged 12 to 25 years were recruited from the urban area of Newcastle or the rural area of Orange, New South Wales, Australia, and identified as UHR by the Comprehensive Assessment of At Risk Mental States. Rural and urban youth were compared on clinical profiles, social and occupational functioning and substance use.The rural youth showed different help-seeking behaviours and had greater functional impairment than urban youth. Substance use was common across the sample of 57 youth (mean age 16.5 years, 56% female) and a history of hazardous substance use was associated with higher levels of depression. Rural youth (n = 32) were more likely than urban youth to be taking antidepressants at baseline (44% compared with 16%).Different patterns of help seeking by rural UHR youth suggest a need for greater access to psychosis informed primary care early intervention services. Interventions should target functional decline to prevent adverse outcomes such as reduced community participation and unemployment. In addition, interventions for substance use should be a priority for UHR youth, who should also be screened and monitored for depressive symptoms and treated for depression if indicated.

Background This study examines the long-term outcomes of lifetime trauma exposure, including factors that contribute to the development of PTSD, in a sample of rural adults. Methods In 623 rural community residents, lifetime trauma exposure, PTSD, other psychiatric disorders and lifetime suicidal ideation were assessed using the World Mental Health Composite International Diagnostic Interview. Logistic regressions were used to examine relationships between potentially traumatic events (PTEs) and lifetime PTSD and other diagnoses. Results 78.2 % of participants reported at least on PTE. Rates were broadly comparable with Australian national data: the most commonly endorsed events were unexpected death of a loved one (43.7 %); witnessing injury or death (26.3 %); and life-threatening accident (19.3 %). While the mean age of the sample was 55 years, the mean age of first trauma exposure was 19 years. The estimated lifetime rate of PTSD was 16.0 %. Events with the strongest association with PTSD were physical assault and unexpected death of a loved one. Current functioning was lowest among those with current PTSD, with this group reporting elevated psychological distress, higher mental health service use, a greater number of comorbidities, and lower perceived social support. Respondents with a past PTE but no PTSD history were generally similar in terms of their current wellbeing to those with no lifetime PTE. Conclusions PTEs may have diverse psychological and social consequences beyond the development of PTSD. Ensuring that adequate support services are available in rural areas, particularly in the period immediately following a PTE, may reduce the long-term impact of traumatic events.

Background: Patient and Public Involvement is now an essential part of health-related research. Evidence suggests that research that involves patients and members of the public can enhance methodological rigor and facilitate the implementation of research findings. Aims: Our paper describes the development of a youth research group (Youth Speak) aimed at increasing youth engagement in mental health research. Method: We provide a selective review of the literature and outline the challenges and benefits of involving young people in research. Examples of how our group has facilitated involvement and the challenges we have encountered are also discussed. Results: Meaningful involvement of young people in mental health research is poorly documented or significantly lacking given the dearth of published literature. This may reflect the difficulty of obtaining sustained funding which is required to facilitate non-tokenistic involvement or a perception that young people are unable to provide meaningful contributions in this area. Conclusions: By establishing groups such as Youth Speak, which focus on the long-term involvement and development of young people in all stages of the research process, we hope to empower young people so that they can reshape youth mental health services.

Background Loneliness involves subjective, rather than objective, social isolation and has a range of negative effects on mental and physical functioning. The purpose of this study was to examine the prevalence of loneliness in psychotic disorders and its association with symptoms and cognitive performance. Method Data were drawn from the second Australian National Survey of Psychosis and comprised responses from 1642 participants with an International Classification of Diseases 10 diagnosis of psychotic disorder who had completed a semi-structured interview of symptoms and social functioning (including loneliness), along with standardized assessments of current (digit symbol coding; DSC) and premorbid (National Adult Reading Test) cognitive ability. We examined the prevalence of loneliness across the diagnostic categories of psychosis, and its association with psychotic and non-psychotic symptoms and digit symbol coding scores. Results The prevalence of loneliness was high, ranging from 74.75% in participants with delusional disorders to 93.8% in depressive psychosis, and was significantly higher than in the general population. Loneliness was also significantly associated with anhedonia and subjective thought disorder. Participants feeling socially isolated/lonely for company had significantly lower DSC scores than those who only felt lonely occasionally. Unexpectedly, participants who reported not feeling lonely had the lowest DSC scores. Conclusions Loneliness is common across all psychotic disorders, particularly in depressive psychosis. It is specifically associated with ongoing loss of pleasure and disordered thoughts as well as impairment in current cognitive functioning. However, poor cognitive functioning is not inevitably associated with loneliness. Implications for personalized treatment of psychosis are discussed.

Objective: Drought is a serious and recurring problem for rural and remote Australia. This paper reports the proceedings of a consultative conference concerning the mental health effects of drought held at the Centre for Rural and Remote Mental Health, Orange, in December 2003. The conference objective was to record the collective experience of government and non-government agencies dealing with the effects of drought in rural areas and to collate information for the development of a mental health strategy for future drought. Design: Participants were recruited in consultation with rural mental health organisations. Questions about mental health service strategies to minimise and respond to the mental health impact of the drought were posed to participants. Qualitative data were collected using a Nominal Group Technique. Setting: The Centre for Rural and Remote Mental Health, Bloomfield Hospital, Orange, New South Wales. Participants: Twenty-three professionals participated, including representatives from New South Wales Health, Mental Health, and Agriculture; the Department of Community Services, and Rural Financial Counsellors. Main outcome measure: Qualitative analysis of participant responses. Results: Three general strategies emerged as the most beneficial in minimising adverse mental health outcomes in times of drought: community-building and education about the physical, financial and mental health effects of drought; co-operation between and co-ordination of agencies in delivering mental health and other drought support; and continuity and planning of improved mental health services. Conclusions: Drought has a serious effect on the mental health of communities. It is important to plan a response beyond the end of the drought, bringing together different government and non-government agencies to build community capacity to address common mental health needs.

Background. We describe the development, reliability and applications of the Diagnostic Interview for Psychoses (DIP), a comprehensive interview schedule for psychotic disorders.Method. The DIP is intended for use by interviewers with a clinical background and was designed to occupy the middle ground between fully structured, lay-administered schedules, and semi-structured, psychiatrist-administered interviews. It encompasses four main domains: (a) demographic data; (b) social functioning and disability; (c) a diagnostic module comprising symptoms, signs and past history ratings; and (d) patterns of service utilization and patient-perceived need for services. It generates diagnoses according to several sets of criteria using the OPCRIT computerized diagnostic algorithm and can be administered either on-screen or in a hard-copy format.Results. The DIP proved easy to use and was well accepted in the field. For the diagnostic module, inter-rater reliability was assessed on 20 cases rated by 24 clinicians: good reliability was demonstrated for both ICD-10 and DSM-III-R diagnoses. Seven cases were interviewed 2–11 weeks apart to determine test–retest reliability, with pairwise agreement of 0·8–1·0 for most items. Diagnostic validity was assessed in 10 cases, interviewed with the DIP and using the SCAN as ‘gold standard’: in nine cases clinical diagnoses were in agreement.Conclusions. The DIP is suitable for use in large-scale epidemiological studies of psychotic disorders, as well as in smaller studies where time is at a premium. While the diagnostic module stands on its own, the full DIP schedule, covering demography, social functioning and service utilization makes it a versatile multi-purpose tool.

Background: Social functioning is an important treatment outcome for psychosis, and yet, we know little about its relationship to trauma despite high rates of trauma in people with psychosis. Childhood trauma is likely to disrupt the acquisition of interpersonal relatedness skills including the desire for affiliation and thus lead to impaired social functioning in adulthood. Aims: We hypothesized that childhood trauma would be a predictor of poor social functioning for adults with psychosis and that further trauma in adulthood would moderate this relationship. Method: A first-episode psychosis sample aged 15–65 years (N = 233) completed measures of social functioning (Lehman’s Quality of Life Interview and Strauss Carpenter Functioning Scale) and trauma (Brief Betrayal Trauma Survey), as well as clinical assessments. Results: Childhood trauma (any type) was associated with poorer premorbid functioning and was experienced by 61% of our sample. There were no associations with clinical symptoms. Interpersonal trauma in childhood was a significant predictor of social functioning satisfaction in adulthood, but this was not the case for interpersonal trauma in adulthood. However, 45% of adults who reported childhood interpersonal trauma also experienced adulthood interpersonal trauma. Conclusion: Our results emphasize the importance of early relationship experience such as interpersonal trauma, on the social functioning of adults with psychosis. We recommend extending our research by examining the impact of interpersonal childhood trauma on occupational functioning in psychosis.

Background: Whilst the majority of young people succeed in education and make a positive transition to the world of work and adult life, recent statistics identify that youth comprise 40% of the world's unemployed, equating to nearly 75 million individuals. These numbers are associated with both decreased economic activity and adverse well-being, with accompanying social, health and financial costs. As a result, a wide range of providers have implemented interventions targeting this population; however, their relative effectiveness is unknown. This is exacerbated by a diverse literature base, the delivery of provision and policy across multiple sectors and disparate approaches to programme evaluation. Methods and design: We will undertake a systematic review of interventions targeting youth not in employment, education or training (NEET) populations. Only randomised and non-randomised controlled trials will be included. The objectives of the review will be to: (i) systematically review, synthesise and quality appraise experimental evidence on the effects of interventions with NEET young people, (ii) estimate effects on current NEET status, well-being and other relevant psychological and behavioural outcomes, (iii) investigate potential variation in intervention effects among sub-groups stratified by pre-trial duration of current status, socioeconomic status, gender, sub-classifications of NEET individuals and intervention components (e.g. type, frequency, duration, provider and setting) and (iv) assess the robustness of results in separate sensitivity analyses that exclude studies with higher risk of bias (e.g. in terms of study quality) or follow-up length. A rigorous literature search of English language publications post-1990 will be conducted using the following electronic databases: Medline, Embase, PsycINFO, ERIC, EPPI-Centre (Bibliomap), Social Science Citation Index, British Education Index, Conference Proceedings Index, Dissertation Abstracts, Popline and grey literature collections (e.g. GLADNET). These database searches will be supplemented with hand searching, requests for unpublished literature and website searches. Discussion: A report and executive summary will be developed by the research team with input from consultant stakeholders to aid translation of the findings into practice. The research will be disseminated at national and international conferences and submitted for peer-reviewed publication. Systematic review registration: PROSPERO CRD42014007535

IntroductionMulti-attribute utility instruments (MAUIs) are generic health-related quality of life (HRQoL) measures that enable valuation of health states relative to death (0.0) and full health (1.0). The usefulness of MAUIs in people with psychosis has been questioned, with the EQ-5D considered “insensitive”, the 15D “problematic” and the SF-6D “unsuitable”.ObjectivesConfirm the Assessment of Quality of Life (AQoL)-4D MAUI is useful and meaningful in people with psychosis.AimsAssess utility values across demographic, general and disease-specific health categorisations for a large nationally-representative sample with psychosis (n = 1825).MethodsParticipants underwent a comprehensive 32 module interview encompassing psychopathology to service use. Utility values were calculated by applying a standard algorithm to responses to each of 12 items of the AQoL-4D.ResultsUtility values were assessed for 1793 participants (98.2%). No ceiling effect was observed and only 6.6% of participants scored in the top decile of HRQoL [0.9–10.0]. In contrast, 10.8% scored in the lowest decile [−0.04–0.10], a floor effect observed in 0.4%. The mean utility value was 0.49 (95% CI: 0.48–0.51), significantly lower than the Australian population norm of 0.81 (95% CI: 0.81–0.82). Greatest impacts on HRQoL were for diminishing global independent functioning as measured by the MSIF (ESMSIF: 0.68–2.24), self-rated current mental health (ESMH: 0.15–1.65) and physical health status (ESPH: 0.11–1.21). Strong effects also observed for course of disorder (ESCoD: 0.08–1.13), current suicidal ideation (ESCSI1: 0.76–1.08), and labor force participation (ESLFP: 0.11–0.97).ConclusionsThe AQoL-4D had good lower end sensitivity in a large sample of people with a psychotic illness, and demonstrated responsiveness across subjective, objective and symptom measures.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Objective: Participation in mainstream education and employment facilitates both the recovery and the social inclusion of people with psychotic disorders. As part of the second Australian survey of psychosis, we assessed labour force activity and participation in formal education among working age adults with psychotic disorders. Method: Data were drawn from a large national community prevalence survey of adults with psychotic disorders. Known as the Survey of High Impact Psychosis (SHIP), it was conducted in seven Australian catchment areas during March to December 2010. Current and past year labour force activity, current employment, past year participation in formal education and vocational training, and key clinical and demographic characteristics were examined in a sample of 1825 participants. Results: Only 22.4% of people with psychotic disorders were found to be employed (either full-time or part-time) in the month prior to the survey. In the previous 12 months, 32.7% were employed at some time. Of those in competitive employment, the majority worked part-time (63.9%), while a quarter worked 38 or more hours per week (23.4%). In terms of educational attainment, 18.4% reported difficulties with reading or writing, while 31.9% completed high school, which represents 12 years of formal education. Conclusions: The proportion currently employed has remained stable at 22% since the last national survey in 1997. Policy makers and service providers could do more to ensure people with psychotic disorders obtain access to more effective forms of assistance with respect to both their continuing education and employment. More effective vocational and educational interventions for people with psychotic disorders appear to be urgently needed.

Background: Social inclusion is a key priority of the Fourth National Mental Health Plan for Australia (2009–2014), with strong evidence for its protective impact on mental health. Social integration has been associated with enhanced well-being for people with mental illnesses such as psychosis. Objective: To explore the impact of psychosis on an individual’s social and community participation. Method: The second Australian national survey of psychosis was conducted across seven Australian sites. Semi-structured interviews with adults living with psychosis assessed mental health status, social and role functioning, life satisfaction and future goals. The cohort comprised 1825 adults with a psychotic illness (59.6% were male; 42.4% were aged 18–34 years; 31.5% had 12 years or more of education) of whom 32.7% had been employed in the past year. Results: Most adults indicated experiencing loneliness (80.1%) and a need for more friends (48.1%). Men were more likely to have never had a long-term relationship (59.4% M, 33.2% F). Even though women were more likely to experience anxiety in social situations [(χ2(1) = 8.95, p < 0.01)], they were more likely to have attended a social activity in the past year [χ2(2) = 11.84, p < 0.01]. Just over half of the survey participants (56.7%) reported having daily or nearly daily contact with family members. In the past year, 69% had not attended any social activity and 43% described stigma as a barrier. Although 63.2% showed significant impairment in social functioning, only 29.5% had received help for this in the last year. Social isolation and loneliness were rated as major challenges by 37.2% of the cohort. Conclusions: Social isolation and dysfunction experienced by people with psychosis have not decreased since the last Australian national survey of people with psychosis. Alongside education and employment, social functioning and participation must be addressed to improve social inclusion for people with psychosis. Programs targeting social opportunities (befriending, peer support), social anxiety and social functioning for all stages of psychosis are warranted.

We conducted a pilot study of the feasibility of videoconferencing as a mode of neuropsychological assessment in young people (14–30 years) from a rural area of New South Wales experiencing early psychosis. All participants ( n = 11) completed assessments both face-to-face and by videoconference at a bandwidth of 384 kbit/s. Assessments included confirmation of diagnosis, quality of life and neurocognitive functioning. There was a strong correlation between modes of assessment for most instruments. Bland-Altman plots indicated that in general the mean difference between face-to-face and videoconference modes of assessment was close to zero with significant bias only evident for general cognitive functioning (WTAR), where videoconferencing produced higher ratings than face-to-face assessments. Feedback from the participants indicated strong acceptability of assessment by videoconferencing, thus supporting further investigation of use of this mode of assessment for clinical and research purposes.

Childhood adversity is associated with elevated risk for a wide range of adult psychiatric disorders, and has significant and sustained negative effects on adult behavioural and social functioning. Elevated rates of childhood adversity have been reported for people with a diagnosis of schizophrenia. The aim of the present study was to assess rates of retrospectively reported childhood adversity among adults with schizophrenia and to examine the relationship between childhood adversity and clinical and cognitive features. Data were available for 408 schizophrenia participants and 267 healthy control participants recruited through the Australian Schizophrenia Research Bank (ASRB). History of childhood adversity was obtained using the Childhood Adversity Questionnaire (CAQ). A five-factor solution was identified from the CAQ. Schizophrenia participants reported experiencing more childhood adversities than controls. In both groups, those reporting childhood adversity were more likely to be female and older. Among participants with schizophrenia, positive symptom severity and fewer years of education were associated with childhood adversity. Lower IQ scores and personality traits were associated with reporting a greater number of childhood adversities and with adversity sub-types of abusive, neglectful and dysfunctional parenting. The rate of childhood adversity reported in this sample was high which suggests greater exposure to adverse childhood events among participants with schizophrenia in comparison with healthy controls. We identified unique groups amongst CAQ items that provided a salient framework from which to investigate the connection between childhood adversity and clinical and cognitive features.

The health problems faced by rural and remote communities are complex and not amenable to simple or short-term solutions. The Australian Rural Health Research Collaboration, which comprises rural research centres, area health services and policy makers in NSW, investigates these problems. Founded in 2002, it has grown to become the leading rural research collaboration in Australia. It aims to: conduct high quality research; build the capacity of researchers and clinicians; and encourage the translation of research evidence into practice for the benefit of rural and remote communities. The success of the Collaboration is illustrated by the increase in research outputs, funds generated, the strength of the relationships between partners and the ability to address complex research problems such as the mental health of rural and remote communities often deemed too difficult or expensive to include in metropolitan-based research. Keys to success have been the inclusive public health ethos, the participation of senior researchers and service managers, the critical mass of researchers achieved through collaboration and effective leadership and governance. This demonstrates the value of supporting cooperative research and capacity building in rural and remote areas where the size of research groups is small and where effective multi-disciplinary and co-operative research can pay dividends.

Research regarding psychological distress has often underestimated the importance of contextual social factors. This research aims to investigate patterns of psychological distress within the family system (parent dyads) across rural and remote communities and the influence of remoteness on such distress.Self-report survey data from the Australian Rural Mental Health Study was used to examine the distress levels of cohabitating parental figures in rural and remote Australia.The survey was conducted across rural and remote communities within New South Wales.The sample consisted of 129 adult couples (mean age = 42.66 years, SD = 8.11), 43 from Inner Regional areas, 48 from Outer Regional areas, 24 from Remote areas and 14 from Very Remote areas.Distress levels (Kessler-10).A significant association was detected between the levels of psychological distress among parents within a household. The strength of this relationship increased with increasing remoteness of residence.Identifying the influence of spousal factors on mental health in rural and remote areas allows health services in such regions to be aware of the needs of rural couples and families. These results support the need to consider partner/spouse mental health in clinical assessment and support the importance of household factors especially in remote communities.

Impairments in speech, communication and Theory of Mind are common in schizophrenia, and compromise social functioning. Some of these impairments may already be present pre-morbidly. This study aimed to investigate verbal functions in relation to written story production and social functioning in people experiencing a first episode of psychosis (FEP).Two groups of participants: FEP (N=31) and healthy controls (HC, N=31), completed measures of clinical status, social functioning, a series of neuropsychological tests targeting verbal functioning, and the "Frog Where Are You?" story production task.Story results showed reduced efficiency (words per minute) and self-monitoring (corrections per minute) for FEP compared with HC groups (p0.01). The FEP group performed significantly poorer than the HC group on most indices of verbal learning and verbal fluency. Story production was positively associated with verbal learning and verbal fluency for the FEP group only (p0.05). Premorbid function decline was associated with impaired verbal learning and memory for the FEP group.Individuals with FEP show a childhood history of reduced social and academic performance that is associated with skills essential for daily social interactions, as evidenced by the findings for story production, verbal learning and verbal fluency.

Early intervention into prodromal schizophrenia has shown promise, but controversy continues regarding the ethical acceptability of identifying a group of ‘ultra high risk’ individuals of whom only 30 to 50% will develop a psychotic disorder. With well developed early intervention services this group faces the possibility of being labelled as ‘pre-psychotic’, a condition for which the well known stigma associated with the diagnosis of schizophrenia or bipolar disorder is likely to be associated. In addition, the use of potent antipsychotic and other medications (albeit usually at lower doses than those used for those with manifest psychosis) mandates consideration of the risks associated with their use and neurological and metabolic side effects. The potential for iatrogenic morbidity in the ‘false positive’ group must be weighed against the need of the ‘true positives’ identified through screening and assessment. Current evidence for the concept of ‘at-risk mental state’ was reviewed within a neurodevelopmental framework, including emerging data on the effectiveness of early intervention for the purpose of providing recommendations for community mental health services. The review suggests that different treatment strategies may be appropriate depending on the clinical stage of the condition as long as the benefits of intervention outweigh its risk burden. It further suggests that the severity of psychoses and the evidence of its early onset in utero and its acceleration in adolescence positions ‘ultra high risk’ intervention as a core model for early intervention for young people by teasing apart the symptomatic components of the ‘prepsychotic state’ and ensuring the population is reaching targeted mental health services for screening. The model is not restricted to the delivery of intervention for ‘pre-psychotic’ young people but is applicable for targeted programmes for a number of clinical groups considered at ‘ultra high risk’. However, only further research in naturalistic populations embedded in clinical practice and ideally conducted in partnership of mental health services with academic research institutions will help clarify potential risks of early identification and intervention and assist in updating and making more explicit the clinical guidelines services will use in approaching those in the ‘ultra high risk’ group.

The health effects of chronic environmental adversity have received insufficient attention, particularly those associated with the psychological impact of drought. Resilience or adaptive response to drought has received even less attention than vulnerability factors. This research examined factors associated with drought impact in rural and remote Australian communities. In 2008 postal surveys were completed by 302 adults (mean age 53 years; 57% female, 77% married) living in rural areas of prolonged drought exposure. Outcome measures were: (i) psychological distress (Kessler 10) and (ii) an index of concern or worry about drought. A range of predictor variables were assessed: adaptability (hopefulness, neuroticism), other adverse events, personal support and community connectedness, and sense of place, as a measure of connection to the local environment. Predictors of drought related worry differed from those associated with psychological distress levels. The former included socio-economic factors (living on a farm [Odds Ratio, OR 3.09], current employment [OR 3.64]), personal psychological characteristics (neuroticism [OR 1.29]), and greater connection with the environment (sense of place [OR 1.05]). On the other hand, psychological distress was associated chiefly with personal factors, such as higher neuroticism [OR 1.92], lower levels of hopefulness [OR 0.28], and lower perceived social support and community connectedness [OR 0.39]. Practical financial, employment and family factors were identified as important elements of drought impact, as to a lesser extent was sense of place, reflecting a confrontation with the consequences of chronic environmental degradation, while personal hopefulness may help mitigate the psychological impact of such adversity.

Many rural Australian communities continue to endure a prolonged drought. The mental health effects of short-term natural disaster are well known; those of a long-term and chronic natural disaster such as drought are less well understood. However, in addition to immediate distress there are likely to be feelings of loss, grief and hopelessness, all of which are implicated in an increased risk of subsequent psychiatric morbidity. Furthermore, rural Australia is at a relative disadvantage for early and effective mental health intervention due to a lack of resources, compared with urban Australia. This qualitative research investigates the experience of drought in two farming communities in the state of New South Wales. Farmers, farm and non-farm businesspeople, and health workers took part in focus group discussions of the effects of drought on themselves, their families and their community. In addition to current distress related to financial and workload problems, people reported experiencing significant distress from the emotional impact of environmental degradation, from loss of hope for the future of their community, and from feelings of being misunderstood by the wider Australian community. The stressors affecting farming communities during times of drought are likely to be associated with increased risk of mental health problems.

Drought has been a major stressor affecting rural New South Wales communities since late 2001. While much is known about the effects on mental health of acute natural disasters, there is less research available on the effect to communities of chronic natural disasters. Of great concern for Australian rural communities is that independent of drought, the rate of suicide for some groups is higher in rural than urban communities, while access to mental health services is less.This article explores how general practitioners can identify and respond to the drought related mental health needs of farming residents.Limited availability of mental health services to rural communities increases reliance on GPs for mental health care. Residents of farming communities report experiencing substantial distress in relation to the drought. The local GP is a key source of consultation, advice and treatment. Early intervention is a critical task in improving the mental health of rural communities. Early intervention provided by GPs will be enhanced through: working closely with other community agencies to promote early effective intervention for mental health problems, improve access to advice and initial consultation, and facilitate urgent consultation when needed; increasing access to services for farmers and responding promptly to needs; and utilising the support of rural organisational workers.