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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 Childhood interpersonal trauma (CIT) and premorbid adjustment are both associated with poor outcome in psychosis. In this study we investigate the relative impact of CIT and premorbid adjustment on symptom remission in first episode psychosis (FEP) over two years. Method A total of 232 participants with FEP were recruited through the early detection program of the The early detection and Intervention in Psychosis (TIPS)-2 study and followed up after two years. Symptom remission was according to consensus criteria. CIT was assessed with the semi-structured interview Freyd Goldberg Brief Betrayal Trauma Survey, and premorbid adjustment with the Premorbid Adjustment Scale. Generalized estimating equations and multivariate models were used to analyze the associations between remission, symptom levels over time, CIT and premorbid adjustment; and a path analysis of mediation effects of CIT through premorbid adjustment on remission. Results In this sample with 57% males and a mean age of 26.6 years (SD 10.2), a third of participants had experienced CIT. The participants with CIT had poorer premorbid adjustment compared to those without. Statistical analyses found independent effects of CIT and an interaction effect of CIT with premorbid adjustment on remission after two years, suggesting that CIT moderates the effect of premorbid adjustment. However contrary to expectations, premorbid adjustment did not mediate the effect of CIT. Conclusion Our findings indicate a complex interplay between effects of interpersonal trauma and premorbid social adjustment on remission in psychosis. CIT appeared to moderate the effect of premorbid adjustment such that individuals with CIT and who had poor social functioning in childhood are at greater risk of non-remission. Findings indicate that better premorbid social relations could provide a buffer for the effects of trauma on symptom course.

Objective: Parenthood is central to the personal and social identity of many people. For individuals with psychotic disorders, parenthood is often associated with formidable challenges. We aimed to identify predictors of adequate parenting among parents with psychotic disorders. Methods: Data pertaining to 234 parents with psychotic disorders living with dependent children were extracted from a population-based prevalence study, the 2010 second Australian national survey of psychosis, and analysed using confirmatory factor analysis. Parenting outcome was defined as quality of care of children, based on participant report and interviewer enquiry/exploration, and included level of participation, interest and competence in childcare during the last 12 months. Results: Five hypothesis-driven latent variables were constructed and labelled psychosocial support, illness severity, substance abuse/dependence, adaptive functioning and parenting role. Importantly, 75% of participants were not identified to have any dysfunction in the quality of care provided to their child(ren). Severity of illness and adaptive functioning were reliably associated with quality of childcare. Psychosocial support, substance abuse/dependence and parenting role had an indirect relationship to the outcome variable via their association with either severity of illness and/or adaptive functioning. Conclusion: The majority of parents in the current sample provided adequate parenting. However, greater symptom severity and poorer adaptive functioning ultimately leave parents with significant difficulties and in need of assistance to manage their parenting obligations. As symptoms and functioning can change episodically for people with psychotic illness, provision of targeted and flexible support that can deliver temporary assistance during times of need is necessary. This would maximise the quality of care provided to vulnerable children, with potential long-term benefits.

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 Remission in schizophrenia is difficult to achieve. Antipsychotic drugs are critical in the treatment of schizophrenia. International guidelines for the pharmacological treatment of schizophrenia recommend a 3-step algorithm with clozapine being the third-line antipsychotic agent. This study investigated the 1-year outcome and the application of the guidelines for the pharmacological treatment of nonremitted first-episode schizophrenia (FES) patients during the first year of follow-up. Methods A sample of 78 FES patients from the Norwegian TIPS (Early Treatment and Intervention in Psychosis) 2 study was assessed at the end of the first year of follow-up. The symptom remission criteria were those defined by the Remission in Schizophrenia Working Group. The adherence to the pharmacological guidelines was assessed by reading the medical files and by a digital search of the words “clozapine,” “klozapin,” and “Leponex” in the hospital electronic data system. Results The majority (n = 53, 67.9%) of the patients included were nonremitted at the 1-year follow-up. The majority of the nonremitted patients received either none (7.5%), one (56.6%), or 2 types (15.1%) of antipsychotic drugs during the first year of follow-up. Only 2 (3.8%) received treatment with clozapine, and 3 (5.7%) in total were offered it. Conclusions For our FES sample, there was a low 1-year remission rate and a poor adherence to the pharmacological guidelines. Higher adherence to treatment guidelines with a more intensified antipsychotic treatment, which in some cases will include clozapine, will enhance the quality of treatment and may enhance the rates of remission for schizophrenia. publishedVersion

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. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) CRD42017058514; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017058514.

BACKGROUND: Social functioning impairment is a core predictor of outcome in psychosis and a main target for interventions. Assessments reflecting social reality are thus essential. After the 2004 advent of Facebook, social networking platforms have become integral to young peoples’ social life and yet it is unclear whether this is being assessed. The aim of this systematic review is to examine the inclusion of social media activity in measures of social functioning in psychosis and ultra-high-risk for psychosis. METHODS: Design: Systematic review. Data sources: Epistemonikos, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effect (DARE), MEDLINE, EMBASE and PsycINFO. Eligibility criteria for study selection: Empirical study published in English language in peer reviewed journals, with a sample meeting criteria (DSM/ICD) for a psychotic disorder or ultra-high risk for psychosis, and including a measure of social functioning. Papers published between January 2004 and April 2018 were included. Data extraction: The electronic search resulted in 10,575 distinct articles. Full-text evaluation was conducted on 690 articles of which 573 articles met inclusion criteria. RESULTS: 58 social functioning measures were identified. With some exceptions, reports on reliability and validity were scarce and only one measures integrated social media social activity. DISCUSSION: 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.

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

Purpose Team formulation, used to understand patient problems and plan care, is a growing practice in adult mental health and learning disability services. The purpose of this paper is to explore definitions applied to team formulation (as distinct to therapy formulation), its underpinning theories, and the inter-relationship between the team and the process of formulation. Design/methodology/approach A database search (main search term of team formulation) of peer-reviewed studies was conducted using PRISMA guidelines. A main and second reviewer conducted quality appraisals and thematic analysis. Data were analysed by convergent qualitative synthesis design using thematic analysis to transform evidence from quantitative and qualitative studies into qualitative findings. Findings Initial searching produced 4,532 papers, 10 of which were eligible for inclusion. Team formulation has no distinct definition. Theories underpinning the practice of therapy formulation emanating from general psychological theory underpin team formulation. Seven studies applied psychological theories to the examination of team formulation. No studies examined the impact of the team on the formulation. Six themes were generated regarding the impact of team formulation on the team; “increased knowledge and understanding”, “altered perceptions, leading to altered relationships, feelings and behaviours”, “space to reflect”, “useful when stuck or challenged”, “perceived increase in effectiveness” and “improved team working”. Research limitations/implications Limited evidence and variable quality compromised the availability of review evidence. Originality/value This is the first review to examine team formulation through the context of the team. The authors argue that a conceptual framework to encompass team inputs, processes and outputs in team formulation practice should guide future research.

Prevalence of mental health problems in university students is increasing and attributable to academic, financial and social stressors. Lack of social support is a known determinant of mental health problems. We examined the differential impact of sources of social support on student wellbeing. University students completed an online survey measuring depressive symptoms (Patient Health Questionnaire (PHQ-9)), social support (Multidimensional Perceived Social Support (MPSS)), and quality of life (WHOQOL-BREF). The sample was 461 students (82% female, mean age 20.62 years). The prevalence of depressive symptoms was 33%. Social support from family, and friends was a significant predictor of depressive symptoms (p = 0.000*). Quality of life (psychological) was significantly predicted by social support from family and friends. Quality of life (social relationships) was predicted by social support from significant others and friends. Sources of social support represent a valuable resource for universities in protecting the mental health of students.

Highlights • Childhood imaginary friend report predicted adult prodromal hallucination symptoms. • Childhood imaginary friend report did not predict other adult prodromal symptoms. • Childhood adversity report predicted all types of adult prodromal symptoms. • Childhood adversity mediated imaginary friend prodromal hallucination symptoms., Hallucination and dissociation have been found to be associated with imaginary friend play in childhood (CIC). Past studies have not investigated how this play relates to adult prodromal symptoms or how childhood adversity mediates the relationship. CIC play was examined in 278 participants, 18–24 years. CIC status predicted prodromal symptoms of hallucination only, whereas childhood adversity predicted all other symptoms. Mediation analysis found CIC's relation to hallucination symptoms was partially mediated by childhood adversity. Findings fit with views that CIC are a positive childhood experience which may convert to a negative developmental trajectory through the impact of childhood adversity.

Background Few studies relating to youth mental health have actively involved young people in the design and conduct of research. Aims This qualitative study explores the perceptions of young people about involving them in mental health research. Method An opportunistic sample of eight young people (aged 14–24 years) from non-statutory mental health organizations was interviewed. Interviews were transcribed verbatim, and inductive thematic analysis was conducted. Results Six key themes emerged reflecting a desire for young people to have the opportunity to actively contribute to every stage of the research process. Meaningful research involvement was perceived as offering opportunities to develop personal skills, contribute to making a difference and ensuring research projects were more relevant. Conclusions Young people with an active interest in mental health promotion demonstrate a desire to be involved in research with training in research methods likely to facilitate this process. Researchers need training on how best to actively and meaningfully involve young people in mental health research.

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.

BackgroundThere are insufficient data from nationwide surveys on the prevalence of specific psychotic disorders and associated co-morbidities.MethodThe 2010 Australian national psychosis survey used a two-phase design to draw a representative sample of adults aged 18–64 years with psychotic disorders in contact with public treatment services from an estimated resident population of 1 464 923 adults. This paper is based on data from 1642 participants with an International Classification of Diseases (ICD)-10 psychotic disorder. Its aim is to present estimates of treated prevalence and lifetime morbid risk of psychosis, and to describe the cognitive, physical health and substance use profiles of participants.ResultsThe 1-month treated prevalence of psychotic disorders was 3.10 cases per 1000 population aged 18–64 years, not accounting for people solely accessing primary care services; lifetime morbid risk was 3.45 per 1000. Mean premorbid intelligence quotient was approximately 0.5 s.d.s below the population mean; current cognitive ability (measured with a digit symbol coding task) was 1.6 s.d.s below the population mean. For both cognitive tests, higher scores were significantly associated with better independent functioning. The prevalence of the metabolic syndrome was high, affecting 60.8% of participants, and pervasive across diagnostic groups. Of the participants, two-thirds (65.9%) were current smokers, 47.4% were obese and 32.4% were sedentary. Of the participants, half (49.8%) had a lifetime history of alcohol abuse/dependence and 50.8% lifetime cannabis abuse/dependence.ConclusionsOur findings highlight the need for comprehensive, integrative models of recovery to maximize the potential for good health and quality of life for people with psychotic illness.

The onset of schizophrenia is typically preceded by a prodromal period lasting several years during which sub-threshold symptoms may be identified retrospectively. Clinical interviews are currently used to identify individuals who have an ultra-high risk (UHR) of developing a psychotic illness with a view to provision of interventions that prevent, delay or reduce severity of future mental health issues. The utility of bio-markers as an adjunct in the identification of UHR individuals is not yet established. Several event-related potential measures, especially mismatch-negativity (MMN), have been identified as potential biomarkers for schizophrenia. In this 12-month longitudinal study, demographic, clinical and neuropsychological data were acquired from 102 anti-psychotic naive UHR and 61 healthy controls, of whom 80 UHR and 58 controls provided valid EEG data during a passive auditory task at baseline. Despite widespread differences between UHR and controls on demographic, clinical and neuropsychological measures, MMN and P3a did not differ between these groups. Of 67 UHR at the 12-month follow-up, 7 (10%) had transitioned to a psychotic illness. The statistical power to detect differences between those who did or did not transition was limited by the lower than expected transition rate. ERPs did not predict transition, with trends in the opposite direction to that predicted. In exploratory analysis, the strongest predictors of transition were measures of verbal memory and subjective emotional disturbance.

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.

Background Intervention trials for young people at ultra high risk (UHR) for psychosis have shown cognitive behaviour therapy (CBT) to have promising effects on treating psychotic symptoms but have not focused on functional outcomes. We hypothesized that compared to an active control, CBT would: (i) reduce the likelihood of, and/or delay, transition to psychosis; (ii) reduce symptom severity while improving social functioning and quality of life, whether or not transition occurred. Method This was a single-blind randomised controlled trial for young people at UHR for psychosis comparing CBT to an active control condition, Non Directive Reflective Listening (NDRL), both in addition to standard care, with a 6 month treatment phase and 12 months of follow-up. Statistical analysis is based on intention-to-treat and used random effect models to estimate treatment effects common to all time-points. Results Fifty-seven young people (mean age = 16.5 years) were randomised to CBT ( n = 30) or NDRL ( n = 27). Rate of transition to psychosis was 5%; the 3 transitions occurred in the CBT condition (baseline, 2 months, 5 months respectively). The NDRL condition resulted in a significantly greater reduction in distress associated with psychotic symptoms compared to CBT (treatment effect = 36.71, standard error = 16.84, p = 0.029). There were no significant treatment effects on frequency and intensity of psychotic symptoms, global, social or role functioning. Conclusion Our sample was higher functioning, younger and experiencing lower levels of psychotic like experiences than other trials. The significantly better treatment effect of NDRL on distress associated with psychotic symptoms supports the recommendations for a stepped-care model of service delivery. This treatment approach would accommodate the younger UHR population and facilitate timely intervention. Trial registration : ANZCTR 12606000101583

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.

Background Evidence from meta-analyses of randomised clinical trials show 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. Methods A self-report online survey was completed by clinical leaders of Early Intervention in Psychosis (EIP) teams (N=50) within the NHS across the UK. Results Of the 50 EIP teams responding (from 30 NHS Trusts), 53% reported inclusion of the UHR group in their service mandate, with age range predominantly 14–35 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. Discussion Despite 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.

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.