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There is robust evidence that child maltreatment is a significant risk factor and linked to negative psychological outcomes. However, few studies have examined the impact of child maltreatment on mental health and substance use trajectories across adolescence.Data were drawn from a larger longitudinal project, in which participants were recruited starting in grade 7-8 and followed on two more occasions biennially. The final baseline sample was comprised of 765 youth (MYouth who experienced maltreatment were more likely to display more severe internalizing, externalizing, and substance use problem trajectories than youth without such histories. While not significant as moderators, perceived family support and school connectedness were significantly associated with each of the trajectories, with lower levels of perceived family support and school connectedness linked to more severe problem trajectories.Results highlight the ongoing and significant harmful impact of maltreatment among youth. Results also support further prevention and intervention efforts for child maltreatment, particularly at the family and school level.

Youth view gender as a spectrum of experiences, not the cis-binary framework of girls/women versus boys/men. However, research has historically focused on cisgender people, without considering the rich experiences of transgender and non-binary people. Method. To address gaps in the inclusion of transgender and gender non-binary youth in research, a group of transgender and non-binary youth came together through a research-based youth engagement initiative to discuss what they wanted researchers to know about gender. Results. Youth propose ten guidelines and principles that they ask researchers to acknowledge, respect, and apply. These guidelines and principles focus on acknowledging and accepting diverse experiences situated on a gender spectrum, committing to learning more about gender, incorporating gender appropriately in their research initiatives, and engaging with transgender and non-binary youth in the research they conduct. Funders, research ethics boards, and publishers are also responsible for attending to gender. Conclusions. Researchers are called on to consider these guidelines and principles and to engage in dialogue around them in order to better capture the experiences of transgender and non-binary youth in the new evidence base as it emerges.

Background There is growing recognition that engaging people with lived experience (PWLE) in mental health and substance use research improves the quality of the research in terms of relevance to the population and the feasibility of the work. Engagement also provides positive opportunities for research teams and the PWLE engaged. However, there are many gaps in the research on PWLE engagement. This scoping review synthesizes the gaps in the implementation of PWLE engagement and in the research on engagement as presented by research teams engaging PWLE in their work. Method A systematic electronic database search was conducted in 2022 for published articles on PWLE engagement in mental health and substance use research. Potential articles were screened for relevance. The search led to 49 final articles included in the review. The 49 articles were then coded using codebook thematic analysis to answer two research questions: (1) What are the research evidence gaps regarding the engagement of PWLE in mental health and substance use research?; and (2) What are the gaps in implementing PWLE engagement in mental health and substance use research? PWLE were engaged in the conduct of this review. Results Results showed that research evidence gaps include further work on conceptualizing engagement; developing resources, tools, and practice recommendations to support research teams; increasing diversity in evaluations of engagement; and evaluating engagement, including its impact on the research, on PWLE, and on researchers. Implementation gaps included several broader institutional gaps and gaps in the day-to-day practice of engagement. Conclusions Despite progress in PWLE engagement in mental health and substance use research in recent years, research evidence and implementation gaps remain. Research teams are encouraged to consider these gaps and conduct research and implementation activities to address them in a rigorous manner.

Background Youth and young adults have been significantly impacted by the opioid overdose and health crisis in North America. There is evidence of increasing morbidity and mortality due to opioids among those aged 15–29. Our review of key international reports indicates there are few youth-focused interventions and treatments for opioid use. Our scoping review sought to identify, characterize, and qualitatively evaluate the youth-specific clinical and pre-clinical interventions for opioid use among youth. Method We searched MedLine and PsycInfo for articles that were published between 2013 and 2021. Previous reports published in 2015 and 2016 did not identify opioid-specific interventions for youth and we thus focused on the time period following the periods covered by these prior reports. We input three groups of relevant keywords in the aforementioned search engines. Specifically, articles were included if they targeted a youth population (ages 15–25), studied an intervention, and measured impacts on opioid use. Results We identified 21 studies that examined the impacts of heterogeneous interventions on youth opioid consumption. The studies were classified inductively as psycho-social-educational, pharmacological, or combined pharmacological-psycho-social-educational. Most studies focused on treatment of opioid use disorder among youth, with few studies focused on early or experimental stages of opioid use. A larger proportion of studies focused heavily on male participants (i.e., male gender and/or sex). Very few studies involved and/or included youth in treatment/program development, with one study premised on previous research about sexual minority youth. Conclusions Research on treatments and interventions for youth using or at-risk of opioids appears to be sparse. More youth involvement in research and program development is vital. The intersectional and multi-factorial nature of youth opioid use and the youth opioid crisis necessitates the development and evaluation of novel treatments that address youth-specific contexts and needs (i.e., those that address socio-economic, neurobiological, psychological, and environmental factors that promote opioid use among youth).

Background Stigma associated with mental health challenges is a major barrier to service seeking among youth. Understanding how stigma impacts service-seeking decisions from the perspectives of youth remains underexplored. Such research is necessary to inform effective stigma reduction. Objective This study aims to understand how stigma influences service seeking among youth with mental health challenges. Methods Qualitative inquiry was taken using youth engagement, underpinned by pragmatism. Data were collected via 4 virtual focus groups with 22 purposively selected youth participants with lived experience of mental health challenges in Ontario, Canada. Focus group guides were developed collaboratively among research team members, including youth co-researchers. Data were analyzed inductively using reflexive thematic analysis. Results Three main themes were constructed from the data: point of entry into the system, being biomedicalized or trivialized, and paving the way for non-stigmatizing services. Initial contact with the mental healthcare system was seen to be affected by stigma, causing participants to delay contact or be refused services if they do not fit with an expected profile. Participants described a constant negotiation between feeling ‘sick enough’ and ‘not sick enough’ to receive services. Once participants accessed services, they perceived the biomedicalization or trivialization of their challenges to be driven by stigma. Lastly, participants reflected on changes needed to reduce stigma’s effects on seeking and obtaining services. Conclusion A constant negotiation between being ‘sick enough’ or ‘not sick enough’ is a key component of stigma from the perspectives of youth. This tension influences youth decisions about whether to seek services, but also service provider decisions about whether to offer services. Building awareness around the invisibility of mental health challenges and the continuum of wellness to illness may help to break down stigma’s impact as a barrier to service seeking. Early intervention models of care that propose services across the spectrum of challenges may prevent the sense of stigma that deters youth from accessing and continuing to access services.

Objective Integrated youth services (IYS) are an emerging model of care offering a broad range of mental health and social services for youth in one location. This study aimed to determine the IYS service characteristics most important to youth, as well as to determine whether different classes of youth have different service preferences, and if so, what defines these classes. Methods Ontario youth aged 14–29 years with mental health challenges were recruited to participate in a discrete choice experiment (DCE) survey. The DCE contained 12 attributes, each represented by 4 levels representing core characteristics of IYS models. To supplement the DCE questions, demographic information was collected and a mental health screener was administered. Preferences were examined, latent class analyses were conducted, and latent classes were compared. Results As a whole, participants endorsed the IYS model of service delivery. Among 274 youth, there were three latent classes: 1) the Focused Service (37.6%) latent class prioritized efficient delivery of mental health services. 2) The Holistic Services (30.3%) latent class prioritized a diverse array of mental health and social services delivered in a timely fashion. 3) The Responsive Services (32.1%) latent class prioritized services that matched the individual needs of the youth being served. Differences between classes were observed based on sociodemographic and clinical variables. Conclusions IYS is an acceptable model of care, in that it prioritizes components that reflect youth preferences. The differences in preference profiles of different groups of youth point to the need for flexible models of service delivery. Service design initiatives should take these preferences into account, designing services that meet the needs and preferences of a broad range of youth. Working locally to co-design services with the youth in the target population who wish to be engaged will help meet the needs of youth.

Given the important implications of youth substance use, it is essential to document and describe changes in substance use during the coronavirus disease 2019 pandemic.This multimethod survey study examines the impacts of the coronavirus disease 2019 pandemic on youth substance use among 149 Canadian youth who were using substances at a mid-pandemic period. Participants were 21.9 years of age on average (SD=2.2), including 99 girls/young women, 42 boys/young men, and 8 transgender or nonbinary individuals. The majority were Caucasian and born in Canada. Qualitative and quantitative findings are reported, with thematic analysis combined with descriptive and inferential statistical analyses.Qualitatively, many youth reported increases or shifts in their substance use over the course of the pandemic. Youth reported using substances with limited numbers of peers, with family, or alone. Many reported using substances out of boredom and to cope. While legal substances remained highly accessible, illegal substances were reported to be more difficult to acquire and less trustworthy. Spending had increased. Quantitative findings suggested alcohol use has decreased, but other substance use has remained stable in the sample as a whole, although for each substance, some youth reported increases.Despite minimal quantitative change, qualitative findings show that some youth increased their use of some substances during the pandemic, decreased others, changed their motivation to use, and decreased in safety behaviors. Youth-serving organizations should be aware of individual differences, the changing context of substance use, and the potential long-term impacts.Compte tenu des implications importantes de la consommation de substances chez les jeunes, il est essentiel d’identifier, documenter et décrire l’évolution de la consommation de substances pendant la pandémie de COVID-19 afin d’élaborer des stratégies de prévention et des traitements efficaces.Cette étude d’enquête multiméthodes examine les impacts de la pandémie de COVID-19 sur la consommation de substances chez 149 jeunes canadiens qui consommaient des substances au milieu de la période de la pandémie. Les participants avaient 21,9 ans en moyenne (ET=2,2), dont 99 filles/jeunes femmes, 42 garçons/jeunes hommes et 8 personnes transgenres ou non binaires. La majorité des participants étaient caucasien et née au Canada. Les résultats qualitatifs et quantitatifs sont rapportés avec une analyse thématique combinée à des analyses statistiques descriptives et analogiques.Sur le plan qualitatif, de nombreux jeunes qui consommaient des substances pendant la pandémie ont signalé des augmentations ou des changements dans leur consommation de substances au cours de la pandémie. Les jeunes ont déclaré consommer des substances avec un nombre limité de pairs, en famille ou seul. De nombreux jeunes ont déclaré consommer des substances par ennui et pour faire face à la situation. Alors que les substances légales sont restées très accessibles, les substances illicites sont devenues plus difficiles à acquérir et moins dignes de confiance ce qui a entraîné une augmentation des dépenses. Les résultats quantitatifs suggèrent que la consommation d’alcool a diminué pour ces jeunes, mais la consommation d’autres substances est restée stable dans l’ensemble de l'échantillon, bien que pour chaque substance, certains jeunes ont signalé des augmentations.Malgré un changement quantitatif minime, les résultats qualitatifs montrent que chez les jeunes qui consommaient des substances au milieu de la période de la pandémie, certains jeunes ont connu une augmentation de la consommation de certaines substances pendant la pandémie, une diminution de leur consommation d’autres substances, des changements dans leur motivation à consommer des substances et une diminution des comportements sécuritaires. Les organisations au service des jeunes doivent être conscientes des différences individuelles, du contexte changeant de la consommation de substances et des impacts potentiels à long terme. Les prestataires de services devraient travailler avec les jeunes de manière centrée sur la personne pour identifier des solutions dans le contexte des expériences vécues en lien avec la COVID-19.

Adolescents experience rapid changes and are more vulnerable for developing substance use problems than other age groups. Many studies have focused on the trajectories of adolescent substance useThe present study examined the trajectory of substance use disorder symptoms, particularly beginning in early adolescence and within a Canadian context.Data were drawn from a Canadian longitudinal project, in which a province-wide survey was administered to students across three biennial waves starting in grades 7-8. The final sample was comprised of 765 adolescents (baselineFour classes were identified, labelled as low stable (Results fill a gap in the evidence on the trajectory of symptoms of substance use disorder among adolescents, using a Canadian sample, an area of limited study. Results highlight an at-risk group (i.e., high-risk relapse class) that warrants further tailored prevention and intervention efforts.Les adolescents connaissent des changements rapides et sont plus vulnérables de développer des problèmes d’utilisation de substances que d’autres groupes d’âge. De nombreuses études ont porté sur les trajectoires desLa présente étude a examiné la trajectoire des symptômes du trouble d’utilisation de substances, particulièrement lorsque le trouble commence au début de l’adolescence et dans un contexte canadien.Les données ont été tirées d’un projet longitudinal canadien, dans lequel un sondage à l’échelle provinciale a été administré à des élèves sur trois vagues biennales à partir de la 7Quatre classes ont été identifiées, étiquetées comme faibles stables (Les résultats comblent un vide dans les données probantes sur la trajectoire des symptômes du trouble d’utilisation de substances chez les adolescents, à l’aide d’un échantillon canadien, un domaine d’étude limité. Les résultats présentent un groupe à risque (c.-à-d., une classe à risque élevé de rechute) qui justifie des efforts plus ciblés de prévention et d’intervention.

The objective of this paper was to examine the school-related experiences of youth during the COVID-19 pandemic. Participants represented both clinical and community youth aged 14 to 28 who were sampled as part of a larger study. Feedback from youth attending school during the pandemic was qualitatively examined and youth who planned to attend school prior to the pandemic and did ( n = 246) and youth who planned to attend but did not ( n = 28) were compared quantitatively. Youth appreciated the flexibility of online learning and some also reported experiencing a lack of support from their school and the need for instructor training on how to deliver virtual classes effectively. Future studies should examine what factors influence student engagement with virtual learning, what strategies could improve supports for student in their long-term career development, and the longitudinal experiences of youth who may have chosen not to go back to school due to the pandemic. This survey was conducted in Ontario, Canada. A more diverse sample collected outside of Ontario would improve generalizability. Qualitative data were based on survey responses and not interviews. Thus we were unable to discern the reasons youth decided to attend school, or not, during the COVID-19 pandemic.

BackgroundAmong patients diagnosed with COVID-19, a substantial proportion are experiencing ongoing symptoms for months after infection, known as ‘long COVID’. Long COVID is associated with a wide range of physical and neuropsychological symptoms, including impacts on mental health, cognition, and psychological wellbeing. However, intervention research is only beginning to emerge. This systematic review synthesizes currently registered trials examining interventions for mental health, cognition, and psychological wellbeing in patients with long COVID.MethodsStandard systematic review guidelines were followed. Trials registered in two large trial registries in 2020 to May 2022 were reviewed. Included studies were narratively synthesized by type of intervention and a risk-of-bias assessment was conducted.ResultsForty-two registered trials were included, with a total target sample size of 5814 participants. These include 11 psychological interventions, five pharmacological and other medical interventions, and five evaluating herbal, nutritional, or natural supplement interventions. An additional nine trials are examining cognitive and neurorehabilitation interventions and 12 are examining physiotherapy or physical rehabilitation. Most trials are randomized, but many are feasibility trials; trials are evaluating a wide spectrum of outcomes.ConclusionsWhile there is a newly emerging body of research testing interventions for mental health, cognition, and psychological wellbeing in long COVID, the breadth and scope of the research remains limited. It is urgently incumbent on researchers to expand upon the intervention research currently under way, in order to generate high-quality evidence on a wide range of candidate interventions for diverse long COVID patient populations.

Background Youth mental health appears to have been negatively impacted by the COVID-19 pandemic. The impact on substance use is less clear, as is the impact on subgroups of youth, including those with pre-existing mental health or substance use challenges. Objective This hypothesis-generating study examines the longitudinal evolution of youth mental health and substance use from before the COVID-19 pandemic to over one year into the pandemic among youth with pre-existing mental health or substance use challenges. Method A total of 168 youth aged 14–24 participated. Participants provided sociodemographic data, as well as internalizing disorder, externalizing disorder, and substance use data prior to the pandemic’s onset, then every two months between April 2020–2021. Linear mixed models and Generalized Estimating Equations were used to analyze the effect of time on mental health and substance use. Exploratory analyses were conducted to examine interactions with sociodemographic and clinical characteristics. Results There was no change in internalizing or externalizing disorder scores from prior to the pandemic to any point throughout the first year of the pandemic. Substance use scores during the pandemic declined compared to pre-pandemic scores. Exploratory analyses suggest that students appear to have experienced more mental health repercussions than non-students; other sociodemographic and clinical characteristics did not appear to be associated with mental health or substance use trajectories. Conclusions While mental health remained stable and substance use declined from before the COVID-19 pandemic to during the pandemic among youth with pre-existing mental health challenges, some youth experienced greater challenges than others. Longitudinal monitoring among various population subgroups is crucial to identifying higher risk populations. This information is needed to provide empirical evidence to inform future research directions.

Background Engaging youth and family members as active partners in research and service design offers great promise in improving projects. In youth mental health, recent research has highlighted the value of youth and family engagement. However, research on the experience and impacts of engagement is sparse. Objective This study explores the project team's experience of youth and family engagement in the design and development of the YouthCan IMPACT randomized controlled trial and clinical service pathway design. Design Qualitative data collected using semi-structured interviews and a focus group as part of the YouthCan IMPACT clinical trial were analysed to understand the impacts of engagement. Twenty-eight team members were interviewed, including youth and family members. A qualitative content analysis was conducted, with a member checking process. Results Team members reported facilitators, barriers and impacts of youth and family engagement. Facilitators included a safe environment and strong procedures conducive to inclusion in co-design. Barriers included logistical, structural and institutional constraints. Overall, team members found youth and family engagement to be valuable and to positively impact the research and service design process. Discussion and conclusions Youth and family engagement played a critical role in research and clinical service pathway design. The team found that their involvement improved the quality of the research and service pathway through sustained and multifaceted engagement. Facilitators and barriers to engagement may serve to guide future engagement initiatives. Future research should evaluate the long-term impact of early engagement and further focus on family engagement. Patient/public contribution Youth and family members were engaged in the data analysis and interpretation process.

Background During the COVID-19 pandemic, youth mental health and substance use services rapidly moved to virtual modalities to meet social distancing requirements. It is important to understand youth attitudes toward and experience of virtual services. Objective This study examined the attitudes toward and experiences of virtual mental health and substance use services among youth drawn from clinical and non-clinical samples. Method Four hundred nine youth completed a survey including questions about their attitudes toward and experience of virtual services. The survey included quantitative and open-ended questions on virtual care, as well as a mental health and substance use screener. Results The majority of youth with mental health or substance use challenges would be willing to consider individual virtual services, but fewer would consider group virtual services. However, many have not received virtual services. Youth are interested in accessing a wide variety of virtual services and other supportive wellness services. Advantages and disadvantages of virtual services are discussed, including accessibility benefits and technological barriers. Discussion As youth mental health and substance use services have rapidly gone virtual during the COVID-19 pandemic, it is essential that we hear the perspectives of youth to promote service utilization among those in need. Diverse, accessible, technologically stable virtual services are required to meet the needs of different youth, possibly with in-person options for some youth. Future research, engaging youth in the research process, is needed to evaluate the efficacy of virtual services to plan for the sustainability of some virtual service gains beyond the pandemic period.

Background The Family Connections™ (FC) program is a 12‐week support and skill‐training program for caregivers of youth with mental health challenges. The intervention was originally developed with a focus on borderline personality disorder (BPD). It is important to understand the experiences of caregivers in such interventions, as well as its applicability beyond BPD, for the purposes of evaluation and ongoing program improvement. Objective To explore and analyse the experiences of caregivers of youth with diverse mental health challenges and who participated in FC. Design Semi‐structured interviews with thirteen FC‐participating caregivers of youth with mental health challenges. Results Thematic analysis uncovered three major themes regarding caregivers' experience with FC: (a) FC increased the caregivers' ability to manage their youth's mental health challenges; (b) participating in FC impacted their intra‐ and interpersonal spheres; and (c) improvements to the program were proposed. Following participation in FC, caregivers felt they learned a new approach to understanding themselves, their youth and mental health, and were better able to manage their youth's mental health challenges. Discussion and conclusion FC is a promising intervention for caregivers of youth with mental health challenges, beyond the traditional BPD focus. The intervention has the potential to provide broad‐based benefits for caregivers and should be considered for implementation and scale‐up across youth‐ and caregiver‐serving organizations. Potential areas of intervention flexibility and improvement are discussed. Patient/public contribution Caregivers were involved in the program development and facilitation of FC. A person with lived experience was involved with the analysis.

BACKGROUND The Family Connections™ (FC) program is a 12-week support and skill-training program for caregivers of youth with mental health challenges. The intervention was originally developed with a focus on borderline personality disorder (BPD). It is important to understand the experiences of caregivers in such interventions, as well as its applicability beyond BPD, for the purposes of evaluation and ongoing program improvement. OBJECTIVE To explore and analyse the experiences of caregivers of youth with diverse mental health challenges and who participated in FC. DESIGN Semi-structured interviews with thirteen FC-participating caregivers of youth with mental health challenges. RESULTS Thematic analysis uncovered three major themes regarding caregivers' experience with FC: (a) FC increased the caregivers' ability to manage their youth's mental health challenges; (b) participating in FC impacted their intra- and interpersonal spheres; and (c) improvements to the program were proposed. Following participation in FC, caregivers felt they learned a new approach to understanding themselves, their youth and mental health, and were better able to manage their youth's mental health challenges. DISCUSSION AND CONCLUSION FC is a promising intervention for caregivers of youth with mental health challenges, beyond the traditional BPD focus. The intervention has the potential to provide broad-based benefits for caregivers and should be considered for implementation and scale-up across youth- and caregiver-serving organizations. Potential areas of intervention flexibility and improvement are discussed. PATIENT/PUBLIC CONTRIBUTION Caregivers were involved in the program development and facilitation of FC. A person with lived experience was involved with the analysis.

Background Less than 20% of youth who experience mental health difficulties access and receive appropriate treatment. This is exacerbated by barriers such as stigma, confidentiality concerns and lack of mental health literacy. A youth team developed the Wellness Quest: a health literacy tool to enable help-seeking youth to advocate for themselves. Objective To evaluate the content, presentation and utility of the Wellness Quest tool among youth. Participants Participants aged 14 to 26. Methods A youth research team conducted five focus groups and one online survey to evaluate the Wellness Quest tool. Thematic analysis was used to analyse the qualitative data, and descriptive statistics were used to explore the survey results. Main results Overall evaluations of the Wellness Quest were positive: participants felt it would be useful during their mental health help-seeking journey. Participants expressed the need for information about services for specific populations, such as Indigenous, immigrants, refugees and 2SLGBTQ + youth. They expressed that the tool should be available in complementary online and print versions. Discussion Improving mental health literacy may improve mental health by enabling youth and those who support them to recognize and respond to signs of distress and understanding where and how to get help. The Wellness Quest tool may equip youth with the knowledge to make informed decisions and advocate for their own mental health, thereby facilitating help-seeking among youth. Patient or public contribution Youth as service users led all stages of the project, from designing and conducting the study and analysing the data to writing the manuscript.

Aim To examine mental health in conjunction with physical health during the COVID‐19 pandemic among youth with physical health conditions compared to those without. Methods A cross‐sectional survey of 622 youth aged 14 to 28 was conducted. Analyses were conducted to understand the changes in mental and physical health among youth in four groups: (a) participants with a friend or family member diagnosed with COVID‐19, (b) participants with symptoms associated with COVID‐19, (c) participants with atopic conditions (asthma and allergies), and (d) participants with other preexisting physical health conditions. Results Many participants with physical health concerns met screening criteria for an internalizing disorder, which was significantly higher than the rate found among participants without physical health conditions. Significantly greater declines in self‐reported mental health were observed during the COVID‐19 period compared to 3 months earlier among youth reporting physical health concerns compared to those without physical health concerns. Substance use does not appear to have been affected. Conclusions Mental health concerns are highly prevalent among youth with physical health concerns, and also appear to be exacerbated by the COVID‐19 pandemic. Physical health concerns appear to constitute risk factors for heightened mental health responses to the pandemic situation. System planners striving to adapt mental health services to meet social/physical distancing recommendations are urged to consider youth with physical health conditions and ensure that adequate integrated mental health and physical health supports are available to them.

Aim The issue of youth who are not engaged in education, employment or training has been a focus of policymakers for decades. Although interventions exist for these youth, they often measure success in ways that fail to capture what youth seek to gain. The project aims to address this gap by assessing youth-oriented outcomes for interventions targeting upcoming youth. Acknowledging the stigma attached to the deficit-based notion of not engaged in education, employment or training, hereafter we refer to 'upcoming youth', a term coined by youth partners on the project. This study asks what youth want to achieve by participating in an intervention for upcoming youth, with a view to guiding service and research design. Methods A mixed-methods discrete choice experiment will be conducted with youth engaged as partners. A qualitative (focus group) stage will be conducted to design discrete-choice experiment attributes and levels. The experiment will be piloted and administered online to approx. 500 youth (aged 14-29) across Canada to identify the outcomes that youth prioritize for interventions. Latent class analyses will then be conducted to explore clusters of outcomes that different groups of youth prioritize. Conclusions From a strengths-based recovery-oriented framework, hearing the voices of the target population is important in designing and evaluating services. This youth-oriented research project will identify the intervention outcomes that are the highest priority for upcoming youth. Findings will inform the development, implementation and testing of interventions targeting relevant outcomes for youth who are not engaged in education, employment or training.

Background Engaging youth in research provides substantial benefits to research about youth‐related needs, concerns and interventions. However, researchers require training and capacity development to work in this manner. Methods A capacity‐building intervention, INNOVATE Research, was co‐designed with youth and adult researchers and delivered to researchers in three major academic research institutions across Canada. Fifty‐seven attendees participated in this research project evaluating youth engagement practices, attitudes, perceived barriers, and perceived capacity development needs before attending the intervention and six months later. Results The intervention attracted researchers across various career levels, roles and disciplines. Participants were highly satisfied with the workshop activities. Follow‐up assessments revealed significant increases in self‐efficacy six months after the workshop (P = .035). Among possible barriers to youth engagement, four barriers significantly declined at follow‐up. The barriers that decreased were largely related to practical knowledge about how to engage youth in research. Significantly more participants had integrated youth engagement into their teaching activities six months after the workshop compared to those who were doing so before the workshop (P = .007). A large proportion (71.9%) of participants expressed the need for a strengthened network of youth‐engaged researchers; other future capacity‐building approaches were also endorsed. Conclusions The INNOVATE Research project provided improvements in youth engagement attitudes and practices among researchers, while lifting barriers. Future capacity‐building work should continue to enhance the capacity of researchers to engage youth in research. Researchers notably pointed to the need to establish a network of youth‐engaged researchers to provide ongoing, sustainable gains in youth engagement.

Early cannabis use is associated with mental health and substance use (MHSU) challenges into adulthood. Given the vulnerability of youth who use cannabis, it is important to understand their clinical profiles and markers of risk. This cross-sectional descriptive study examines youth who began using cannabis during early adolescence compared to those who initiated at an older age.634 youth and emerging adults (age M = 19.5, SD = 2.3; 46.5% female) were assessed at intake in a Canadian youth mental health and concurrent disorder out-patient service. Measures of demographic characteristics and MHSU were compared for youth who initiated cannabis use under the age of 14 versus 14 years or over.Nearly 30% of youth initiated cannabis use before age 14. Those who initiated cannabis early were younger and had distinct psychosocial risk factors. They were more likely to use cannabis (p = .005), tobacco (p = .006), powder cocaine (p = .030), and/or benzodiazepines (p = .033) at a high frequency. If they used other substances, they were more likely to have begun using them younger (all p .001). Early initiators had more externalizing mental health symptoms (p = .024), crime/violence concerns (p .001), and past trauma (p = .001).Distinct, clinically meaningful differences emerged between youth who initiated cannabis use early versus later. Early cannabis use is associated with multiple, overlapping needs. Cannabis use and concurrent MHSU should be systematically assessed from an early age, and prevention/promotion efforts should take early onset into account.

Background There is increasing emphasis on engaging youth in research about youth, their needs, experiences and preferences, notably in health services research. By engaging youth as full partners, research becomes more feasible and relevant, and the validity and richness of findings are enhanced. Consequently, researchers need guidance in engaging youth effectively. This study examines the experiences, needs and knowledge gaps of researchers. Methods Eighty‐four researchers interested in youth engagement training were recruited via snowball sampling. They completed a survey regarding their youth engagement experiences, attitudes, perceived barriers and capacity development needs. Data were analysed descriptively, and comparisons were made based on current engagement experience. Results Participants across career stages and disciplines expressed an interest in increased capacity development for youth engagement. They had positive attitudes about the importance and value of youth engagement, but found it to be complex. Participants reported requiring practical guidance to develop their youth engagement practices and interest in a network of youth‐engaged researchers and on‐going training. Those currently engaging youth were more likely to report the need for greater appreciation of youth engagement by funders and institutions. Conclusions Engaging youth in research has substantial benefits. However, skills in collaborating with youth to design, conduct and implement research have to be learned. Researchers need concrete training and networking opportunities to develop and maximize these skills. They also need mechanisms that formally acknowledge the value of engagement. Researchers and those promoting youth engagement in research are encouraged to consider these findings in their promotion and training endeavours.

Background While interventions have been developed and tested to help youth who have become disconnected from work and school, there is a paucity of research on young people’s intervention preferences. This study aims to understand young people’s preferred intervention outcomes and approaches for youth who are out of work and school. Methods Thirty youth participated in virtual focus groups. Transcripts were analyzed using thematic analysis. Results Youth want interventions and approaches that support them in (1) vocational readiness, (2) securing a job, and (3) mental health and well-being, while providing them with (4) high-contact, individualized, and integrated support. Conclusions Young people want interventions to be individualized and integrated, providing a high level of support for their educational and employment pursuits as well as their mental health and well-being. Incorporating youth's perspectives when designing interventions can increase intervention relevance and potentially service uptake, helping youth continue to pursue their educational and vocational goals.

Background Problem-solving training is a common ingredient of evidence-based therapies for youth depression and has shown effectiveness as a versatile stand-alone intervention in adults. This scoping review provided a first overview of the evidence supporting problem solving as a mechanism for treating depression in youth aged 14 to 24 years. Methods Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for controlled trials of stand-alone problem-solving therapy; secondary analyses of trial data exploring problem-solving-related concepts as predictors, moderators, or mediators of treatment response within broader therapies; and clinical practice guidelines for youth depression. Following the scoping review, an exploratory meta-analysis examined the overall effectiveness of stand-alone problem-solving therapy. Results Inclusion criteria were met by four randomized trials of problem-solving therapy (524 participants); four secondary analyses of problem-solving-related concepts as predictors, moderators, or mediators; and 23 practice guidelines. The only clinical trial rated as having a low risk of bias found problem-solving training helped youth solve personal problems but was not significantly more effective than the control at reducing emotional symptoms. An exploratory meta-analysis showed a small and non-significant effect on self-reported depression or emotional symptoms (Hedges’ g = − 0.34; 95% CI: − 0.92 to 0.23) with high heterogeneity. Removing one study at high risk of bias led to a decrease in effect size and heterogeneity (g = − 0.08; 95% CI: − 0.26 to 0.10). A GRADE appraisal suggested a low overall quality of the evidence. Tentative evidence from secondary analyses suggested problem-solving training might enhance outcomes in cognitive-behavioural therapy and family therapy, but dedicated dismantling studies are needed to corroborate these findings. Clinical practice guidelines did not recommend problem-solving training as a stand-alone treatment for youth depression, but five mentioned it as a treatment ingredient. Conclusions On its own, problem-solving training may be beneficial for helping youth solve personal challenges, but it may not measurably reduce depressive symptoms. Youth experiencing elevated depressive symptoms may require more comprehensive psychotherapeutic support alongside problem-solving training. High-quality studies are needed to examine the effectiveness of problem-solving training as a stand-alone approach and as a treatment ingredient.

Background Given high rates of mental health and substance challenges among youth and substantial system access barriers, system innovation is required. Integrated youth services (IYS) models aim to transform youth mental health and substance use services by creating integrative, collaborative models of care in youth-friendly settings. This study examines service provider perspectives on the key service components to include in IYS models. Method A discrete choice experiment modeled service provider preferences for the service components of IYSs. The sample includes 388 service provider/agency leader participants (age 18+) from youth-serving organizations in Ontario. Importance scores and utility values were calculated for 12 attributes represented by four levels each. Latent class analysis identified subgroups of participants with different preferences. Results The majority of participants were direct service providers working in larger organizations in the mental health and/or substance use sectors in large urban centers. Participants strongly endorsed service models that provide rapid access to the widest variety of culturally sensitive service options, with supplementary e-health services, in youth-focused community settings with evening and weekend hours. They prefer caregiver involvement in youth services and treatment decisions and support youth and family engagement. Latent class analyses reveal three segments of service providers: a Youth-Focused Service Accessibility segment representing 62.1% (241/388) of participants, a Service Options segment representing 27.6% (107/388) of participants, and a Caregiver Integration segment representing 10.3% (40/388) of participants. Within these segments, the degree of prioritization of the various service components differ; however, the overall endorsement of the service components remains largely consistent across classes for most attributes. The segments did not differ based on demographic or agency characteristics. Conclusions The core characteristics of IYS settings for youth with mental health and substance use challenges, i.e., rapid access to a wide range of youth-oriented services, are strong priorities of service providers and youth-serving agency leaders. These findings confirm that youth-oriented service providers endorse the importance and relevance of IYS models as a whole; strong service provider buy-in to the model is expected to facilitate development, implementation and scaling of IYS models. Hearing stakeholder perspectives, including those of service providers, youth, and caregivers, is essential to developing, effectively implementing, and scaling effective youth services.

BACKGROUND There are growing calls to engage service users in research about issues relevant to them. Youth and family members can make meaningful contributions to research projects, improving quality and relevance. However, more information is needed on the contributions that youth and family members can make to various study designs. OBJECTIVE This paper describes the contributions that youth and family members have made to a multi-site pragmatic randomized-controlled trial, YouthCan IMPACT, and the way project-based engagement learnings accelerated change at the institutional level and beyond. RESULTS Youth and family members were full members of the project team, including the project's core governance and working groups. They contributed to project leadership, as funding co-applicants and as equal members of the governance team. They were also engaged in study design. Youth defined the primary outcome measure and contributed to decisions on all secondary measures. The service pathway was co-designed with youth and family members; for example, they guided the inclusion of peer support and a family member intervention as core service components. Study implementation contributions included ensuring a youth- and family-friendly research process and training research staff on working with youth and family members. Knowledge translation activities have included youth and family members as co-presenters and manuscript co-authors. The learnings from this trial have been leveraged to expand youth and family engagement at the institution and beyond. CONCLUSIONS Youth and family members make substantial contributions to complex research projects, including randomized-controlled trials, thereby improving project design, study implementation, associated interventions, and knowledge translation.

IntroductionFor some people, COVID-19 infection leads to negative health impacts that can last into the medium or long term. The long-term sequelae of COVID-19 infection, or ‘long COVID’, negatively affects not only physical health, but also mental health, cognition or psychological well-being. Complex, integrated interventions are recommended for long COVID, including psychological components; however, the effectiveness of such interventions has yet to be critically evaluated. This protocol describes a systematic review to be conducted of scientific literature reporting on clinical trials of interventions to promote mental health, cognition or psychological well-being among individuals with long COVID.Methods and analysisThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines will be followed. A health sciences librarian will identify the relevant literature through comprehensive systematic searches of Medline, Embase, APA PsycINFO, Cumulative Index to Nursing and Allied Health Literature, medRxiv, PsyArXiv, China National Knowledge Internet and WANFANG Data databases, as well as The Cochrane Central Register of Controlled Trials, clinicaltrials.gov and the WHO International Clinical Trials Registry Platform. Studies will be selected through a title and abstract review, followed by a full-text review using inclusion and exclusion criteria. Data extracted will include intervention descriptions and efficacy metrics. Data will be narratively synthesised; if the data allow, a meta-analysis will be conducted. Risk of bias assessment will be conducted using the Cochrane Risk of Bias 2.0 tool.Ethics and disseminationEthical approval for systematic reviews is not required. As researchers and clinicians respond to the new clinical entity that long COVID represents, this review will synthesise a rapidly emerging evidence base describing and testing interventions to promote mental health, cognition or psychological well-being. Results will therefore be disseminated through an open-access peer-reviewed publication and conference presentations to inform research and clinical practice.Prospero registration numberCRD42022318678

Objective: The coronavirus 2019 (COVID-19) pandemic is raising concerns about mental health across the population Because transgender and gender-diverse youth have particular mental health vulnerabilities, this study examines their mental health challenges during the early stages of the pandemic Method: A cross-sectional survey was conducted in the early COVID-19 pandemic period, which included 29 transgender and gender-diverse youth and 593 cisgender youth Descriptive statistics, Fisher's exact tests, and logistic regression analyses were conducted to understand the differential impact of COVID-19 on mental health and related constructs Results: Results show that transgender and gender diverse youth are more greatly affected by mental health challenges during the COVID-19 pandemic than cisgender youth (p = 001) They report more mental health and substance use service disruptions (p < 001) and less social support from their families (p = 007) compared with cisgender youth A large proportion (63 0%) report unmet needs for mental health and substance use during the early pandemic period, compared with 27 9% of cisgender youth (p = 008) Conclusions: Transgender and gender-diverse youth constitute a vulnerable population during the COVID-19 pandemic and are experiencing substantial mental health impacts, in conjunction with high levels of service disruption and less support from family members Researchers and service planners are encouraged to engage directly with transgender and gender diverse youth to understand how their support needs evolve over the course of the pandemic and how services can be adapted to meet their needs (PsycInfo Database Record (c) 2021 APA, all rights reserved) Impact Statement Because the COVID-19 pandemic is raising concerns about mental health, especially among vulnerable populations, we examined mental health during COVID-19 among youth with cisgender versus transgender and gender-diverse identities Results show that transgender and gender-diverse youth are experiencing substantial negative mental health impacts from the pandemic, more so than cisgender youth They also report more mental health and substance use service disruptions and less social support from their families compared with cisgender youth Researchers and service planners are encouraged to work directly with transgender and gender-diverse youth to understand how services can be adapted to meet their needs (PsycInfo Database Record (c) 2021 APA, all rights reserved)

Background There are increasing calls to make mental health and substance use services youth friendly, with hopes of improving service uptake, engagement and satisfaction. However, youth-friendliness in this area has not been clearly defined and there is a lack of information about the characteristics that make such services youth friendly. The purpose of this scoping review was to examine the literature available on youth-friendly mental health and substance use services in order to identify the characteristics, outline the expected impacts, and establish a definition. Methods A scoping review of seven databases and grey literature sources was conducted. Twenty-eight documents were retained as relevant to the research questions. Relevant data from these documents was extracted, analyzed and presented to stakeholders, including youth, caregivers and service providers to validate and refine the results. Results Youth-friendly mental health and substance use services include integrated, inclusive, confidential and safe organization and policy characteristics; bright, comfortable, environment with informational materials; welcoming and genuine service providers with appropriate communication and counselling skills; an accessible location; minimal wait times; and individualized and innovative approaches. All areas in which youth friendliness should be implemented in a mental health and substance use service organization had a core value of youth voice. Conclusion Improving the youth friendliness of mental health and substance use services includes incorporating youth voice in organization, policy, environment, service providers, and treatment services, and has implications for treatment uptake, engagement and satisfaction. Further research is required to determine the impact of youth friendliness in such services. Electronic supplementary material The online version of this article (10.1186/s12913-019-4066-5) contains supplementary material, which is available to authorized users.

Introduction There is paucity of research on treatment-related coercion in youth: most research focuses on adult populations and legally mandated treatment. This study aims to examine the service-seeking profiles of youth with substance misuse issues who report a legal mandate or perceived coercion to enter treatment. Methods Differences between youth who were legally mandated and not legally mandated, and differences between youth reporting high and low perceived coercion, were examined for demographic characteristics, mental health and substance use profiles, motivation, and readiness to change. Results Compared to participants reporting low perceived coercion, those experiencing high perceived coercion reported more substance use problems, greater mental health needs, and greater external and introjected motivation. Legally mandated youth reported fewer mental health issues, lower identified motivation, and greater readiness to change than those reporting no legal mandate. Discussion Many youth who present for substance use services report experiencing a sense of coercion, which suggests the potential importance of considering youth-centered strategies for involving youth in treatment planning and the development of treatment goals. Youth seeking treatment also have multiple intersecting needs which may benefit from a collaborative and integrative approach.

Background The design and implementation of community-based integrated youth service hubs (IYSHs) is burgeoning around the world. This collaborative model of care aims to address barriers in youth service access by designing services that meet the needs of youth and caregivers. However, heterogeneity across models requires a better understanding of the preferences for key service characteristics. Method A discrete choice experiment was conducted among 274 caregivers of youth aged 14–29 years with mental health challenges. The experiment consisted of 12 attributes with four levels each, representing different service components; additional measures were collected, including demographics and burden assessments. Utility values were calculated, representing the degree of preference for a given level of an attribute. Latent class analysis was conducted to understand subgroups with different service preferences, identifying three latent classes with differing IYSH service preferences. Results The largest class (n = 173, 63.1%), entitled ‘Comprehensive, Integrative Service Access’, strongly valued practical aspects of service design, such as rapid access and support for a wide range of needs. The ‘Service Process Features’ class (n = 67, 24.5%) expressed a relative prioritization of process features of service access, while the smaller ‘Caregiver Involvement’ (n = 34, 12.4%) class most highly prioritized caregiver involvement in their youths’ services. Similar demographic characteristics and caregiver burden were found across classes, although participants in the Caregiver Involvement latent class were supporting younger youth. Discussion and Conclusions Caregivers have diverse youth service preferences and relative priorities that should be taken into account when designing services. System designers and service providers are encouraged to take caregivers’ preferences and priorities into account, alongside youth priorities, whether designing service delivery models or an individual service plan for a youth. Supplementary Information The online version contains supplementary material available at 10.1007/s40271-021-00510-6.

The Canadian youth services system is fragmented with less than one third of youth accessing the mental health services they need. Experts have called for systems transformation that will increase the integration of youth services and take advantage of complementary services, such as peer supports. Further, researchers have suggested that there is a need to identify the unique contribution and underlying mechanisms that support client recovery within youth peer support interventions. This paper describes the steps taken to implement a hybrid realist and participatory evaluation examining peer support services for youth (14–26 years old) with mental health, physical health and/or substance use challenges. We describe the procedures followed to engage peers in the design of the study and how this was integrated with a realist approach. We also provide a detailed description of the related adaptations to the methods applied within the second stage of the study. Lessons learned through the integration of the two methods are provided as well as potential implications for the findings and related research.

Objective To shorten the Patient Engagement In Research Scale (PEIRS) to its most essential items and evaluate its measurement properties for assessing the degree of patients’ and family caregivers’ meaningful engagement as partners in research projects. Methods A prospective cross‐sectional web‐based survey in Canada and the USA, and also paper‐based in Canada. Participants were patients or family caregivers who had engaged in research projects within the last 3 years, were ≥17 years old, and communicated in English. Extensive psychometric analyses were conducted. Results 119 participants: 99 from Canada, 74 female, 51 aged 17‐35 years and 50 aged 36‐65 years, 60 had post‐secondary education, and 74 were Caucasian/white. The original 37‐item PEIRS was shortened to 22 items (PEIRS‐22), mainly because of low inter‐item correlations. PEIRS‐22 had a single dominant construct that accounted for 55% of explained variance. Analysis of PEIRS‐22 scores revealed the following: (1) acceptable floor and ceiling effects (

This study characterizes patterns of mental health, substance use and their co-occurrence, and identifies developmental trajectories associated with progression from single to concurrent mental health and substance use concerns in an Ontario school-based population. It is a longitudinal extension of the Ontario Student Drug Use and Mental Health Survey, as part of the RAFT collaborative project.In this study, an Ontario-wide survey was administered to students across three biennial waves starting in grades 7-8 (ages 12-14). We explored how developmental patterns of externalizing, internalizing and co-occurring symptoms were differentially associated with late-adolescent (ages 17-19) problematic substance use.On average, students exhibited early (ages 12-14) moderate risk of an internalizing and/or externalizing disorder and approached the low threshold for a diagnostic concern for substance use disorder at age 17-19. The pattern confirmed a potential pathway from early mental health concerns to later adolescent problematic substance use, with rates of co-occurrence increasing with age. Youth with early moderate-to high externalizing and co-occurring internalizing and externalizing symptomology had the highest levels of problematic substance use, with scores indicating high likelihood of a substance use disorder diagnosis.Given the overall pattern of progression, early identification and referral of at-risk youth, especially youth with co-occurring mental health concerns, is of critical importance. Findings support the importance of integrated and co-located mental health and substance use services for youth to more effectively serve a diverse population of youth with varying levels of need.La présente étude caractérise les modèles de santé mentale, l’utilisation de substances et leur cooccurrence, et identifie les trajectoires développementales associées à la progression des problèmes isolés à concurrents de santé mentale et d’utilisation de substances dans une population scolaire de l’Ontario. Il s’agit d’une extension longitudinale du Sondage sur la consommation de drogues et la santé des élèves de l’Ontario, dans le cadre d’un projet RAFT de collaboration.Dans la présente étude, un sondage a été administré à l’échelle de l’Ontario à des élèves de trois vagues biennales commençant en 7En moyenne, les élèves montraient un risque modéré précoce (de 12 à 14 ans) d’un trouble d’internalisation et/ou d’externalisation et s’approchaient du seuil bas d’un problème diagnostique d’utilisation de substances entre 17 et 19 ans. Le modèle confirmait une trajectoire potentielle allant de problèmes précoces de santé mentale à l’apparition ultérieure d’une utilisation de substances problématique, avec des taux de cooccurrence augmentant avec l’âge. Les jeunes ayant une externalisation modérée à élevée et une symptomatologie d’internalisation et d’externalisation co-occurrentes avaient les taux les plus élevés d’utilisation de substances problématique, leurs scores indiquant une probabilité élevée d’un diagnostic de trouble d’utilisation de substances.Étant donné le modèle de progression général, l’identification précoce et l’aiguillage d’un jeune à risque, surtout les jeunes présentant des problèmes de santé mentale co-occurrents, sont d’une importance vitale. Les résultats appuient l’importance des services intégrés et en colocation de santé mentale et d’utilisation de substances pour les jeunes afin de servir plus efficacement une population de jeunes diversifiée dont les besoins sont de niveaux variés.

Child fireplay may be regarded as developmentally appropriate, yet can negatively impact those who engage in it and those around them. This study discusses the mental health, fire-specific, and psychosocial risk factors of children who set fires. Fifty-seven caregivers reported on their children’s demographics, firesetting behaviors, mental health symptoms, and family history. Children were aged 2–6 years and the majority were male. Most children used lighters and matches on paper and small objects. The majority of the children were motivated by curiosity. Children who set more fires had more externalizing symptoms, and were more likely to have accomplices, to have been exposed to firesetting media, and to have been disciplined or punished for their firesetting behaviors. The study identifies important psychosocial risk factors among young children who set fires. Given the long-term implications of firesetting, understanding firesetting in children will set the foundation of intervention and prevention models.

Background Cannabis is a highly used substance among youth, but has the potential to negatively impact the developing brain. Recreational cannabis use was legalized in Canada in October 2018. This exploratory study examines cannabis use profiles of high-risk youth before and after the national legalization of recreational cannabis use. Method This cross-sectional cohort study examines the cannabis use profiles of two cohorts of youth, one recruited prior to legalization (N = 101) and one recruited after legalization (N = 168). Results This study found few changes in cannabis use patterns after legalization. The rate of high-frequency cannabis use, polysubstance use, social circles of use, and mental health and substance use challenges showed no change, and the study found no associations with age. Exceptions were that youth were more likely to report purchasing cannabis from a legal source after legalization. Concealment of cannabis use from legal authorities declined after legalization among youth over the age of majority (19+ years), but not among younger youth ( Conclusions Minimal changes have occurred in the cannabis use patterns of service-seeking youth in the short term following legalization. This holds true both for youth who have reached the age of majority and those who have not. Nevertheless, this population has overlapping substantial mental health and substance use challenges. Integrated services should address cannabis use and other concurrent challenges and be sensitive to the postlegalization social climate.

Objective: The goal of this study was to validate the French version of the Quality of Life in Bipolar Disorder (QoL.BD) scale, a condition-specific measure for bipolar disorder (BD). Method: The QoL.BD scale was translated into French in accordance with the recommendations for transcultural adaptation. It was administered to 125 participants with BD living in Quebec, Canada. Construct validity was evaluated through correlations with other measures of self-reported quality of life (QoL), functioning, and symptoms. Factorial structure was examined through an exploratory factor analysis. Results: Internal reliability and test–retest reliability standards were met. Correlations in expected directions with other QoL, functioning, and depressive symptom scales supported convergent validity. The item loadings structure of the French QoL.BD largely replicated the original English version, with some modifications. Conclusion: The French version of the QoL.BD (full and brief) is comparable in its psychometric properties to the English version. It is a valid and sound measure for the evaluation of the QoL of French-speaking patients with BD.

Background: Schema theory, developed for chronic, treatment-resistant patients, has been largely applied to personality disorders. However, many patients with other psychiatric disorders, including mood and anxiety disorders, also demonstrate elevated early maladaptive schemas mas (EMSs). Based on schema theory and clinical observations, individuals with greater case complexity would be expected to demonstrate higher EMS activation. Aim: This study examines EMSs as a function of case complexity in individuals with mood and anxiety disorders. Method: 69 patients consulting for mood or anxiety disorders completed the YSQ-S3 and a thorough intake assessment. The relationship between EMSs and case complexity is explored.Results: Although some EMSs are more strongly activated as a function of comorbidities and degree of functional impairment, the greatest difference is a function of multiaxial case complexity. Conclusion: Complex clinical presentations are associated with EMS activation. Case complexity should be considered when applying schema theory to mood and anxiety disorders. Schema therapy may be a useful treatment alternative particularly for the more complex plex cases.Keywords: early maladaptive schemas; cognitive schemas; mood disorders; anxiety disorders; comorbiditySchema theory is an integrative theory developed to explain treatment-resistant psychological problems with a characterological underpinning (Young, 1990; Young, Klosko, & Weishaar, 2003). Consistent with Beckian cognitive theory, schema theory proposes that early experiences shape individuals' beliefs about themselves, the world and others, and that their impacts go on to influence behavior in adulthood. However, schema theory adds a broader conception of the developmental origins of the biases seen among people with severe psychopathology. It also expands the notion of schemas.At the heart of schema theory are "early maladaptive schemas" (EMSs), considered stable character traits that develop in reaction to toxic childhood experiences. The EMSs extend beyond cognition to incorporate emotions, memories, and bodily sensations. Young et al. (2003) have identified 18 different EMSs to date, each with its own proposed origin and long-term impact. The 18 EMSs are described in Table 1. A broad range of studies have demonstrated that EMSs are highly activated in a wide range of clinical populations (e.g., Halvorsen et al., 2009; Hawke & Provencher, 2012b; Renner, Lobbestael, Peeters, Arntz, & Huibers, 2012). Multiple studies have also confirmed that EMSs mediate the relationship between parenting style and the symptoms of depression and anxiety in adulthood, supporting the developmental aspect of the theory (e.g., Harris & Curtin, 2002; McGinn, Cukor, & Sanderson, 2005; Wright, Crawford, & Del Castillo, 2009).Schema theory has been widely associated with personality disorders, whereas EMSs have been clearly demonstrated to be elevated in this category of disorders (e.g., Jovev & Jackson, 2004). However, the theory also extends to mood and anxiety disorders (Hawke & Provencher, 2011). In fact, Young et al. (2003) propose that EMSs underlie chronic symptoms of depression and anxiety. Lending support to this notion, various studies have found that heightened EMS activation is associated with the general symptoms of depression and anxiety, as well as fully diagnosable depressive and anxiety disorders (Hawke & Provencher, 2011). Yet, schema activation is not limited to purely psychiatric disorders. Higher EMS scores have also been found among respondents who have physical health problems with a psychological component, such as chronic pain and obesity (Anderson, Rieger, & Caterson,2006; Saariaho, Saariaho, Karila, & Joukamaa, 2009). Furthermore, one preliminary investigation suggested an association between EMSs and global functional level (Hawke & Provencher, 2010).Given that schema theory was developed specifically for patients who are resistant to traditional cognitive behavioral therapy and who have considerable characterological issues underlying their diagnosed disorder, it would appear likely that EMSs would apply more strongly to complex, comorbid cases. …