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INTRODUCTION: New Zealand (NZ) has a persistently high rate of suicide, particularly among young people. Hospital presentation for self-harm (SH) is one of the strongest predictors of death by suicide. Improving the monitoring of SH and suicide is a key recommendation for suicide prevention by WHO. This study will establish the first ever sentinel surveillance for SH at several large hospitals and a monthly survey of all practicing paediatricians in NZ. The study will provide robust information about the epidemiology of SH, factors associated with SH and the types of interventions required for those presenting to hospital with SH. METHOD AND ANALYSIS: This observational study will establish SH surveillance in the emergency departments of three public hospitals for the first time in NZ, where study population will include individuals of all ages who present with SH or suicidal ideation. The study methodology is in line with the WHO Best Practice guidelines and international collaborators in Australia and Europe. Electronic triage records will be reviewed manually by the research team to identify potential cases that meet inclusion criteria. For all eligible cases, variables of interest will be extracted from routine clinical records by the research team and recorded on a secure web-based survey application. Additionally, SH surveillance data for the national paediatric population (<15 years) will be obtained via the New Zealand Paediatric Surveillance Unit (NZPSU); paediatricians will report on included cases using the same variables using a secure survey application. A deidentified dataset will be produced for aggregated statistical analysis. ETHICS AND DISSEMINATION: The University of Otago Health Ethics Committee granted ethical approval for this study in addition to local ethics approval at participating hospital sites. The study findings will be disseminated to relevant stakeholders in NZ, in addition to international audiences through publications in peer-revie

BACKGROUND: The internet and social media are increasingly popular sources of health information for adolescents. Using online health information requires digital health literacy, consisting of literacy, analytical skills and personal capabilities such as self-efficacy. Appraising trustworthiness and relevance of online health information requires critical health literacy to discriminate between sources, critically analyse meaning and relevance, and use information for personal health. Adolescents with poor digital health literacy risk using misinformation, with potential negative health outcomes. We aimed to understand adolescents' contemporary digital health literacy and compared self-efficacy with capability. METHODS: Adolescents (12-17 years) completed an eHEALS self-report digital health literacy measure, a practical search task using a think-aloud protocol and an interview to capture perceived and actual digital health literacy. eHEALS scores were generated using descriptive statistics, search tasks were analysed using an observation checklist and interviews were thematically analysed based on Social Cognitive Theory, focussing on self-efficacy. RESULTS: Twenty-one participants generally had high self-efficacy using online health information but perceived their digital health literacy to be higher than demonstrated. They accessed online health information unintentionally on social media and intentionally via search engines. They appraised information medium, source and content using general internet searching heuristics taught at school. Information on social media was considered less trustworthy than websites, but participants used similar appraisal strategies for both; some search/appraisal heuristics were insufficiently nuanced for digital health information, sometimes resulting in misplaced trust or diminished self-efficacy. Participants felt anxious or relieved after finding online health information, depending on content, understanding and satisfaction.

BACKGROUND: Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment. METHODS: Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment. RESULTS: The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors w

Problem: The mistreatment of medical and nursing students and junior health professionals has been reported internationally in research and the media. Mistreatment can be embedded and normalized in hierarchical healthcare workplaces, limiting the effectiveness of policies and reporting tools to generate change; as a result, some of those who experience mistreatment later perpetuate it. We used a novel, creative approach, verbatim theater, to highlight the complexity of healthcare workplaces, encourage critical reflection, and support long-term culture change. Intervention: Verbatim theater is a theater-for-change documentary genre in which a playscript is devised using only the words spoken by informants. In 2017, 30 healthcare students and health professionals were recruited and interviewed about their experience of work and training by the multidisciplinary Sydney Arts and Health Collective using semi-structured interviews. Interview transcripts became the primary material from which the script for the verbatim theater play 'Grace Under Pressure' was developed. The performing arts have previously been used to develop the communication skills of health professional students; this esthetic expression of the real-life effects of healthcare workplace culture on trainees and students was implemented to stimulate consciousness of, and dialogue about, workplace mistreatment in healthcare work and training. Context: The play premiered at a major Sydney theater in October 2017, attended by the lay public and student and practicing health professionals. In November 2017, three focus groups were held with a sample of audience members comprising healthcare professionals and students. These focus groups explored the impact of the play on reflection and discussion of healthcare culture and/or promoting culture change in the health workplace. We analyzed the focus group data using theoretical thematic analysis, informed by Turner's theory of the relation between 'social' and 'es

BACKGROUND: Specific phobia (SP) is a relatively common disorder associated with high levels of psychiatric comorbidity. Because of its early onset, SP may be a useful early marker of internalizing psychopathology, especially if generalized to multiple situations. This study aimed to evaluate the association of childhood generalized SP with comorbid internalizing disorders. METHODS: We conducted retrospective analyses of the cross-sectional population-based World Mental Health Surveys using the Composite International Diagnostic Interview. Outcomes were lifetime prevalence, age of onset, and persistence of internalizing disorders; past-month disability; lifetime suicidality; and 12-month serious mental illness. Logistic and linear regressions were used to assess the association of these outcomes with the number of subtypes of childhood-onset (< 13 years) SP. RESULTS: Among 123,628 respondents from 25 countries, retrospectively reported prevalence of childhood SP was 5.9%, 56% of whom reported one, 25% two, 10% three, and 8% four or more subtypes. Lifetime prevalence of internalizing disorders increased from 18.2% among those without childhood SP to 46.3% among those with one and 75.6% those with 4+ subtypes (OR = 2.4, 95% CI 2.3-2.5, p < 0.001). Twelve-month persistence of lifetime internalizing comorbidity at interview increased from 47.9% among those without childhood SP to 59.0% and 79.1% among those with 1 and 4+ subtypes (OR = 1.4, 95% CI 1.4-1.5, p < 0.001). Respondents with 4+ subtypes also reported significantly more disability (3.5 days out of role in the past month) than those without childhood SP (1.1 days) or with only 1 subtype (1.8 days) (B = 0.56, SE 0.06, p < 0.001) and a much higher rate of lifetime suicide attempts (16.8%) than those without childhood SP (2.0%) or with only 1 subtype (6.5%) (OR = 1.7, 95% CI 1.7-1.8, p < 0.001). CONCLUSIONS: This large international study shows that childhood-onset generalized SP is related to adverse outcomes in t

AIM: The continuing existence of 'teaching by humiliation' of medical students and junior doctors in Australia has recently been highlighted in a number of research publications and media reports. This study investigates medical students' experiences of being intimidated or humiliated during their clinical rotations in Australian hospitals in paediatrics and adult medicine. METHODS: From factors identified in earlier research, a two-page survey was developed for administration at two Australian medical schools. Administered in Semester 2 of 2014, students were invited to add their own free-text comments at the conclusion of 17 closed questions. Using thematic analysis of the qualitative data, the researchers identified the common themes in the students' free-text comments, which are reported in this paper. RESULTS: We found five main themes in the qualitative data: a spectrum of interpretations of and responses to 'teaching by humiliation', an accepted means of enculturating the young, teachers' techniques for asking questions, the victims and perpetrators of mistreatment and the variance of prevalence in different contexts. CONCLUSION: Research shows the persistence of 'teaching by humiliation', even in paediatrics, particularly when doctors are questioning students in ways that shame them for their lack of knowledge. Given the many personal and professional costs of these practices, this cycle of mistreatment needs to be brought to an end. There is a need for students' reports of intimidation and humiliation to be acknowledged; the offending practices need to be interrupted, and more effective and respectful approaches to teaching need to be adopted.

BACKGROUND AND AIMS: Prior research has found bidirectional associations between psychotic experiences (PEs) and selected substance use disorders. We aimed to extend this research by examining the bidirectional association between PEs and various types of substance use (SU) and substance use disorders (SUDs), and the influence of antecedent mental disorders on these associations. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: We used data from the World Health Organization World Mental Health surveys. A total of 30 902 adult respondents across 18 countries were assessed for (a) six types of life-time PEs, (b) a range of types of SU and DSM-IV SUDs and (c) mental disorders using the Composite International Diagnostic Interview. Discrete-time survival analyses based on retrospective age-at-onset reports examined the bidirectional associations between PEs and SU/SUDs controlling for antecedent mental disorders. FINDINGS: After adjusting for demographics, comorbid SU/SUDs and antecedent mental disorders, those with prior alcohol use disorders [odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.2-2.0], extra-medical prescription drug use (OR = 1.5, 95% CI = 1.1-1.9), alcohol use (OR = 1.4, 95% CI = 1.1-1.7) and tobacco use (OR = 1.3, 95% CI = 1.0-1.8) had increased odds of subsequent first onset of PEs. In contrast, those with temporally prior PEs had increased odds of subsequent onset of tobacco use (OR = 1.5, 95% CI = 1.2-1.9), alcohol use (OR = 1.3, 95% CI = 1.1-1.6) or cannabis use (OR = 1.3, 95% CI = 1.0-1.5) as well as of all substance use disorders (ORs ranged between 1.4 and 1.5). There was a dose response relationship between both count and frequency of PEs and increased subsequent odds of selected SU/SUDs. CONCLUSIONS: Associations between psychotic experiences (PEs) and substance use/substance use disorders (SU/SUDs) are often bidirectional, but not all types of SU/SUDs are associated with PEs. These findings suggest that it is important to be aware of t

© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Background: Although post-traumatic stress disorder (PTSD) onset-persistence is thought to vary significantly by trauma type, most epidemiological surveys are incapable of assessing this because they evaluate lifetime PTSD only for traumas nominated by respondents as their ‘worst.’ Objective: To review research on associations of trauma type with PTSD in the WHO World Mental Health (WMH) surveys, a series of epidemiological surveys that obtained representative data on trauma-specific PTSD. Method: WMH Surveys in 24 countries (n = 68,894) assessed 29 lifetime traumas and evaluated PTSD twice for each respondent: once for the ‘worst’ lifetime trauma and separately for a randomly-selected trauma with weighting to adjust for individual differences in trauma exposures. PTSD onset-persistence was evaluated with the WHO Composite International Diagnostic Interview. Results: In total, 70.4% of respondents experienced lifetime traumas, with exposure averaging 3.2 traumas per capita. Substantial between-trauma differences were found in PTSD onset but less in persistence. Traumas involving interpersonal violence had highest risk. Burden of PTSD, determined by multiplying trauma prevalence by trauma-specific PTSD risk and persistence, was 77.7 person-years/100 respondents. The trauma types with highest proportions of this burden were rape (13.1%), other sexual assault (15.1%), being stalked (9.8%), and unexpected death of a loved one (11.6%). The first three of these four represent relatively uncommon traumas with high PTSD risk and the last a very common trauma with low PTSD risk. The broad category of intimate partner sexual violence accounted for nearly 42.7% of all person-years with PTSD. Prior trauma history predicted both future trauma exposure and future PTSD risk. Conclusions: Trauma exposure is common throughout the world, unequally distributed, and differential across trauma type

IMPORTANCE: Previous research has documented significant variation in the prevalence of posttraumatic stress disorder (PTSD) depending on the type of traumatic experience (TE) and history of TE exposure, but the relatively small sample sizes in these studies resulted in a number of unresolved basic questions. OBJECTIVE: To examine disaggregated associations of type of TE history with PTSD in a large cross-national community epidemiologic data set. DESIGN, SETTING, AND PARTICIPANTS: The World Health Organization World Mental Health surveys assessed 29 TE types (lifetime exposure, age at first exposure) with DSM-IV PTSD that was associated with 1 randomly selected TE exposure (the random TE) for each respondent. Surveys were administered in 20 countries (n = 34 676 respondents) from 2001 to 2012. Data were analyzed from October 1, 2015, to September 1, 2016. MAIN OUTCOMES AND MEASURES: Prevalence of PTSD assessed with the Composite International Diagnostic Interview. RESULTS: Among the 34 676 respondents (55.4% [SE, 0.6%] men and 44.6% [SE, 0.6%] women; mean [SE] age, 43.7 [0.2] years), lifetime TE exposure was reported by a weighted 70.3% of respondents (mean [SE] number of exposures, 4.5 [0.04] among respondents with any TE). Weighted (by TE frequency) prevalence of PTSD associated with random TEs was 4.0%. Odds ratios (ORs) of PTSD were elevated for TEs involving sexual violence (2.7; 95% CI, 2.0-3.8) and witnessing atrocities (4.2; 95% CI, 1.0-17.8). Prior exposure to some, but not all, same-type TEs was associated with increased vulnerability (eg, physical assault; OR, 3.2; 95% CI, 1.3-7.9) or resilience (eg, participation in sectarian violence; OR, 0.3; 95% CI, 0.1-0.9) to PTSD after the random TE. The finding of earlier studies that more general history of TE exposure was associated with increased vulnerability to PTSD across the full range of random TE types was replicated, but this generalized vulnerability was limited to prior TEs involving violence, includi

A positive and respectful learning environment is fundamental to the development of professional identities in healthcare. Yet medical students report poor behaviour from healthcare professionals that contradict professionalism teaching. An interdisciplinary group designed and implemented a drama-based workshop series, based on applied theatre techniques, to help students develop positive professional qualities and interpersonal skills to deal with challenges in the healthcare setting. We piloted the workshops at the University of Sydney in 2015. Attendees completed evaluation questionnaires and participated in a focus group or interview. Of 30 workshop attendances, there were 29 completed questionnaires and three participants attended a focus group or interview. Workshop activities were rated as 'very good' or 'good' by 21/22 (95.5%). Thematic analysis of qualitative data highlighted the rationale for participation (to deal with bullying, prevent becoming a bully, learn social skills), workshop benefits (express emotions, learn about status dynamics and deconstructing personalities, empathy, fun), challenges (meeting participants' expectations, participants' need for further practice) and implications for medical education (need to develop awareness of others' perspectives). Our research has shown that there is momentum to challenge mistreatment in medical education. While a multipronged approach is needed to generate systemic change, this pilot offers a positive and creative innovation. It helps students improve their interpersonal skills and sense of self to deal with challenges in the healthcare setting, including mistreatment.

Understanding how students and educators use social media, and their perceptions of its benefits, may lead toopportunities for successful integration of social media to benefit all those involved in medical education. Weaimed to explore and describe how medical students use social media in countries across the world, including theextent to which they consume and contribute. 741 students from 8 institutions in 5 countries answered a 16-itemquestionnaire. The majority of students were using some form of social media, with the most popular applicationbeing Facebook. Social communication and entertainment were the most cited reasons for using social media.Students reported valuing social media for educational reasons and, in particular, information and resourcesharing between peers. Institution-student interactions were not common amongst medical students and whilstsome students reported wanting more of this, others reported that they did not. The paucity of student-institutioninteractions on social media did not vary across institutions. Although some students could see benefits toincreasing use of social media by medical schools, others had concerns about this. Of particular concern wereconfidentiality and professionalism online and the perception that the medical schools might not do it well.Medical schools should have a clear rationale for engaging further in social media, mindful of what students wantand of the need for the engagement to be conducted professionally.

© 2016 Chunfeng Liu et al. Background: Doctors' verbal and non-verbal communication skills have an impact on patients' health outcomes, so it is important for medical students to develop these skills. Traditional, non-verbal communication skills training can involve a tutor manually annotating a student's non-verbal behaviour during patient- doctor consultations, but this is very time-consuming. Tele-conference systems have been used in verbal communication skills training. Methods: We describe EQClinic, a system that enables verbal and non-verbal communication skills training during tele-consultations with simulated patients (SPs), with evaluation exercises promoting reflection. Students and SPs can have tele-consultations through the tele-consultation component. In this component, SPs can provide feedback to students through a thumbs-up/ thumbs-down tool and a comments box. EQClinic automatically analyses communication features in the recorded consultations, such as facial expressions, and provides graphical representations. Our 2015 pilot study investigatedwhether EQClinic helped students be aware of their non-verbal behaviour and improve their communication skills, and evaluated the usability of the platform. Students received automated feedback, and SP and tutor evaluations, and then completed selfassessment and reflection questionnaires. Results: Eight medical students and three SPs conducted 13 tele-consultations using EQClinic. More students paid attention to their non-verbal communication and students who were engaged in two consultations felt more confident in their second consultation. Students rated the system positively, felt comfortable using it (5.9/7), and reported that the structure (5.4/7) and information (5.8/7) were clear. This pilot provides evidence that EQClinic helps, and positively influences, medical students practise their communication skills with SPs using a tele-conference platform. Discussion: It is not easy to improve non-verbal commu

CONTEXT: The scarcity of cross-national reports and the changes in Diagnostic and Statistical Manual version 5 (DSM-5) regarding panic disorder (PD) and panic attacks (PAs) call for new epidemiological data on PD and PAs and its subtypes in the general population. OBJECTIVE: To present representative data about the cross-national epidemiology of PD and PAs in accordance with DSM-5 definitions. DESIGN AND SETTING: Nationally representative cross-sectional surveys using the World Health Organization Composite International Diagnostic Interview version 3.0. PARTICIPANTS: Respondents (n = 142,949) from 25 high, middle, and lower-middle income countries across the world aged 18 years or older. MAIN OUTCOME MEASURES: PD and presence of single and recurrent PAs. RESULTS: Lifetime prevalence of PAs was 13.2% (SE 0.1%). Among persons that ever had a PA, the majority had recurrent PAs (66.5%; SE 0.5%), while only 12.8% fulfilled DSM-5 criteria for PD. Recurrent PAs were associated with a subsequent onset of a variety of mental disorders (OR 2.0; 95% CI 1.8-2.2) and their course (OR 1.3; 95% CI 1.2-2.4) whereas single PAs were not (OR 1.1; 95% CI 0.9-1.3 and OR 0.7; 95% CI 0.6-0.8). Cross-national lifetime prevalence estimates were 1.7% (SE 0.0%) for PD with a median age of onset of 32 (IQR 20-47). Some 80.4% of persons with lifetime PD had a lifetime comorbid mental disorder. CONCLUSIONS: We extended previous epidemiological data to a cross-national context. The presence of recurrent PAs in particular is associated with subsequent onset and course of mental disorders beyond agoraphobia and PD, and might serve as a generic risk marker for psychopathology.

Although only a few people exposed to a traumatic event (TE) develop posttraumatic stress disorder (PTSD), symptoms that do not meet full PTSD criteria are common and often clinically significant. Individuals with these symptoms sometimes have been characterized as having subthreshold PTSD, but no consensus exists on the optimal definition of this term. Data from a large cross-national epidemiologic survey are used in this study to provide a principled basis for such a definition.

No studies have evaluated whether the frequently observed associations between depression and diabetes could reflect the presence of comorbid psychiatric conditions and their associations with diabetes. We therefore examined the associations between a wide range of pre-existing Diagnostic Statistical Manual, 4th edition (DSM-IV) mental disorders with self-reported diagnosis of diabetes.

The associations between mental disorders and cancer remain unclear. It is also unknown whether any associations vary according to life stage or gender. This paper examines these research questions using data from the World Mental Health Survey Initiative.

BACKGROUND: Population-based studies provide the understanding of health-need required for effective public health policy and service-planning. Mental disorders are an important but, until recently, neglected agenda in global health. This paper reviews the coverage and limitations in global epidemiological data for mental disorders and suggests strategies to strengthen the data. METHODS: Systematic reviews were conducted for population-based epidemiological studies in mental disorders to inform new estimates for the global burden of disease study. Estimates of population coverage were calculated, adjusted for study parameters (age, gender and sampling frames) to quantify regional coverage. RESULTS: Of the 77,000 data sources identified, fewer than 1% could be used for deriving national estimates of prevalence, incidence, remission, and mortality in mental disorders. The two major limitations were (1) highly variable regional coverage, and (2) important methodological issues that prevented synthesis across studies, including the use of varying case definitions, the selection of samples not allowing generalization, lack of standardized indicators, and incomplete reporting. North America and Australasia had the most complete prevalence data for mental disorders while coverage was highly variable across Europe, Latin America, and Asia Pacific, and poor in other regions of Asia and Africa. Nationally-representative data for incidence, remission, and mortality were sparse across most of the world. DISCUSSION: Recent calls to action for global mental health were predicated on the high prevalence and disability of mental disorders. However, the global picture of disorders is inadequate for planning. Global data coverage is not commensurate with other important health problems, and for most of the world's population, mental disorders are invisible and remain a low priority.