Understanding mental health treatment effectiveness in young people

Mental disorders are one of the leading causes of non-communicable disease burden worldwide, with distress emerging as a common factor among such disorders. Most lifetime mental disorders emerge during adolescence and young adulthood, yet no studies have robustly assessed changes in common distress over time during this broad developmental epoch. Common distress is particularly pertinent when assessing mental health treatment effectiveness, as comorbidity rates are higher amongst those who seek treatment. In this dissertation, I seek to redress the paucity of evidence regarding mental health treatment effectiveness in young people. Herein I longitudinally validate a common distress factor, enabling me to use specific and broad mental health outcomes to assess the effectiveness of treatment-as-usual mental health services in two separate samples. In chapter 2, I use a community sample of adolescents to test the relationship of age 14 service contact on depressive symptoms by age 17. I found that 14-year-old adolescents who had contact with mental health services in the past year had a greater decrease in depressive symptoms than those without contact. By age 17 years, the odds of reporting clinical depression were higher in individuals without contact than in service users who had been similarly depressed at baseline. In addition to propensity score weighting to adjust for participants’ initial likelihood to access services, I used a clinically relevant cutoff and adjusted for a wide range of time-varying confounding variables. These adjustments give greater confidence than previous studies to the notion that mental health service contact is related to meaningful improvements in subsequent mental health. Policy implications of these findings are addressed. In chapter 3, I develop a transdiagnostic measure of mental health to be used to assess treatment effectiveness with relevancy across multiple disorders. This transdiagnostic measure is the general factor (common distress or p) from a bifactor model of 118 self-report items from previously validated measures of depression, anxiety, behavioural problems, obsessions, psychotic symptoms, wellbeing, and self-esteem. Longitudinal and gender measurement invariance and reliability of this model was demonstrated in a sample of 14- to 24-year olds assessed annually three times. Predictive validity of the general and specific factors was demonstrated using an extensive set of external variables covering factors such as social environment, personality, and risk behaviour. Accelerated growth modelling revealed developmental changes in the factors from ages 14-27 largely consistent with epidemiological patterns of the associated disorders. I use this validated distress factor in chapter 4 to further test the effectiveness of mental health treatment-as-usual, in a broader age range with a broader outcome than the adolescent sample. Family functioning and friendship support were also explored as potential mechanisms of action. Treatment was related to decreased distress over two years, in unadjusted and adjusted models. In order to propensity weight, I focused analyses on those above the population mean in baseline distress, which contained 85% of young people reporting treatment for a mental disorder. Such individuals were more likely to have required treatment, so treated and untreated groups are more meaningful and comparable. In propensity score weighted models, treatment was related to decreased subsequent distress. Treatment was also related to improved family functioning over two years, but only in adolescents aged 14-18, more likely to be living with their family. In this younger group, the best fitting model revealed distress as a significant mediator: the majority of improvements in family functioning occurred through improvements in distress. However, treatment was not related to a change in friendship support over time. Thus, not only is mental health treatment-as-usual related to a significant decline in young people’s distress, but also improvements in adolescent family functioning. Finally, in chapter 5 I discuss the broader implications of the findings. Analyses in two separate community samples of young people strongly support the notion that treatment-as-usual is related to improvements in both specific and broad measures of mental health. Such treatment-related improvements in mental health appear to also yield benefits in family functioning in adolescents. Findings as a whole argue for increased access to mental health services

Understanding mental health treatment effectiveness in young people

Mental disorders are one of the leading causes of non-communicable disease burden worldwide, with distress emerging as a common factor among such disorders. Most lifetime mental disorders emerge during adolescence and young adulthood, yet no studies have robustly assessed changes in common distress over time during this broad developmental epoch. Common distress is particularly pertinent when assessing mental health treatment effectiveness, as comorbidity rates are higher amongst those who seek treatment. In this dissertation, I seek to redress the paucity of evidence regarding mental health treatment effectiveness in young people. Herein I longitudinally validate a common distress factor, enabling me to use specific and broad mental health outcomes to assess the effectiveness of treatment-as-usual mental health services in two separate samples. In chapter 2, I use a community sample of adolescents to test the relationship of age 14 service contact on depressive symptoms by age 17. I found that 14-year-old adolescents who had contact with mental health services in the past year had a greater decrease in depressive symptoms than those without contact. By age 17 years, the odds of reporting clinical depression were higher in individuals without contact than in service users who had been similarly depressed at baseline. In addition to propensity score weighting to adjust for participants’ initial likelihood to access services, I used a clinically relevant cutoff and adjusted for a wide range of time-varying confounding variables. These adjustments give greater confidence than previous studies to the notion that mental health service contact is related to meaningful improvements in subsequent mental health. Policy implications of these findings are addressed. In chapter 3, I develop a transdiagnostic measure of mental health to be used to assess treatment effectiveness with relevancy across multiple disorders. This transdiagnostic measure is the general factor (common distress or p) from a bifactor model of 118 self-report items from previously validated measures of depression, anxiety, behavioural problems, obsessions, psychotic symptoms, wellbeing, and self-esteem. Longitudinal and gender measurement invariance and reliability of this model was demonstrated in a sample of 14- to 24-year olds assessed annually three times. Predictive validity of the general and specific factors was demonstrated using an extensive set of external variables covering factors such as social environment, personality, and risk behaviour. Accelerated growth modelling revealed developmental changes in the factors from ages 14-27 largely consistent with epidemiological patterns of the associated disorders. I use this validated distress factor in chapter 4 to further test the effectiveness of mental health treatment-as-usual, in a broader age range with a broader outcome than the adolescent sample. Family functioning and friendship support were also explored as potential mechanisms of action. Treatment was related to decreased distress over two years, in unadjusted and adjusted models. In order to propensity weight, I focused analyses on those above the population mean in baseline distress, which contained 85% of young people reporting treatment for a mental disorder. Such individuals were more likely to have required treatment, so treated and untreated groups are more meaningful and comparable. In propensity score weighted models, treatment was related to decreased subsequent distress. Treatment was also related to improved family functioning over two years, but only in adolescents aged 14-18, more likely to be living with their family. In this younger group, the best fitting model revealed distress as a significant mediator: the majority of improvements in family functioning occurred through improvements in distress. However, treatment was not related to a change in friendship support over time. Thus, not only is mental health treatment-as-usual related to a significant decline in young people’s distress, but also improvements in adolescent family functioning. Finally, in chapter 5 I discuss the broader implications of the findings. Analyses in two separate community samples of young people strongly support the notion that treatment-as-usual is related to improvements in both specific and broad measures of mental health. Such treatment-related improvements in mental health appear to also yield benefits in family functioning in adolescents. Findings as a whole argue for increased access to mental health services.Funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research & Care for East of England

Research data supporting RESIST publication "The Youth and Childhood Adversity Scale: A step towards developing a new measure of adversity and its severity"

A detailed description of the data can be found in the belonging data description, with the name "RESIST_Handbook_13102021"

Reduction in adolescent depression after contact with mental health services: a longitudinal cohort study in the UK

Background: Evidence regarding the association between service contact and subsequent mental health in adolescents is scarce, and previous findings are mixed. We aimed to longitudinally assess the extent to which depressive symptoms in adolescents change after contact with mental health services. Methods: As part of a longitudinal cohort study, between April 28, 2005, and March 17, 2010, we recruited 1238 14-year-old adolescents and their primary caregivers from 18 secondary schools in Cambridgeshire, UK. Participants underwent follow-up assessment at months 18 and 36. Trained researchers assessed the adolescents for current mental disorder using the Schedule for Affective Disorders and Schizophrenia for School-Age Children Present and Lifetime version (K-SADS-PL). Caregivers and adolescents reported contact with mental health services in the year before baseline. Adolescents self-reported depressive symptoms (Mood and Feelings Questionnaire [MFQ]) at each timepoint. We assessed change in MFQ sum scores from baseline contact with mental health services using multilevel mixed-effects regression adjusted for sociodemographic, environmental, individual, and mental health confounders, with multiple imputation of missing data. We used propensity score weighting to balance confounders between treatment (users of mental health services) and control (non-users of mental health services) groups. We implemented an MFQ clinical cutoff following the results of receiver operating characteristic analysis. Findings: 14-year-old adolescents who had contact with mental health services in the past year had a greater decrease in depressive symptoms than those without contact (adjusted coefficient −1·68, 95% CI −3·22 to −0·14; p=0·033). By age 17 years, the odds of reporting clinical depression were higher in individuals without contact than in service users who had been similarly depressed at baseline (adjusted odds ratio 7·38, 1·73–31·50; p=0·0069). Interpretation: Our findings show that contact with mental health services at age 14 years by adolescents with a mental disorder reduced the likelihood of depression by age 17 years. This finding supports the improvement of access to adolescent mental health services.This study was funded by The Wellcome Trust (grant number 074296), and the National Institute for Health Research Collaboration for Leadership in Applied Health Research & Care for Cambridgeshire and Peterborough

Poor family functioning mediates the link between childhood adversity and adolescent non-suicidal self-injury

Background: Non-suicidal self-injury (NSSI) is a common harmful behavior during adolescence. Exposure to childhood family adversity (CFA) is associated with subsequent emergence of NSSI during adolescence. However, the pathways through which this early environmental risk may operate are not clear. Aims: We tested four alternative hypotheses to explain the association between CFA and adolescent-onset NSSI. Methods: A community sample of n = 933 fourteen year olds with no history of NSSI were followed for three years. Results: Poor family functioning at age 14 mediated the association between CFA before age 5 and subsequent onset of NSSI between 14-17 years. Conclusion: The findings support the cumulative suboptimal environmental hazards (proximal family relationships as a mediator) hypothesis. Improving the family environment at age 14 may mitigate the effects of CFA on adolescent onset of NSSI.MC was funded by a doctoral scholarship from the Gates Cambridge Trust. ALvH is funded by a Royal Society Dorothy Hodgkin Fellowship (No DH150176). PBJ by the NIHR CLAHRC East of England. The study was funded by the Wellcome Trust (Grant no. 074296)

Increased Cross-Gender Identification Independent of Gender Role Behavior in Girls with Congenital Adrenal Hyperplasia: Results from a Standardized Assessment of 4- to 11-Year-Old Children.

While reports showing a link between prenatal androgen exposure and human gender role behavior are consistent and the effects are robust, associations to gender identity or cross-gender identification are less clear. The aim of the current study was to investigate potential cross-gender identification in girls exposed prenatally to high concentrations of androgens due to classical congenital adrenal hyperplasia (CAH). Assessment included two standardized measures and a short parent interview assessing frequency of behavioral features of cross-gender identification as conceptualized in Part A of the diagnostic criteria for gender identity disorder (GID) in the DSM-IV-TR. Next, because existing measures may have conflated gender role behavior with gender identity and because the distinction is potentially informative, we factor analyzed items from the measures which included both gender identity and gender role items to establish the independence of the two constructs. Participants were 43 girls and 38 boys with CAH and 41 unaffected female and 31 unaffected male relatives, aged 4- to 11-years. Girls with CAH had more cross-gender responses than female controls on all three measures of cross-gender identification as well as on a composite measure of gender identity independent of gender role behavior. Furthermore, parent report indicated that 5/39 (12.8 %) of the girls with CAH exhibited cross-gender behavior in all five behavioral domains which comprise the cross-gender identification component of GID compared to 0/105 (0.0 %) of the children in the other three groups combined. These data suggest that girls exposed to high concentrations of androgens prenatally are more likely to show cross-gender identification than girls without CAH or boys with and without CAH. Our findings suggest that prenatal androgen exposure could play a role in gender identity development in healthy children, and may be relevant to gender assignment in cases of prenatal hormone disruption, including, in particular, cases of severely virilized 46, XX CAH.The study was supported by USPHS grant HD24542 to Melissa Hines and by funds from Cambridge University, Cambridge, UK.This is the accepted manuscript version. The final version is available from Springer at http://link.springer.com/article/10.1007%2Fs10508-014-0385-0

Measurement Invariance in Longitudinal Bifactor Models: Review and Application Based on the p Factor.

Bifactor models are increasingly being utilized to study latent constructs such as psychopathology and cognition, which change over the lifespan. Although longitudinal measurement invariance (MI) testing helps ensure valid interpretation of change in a construct over time, this is rarely and inconsistently performed in bifactor models. Our review of MI simulation literature revealed that only one study assessed MI in bifactor models under limited conditions. Recommendations for how to assess MI in bifactor models are suggested based on existing simulation studies of related models. Estimator choice and influence of missing data on MI are also discussed. An empirical example based on a model of the general psychopathology factor (p) elucidates our recommendations, with the present model of p being the first to exhibit residual MI across gender and time. Thus, changes in the ordered-categorical indicators can be attributed to changes in the latent factors. However, further work is needed to clarify MI guidelines for bifactor models, including considering the impact of model complexity and number of indicators. Nonetheless, using the guidelines justified herein to establish MI allows findings from bifactor models to be more confidently interpreted, increasing their comparability and utility

Prenatal androgen exposure alters girls' responses to information indicating gender-appropriate behaviour.

Individual variability in human gender-related behaviour is influenced by many factors, including androgen exposure prenatally, as well as self-socialization and socialization by others postnatally. Many studies have looked at these types of influences in isolation, but little is known about how they work together. Here, we report that girls exposed to high concentrations of androgens prenatally, because they have the genetic condition congenital adrenal hyperplasia, show changes in processes related to self-socialization of gender-related behaviour. Specifically, they are less responsive than other girls to information that particular objects are for girls and they show reduced imitation of female models choosing particular objects. These findings suggest that prenatal androgen exposure may influence subsequent gender-related behaviours, including object (toy) choices, in part by changing processes involved in the self-socialization of gendered behaviour, rather than only by inducing permanent changes in the brain during early development. In addition, the findings suggest that some of the behavioural effects of prenatal androgen exposure might be subject to alteration by postnatal socialization processes. The findings also suggest a previously unknown influence of early androgen exposure on later processes involved in self-socialization of gender-related behaviour, and thus expand understanding of the developmental systems regulating human gender development.This is the author accepted manuscript. The final version is available from Royal Society Publishing via http://dx.doi.org/10.1098/rstb.2015.012

Sporadic and Recurrent Non-Suicidal Self-Injury Before Age 14 and Incident Onset of Psychiatric Disorders by 17 Years: a Prospective Cohort Study

Background: Non-suicidal self-injury (NSSI) is highly prevalent in adolescents and may be a behavioural marker for emergent mental illnesses. Aims: We sought to determine whether sporadic or recurrent NSSI up to the age of 14 years predicted increased risk of new onset of psychiatric disorder in the subsequent 3 years, independent of psychiatric symptoms and social risk factors. Method: 945 14 year olds with no past/present history of mental illness completed a clinical interview and completed a questionnaire about NSSI at the ages of 14 and 17 years. Results: Recurrent NSSI at baseline predicted total disorders, depression and eating disorders. Sporadic baseline NSSI predicted new onset of anxiety disorders only. Conclusions: NSSI (especially recurrent NSSI) in the early adolescent years is a behavioural marker of newly emerging mental illnesses. Professionals should treat both recurrent and sporadic NSSI as important risk factors, and prevention strategies could be targeted at this vulnerable group. Declaration of Interest: NoneThe Roots study was funded by the Wellcome Trust (Grant no. 074296)

The association between pubertal status and depressive symptoms and diagnoses in adolescent females: A population-based cohort study.

BACKGROUND: There is an association between puberty and depression, but many things remain poorly understood. When assessing puberty in females, most studies combine indicators of breast and pubic hair development which are controlled by different hormonal pathways. The contributions of pubertal timing (age at onset) and pubertal status (stage of development, irrespective of timing) are also poorly understood. We tested the hypothesis that stage of breast development in female adolescents, controlled largely by increased estradiol, would be more strongly associated with depression than pubic hair development which occurs in both males and females, and is controlled by adrenal androgens. We investigated whether this association was independent of pubertal timing. METHODS: ROOTS is an ongoing cohort of 1,238 adolescents (54% female) recruited in Cambridgeshire (UK) at age 14.5, and followed-up at ages 16 and 17.5. Depression was assessed using the Mood and Feelings Questionnaire (MFQ) and clinical interview. Breast and pubic hair development were assessed at 14.5, using Tanner rating scales. RESULTS: For each increase in Tanner breast stage at 14.5, depressive symptoms increased by 1.4 MFQ points (95% CI 0.6 to 2.3), irrespective of age at onset. Pubic hair status was only associated with depressive symptoms before adjustment for breast status, and was not associated with depression in males. The same pattern was observed longitudinally, and for depression diagnoses. LIMITATIONS: We did not directly measure hormone levels, our findings are observational, and the study had a relatively low response rate. CONCLUSIONS: Females at more advanced stages of breast development are at increased risk of depression, even if their age at pubertal onset is not early. Alongside social and psychological factors, hormones controlling breast but not pubic hair development may contribute to increased incidence of female depression during puberty