Personalised Mental Health Care for Young People
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Personalised Mental Health Care for Young People: Using Past Outcomes to Build Future Solutions A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy By Frank Iorfino Brain and Mind Centre Faculty of Medicine and Health The University of Sydney 2018 1 Acknowledgements Firstly, thank you to all the incredible young people who have taken part in this clinical research program over the years. Your generosity has been admirable and I hope that this work will play some role in bringing about a healthier future for all young people. I would like to thank my supervisor Professor Daniel Hermens, for the incredibly valuable advice and support you have given me over the past few years. Your guidance has extended way beyond this thesis to other areas of academic life that will certainly stay with me forever. Thank you for always reminding me that the map is the treasure—it always provided a sense of composure that inspired discovery and creativity. To Professor Ian Hickie, you have been an inspirational mentor whose passion and genuine interest in making a difference for young people with mental health disorders has been a constant motivation. I have thoroughly enjoyed working with you both, and look forward to continuing our work in the future. Much of the work in this thesis could not have been completed without contributions from my co-authors who each had a major role in getting the work done. I’d like to give special mention to Dr Shane Cross who provided such valuable clinical insights. Your clinical and health service experience has really been key to ensuring the focus of this work was always directed towards having a real-world clinical impact. To Tracey Davenport, I would like to thank you for always challenging me to be creative and providing me with so many opportunities to learn and develop new skills. Special thanks also to Laura- Ospina Pinillos. I feel incredibly lucky to have shared this PhD experience with you, and while your clinical expertise has always been so helpful, your friendship and support over the course of this thesis is something I will always remember. To everyone who helped gather such incredible data for this project, specifically, Natalia, Alissa and Josine, I could not have done any of this without your incredible efforts, so thank you very much. 2 Thank to my other friends at the BMC who have made my time here so memorable, particularly Courtney, Kate, Julie, Mac, Amelia, Django, Sarah and Haley. These friendships have been so important to me and made coming to work every day so enjoyable. Specific thanks to Courtney, I am very grateful for the friendship we have developed over coffee breaks and endless debates about sport, which were always the perfect way to clear the head and break up a day of writing. Thank you to all my friends and family who have been so very patient and supportive during this time. Specifically, my parents, sister Tania and Michael, who despite having no clue what it is I do, constantly provided encouragement and support. Hopefully this document will provide some insight into what it is I have been doing all these years. To my wonderful group of friends; Matt, Steph, Sam, Dom, Luke, Britt, Alex and Jenny, thank you for the major role you have each played in helping me maintain a healthy balance over the past few years through a plentiful supply of food, wine and good times. Finally, thank you to Charlotte. You have been by my side every single day with your unwavering belief, love and encouragement. Your endless support has kept me going and is something I will always cherish. The work you do every day with young people is truly inspirational and I would be happy if this thesis could have even a quarter of the real-world impact that your work has in a single day. Now, I’m off to read Dune on a beach somewhere. 3 Table of Contents Acknowledgements ............................................................................................. 2 Declaration of originality .................................................................................... 5 Authorship attribution statement....................................................................... 6 Publications presented for examination ............................................................ 7 Additional relevant peer-reviewed publications .............................................. 8 Conference presentations during candidature .................................................. 9 List of common abbreviations .......................................................................... 11 Abstract .............................................................................................................. 12 Thesis overview ................................................................................................. 15 Chapter 1: Introduction ..................................................................................... 16 1.1. Mental health disorders and the vulnerability of young people ......... 16 1.2. The broad impact of mental health disorders ....................................... 18 1.3. Early intervention and youth mental health services ........................... 21 1.4. Addressing the needs of young people—challenges in practice ......... 23 1.5. Aims of the current thesis ....................................................................... 26 Chapter 2: Trajectories of social and occupational function .......................... 28 Chapter 3: Suicide attempts and long-term outcomes .................................... 39 Chapter 4: Responding to suicidality using technology ................................. 47 Chapter 5: Neurobiological correlates and multidimensional outcomes ...... 62 Chapter 6: Discussion ...................................................................................... 101 6.1. Summary of findings............................................................................. 101 6.1.1. Delineating long-term outcomes ............................................... 101 6.1.2. Future solutions for personalised mental health care ............. 102 6.2. Early intervention—not early enough ................................................. 103 6.3. Individual care needs over time ........................................................... 107 6.4. Integrated and outcomes-focused care ................................................ 111 6.5. Technology-enhanced mental health care ........................................... 115 6.6. Limitations of the current work ........................................................... 117 6.6.1. Clinical cohort ............................................................................ 117 6.6.2. Data collection methodology ..................................................... 118 6.6.3. Limited treatment and evaluation data .................................... 119 6.7. Future directions ................................................................................... 120 6.8. Concluding remarks .............................................................................. 123 References ........................................................................................................ 124 4 Declaration of originality To the best of my knowledge, this thesis contains no copy or paraphrase of work published by another person, accept where duly acknowledged in the text. This thesis contains no material that has been presented for a degree at the University of Sydney, or any other University. Frank Iorfino Date: 28th April, 2018 5 Authorship attribution statement This thesis principally represents the work of Frank Iorfino. The data forming the basis of the empirical studies was collected under protocol conceptualised and designed by Prof. Ian B. Hickie, Prof. Daniel F. Hermens, Prof. Sharon L. Naismith, A/Prof Elizabeth M. Scott, Prof Adam Guastella and Ms Tracey Davenport. Mr Iorfino contributed significantly to data collection throughout the candidature, and was primarily responsible for all data analyses, interpretation, and preparation of manuscripts presented in this thesis. Assistance with data collection and interpretation across the studies presented here was provided by Ms Laura Ospina-Pinillos, Dr Shane Cross, Ms Natalia Zmicerevska, Ms Alissa Nichles and Ms Josine Groot. Assistance with data analysis for chapter two was provided by Ms Caro-Anne Badcock. Each author provided comments on manuscript drafts and approved the final versions of papers on which they are listed as co-authors. As supervisor for the candidature upon which this thesis is based, I can confirm that the authorship attribution statements above are correct. Prof. Daniel Hermens Date: 28th April, 2018 6 Publications presented for examination The following papers form the basis of this thesis: . Iorfino, F., Hermens, D. F., Cross, S. P., Zmicerevska, N., Nichles, A., Badcock, C. A., Groot J., Scott, E., & Hickie, I. B. (2018). Delineating the trajectories of social and occupational functioning of young people attending early intervention mental health services in Australia: a longitudinal study. BMJ Open, 8(3), e020678. Presented in Chapter 2 of this thesis. Iorfino, F., Hermens, D. F., Cross, S. P., Zmicerevska, N., Nichles, A., Groot J., Guastella, A.G., Scott, E., & Hickie, I.H. (2018). Prior suicide attempts predict worse clinical and functional outcomes in young people attending a mental health service. Journal of Affective Disorders. 238: 563- 569. Presented in Chapter 3 of this thesis. Iorfino, F., Davenport,