Estimating the burden of psychiatric disorders in adolescence: the impact of subthreshold disorders

Actigraphy-derived circadian rhythms, sleep-wake patterns, and physical activity across clinical stages and pathophysiological subgroups in young people presenting for mental health care

Staging models for youth mental health aim to locate clinical presentations on a spectrum from at-risk states to persistent disorder and predict future illness trajectories. Our previous publications on trans-diagnostic staging proposed three pathophysiological subgroups of major mood or psychotic disorders in youth ('hyperarousal-anxious depression', 'circadian-bipolar spectrum', 'neurodevelopmental-psychosis'). This study aims to investigate differences in objective measures of 24hr sleep-wake patterns, circadian rhythms, and physical activity across clinical stages and pathophysiological subgroups. Actigraphy data (median: 13 days) was collected from 497 youth presenting for mental health care (21.6 ± 4.7 years, 37% male) and 88 controls (24.1 ± 3.8 years, 44% male). Actigraphy estimates were compared across groups using analysis of covariance adjusting for age and sex. Compared with controls or earlier clinical stages, later clinical stages were significantly associated with longer sleep duration(η2 = 0.04), later sleep midpoint(η2 = 0.02), lower sleep regularity(η2 = 0.02), lower relative amplitude of the rest-activity cycle(η2 = 0.05), higher interdaily stability(η2 = 0.03), lower total activity(η2 = 0.08) and less moderate-vigorous physical activity(η2 = 0.06). Compared to controls, the 'circadian-bipolar spectrum' subgroup had later sleep midpoint(η2 = 0.02), and higher interdaily stability(η2 = 0.03); the 'neurodevelopmental-psychosis' subgroup had longer sleep duration(η2 = 0.02), and lower total activity(η2 = 0.03); and the 'hyperarousal-anxious depression' subtype had later sleep midpoint(η2 = 0.02), and lower sleep regularity(η2 = 0.02). The findings suggest differences in sleep-wake and rest-activity patterns according to clinical stage and proposed illness trajectory subtypes. The cross-sectional associations of sleep regularity and physical activity with clinical stage highlight a need for longitudinal explorations of how sleep-wake patterns and circadian rhythms interact with treatment factors and progression of both mental and physical illness.

Is it still autism? The increasing broadening of the autism spectrum

Clinical significance of a broad autism phenotype (BAP) seems to be increasingly supported by growing reports of high prevalence of subthreshold autism spectrum disorder (sASD) or autistic traits (AT) in various demographic samples, particularly in individuals with psychiatric conditions. We question this increasing extension of the autism spectrum and its potential negative consequences for clinical services, research, cultural attitudes, and resource allocation, as well as alternative explanations of what is currently attributed to sASD and AT. In modern psychiatry the diagnostic threshold is paramount and associated with a significant impairment of functioning, implying that symptom specificity is more relevant than sensitivity. Within a syndrome, symptoms have to be present together, with the parts related to and interconnected with the whole. Single autism symptomatic dimensions have low syndromic specificity and can be observed in many different mental disorders. For instance, communication problems may present in communication disorders, social-cognitive difficulties can be found in schizophrenia, and rigid and/or repetitive behaviors can be found in obsessive compulsive disorder. One alternative interpretation of AT and/or sASD relates to personality traits. For example, within the Big 5 Model, low openness is associated with a dislike of change and a narrow range of interests, low extraversion with social withdrawal and coldness, and low agreeableness with disinterest in others and disregard for their feelings. These risks of overreliance on non-specific aspects of autism are particularly likely to occur with screening checklists, self-assessment, or assessment by a lay interviewer with only limited expertise in clinical assessment.

Epidemiology of Body Dysmorphic Disorder and Appearance Preoccupation in Youth: Prevalence, Comorbidity and Psychosocial Impairment

OBJECTIVE

Little is known about how common and impairing body dysmorphic disorder (BDD) is in the general population of youth. We evaluated the prevalence, comorbidity, and psychosocial impairment associated with BDD and more broadly defined appearance preoccupation in young people.

METHOD

Data were drawn from the 2017 Mental Health of Children and Young People in England survey. BDD and psychiatric comorbidity were assessed in individuals 5 to 19 years of age (N = 7,654) according to DSM-5 criteria, using a clinician-rated standardized diagnostic assessment. Psychosocial impairment was measured with a quantitative scale and was indexed by reported self-harm and suicide attempts, as well as service use, assessed using structured interviews.

RESULTS

The point prevalence of BDD was 1.0% (95% CI = 0.8%-1.3%). BDD was significantly more common among adolescents than children (1.9 vs 0.1%; OR = 22.5, p < .001), and among female than male participants (1.8% vs 0.3%; OR = 7.3, p < .001). Approximately 70% of young people with BDD had psychiatric comorbidity, most commonly internalizing disorders. BDD was associated with self- and parent-reported psychosocial impairment, self-harm and suicide attempts, and service utilization. Appearance preoccupation was more common than full-syndrome BDD, but showed similar age and sex effects, patterns of comorbidity, and associated impairment.

CONCLUSION

BDD and appearance preoccupation are relatively common, especially among adolescent girls, and are associated with substantial co-occurring psychopathology, impairment, and risk. Improved screening is needed to increase detection and diagnosis of BDD, and to facilitate access to evidence-based treatment.

PLAIN LANGUAGE SUMMARY

This study aimed to determine the prevalence, comorbidity, and psychosocial impairment associated with body dysmorphic disorder (BDD) and more broadly defined appearance preoccupation in young people. Data from an epidemiological survey of 7,654 youth aged 5 to19 years in England indicated that BDD affects approximately 1% of children and adolescents. BDD was significantly more common in adolescents compared to children and in females compared to males. Both BDD and broader appearance preoccupation were linked with high rates of psychiatric comorbidity and significant psychosocial impairment, indicating a need for better screening and access to treatment.

STUDY PREREGISTRATION INFORMATION

The epidemiology of body dysmorphic disorder the youth: prevalence, comorbidity and psychosocial impact; https://osf.io/; g83jy.

Efficacy of a transdiagnostic Internet prevention approach in adolescents (EMPATIA study): study protocol of a randomized controlled trial

BACKGROUND

Most mental disorders have their onset in adolescence. Preventive interventions during this period are important; however, help-seeking behavior is generally poor in this age group resulting in low treatment rates. Internet interventions are expected to be an effective, low-threshold, and scalable approach to overcome barriers to help-seeking, particularly for individuals experiencing subclinical symptoms. Internet-delivered indicated prevention seems promising as it targets individuals with minimal symptoms of mental disorders who might need care but are not help-seeking yet. Previous indicated prevention-approaches have mainly targeted specific risk-syndromes. However, this contradicts the increasing recognition of emerging psychopathology as a complex system characterized by co-occurrence and rapid shifts of subclinical symptoms cutting across diagnostic categories. Therefore, this study will investigate the efficacy, mediators, moderators, and core symptomatic changes of a transdiagnostic Internet-delivered indicated prevention program (EMPATIA program) for adolescents.

METHODS

This randomized controlled trial (RCT) will be conducted in a general population sample (planned n = 152) of adolescents aged 12-18 years with subclinical symptoms but without any current or past mental disorder. Participants will be randomly assigned to the EMPATIA program or a care as usual (CAU) control condition. The 8-week guided EMPATIA program encompasses 8 modules targeting the following transdiagnostic mechanisms: repetitive negative thinking, self-perfectionism, emotion regulation, intolerance of uncertainty, rejection sensitivity, and behavioral avoidance. Participants will be asked to answer online self-report questionnaires at baseline, after 8 weeks, and at 6-, 9-, and 12-month follow-up. Diagnostic telephone interviews will be conducted at baseline and at 12-month follow-up. Additionally, intervention-specific constructs (motivation, alliance, negative effects, satisfaction, adherence) will be assessed during and after the EMPATIA program. The level of self-reported general psychopathology post-intervention is the primary outcome.

DISCUSSION

Results will be discussed considering the potential of Internet interventions as a scalable, low-threshold option for indicated prevention in adolescents experiencing subclinical symptoms. The EMPATIA program introduces a novel Internet prevention program targeting six transdiagnostic mechanisms associated with various mental health outcomes. Thereby, this trial pursues a very timely and important topic because it may contribute to narrow the current care gap for adolescents, to prevent mental health problems and related negative consequences, and to promote mental health in the long-term.

TRIAL REGISTRATION

The trial was approved by Swissmedic (Registration Number: 10001035, 08/22/2022) and the Ethics Committee of Bern (Registration Number: 2022-D0036, 08/22/2022). The trial was registered at ClinicalTrials.gov NCT05934019 on 07-03-2023.

Preference for digital media use, biobehavioral attention bias, and anxiety symptoms in adolescents

Adolescence is a critical developmental period of biological and social change during which 1 in 3 youth experience significant anxiety symptoms. The social-emotional lives of the majority of adolescents are largely conducted via digital media use (DMU; e.g., social media, text messaging). Yet the past decade of research on DMU and anxiety has yielded mixed results (e.g., Keles et al., 2020 review), leaving the complex role that DMU might play in the emergence and maintenance of anxiety poorly understood. A key step forward is to leverage psychophysiology to identify individual differences in cognitive and emotional processes that confer vulnerability to potential negative effects of DMU. Further, given the ubiquity of DMU, a greater focus is needed on measurements that move beyond sheer frequency to capture DMU in comparison to face-to-face (FTF) social interactions. This study examined attention bias (AB), characterized by selective and exaggerated attention toward or away from threat, as a moderator of the link between DMU and anxiety in adolescents (N = 75; 42 female) aged 12-14 years (M = 13.28, SD = 0.87). AB was indexed during a dot probe task using reaction time metrics (i.e., trial-level bias) and via ERPs capturing attentional selection and discrimination (N170) and cognitive control (N2) to threat compared to neutral faces. AB moderated associations between DMU and anxiety. A greater preference to use DMU vs FTF predicted greater anxiety among those with a greater behavioral bias away from threat, blunted N170, and blunted N2 in the presence of threat. Future research should examine potential causal and bidirectional links between DMU and anxiety and explore whether preferences for technology-mediated interactions and individual differences in threat processing increase risk.

Co-occurring psychological distress and alcohol or other drug use among Indigenous Australians: Data from the National Aboriginal and Torres Strait Islander Health Survey

OBJECTIVES

To determine the prevalence and demographic, social and health characteristics associated with co-occurring psychological distress symptoms, risky alcohol and/or substance use among a national sample of Aboriginal and Torres Strait Islander people aged 15 years or older.

METHODS

This study uses secondary cross-sectional data from the 2018-19 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS). Data were collected via face-to-face interviews with those living in private dwellings across Australia. Participants were Aboriginal and Torres Strait Islander people (n = 10,579) aged 15 years or older. Data pertaining to psychological distress, alcohol and substance use were obtained and weighted to represent the total population of Aboriginal and Torres Strait Islander people in Australia.

RESULTS

A total of 20.3% participants were found to have co-occurring psychological distress, risky alcohol use and/or substance use, and 4.0% reported co-occurrence of all three conditions. Female participants in a registered marriage and fully engaged in study or employment had lower rates of co-occurring conditions. Poorer self-rated health, one or more chronic conditions and increased experiences of unfair treatment and physical harm in the past 12 months were associated with increased rates of co-occurring conditions.

CONCLUSION

A range of potential risk and protective factors were identified for co-occurring psychological distress, risky alcohol and/or substance use among Aboriginal and Torres Strait Islander people. This information is critical for planning effective holistic strategies to decrease the burden of suffering imposed upon the individual, family and community members impacted by co-occurring conditions.

Attention Training for Child Anxiety and Its Disorders: Moving from Research to Clinical Implementation

Attention training is an evidence-based, computerized treatment for anxiety and its disorders rooted in cognitive neuroscience. Though experimental research and clinical trials data on attention training in children span two decades, the literature has focused on attention training's anxiety reduction effects, with little guidance on its implementation in clinical practice. Guidance on implementation is needed given recent efforts to increase accessibility of attention training in clinical practice settings. In this article, we move from research to clinical implementation, providing guidelines with pragmatic clinical steps. We include guidance on psychoeducation, setting and delivery of sessions, potential challenges, and frequently asked questions regarding implementation.

Staging 2.0: refining transdiagnostic clinical staging frameworks to enhance reliability and utility for youth mental health

Globally, 75% of depressive, bipolar, and psychotic disorders emerge by age 25 years. However, these disorders are often preceded by non-specific symptoms or attenuated clinical syndromes. Difficulties in determining optimal treatment interventions for these emerging mental disorders, and uncertainties about accounting for co-occurring psychopathology and illness trajectories, have led many youth mental health services to adopt transdiagnostic clinical staging frameworks. In this Health Policy paper, an international working group highlights ongoing challenges in applying transdiagnostic staging frameworks in clinical research and practice, and proposes refinements to the transdiagnostic model to enhance its reliability, consistent recording, and clinical utility. We introduce the concept of within-stage heterogeneity and describe the advantages of defining stage in terms of clinical psychopathology and stage modifiers. Using examples from medicine, we discuss the utility of categorising stage modifiers into factors associated with progression (ie, potential predictors of stage transition) and extension (ie, factors associated with the current presentation that add complexity to treatment selection). Lastly, we suggest how it is possible to revise the currently used transdiagnostic staging approach to incorporate these key concepts, and how the revised framework could be applied in clinical and research practice.

The temporal dependencies between social, emotional and physical health factors in young people receiving mental healthcare: a dynamic Bayesian network analysis

AIMS

The needs of young people attending mental healthcare can be complex and often span multiple domains (e.g., social, emotional and physical health factors). These factors often complicate treatment approaches and contribute to poorer outcomes in youth mental health. We aimed to identify how these factors interact over time by modelling the temporal dependencies between these transdiagnostic social, emotional and physical health factors among young people presenting for youth mental healthcare.

METHODS

Dynamic Bayesian networks were used to examine the relationship between mental health factors across multiple domains (social and occupational function, self-harm and suicidality, alcohol and substance use, physical health and psychiatric syndromes) in a longitudinal cohort of 2663 young people accessing youth mental health services. Two networks were developed: (1) 'initial network', that shows the conditional dependencies between factors at first presentation, and a (2) 'transition network', how factors are dependent longitudinally.

RESULTS

The 'initial network' identified that childhood disorders tend to precede adolescent depression which itself was associated with three distinct pathways or illness trajectories; (1) anxiety disorder; (2) bipolar disorder, manic-like experiences, circadian disturbances and psychosis-like experiences; (3) self-harm and suicidality to alcohol and substance use or functioning. The 'transition network' identified that over time social and occupational function had the largest effect on self-harm and suicidality, with direct effects on ideation (relative risk [RR], 1.79; CI, 1.59-1.99) and self-harm (RR, 1.32; CI, 1.22-1.41), and an indirect effect on attempts (RR, 2.10; CI, 1.69-2.50). Suicide ideation had a direct effect on future suicide attempts (RR, 4.37; CI, 3.28-5.43) and self-harm (RR, 2.78; CI, 2.55-3.01). Alcohol and substance use, physical health and psychiatric syndromes (e.g., depression and anxiety, at-risk mental states) were independent domains whereby all direct effects remained within each domain over time.

CONCLUSIONS

This study identified probable temporal dependencies between domains, which has causal interpretations, and therefore can provide insight into their differential role over the course of illness. This work identified social, emotional and physical health factors that may be important early intervention and prevention targets. Improving social and occupational function may be a critical target due to its impacts longitudinally on self-harm and suicidality. The conditional independence of alcohol and substance use supports the need for specific interventions to target these comorbidities.

Guiding Principles for Implementing Stepped Care in Mental Health: Alignment on the Bigger Picture

Stepped care models are a mental healthcare delivery framework in which a continuum of support allows selection of a range of interventions to match a client's evolving needs and preferences. Currently in use in multiple settings worldwide, stepped care has the potential to provide a needed advance for the development of comprehensive mental health systems. However, definitions of stepped care lack consistency, resulting in differing interpretations reflected in variable implementation, ultimately limiting its replicability, utility and potential for impact. To help foster greater alignment in research and practice, we propose a set of principles for stepped care which can provide guidance on how to bridge multiple mental health services together, reduce fragmentation, and respond to the full breadth of mental health needs along a continuum of care in diverse settings. We hope that articulating these principles will foster discussion and spur mental health stakeholders to translate them into actionable standards.

Attention Training as a Low-Intensity Treatment for Concerning Anxiety in Clinic-Referred Youth

Although youth anxiety treatment research has focused largely on severe and impairing anxiety levels, even milder anxiety levels, including levels that do not meet full criteria for a diagnosis, can be impairing and cause for concern. There is a need to develop and test viable treatments for these concerning anxiety levels to improve functioning and reduce distress. We present findings from a randomized controlled efficacy trial of attention bias modification treatment (ABMT) and attention control training (ACT) for youths with concerning anxiety levels. Fifty-three clinic-referred youths (29 boys, M age = 9.3 years, SD age = 2.6) were randomized to either ABMT or ACT. ABMT and ACT consisted of attention-training trials in a dot-probe task presenting angry and neutral faces; probes appeared in the location of neutral faces in 100% of ABMT trials and 50% of ACT trials. Independent evaluators provided youth anxiety severity ratings; youths and parents provided youth anxiety severity and global impairment ratings; and youths completed measures of attention bias to threat and attention control at pretreatment, posttreatment, and 2-month follow-up. In both arms, anxiety severity and global impairment were significantly reduced at posttreatment and follow-up. At follow-up, anxiety severity and global impairment were significantly lower in ACT compared with ABMT. Attention control, but not attention bias to threat, was significantly improved at follow-up in both arms. Changes in attention control and attention focusing were significantly associated with changes in anxiety severity. Findings support the viability of attention training as a low-intensity treatment for youths with concerning anxiety levels, including levels that do not meet full criteria for a diagnosis. Superior anxiety reduction effects in ACT highlight the critical need for mechanistic research on attention training in this population.

The Longitudinal Youth in Transition Study (LYiTS) Cohort Profile: Exploration by Hospital- Versus Community-Based Mental Health Services

OBJECTIVES

Youth face numerous challenges in receiving coordinated and continuous mental health services, particularly as they reach the age of transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). The Longitudinal Youth in Transition Study (LYiTS) follows youth prospectively as they cross this transition boundary to better understand their transition pathways and resulting symptoms and health service use outcomes. The current paper presents the baseline profile description for the LYiTS cohort and additionally examines differences in symptoms and functioning and health service utilization between youth receiving services at hospital- versus community-based CAMHS.

METHODS

A cross-sectional design was used. A sample of 237 16-18-year-old youth recruited from outpatient CAMHS at two hospitals and two community sites completed self-report measures at their first of four annual assessments. A latent profile analysis was conducted to identify symptomology profiles, and youth were compared on symptoms and health service use between hospital- and community-based sites.

RESULTS

Four distinct symptomology profiles were identified (subclinical, moderate internalizing, moderate externalizing, and high symptomology). Symptom profiles and functioning levels reported by youth were no different across both types of organization, although there were differences detected in health service utilization, such as type of provider seen and use of medications.

CONCLUSIONS

These findings suggest that there is little difference in symptomology between youth accessing hospital versus community-based CAMHS. With growing interest in understanding the effectiveness and cost-effectiveness of different models of mental health care, these findings provide a new understanding of the clinical and service use profiles of transition-aged youth that will be explored further as this cohort is followed across the CAMHS to AMHS transition boundary.

Subsyndromal generalised anxiety disorder: operationalisation and epidemiology - a systematic literature survey

The diagnosis of anxiety disorders, like other psychiatric disorders also, is operationalised since the introduction of diagnostic manuals. The diagnostic criteria of Generalised Anxiety Disorder (GAD) have been tightened in the last decades. This leads to the exclusion of patients with a high level of anxiety, but not fulfilling certain of the GAD-criteria, from effective treatment. Such so-called subsyndromal, subthreshold or subclinical GAD-states, however, often exhibit a comparable burden of disease like the full syndromal disorder and often tend to develop into the full syndromal disorder. The purpose of this review is - beside systematically reporting the papers found in respective data bases from 2013 onwards - to summarise the relevant data regarding definitions, epidemiology and consequences of subsyndromal anxiety states in order to give a comprehensive review.

A cascade of rejection and appearance preoccupation: Adolescents' body dysmorphic symptoms and appearance rejection sensitivity over 4 years

Adolescence is a high-risk period for body image disturbance and appearance concerns. In a cascade model, we examined interrelations of body dysmorphic symptoms (BDS) with appearance rejection sensitivity (ARS) and tested gender moderation. Participants were 397 Australian adolescents (T1 Mage = 11.7, SD = 0.91; 56% girls) who completed six surveys over 4 years. In a random-intercept cross-lag model, two (of five possible) paths showed ARS predicted higher subsequent BDS, and three (of five possible) paths showed BDS predicted higher subsequent ARS. Girls reported more BDS and ARS than boys, and random intercepts of BDS and ARS were correlated with the correlation stronger in girls than boys. Cross-lag BDD-ARS associations over the six waves were not significantly moderated by gender. Overall, girls are at higher risk of appearance concerns than boys, but BDD-ARS cascade effects do not differ between girls and boys.

ADHD and Exposure to Maltreatment in Children and Youth: a Systematic Review of the Past 10 Years

PURPOSE OF THE REVIEW

The purpose of the current paper was to review and summarize the literature on ADHD and maltreatment over the past 10 years.

RECENT FINDINGS

The majority of research on ADHD and exposure to maltreatment focuses on the high rates of comorbidity, including international studies from Asia, South America, North America, and Europe. Longitudinal studies showed that early exposure to maltreatment is a risk factor for ADHD symptoms later in development; however, this finding was not consistent. There were some preliminary studies on the neurological and genetic mechanisms underlying the link between ADHD and exposure to maltreatment. Finally, ADHD and exposure to maltreatment were found to have an additive effect on clinically salient outcomes (e.g., aggression, suicide attempts). Results from the review have direct clinical and future implications, including the need to understand the effect of comorbid ADHD and exposure to maltreatment in treatment studies.

The latent structure of olfactory reference disorder symptoms: A taxometric analysis

Olfactory reference disorder (ORD), a newly included disorder in the ICD-11, is characterized by 'pathological' concerns about emitting body odor. While research is emerging on the construct, no study has directly examined the boundary between ORD and normal body odor concerns. That is, should ORD be considered as categorical in nature versus a more dimensional construct? As such, the current study explored the extent to which ORD symptoms correspond to a distinct category or dimension in a mixed university student and community sample (n = 757). Three indicators, derived from the Yale-Brown Obsessive Compulsive Scale Modified for Olfactory Reference Syndrome, were submitted to three independent taxometric procedures: MAMBAC, MAXEIG, and L-Mode. Two of three procedures showed that the latent structure of ORD is dimensional rather than categorical. The comparison curve fit index profile method yielded dimensional structure. Results suggested that researchers and clinical practitioners would be well-advised to conceptualize, assess, and treat ORD symptoms in a dimensional way.

Cohort profile: the Brain and Mind Centre Optymise cohort: tracking multidimensional outcomes in young people presenting for mental healthcare

PURPOSE

The Brain and Mind Centre (BMC) Optymise cohort assesses multiple clinical and functional domains longitudinally in young people presenting for mental health care and treatment. Longitudinal tracking of this cohort will allow investigation of the relationships between multiple outcome domains across the course of care. Subsets of Optymise have completed detailed neuropsychological and neurobiological assessments, permitting investigation of associations between these measures and longitudinal course.

PARTICIPANTS

Young people (aged 12-30) presenting to clinics coordinated by the BMC were recruited to a research register (n=6743) progressively between June 2008 and July 2018. To date, 2767 individuals have been included in Optymise based on the availability of at least one detailed clinical assessment.

MEASURES

Trained researchers use a clinical research proforma to extract key data from clinical files to detail social and occupational functioning, clinical presentation, self-harm and suicidal thoughts and behaviours, alcohol and other substance use, physical health comorbidities, personal and family history of mental illness, and treatment utilisation at the following time points: baseline, 3, 6, 12, 24, 36, 48, and 60 months, and time last seen.

FINDINGS TO DATE

There is moderate to substantial agreement between raters for data collected via the proforma. While wide variations in individual illness course are clear, social and occupational outcomes suggest that the majority of cohort members show no improvement in functioning over time. Differential rates of longitudinal transition are reported between early and late stages of illness, with a number of baseline factors associated with these transitions. Furthermore, there are longitudinal associations between prior suicide attempts and inferior clinical and functional outcomes.

FUTURE PLANS

Future reports will detail the longitudinal course of each outcome domain and examine multidirectional relationships between these domains both cross-sectionally and longitudinally, and explore in subsets the associations between detailed neurobiological measures and clinical, social and functional outcomes.

Right care, first time: a highly personalised and measurement-based care model to manage youth mental health

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people.

Using measures of intrinsic homeostasis and extrinsic modulation to evaluate mental health in adolescents: Preliminary results from the longitudinal adolescent brain study (LABS)

Adolescence is a period when complex interactions occur between mental health risk factors. The Longitudinal Adolescent Brain Study (LABS) commenced in 2018, to monitor environmental and psychosocial factors thought to influence mental health in 500 young people. Participants commence at 12 years of age, via a community-based recruitment model, and data is collected at 15 time-points over five years. This study examines demographic and psychosocial self-report data from time-point 1, for the first 50 participants. Here we investigate associations between environmental and psychosocial factors, considered as measures of intrinsic homeostasis and extrinsic modulation. Numerous strong correlations were found. Findings indicate that sleep dysfunction and social connectedness were strongly associated external modulators of intrinsic homeostasis in this sample of 12-year old participants. To successfully address the increase in mental health problems in young people, comprehensive evaluation of lifestyle and environmental risk factors is recommended in addition to medicalised approaches. Interventions to promote mental health wellbeing in young adolescents should include a focus on sleep quality and patterns and the positive and negative aspects of social connectedness.

The General Factor of Psychopathology

An important advance in understanding and defining mental disorders has been the development of empirical approaches to mapping dimensions of dysfunction and their interrelatedness. Such empirical approaches have consistently observed intercorrelations among the many forms of psychopathology, leading to the identification of a general factor of psychopathology (the p factor). In this article, we review empirical support for p, including evidence for the stability and criterion validity of p. Further, we discuss the strong relationship between p and both the general factor of personality and the general factor of personality disorder, substantive interpretations of p, and the potential clinical utility of p. We posit that proposed substantive interpretations of p do not explain the full range of symptomatology typically included in p. The most plausible explanation is that p represents an index of impairment that has the potential to inform the duration and intensity of a client's mental health treatment.

Specificity of psychopathology across levels of severity: a transdiagnostic network analysis

A prominent hypothesis within the field of psychiatry is that the manifestation of psychopathology changes from non-specific to specific as illness severity increases. Using a transdiagnostic network approach, we investigated this hypothesis in four independent groups with increasing psychopathology severity. We investigated whether symptom domains became more interrelated and formed more clusters as illness severity increased, using empirical tests for two network characteristics: global network strength and modularity-based community detection. Four severity groups, ranging from subthreshold psychopathology to having received a diagnosis and treatment, were derived with a standardized diagnostic interview conducted at age 18.5 (n = 1933; TRAILS cohort). Symptom domains were assessed using the Adult Self Report (ASR). Pairwise comparisons of the symptom networks across groups showed no difference in global network strength between severity groups. Similar number and type of communities detected in the four groups exceeded the more minor differences across groups. Common clusters consisted of domains associated with attention deficit hyperactivity disorder (ADHD) and combined depression and anxiety domains. Based on the strength of symptom domain associations and symptom clustering using a network approach, we found no support for the hypothesis that the manifestation of psychopathology along the severity continuum changes from non-specific to specific.

Evaluation of a screening algorithm using the Strengths and Difficulties Questionnaire to identify children with mental health problems: A five-year register-based follow-up on school performance and healthcare use

BACKGROUND

Treatment of mental health problems (MHP) is often delayed or absent due to the lack of systematic detection and early intervention. This study evaluates the potential of a new screening algorithm to identify children with MHP.

METHODS

The study population comprises 2,015 children from the Copenhagen Child Cohort 2000 whose mental health was assessed at age 11-12 years and who had no prior use of specialised mental health services. A new algorithm based on the Strengths and Difficulties Questionnaire (SDQ) is utilised to identify MHP by combining parent-reported scores of emotional and behavioural problems and functional impairments. The screening is done on historical data, implying that neither parents, teachers nor health care professionals received any feedback on the screening status. The screening status and results of an IQ-test were linked to individual-level data from national registries. These national registers include records of each child's school performance at the end of compulsory schooling, their health care utilisation, as well as their parents' socio-economic status and health care utilisation.

RESULTS

10% of the children screen positive for MHP. The children with MHP achieve a significantly lower Grade Point Average on their exams, independently of their IQ-score, perinatal factors and parental characteristics. On average, the children with MHP also carry higher health care costs over a five-year follow-up period. The higher health care costs are only attributed to 23% of these children, while the remaining children with MHP also show poorer school performance but receive no additional health care.

CONCLUSIONS

The results demonstrate that children with MHP and a poor prognosis can be identified by the use of the brief standardised questionnaire SDQ combined with a screening algorithm.

A Digital Platform Designed for Youth Mental Health Services to Deliver Personalized and Measurement-Based Care

Mental disorders that commonly emerge during adolescence and young adulthood are associated with substantial immediate burden and risks, as well as potentially imparting lifetime morbidity and premature mortality. While the development of health services that are youth focused and prioritize early intervention has been a critical step forward, an ongoing challenge is the heterogeneous nature of symptom profiles and illness trajectories. Consequently, it is often difficult to provide quality mental health care, at scale, that addresses the broad range of health, social, and functional needs of young people. Here, we describe a new digital platform designed to deliver personalized and measurement-based care. It provides health services and clinicians with the tools to directly address the multidimensional needs of young people. The term "personalized" describes the notion that the assessment of, and the sequence of interventions for, mental disorders are tailored to the young person-and their changing needs over time, while "measurement-based" describes the use of systematic and continuing assessment of a young person's outcomes over the entire course of clinical care. Together, these concepts support a framework for care that transcends a narrow focus on symptom reduction or risk reduction. Instead, it prioritizes a broader focus on enhancing social, health, and physical outcomes for young people and a commitment to tracking these outcomes throughout this key developmental period. Now, with twenty-first century technologies, it is possible to provide health services with the tools needed to deliver quality mental health care.

Are subsyndromal manifestations of attention deficit hyperactivity disorder morbid in children? A systematic qualitative review of the literature with meta-analysis

We conducted a qualitative review (n = 15 manuscripts) and meta-analysis (n = 9 manuscripts) of the extant literature to evaluate the prevalence and morbidity of subthreshold Attention Deficit Hyperactivity Disorder (ADHD). Our qualitative review showed that a sizable minority (mean: 17.7%) of clinically referred and non-referred children met a priori definitions of subthreshold ADHD. Those affected exhibited significantly higher rates of family dysfunction, cognitive impairment, executive dysfunction, interpersonal and school deficits, temperament problems, psychiatric comorbidity, and juvenile delinquency compared to children with no ADHD symptoms. These deficits were highly consistent with those observed in children with full threshold ADHD. These findings indicate that children with subthreshold ADHD symptoms are at significantly greater risk for negative outcomes in a wide range of non-overlapping functional domains worthy of further clinical and scientific consideration.

First incidence, age of onset outcomes and risk factors of onset of DSM-5 oppositional defiant disorder: a cohort study of Spanish children from ages 3 to 9

OBJECTIVE

To examine the 1-year first incidence and prevalence of oppositional defiant disorder (ODD), the outcomes on psychopathology and functioning by age of onset and the risk factors of onset of ODD from ages 3 to 9 in children from the Spanish general population.

DESIGN

Longitudinal with seven follow-ups and double cohort (ODD and non-ODD children).

SETTING

General population of preschool and elementary school children in Barcelona (Spain).

PARTICIPANTS

On a first phase, the parent-rated Strengths and Difficulties Questionnaire conduct problems scale plus ODD Diagnostic and Statistical Manual of Mental Disorders, fourth version, symptoms were used to screen for behavioural problems. The second phase sample size contained 622 cases at age 3 and, at age 9, 418 remained in the study.

RESULTS

The probability of the onset of ODD showed increasing values at ages 4 (R=2.7%) and 5 years (R=4.4%). These values decreased until age 7 (R=1.9%) and increased again until age 9 (R=3.6%). Up to 9 years old, the cumulative risk of new cases of ODD was 21.9%. Early onset was associated with a higher risk of depression comorbidity and later onset with higher functional impairment and symptomatology. Subthreshold ODD, high scores in irritability and headstrong dimensions, attention deficit/hyperactivity disorder and other comorbidity, negative affectivity until age 7, difficulties in inhibit and emotional control, punitive parenting and maternal internalising problems were risk factors of a first episode of ODD during this 7-year period.

CONCLUSIONS

The risk of new cases of ODD in the general population at preschool age and during childhood is high. Preschool age is a target period for preventive interventions. Identified risk factors are objectives for targeted and indicated interventions.

The morbidity of subthreshold pediatric bipolar disorder: A systematic literature review and meta-analysis

OBJECTIVE

The objective of this study was to evaluate the morbidity of subthreshold pediatric bipolar (BP) disorder.

METHODS

We performed a systematic literature search in November 2017 and included studies examining the morbidity of pediatric subthreshold BP. Extracted outcomes included functional impairment, severity of mood symptoms, psychiatric comorbidities, suicidal ideation and behaviors, and mental health treatment. We used meta-analysis to compute the pooled standardized mean difference (SMD) for continuous measures and the pooled risk ratio (RR) for binary measures between two paired groups: subthreshold pediatric BP vs controls and subthreshold pediatric BP vs pediatric BP-I.

RESULTS

Eleven papers, consisting of seven datasets, were included. We compared subthreshold pediatric BP (N = 244) to non-BP controls (N = 1125) and subthreshold pediatric BP (N = 643) to pediatric BP-I (N = 942). Subthreshold pediatric BP was associated with greater functional impairment (SMD = 0.61, CI 0.25-0.97), greater severity of mood symptomatology (mania: SMD = 1.88, CI 1.38-2.38; depression: SMD = 0.66, CI 0.52-0.80), higher rates of disruptive behavior (RR = 1.75, CI 1.17-2.62), mood (RR = 1.78, CI 1.29-2.79) and substance use (RR = 2.27, CI 1.23-4.21) disorders, and higher rates of suicidal ideation and attempts (RR = 7.66, CI 1.71-34.33) compared to controls. Pediatric BP-I was associated with greater functional impairment, greater severity of manic symptoms, higher rates of suicidal ideation and attempts, and higher rates of mental health treatment compared to subthreshold pediatric BP. There were no differences between full and subthreshold cases in the severity of depressive symptoms or rates of comorbid disorders.

CONCLUSIONS

Subthreshold pediatric BP disorder is an identifiable morbid condition associated with significant functional impairment including psychiatric comorbidities and high rates of suicidality.

Measuring the hierarchical general factor model of psychopathology in young adults

There is evidence that models of psychopathology specifying a general factor and specific second-order factors fit better than competing structural models. Nonetheless, additional tests are needed to examine the generality and boundaries of the general factor model. In a selected second wave of a cohort study, first-order dimensions of psychopathology symptoms in 499 23- to 31-year-old twins were analyzed. Using confirmatory factor analysis, a bifactor model specifying a general factor and specific internalizing and externalizing factors fit better than competing models. Factor loadings in this model were sex invariant despite greater variances in the specific internalizing factor among females and greater variances in the general and specific externalizing factors among males. The bifactor structure was robust to the exclusion of any single first-order dimension of psychopathology. Furthermore, the results were essentially unchanged when all overlapping symptoms that define multiple disorders were excluded from symptom dimensions. Furthermore, the best-fitting bifactor model also emerged in exploratory structural equation modeling with freely estimated cross-loadings. The general factor of psychopathology was robust across variations in measurement and analysis.

The classification of body dysmorphic disorder symptoms in male and female adolescents

BACKGROUND

Body dysmorphic disorder (BDD) was categorised in DSM-5 within the newly created 'obsessive-compulsive and related disorders' chapter, however this classification remains subject to debate. Confirmatory factor analysis was used to test competing models of the co-occurrence of symptoms of BDD, obsessive-compulsive disorder, unipolar depression, anxiety, and eating disorders in a community sample of adolescents, and to explore potential sex differences in these models.

METHODS

Self-report questionnaires assessing disorder symptoms were completed by 3149 Australian adolescents. The fit of correlated factor models was calculated separately in males and females, and measurement invariance testing compared parameters of the best-fitting model between males and females.

RESULTS

All theoretical models of the classification of BDD had poor fit to the data. Good fit was found for a novel model where BDD symptoms formed a distinct latent factor, correlated with affective disorder and eating disorder latent factors. Metric non-invariance was found between males and females, and the majority of factor loadings differed between males and females. Correlations between some latent factors also differed by sex.

LIMITATIONS

Only cross-sectional data were collected, and the study did not assess a broad range of DSM-5 defined eating disorder symptoms or other disorders in the DSM-5 obsessive-compulsive and related disorders chapter.

CONCLUSIONS

This study is the first to statistically evaluate competing models of BDD classification. The findings highlight the unique features of BDD and its associations with affective and eating disorders. Future studies examining the classification of BDD should consider developmental and sex differences in their models.

Targeting mental health care attributes by diagnosis and clinical stage: the views of youth mental health clinicians

OBJECTIVES

To explore the potential utility of clinical stage and mental disorder categories as a basis for determining which attributes of youth mental health care should be offered to which groups of young people.

METHODS

In June 2017, we conducted an online survey of youth mental health clinicians that collected information on the participants' background and areas of expertise, then presented vignettes describing young people with different stages of six mental disorders (disorder-based vignettes were matched to participants' area of expertise). For each vignette, participants were asked to give a quantitative estimate of the proportion of young people with similar mental health problems they thought would clinically benefit from each of twelve attributes of mental health care (other than pharmacological or individual psychological therapies). Survey results were analysed as independent, disorder-based samples, using standard statistical tests of significance, and as a stratified sample using mixed-effects models.

RESULTS

A total of 412 clinicians working in 32 countries participated in both parts of the survey. Respondents represented a broad range of clinical disciplines, settings and areas of expertise. Their estimated proportions of young people who would benefit from the mental health care attributes varied by clinical stage and disorder (eg, a mean of 93% [interquartile range (IQR), 90%-100%] of young people with Stage 2 psychosis were estimated to benefit from case management with a multidisciplinary team; while only 15% [IQR, 1%-25%] of young people with Stage 1b generalised anxiety disorder were estimated to benefit from collection and processing of biological samples). Neither the background of the respondents nor the sex of the characters in the vignettes significantly influenced the results.

CONCLUSION

A combination of clinical stage and disorder information might be an appropriate basis for ensuring that the right attributes of early intervention mental health care are provided to the right young people at the right time. Policy and research priorities include trialling novel services, preferences research among young people, strengthening service responses to subthreshold disorders and promoting high-fidelity collection of clinical stage data in youth mental health settings.

Subthreshold body dysmorphic disorder in adolescents: Prevalence and impact

The aim of the current study was to establish the prevalence of subthreshold body dysmorphic disorder (subthreshold-BDD) in a community sample of adolescents, and to compare disorder correlates in individuals with subthreshold-BDD to those with probable full-syndrome BDD (probable-BDD) and those without BDD (non-BDD). Self-report questionnaires assessing DSM-IV BDD criteria, past mental health service use, and symptoms of body dysmorphic disorder, anxiety, depression, obsessive-compulsive disorder and eating disorders, were completed by 3149 Australian high school students (mean age =14.6 years, 63.5% male). Male participants also completed measures assessing quality of life, muscularity concerns, emotional symptoms, conduct problems, hyperactivity, and peer problems. The prevalence of subthreshold-BDD was 3.4%, and probable-BDD was 1.7%. Compared to the non-BDD group, subthreshold-BDD was associated with elevated symptoms of comorbid psychopathology and greater past mental health service use, and in male-only measures, with poorer quality of life and elevated muscularity concerns. Subthreshold-BDD participants reported significantly lower mental health service use, and fewer symptoms of depression, eating disorders, and hyperactivity than probable-BDD participants, however, other comorbid symptoms did not differ significantly between these groups. These findings indicate that subthreshold-BDD is associated with substantial difficulties for adolescents in the general community. BDD screening should include subthreshold presentations, as these may be an important target for early intervention programs.

Transforming Life: A Broad View of the Developmental Origins of Health and Disease Concept from an Ecological Justice Perspective

The influential scientist Rene J. Dubos (1901–1982) conducted groundbreaking studies concerning early-life environmental exposures (e.g., diet, social interactions, commensal microbiota, housing conditions) and adult disease. However, Dubos looked beyond the scientific focus on disease, arguing that “mere survival is not enough”. He defined mental health as fulfilling human potential, and expressed concerns about urbanization occurring in tandem with disappearing access to natural environments (and elements found within them); thus modernity could interfere with health via “missing exposures”. With the advantage of emerging research involving green space, the microbiome, biodiversity and positive psychology, we discuss ecological justice in the dysbiosphere and the forces—financial inequity, voids in public policy, marketing and otherwise—that interfere with the fundamental rights of children to thrive in a healthy urban ecosystem and learn respect for the natural environment. We emphasize health within the developmental origins of health and disease (DOHaD) rubric and suggest that greater focus on positive exposures might uncover mechanisms of resiliency that contribute to maximizing human potential. We will entrain our perspective to socioeconomic disadvantage in developed nations and what we have described as “grey space”; this is a mental as much as a physical environment, a space that serves to insidiously reinforce unhealthy behavior, compromise positive psychological outlook and, ultimately, trans-generational health. It is a dwelling place that cannot be fixed with encephalobiotics or the drug-class known as psychobiotics.

Sub-threshold mental illness in adolescents: within and beyond DSM's boundaries

As researchers, clinicians and health systems strive to understand and improve mental health and well-being in youth, the parameters by which mental illness itself is defined have increasingly become the topic of inquiry. In the March 2015 issue of SPPE, Roberts et al. (Soc Psychiatry Psychiatr Epidemiol 50(3):397-406, 2015) integrate DSM diagnostic criteria with impairment in adolescents, showing that the latter is more frequent in full-syndrome disorders but still relevant for sub-threshold conditions, which have higher overall prevalence. These findings shift the focus away from specific diagnostic criteria and thresholds, and towards the backdrop of distress and impairment in young people. They also have implications for staging models and clinical services for youth mental health, particularly for prevention and early intervention efforts.

A plea for symptom-based research in psychiatry

BACKGROUND

The significant proportion of patients suffering from subthreshold diagnoses such as partial posttraumatic stress disorder (PTSD) shows that today's diagnostic entities do not fully meet the reality and needs of clinical practice. Moreover, as stated also in the recently announced concept of research domain criteria (RDoC), the use of today's traditional diagnostic systems in psychiatric research does not sufficiently promote an integrative understanding of mental disorders across multiple units of analysis from behavior to neurobiology. Besides RDoC, core symptom-based research concepts have been proposed to bridge the translational gap in psychiatry, but, unfortunately, have not yet become the rule.

OBJECTIVE/METHOD

First, this article briefly reviews literature on subthreshold PTSD (as an example for subthreshold diagnoses) and, second, pleas for and proposes a modified symptom-based research concept in psychiatry.

RESULTS

Subthreshold PTSD has, like other subthreshold psychiatric diagnoses, not yet been clearly defined. Diagnostic entities such as subthreshold PTSD are subject to a certain arbitrariness as they are mainly the result of empiricism. This fact stresses the urgent need for neurobiologically-informed psychiatric diagnoses and motivated the here-presented proposal of a symptom-based research concept. As proposed here, and before by other researchers, symptom-based research in psychiatry should refrain from studying patient cohorts compiled according to diagnoses but, instead, should focus on assessing cohorts grouped according to chief complaints or predominant psychopathological symptoms.

CONCLUSIONS

The linkage of the RDoC concept and symptom-based psychiatric research might probably speed up the definition of biologically or symptom-based psychiatric diagnoses, which might replace the auxiliary constructs of "traditional" diagnoses such as full and subthreshold PTSD, and promote the development of novel psychological and pharmacological treatments.