Legal issues: minors' decision-making capacity to refuse life-saving and life-sustaining treatment: legal and psychiatric perspectives

Laws in Belgium and the Netherlands permit euthanasia and assisted suicide for seriously ill children who experience "constant and unbearable suffering" – they have the capacity to request death by lethal injection if they convey a "reasonable understanding of the consequences" of that request. The child's capacity to understand death is therefore a prerequisite to the implementation of the request. However, modern neuro-psychological and fMRI (functional Magnetic Resonance Imaging) studies of the relationship between the neuro-anatomical development of the brain in human beings and their emotional and experiential capacity, demonstrates that both are not fully developed until the early 20s for girls and mid-20s for boys. Unlike Belgium and the Netherlands, the clinical and legal implications of the immaturity of the brain on medical decision-making of minors, in particular life and death decisions, have been implicit in the Australian courts' approach to the refusal of life-saving and life-sustaining treatment by minors. This approach is exemplified by X v Sydney Children's Hospitals Network [2013] NSWCA 320 (and a series of earlier cases).

Depression and suicidal behavior in adolescents : a multi-informant and multi-methods approach to diagnostic classification

Informant discrepancies have been reported between parent and adolescent measures of depressive disorders and suicidality. We aimed to examine the concordance between adolescent and parent ratings of depressive disorder using both clinical interview and questionnaire measures and assess multi-informant and multi-method approaches to classification.

Evolution of adolescent mental health in a rapidly changing socioeconomic environment: a review of mental health studies in adolescents in India over last 10 years

Background: Significant changes in the economic, familial and social support aspects in India have occurred in recent times, making it an interesting naturalistic setting to observe the effects of a dynamic socioeconomic environment on behavioral and emotional disorders in adolescents. Objective: This systematic review attempts to synthesize and evaluate the available evidence on mental health disorders and interventions in adolescents in India in last 10 years as well as identify conceptual trends and methodological lacunae in these studies. Method: A systematic search of electronic databases was performed in March 2014 and 27 school and community based studies evaluating behavioral problems, psychiatric morbidity, stress, suicide-related behaviors, depression, anxiety, aggression, self concept in adolescents in India were reviewed. Conclusion: There is a wide variation in the reported prevalence of psychiatric morbidity and behavioral problems in Indian adolescents. Some of the risk and protective factors are similar to those identified by other International studies in this age group. These include female gender, academic difficulties, parental fights, strained familial relationships, school absenteeism, school dropout and other school related factors. However, there are certain variables that appear to be context specific and need further investigation. These are mother's working status, studying in Government institutions or belonging to a nuclear family as risk factors and praying as a coping skill, parental involvement as a protective factor for psychiatric disorders. The suspected upward trend in the psychiatric morbidity in this age group needs more studies to be established. © 2014 Elsevier B.V.

Genetic polymorphisms in glutathione-S-transferases are associated with anxiety and mood disorders in nicotine dependence

Nicotine dependence is associated with an increased risk of mood and anxiety disorders and suicide. The primary hypothesis of this study was to identify whether the polymorphisms of two glutathione-S-transferase enzymes (GSTM1 and GSTT1 genes) predict an increased risk of mood and anxiety disorders in smokers with nicotine dependence.

Economically inactive, unemployed and employed suicides in Australia by age and sex over a 10-year period: what was the impact of the 2007 economic recession?

Suicide is higher among economically inactive and unemployed persons than employed persons. This paper investigates differences in this relationship by sex and age over the period 2001 to 2010 in Australia. It also examines changes in suicide among employed, unemployed and economically inactive persons during the recession of 2007-09.

Association of serum leptin and ghrelin with depressive symptoms in a Japanese working population: a cross-sectional study

Leptin and ghrelin have been implicated in the pathogenesis of major depression. However, evidence is lacking among apparently healthy people. This study examined the relationship of these appetite hormones to depressive symptoms in a Japanese working population.

Young adult sequelae of adolescent cannabis use: an integrative analysis

 Background: Debate continues about the consequences of adolescent cannabis use. Existing data are limited in statistical power to examine rarer outcomes and less common, heavier patterns of cannabis use than those already investigated; furthermore, evidence has a piecemeal approach to reporting of young adult sequelae. We aimed to provide a broad picture of the psychosocial sequelae of adolescent cannabis use. Methods: We integrated participant-level data from three large, long-running longitudinal studies from Australia and New Zealand: the Australian Temperament Project, the Christchurch Health and Development Study, and the Victorian Adolescent Health Cohort Study. We investigated the association between the maximum frequency of cannabis use before age 17 years (never, less than monthly, monthly or more, weekly or more, or daily) and seven developmental outcomes assessed up to age 30 years (high-school completion, attainment of university degree, cannabis dependence, use of other illicit drugs, suicide attempt, depression, and welfare dependence). The number of participants varied by outcome (N=2537 to N=3765). Findings: We recorded clear and consistent associations and dose-response relations between the frequency of adolescent cannabis use and all adverse young adult outcomes. After covariate adjustment, compared with individuals who had never used cannabis, those who were daily users before age 17 years had clear reductions in the odds of high-school completion (adjusted odds ratio 0·37, 95% CI 0·20-0·66) and degree attainment (0·38, 0·22-0·66), and substantially increased odds of later cannabis dependence (17·95, 9·44-34·12), use of other illicit drugs (7·80, 4·46-13·63), and suicide attempt (6·83, 2·04-22·90). Interpretation: Adverse sequelae of adolescent cannabis use are wide ranging and extend into young adulthood. Prevention or delay of cannabis use in adolescence is likely to have broad health and social benefits. Efforts to reform cannabis legislation should be carefully assessed to ensure they reduce adolescent cannabis use and prevent potentially adverse developmental effects. Funding: Australian Government National Health and Medical Research Council. © 2014 Elsevier Ltd.

International perspectives on psychosocial working conditions, mental health, and stress of dairy farm operators

Dairy farm operators-farmers, workers, and family members-are faced with many demands and stressors in their daily work and these appear to be shared across countries and cultures. Dairy operators experience high psychosocial demands with respect to a hard work and production ethos, economic influences, and social and environmental responsibility. Furthermore, both traditional and industrial farms are highly dependent on external conditions, such as weather, fluctuating markets, and regulations from government authorities. Possible external stressors include disease outbreaks, taxes related to dairy production, and recent negative societal attitudes to farming in general. Dairy farm operators may have very few or no opportunities to influence and control these external conditions, demands, and expectations. High work demands and expectations coupled with low control and lack of social support can lead to a poor psychosocial work environment, with increased stress levels, ill mental health, depression, and, in the worst cases, suicide. Internationally, farmers with ill mental health have different health service options depending on their location. Regardless of location, it is initially the responsibility of the individual farmer and farm family to handle mental health and stress, which can be of short- or long-term duration. This paper reviews the literature on the topics of psychosocial working conditions, mental health, stress, depression, and suicide among dairy farm operators, farm workers, and farm family members in an international perspective.

Out & online; effectiveness of a tailored online multi-symptom mental health and wellbeing program for same-sex attracted young adults: study protocol for a randomised controlled trial

Same-sex attracted young adults have been found to experience higher rates of mental health problems and greater difficulties in accessing specialist mental health care services compared to their heterosexual peers. Internet-based mental health interventions have the potential to be more engaging and accessible to young adults compared to those delivered face-to-face. However, they are rarely inclusive of lesbian women and gay men. Thus, the current study aims to evaluate the effectiveness of an online mental health and wellbeing program, Out & Online (http://www.outandonline.org.au), in comparison to a wait-list control group, for reducing anxiety and depressive symptoms in same-sex attracted young adults aged between 18 and 25 years.

Development of mental health first aid guidelines for suicidal ideation and behaviour: a Delphi study

BACKGROUND: Suicide is a statistically rare event, but devastating to those left behind and one of the worst possible outcomes associated with mental illness. Although a friend, family member or co-worker may be the first person to notice that a person is highly distressed, few have the knowledge and skills required to assist. Simple guidelines may help such a person to encourage a suicidal individual to seek professional help or decide against suicide.

METHODS: This research was conducted using the Delphi methodology, a method of reaching consensus in a panel of experts. Experts recruited to the panels included 22 professionals, 10 people who had been suicidal in the past and 6 carers of people who had been suicidal in the past. Statements about how to assist someone who is thinking about suicide were sourced through a systematic search of both professional and lay literature. The guidelines were written using the items most consistently endorsed by all three panels.

RESULTS: Of 114 statements presented to the panels, 30 were accepted. These statements were used to develop the guidelines appended to this paper.

CONCLUSION: There are a number of actions which are considered to be useful for members of the public when they encounter someone who is experiencing suicidal thoughts or engaging in suicidal behaviour. These guidelines will be useful in revision of curricula of mental health first aid and suicide intervention training programs. They can also be used by members of the public who want immediate information about how to assist a suicidal person.

Effects of asenapine in bipolar I patients meeting proxy criteria for moderate-to-severe mixed major depressive episodes: a post hoc analysis

OBJECTIVE: Depression is the predominant psychosocial and suicide burden in bipolar disorder, yet there is a paucity of evidence-based treatments for bipolar depression. METHODS: This post hoc subgroup analysis of data pooled from two 3-week, randomized, placebo- and olanzapine-controlled trials (December 2004-April 2006, N = 489 and November 2004-April 2006, N = 488) examined a subgroup of patients meeting criteria for moderate-to-severe mixed major depressive episodes, defined using DSM-IV-TR criteria for mixed episodes (mania and major depression simultaneously) with a baseline Montgomery-Asberg Depression Rating Scale (MADRS) total score ≥ 20. RESULTS: Decreases in MADRS scores (least squares mean [SE]), the a priori primary outcome, were significantly greater in the asenapine group than in the placebo group from baseline to day 7 (-11.02 [1.82] vs -4.78 [1.89]; P = .0195), day 21 (-14.03 [2.01] vs -7.43 [2.09]; P = .0264), and endpoint (-10.71 [1.76] vs -5.19 [1.98]; P = .039). Decreases in MADRS scores with asenapine were significantly greater than with olanzapine from baseline to day 7 (-6.26 [1.47]; P = .0436). Decreases in Young Mania Rating Scale mean total score were greater with asenapine than with placebo or olanzapine at all time points assessed. A significantly greater reduction from baseline to day 21 in the Short Form-36 mental component summary score was observed with asenapine, but not olanzapine, compared with placebo (16.57 vs 5.97; P = .0093). Asenapine was generally well tolerated. CONCLUSIONS: These data provide support for the potential efficacy of asenapine in mixed major depressive episodes; however, these data cannot be linearly extrapolated to nonmixed major depression.

Contact & connect-an intervention to reduce depression stigma and symptoms in construction workers: protocol for a randomised controlled trial

BACKGROUND: Males employed in the construction industry have high rates of suicide. Although reasons underpinning this risk are multifaceted, poor help-seeking and stigma are represent major contributors. Males in the construction industry are also exposed to other risk factors for mental ill health and suicide, including unemployment. Sigma-reducing interventions that are accessible and attractive to recently unemployed males in the construction industry could therefore improve help-seeking, and address depression and suicidal behaviour in this population. METHODS/DESIGN: Contact&Connect will use a parallel individual randomized design to evaluate the effectiveness of a multimedia-based intervention aimed at reducing stigma. The intervention consists of a package of 12 brief contact interventions (BCIs) delivered over a six month period. BCIs will direct participants to informational programs and microsites. Content will address three major themes: debunking depression myths and stereotypes, normalisation, and empowerment. Target enrolment is 630 (315 in each arm), each to be followed for 12 months. Eligible participants will be males, between 30 and 64 years, unemployed at the time of recruitment, registered with Incolink (a social welfare trustee company for unemployed members of the construction industry), and own a smart phone with enabled internet connectivity. DISCUSSION: At present, there are no programs that have been shown to be effective in reducing stigma in the blue-collar male population. Contact&Connect promises to provide a tailored, efficient, and scalable approach to reducing stigma, depressive symptoms and suicidality among unemployed males. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Register ACTRN12615000792527  (date of registration: 30 July, 2015).

Pharmacological interventions for self-harm in adults

Background
Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review in to three separate reviews. This review is focused on pharmacological interventions in adults who self harm.
Objectives
To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients.
Search methods
For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013.
Selection criteria
We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services.
Data collection and analysis
We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta-analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow-up. For this analysis, we pooled data using a random-effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach.
Main results
We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low-dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0. 50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported.
Authors’ conclusions
Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.

Suicidal ideation reported by adults with type 1 or type 2 diabetes: results from Diabetes MILES-Australia

AIMS: To examine the prevalence and correlates of suicidal ideation in a community-based sample of adults with Type 1 or Type 2 diabetes.

METHODS: Participants were 3338 adults aged 18-70 years with Type 1 diabetes (n=1376) or Type 2 diabetes (non-insulin: n=1238; insulin: n=724) from a national survey administered to a random sample registered with the National Diabetes Services Scheme. Depression and suicidal ideation were assessed using the Patient Health Questionnaire, and diabetes-specific distress with the Problem Areas In Diabetes scale. Separate logistic regression analyses by diabetes type/treatment were used to determine relative contribution to suicidal ideation.

RESULTS: Overall, we observed a suicidal ideation rate of 14% in our sample. Participants with Type 2 diabetes using insulin reported more frequent depressive symptoms, and were more likely to report recent suicidal ideation (19%) compared with those with either Type 1 diabetes or Type 2 diabetes not using insulin (14 and 12%, respectively). After controlling for depression, there was little difference in the prevalence of suicidal ideation between diabetes types/treatments, but higher diabetes-specific distress significantly increased the odds of suicidal ideation.

CONCLUSIONS: As suicidal ideation is a significant risk factor for a suicide attempt, the findings have implications for healthcare professionals, pointing to the importance of adequate screening and action plans for appropriate follow-up of those reporting depression. Our findings are also indicative of the psychological toll of diabetes more generally, and the need to integrate physical and mental healthcare for people with diabetes. This article is protected by copyright. All rights reserved.

Interventions for self-harm in children and adolescents

Background : Self-harm(SH; intentional self-poisoning or self-injury) is common in children and adolescents, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews; this review is focused on psychosocial and pharmacological interventions for SH in children and adolescents.

Objectives : To identify all randomised controlled trials of psychosocial interventions, pharmacological agents, or natural products for SHin children and adolescents, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., treatment as usual (TAU), placebo, or alternative pharmacological treatment) for children and adolescents who SH.

Search methods : For this update the Cochrane Depression, Anxiety and Neurosis Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (30 January 2015).

Selection criteria : We included randomised controlled trials comparing psychosocial or pharmacological treatments with treatment as usual, alternative treatments, or placebo or alternative pharmacological treatment in children and adolescents (up to 18 years of age) with a recent (within six months) episode of SH resulting in presentation to clinical services.