Professor Brian Kelly

Background: The methodological choice of aggregated estimates for meta-analysis may be notable for some common drawbacks, including variations in the cut-off values of depression, and lower statistical power for analyzing the associated factors. The study aimed to refine the precision of previous findings on the prevalence of depressive symptoms among medical students, through gathering individual participant data (IPD) as identified from our previous reviews. Material and methods: In the present study, we searched MEDLINE, EMBASE, PsycINFO, WanFang, Scielo and LILACS to identify published systematic reviews and meta-analyses up to March 2018, then individual data was requested for further analysis (PROSPERO registration: CRD42018091917). The participants¿ age, sex, year of study, scores for depressive symptoms, and other predictor variables were requested. To pool the prevalence from the included studies, random-effects model (two-step method) was used. Multiple linear regression was used to examine the associated factors on the depression z-scores (one-step method). Results: Of the 249 studies, the datasets of 34 studies were included. The crude prevalence was 19.4% (95% CI: 18.8%, 19.9%) by one-step method and the pooled prevalence was 18.1% (95% CI: 14.1%, 22.1%) by two-step method. Multiple linear regression revealed that being a female, older age, and senior year of study were significantly associated with the z-score. Conclusion: The pooled prevalence of depressive symptoms from the Individual Participant Data (IPD) meta-analysis was lower than the previous meta-analyses using aggregated data. Age, sex, and year of study were significantly associated with the depression z-score. IPD meta-analysis may provide a more accurate estimation of disease burden, and allow verification of associated factors.

Background: Optimal strategies to facilitate implementation of evidence-based clinical pathways are unclear. We evaluated two implementation strategies (Core versus Enhanced) to facilitate implementation of a clinical pathway for the management of anxiety and depression in cancer patients (the ADAPT CP). Methods: Twelve cancer services in NSW Australia were cluster randomised, stratified by service size, to the Core versus Enhanced implementation strategy. Each strategy was in place for 12¿months, facilitating uptake of the ADAPT CP (the intervention being implemented). The Core strategy included a lead team with champions, staff training and awareness campaigns prior to implementation, plus access to feedback reports and telephone or online support during implementation. The Enhanced strategy included all Core supports plus monthly lead team meetings, and proactive, ongoing advice on managing barriers, staff training and awareness campaigns throughout implementation. All patients at participating sites were offered the ADAPT CP as part of routine care, and if agreeable, completed screening measures. They were allocated a severity step for anxiety/depression from one (minimal) to five (severe) and recommended management appropriate to their severity step. Multi-level mixed-effect regression analyses examined the effect of Core versus Enhanced implementation strategy on adherence to the ADAPT CP (binary primary outcome: adherent = 70% of key ADAPT CP components achieved versus non-adherent < 70%), with continuous adherence as a secondary outcome. Interaction between study arm and anxiety/depression severity step was also explored. Results: Of 1280 registered patients, 696 (54%) completed at least one screening. As patients were encouraged to re-screen, there were in total 1323 screening events (883 in Core and 440 in Enhanced services). The main effect of implementation strategy on adherence was non-significant in both binary and continuous analyses. Anxiety/depression step was significant, with adherence being higher for step 1 than for other steps (p = 0.001, OR = 0.05, 95% CI 0.02¿0.10). The interaction between study arm and anxiety/depression step was significant (p = 0.02) in the continuous adherence analysis only: adherence was significantly higher (by 7.6% points (95% CI 0.08¿15.1%) for step 3 in the Enhanced arm (p =.048) and trending to significance for step 4. Discussion: These results support ongoing implementation effort for the first year of implementation to ensure successful uptake of new clinical pathways in over-burdened clinical services. Trial registration: ANZCTR Registration: ACTRN12617000411347 (Trial registered 22/03/2017; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372486&isReview=true)

Schizophrenia (SCZ) is a chronic mental illness and among the most debilitating conditions encountered in medical practice. A recent landmark SCZ study of the protein-coding regions of the genome identified a causal role for ten genes and a concentration of rare variant signals in evolutionarily constrained genes1. This recent study¿and most other large-scale human genetics studies¿was mainly composed of individuals of European (EUR) ancestry, and the generalizability of the findings in non-EUR populations remains unclear. To address this gap, we designed a custom sequencing panel of 161 genes selected based on the current knowledge of SCZ genetics and sequenced a new cohort of 11,580 SCZ cases and 10,555 controls of diverse ancestries. Replicating earlier work, we found that cases carried a significantly higher burden of rare protein-truncating variants (PTVs) among evolutionarily constrained genes (odds ratio = 1.48; P = 5.4 × 10-6). In meta-analyses with existing datasets totaling up to 35,828 cases and 107,877 controls, this excess burden was largely consistent across five ancestral populations. Two genes (SRRM2 and AKAP11) were newly implicated as SCZ risk genes, and one gene (PCLO) was identified as shared by individuals with SCZ and those with autism. Overall, our results lend robust support to the rare allelic spectrum of the genetic architecture of SCZ being conserved across diverse human populations.

In vivo experimental analysis of human brain tissue poses substantial challenges and ethical concerns. To address this problem, we developed a computational method called the Brain Gene Expression and Network-Imputation Engine (BrainGENIE) that leverages peripheral-blood transcriptomes to predict brain tissue-specific gene-expression levels. Paired blood¿brain transcriptomic data collected by the Genotype-Tissue Expression (GTEx) Project was used to train BrainGENIE models to predict gene-expression levels in ten distinct brain regions using whole-blood gene-expression profiles. The performance of BrainGENIE was compared to PrediXcan, a popular method for imputing gene expression levels from genotypes. BrainGENIE significantly predicted brain tissue-specific expression levels for 2947¿11,816 genes (false-discovery rate-adjusted p < 0.05), including many transcripts that cannot be predicted significantly by a transcriptome-imputation method such as PrediXcan. BrainGENIE recapitulated measured diagnosis-related gene-expression changes in the brain for autism, bipolar disorder, and schizophrenia better than direct correlations from blood and predictions from PrediXcan. We developed a convenient software toolset for deploying BrainGENIE, and provide recommendations for how best to implement models. BrainGENIE complements and, in some ways, outperforms existing transcriptome-imputation tools, providing biologically meaningful predictions and opening new research avenues.

Objective: In response to the COVID-19 pandemic, use of telehealth to deliver care was recommended across the Australian health system. This study aims to explore the barriers and enablers to delivery of psycho-oncology services via telehealth and attitudes to use of telehealth in psycho-oncology. Methods: Twenty-one psycho-oncology clinicians participated in semi-structured telephone interviews. Transcribed interviews were thematically analysed using the framework method. Results: Three key themes were identified which described the overall experience of delivering psycho-oncology services via telehealth: (1) Context Matters-for whom is telehealth effective, when is it less effective; (2) Therapy content and telehealth implementation; (3) Recommendations for Sustainability. Conclusions: These insights into the barriers and enablers to delivering psycho-oncology services via telehealth inform future research and clinical practice. While there is support for the continued use of telehealth in psycho-oncology, there are significant improvements needed to ensure effective implementation and continued benefit.

Schizophrenia has a heritability of 60¿80%1, much of which is attributable to common risk alleles. Here, in a two-stage genome-wide association study of up to 76,755 individuals with schizophrenia and 243,649 control individuals, we report common variant associations at 287 distinct genomic loci. Associations were concentrated in genes that are expressed in excitatory and inhibitory neurons of the central nervous system, but not in other tissues or cell types. Using fine-mapping and functional genomic data, we identify 120 genes (106 protein-coding) that are likely to underpin associations at some of these loci, including 16 genes with credible causal non-synonymous or untranslated region variation. We also implicate fundamental processes related to neuronal function, including synaptic organization, differentiation and transmission. Fine-mapped candidates were enriched for genes associated with rare disruptive coding variants in people with schizophrenia, including the glutamate receptor subunit GRIN2A and transcription factor SP4, and were also enriched for genes implicated by such variants in neurodevelopmental disorders. We identify biological processes relevant to schizophrenia pathophysiology; show convergence of common and rare variant associations in schizophrenia and neurodevelopmental disorders; and provide a resource of prioritized genes and variants to advance mechanistic studies.

Objective: ComPsych communication skills training is designed to teach psychiatry trainees effective skills and strategies for undertaking key communication tasks relating to mental illness, such as schizophrenia, with patients and their families/carers. This study examined the program¿s feasibility, utility, and trainees¿ self-efficacy. Methods: Trainee cohorts attending their first year formal education course were recruited annually over 4¿years between 2015 and 2018. Each trainee attended at least one session of training in their cohort year. Trainees completed a questionnaire presenting questions about personal demographics, their perceived confidence in communication, and the effectiveness of elements of training delivery. A total of 41 trainee psychiatrists (15 male) completed the questionnaires presented at four time points (two pre-training and two post-training). Results: Participants reported a significant increase in confidence in their own communication skills post-training (d = 1.12) and rated elements of training delivery (video feedback, feedback from peers in small groups, small group facilitation, and use of simulated patients) as significantly more helpful or effective post-training (d = 0.42). Trainees also reported a significantly increased ability to critically evaluate their own communication skills post-training (d = 0.59), suggesting an increased ability to recognize their own communication skill competence. Conclusions: Following ComPsych training, trainees were more confident discussing information about schizophrenia with patients and their families/carers and were more able to critically evaluate their own communication skills: an important feature of good clinical acumen. These subjective ratings provide important self-efficacy information, including the benefits perceived and evidence of the program¿s feasibility and utility.

Background: Depression and obesity are major health concerns and commonly co-exist, but men rarely seek help for these conditions. SHED-IT: Recharge was a gender-tailored eHealth program for men that generated clinically meaningful improvements in weight and depressive symptoms. Purpose: To evaluate behavioral and psychological outcomes from the SHED-IT: Recharge intervention designed for overweight/obese men with low mood. Methods: Overall, 125 men (18-70 years) with a BMI between 25 and 42 kg/m2 and depressive symptoms (PHQ-9 = 5) were randomly allocated to SHED-IT: Recharge (n = 62) or wait-list control (n = 63) groups. The self-directed program targeted key health behaviors combined with online mental fitness modules based on cognitive behavioral therapy. Behavioral (e.g., physical activity) and psychological outcomes (e.g., cognitive flexibility) were assessed with validated measures at baseline, 3 months (post-test) and 6 months (follow-up). Intention-to-treat linear mixed models examined treatment effects, which were adjusted for covariates, and effect size estimated (Cohen's d). Results: At post-test, intervention men achieved small-to-medium improvements in several health behavior outcomes including moderate-to-vigorous physical activity, light physical activity, sedentary behavior, sleep, energy intake, portion size, and risky alcohol consumption (range, d = 0.3-0.5), when compared with the control group. Intervention effects were also observed for perceived physical self-worth, perceived physical strength, cognitive flexibility, and behavioral activation (range, d = 0.3-0.8). No effects were found for fruit and vegetable intake, or mindful attention. Most effects were maintained at follow-up. Conclusions: This gender-tailored, eHealth program with integrated mental fitness support elicited meaningful improvements in health behaviors and psychological outcomes for men with low mood. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12619001209189).

Background: Cross-sectional research has highlighted the emotional impacts of coronavirus disease 2019 (COVID-19) in cancer communities. The aim of this study was to extend findings and to provide a longitudinal perspective of emotional effects of COVID-19 on a range of participants, including patients with cancer, their family members, and oncology health professionals (HPs) in Australia. Methods: This mixed-methods, longitudinal study incorporated semistructured interviews and psychological well-being survey data collected at three time points between June 2020 and October 2021. Results: Seventy-seven participants volunteered at time point 1 (T1; 32 patients, 16 caregivers, 29 HPs), 52 at timepoint 2 (23 patients, 10 caregivers, 19 HPs), and 43 at timepoint 3 (19 patients, 8 caregivers, 16 HPs). Overall, participants were psychologically well; however, elevated depressive symptoms were detected in HPs by timepoint 3. Qualitative results highlighted the emotional toll of COVID-19 for all participant groups over time. Three shared themes emerged: (1) balancing fear and safety, (2) uncertainty in an ever-changing situation, and (3) fatigue due to lack of support and sense of isolation. An additional theme unique to HPs was also identified: (4) a sense of dread for what is to come in an already exhausted workforce. Conclusion: Despite Australia's relatively low COVID-19 case numbers, an emotional toll on the cancer community was apparent. Longitudinal results indicate consistency of themes over time with the burden for HPs adding a theme by the third interview. Participants were challenged to balance needs of personal safety against cancer priorities in an environment of uncertainty and isolation. Over time, a sense of fatigue emerged, and for HPs, increased workloads left many feeling overwhelmed and unsupported with a sense of dread around future outcomes. © 2022

Background: Clinical pathways (CPs) are intended to standardise and improve care but do not always produce positive outcomes, possibly because they were not adapted to suit the specific context in which they were enacted. This qualitative study aimed to explore staff perspectives of implementation of a CP for routine screening, assessment, referral and management of anxiety and depression (the ADAPT CP) for patients with cancer, focussing on perceived feasibility of the CP and negotiated adaptations made during the implementation phase. Methods: The ADAPT CP was implemented in 12 urban and regional oncology services in Australia. Services were randomised to receive core versus enhanced implementation strategies. Core sites received support until implementation commencement and could access progress reports. Enhanced sites received proactive, ongoing support during the 12-month implementation. Purposively selected staff were interviewed prior to implementation (n = 88) and 6 months later, half-way through the implementation period (n = 89). Monthly meetings with lead multi-disciplinary teams at the eight enhanced sites were recorded. Data were thematically analysed. Results: Six overarching themes were identified: ADAPT is of high value; timing for introducing the CP and screening is difficult; online screening is challenging; a burden too much; no-one to refer patients to; and micro-logistics are key. While early screening was deemed desirable, diverse barriers meant this was complex, with adaptations made to time and screening location. Online screening prompted by email, seen as time-saving and efficient, also proved unsuccessful in some services, with adaptations made to in-clinic or phone screening, or repeated email reminders. Staff negative attitudes to ADAPT, time constraints, and perceived poor fit of ADAPT to work roles and flows, all impacted implementation, with key tasks often devolving to a few key individuals. Nevertheless, services remained committed to the ADAPT CP, and worked hard to create, review and adapt strategies to address challenges to optimise success. Conclusions: This study demonstrates the interactive nature of health service change, with staff actively engaging with, forming views on, and problem-solving adaptations of the ADAPT CP to overcome barriers. Obtaining staff feedback is critical to ensure health service change is sustainable, meaningful and achieves its promise of improving patient outcomes. Trial registration: The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347.

Background: There is growing recognition of mental health aspects of workplace health and safety. Mining is a significant enterprise in the African continent; however, limited attention has been given to mental health in mining in this region. Ghana is the largest gold producer in Africa and mining contributes significantly to the economy. Mental health problems can have significant implications for the wellbeing and safety of mining employees, yet little is known about this in diverse geographic and cultural contexts. This study aims to explore mental health and available supports from the perspective of managers in mining companies in Ghana. Methods: A qualitative descriptive methodology was used to collect in-depth information from managers of international mining companies in Ghana. After receiving institutional ethics approval, all managers from the five mine sites were invited to participate in an interview. All interviews were audiotaped and transcribed verbatim for thematic analysis. Results: Three major themes were identified: Health Promotion, which explored health assessments and health promotion onsite activities; Onsite Support which included policy, human resources and medical supports; thirdly External Support, examined formal and informal supports such as family and social networks. Conclusion: Mental health was implied in various activities undertaken at the mine rather than being specific to targeting mental health directly. This study demonstrates the absence of mental health supports in mining in Ghana. Efforts should be made to incorporate mental health programs within the general health and safety policy, and an understanding of the local social norms and culture is vital.

Background: In 2019, cancer patients comprised over 65% of all individuals who requested and received Medical Assistance in Dying (MAID) in Canada. This descriptive study sought to understand the self-reported symptom burden and complexity of cancer patients in the 12 months prior to receiving MAID in Alberta. Methods: Between July 2017 and January 2019, 337 cancer patients received MAID in Alberta. Patient characteristics were descriptively analyzed. As such, 193 patients (57.3%) completed at least one routine symptom-reporting questionnaire in their last year of life. Mixed effects models and generalized estimating equations were utilized to examine the trajectories of individual symptoms and overall symptom complexity within the cohort over this time. Results: The results revealed that all nine self-reported symptoms, and the overall symptom complexity of the cohort, increased as patients¿ MAID provision date approached, particularly in the last 3 months of life. While less than 20% of patients experienced high symptom complexity 12 months prior to MAID, this increased to 60% in the month of MAID provision. Conclusions: Cancer patients in this cohort experienced increased symptom burden and complexity leading up to their death. These findings could serve as a flag to clinicians to closely monitor advanced cancer patients¿ symptoms, and provide appropriate support and interventions as needed.

Objective: Cancer patients, carers and oncology health professionals have been impacted by the COVID-19 pandemic in many ways, but their experiences and psychosocial responses to the pandemic are still being explored. This study aimed to document the experience of Australians living with cancer, family carers, and Oncology health professionals (HPs) when COVID-19 first emerged. Methods: In this qualitative study, participants (cancer patients currently receiving treatment, family carers and HPs) completed a semi-structured interview exploring their experiences of COVID-19 and the impact it had on cancer care. Participants also completed the Hospital Anxiety and Depression Scale (patients) and the Depression, Anxiety and Stress Scale (carers and HPs) to assess emotional morbidity. Thematic analysis was undertaken on qualitative data. Results: 32 patients, 16 carers and 29 HPs participated. Qualitative analysis yielded three shared themes: fear and death anxiety, isolation, and uncertainty. For HPs, uncertainty incorporated the potential for moral distress and work-stress. Patients and carers scoring high on anxiety/depression measures were more likely to have advanced disease, expressed greater death anxiety, talked about taking more extreme precautionary measures, and felt more impacted by isolation. Conclusion: Cancer and COVID-19 can have compounding psychological impacts on all those receiving or giving care. Practice Implications: Screening for distress in patients, and burnout in HPs, is recommended. Increased compassionate access and provision of creative alternatives to face-to-face support are warrented.

Aims: Translation of evidence-based psycho-oncology interventions into routine care can significantly improve patient outcomes, yet effective implementation remains challenging due to numerous real-world barriers. A key factor that may influence implementation is organisational readiness for change. This mixed method study sought to identify factors associated with organisational readiness for implementing the Australian clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP). Methods: We collected data from multidisciplinary staff across six Australian cancer services who were preparing to implement the ADAPT CP. Services were categorised as having ¿high¿ versus ¿mid-range¿ organisational readiness based on a median split on the Organizational Readiness for Implementing Change (ORIC) questionnaire (score range = 12¿60). Qualitative data from the semi-structured interviews based on the Promoting Action Research in Health Services (PARiHS) framework were analysed thematically and compared for services with high- versus mid-range organisational readiness. Results: Three services with high- (mean ORIC range, 52.25¿56.88), and three with mid-range (range, 38.75¿46.39) organisational readiness scores were identified. Staff at services reporting higher readiness described a more collaborative and proactive service culture, strong communication processes and greater role flexibility. They also reported greater confidence in overcoming anticipated barriers and clearer strategies for addressing issues. Conclusions: Levels of organisational readiness were related to distinct qualitative themes. Targeting these issues in services where readiness is mid-range or low prior to full-scale roll-out may improve staff levels of confidence and efficacy in implementing psycho-oncology-focused interventions.

Purpose: There is limited empirical evidence regarding mental health in workplace settings in Africa. Gold mining is a major industry in Ghana, and this study investigated mental health-related symptoms and the factors contributing to such symptoms among employees in the Ghanaian. Methods: A cross-sectional survey design study was used to collect data from employees working in the mining industry across five gold mines in Ghana. All mining employees were invited to participate in the survey. Sociodemographic and work characteristic data (including job content) was collected alongside measures of recent mental health-related symptoms (Kessler-10). Questionnaires were administered in English. Data were analysed using descriptive statistics and logistic regression models. Results: Of 1165 participants (response rate: 78%), 87% were male and 13% were female. The majority of the participants were in the 25¿34 age category. Psychological distress was categorized as low (62.6%), moderate (24.3%), high (10.0%) and very high (3.2%). Shift type (working 12¿h or more), physical working conditions and financial factors were significantly associated with psychological distress. Job resources and job demands was not significantly associated with levels of psychological distress. Conclusion: This is the first study to explore mental health in the Ghanaian gold mining industry. The findings identify workplace factors associated with psychological distress in the mining industry in Ghana and support the importance of promoting mental health as part of workplace health and safety strategy to improve mental health across the mining population.

Objectives: To examine if baseline stigma predicts psychological distress at 3 and 6 months follow-up among patients newly diagnosed with lung cancer. Methods: This longitudinal study was nested within a larger randomised controlled trial. Eligible participants were recruited via respiratory and oncology out-patient clinics in Australia (n¿=¿194). Consenting participants were asked to complete surveys at baseline, 3 and 6 months post-recruitment. Measures included lung cancer stigma (Cataldo Lung Cancer Stigma Scale) and psychological distress (General Health Questionnaire-12 [GHQ-12]). Results: One-hundred and ninety-four participants were included for analysis. Most were male (57.7%) with a mean age of 68 years (SD¿=¿8.8). A significant relationship between baseline lung cancer stigma and psychological distress at 6 months was found, where a one unit increase in lung cancer stigma increases psychological distress by 0.044 when adjusting for age, gender, smoking status, baseline GHQ-12 scores and intervention allocation (as part of the larger trial; p¿=¿0.001; ß¿=¿0.044, 95% CI¿=¿0.010, 0.079). Conclusion: Temporal links between lung cancer stigma and psychological distress was found at 6 months, suggesting stigma-related experiences may have a delayed impact. Development of routine lung cancer stigma assessments is recommended to identify those at risk of psychological distress.

Drought is a global threat to public health. Increasingly, the impact of drought on mental health and wellbeing is being recognized. This paper investigates the relationship between drought and well-being to determine which drought indices most effectively capture well-being outcomes. A thorough understanding of the relationship between drought and well-being must consider the (i) three aspects of drought (duration, frequency, and magnitude); (ii) different types of drought (meteorological, agricultural, etc.); and (iii) the individual context of specific locations, communities, and sectors. For this reason, we used a variety of drought types, drought indices, and time windows to identify the thresholds for wet and dry epochs that enhance and suppress impacts to well-being. Four postcodes in New South Wales (NSW), Australia, are used as case studies in the analysis to highlight the spatial variability in the relationship between drought and well-being. The results demonstrate that the relationship between drought indices and well-being outcomes differs temporally, spatially, and according to drought type. This paper objectively tests the relationship between commonly used drought indices and wellbeing outcomes to establish whether current methods of quantifying drought effectively capture well-being outcomes. For funding, community programs, and interventions to result in successful adaptation, it is essential to critically choose which drought index, time window, and well-being outcome to use in empirical studies. The uncertainties associated with these relationships must be accounted for, and it must also be realized that results will differ on the basis of these decisions.

Background: Coal miners have been reported to have higher rates of risky/harmful alcohol misuse; however, it is not known if metalliferous mining employees whose working conditions differ in workplace practices, also have increased rates of risky/harmful alcohol misuse. This study aimed to examine alcohol consumption in a sample of Australian metalliferous mining workers and to examine the demographic and workplace factors associated with risky/harmful alcohol use. Methods: All employees from a convenience sample of four Australian mine sites were invited to complete a paper-based cross-sectional survey between June 2015 and May 2017. The survey contained questions relating to social networks, health behaviors, psychological distress, demographic characteristics, and risky/harmful drinking. Current alcohol use was measured by the Alcohol Use Disorders Identification Test (AUDIT), a validated measure of risky and/or harmful drinking. Factors associated with risky/harmful drinking were investigated using univariate and multivariable logistic regression. Findings: A total of 1,799 participants completed the survey (average site response rate 95%). Overall, 94.8% of males and 92.1% of females reported using alcohol in the preceding 12 months. The odds of risky/harmful alcohol use were significantly higher in those who were male, younger, and reported higher psychological distress. Conclusions/Application to Practice: This study identified that metalliferous mining employees engage in at-risk levels of alcohol consumption significantly higher than the national average despite workplace policies and practices that restrict alcohol use. Personal and workplace risk factors that may help target specific employee groups and inform the development of tailored, integrated multicomponent intervention strategies for the industry were identified.

Background: In Australia, it is projected that one in four individuals will be at the nominal retirement age of 65 or over by 2056; this effect is expected to be especially pronounced in rural areas. Previous findings on the effects of retirement on wellbeing have been mixed. The present study explores the effects of employment and retirement on health and wellbeing among a sample of rural Australians. Methods: Australian Rural Mental Health Study participants who were aged 45 or over (N = 2013) were included in a series of analyses to compare the health and wellbeing of individuals with differing employment and retirement circumstances. Self-reported outcome variables included perceived physical health and everyday functioning, financial wellbeing, mental health, relationships, and satisfaction with life. Results: Across the outcomes, participants who were employed or retired generally reported better health and wellbeing than those not in the workforce. Retired participants rated more highly than employed participants on mental health, relationships, and satisfaction with life. There was also a short-term benefit for perceived financial status for retired participants compared to employed participants, but this effect diminished over time. Conclusions: While retirement is a significant life transition that may affect multiple facets of an individual¿s life, the direction and magnitude of these effects vary depending on the retirement context, namely the pre-retirement and concurrent circumstances within which an individual is retiring. Personal perceptions of status changes may also contribute to an individual¿s wellbeing more so than objective factors such as income. Policies that promote rural work/retirement opportunities and diversity and address rural disadvantage are needed.

Background: The significant psychosocial morbidity experienced by cancer patients is often undetected and untreated. Despite international priority given to psychosocial care for cancer patients, implementation of psychosocial programs into routine cancer care is limited. We developed, implemented, and assessed the impact, acceptability, and cost of an integrated, patient-centered Psychosocial Assessment, Care and Treatment (PACT) model of care for cancer patients within a general hospital setting. Methods: A time series research design was implemented to test the PACT model of care, newly introduced in an Australian tertiary hospital. System-level impact on systematic distress screening and management was assessed through audit of the medical records of three cross-sectional samples of 141 patients, at baseline and at 12 and 24¿months post-baseline. The impact of the model on patient experience and health care professionals' (HCPs) knowledge and confidence was assessed via surveys. The acceptability of the intervention was assessed through HCP interviews at 24¿months. The cost of the intervention was assessed by PACT staff recording the time spent on care provision, training, and intervention administration, and associated costs were calculated using staff payment rates adjusted for superannuation and leave. Results: Across the 24¿months of implementation, formal distress screening increased from 0% at baseline to 29% of patients at 12¿months and 31% of patients at 24¿months, with an associated decrease in informal screening as formal screening increased. There was no notable change in distress management (ie, development of care plans) across the time period. Baseline patient experience was already high (mean score = 46.85/55) and did not change significantly over the course of the study. In both general and specific areas of addressing patient psychosocial concerns, HCP knowledge and confidence was moderate and remained largely unchanged over the course of the study. HCPs perceived the PACT model as highly beneficial and instrumental in bringing about significant changes to staff's knowledge, practices and awareness of psychosocial issues. The estimated total labor cost (including on-costs) was AUD$119,239 (over the 2¿years); with a declining cost over the lifetime of the intervention reflecting the higher initial set-up costs. Conclusions: Although the PACT model was associated with an increase in distress screening, staff workloads, high turnover, and administrative barriers may have restricted the translation into distress management. Future research exploring effective avenues to engage staff at a management level and ensure that staff view distress management as a valuable component of their role may assist to embed strategies into the general hospital culture and lead to more sustainable changes.

As with many OECD countries, graduating medical students have been choosing specialist careers at a greater rate than ever before. Generalism in the form of family (general practice) and more generalist medical specialties have been trending down resulting in distributional geographic challenges. With the advent of COVID-19 in March 2020, medical schools and in particular the Joint Medical Program situated in a regional and rural area in NSW Australia had the unique opportunity to rethink the penultimate year curriculum when the previous rapid rotation model through numerous medical specialities became untenable. The need to vision a new practical pragmatic curriculum spurred a rapid revaluation of assessment, placement length and model with a pivot to an "embedded senior student placement" agnostic of discipline and supported by a competency-based learning portfolio. This article explores the barriers and enablers and identifies the potential elements of this type of placement which can be adapted to community and smaller rural sites. The positive student and supervisor experience also enabled an employment model to be woven into the students learning and ensured on hand medical student workforce for hospitals throughout the rural footprint. The capacity of these placements to celebrate variation in experience and support students to learn on the job have now caused a revision of the penultimate year with expectation of gains in students' satisfaction and in employability. It has also opened up options to deliver and increase the inherent value of generalist placements with likely long term workforce benefit.

The goals of this study were to determine the feasibility of engaging youth with major depressive disorder (MDD) in a multimodal exercise intervention (Healthy Body Healthy Mind) plus usual care and to evaluate the magnitude of its effects on psychological, physical fitness, and biomarker outcomes to inform a future randomized controlled trial. Youth (15 to 25 y of age) with MDD diagnosed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) were eligible to participate. Feasibility measures included recruitment, retention, and program adherence rates. The exercise program consisted of a single session of motivational interviewing to enhance exercise adherence, then 1-hour, small-group supervised exercise sessions 3 times per week for 12 weeks. Assessments were administered at baseline and at 12 weeks. Depression symptoms were assessed using the Beck Depression Inventory (BDI-II). Physical fitness and blood biomarkers were also measured. Three males and 10 females with MDD, who were 18 to 24 years of age, participated. Retention at 12 weeks was 86%, and attendance at exercise sessions averaged 62% ± 28%. After 12 weeks, 69% of participants experienced a remission of MDD based on the SCID. Mean BDI-II scores decreased from 31.9 ± 9.1 to 13.1 ± 10.1 [Cohen d effect size (ES) = 1.96]. Improvements were observed in upper (ES = 0.64) and lower (ES = 0.32) body muscular endurance. Exercise session attendance was moderately correlated with changes in BDI-II scores (Pearson r = 0.49). It appears feasible to attract and engage some youth with MDD in an exercise intervention. The positive impact on depression symptoms justifies further studies employing exercise interventions as an adjunct to routine care for young people with MDD.

Introduction The debate regarding euthanasia and physician-assisted suicide (E/PAS) raises key issues about the role of the doctor, and the professional, ethical, and clinical dimensions of the doctor-patient relationship. This review aimed to examine the published evidence regarding the response of doctors who have participated in E/PAS.Methods Original research papers were identified reporting either qualitative or qualitative data published in peer-reviewed literature between 1980 and March 2018, with a specific focus on the impact on, or response from, physicians to their participation in E/PAS. PRISMA and CASP guidelines were followed.Results Nine relevant papers met selection criteria. Given the limited published data, a descriptive synthesis of quantitative and qualitative findings was performed. Quantitative surveys were limited in scope but identified a mixed set of responses. Where studies measured psychological impact, 30-50% of doctors described emotional burden or discomfort about participation, while findings also identified a comfort or satisfaction in believing the request of the patient was met. Significant, ongoing adverse personal impact was reported between 15% to 20%. A minority of doctors sought personal support, generally from family or friends, rather than colleagues. The themes identified from the qualitative studies were summarized as: 1) coping with a request; 2) understanding the patient; 3) the doctor's role and agency in the death of a patient; 4) the personal impact on the doctor; and 5) professional guidance and support.Significance of results Participation in E/PAS can have a significant emotional impact on participating clinicians. For some doctors, participation can contrast with perception of professional roles, responsibilities, and personal expectations. Despite the importance of this issue to medical practice, this is a largely neglected area of empirical research. The limited studies to date highlight the need to address the responses and impact on clinicians, and the support for clinicians as they navigate this challenging area.

We performed a transcriptome-wide meta-analysis and gene co-expression network analysis to identify genes and gene networks dysregulated in the peripheral blood of bipolar disorder (BD) cases relative to unaffected comparison subjects, and determined the specificity of the transcriptomic signatures of BD and schizophrenia (SZ). Nineteen genes and 4 gene modules were significantly differentially expressed in BD cases. Thirteen gene modules were shown to be differentially expressed in a combined case-group of BD and SZ subjects called ¿major psychosis¿, including genes biologically linked to apoptosis, reactive oxygen, chromatin remodeling, and immune signaling. No modules were differentially expressed between BD and SZ cases. Machine-learning classifiers trained to separate diagnostic classes based solely on gene expression profiles could distinguish BD cases from unaffected comparison subjects with an area under the curve (AUC) of 0.724, as well as BD cases from SZ cases with AUC = 0.677 in withheld test samples. We introduced a novel and straightforward method called ¿polytranscript risk scoring¿ that could distinguish BD cases from unaffected subjects (AUC = 0.672) and SZ cases (AUC = 0.607) significantly better than expected by chance. Taken together, our results highlighted gene expression alterations common to BD and SZ that involve biological processes of inflammation, oxidative stress, apoptosis, and chromatin regulation, and highlight disorder-specific changes in gene expression that discriminate the major psychoses.

Purpose: Previous research has suggested high levels of unaddressed mental health needs among male-dominated work settings. The mining industry has been a recent focus internationally. This paper aims to critically examine research regarding organizational mental health interventions for people working in mining industries. Design/methodology/approach: The narrative review used a systematic standardized search strategy in six databases and grey literature from 1990 to 2019. Findings: Of the 418 studies identified, seven studies (five quantitative and two qualitative studies) met the inclusion criteria. Analysis of these studies revealed the organisational interventions available to address mental health needs of miners. Interventions were categorised into organisational and individual-focused approaches. Evidence shows there is great potential in conducting workplace mental health programs, yet further research is required to create a strong evidence base for substantiated policy and practice implications. Practical implications: Mental health interventions and programs should be available in mining industry to enhance mental health. Organisations can also improve mental health by implementing significant changes in the work environment and identifying workplace factors that induce strain and contribute to psychological distress in employees. Attempt can be made at restructuring safety policies and practices to include mental health, addressing organisational structures such as work schedules and providing training for managers and supervisors. Originality/value: This review focuses on the unique characteristics pertaining to male-dominated mining industries and workplace mental health interventions which are aimed at supporting employee mental health.

Globally, a growing body of evidence has reported significant disparities in cancer outcomes between indigenous and nonindigenous people. Although some effort is being made to address these disparities, relatively little attention has been directed toward identifying and focusing on the psychosocial aspects of cancer care for indigenous patients, which are critical components in improving cancer care and outcomes. The purpose of this article is to describe the results of a scoping review of the psychosocial aspects of cancer care for indigenous people. We highlight considerations in undertaking research in this field with indigenous people and the implications for clinical practice.

Genetic influences on psychiatric disorders transcend diagnostic boundaries, suggesting substantial pleiotropy of contributing loci. However, the nature and mechanisms of these pleiotropic effects remain unclear. We performed analyses of 232,964 cases and 494,162 controls from genome-wide studies of anorexia nervosa, attention-deficit/hyperactivity disorder, autism spectrum disorder, bipolar disorder, major depression, obsessive-compulsive disorder, schizophrenia, and Tourette syndrome. Genetic correlation analyses revealed a meaningful structure within the eight disorders, identifying three groups of inter-related disorders. Meta-analysis across these eight disorders detected 109 loci associated with at least two psychiatric disorders, including 23 loci with pleiotropic effects on four or more disorders and 11 loci with antagonistic effects on multiple disorders. The pleiotropic loci are located within genes that show heightened expression in the brain throughout the lifespan, beginning prenatally in the second trimester, and play prominent roles in neurodevelopmental processes. These findings have important implications for psychiatric nosology, drug development, and risk prediction.

The prevalence of health risk behaviours and associated poor physical health is high in people with severe mental illness. Mental health service guidelines and policies stipulate that mental health services should address physical health of people who access services. This study reports results from a large, interdisciplinary, cross-sectional study exploring mental health clinicians¿ (n¿=¿385) views of role legitimacy in physical health service provision. All disciplines reported that mental health clinicians have a role to play in addressing the physical health of consumers. Among mental health clinicians, psychiatrists and mental health nurses received higher endorsement than allied health clinicians in relation to the provision of physical health care, with primary care providers including general practitioners also ranking highly. As community mental health services routinely appoint allied health staff to case management roles, a challenge for services and a challenge for clinicians are to ensure that physical health and the effects of medication are monitored appropriately and systematically. Online and telephone support services received relatively lower endorsement. As the availability of nonface to face services increases, there is a need to explore their utility in this population and where appropriate promote their uptake.

Background: Exercise is increasingly recognised as an efficacious intervention for major depressive disorder (MDD) but to our knowledge differential treatment effects on depressive symptom profiles (cognitive, somatic and affective) and associated changes in psychological, physiological and behavioural factors have not been examined among youth with MDD. Methods: Sixty-eight participants (mean age 20.8) meeting DSM-IV diagnostic criteria for MDD were randomised to an Immediate intervention or Control/delayed condition (n = 34 per group). The integrated intervention comprised an initial session of motivational interviewing (MI) followed by a 12-week, multi-modal exercise program. Changes in depressive symptom profiles were assessed with the Beck Depression Inventory-II (BDI-II) total score and factorial symptom subscales. Results: There were significant differential improvements in BDI-II total scores post-treatment among intervention participants, which were also observed across the cognitive and affective subscales. Individual BDI-II items from the cognitive subscale showing significant differential improvement related to negative self-concept, while those from the affective subscale related to interest/activation; the energy item within the somatic subscale also revealed significant differential improvement. Significant differential improvements were also observed in exercise participation, negative automatic thoughts, behavioural activation and bench press repetitions among intervention participants, which correlated significantly with depression improvements. Limitations: The exercise intervention was delivered in a supervised, group format and potential social meditators of change cannot be excluded. Conclusions: Exercise differentially effects depressive symptom profiles with similar antidepressant effects as would be expected from psychological therapies improving negative cognition and emotional health.

Objective: Psychological therapies combined with medication are effective treatments for depression and anxiety in patients with cancer. However, the psycho-oncology workforce is insufficient to meet patient need and is hard to access outside of the major cities. To bridge this gap, innovative models of care are required. Implementation of a new model of care requires attention to the facilitators and barriers. The aim of this study was to explore stakeholders¿ attitudes to the feasibility and acceptability of a community-based, shared care model for the treatment of depression and anxiety. Methods: Semi-structured interviews were conducted with community-based clinical psychologists (n = 10), general practitioners (n = 6), and hospital-based psychologists working in psycho-oncology (n = 9). Framework analysis was conducted to identify key themes. Results: All stakeholders perceived the model as feasible and acceptable. Potential barriers/facilitators to implementation were summarised under six key themes: (a) initiative, ownership, and autonomy; (b) resources; (c) pathway establishment; (d) support; (e) skill acquisition; and (f) patient engagement. Facilitators included quality communication between health professionals across primary and tertiary care and appropriate education and support for community-based clinicians. Conclusions: This in-depth exploration of Australian health professionals¿ perceptions of the feasibility and acceptability of a community-based model of psycho-oncology care revealed that most clinicians were willing to adopt the proposed changes into practice. An RCT of a shared care intervention for depressed patients with cancer is needed.

Objectives: To investigate help seeking behavior and attitudes to mental health in mining employees. Methods: A pre-post survey study of employees from two Australian coal mines. Data were collected prior to, at baseline, at 6 and 18 months following delivery of the MATES in mining (MIM) peer support mental health intervention. Results: Help seeking behaviors increased, with participants' sex, age, relationship status, shift type, and psychological distress significantly associated with likelihood of seeking help (P < 0.05). In relation to stigma, significantly more participants' disagreed that they would be treated differently by friends or colleagues following disclosure of mental illness (P < 0.01). Conclusions: Results provide an understanding of help seeking behaviors of mining employees; support the MATES in Mining peer support program in the men dominated industry and provide information to guide mental health workplace program development more broadly.

Purpose: Many major studies of depression in Australia are under-representative of rural and remote residents, limiting the generalizability of their findings. This study explores the contributions of a range of individual, social, and community factors to the trajectory of depressive symptoms among a cohort of rural and remote residents. Methods: Data from four waves of the Australian Rural Mental Health Study (baseline n = 2639), a 5¿year longitudinal study of rural community residents, were examined within generalized linear mixed models to predict depressive symptoms. Depression was measured using the PHQ-9, with key correlates including social support, employment status, financial wellbeing, neuroticism, and rural community factors. Results: Moderate-to-severe depression was reported by 6.3% of the baseline sample. Being permanently unable to work resulted in over a threefold increase in the odds of depression at the following survey wave. Self-rated financial hardship was associated with a fourfold increase in the odds of future depression, as was a high level of community concerns. Neuroticism and tobacco use also made a significant independent contribution to future depressive symptoms. Interpersonal support was a protective factor, reducing the odds of next-wave depression by 64%. Conclusion: Financial and employment-related difficulties appear to be important risk factors for depression, and targeting individuals experiencing such difficulties may be an effective means of reducing depression among certain sub-groups. Strategies to prevent depression in rural and remote Australia may benefit from a focus on interpersonal and community-level support, as the effects of this support are lasting and contribute to a reduced likelihood of depressive episodes in future years.

Adverse events in health care significantly impact health professionals who become the second victims of medical error. The aim of the present study was to understand the effects of adverse events in health care on nurses in acute health-care settings in an Australian context. In this qualitative, descriptive study, we used purposeful sampling and recruited 10 acute care nurses. Interviews were conducted from 2011 to 2012 and were recorded, transcribed, and returned to participants to verify their accuracy. Data were categorized and analyzed to determine four emergent themes and subthemes. The four themes were: rescuing patients, effects on nurses, professional responsibility, and needs of nurses. Our analysis indicated that nurses need organizational responses to adverse events, including the provision of information and collegial support after adverse events occur. This will minimize the psychological trauma associated with these events for second victims and support effective communication and collegial working relationships.

Purpose: Farmer suicide is a major public issue in Australia. Using the psychological autopsy method, this study aimed to examine the life and death circumstances of Australian male farmers who died by suicide through verbal reports from their close significant others. Methods: Individual semistructured interviews were conducted with 12 relatives of male farmers who had died by suicide in Queensland or New South Wales, Australia (2006-2014). This study followed the COREQ checklist criteria for the reporting of qualitative research. Findings: Six interrelated themes were identified: (1) masculinity, (2) uncertainty and lack of control in farming, (3) feelings of failure in relationships and farming, (4) escalating health problems, (5) maladaptive coping, and (6) acquired capability with access to means. Conclusions: Effective clinical interventions, as well as suicide prevention strategies, need to consider the importance of 3 key issues in suicide among farmers: adherence to masculine norms and socialization; expectations of self in maintaining family traditions and occupation; and a male subtype of depression.

Aims. Rural and remote regions tend to be characterised by poorer socioeconomic conditions than urban areas, yet findings regarding differences in mental health between rural and urban areas have been inconsistent. This suggests that other features of these areas may reduce the impact of hardship on mental health. Little research has explored the relationship of financial hardship or deprivation with mental health across geographical areas.Methods. Data were analysed from a large longitudinal Australian study of the mental health of individuals living in regional and remote communities. Financial hardship was measured using items from previous Australian national population research, along with measures of psychological distress (Kessler-10), social networks/support and community characteristics/locality, including rurality/remoteness (inner regional; outer regional; remote/very remote). Multilevel logistic regression modelling was used to examine the relationship between hardship, locality and distress. Supplementary analysis was undertaken using Australian Household, Income and Labour Dynamics in Australia (HILDA) Survey data.Results. 2161 respondents from the Australian Rural Mental Health Study (1879 households) completed a baseline survey with 26% from remote or very remote regions. A significant association was detected between the number of hardship items and psychological distress in regional areas. Living in a remote location was associated with a lower number of hardships, lower risk of any hardship and lower risk of reporting three of the seven individual hardship items. Increasing hardship was associated with no change in distress for those living in remote areas. Respondents from remote areas were more likely to report seeking help from welfare organisations than regional residents. Findings were confirmed with sensitivity tests, including replication with HILDA data, the use of alternative measures of socioeconomic circumstances and the application of different analytic methods.Conclusions. Using a conventional and nationally used measure of financial hardship, people residing in the most remote regions reported fewer hardships than other rural residents. In contrast to other rural residents, and national population data, there was no association between such hardship and mental health among residents in remote areas. The findings suggest the need to reconsider the experience of financial hardship across localities and possible protective factors within remote regions that may mitigate the psychological impact of such hardship.

Background Recent meta-analytic reviews suggest exercise can reduce depression severity among adults with major depressive disorder (MDD); however, efficacy studies with depressed youth are limited. Few studies have investigated the efficacy of multi-modal exercise interventions in this population, addressed treatment engagement, or explored the differential effects of exercise on depressive symptom profiles. Objectives This paper describes the study protocol and recruitment pattern for an assessor blinded, two-arm randomised controlled trial investigating the efficacy of an integrated motivational interviewing (MI) and multi-modal exercise intervention in youth diagnosed with MDD. Associations between depressive symptom profiles (cognitive, somatic and affective) and psychological, physiological (fitness), and biological (blood biomarker) outcomes will also be examined. Methods Participants aged 15¿25 years with current MDD were recruited. Eligible participants were randomised and stratified according to gender and depression severity to either an immediate or delayed (control) group. The immediate group received a brief MI intervention followed by a 12-week small group exercise intervention (3 times per week for 1 h), all delivered by personal trainers. The delayed control group received the same intervention 12-weeks later. Both groups were reassessed at mid-treatment or mid-control, post-treatment or post-control, and follow-up (12 weeks post-treatment). Results 68 participants were recruited and randomly allocated to an intervention group. Conclusion This trial will increase our understanding of the efficacy of multi-modal exercise interventions for depression and the specific effects of exercise on depressive symptom profiles. It also offers a novel contribution by addressing treatment engagement in exercise efficacy trials in youth with MDD.

Objective: This study explored help-seeking behaviours, group identification, and perceived legitimacy of discrimination, and its potential relationship with perceived lung cancer stigma. Methods: Consecutive consenting adults (n¿=¿274) with a primary diagnosis of lung cancer within the previous 4¿months were recruited at 31 outpatient clinics in Australia. A self-report survey assessed help-seeking, group identification, perceived legitimacy of discrimination, and perceived lung cancer stigma. Results: Services providing assistance from health professionals (69.5%) and informational support (68.5%) were more frequently used than emotional-based support. Only a small proportion (2.6%) of participants were unlikely to seek help from anyone, with the most popular sources of help being the general practitioner (91.0%), and oncologist/treating clinician (81.3%). One-fifth (21.1%) indicated they identified with being a lung cancer patient, and most did not perceive discrimination against lung cancer patients. Higher perceived lung cancer stigma was significantly associated with greater perceived legitimacy of discrimination (P¿<¿0.001), but not help-seeking behaviours or group identification. Conclusions: The relationship between lung cancer stigma and perceived legitimacy of discrimination may guide initiatives to reduce stigma for patients. It is encouraging that perceived stigma did not appear to inhibit help-seeking behaviours. However, further research in this emerging field is needed to investigate patterns of perceived stigma and help-seeking over time to identify how and when to offer support services most appropriate to the needs of lung cancer patients.

Objective: Although mental health literacy has increased in recent years, mental illness is often under-recognised. There has been little research conducted on mental illness in rural areas; however, this can be most prominent in rural areas due to factors such as greater stigma and stoicism. The aim of this study is to create a profile of those who are most and least likely to self-identify mental health problems among rural residents with moderate- to-high psychological distress. Design: Secondary analysis of a longitudinal postal survey. Setting: Rural and remote New South Wales, Australia. Participants: Four-hundred-and-seventy-two community residents. Main outcome measure: Participants completed the K10 Psychological Distress Scale, as well as the question ¿In the past 12 months have you experienced any mental health problems?¿ The characteristics of those who reported moderate/high distress scores were explored by comparing those who did and did not experience mental health problems recently. Results: Of the 472 participants, 319 (68%) with moderate/high distress reported a mental health problem. Reporting a mental health problem was higher among those with recent adverse life events or who perceived more stress from life events while lower among those who attributed their symptoms to a physical cause. Conclusions: Among a rural sample with moderate/high distress, one-third did not report a mental health problem. Results suggest a threshold effect, whereby mental health problems are more likely to be acknowledged in the context of additional life events. Ongoing public health campaigns are necessary to ensure that symptoms of mental illness are recognised in the multiple forms that they take.

OBJECTIVES: To investigate perceived stigma and its possible associations with treatment expectations and preferences in newly diagnosed patients with lung cancer. SAMPLE & SETTING: 274 patients with lung cancer diagnosed in the previous four months at oncology and respiratory outpatient clinics in Australia. METHODS & VARIABLES: Participants completed a self-report survey about perceived lung cancer stigma and treatment expectations and preferences. RESULTS: A mean perceived stigma score of 52 of a possible 124 was reported, which is lower than scores reported in other studies using the same measure; the current study determined that perceived lung cancer stigma was observed less frequently. Significantly higher scores were observed in participants who were younger or who had a history of smoking. Perceived lung cancer stigma was significantly related to treatment expectations. No relationship was found between perceived lung cancer stigma and treatment preferences. IMPLICATIONS FOR NURSING: Healthcare providers are in a key position to provide support and communicate empathetically with patients to minimize potential stigma experiences.

The stigma of non-communicable respiratory diseases (NCRDs), whether perceived or otherwise, can be an important element of a patient's experience of his/her illness and a contributing factor to poor psychosocial, treatment and clinical outcomes. This systematic review examines the evidence regarding the associations between stigma-related experiences and patient outcomes, comparing findings across a range of common NCRDs. Electronic databases and manual searches were conducted to identify original quantitative research published to December 2015. Articles focussing on adult patient samples diagnosed with asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, lung cancer or mesothelioma, and included a measurement of stigma-related experience (i.e. perceived stigma, shame, blame or guilt), were eligible for inclusion. Included articles were described for study characteristics, outcome scores, correlates between stigma-related experiences and patient outcomes and methodological rigor. Twenty-five articles were eligible for this review, with most (n = 20) related to lung cancer. No articles for cystic fibrosis were identified. Twenty unique scales were used, with low to moderate stigma-related experiences reported overall. The stigma-related experiences significantly correlated with all six patient-related domains explored (psychosocial, quality of life, behavioral, physical, treatment and work), which were investigated more widely in COPD and lung cancer samples. No studies adequately met all criteria for methodological rigor. The inter-connectedness of stigma-related experiences to other aspects of patient experiences highlight that an integrated approach is needed to address this important issue. Future studies should adopt more rigorous methodology, including streamlining measures, to provide robust evidence.

Purpose: A stepped-wedge cluster-randomised controlled trial was conducted to evaluate the feasibility and effectiveness of a brief psychosocial intervention for depressed cancer patients, delivered by trained front-line health professionals in routine clinical care. Methods: Nine hundred two patients were assessed across four treatment centres which were allocated in random order from control epoch to intervention epoch. Eligible patients had Hospital Anxiety and Depression Scale (HADS) scores of 8 or greater. Of eligible patients, 222 were recruited in control epoch and 247 in intervention epoch. Twenty-seven health professionals (HPs) were trained to deliver the psychosocial intervention consisting of up to four sessions, tailored to patient symptoms and distress. HPs participated in group supervision with a psychiatrist. The primary outcome, analysed by intention to treat, was depression measured with the HADS at 10¿weeks after receiving the intervention. Results: At 10-week follow-up, there were no significant differences in HADS score for the 181 patients in control epoch and 177 in intervention epoch (adjusted difference -1.23, 95¿% CI -3.81¿¿1.35, p¿=¿0.35). Patients with disease progression who received the intervention experienced significant benefits in unmet practical support needs including care and support, information, and physical and daily living. Conclusion: A brief psychosocial intervention delivered by front-line oncology health professionals is feasible to deliver but is insufficient as a stand-alone treatment for depression in cancer patients. Psychosocial interventions should be targeted to populations most likely to experience benefit.

This study assesses the feasibility of integrating motivational interviewing (MI) with an exercise intervention. It also explores patterns of depressive symptom changes (cognitive, affective, and somatic subscales) and their relationship to cognitive, behavioral, and immunological factors (interleukin 6, IL-6, a marker for inflammation) across the exercise intervention. Twelve young adults (20.8 ± 1.7 years) meeting DSM-IV criteria for major depressive disorder received a brief MI intervention followed by a 12-week exercise intervention. Assessments were conducted preintervention, postintervention, throughout the intervention, and at follow-up. Preliminary results show differential effects of exercise, with the largest standardized mean improvements for the affective subscale (-1.71), followed by cognitive (-1.56) and somatic (-1.39) subscales. A significant relationship was observed between increased behavioral activation and lower levels of IL-6. Despite study limitations, the magnitude of changes suggests that natural remission of depressive symptoms is an unlikely explanation for the findings. A randomized controlled trial has commenced to evaluate effectiveness of the intervention.

Objectives: To investigate patterns of alcohol use within the coal mining industry, and associations with the personal, social, workplace and employment characteristics. Design: 8 mine sites across 3 eastern Australian states were surveyed, selected to encompass key geographic characteristics (accessibility and remoteness) and mine type (open cut and underground). Problematic alcohol use was measured using the Alcohol Use Disorders Identification Test (AUDIT) to determine: (1) overall risky or hazardous drinking behaviour; and (2) frequency of single-occasion drinking (6 or more drinks on 1 occasion). Results: A total of 1457 employees completed the survey, of which 45.7% of male and 17.0% of female participants reported levels of alcohol use within the range considered as risky or hazardous, considerably higher than the national average. Hierarchical linear regression revealed a significant contribution of many individual level factors associated with AUDIT scores: younger age, male, current smoking status; illicit substance use; previous alcohol and other drug use (AOD) problems; and higher psychological distress. Workplace factors associated with alcohol use included working in mining primarily for the high remuneration, and the type of mining, with underground miners reporting higher alcohol use than open-cut miners. Conclusions: Our findings provide support for the need to address alcohol use in the coal mining industry over and above routine on-site testing for alcohol use.

Objective: People with a life-limiting physical illness experience high rates of significant psychological and psychiatric morbidity. Nevertheless, psychiatrists often report feeling ill-equipped to respond to the psychiatric needs of this population. Our aim was to explore psychiatry trainees' views and educational needs regarding the care of patients with a life-limiting physical illness. Method: Using semistructured interviews, participants' opinions were sought on the role of psychiatrists in the care of patients with a life-limiting illness and their caregivers, the challenges faced within the role, and the educational needs involved in providing care for these patients. Interviews were audiotaped, fully transcribed, and then subjected to thematic analysis. Results: A total of 17 psychiatry trainees were recruited through two large psychiatry training networks in New South Wales, Australia. There were contrasting views on the role of psychiatry in life-limiting illness. Some reported that a humanistic, supportive approach including elements of psychotherapy was helpful, even in the absence of a recognizable mental disorder. Those who reported a more biological and clinical stance (with a reliance on pharmacotherapy) tended to have a nihilistic view of psychiatric intervention in this setting. Trainees generally felt ill-prepared to talk to dying patients and felt there was an educational famine in this area of psychiatry. They expressed a desire for more training and thought that increased mentorship and case-based learning, including input from palliative care clinicians, would be most helpful. Significance of Results: Participants generally feel unprepared to care for patients with a life-limiting physical illness and have contrasting views on the role of psychiatry in this setting. Targeted education is required for psychiatry trainees in order to equip them to care for these patients.

CONTEXT: Students from backgrounds of low socio-economic status (SES) or who are first in family to attend university (FiF) are under-represented in medicine. Research has focused on these students' pre-admission perceptions of medicine, rather than on their lived experience as medical students. Such research is necessary to monitor and understand the potential perpetuation of disadvantage within medical schools.

Disengagement from services is common before suicide, hence identifying factors at treatment presentation that predict future suicidality is important. This article explores risk profiles for suicidal ideation among treatment seekers with depression and substance misuse. Participants completed assessments at baseline and 6 months. Baseline demographics, psychiatric history, and current symptoms were entered into a decision tree to predict suicidal ideation at follow-up. Sixty-three percent of participants at baseline and 43.5% at follow-up reported suicidal ideation. Baseline ideation most salient when psychiatric illness began before adulthood, increasing the rate of follow-up ideation by 16%. Among those without baseline ideation, dysfunctional attitudes were the most important risk factor, increasing rates of suicidal ideation by 35%. These findings provide evidence of factors beyond initial diagnoses that increase the likelihood of suicidal ideation and are worthy of clinical attention. In particular, providing suicide prevention resources to those with high dysfunctional attitudes may be beneficial.

Objective: In Australia and internationally, psychiatry has struggled to fill training places to keep up with demand for service. The objective of this study was to review the components of psychiatry terms and placements that determine a positive experience and potentially influence interest in vocational training in psychiatry. Method: A literature review and narrative synthesis was undertaken on 20 papers identified as meeting inclusion criteria. Results: The top themes contributing to positive experiences during the psychiatry term were: receiving high quality supervision; supported autonomy; and witnessing patient recovery. There was a paucity of Australian literature preventing investigation of the Australian context alone. Conclusions: There is a need to better understand how the junior doctor and medical student psychiatry experience influences perceptions of psychiatry and intention to specialise, especially in the Australian context.

Objective: The project aimed to test of the quality and acceptability of researcher-developed Short Message Service (SMS) messages designed to support fathers of infants aged 12 months or less. Background: The findings of previous studies suggest antenatal and postnatal depression among fathers¿ impacts negatively on the health of family members. Method: Draft messages were first modified based on expert review. In a second phase, parents (mothers n¿=¿56; fathers n¿=¿46; unknown n¿=¿4) were recruited through two early childhood parenting services to rate the clarity, usefulness and relevance of the 70 SMS messages using a paper-based survey. In a third phase, 15 fathers were recruited to receive texts at different times over three weeks. Results: Findings suggest that SMS items were easily understood by the majority of parents, with only 3% of responses indicating an item was ¿not easily understood¿. Feedback from parents indicated that negatively rated SMS messages were considered as either poorly phrased, lacking enough information or as not offering sufficient support. The majority (88%) of the SMS items were also rated as ¿useful¿ by the parents. Conclusion: Fathers¿ responses indicated that receiving the texts at different times was acceptable and that message content was relevant to their fathering. The study has produced a set of brief text messages suitable and acceptable to new fathers and their partners.

The application of microarray technology in schizophrenia research was heralded as paradigm-shifting, as it allowed for high-throughput assessment of cell and tissue function. This technology was widely adopted, initially in studies of postmortem brain tissue, and later in studies of peripheral blood. The collective body of schizophrenia microarray literature contains apparent inconsistencies between studies, with failures to replicate top hits, in part due to small sample sizes, cohort-specific effects, differences in array types, and other confounders. In an attempt to summarize existing studies of schizophrenia cases and non-related comparison subjects, we performed two mega-analyses of a combined set of microarray data from postmortem prefrontal cortices (n = 315) and from ex-vivo blood tissues (n = 578). We adjusted regression models per gene to remove non-significant covariates, providing best-estimates of transcripts dysregulated in schizophrenia. We also examined dysregulation of functionally related gene sets and gene co-expression modules, and assessed enrichment of cell types and genetic risk factors. The identities of the most significantly dysregulated genes were largely distinct for each tissue, but the findings indicated common emergent biological functions (e.g. immunity) and regulatory factors (e.g., predicted targets of transcription factors and miRNA species across tissues). Our network-based analyses converged upon similar patterns of heightened innate immune gene expression in both brain and blood in schizophrenia. We also constructed generalizable machine-learning classifiers using the blood-based microarray data. Our study provides an informative atlas for future pathophysiologic and biomarker studies of schizophrenia.

Objective: The aim of this study was to estimate the economic impact of psychological distress among employees of the Australian Coal Mining Industry. Methods: Sample data were gathered from 1456 coal mining staff across eight sites in two Australian states. Two measures were taken of work time lost over four weeks due to psychological distress: (1) full-day absences; (2) presenteeism. Lost work time was valued using hourly wages. Sample data was modeled to estimate annual monetary losses for the Australian Coal Mining Industry. Results: For the sample, estimated annual value of time lost due to psychological distress was $4.9 million ($AUS2015) ($0.61 million per mine), and for the Australian Coal Mining Industry, $153.8 million ($AUS2015). Conclusion: Psychological distress is a significant cost for the Australian Coal Mining Industry. Relevant intervention programs are potentially cost-effective.

Objective: Psychosocial interventions directed to couples where one has advanced cancer can reduce distress, enhance communication, and provide an opportunity for relational growth. The present study aimed to develop an intervention to facilitate communication about living with advanced cancer using the Patient Dignity Inventory (PDI) as the focus of a clinical interview with couples toward the end of life. Method: Couples were recruited from oncology and palliative care services at a Sydney hospital. After the PDI was developed and manualized as an intervention for couples, the PDI-Couple Interview (PDI-CI) was delivered by a clinical psychologist and comprised the following: (1) the patient completed the PDI; (2) the patient's identified partner completed the PDI about how they thought the patient was feeling; and (3) the clinician reviewed the results with the couple, summarizing areas of concurrence and discordance and facilitating discussion. Results: Some 34 couples were referred, of which 12 consented, 9 of whom completed the clinical interview. Reported benefits included enabling couples to express their concerns together, identifying differences in understanding, and giving permission to speak with each other. The focus of the interview around the PDI provided a structure that was particularly acceptable for men. Most couples confirmed that they were on the same page, and where differences were identified, it provided a forum for discussion and a mutual understanding of the challenges in managing advanced cancer within a supportive context. Significance of Results: Participant couples' experiences of the PDI-CI provide valuable insight into the benefits of this intervention. This preliminary study indicates that the intervention is a relatively simple means of enhancing closer communication and connection between couples where one has advanced cancer and may be an important adjunct in helping prepare couples for the challenges inherent toward the end of life. Further investigation of feasibility with a larger sample is recommended.

Objective: This research sought to gain insight into the processes used by clinicians to discuss a schizophrenia diagnosis with patients/families, with the aim of informing the development of a communications skills training program. Methods: A generic qualitative methodological approach was used. Sixteen mental health clinicians were recruited. Semi-structured individual interviews were used to explore their perceptions and experiences communicating a schizophrenia diagnosis. Interviews were recorded, transcribed, and thematic analysis undertaken. Results: There were five key themes relating to the process of communication about a diagnosis of schizophrenia: (1) orientation to patient care, (2) planning of communication, (3) the impact of team leadership and inter/intra-professional functioning on communication tasks, (4) the roles of different clinicians in communicating about diagnosis and treatment, and (5) time and resource deficiencies. Despite expressing care and concern for vulnerable patients and embracing the concept of multidisciplinary teams, communicating diagnostic information to patients and families was generally unplanned for, with little consistency regarding leadership approaches, or how the team communicated diagnostic information to the patient and family. This contributed to tensions between different team members. Conclusion: The findings demonstrated a number of issues compromising good communication around a schizophrenia diagnosis, both in terms of clinician skill and clinical context, and support the importance of education and training for all members of the multidisciplinary team about their role in the communication process.

Objectives: Older adults are the fastest growing age group in Australia, necessitating an increase in appropriate mental health services in the coming years. While Internet-delivered mental health treatments have been established as acceptable and efficacious among younger samples, little research has explored whether they would be similarly useful in older populations.Methods: The participants were part of the Australian Rural Mental Health study, which explores mental health and well-being in residents of non-metropolitan New South Wales. A postal survey was used to assess knowledge of and intentions to use Internet-delivered mental health treatments. Demographics, mental health, and frequency of Internet use were also measured.Results: The survey was completed by 950 adults aged 50-93. The sample was largely unfamiliar with Internet mental health services, with 75% reporting that they had never heard of them and a further 20% not knowing any details of what they involved. Intentions to use these services were also low, at 13.5%; however, this increased with level of familiarity. Respondents with higher psychological distress, higher education, and more frequent Internet use were significantly more likely to consider using Internet treatments.Conclusions: Among older adults, overall awareness of Internet-delivered mental health treatments appears to be limited; however, higher familiarity contributes to higher intentions to use these treatments. Importantly, respondents with higher distress and greater computer literacy were more likely to consider mental health treatments delivered via the Internet. Future research exploring strategies to increase the promotion of these services to older samples may further improve their perceptions and use.

Objective: Important gaps are observed in clinicians' communication with patients and families about psychiatric disorders such as schizophrenia. Communication skills can be taught, and models for education in these skills have been developed in other fields of medicine, such as oncology, providing a framework for training communication skills relevant to psychiatric practice. This study evaluated a pilot communication skills education program for psychiatry trainees, focusing on discussing schizophrenia diagnosis and prognosis. Method: Communication skills training modules were developed based on an existing theoretical framework (ComSkil), adapted for discussing a schizophrenia diagnosis and prognosis. Pre-post training rating of self-reported confidence in a range of communication tasks was obtained, along with trainee views on the training methods. Results: Thirty-eight participants completed the training. Significant improvements in confidence were reported post training for discussing schizophrenia prognosis, including an increased capacity to critically evaluate their own communication skills. Participants reported high levels of satisfaction with the program. Conclusion: This preliminary study provides support for the translation of a well-established educational model to psychiatric training addressing core clinical communication tasks and provides the foundation for the development of a more comprehensive evaluation and an extended curriculum regarding other aspects of care for patients with schizophrenia: ongoing management and recovery, dealing with conflict, and conducting a family interview.

Background: Palliative care incorporates comprehensive support of family caregivers because many of them experience burden and distress. However, evidence-based support initiatives are few. Purpose: We evaluated a one-to-one psychoeducational intervention aimed at mitigating the distress of caregivers of patients with advanced cancer receiving home-based palliative care. We hypothesised that caregivers would report decreased distress as assessed by the General Health Questionnaire (GHQ). Method: A randomised controlled trial comparing two versions of the delivery of the intervention (one face-to-face home visit plus telephone calls versus two visits) plus standard care to a control group (standard care only) across four sites in Australia. Results: Recruitment to the one visit condition was 57, the two visit condition 93, and the control 148. We previously reported non-signi fi cant changes in distress between times 1 (baseline) and 2 (1-week post-intervention) but signifi cant gains in competence and preparedness. We report here changes in distress between times 1 and 3 (8-week post-death). There was significantly less worsening in distress between times 1 and 3 in the one visit intervention group than in the control group; however, no significant difference was found between the two visit intervention and the control group. Conclusions: These results are consistent with the aim of the intervention, and they support existing evidence demonstrating that relatively short psychoeducational interventions can help family caregivers who are supporting a dying relative. The sustained benefit during the bereavement period may also have positive resource implications, which should be the subject of future inquiry.

Both polygenicity (many small genetic effects) and confounding biases, such as cryptic relatedness and population stratification, can yield an inflated distribution of test statistics in genome-wide association studies (GWAS). However, current methods cannot distinguish between inflation from a true polygenic signal and bias. We have developed an approach, LD Score regression, that quantifies the contribution of each by examining the relationship between test statistics and linkage disequilibrium (LD). The LD Score regression intercept can be used to estimate a more powerful and accurate correction factor than genomic control. We find strong evidence that polygenicity accounts for the majority of the inflation in test statistics in many GWAS of large sample size.

Background: This study examines the long-term outcomes of lifetime trauma exposure, including factors that contribute to the development of PTSD, in a sample of rural adults. Methods: In 623 rural community residents, lifetime trauma exposure, PTSD, other psychiatric disorders and lifetime suicidal ideation were assessed using the World Mental Health Composite International Diagnostic Interview. Logistic regressions were used to examine relationships between potentially traumatic events (PTEs) and lifetime PTSD and other diagnoses. Results: 78.2 % of participants reported at least on PTE. Rates were broadly comparable with Australian national data: the most commonly endorsed events were unexpected death of a loved one (43.7 %); witnessing injury or death (26.3 %); and life-threatening accident (19.3 %). While the mean age of the sample was 55 years, the mean age of first trauma exposure was 19 years. The estimated lifetime rate of PTSD was 16.0 %. Events with the strongest association with PTSD were physical assault and unexpected death of a loved one. Current functioning was lowest among those with current PTSD, with this group reporting elevated psychological distress, higher mental health service use, a greater number of comorbidities, and lower perceived social support. Respondents with a past PTE but no PTSD history were generally similar in terms of their current wellbeing to those with no lifetime PTE. Conclusions: PTEs may have diverse psychological and social consequences beyond the development of PTSD. Ensuring that adequate support services are available in rural areas, particularly in the period immediately following a PTE, may reduce the long-term impact of traumatic events.

The molecular mechanisms underlying schizophrenia remain largely unknown. Although schizophrenia is a mental disorder, there is increasing evidence to indicate that inflammatory processes driven by diverse environmental factors play a significant role in its development. With gene expression studies having been conducted across a variety of sample types, e.g., blood and postmortem brain, it is possible to investigate convergent signatures that may reveal interactions between the immune and nervous systems in schizophrenia pathophysiology. We conducted two meta-analyses of schizophrenia microarray gene expression data (N= 474) and non-psychiatric control (N= 485) data from postmortem brain and blood. Then, we assessed whether significantly dysregulated genes in schizophrenia could be shared between blood and brain. To validate our findings, we selected a top gene candidate and analyzed its expression by RT-qPCR in a cohort of schizophrenia subjects stabilized by atypical antipsychotic monotherapy (N= 29) and matched controls (N= 31). Meta-analyses highlighted inflammation as the major biological process associated with schizophrenia and that the chemokine receptor CX3CR1 was significantly down-regulated in schizophrenia. This differential expression was also confirmed in our validation cohort. Given both the recent data demonstrating selective CX3CR1 expression in subsets of neuroimmune cells, as well as behavioral and neuropathological observations of CX3CR1 deficiency in mouse models, our results of reduced CX3CR1 expression adds further support for a role played by monocyte/microglia in the neurodevelopment of schizophrenia.

Objectives: This study was designed to elucidate why students from backgrounds of lower socio-economic status (SES) and who may be first in their family (FIF) to enter university continue to be under-represented in medical schools. Methods: Academically able high school students (n = 33) from a range of socio-economic backgrounds participated in focus groups. School careers advisors (n = 5) were interviewed. Students discussed their career and education plans and ideas about a medical career. Careers advisors discussed enablers and barriers to a medical career for their students. Results: Students of lower SES and of FIF status attending schools situated in poorer geographic locations had limited access to suitable work experience and, despite their participation in gifted and talented classes, were considered to be at greater risk of not achieving the high level of academic achievement required for admission to medical school. Conclusions: There is utility in exploring intersecting differences and Appardurai's theory of the 'capacity to aspire' for the purpose of understanding the causes of the under-representation of disadvantaged students in medical schools. A focused materialist approach to building the aspirations of disadvantaged students, particularly those attending schools located in poorer areas, is required if effective pre-entry equity programmes are to be developed and evaluated. Alternatively, medical schools might rethink their reliance on very high academic attainment in the admission process. Discuss ideas arising from the article at www.mededuc.com discuss.

Polygenic risk scores have shown great promise in predicting complex disease risk and will become more accurate as training sample sizes increase. The standard approach for calculating risk scores involves linkage disequilibrium (LD)-based marker pruning and applying a p value threshold to association statistics, but this discards information and can reduce predictive accuracy. We introduce LDpred, a method that infers the posterior mean effect size of each marker by using a prior on effect sizes and LD information from an external reference panel. Theory and simulations show that LDpred outperforms the approach of pruning followed by thresholding, particularly at large sample sizes. Accordingly, predicted R2 increased from 20.1% to 25.3% in a large schizophrenia dataset and from 9.8% to 12.0% in a large multiple sclerosis dataset. A similar relative improvement in accuracy was observed for three additional large disease datasets and for non-European schizophrenia samples. The advantage of LDpred over existing methods will grow as sample sizes increase.

Background: As research focuses on the concept of resilience, evidence suggests that greater levels of personal hope may have a mitigating effect on the mental health impact of adversity. In view of the adversity affecting rural communities, a better understanding of factors influencing personal hope may help identify foci for mental health promotion and mental illness prevention research and interventions. Aim: To explore the relationship between demographic, socioeconomic and mental health factors and personal hopefulness, including the influence of locality and remoteness. Method: Using data from two community-based longitudinal cohorts from New SouthWales ¿ one urban and one rural ¿ we analysed cross-sectional relationships between a range of factors and personal hopefulness using logistic regression techniques, as part of a common follow-up. Personal hopefulness was measured using a 12-item scale and scores were categorised as low (<2.5), medium (2.5¿3.4) and high (=3.5). Results: Of 2774 participants (53% female, mean age 69.1 years [SD 7.3, range 58¿91 years], 36% living outside metropolitan areas) 32% had low, 51% had medium and 17% had high personal hopefulness scores. Several factors displayed univariate associations with personal hopefulness. In the multivariate model, five factors were independently associated with lower personal hopefulness: being older, having lower perceived prosperity, less frequent socialisation, experiencing high psychological distress or psychological impairment. Hopefulness was not associated with geographical location. Conclusion: The impact of current psychological distress and aspects of adversity on personal hopefulness over time should be further investigated in longitudinal research. Personal hopefulness did not differ across geographical location.

Aim: Regional variation in the prevalence of mental disorders and particularly variation in the role of risk and protective factors has received limited research attention. This study investigates variation in the prevalence of significant psychological distress across regions, and quantifies the relative impact of family functioning and social support. Subject and method: Multilevel analysis of data from the longitudinal Australian Rural Mental Health Study, comprising a stratified random sample from non-metropolitan New South Wales. Distress was assessed using the Kessler-10. The analysis considered clustering within households and across geographic regions based on Local Government Areas and collapsed to represent residence in inner regional, outer regional, remote and very remote locations. Results: There was limited clustering of psychological distress within areas (0.4¿%). However, the household accounted for almost 45¿% of the variance in psychological distress, and the salience of the household was greater in more remote regions (33.1¿% in inner regional to 60.5¿% in very remote areas). Family functioning and perceived social support were associated with increased risk of psychological distress, but explained only a modest amount of variance in mental health at household level. After controlling for individual and family/social covariates, 34.5¿% of the remaining variance in psychological distress was observed at the household level. Conclusion: The findings suggest that individuals in remote locations are more reliant on their family/confidants for their mental health than those in more populated areas. Future research will consider whether this simply reflects differences in the accessibility of formal health services or broader social and cultural differences.

Much attention has been given to implementing routine screening programs in cancer care to improve the management of distress following diagnosis. Although patients might screen positive for distress, several studies have found that most then refuse additional psychosocial support. To inform the development of successful models of distress screening, this qualitative study explored preferences for psychosocial care among 18 women diagnosed with a gynecologic cancer who scored at least 4 on the Distress Thermometer (DT). Participants were recruited from a gynecologic oncology outpatient clinic in Newcastle, Australia, and interviewed. Unanimously, participants felt that completing the DT was an integral part of their cancer care. However, half then refused the referral to see a psychologist. These women typically reported that a referral was not needed, because their rating on the DT reflected transient stressors or physical distress. Many also spoke about their need to cope with the challenges they were facing on their own and the extensive social support they already had in place to help them overcome these challenges. In contrast, women who accepted referral to the psychologist often struggled to cope with several losses they felt had existential and long-term effects. Commonly, these women reported not having the social support they needed, managing several concurrent life stressors, and/or not having the repertoire of coping skills they required to "remain afloat." Findings from this study begin to bridge the gap between clinicians' and patients' expectations of how psychosocial services should be used in response to distress screening. © JNCCN - Journal of the National Comprehensive Cancer Network.

Depression is a leading contributor to the global burden of diseases. Despite advances in research, challenges still exist in managing this disorder. Sufferers of autoimmune diseases are often observed to suffer from depression more often than healthy individuals, an association that cannot be completely accounted for by the impact of the disease on the individual. An association between autoimmunity and depressive symptoms also appears to exist in populations with subclinical symptoms. Moreover, researchers have successfully developed murine models illustrating the ability of autoantibodies to induce depressive-like symptoms. This paper will provide an overview of the association between autoantibodies and occurrence of depressive symptoms. Though current evidence appears to support a role for autoantibodies in the pathogenesis of depression, the majority of studies have examined this relationship cross-sectionally, therefore failing to establish a temporal association. Nonetheless, this novel theory meshes with older and newer neurochemical theories of depression. A better understanding of the immuno-pathogenesis underlying depression presents opportunities for more targeted treatment approaches and more timely and appropriate measures of detection. © 2014 Elsevier Ltd.

Aim: This paper describes the research protocol for a study exploring if and how clinical supervision facilitates change in practice relating to psychosocial aspects of care for Health Professionals, who have been trained to deliver a psychosocial intervention to adults with cancer. Background: There is a recognized need to implement care that is in line with clinical practice guidelines for the psychosocial care of adults with cancer. Clinical supervision is recommended as a means to support Health Professionals in providing the recommended psychosocial care. Design: A qualitative design embedded within an experimental, stepped wedge randomized control trial. Methods: The study will use discourse analysis to analyse audio-recorded data collected in clinical supervision sessions that are being delivered as one element of a large randomized control trial. The sessions will be attended primarily by nurses, but including physiotherapists, radiation therapists, occupational therapists. The Health Professionals are participants in a randomized control trial designed to reduce anxiety and depression of distressed adults with cancer. The sessions will be facilitated by psychiatrists experienced in psycho-oncology and the provision of clinical supervision. Discussion: The proposed research is designed specifically to facilitate exploration of the mechanisms by which clinical supervision enables Health Professionals to deliver a brief, tailored psychosocial intervention in the context of their everyday practice. This is the first study to use discourse analysis embedded within an experimental randomized control trial to explore the mechanisms of change generated within clinical supervision by analysing the discourse within the clinical supervision sessions. © 2013 John Wiley & Sons Ltd.

Objective: To investigate psychiatry trainees' confidence in their role as teachers, their perceptions of support and preferences for a program to support this role. Methods: Psychiatry trainees in New South Wales (NSW) (Australia) in the first three years of psychiatry training (N = 118) were invited to complete a survey which included demographic data, self-assessment of teaching confidence and perceptions of support for teaching. Results: A total of 63% (N = 74) agreed to participate. Overall, 62% percent of participants regarded teaching as an important part of their role, 46% felt supported in the role by their training supervisors, but only 18% regularly discussed their teaching role in routine supervision. Conclusions: Psychiatry trainees viewed teaching as part of their role. They reported a low level of formal training in teaching skills and perceived a low level of support from supervisors. Registrar training needs to address trainees' competencies in a range of teaching skills along with supervisor support. Further research is required to assess the impact of a teaching program on teaching performance and learner outcomes. © The Royal Australian and New Zealand College of Psychiatrists 2014.

Purpose: Rural populations face numerous barriers to mental health care. Although internet-delivered mental health treatments may offer an accessible and cost-effective answer to these barriers, there has been little evaluation of the feasibility of this approach among rural communities. Methods: Data were obtained from a random rural community sample through the third wave of the Australian Rural Mental Health Study. Attitudes towards internet-delivered mental health treatments and availability of internet access were explored. Data were analysed to identify sub-groups in whom internet-delivered treatments may be usefully targeted. Results: Twelve hundred and forty-six participants completed the survey (mean age 59 years, 61 % females, 22 % from remote areas). Overall, 75 % had internet access and 20 % would consider using internet-based interventions, with 18 % meeting both of these feasibility criteria. Logistic regression revealed feasibility for internet-delivered mental health treatment was associated with younger age, male gender, being a carer, and a 12-month mental health problem. Participants who had used internet-delivered services in the past were significantly more likely to endorse these treatments as acceptable. Conclusions: There is considerable potential for internet-delivered treatments to increase service accessibility to some sub-groups, particularly among people with mental health problems who are not currently seeking help. Resistance to internet treatments appears to be largely attitudinal, suggesting that enhancing community education and familiarity with such programs may be effective in improving perceptions and ultimately access. © 2013 Springer-Verlag Berlin Heidelberg.

Objective To explore the barriers experienced and perceived by health professionals and patients in the delivery of psychosocial care to adults with cancer. Methods Systematic searches were undertaken using the Psych Info, Medline and CINAHL electronic databases, up to October 2013. Research reporting health professional or patient experiences and perceptions of barriers to psychosocial care are included in the review. The systematic review includes studies that have non-experimental, exploratory and observational designs, as is appropriate to answer the review question. Included studies were critically appraised. The results of individual quantitative studies were aggregated. Qualitative content analysis was used to analyse the qualitative results. Results Twenty-five papers met the pre-specified inclusion criteria for the final review. The most commonly perceived barrier for patients relates to receiving adequate support from elsewhere and a lack of perceived need for psychosocial care. Health professionals report barriers at an organisational level most frequently followed by cultural and then individual clinician-related barriers. Conclusions Barriers exist on a variety of levels. People with cancer need clear appropriate information and communication about psychosocial services, including information about the role of psychosocial care in addition to existing supports. Interventions that target the complex interplay of individual, organisational and cultural factors need to be developed. Strategies that improve health professional communication skills, identify clear referral pathways, improve acceptability of interventions and clearly identify the need for services could address many of the barriers identified in this review. Copyright © 2014 John Wiley & Sons, Ltd.

Background: Rural and remote Australians face a range of barriers to mental health care, potentially limiting the extent to which current services and support networks may provide assistance. This paper examines self-reported mental health problems and contacts during the last 12¿months, and explores cross-sectional associations between potential facilitators/barriers and professional and non-professional help-seeking, while taking into account expected associations with socio-demographic and health-related factors. Methods: During the 3-year follow-up of the Australian Rural Mental Health Study (ARMHS) a self-report survey was completed by adult rural residents (N = 1,231; 61% female 77% married; 22% remote location; mean age = 59¿years), which examined socio-demographic characteristics, current health status factors, predicted service needs, self-reported professional and non-professional contacts for mental health problems in the last 12¿months, other aspects of help-seeking, and perceived barriers. Results: Professional contacts for mental health problems were reported by 18% of the sample (including 14% reporting General Practitioner contacts), while non-professional contacts were reported by 16% (including 14% reporting discussions with family/friends). Perceived barriers to health care fell under the domains of structural (e.g., costs, distance), attitudinal (e.g., stigma concerns, confidentiality), and time commitments. Participants with 12-month mental health problems who reported their needs as met had the highest levels of service use. Hierarchical logistic regressions revealed a dose-response relationship between the level of predicted need and the likelihood of reporting professional and non-professional contacts, together with associations with socio-demographic characteristics (e.g., gender, relationships, and financial circumstances), suicidal ideation, and attitudinal factors, but not geographical remoteness. Conclusions: Rates of self-reported mental health problems were consistent with baseline findings, including higher rural contact rates with General Practitioners. Structural barriers displayed mixed associations with help-seeking, while attitudinal barriers were consistently associated with lower service contacts. Developing appropriate interventions that address perceptions of mental illness and attitudes towards help-seeking is likely to be vital in optimising treatment access and mental health outcomes in rural areas.

Background: Suicide death rates in Australia are higher in rural than urban communities however the contributors to this difference remain unclear. Geographical differences in suicidal ideation and attempts were explored using two datasets encompassing urban and rural community residents to examine associations between socioeconomic, demographic and mental health factors. Differing patterns of association between psychiatric disorder and suicidal ideation and attempts as geographical remoteness increased were investigated.Methods: Parallel cross-sectional analyses were undertaken using data from the 2007 National Survey of Mental Health and Wellbeing (2007-NSMHWB, n = 8,463), under-representative of remote and very remote residents, and selected participants from the Australian Rural Mental Health Study (ARMHS, n = 634), over-representative of remote and very remote residents. Uniform measures of suicidal ideation and attempts and mental disorder using the World Mental Health Composite International Diagnostic Interview (WMH-CIDI-3.0) were used in both datasets. Geographic region was classified into major cities, inner regional and other. A series of logistic regressions were undertaken for the outcomes of 12-month and lifetime suicidal ideation and lifetime suicide attempts, adjusting for age, gender and psychological distress. A sub-analysis of the ARMHS sample was undertaken with additional variables not available in the 2007-NSMHWB dataset.Results: Rates and determinants of suicidal ideation and suicide attempts across geographical region were similar. Psychiatric disorder was the main determinant of 12-month and lifetime suicidal ideation and lifetime suicide attempts across all geographical regions. For lifetime suicidal ideation and attempts, marital status, employment status, perceived financial adversity and mental health service use were also important determinants. In the ARMHS sub-analysis, higher optimism and better perceived infrastructure and service accessibility tended to be associated with a lower likelihood of lifetime suicidal ideation, when age, gender, psychological distress, marital status and mental health service use were taken into account.Conclusions: Rates and determinants of suicidal ideation and attempts did not differ according to geographical location. Psychiatric disorder, current distress, employment and financial adversity remain important factors associated with suicidal ideation and attempts across all regions in Australia. Regional characteristics that influence availability of services and lower personal optimism may also be associated with suicidal ideation in rural communities. © 2014 Inder et al.; licensee BioMed Central Ltd.

Introduction: While there is good evidence of the effectiveness of a variety of interventions and services to prevent and/or relieve distress experienced by people affected by cancer, much of this psychosocial morbidity is undetected and untreated, with consequent exacerbated suffering, decreased satisfaction with care, impaired adherence to treatment regimens and poorer morbidity and mortality outcomes. The objective of this study is to develop, implement and assess the impact, acceptability and cost of an integrated, patient-centred Psychosocial Assessment, Care and Treatment (PACT) model of care for patients with urological and head and neck cancers. Methods and analysis: A time series research design will be used to test the PACT model of care, newly introduced in an Australian tertiary hospital. The primary outcome is system-level impact, assessed through audit of patients' medical records and Medicare claims for follow-up care. The secondary outcomes are impact of the model on patients' experience and healthcare professionals' (HCPs) knowledge and confidence, assessed via patient and HCP surveys at baseline and at followup. Acceptability of the intervention will be assessed through HCP interviews at follow-up, and cost will be assessed from Medicare and Pharmaceutical Benefits Scheme claims information and information logged pertaining to intervention activities (eg, time spent by the newly appointed psycho-oncology staff in direct patient contact, providing training sessions, engaging in case review) and their associated costs (eg, salaries, training materials and videoconferencing). Ethics and dissemination: Ethics approval was obtained from the Human Research Ethics Committees of Hunter New England Local Health District and the University of NSW. Results: The results will be widely disseminated to the funding body and through peer-reviewed publications, HCP and consumer publications, oncology conferences and meetings.

Objective Recognition that patients and partners are both affected by a cancer diagnosis has led to increased interest in couple-based interventions. Although these interventions show promise for enhancing both patients' and partners' illness adjustment, couples' acceptance of these interventions is not well documented. This review explores these issues as reflected in uptake and attrition rates in published trials. Methods A literature search identified 17 manuscripts reporting the uptake and attrition rates of couple-based interventions for couples facing cancer. The uptake (percentage of eligible couples randomised into a trial) and the attrition (percentage of couples who dropped out of a trial) rates were extracted by cancer type, cancer stage, intervention type, intervention focus and intervention delivery method. Results Uptake and attrition rates ranged from 13.6% to 94.2% and 0% to 49.4%, respectively. Low uptake rates were noted for communication-focused interventions and those requiring both the patient and the partner to participate in the intervention simultaneously. Attrition was also high in the latter group. Uptake rates appeared slightly lower than individual-based interventions (58%-76%), as were attrition rates, although only for late stage cancer (~30% couple-based vs. ~69% individual-based). Common barriers to uptake included accessibility, competing priorities and illness severity. Conclusions The couple-based interventions had slightly lower uptake rates than what has been previously reported for individual-based interventions; however, lower attrition suggests patients and partners may be more inclined to complete an intervention when they participate together. The findings support the need to develop strategies to improve the delivery and acceptability of couple-based interventions in clinical practice. Copyright © 2013 John Wiley & Sons, Ltd.

Purpose: The purpose of this paper is to critically examine multidisciplinary, group clinical supervision sessions and to extend current understandings of the barriers/enablers to the implementation of an innovative psychosocial intervention for distressed adults with cancer. Design/methodology/approach: Discourse analysis was used to analyse audio recordings from clinical supervision sessions delivered as part of a psychosocial intervention within the context of a randomised control trial (RCT). Findings: Examination of subject positions, representation and tensions reveals that Health Professionals can resists the pressures of systemic barriers to provide much-needed psychosocial support for distressed adults with cancer. Critical examination of multidisciplinary clinical supervision sessions describes how Health Professionals are able to construct new meanings and reposition themselves as being able to provide supportive care within the context of their everyday practices. Research limitations/implications: This paper reports only a small part of a larger analysis that aims to explore how discourse maps the current state of psychosocial care for adults with cancer and illustrates the fragility and potential for change in this area. Originality/value: Extension on the previous literature is seen within the data through the presence of positive resistance against systemic barriers. Previous exploration of clinical supervision has not collected data generated within the sessions. It is also novel in the use of discourse analysis being used in association with a randomised controlled trial to understand the situational complexities associated with bringing about practice change. © Emerald Group Publishing Limited.