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Objectives Many adolescents and young adults with emerging mood disorders do not achieve substantial improvements in education, employment, or social function after receiving standard youth mental health care. We have developed a new model of care referred to as 'highly personalised and measurement-based care' (HP&MBC). HP&MBC involves repeated assessment of multidimensional domains of morbidity to enable continuous and personalised clinical decision-making. Although measurement-based care is common in medical disease management, it is not a standard practice in mental health. This clinical effectiveness trial tests whether HP&MBC, supported by continuous digital feedback, delivers better functional improvements than standard care and digital support. Method and analysis This controlled implementation trial is a PROBE study (Prospective, Randomised, Open, Blinded End-point) that comprises a multisite 24-month, assessor-blinded, follow-up study of 1500 individuals aged 15-25 years who present for mental health treatment. Eligible participants will be individually randomised (1:1) to 12 months of HP&MBC or standardised clinical care. The primary outcome measure is social and occupational functioning 12 months after trial entry, assessed by the Social and Occupational Functioning Assessment Scale. Clinical and social outcomes for all participants will be monitored for a further 12 months after cessation of active care. Ethics and dissemination This clinical trial has been reviewed and approved by the Human Research Ethics Committee of the Sydney Local Health District (HREC Approval Number: X22-0042 & 2022/ETH00725, Protocol ID: BMC-YMH-003-2018, protocol version: V.3, 03/08/2022). Research findings will be disseminated through peer-reviewed journals, presentations at scientific conferences, and to user and advocacy groups. Participant data will be deidentified. Trial registration number ACTRN12622000882729.

INTRODUCTION: There is limited research into informal support processes amongst young people supporting a peer through a traumatic event and how this process occurs specifically within a rural setting. OBJECTIVE: The aim of this research was to understand how the contextual environment impacts on the personal and interpersonal processes of rural-based young people supporting a peer who experienced a traumatic event. DESIGN: Qualitative interviews were conducted with 22 young people (aged 14-19), who resided in Gippsland, Victoria, Australia. A substantive theory was developed using Charmaz's (1) Constructivist grounded theory methodology. FINDINGS: Young people who shared responsibility for supporting their peer went back to life as normal and felt connected to their community, whereas young people who maintained sole responsibility, experienced mental health problems, disconnected from their community and felt like an outsider. The contextual environmental factors (i.e., service accessibility, limited transport, and internet blackspots) impacted both negatively and positively on young people's ability to provide support as well as influenced whether they felt safe share responsibility. DISCUSSION: This theory implies that providing pathways to reconnecting with place and community, are essential in guiding young people back to their foundations of support. CONCLUSION: Integrating these insights can create new service models in rural areas, whilst also creating opportunities to form healthy foundations of support.

AIM: The sexual health of adults with schizophrenia is poorer than the general population; however, less is known about young people experiencing a first episode of psychosis (FEP). The aim of this study was to explore the high-risk sexual behaviours and sexual well-being indicators of a cohort of young people with FEP. METHODS: Data collected from young people (15-24 years) with FEP attending the EPPIC service in Melbourne and participating in a physical health intervention were analysed. Baseline trial data collected on sexual health and high-risk behaviours, psychiatric symptomology, functioning, and substance use are presented by gender. Associations between symptomology and functioning with sexual behaviour are explored. RESULTS: A total of 69 young people were included in this study; mean age was 19.6 years (SD±2.8), 53.6% were male, 59.6% identified as heterosexual, and 21.7% were currently in a relationship. Within the cohort, 78.3% had ever been sexually active. Of these, 44.2% consistently used a condom at last sex act and 35.7% used barrier contraception consistently, 22.5% had previously been pregnant, and 18.6% had tested positive for an STI. Finally, young people were more likely to have been sexually active if they were currently using substances. CONCLUSIONS: These findings suggest that high rates of high-risk sexual behaviour remain an issue for young people experiencing a first episode of psychosis. Promoting sexual well-being and communication skills between sexual partners should be targeted to ensure that high-risk sexual health outcomes are mitigated as early as possible.

Individual Placement and Support (IPS) is an evidence-based supported employment program that helps people with severe mental illness to achieve steady, meaningful employment in competitive mainstream jobs. The purpose of this study is to investigate the impact of Covid-19 restrictions on IPS service delivery in Northern Norway between March and October 2020. In Norway, IPS is in the early stages of full-scale implementation and is therefore potentially sensitive to external stressors such as the Covid-19 pandemic. In October 2020 we conducted a retrospective, cross-sectional survey with IPS employment specialists in Northern Norway (n = 25). The purpose was to collect information about how Covid-19 restrictions between March and October 2020 impacted their ability to deliver IPS services. As a result of Covid-19 restrictions, more than half the employment specialists were reassigned to other roles or non-IPS related work tasks. They also reported less collaborative engagement with clinical teams and employers. 69 (20.4%) of IPS users supported by employment specialists gained employment after the Covid-19 restrictions were introduced and 82.8% of unemployed IPS users continued to seek competitive employment despite Covid-19 restrictions. Covid-19 restrictions appear to have created obstacles for IPS service delivery in Northern Norway and have negatively impacted the employment specialists' collaborative engagement with clinical teams. However, IPS employment specialists have shown strong capabilities in overcoming these challenges and services users have remained motivated to seek employment during the pandemic.

PURPOSE: First-episode psychosis (FEP) is characterised by wide heterogeneity in terms of symptom presentation and illness course. However, the heterogeneity of quality of life (QoL) in FEP is not well understood. We investigated whether subgroups can be identified using participants' responses on four QoL domains (physical health, psychological, social relationships, and environmental) 18-months into the recovery phase of FEP. We then examined the discriminant validity of these subgroups with respect to clinical, cognitive, and functioning features of FEP. METHOD: Demographic and clinical characteristics, QoL, cognition, and functioning were assessed in 100 people with FEP at the 18-month follow-up of a randomised controlled trial of Individual Placement Support, which aims to facilitate vocational recovery. QoL was measured using the World Health Organisation's QoL-BRIEF. A two-stage clustering approach using Ward's method and Squared Euclidean Distance with a k-means confirmation was conducted. Multinomial logistic regressions were used to establish external validity. RESULTS: Three QoL subgroups emerged: a 'good' subgroup with relatively high QoL across all domains (31%), an 'intermediate' subgroup with relatively low psychological QoL (48%) and a 'poor' subgroup with markedly low social relationship QoL (21%). Negative symptoms, depressive symptoms, social/occupational functioning, and social inclusion at follow-up predicted subgroup membership. Sensitivity analysis found similar results. CONCLUSION: Although some individuals with FEP have QoL comparable to individuals without mental ill health, QoL can remain concerningly low despite treatment efforts. Future research on interventions that target factors associated with poor QoL, such as low social inclusion, is required to counteract prolonged poor QoL in FEP.

BACKGROUND: No biological treatment has been firmly established for the at-risk stage of psychotic disorder. In this study we aim to test if subthreshold psychotic symptoms can be effectively treated with cannabidiol (CBD), a non-psychoactive compound of the plant Cannabis sativa. The question has taken on increased importance in the wake of evidence questioning both the need and efficacy of specific pharmacological interventions in the ultra-high risk (UHR) for psychosis group. METHODS: Three-arm randomized controlled trial of 405 patients (135 per arm) aged 12-25 years who meet UHR for psychosis criteria. The study includes a 6-week lead-in phase during which 10% of UHR individuals are expected to experience symptom remission. Participants will receive CBD (per oral) at doses 600 or 1000 mg per day (fixed schedule) for 12 weeks. Participants in the third arm of the trial will receive matching placebo capsules. Primary outcome is severity of positive psychotic symptoms as measured by the Comprehensive Assessment of At-Risk Mental States at 12 weeks. We hypothesize that CBD will be significantly more effective than placebo in improving positive psychotic symptoms in UHR patients. All participants will also be followed up 6 months post baseline to evaluate if treatment effects are sustained. CONCLUSION: This paper reports on the rationale and protocol of the Cannabidiol for At Risk for psychosis Youth (CanARY) study. This study will test CBD for the first time in the UHR phase of psychotic disorder.

BACKGROUND: Factors that contribute to the early mortality observed in psychotic disorders, specifically obesity, smoking and sedentary behaviour, occur early in the disorder. AIMS: We aimed to determine whether the integration of a physical health nurse in the care of young people with first-episode psychosis could prevent clinically significant weight gain (≥7% body weight). Secondary outcomes included rates of smoking, metabolic syndrome and sedentary behaviour. METHOD: In this single-blind, randomised controlled trial, participants who had received under 4 weeks of antipsychotic medication were randomly allocated to either the intervention (addition of a physical health nurse to their care) or treatment as usual (TAU) for 12 weeks. RESULTS: Of the 77 participants, there were follow-up data for 86.8% (n = 33) of the intervention group and 82.1% (n = 32) of the TAU group. After 12 weeks, 27.3% of the intervention group experienced clinically significant weight gain compared with 34.4% of the TAU group (odds ratio 0.72, 95% CI 0.25-2.06, P = 0.54). After 6 months, 40.7% of the intervention group gained clinically significant weight compared with 44.1% of the TAU group (P = 0.79). There was no difference in mean change in weight between groups after 12 weeks (2.6 kg v. 2.9 kg, P = 0.87) or 6 months (3.6 kg v. 4.3 kg, P = 0.64). There were no differences in the rates of tobacco smoking cessation, prevalence of metabolic syndrome or physical activity levels. CONCLUSIONS: This intervention failed to prevent the metabolic complications that are highly prevalent in psychotic disorders in the short to medium term, indicating that more intensive interventions are required.

BACKGROUND: Employment is intrinsic to recovery from mental health conditions, helping people live independently. Systematic reviews indicate supported employment (SE) focused on competitive employment, including individual placement and support (IPS), is effective in helping people with mental health conditions into work. Evidence is limited on cost-effectiveness. We comprehensively reviewed evidence on the economic case for SE/IPS programmes. METHODS: We searched PubMed/MEDLINE, EMBASE, PsycINFO, CINAHL, IBSS, Business Source Complete, and EconLit for economic and return on investment analyses of SE/IPS programmes for mental health conditions. Traditional vocational rehabilitation, sheltered work, and return to work initiatives after sickness absence of less than 1 year were excluded. Studies were independently screened by two reviewers. We assessed quality using the Consolidate Health Economic Evaluation Reporting Standards checklist. The protocol was preregistered with PROSPERO-CRD42020184359. RESULTS: From 40,015 references, 28 studies examined the economic case for IPS, four IPS augmented by another intervention, and 24 other forms of SE. Studies were very heterogenous, quality was variable. Of 41 studies with quality scores over 50%, 10 reported cost per quality-adjusted life year gained, (8 favourable to SE/IPS), 14 net monetary benefits (12 positive), 5 return on investment (4 positive), and 20 cost per employment outcome (14 favorable, 5 inconclusive, 1 negative). Totally, 24 of these 41 studies had monetary benefits that more than outweighed the additional costs of SE/IPS programmes. CONCLUSIONS: There is a strong economic case for the implementation of SE/IPS programmes. The economic case is conservative as evidence on long-term impacts of programmes is limited.

BACKGROUND: For decades there has been a continuous increase in the number of people receiving welfare benefits for being outside the work force due to mental illness. There is sufficient evidence for the efficacy of Individual Placement and Support (IPS) for gaining and maintaining competitive employment. Yet, IPS is still not implemented as routine practice in public community mental health services. Knowledge about implementation challenges as experienced by the practitioners is limited. This study seeks to explore the experiences of the front-line workers, known as employment specialists, in the early implementation phase. METHODS: Qualitative data were collected through field notes and five focus group interviews. The study participants were 45 IPS employment specialists located at 14 different sites in Northern Norway. Transcripts and field notes were analysed by thematic analyses. RESULTS: While employment specialists are key to the implementation process, implementing IPS requires more than creating and filling the role of the employment specialist. It requires adjustments in multiple organisations. The new employment specialist then is a pioneer of service development. Some employment specialists found this a difficult challenge, and one that did not correspond to their expectations going into this role. Others appreciated the pioneering role. IPS implementation also challenged the delegation of roles and responsibilities between sectors, and related legal frameworks related to confidentiality and access. The facilitating role of human relationships emphasised the importance of social support which is an important factor in a healthy work environment. Rural areas with long distances and close- knit societies may cause challenges for implementation. CONCLUSION: The study provides increased understanding on what happens in the early implementation phase of IPS from the employment specialists' perspective. Results from this study can contribute to increased fo

AIM: People diagnosed with mental disorders experience higher rates of unemployment than those without. Career adaptability, defined as the ability to respond flexibly and make informed career decisions in work and throughout career transitions, is becoming increasingly important as the nature of work changes rapidly. Early vocational intervention may ameliorate poor education and employment outcomes experienced by young people with mental ill-health and promote transferable skills and adaptability. Online-based career support allows for ongoing access throughout different career stages. The current study combines mental health-informed digital career and peer motivation, to create a Youth Online Training and Employment System (YOTES) that supports young people with mental ill-health obtain and remain in education or employment. METHODS: This study is an unblinded randomized controlled trial for young people with mental ill-health, aged 16-25, who are seeking vocational support. Participants will be randomized to receive either YOTES, a moderated, online intervention with vocational, social, and peer motivation, or a control intervention, the headspace Digital Work and Study Service. Both groups will have access to in-person career support if seeking employment. The primary outcome will be career adaptability compared between the YOTES and control groups at 6-months post baseline. Secondary outcomes include number of hours worked in the past 7 days, hope, career confidence, psychological distress and health economic outcomes at 6- and 12-months post baseline. CONCLUSION: Results will demonstrate whether an online career intervention moderated by career practitioners with peer motivation can result in improved career adaptability in young people with mental ill-health.

AIM: Standards for health care quality, access and evaluation of early intervention in psychosis services are required to assess implementation, provide accountability to service users and funders and support quality assurance. The aim of this article is to review the application of standards in Europe and North America. METHODS: Descriptive methods will be used to illustrate the organizational context in which standards are being applied and used, specific measures being applied and results so far. RESULTS: Both fidelity scales and quality indicators of health care are being used. Fidelity scales are being applied in Australia, Canada, Denmark, Italy and United States. In England, quality indicators derived from the National Institute for Health and Care Excellence guidance are being used. CONCLUSION: In the last 4 years, significant progress has been made in the development and application of measures that assess quality and access to evidence-based practices for early intervention in psychosis services. This represents an important step towards providing accountability, improving outcomes and service user experience. The methods used allow for comparison between the services that are assessed with the same methods, but there is a need to compare the different methods. Further research is also required to explore links between quality of care and outcomes for community mental health services that deliver early intervention in psychotic disorders.

AIM: Early psychosis delivery models have proliferated worldwide, but there is limited research into establishing model fidelity. In this context, this article aims to describe the development and implementation of a fidelity tool in a national network of early psychosis services across Australia-the headspace Early Psychosis program. METHODS: Following a detailed consultation process, and based on the Australian Early Psychosis model, an 80-item Early Psychosis Prevention and Intervention Centre Model Integrity Tool (EMIT) was developed along with predefined thresholds for fidelity. The tool was used to assess adherence to the model in six clusters of service sites across Australia. Ratings on the EMIT were informed by interviews with site staff and young people receiving the service, routinely collected data and site policies and procedures. RESULTS: All six clusters of headspace Early Psychosis programs participated in five fidelity assessments across a period of two and a half years. In the initial two visits, the average fidelity score was in the 'low' fidelity range (i.e., <75%). By the fifth fidelity visit, the network average improved to 92.35%, reflecting 'superior' fidelity. CONCLUSIONS: Results of the longitudinal fidelity assessments indicate the successful implementation of the Australian Early Psychosis model across the headspace Early Psychosis program. Utilisation of ongoing fidelity assessments has proved an effective method to improve and maintain adherence to the model.

AIM: The issue of youth who are not engaged in education, employment or training has been a focus of policymakers for decades. Although interventions exist for these youth, they often measure success in ways that fail to capture what youth seek to gain. The project aims to address this gap by assessing youth-oriented outcomes for interventions targeting upcoming youth. Acknowledging the stigma attached to the deficit-based notion of not engaged in education, employment or training, hereafter we refer to 'upcoming youth', a term coined by youth partners on the project. This study asks what youth want to achieve by participating in an intervention for upcoming youth, with a view to guiding service and research design. METHODS: A mixed-methods discrete choice experiment will be conducted with youth engaged as partners. A qualitative (focus group) stage will be conducted to design discrete-choice experiment attributes and levels. The experiment will be piloted and administered online to approx. 500 youth (aged 14-29) across Canada to identify the outcomes that youth prioritize for interventions. Latent class analyses will then be conducted to explore clusters of outcomes that different groups of youth prioritize. CONCLUSIONS: From a strengths-based recovery-oriented framework, hearing the voices of the target population is important in designing and evaluating services. This youth-oriented research project will identify the intervention outcomes that are the highest priority for upcoming youth. Findings will inform the development, implementation and testing of interventions targeting relevant outcomes for youth who are not engaged in education, employment or training.

OBJECTIVE: This paper provides the rationale for the development of sub-specialty training in youth psychiatry. METHOD: Training needs for youth psychiatry are discussed and the opportunities provided by sub-specialisation in youth psychiatry are presented. RESULTS: The majority of mental disorders have their onset prior to 25 years. There has been substantial recent growth in services to meet the clinical needs of young people. The development of these services has exposed gaps in current training for psychiatrists, which varies considerably between child and adolescent, and adult psychiatry. Competencies acquired by psychiatrists in youth mental health are non-standardised, which may hinder optimal care. CONCLUSIONS: Sub-specialty training in youth psychiatry is needed to meet workforce demands. The development of a certificate in youth psychiatry, by the RANZCP Section for Youth Mental Health, is underway. This will complement existing training and provide trainees and psychiatrists the opportunity to develop specialist skills in the provision of mental health care for young people negotiating the transition between adolescence and adulthood.

AIM: Young people with psychotic disorders have poorer physical health compared to their healthy peers, a state compounded by the metabolic side-effects of antipsychotic medications. To address this, Orygen Youth Health has introduced physical health services including exercise physiologists and dieticians. These services are typically coordinated by the case manager and doctor. It is not yet known whether a treating team member dedicated to physical health will improve engagement, adherence and outcomes with these services. Hence, the protocol is presented here for a trial to evaluate the effect of including a physical health nurse in the care of young people with first-episode psychosis. METHODS: This will be a single-blind randomized controlled trial that includes 15- to 24-year-olds with first-episode psychosis who have just commenced (within 30 days) antipsychotic medication. The primary outcome will be the event of clinically significant weight gain (≥7% body weight). Participants will be assigned either a physical health nurse in their treating team (in addition to the case manager and doctor) for a 12-week period, or treatment as usual (case manager and doctor). Research assessments will be conducted at baseline, 12 and 26 weeks. Activity trackers worn by participants for the study's duration will measure sleep and physical activity. CONCLUSION: The present study will determine whether a physical health nurse will facilitate participants in attending and engaging in physical health interventions and whether this will be associated with physical health improvements or the prevention of worsening physical health.

AIM: Approximately 15 years ago, four youth access clinics (YACs) were established in the Gippsland region to improve mental and general healthcare for young people living in the region. The aim of the study was to examine the barriers and enablers for young people accessing the YACs in Gippsland. METHODS: Using qualitative methodology, nine female YAC staff members and seven youth YAC consumers were interviewed. Thematic analysis was utilized to identify important and consistent themes in the data derived through the consultation process. RESULTS: Barriers under four themes were identified: environmental (eg, limited transport); service (ie, limited opening hours); client (eg, parent permission) and staff (ie, retention of staff). Enablers were identified as environmental (ie, high social proximity), service (eg, funding), client (ie, awareness of service) and staff (eg, champion staff). CONCLUSION: The success of new rural service models will likely depend on learning from what has already worked in some of the many small communities in this region. Beyond learning, further success and uptake of new service offerings will be enhanced through understanding community needs, obtaining community support and enhancing high social proximity.

Background: The clinical onset of borderline personality disorder (BPD) usually occurs in young people (aged 12–25 years) and commonly leads to difficulty achieving and maintaining vocational (education and/or employment) engagement. While current psychosocial interventions lead to improvements in psychopathology, they have little effect upon functioning. Individual Placement and Support (IPS) is a client-driven model that assists individuals with severe mental illness to engage with education and/or employment appropriate to their personal goals, and that provides ongoing support to maintain this engagement. The objective of the INdividual Vocational and Educational Support Trial (INVEST) is to evaluate the effectiveness of adding IPS to an evidence-based early intervention programme for BPD, with the aim of improving vocational outcomes. Methods/design: INVEST is a single-blind, parallel-groups, randomised controlled trial (RCT). The randomisation is stratified by gender and age and uses random permuted blocks. The interventions are 39 weeks of either IPS, or ‘usual vocational services’ (UVS). Participants will comprise 108 help-seeking young people (aged 15–25 years) with three or more DSM-5 BPD features and a desire to study or work, recruited from the Helping Young People Early (HYPE) early intervention programme for BPD at Orygen, in Melbourne, Australia. All participants will receive the HYPE intervention. After baseline assessment, staff who are blind to the intervention group allocation will conduct assessments at 13, 26, 39 and 52 weeks. At the 52-week primary endpoint, the primary outcome is the number of days in mainstream education/employment since baseline. Secondary outcomes include the cost-effectiveness of the intervention, quality of life, and BPD severity. Discussion: Current treatments for BPD have little impact on vocational outcomes and enduring functional impairment is prevalent among this patient group. IPS is a targeted functional interventi

AIM: Over the past two decades, the youth mental health field has expanded and advanced considerably. Yet, mental disorders continue to disproportionately affect adolescents and young adults. Their prevalence and associated morbidity and mortality in young people have not substantially reduced, with high levels of unmet need and poor access to evidence-based treatments even in high-income countries. Despite the potential return on investment, youth mental disorders receive insufficient funding. Motivated by these continual disparities, we propose a strategic agenda for youth mental health research. METHOD: Youth mental health experts and funders convened to develop youth mental health research priorities, via thematic roundtable discussions, that address critical evidence-based gaps. RESULTS: Twenty-one global youth mental health research priorities were developed, including population health, neuroscience, clinical staging, novel interventions, technology, socio-cultural factors, service delivery, translation and implementation. CONCLUSIONS: These priorities will focus attention on, and provide a basis for, a systematic and collaborative strategy to globally improve youth mental health outcomes.

AIM: A growing number of quantitative studies have investigated the utility of neuropsychological assessment in mental health settings. However, to the best of our knowledge, no previous study has qualitatively explored youth mental health providers' perceptions of neuropsychological assessment services. A more in-depth understanding of the perceived advantages and barriers associated with neuropsychological assessment in youth mental health settings is critical to better inform policy, practice and service uptake. Thus, the aim of this study was to qualitatively explore clinicians' views about neuropsychological assessments for youth with mental health concerns. METHODS: A single open-ended qualitative question, included as part of an anonymous cross-sectional online survey, was completed by clinicians (N = 206) treating or assessing adolescents and young adults within Australian primary care mental health centres (headspace). Responses were analysed using an inductive approach to thematic analysis. RESULTS: Five main themes were identified. Clinicians (a) identified barriers to accessing neuropsychological assessments (53%), (b) indicated a range of mixed outcomes following neuropsychological assessment (39%), (c) highlighted a need for neuropsychological assessments (22%), (d) reported a lack of awareness about this resource (10%) and (e) described practice issues associated with neuropsychological services (4%). CONCLUSION: This study uncovered perceived factors contributing to reduced access to neuropsychological assessment in Australian youth mental health settings. Given potential adverse outcomes resulting from this clinical service gap, efforts should be made to address factors contributing to poorer access, thereby mitigating the impact of poor access on the management of mental illness in youth. Several strategies, including funding neuropsychological assessments, are discussed.