Mental ill-health has a major impact on young people, with pain often co-occurring. We estimated the prevalence and impact of pain in young people with mental ill-health.

Longitudinal data (baseline and three-month follow-up) of 1,107 Australian young people (aged 12–25 years) attending one of five youth mental health services. Multi-level linear mixed models estimated associations between pain characteristics (frequency, intensity, and limitations) and outcomes with false discovery rate (FDR) adjustment. Pain characteristics were baseline-centered to estimate if the baseline score (between-participant effect) and/or change from baseline (within-participant effect) was associated with outcomes.

At baseline, 16% reported serious pain more than 3 days, 51% reported at least moderate pain, and 25% reported pain-related activity limitations in the last week. Between participants, higher serious pain frequency was associated with greater anxiety symptoms (β[95%CI]: 0.90 [0.45, 1.35], FDR-p=0.001), higher pain intensity was associated with greater symptoms of depression (1.50 [0.71, 2.28], FDR-p=0.001), anxiety (1.22 [0.56, 1.89], FDR-p=0.002), and suicidal ideation (3.47 [0.98, 5.96], FDR-p=0.020), and higher pain limitations were associated with greater depressive symptoms (1.13 [0.63, 1.63], FDR-p<0.001). Within participants, increases in pain intensity were associated with increases in tobacco use risk (1.09 [0.48, 1.70], FDR-p=0.002), and increases in pain limitations were associated with increases in depressive symptoms (0.99 [0.54, 1.43], FDR-p<0.001) and decreases in social and occupational functioning (−1.08 [−1.78, −0.38], FDR-p=0.009).

One-in-two young people seeking support for mental ill-health report pain. Youth mental health services should consider integrating pain management.

To improve early intervention and personalise treatment for individuals early on the psychosis continuum, a greater understanding of symptom dynamics is required. We address this by identifying and evaluating the movement between empirically derived attenuated psychotic symptomatic substates—clusters of symptoms that occur within individuals over time.

Data came from a 90-day daily diary study evaluating attenuated psychotic and affective symptoms. The sample included 96 individuals aged 18–35 on the psychosis continuum, divided into four subgroups of increasing severity based on their psychometric risk of psychosis, with the fourth meeting ultra-high risk (UHR) criteria. A multilevel hidden Markov modelling (HMM) approach was used to characterise and determine the probability of switching between symptomatic substates. Individual substate trajectories and time spent in each substate were subsequently assessed.

Four substates of increasing psychopathological severity were identified: (1) low-grade affective symptoms with negligible psychotic symptoms; (2) low levels of nonbizarre ideas with moderate affective symptoms; (3) low levels of nonbizarre ideas and unusual thought content, with moderate affective symptoms; and (4) moderate levels of nonbizarre ideas, unusual thought content, and affective symptoms. Perceptual disturbances predominantly occurred within the third and fourth substates. UHR individuals had a reduced probability of switching out of the two most severe substates.

Findings suggest that individuals reporting unusual thought content, rather than nonbizarre ideas in isolation, may exhibit symptom dynamics with greater psychopathological severity. Individuals at a higher risk of psychosis exhibited persistently severe symptom dynamics, indicating a potential reduction in psychological flexibility.

Diagnosis in psychiatry faces familiar challenges. Validity and utility remain elusive, and confusion regarding the fluid and arbitrary border between mental health and illness is increasing. The mainstream strategy has been conservative and iterative, retaining current nosology until something better emerges. However, this has led to stagnation. New conceptual frameworks are urgently required to catalyze a genuine paradigm shift.

We outline candidate strategies that could pave the way for such a paradigm shift. These include the Research Domain Criteria (RDoC), the Hierarchical Taxonomy of Psychopathology (HiTOP), and Clinical Staging, which all promote a blend of dimensional and categorical approaches.

These alternative still heuristic transdiagnostic models provide varying levels of clinical and research utility. RDoC was intended to provide a framework to reorient research beyond the constraints of DSM. HiTOP began as a nosology derived from statistical methods and is now pursuing clinical utility. Clinical Staging aims to both expand the scope and refine the utility of diagnosis by the inclusion of the dimension of timing. None is yet fit for purpose. Yet they are relatively complementary, and it may be possible for them to operate as an ecosystem. Time will tell whether they have the capacity singly or jointly to deliver a paradigm shift.

Several heuristic models have been developed that separately or synergistically build infrastructure to enable new transdiagnostic research to define the structure, development, and mechanisms of mental disorders, to guide treatment and better meet the needs of patients, policymakers, and society.

The specific and multifaceted service needs of young people have driven the development of youth-specific integrated primary mental healthcare models, such as the internationally pioneering headspace services in Australia. Although these services were designed for early intervention, they often need to cater for young people with severe conditions and complex needs, creating challenges in service planning and resource allocation. There is, however, a lack of understanding and consensus on the definition of complexity in such clinical settings.

This retrospective study involved analysis of headspace’s clinical minimum data set from young people accessing services in Australia between 1 July 2018 and 30 June 2019. Based on consultations with experts, complexity factors were mapped from a range of demographic information, symptom severity, diagnoses, illness stage, primary presenting issues and service engagement patterns. Consensus clustering was used to identify complexity subgroups based on identified factors. Multinomial logistic regression was then used to evaluate whether these complexity subgroups were associated with other risk factors.

A total of 81,622 episodes of care from 76,021 young people across 113 services were analysed. Around 20% of young people clustered into a ‘high complexity’ group, presenting with a variety of complexity factors, including severe disorders, a trauma history and psychosocial impairments. Two moderate complexity groups were identified representing ‘distress complexity’ and ‘psychosocial complexity’ (about 20% each). Compared with the ‘distress complexity’ group, young people in the ‘psychosocial complexity’ group presented with a higher proportion of education, employment and housing issues in addition to psychological distress, and had lower levels of service engagement. The distribution of complexity profiles also varied across different headspace services.

The proposed data-driven complexity model offers valuable insights for clinical planning and resource allocation. The identified groups highlight the importance of adopting a holistic and multidisciplinary approach to address the diverse factors contributing to clinical complexity. The large number of young people presenting with moderate-to-high complexity to headspace early intervention services emphasises the need for systemic change in youth mental healthcare to ensure the availability of appropriate and timely support for all young people.

Cognitive impairments are well-established features of psychotic disorders and are present when individuals are at ultra-high risk for psychosis. However, few interventions target cognitive functioning in this population.

To investigate whether omega-3 polyunsaturated fatty acid (n−3 PUFA) supplementation improves cognitive functioning among individuals at ultra-high risk for psychosis.

Data (N = 225) from an international, multi-site, randomised controlled trial (NEURAPRO) were analysed. Participants were given omega-3 supplementation (eicosapentaenoic acid and docosahexaenoic acid) or placebo over 6 months. Cognitive functioning was assessed with the Brief Assessment of Cognition in Schizophrenia (BACS). Mixed two-way analyses of variance were computed to compare the change in cognitive performance between omega-3 supplementation and placebo over 6 months. An additional biomarker analysis explored whether change in erythrocyte n−3 PUFA levels predicted change in cognitive performance.

The placebo group showed a modest greater improvement over time than the omega-3 supplementation group for motor speed (ηp2 = 0.09) and BACS composite score (ηp2 = 0.21). After repeating the analyses without individuals who transitioned, motor speed was no longer significant (ηp2 = 0.02), but the composite score remained significant (ηp2 = 0.02). Change in erythrocyte n-3 PUFA levels did not predict change in cognitive performance over 6 months.

We found no evidence to support the use of omega-3 supplementation to improve cognitive functioning in ultra-high risk individuals. The biomarker analysis suggests that this finding is unlikely to be attributed to poor adherence or consumption of non-trial n−3 PUFAs.

The utility of quality of life (QoL) as an outcome measure in youth-specific primary mental health care settings has yet to be determined. We aimed to determine: (i) whether heterogeneity on individual items of a QoL measure could be used to identify distinct groups of help-seeking young people; and (ii) the validity of these groups based on having clinically meaningful differences in demographic and clinical characteristics.

Young people, at their first presentation to one of five primary mental health services, completed a range of questionnaires, including the Assessment of Quality of Life–6 dimensions adolescent version (AQoL-6D). Latent class analysis (LCA) and multivariate multinomial logistic regression were used to define classes based on AQoL-6D and determine demographic and clinical characteristics associated with class membership.

1107 young people (12–25 years) participated. Four groups were identified: (i) no-to-mild impairment in QoL; (ii) moderate impairment across dimensions but especially mental health and coping; (iii) moderate impairment across dimensions but especially on the pain dimension; and (iv) poor QoL across all dimensions along with a greater likelihood of complex and severe clinical presentations. Differences between groups were observed with respect to demographic and clinical features.

Adding multi-attribute utility instruments such as the AQoL-6D to routine data collection in mental health services might generate insights into the care needs of young people beyond reducing psychological distress and promoting symptom recovery. In young people with impairments across all QoL dimensions, the need for a holistic and personalised approach to treatment and recovery is heightened.

Subjective cognitive difficulties are common in mental illness and have a negative impact on role functioning. Little is understood about subjective cognition and the longitudinal relationship with depression and anxiety symptoms in young people.

To examine the relationship between changes in levels of depression and anxiety and changes in subjective cognitive functioning over 3 months in help-seeking youth.

This was a cohort study of 656 youth aged 12–25 years attending Australian headspace primary mental health services. Subjective changes in cognitive functioning (rated as better, same, worse) reported after 3 months of treatment was assessed using the Neuropsychological Symptom Self-Report. Multivariate multinomial logistic regression analysis was conducted to evaluate the impact of baseline levels of and changes in depression (nine-item Patient Health Questionnaire; PHQ9) and anxiety symptoms (seven-item Generalised Anxiety Disorder scale; GAD7) on changes in subjective cognitive function at follow-up while controlling for covariates.

With a one-point reduction in PHQ9 at follow-up, there was an estimated 11–18% increase in ratings of better subjective cognitive functioning at follow-up, relative to stable cognitive functioning. A one-point increase in PHQ9 from baseline to follow-up was associated with 7–14% increase in ratings of worse subjective cognitive functioning over 3 months, relative to stable cognitive functioning. A similar attenuated pattern of findings was observed for the GAD7.

A clear association exists between subjective cognitive functioning outcomes and changes in self-reported severity of affective symptoms in young people over the first 3 months of treatment. Understanding the timing and mechanisms of these associations is needed to tailor treatment.