By Professor Patrick McGorry, Alexandra Parker and Dr Rosemary Purcell Department of Psychiatry, The University of Melbourne and ORYGEN Research Centre
The mental health of young people is of growing concern within developed countries and has become the major threat to health during adolescence and early adult life. Since the Second World War there has been a substantial increase in psychosocial disorders among young people between 12 and 26 years (Rutter & Smith, 1995). The incidence of mental illness in young people is now well documented and shown to be the highest of any age group. Recently the National Comorbidity Survey Replication in the United States indicated that 75 percent of people suffering from an adult-type mental disorder (including psychosis, substance use, mood and anxiety disorders) had an age of onset by 24 years (Kessler, Bergland, Demler et al, 2005). This makes the issue of youth mental health critical within the community, and its effective management an urgent priority for mental health services.
In most developed countries, mental health care has traditionally been artificially divided into pediatric and adult services. This model may work well for general medical disorders, which become relatively less common in adolescence and young adulthood, but it is inappropriate for mental health service delivery, as it creates weakness and discontinuity in the system just when it should be at its strongest to address the peak onset and burden of mental illness (Gunn, 2004). In this article, we argue that youth-specific services are required that focus on the onset phase of a broad range of potentially serious mental disorders (including psychosis, mood and eating disorders, and substance use disorders), in order to have maximum impact for prevention and early intervention purposes.
Young people and mental health
There is some variation in the definition of a 'young person', although a reasonable consensus is that young people are those aged between 12 to 25 years. The lower end of this phase is roughly defined by puberty, while the upper end is somewhat more fuzzy, though involves achieving an independent adult identity. It may be helpful to view these individuals as 'emerging adults' who are in the later stages of their education, or the early stages of their employment career, and who may be facing a number of developmental challenges, including establishing employment and sexually intimate relationships, and using alcohol and tobacco (eg. Graham, 2004). Indeed it is the confluence of these experiences which helps put the mental health needs of young people in context (Patel, Fisher & McGorry, in press).
In Australia, the prevalence of mental health problems among children aged 4-12 years is at most 14 percent (based on parental reports; Sawyer, Arney, Baghurst et al, 2000), which rises to 19 percent among adolescents aged 13-17 years (Sawyer et al, 2000) and increases again to 27 percent among young adults aged 18-24 (McLennan, 1997). Based on these figures, approximately one in four to five young Australians are likely to suffer from a mental health problem, most commonly substance abuse or dependency, depression, anxiety and eating disorders (Australian Institute of Health & Welfare: AIHW, 2003). Comorbidity (particularly substance abuse disorders) is unfortunately the norm in this population (AIHW, 2003). High rates of disability are associated with mental disorders among young people (McLennan, 1997), including impaired work productivity, absenteeism, educational failure and poor family functioning. The Victorian Burden of Disease Study reinforces the seriousness of this problem, demonstrating that for young people aged 15-24 years, mental disorders are the single greatest cause of years of healthy life lost (Public Health Group, 2005).
The limitations of current service models
In response to the inherent limitations of the child/adult model of mental health services, specific Child and Adolescent Mental Health Services (CAMHS) have been developed. While an improvement on the traditional model, these services nonetheless struggle to manage the adult pattern of emerging serious mental illness, especially in the middle and later stages of adolescence. Conversely, access to adult public mental health services is limited to individuals aged 18 years or over who have a 'serious mental illness' (SMI), which in practice usually means schizophrenia and related psychotic disorders. The widespread growth of the early psychosis model reflects the fact that these services are even inappropriate for young people in the early stages of psychotic illness. Furthermore, the SMI focus of adult services ignores the tremendous need for services for young people with non-psychotic disorders, which though they tend to be less clinically severe (though not always) are nonetheless productive of significant levels of distress and functional impairment. Furthermore, there are serious iatrogenic effects of mixing young adults with older patients who are chronically affected by mental disorder (McGorry, Chanen, McCarthy et al, 1991), which the current model ignores. Equally disconcerting are problems with initial access and ongoing engagement of young people in adult mental health services, which has been shown to contribute to the long delays in treating early psychosis (Norman & Malla, 2001). As a result of the limitations in the existing service models, the mental health needs of many young people largely go either undetected or receive no effective intervention whatsoever (Department of Health and Ageing, 2005). Even those who do gain access, do so belatedly and often in the context of extreme crisis.
This means that at the very time when mental health services are most needed, they are often inaccessible or unacceptable in design and culture to young people. In Australia, fewer than expected people consult either primary or specialist sectors for mental health concerns (Issakidis & Andrews, 2006) and less than one third of young people who are experiencing mental health problems are in contact with a professional service throughout a 12-month period (Sawyer et al, 2000). Evidence also suggests that young people are poorly informed about mental health issues, including knowledge of the key symptoms of mental disorders, and when, how and from whom to seek appropriate help (Jorm et al, 1997). As a consequence, many young people with distressing and disabling mental health difficulties struggle to find appropriate assistance. Particularly for young people who don't necessarily have a 'serious mental illness', and even for those who do, the stigma associated with attending a mental health clinic is significant, and access is poor, delayed, denied or short-lived. Young people with moderately severe non-psychotic disorders (e.g., depression, anxiety disorders and personality disorders) and those with comorbid mental health and substance use are particularly vulnerable. Without access to appropriate treatment, many young people present in repeated crisis to over-stretched hospital emergency departments, or their parents and carers are left to try and cope alone. In far too many cases their difficulties eventually become chronic and disabling. A more substantial focus on the needs of young people and how a service should orient itself towards this population is critical.
There has been a growing call for the need for a separate system to respond to youth mental health, particularly as youth onset mental disorders are arguably the most serious health problems of their developmental period both in mortality and morbidity (McGorry, 1996; Parry-Jones, 1995). Notwithstanding this, clinical and public health responses have been few, piecemeal and relatively ineffective to date (Patton, 1996). There is an obvious public health significance of the suffering, functional impairment, and exposure to stigma and discrimination that can accompany mental health problems in young people. If the majority of mental disorders have their onset in youth, there is a clear imperative for early diagnosis and interventions that are designed to prevent the progression of primary disorders and the onset of secondary comorbid disorders (Kessler et al, 2005).
Early intervention in youth (mental) health
Early diagnosis of potentially serious psychiatric disorders in young people is essential in order to inform the choice of treatment and to predict outcome or prognosis (McGorry, Hickie, Yung et al, in press). Early intervention at the onset of disorder or for those 'at-risk' of development of a disorder aims to prevent the progression of the illness and to minimise 'collateral damage' to social, educational, and vocational functioning (McGorry & Yung, 2003). For example, self-limiting disorders and milder, yet potentially serious, disorders in an early stage may respond to simple measures such as psychosocial support, self-help strategies and education, while specialised and multidisciplinary care would be required for a substantial minority of young people who have multiple or complex psychiatric needs. In the area of psychosis, for example, research indicates that early intervention and prevention is a crucial determinant in minimising the potential impact of such illnesses (McGorry, Yung, Phillips et al, 2002; Craig, Garety, Power et al, 2005; Petersen, Jeppesen, Thorup et al, 2005).
Patton (1996) supported the need for early intervention and prevention and pointed out that clinical studies of adolescent disorders and evidenced-based treatments remains limited, especially for non-psychotic illnesses. This remains true today. As a result, the efficacy of established treatments for adult disorders remains unclear in adolescents where there is greatest potential for early intervention and secondary prevention.
Developing responsive services for young people with mental disorders
In responding to potentially serious psychiatric disorder in youth, a new model is required that builds on but is qualitatively different from existing child and adolescent and adult approaches. Many of the disorders which have their onset during adolescence and young adulthood occur in the context of major physical and psychological maturational changes as well as complex adjustments within the family and society. These require a complex assessment, diagnosis and treatment response that requires careful consideration and skilled clinical input. Youth-specific approaches are necessary which are characterised by their developmentally-oriented approach to the management of mental disorders, such that they acknowledge the evolving nature and complex pattern of mental illness in this age group, along with young people's individual and group identity and unique life-stage issues (Mrazek & Haggerty, 1994) and their discerning help-seeking behaviours (Rickwood et al, 2005).
It may be useful here to use as an example, the distinction between low and high prevalence disorders, since each will require a different model for early intervention. Psychosis in its many forms is considered relatively low in prevalence, affecting approximately 2-3 percent of the population. However the nature of the disorder is such that it often requires intense intervention and management by specialist mental health services until a period of stabilisation. At this point the primary care sector can then be utilised to assist in the management of the person's psychosis. Despite the high prevalence of mood and anxiety disorders, only a subset of these conditions require treatment by a specialist mental health service. Many, in fact could theoretically be treated far more effectively and efficiently by the primary care sector, particularly by adopting an indicated prevention (subthreshold) and early intervention approach. The primary care sector is also far from youth friendly however and needs major reform in terms of access and skill, plus multi-disciplinary input. The new National Youth Mental Health Foundation (or 'Headspace: Where young minds come first') has been established by the Federal government to tackle this issue. It aims to establish up to 30 new youth-friendly service environments Australia-wide over the next three years to provide multidisciplinary care for young people with emerging mental and substance use disorders. These service platforms will be community-based, deliver evidence-based care and will be supported by national training and education programs as well as awareness and help-seeking initiatives.
Much of the disability associated with mental disorders develops in the early years following illness onset. This period represents a critical period for intervention. Early, effective intervention during adolescence and young adulthood is essential if we wish to reduce the risk of ongoing impairment or disability associated with mental health and related substance use disorders. Regrettably this rarely occurs. Treatment delays are common and unmet need remains disturbingly high. Only one out of every four young persons with mental health problems receives professional help. Even among young people with the most severe mental health problems only half receive professional help and fewer still receive optimal evidence-based care.
New, more engaging and effective healthcare service systems are required which can rapidly engage young people and provide the comprehensive and integrated treatment and support services that are needed to achieve clinical remission and full functional recovery. Taking a population health perspective, we advocate a continuum of response with a series of levels, from the community through to specialist services, albeit retaining sufficient flexibility since the traditional filter model is less likely to work in a smooth, linear way with young people. While many young people can be successfully managed through primary care and enhanced primary care service models, a significant percentage of young people require easier access to more comprehensive, multi-disciplinary youth-specific specialist mental health services.
Australian Institute of Health and Welfare (AIHW). (2003). Australia's Young People: Their Health and Wellbeing. Canberra: AIHW.
Craig, T. K., Garety, P., Power, P., Rahaman, N., Colbert, S., Fornells-Ambrojo, M., & Dunn, G. (2004). The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. British Medical Journal, 329, 1067.
Department of Health and Ageing. (2005). National Mental Health Report 2005: Summary of 10 years of reform in Australia's Mental Health Services under the National Mental Health Strategy 1993-2003. Canberra: Commonwealth of Australia.
Graham, P. J. (2004). The End of Adolescence. Oxford: Oxford University Press.
Gunn, J. (2004). Foreword. Adolescent Forensic Psychiatry (S Bailey & M Dolan, Eds). London: Arnold.
Issakidis, C., & Andrews G. (2006). Who treats whom? An application of the Pathways to Care model in Australia. Australian and New Zealand Journal of Psychiatry, 40, 74-86.
Jorm, A. F., Korten, A. E., Jacomb, P. A., Christensen, H., Rodgers, B., & Pollit, P. (1997). "Mental health literacy": a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia, 166, 182-186.
Judd, L. L., Akiskal, A. S., & Paulus, M. P. (1997). The role and clinical significance of subsyndromal depressive symptoms in unipolar major depressive disorder. Journal of Affective Disorders, 45, 5-17.
Judd, L. L., Paulus, M. P., Wells, K. B., & Rapaport, M. H. (1996). Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population. American Journal of Psychiatry, 153, 1411-1417.
Kessler, R., Bergland, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.
McGorry, P. D., Chanen, A., McCarthy, E., Van Riel, R., McKenzie, D., & Singh, B. S. (1991). Post-traumatic stress disorder following recent-onset psychosis: an unrecognised post-psychotic syndrome. Journal of Nervous and Mental Disease, 179, 253-258.
McGorry, P. D. (1996). The Centre for Young People's Mental Health: Blending epidemiology and developmental psychiatry. Australasian Psychiatry, 4, 243-247.
McGorry, P. D., Yung, A.R., Phillips, L. J., Yuen, H. P., Francey, S., Cosgrave, E. M., Germano, D., Bravin, J., McDonald, T., Blair, A., Adlard, S., & Jackson, H. (2002). Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms. Archives of General Psychiatry, 59, 921-928.
McGorry, P. D., & Yung, A. R. (2003). Early intervention in psychosis: an overdue reform: An introduction to the Early Psychosis Symposium. Australian & New Zealand Journal of Psychiatry, 37, 393-398.
McGorry, P. D., Hickie, I. B., Yung, A. R., Pantelis, C., & Jackson, H. J. (in press). Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions. Australian & New Zealand Journal of Psychiatry.
McLennan, W (1997). Mental Health and Wellbeing: Profile of Adults, Australia. Canberra: Australian Bureau of Statistics.
Mrazek, P. J., & Haggerty, R. J. (Eds.) (1996). Reducing Risks for Mental Disorders. Washington: National Academy Press.
Norman, R. M. G., & Malla, A. K. (2001). Duration of untreated psychosis: a critical examination of the concept and its importance. Psychological Medicine, 31, 381-400.
Parry-Jones, W. L. L. (1995). The future of adolescent psychiatry. British Journal of Psychiatry, 166, 299-305.
Patel, V. P., Fisher, A., & McGorry, P. D. (in press). The mental health of young people: a global public health challenge. The Lancet.
Patton, G. (1996). An epidemiological case for separate adolescent psychiatry? Australian and New Zealand Journal of Psychiatry, 30, 563-566.
Petersen, L., Jeppesen, P., Thorup, A., Abel, M. B., Ohlenschlaeger, J., Christensen, T. O., Krarup, G., Jorgensen, P., & Nordentoft, M. (2005). A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. British Medical Journal, 331, 602.
Public Health Group (2005). Victorian Burden of Disease Study: mortality and morbidity in 2001. Melbourne: Victorian Government Department of Human Services.
Rickwood, D., Deane, F. P., Wilson, C. J., & Ciarrochi, J. (2005). Young people's help-seeking for mental health problems. Australian e-Journal for the Advancement of Mental Health, 4, 1-34.
Rutter, M. & Smith, D. J. (1995). Psychosocial Disorders in Young People, Time Trends and Their Causes. Chichester, England: John Wiley & Sons.
Sawyer, M.G., Arney, F.M., Baghurst, P.A., Clark, J.J., Graetz, B.W., & Kosky, R.J.,et al (2000). The Mental Health of Young People in the Australia. Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged and Care.