Volume 187 · Issue 7 · Supplement

The logic and plan for achieving early intervention in youth mental health in Australia

Patrick D McGorry MD, PhD, FRCP, FRANZCP · Rosemary Purcell MPsych, PhD · Ian B Hickie MD, FRANZCP · Anthony F Jorm PhD, DSc

The two main goals of early intervention in psychotic disorders are to reduce the period of time between the onset of psychosis and the commencement of effective treatment, and to provide consistent and comprehensive care during the critical early years of illness. Effective care during the critical early years involves proactive engagement and initiation of drug and psychosocial treatments, aiming for maximal symptomatic and functional recovery and the prevention of relapse. Over the past 15 years, an increasing number of specialised or streamed treatment delivery systems for early psychosis have been established around the world. There is now evidence that these services can reduce the duration of untreated psychosis and produce better symptomatic and functional recovery. In addition, they are more cost-effective than standard models of mental health care for these patients. Fully fledged, specialised early intervention services should be established, with full integration with local communities, as well as enhanced primary care systems focused on young people.

Patrick D McGorry MD, PhD, FRCP, FRANZCP · Eóin Killackey BSc(Hons), DPsych(Clin) · Alison R Yung MB BS, MPM, FRANZCP

The early phases of bipolar disorders are difficult to diagnose and have specific treatment issues. The initial polarity of the illness is more commonly depressive, yet in counterpoint, mania is required for diagnosis; consequently, there is often a substantial delay in the initiation of appropriate therapy. There is good evidence that lithium in particular is most effective early in the illness course, and that its efficacy declines after multiple episodes. The notion of neuroprotection reflects this, and furthermore suggests that appropriate therapy may prevent the neurostructural and neurocognitive changes seen in the disorder. Inappropriate therapy may worsen the course of the illness. Patients with a first episode have specific psychosocial needs, and adherence to medication is relatively poor. There is a need for early identification, and to develop treatments and services applicable to the specific needs of this population.

Michael Berk MMed(Psych), FF(Psych)SA, FRANZCP, PhD · Karen Hallam BBSc(Hons), PhD · Nellie Lucas BPsych(Hons), DPsych · Melissa Hasty BAppSc(Hons), DPsych · Craig A McNeil DPsych · Philippe Conus MD, FRANZCP · Linda Kader MD, FRANZCP · Patrick D McGorry MD, PhD, FRCP, FRANZCP

Young people experiencing their first onset of depression are a group at risk of relapse and recurrence to whom early intervention and prevention efforts should be targeted. Despite the argument for a significant research effort addressing these issues, the evidence regarding optimal intervention strategies for first episodes is lacking. Cognitive behaviour therapy is an effective approach to treatment and relapse prevention among depressed adolescents, and is likely to be an important component of any evidenced-based approach to early intervention. Antidepressants are not recommended as first-line treatment for most first episodes of depression. The role that they may play in patients with severe depression, or those who do not respond to psychological therapies, requires further evaluation. Given the high prevalence of depressive disorders, and the significant burden of disease they represent within our community, early intervention in depressive disorders is a critical research agenda for the future.

Nicholas B Allen PhD · Sarah E Hetrick MA, DPsych · Julian G Simmons BSc, PostGradDipPsych · Ian B Hickie MD, FRANZCP

Borderline personality disorder (BPD) is a severe mental disorder that is associated with substantial psychosocial impairment and morbidity, disproportionate use of health resources, a high suicide rate, and a reputation for being “untreatable”. A diagnosis of BPD in young people has similar reliability, validity and prevalence to BPD in adults, and almost certainly has serious and pervasive negative repercussions over subsequent decades. Current data are inadequate to inform specific universal or selective prevention programs for BPD. However, they do support including BPD prevention as an outcome when evaluating universal and/or selective interventions for a variety of mental health problems and adverse psychosocial outcomes. The strongest data support early intervention for the emerging BPD phenotype. Early intervention programs will need to be realistic in their aims, require change in clinician attitudes and service systems, and must be mindful of the risk of iatrogenic harm.

Andrew M Chanen MB BS, MPM, FRANZCP · Louise K McCutcheon DPsych, MAPS · Martina Jovev MA(ClinPsych), PhD · Henry J Jackson PhD, FAPS · Patrick D McGorry MD, PhD, FRCP, FRANZCP

Early-onset or frequent substance use during adolescence increases the risk of developing mental health problems, as well as a range of other adverse outcomes (eg, alcohol or drug dependence, educational underachievement, health problems, social difficulties) during late adolescence and early adulthood. Increases in rates of risky drinking among young people are particularly concerning, suggesting that an effective, evidence-based alcohol policy and preventive framework needs to be developed. Restricting the supply of licit and illicit substances to adolescents, delaying the age that licit substances can be legally purchased, reducing positive media portrayals of substance use, and banning targeted promotions, should be universal, public prevention priorities. Mass-media campaigns need to deliver coherent and credible evidence-based messages to young people, utilising a broad array of dissemination strategies. Clear policy and guidelines for parents regarding appropriate alcohol use for adolescents also need to be developed. Prevention programs should target children and adolescents in families with parents who use drugs, young people who have been suspended from school, or those with mental health problems. Preventive screening and targeted brief interventions can be effectively delivered in a variety of settings by a range of health professionals.

Dan I Lubman BSc(Hons), MB ChB, PhD, FRANZCP, FAChAM · Leanne Hides BBehSci(Hons), PhD(Clin) · Murat Yücel BA(Hons), ClinPhD(Npsych) · John W Toumbourou MA, PhD

Good mental health literacy in young people and their key helpers may lead to better outcomes for those with mental disorders, either by facilitating early help-seeking by young people themselves, or by helping adults to identify early signs of mental disorders and seek help on their behalf. Few interventions to improve mental health literacy of young people and their helpers have been evaluated, and even fewer have been well evaluated. There are four categories of interventions to improve mental health literacy: whole-of-community campaigns; community campaigns aimed at a youth audience; school-based interventions teaching help-seeking skills, mental health literacy, or resilience; and programs training individuals to better intervene in a mental health crisis. The effectiveness of future interventions could be enhanced by using specific health promotion models to guide their development.

Claire M Kelly PhD, BA(Hons) · Anthony F Jorm DSc, PhD · Annemarie Wright DAppSc(OT), MMedSc(HProm)

With 75% of mental illness beginning before 25 years of age, it is essential that we improve young people’s capacity to manage adversity and increase their opportunities for accessing professional help. With its unique ability to connect people to information and to other people, the Internet offers opportunities to engage the 70% of young people with mental health problems who currently are not seeking professional help. Reach Out! is a national Internet-based mental health service for young people. It has been accessed by over 6 million users since its launch in 1998. Reach Out! plays a role in the prevention of mental health problems by: facilitating help-seeking and connecting young people with services, such as general practitioners, and allied and mental health professionals in their local communities; and providing opportunities for all young people to develop the skills and capacity to better understand mental health difficulties and manage adversity, thereby complementing traditional support.

Jane Burns PhD · Carolyn Morey MPH · Alexandra Lagelée MA · Anna Mackenzie MPH · Jonathan Nicholas BA(Hons)

Despite the high prevalence of mental health problems and disorders that develop in adolescence and early adulthood, young people tend to not seek professional help. Young men and young people from Indigenous and ethnic minority groups tend to be those most reluctant to seek help. Young people are more inclined to seek help for mental health problems if they: have some knowledge about mental health issues and sources of help; feel emotionally competent to express their feelings; and have established and trusted relationships with potential help providers. Young people are less likely to seek help if they: are experiencing suicidal thoughts and depressive symptoms; hold negative attitudes toward seeking help or have had negative past experiences with sources of help; or hold beliefs that they should be able to sort out their own mental health problems on their own. Young people may seek help through talking to their family and friends, with family being more important for younger adolescents, and friends and partners becoming more influential later on. The professionals most likely to act as gatekeepers to mental health services for young people are school counsellors, general practitioners, and youth workers. Increasingly, Internet-based information and interventions are being used to engage young people in the help-seeking process.

Debra J Rickwood PhD, MAPS · Frank P Deane DipClinPsych, PhD, MAPS · Coralie J Wilson BA(Hons), PhD, MAPS

Diagnosis in psychiatry continues to struggle to fulfil its key purposes, namely to guide treatment and to predict outcome. A clinical staging model, widely used in clinical medicine, could improve the utility of diagnosis in psychiatry, especially in young people with emerging disorders. Clinical staging has immediate potential to improve the logic and timing of interventions in psychiatry, as it does in many complex and potentially serious medical disorders. Interventions could be evaluated in terms of their ability to prevent or delay progression from earlier to later stages of a disorder, and selected by consumers and clinicians on the basis of clear-cut risk–benefit criteria. This would ensure that, as treatments are offered earlier, they remain safe, acceptable and affordable, and potentially more effective. Biological variables and a range of candidate risk and protective factors could be studied within and across stages, and their role, specificity and centrality in risk, onset and progression of disorders clarified. In this way, a clinicopathological framework could be progressively constructed. Clinical staging, with restructuring across and within diagnostic boundaries and explicit operational criteria for extent and progression of disorder, should be actively explored in psychiatry as a heuristic strategy for developing and evaluating earlier, safer, and more effective clinical interventions, and for clarifying the biological basis of psychiatric disorders. Young people with emerging mental and substance use disorders could be the main beneficiaries.

Patrick D McGorry MD, PhD, FRCP, FRANZCP · Rosemary Purcell MPsych, PhD · Ian B Hickie MD, FRANZCP · Alison R Yung MB BS, MPM, FRANZCP · Christos Pantelis MD, FRANZCP · Henry J Jackson BA, MA, MA(ClinPsych), PhD, FAPS

Intervention in the prodromal phase of schizophrenia and related psychotic disorders may prevent or delay the onset of these disorders, or reduce the severity of the psychosis. Identifying the schizophrenia prodrome is difficult, however, because of its non-specific symptoms and the wide symptom variability between individuals. Over the past 15 years, we have investigated the schizophrenia prodrome and developed criteria for detecting people suspected of experiencing a prodromal phase (ie, they are thought to be at imminent risk of onset of a psychotic disorder). About 35% of those meeting our criteria have developed a psychotic disorder within 12 months. We have established a clinical service, the PACE (Personal Assessment and Crisis Evaluation) Clinic, for people with suspected incipient psychosis, and trialled interventions aimed at preventing or delaying the onset of psychotic disorders. Our results and studies in other countries seem to indicate that psychological and psychosocial interventions, either alone or in combination with pharmacotherapy, may be effective in at least delaying, if not preventing, the onset of a psychotic disorder.

Alison R Yung MD, FRANZCP · Patrick D McGorry MD, PhD, FRCP, FRANZCP · Shona M Francey MPsych, PhD · Barnaby Nelson MPsych, PhD · Kathryn Baker BSc(Hons), DPsych · Lisa J Phillips MPsych, PhD · Gregor Berger MD, FMH Psych (CH), FRANZCP · G Paul Amminger MD, FRANZCP

The development of evidence-based (“collaborative care”) mental health services in primary care for young people with anxiety, depression and alcohol or other substance misuse is a major challenge. Data from two clinical audits of selected Australian general practices (1998–1999 and 2000–2002) were analysed to explore actual experiences of care among people aged 16–25 years. Syndromal (1998–1999: 31.0% [n = 1849/5957]; 2000–2002: 37.8% [n = 148/392]) and subsyndromal (1998–1999: 27.4% [n = 1635/5957]; 2000–2002: 29.1% [114/392]) mental disorders are very common among young people presenting to general practitioners. However, a mental health diagnosis (1998–1999: 42.6% [n = 740/1736]; 2000–2002: 52.0% [n = 77/148]) or provision of formal treatment (1998–1999: 36.1% [n = 600/1661]; 2000–2002: 51.7% [n = 74/143]) occurs in only about half of the patients with syndromal conditions. While some active treatment was received by 19.4% (1998–1999 [n = 1018/5236]) and 35.9% (2000–2002 [n = 133/370]) of the young people, respectively, the most commonly reported interventions were non-pharmacological alone (1998–1999: 13.1% [n = 687/5236]; 2000–2002: 22.4% [n = 83/370]) or non-pharmacological and pharmacological combinations (1998–1999: 4.1% [n = 214/5236]; 2000–2002: 10.3% [n = 38/370]). Only rarely is pharmacological treatment alone provided (1998–1999: 2.2% [n = 117/5236]; 2000–2002: 3.2% [n = 12/370]). New systems of primary care for young people need to be based on proven collaborative care models and encourage presentations for care, increase detection rates, and promote access to information and effective e-health services. Improved access to specific psychological treatments should remain a priority.

Ian B Hickie MD, FRANZCP · Andrea S Fogarty BPsy(Hons), MIPH · Tracey A Davenport eMBA · Georgina M Luscombe PhD · Jane Burns PhD

Despite mental disorders being the dominant health issue confronting young people, youth mental health is yet to be recognised as a discrete, unified program area; responsibility for young people’s mental health is currently split across multiple levels of government. Public specialist mental health services have followed a paediatric–adult split in service delivery, mirroring general and acute health care. The pattern of peak onset and the burden of mental disorders in young people means that the maximum weakness and discontinuity in the system occurs just when it should be at its strongest. Young people need youth-friendly services that recognise and respond to their special cultural and developmental needs. At the primary and community level, headspace: the National Youth Mental Health Foundation, is a national response to this and aims to provide better access, engagement and enhanced multidisciplinary care for young people across Australia. The specialist mental health service level should be complemented by youth-specific specialist mental health services for young people, aged 12–25 years, which would strengthen the existing system with a better targeted stream of care, providing access to integrated mental health, substance use, and vocational-recovery services. Alternative approaches to creating this capacity should be urgently developed and evaluated, and sustained reform informed by evidence as well as values.

Patrick D McGorry MD, PhD, FRCP, FRANZCP

Young people with mental illness face many barriers in accessing care and often have different needs to those of adult consumers. Young people’s participation in mental health services is one way of addressing quality and access issues, through receiving feedback and implementing youth-driven and youth-friendly strategies. headspace, the National Youth Mental Health Foundation, established in July 2006, highlights the mental health care sector’s commitment to young people. Existing youth participation programs provide examples of what can be achieved at national and local levels and with varying levels of financial and other support. These include: Ybblue, the youth program of beyondblue; Reach Out!, a web-based service; Headroom, providing health promotion and a website; and Platform Team (ORYGEN Youth Health), comprising current and past clients who advise the service and provide peer support. Current practice in youth participation in mental health services involves a variety of methods, such as ensuring information and education is appropriate for a youth audience, and participating in peer-support programs and staff selection panels. Challenges in the future development of youth participation in mental health services include avoiding tokenism, acknowledging that young people are not a uniform group, translating national strategies into local improvements in services, and gaining the support and cooperation of health care workers in genuine participation.

Anthony M James BVSc, BBus

The impact on family members of mental illness in a young person is intensely distressing. Symptoms that they cannot understand, and the stigma surrounding mental illness may lead to families feeling isolated in their distress. Family carers are reassured by talking with other families who have experienced the same or similar situations. The “Families Helping Families” program at ORYGEN Youth Health trains family peer-support workers, who are employed to provide information and support to families new to the service. Medical practitioners need to appreciate the importance of ensuring that families receive information and emotional support to help them cope effectively. Difficulties in helping family carers, often around perceived confidentiality restraints, need to be overcome so that collateral damage — family breakdown, persistence of symptoms, and behavioural maladjustments — can be reduced. Families who are supported can become advocates for improvements to mental health services for young people.

Margaret S Leggatt PhD, BAppSc(OT)

Creating a collaborative doctor–patient relationship is the bedrock upon which effective treatments are delivered. The interaction between normal developmental changes and psychopathology can present particular challenges to clinicians attempting to assess and treat young people. Assuming an attitude in which young people are seen to be doing their best, rather than being deliberately difficult or manipulative, can help clinicians avoid a controlling or punitive relationship and can facilitate collaborative problem solving. Stigma, denial and avoidance, ambivalence, hopelessness and coercion are potential threats to engagement and must be addressed specifically. Challenging patients, such as the reluctant, resistant, aggressive, self-harming or intoxicated patient require specific management strategies that can be learned.

Louise K McCutcheon DPsych, MAPS · Andrew M Chanen MB BS, MPM, FRANZCP · Richard J Fraser MSc, MRCPsych(UK) · Lorelle Drew MB BS, FRANZCP · Warrick Brewer MA(ClinNeuropsychology), PhD

headspace, Australia’s national youth mental health initiative, was created in 2006 in response to the recognition that the existing health system needed to be much more accessible and effective for young people with mental and substance use disorders. With funding of more than $54 million from the Australian Government, a carefully constructed and selected system of 30 “communities of youth services”, or integrated service hubs and networks, across the nation is being established, supported by programs for community awareness, workforce training and evidence-based resource material. headspace aims to improve access, and service cohesion and quality, and ultimately health and social outcomes, for young people aged 12–25 years experiencing mental illness and related substance use problems. Within the Council of Australian Governments framework, this will require synergistic planning with, and co-investment on behalf of, state and territory governments, as well as the support and involvement of local communities and the wider Australian society.

Patrick D McGorry MD, PhD, FRCP, FRANZCP · Chris Tanti BA, BSW · Ryan Stokes · Ian B Hickie MD, FRANZCP · Kate Carnell BPharm, FAIM · Lyndel K Littlefield MPsych, PhD · John Moran GradDip(Community Development)