Editorials
Health services administration
Volume 211 - Issue 9

Moving beyond stepped care to staged care using a novel, technology‐enabled care model for youth mental health

Author:  Ian B Hickie

Med J Aust 2019; 211 (9): 404-405. || doi: 10.5694/mja2.50379
Published online: 4 November 2019

This model of care emphasises not only early access to assessment across a number of clinical and functional domains but also rapid and ongoing provision of stage-appropriate interventions

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This model of care emphasises not only early access to assessment across a number of clinical and functional domains but also rapid and ongoing provision of stage‐appropriate interventions

Australia can rightly claim to lead the world in mental health awareness, especially for the mental health and wellbeing of young people.1 However, despite the development of designated primary care‐style services (eg, headspace),1 we still do not deliver effective care, early in the course of illness, to most young people with anxiety, depression, or alcohol or other substance misuse.2 Even when we do deliver care, the longer term functional outcomes are often disappointing.3 The consequences of this failure remain large — personally, socially and economically.4

While the Morrison Government is committed to expanding youth services and reducing youth suicide,5 practical questions remain to be answered. Specifically, do we have: a viable clinical model; the necessary multidisciplinary workforce and team‐based funding structures; health system capability and integration of key acute and ongoing service settings; regional planning, governance and service commissioning capability; and health information technology infrastructure to enable personal and system‐level data tracking and integration?

All of these elements are necessary for the delivery of the highly personalised and measurement‐based care model we propose in the Supplement that accompanies this issue of the MJA.6 Although this novel, technology‐enabled care model for youth mental health has many evidence‐based components and has been co‐designed with young people and their families, as seen in the Project Synergy trials,7 it remains to be demonstrated whether, compared with either existing child and adolescent or adult service models, it results in improved clinical and social outcomes. If this youth model of care is more effective, the challenge will be to deliver it at sufficient scale to have real population‐level impacts in regions where specialist clinics are not available, so that it connects with populations who are at high risk or traditionally under‐represented in care.

Substantive clinical innovations over the past decade have led to the concept of highly personalised and measurement‐based care (Supporting Information). The highly personalised component is achieved through the integration of three core concepts: assessing multidimensional domains of morbidity and function; clinical staging; and mapping pathophysiological pathways across development, from childhood, through adolescence and into early adulthood, as well as illness trajectories. The measurement‐based care component8 is achieved by linking individual care to the use of more sophisticated real‐time health information technologies that can enhance immediate and continuous clinical decision‐making (see Chapter 5 of the accompanying Supplement).6

The first of these innovations is the development of a more sophisticated, multidimensional approach to clinical and functional assessment.9 This approach provides a more accurate basis for comprehensive treatment planning. It incorporates the domains of social and occupational function; self‐harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and progression of illness trajectories, and requires the development of multidisciplinary teams that can deliver the range of interventions needed (see Chapter 4 of the accompanying Supplement).6

The second innovation is the adoption of clinical staging.10,11 While this concept is well accepted in clinical medicine, evidence is now emerging for its utility in major mood and psychotic syndromes.4,12,13,14 Clinical staging has a strong emphasis on differentiating immediate treatments from secondary prevention strategies.12 While much of the substantive early work focused on emerging psychotic disorders,10,11 more recently it has focused on common anxiety and mood disorders, and in particular the centrality of gateway conditions in early adolescence, such as major depression or social anxiety.15

The third innovation is to propose specific pathophysiological pathways that can underpin primary treatment selection and secondary prevention strategies.16 This approach also recognises that various pathophysiological mechanisms, which are not mutually exclusive, may be associated with different behavioural expressions at different stages along the developmental pathway. For example, excessive brain arousal and reactivity in response to environmental stimuli manifests as separation anxiety in childhood, mixed anxiety and depression in early adolescence, and depression and alcohol or other substance misuse in early adulthood.14,17 The other two common mechanisms (neurodevelopmental and circadian disruption) can be similarly tracked to differing age‐dependent expressions at points along the developmental pathway from childhood risk to longer term adult disorder.18 Other novel mechanisms, particularly engaging autoimmune, neuroimmune, hormonal (particularly with sex‐specific implications) or metabolic paths, are progressing to novel clinical interventions and have broader relevance in mental health practice.19,20,21

This process of assessment departs from the traditional child and adolescent or adult models where specific diagnoses, within their social or family context, often lead to a sequence of recommended interventions. Adoption of this new approach has major implications for revision of traditional teaching, future workforce training and investments in new models of care, and would require a radical revision of the generic national policy framework of stepped care for common mental disorders or the standard provision of undifferentiated and time‐limited psychological services.

This new model emphasises not simply early access to assessment but also rapid and ongoing provision of stage‐appropriate and effective, often multidisciplinary team‐based, interventions. It argues for the need to move beyond stepped care, where care typically proceeds from less intensive to more intensive, only after failure to respond to the initial offering, to staged care with the aim of delivering the right level of care, the first time. Consequently, workforce training needs to increase substantially the availability of health professionals who have more specialised skills to assess and intervene early and effectively. This is a major challenge currently in child and adolescent, youth and adult mental health services.22,23

Implementation of this youth model of care also depends heavily on enhanced regional governance. For health services, this would specifically mean that providers commissioned by the Commonwealth‐funded Primary Health Networks would need to work locally, and in complementary partnerships, with state‐based acute care and other public systems.

Additionally, coordination with other family support, education and employment service providers is critical. These regionally based collaborative systems need to utilise predictive modelling techniques24 to assist with better service development, and be co‐designed with young people and their families. If Primary Health Networks were resourced appropriately and able to access relevant modelling capabilities, health information technologies, information and clinical decision‐making systems, and link these with genuine partnerships between young people and their families, it would then be possible to respond much more effectively to the agenda outlined by the Morrison Government.5

Author

  • Ian B Hickie1
  • 1. Brain and Mind Centre, University of Sydney, Sydney, NSW

Correspondence: ian.hickie@sydney.edu.au

Competing interests

Project Synergy (2014–2016) was commissioned by the Department of Health and conducted by the Young and Well Cooperative Research Centre in partnership with the University of Sydney's Brain and Mind Centre. The Department of Health has provided Project Synergy further funding of $30 million which has led to the development of InnoWell Pty Ltd, a joint venture between the University of Sydney and PricewaterhouseCoopers (Australia) (PwC). InnoWell has developed the InnoWell Platform, which is mentioned throughout the Supplement as a technology‐enabled solution to reform mental health care services. The University of Sydney and PwC (Australia) each have a 45% shareholding in InnoWell. The remaining 10% shareholding is evenly shared between Professor Jane Burns and Professor Ian Hickie.

References

Linked content

  • MJA Supplement: Right care, first time: a highly personalised and measurement-based care model to manage youth mental health

  • MJA Podcast: Professor Ian Hickie

  • InSight+: Are we serious about youth mental health? “Not so far”

Provenance: Commissioned; externally peer reviewed.

View this article on Wiley Online Library