Social and occupational outcomes for young people who attend early intervention mental health services

To the Editor: Iorfino and colleagues1 reported that “two in three young people with emerging mental disorders did not experience meaningful improvement in social and occupational functioning during two years of early intervention care”. Their sample was drawn from two headspace sites. This sounds alarming, especially considering that the study is exemplary in its longitudinal design, large sample size, and robust statistical analyses. Nevertheless, clinicians should be mindful of making too much of these results.

The primary weakness of this study is the measure used: the Social and Occupational Functioning Assessment Scale (SOFAS). A systematic review of measures of functioning considered evaluating the SOFAS, yet excluded it based on the grounds that “the SOFAS has been superseded by the Personal and Social Performance Scale (PSP), which demonstrates stronger psychometric performance”.2 A study in 2007 stated that “the PSP scale is proposed as an improvement over the [Global Assessment of Functioning] and SOFAS because of its clear operational instructions on how to rate the severity of disability and its distinction between levels of impairment”.3 A similar issue was noted in 2000.4 Suffice to say, the SOFAS is a superseded measure of social and occupational functioning.

This is apparent at the theoretical level. The SOFAS is a single item measure, rated on a scale of 0–100, for both social and occupational functioning. How is a clinician meant to score this measure when a young person presents functioning highly in their schooling, yet poorly in their social life? Or when things are going well with friends, yet poorly with their family? With this in mind, it is no surprise that three out of the four trajectories for young people’s mental health journeys identified by Iorfino and colleagues1 demonstrated no significant improvement.

This is indicative of a broader issue identified in a systematic review of 189 articles, which reported that only nine mental health outcome measures in the published literature examined functional outcomes. Of these, “no measures were designed specifically for young people aged 12 to 25 years”.5

In short, the SOFAS is an out‐of‐date, adult measure with poor inter‐rater reliability. The study by Iorfino et al1 is what we need, but not what we are ready for. There is an urgent need in youth mental health services to have valid, reliable measures of social and occupational functioning that have good construct validity. There is an urgent research need for the development of such measures that have robust psychometric properties and clinical utility. Until this issue is resolved, attempting to predict pathways of care, or measure the efficacy of these services at a population level, will remain a guessing game. Future studies should focus on the development and evaluation of these measures. The collateral damage if researchers continue to use these measures will be the young people in need of early intervention.