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Original Article Youth mental health: we know where we are and we can now say where we need to go nextIan B. Hickie Brain and Mind Research Institute, The University of Sydney, Camperdown, Australia Corresponding author: Prof Ian B. Hickie, Brain and Mind Research Institute, The University of Sydney, 100 Mallett Street, Camperdown, NSW 2050, Australia. Email: [email protected] Declaration of conflict of interest: Ian B. Hickie is the Director of headspace, National Youth Mental Health Foundation. Received 30 September 2010; accepted 6 October 2010 Abstract Aim: To provide an overview of the state of knowledge relevant to the development of youth-specific mental health initiatives. Methods: A selective review of data, particularly from Australian commu- nity and health service studies, that are relevant to the decisions faced by those who fund and organize health services internationally. Results: It is possible to reach consen- sus on key issues such as the current state of evidence, myths that need to be challenged, areas of genuine uncertainty, priorities for future reform, and five and ten year goals and targets. Conclusions: There is considerable convergence of evidence from epide- miology, clinical and basic neuro- science, population health and health service evaluation that supports an urgent new investment in develop- ment and evaluation of youth mental health initiatives. Key words: early intervention, health services, youth. Academic Psychiatrist: 1st International Youth Mental Health Conference: Melbourne 2010, ‘One is cynical about movements like youth mental health that are not evidence-based’. Locknote Address, Ian Hickie, Board Member, headspace: the National Youth Mental Health Foundation, ‘I am very cynical about the ‘evidence- based’ reasons offered by many health profession- als, their organizations and the relevant health bureaucracies for resistance to genuine health system reform’. As we reach the end of the first decade of a new century, it is timely to reflect on where we now stand on the key public policy and scientific issues in youth mental health. As with other complex health, social and scientific issues, there remain very many unresolved or contested issues in the field. The active debate that flows from these uncertainties is both necessary and welcome. It should drive our field not only to challenge old dogmas, but also to test new ideas. Importantly, let’s not kid ourselves that current health policies, health financing or current health system practices around young people are ‘evidence-based’. Much of the data on access to our current primary care systems or secondary-care or more specialized systems, indicate the extent to which those systems are demonstrably failing to meet the health needs of young people. 1–5 That is, we have good evidence that these systems do not work. This should drive us to experiment and test new systems and not simply fall back on historically and culturally based models of practice. 6,7 It is far too easy to justify ongoing inaction, neglect and active discrimination on the basis of a lack of definitive evidence for choosing very narrow or spe- cific alternatives. The lack of an ‘evidence-base’ for enhanced public health responses, service innova- tion or new treatments is commonly thrown into this debate to disrupt or shutdown, rather than enhance, a more constructive discourse. The best reason for Governments never to act on complex issues is a perceived lack of consensus among the ‘experts’. Frequently, population health or health service reform options are presented as if decision makers will only ever have the time or resources to make one narrow decision, and, hence, all action should be deferred until we know exactly what that one Early Intervention in Psychiatry 2011; 5 (Suppl. 1): 63–69 doi:10.1111/j.1751-7893.2010.00243.x First Impact Factor released in June 2010 and now listed in MEDLINE! © 2011 Blackwell Publishing Asia Pty Ltd 63

Youth mental health: we know where we are and we can now say where we need to go next

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Page 1: Youth mental health: we know where we are and we can now say where we need to go next

Original Article

Youth mental health: we know where we are andwe can now say where we need to go nexteip_243 63..69

Ian B. Hickie

Brain and Mind Research Institute, TheUniversity of Sydney, Camperdown,Australia

Corresponding author: Prof Ian B. Hickie,Brain and Mind Research Institute, TheUniversity of Sydney, 100 Mallett Street,Camperdown, NSW 2050, Australia.Email: [email protected]

Declaration of conflict of interest: Ian B.Hickie is the Director of headspace,National Youth Mental HealthFoundation.

Received 30 September 2010; accepted 6October 2010

Abstract

Aim: To provide an overview of thestate of knowledge relevant to thedevelopment of youth-specificmental health initiatives.

Methods: A selective review of data,particularly from Australian commu-nity and health service studies, thatare relevant to the decisions faced bythose who fund and organize healthservices internationally.

Results: It is possible to reach consen-sus on key issues such as the current

state of evidence, myths that need tobe challenged, areas of genuineuncertainty, priorities for futurereform, and five and ten year goalsand targets.

Conclusions: There is considerableconvergence of evidence from epide-miology, clinical and basic neuro-science, population health and healthservice evaluation that supports anurgent new investment in develop-ment and evaluation of youth mentalhealth initiatives.

Key words: early intervention, health services, youth.

Academic Psychiatrist: 1st International YouthMental Health Conference: Melbourne 2010, ‘Oneis cynical about movements like youth mentalhealth that are not evidence-based’.

Locknote Address, Ian Hickie, Board Member,headspace: the National Youth Mental HealthFoundation, ‘I am very cynical about the ‘evidence-based’ reasons offered by many health profession-als, their organizations and the relevant healthbureaucracies for resistance to genuine healthsystem reform’.

As we reach the end of the first decade of a newcentury, it is timely to reflect on where we now standon the key public policy and scientific issues inyouth mental health. As with other complex health,social and scientific issues, there remain very manyunresolved or contested issues in the field. Theactive debate that flows from these uncertainties isboth necessary and welcome. It should drive ourfield not only to challenge old dogmas, but also totest new ideas.

Importantly, let’s not kid ourselves that currenthealth policies, health financing or current health

system practices around young people are‘evidence-based’. Much of the data on access to ourcurrent primary care systems or secondary-care ormore specialized systems, indicate the extent towhich those systems are demonstrably failing tomeet the health needs of young people.1–5 That is, wehave good evidence that these systems do not work.This should drive us to experiment and test newsystems and not simply fall back on historically andculturally based models of practice.6,7

It is far too easy to justify ongoing inaction, neglectand active discrimination on the basis of a lack ofdefinitive evidence for choosing very narrow or spe-cific alternatives. The lack of an ‘evidence-base’ forenhanced public health responses, service innova-tion or new treatments is commonly thrown into thisdebate to disrupt or shutdown, rather than enhance,a more constructive discourse. The best reason forGovernments never to act on complex issues is aperceived lack of consensus among the ‘experts’.

Frequently, population health or health servicereform options are presented as if decision makerswill only ever have the time or resources to makeone narrow decision, and, hence, all action shouldbe deferred until we know exactly what that one

Early Intervention in Psychiatry 2011; 5 (Suppl. 1): 63–69 doi:10.1111/j.1751-7893.2010.00243.x

First Impact Factor released in June 2010and now listed in MEDLINE!

© 2011 Blackwell Publishing Asia Pty Ltd 63

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option should be. This paradigm of simple choicesbetween single alternatives derives from clinicalmedicine and clinical intervention trials. It has littleplace in the complex world of continuous improve-ments in population health and health service deliv-ery. My own experience has been that the widercommunity, including our national governments,are very willing to engage in serious reform whenthe agenda is put clearly.8

In reality, health and related social systems areconstantly changing – most frequently, they aresubject to ‘random acts of government’. These occurin response to community pressures rather thanstrategic and planned sequences of action. It isalways more likely that a range of options will beconsidered and then partially implemented ratherthan a clear decision to implement fully the bestavailable (or most ‘evidence-based’) option. In ourcommunity and professional discourse on theseissues, we should be more open about the process ofcollecting and presenting ‘evidence’ (see Table 1).

Frequently, Governments will first choose the‘soft’ options – notably those that involve the leastdisruption of pre-existing systems. From that base,we need to ensure that we push for continuing andprogressive improvements in both the relevantpopulation health and individual service choicesavailable. Most importantly, we should be moreopen with the community about where the current

consensus of opinion lies, the range of optionsworthy of consideration, and where the major gapsexist between current knowledge and practice.

Similarly, we should openly state the basis onwhich we provide advice for developing priorities.The active engagement in the community in theseprocesses is essential.9,10 Those next steps need to bestrategic so that they overtly drive relevant publicpolicy changes, genuine community development,real service innovation or increased accountability.Rather than artificially divide the field on pseudo-academic grounds, we should be more sensitive tothose areas in which there is a clear convergence ofevidence.

KEY AREAS OF CONSENSUS

It is very clear that we have now reached consensusin the field on a variety of major issues (Table 2).These should form the basis of wider public dis-course and stimulate specific debate on the bestavailable responses to these issues. These consen-sus views are based on the best available evidence.They may well need to change or develop in the

TABLE 1. What is evidence and what are the implications?

• Evidence is not a simple or static concept – its continuouslyevolving!

• Evidence is never perfect – you don’t need to defer actionuntil the evidence is all in.

• The paradigm of ‘levels of evidence’, derived largely fromclinical trials, does not fit well with many aspects ofpopulation health or health system reform.

• The same ‘evidence’ may be interpreted and presented quitedifferently by different stakeholders (e.g. the appropriate useof antidepressants in young people; the role of youthservices in the treatment of depression).

• A much better paradigm for social policy, population healthand health service reform may well be a best availablesummary of the evidence and, importantly, convergence ofthat evidence.32

• Health and social policy advice needs to be based on thebest available evidence.

• The ‘time to act’ does not correlate with the size orconsistency of the ‘evidence-base’ but with the socialpressure to act.

• Social policy and health regulatory actions may be contraryto the evidence or based only on a very selective view of theavailable evidence (e.g. health warnings associated with useof antidepressant medications by young people in theUSA33,34).

TABLE 2. Consensus based on convergence of evidence

1 75% of adult disorders start before age 25, with 50% havingtheir onset before age 15.35

2 Up to a quarter of young people will experience a discretemental health problem, with significant impact on their life,during their adolescent or early adult life.36

3 While there are important childhood precursors ofadolescent mental health problems (notably anxiety, conductdisorder, attention deficit and hyperactivity, autism spectrumand other developmental disorders), many young peopledevelop mental ill-health or substance misuse for the firsttime during this key developmental period.35

4 60% of health-related disability in 15–34-year-olds is due tomental ill-health or substance misuse.37

5 Only a minority of young people with mental healthproblems will ever receive professional help for theirproblem. Young women will access services at two to threetimes the rates evident among young men.1–3

6 Early intervention for the more severe forms of mental-illhealth appears to be associated with significantimprovements in outcomes, at least in the first two yearsafter presentation.38–40

7 Traditional primary care services, based largely on the familydoctor model, struggle to provide an appropriateenvironment for the management of those mental healthproblems that emerge in the adolescent period.4

8 Young people are increasingly relying on alternatives totraditional clinic-based health systems for information andassistance about mental health problems. Most notably,these include new on-line and other electronically basedsystems.19,20,41–44

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future in the face of new evidence. However, acrossthe key epidemiological, treatment and serviceissues, we can see a wider pattern of convergence ofevidence.

MYTHBUSTING

Many myths about the youth mental health agendapersist, not because they cannot be challenged, but

TABLE 3. Traditional myths about youth mental health that need to be challenged

Myth Challenge

• Youth are ‘Greedy not needy’ (i.e. the reallyneedy people are older and sicker)

• The epidemiology is clear-cut in terms of peak ages of onset and resultingdisability35,36

• Young people have high rates of disability and the lowest rates of access toclinical care1–3

• There is a simple social or biologicalseparation between those aged12–18 and those 19–25 years

• The developmental period from 12–25 years is characterized by multiplebiological, neurodevelopmental, education and social transitions.13–15 Simplisticdivisions of research or clinical or social interventions into less than or greaterthan 18 years are not justified.

• ‘General health care reform will fixmental health’

• ‘Expansion of traditional primarycare services will engage youngpeople’

• Traditional primary care services work well for middle-aged and older personsbut continuously fail to meet the needs of younger persons2–5,24,45,46

• The outcomes of recent bouts of reform in Australia have the potential tofurther disadvantage mental health47

• The politics of health care always tends to favour further investment inhospital-based care, cancer care, surgical interventions and emergencydepartments47

• Improvements in mental health care are dependent on selective and deliberateaffirmative action33,48

• There is an inadequate evidencebase for supporting the developmentof youth-specific and early-interventionfocused health services for those withmore severe forms of illness

• Early Intervention is the key32

• There is a clear evidence base for early intervention for psychotic disorders andassociated at-risk states.38–40

• There is no evidence base to demonstrate the value of the current style oflate-intervention services39,40

• There is a need to test the value of new service systems for a range of othercommon mental disorders and substance misuse6,23,25,49,50

• Young people have low levels ofknowledge or awareness aboutmental ill health and substance misuse.

• Young people report that mental health problems are among their greatestsocial and health concerns and are increasingly looking for appropriate newways to meet their own needs19,41,44

• Young people do not seek assistancefor mental ill-health or substance misuse

• The majority of young people who have experienced mental ill health alsoreport that they have sought information help or assistance from friends,family and/or the internet44

• Young men will not attend mentalhealth services

• Headspace services that have targeted young men are able to attract as leastas many young men as young women25

• Not intervening early for commonproblems like anxiety or depressionhas no real disadvantages. Theseare largely self-limiting conditions

• Failure to intervene increases the risk of a variety of short and long-term healthand social consequences including suicidal behaviour, secondary alcohol andsubstance misuse, physical ill-health and failures in employment and education

• While episodes of illness may end without professional intervention, they arealso highly likely to recur and are significant risk factors for the development ofother forms of mental ill-health, alcohol and substance misuse and physicalill-health

• Chronic and recurrent depression is associated with major changes to brainstructure and function

• Over time, recurrent and persistent illness are associated with lower responserates to treatment

• Intervening early for depressive disorders,particularly when this is associated withmedication use, may increase the chance ofa poor outcome, including suicidal behaviour

• Treatment for depression, pharmacologically and psychologically, in youngpeople is associated with marked overall reductions in suicidal behaviour in thefirst six months

• Not intervening early for alcohol andsubstance misuse has no serious short orlonger-term consequences. These arelargely self-limiting conditions.

• Alcohol and substance misuse, particularly through the current pattern ofbinge drinking, is associated with short-term injury and other physicalill-health.

• These patterns of misuse are also increasing associated with brain imaging andneuropsychological evidence of damage to key frontal and temporal structures

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because they are long-standing and also continue toprop up our dysfunctional health care systems.These myths need to be named and challenged(Table 3). While there is a real need to continue tocollect evidence in key areas, we also need to beclear that we are now much better informed than wewere only a few short years ago. Those who run,organize and deliver health and social services foryoung people are still more likely than not to adhereto many of these myths.

SERIOUSLY UNRESOLVED ISSUES

It is important to state those areas in which we haveinsufficient evidence to answer pertinent questions(Table 4). However, we should not get distracted bymore trivial or peripheral issues – especially whenthese are promoted by narrow sectional or profes-sional interest groups. These unresolved majorissues are the areas in which we need more serious

public investment. We need to make it clear tonational and international funding bodies as to theneed for more serious short and longer-term invest-ments in strategic and translational research.11 Todate, mental health research has been treated verypoorly in Australia, a situation that is consistentwith the parlous state of affairs in most other devel-oped and developing countries.12

THE NEW BIOLOGY AND THE NEW SOCIOLOGY

Any serious discussion of youth mental healthreform needs to be actively aware of the rapidlychanging fields of basic and clinical neuroscience.13

Our understanding of the ways in which braindevelopment continues actively into the early 20schallenges long-held beliefs about cognitive andbehavioural development.13,14 The recognition of themultiple genetic, brain and social transitions thatoccur between ages 12 and 25 will transform think-ing about optimal points for intervention.15

The changing world in which young people existwill have multiple positive and negative effects onthe ways in which brain development, education,socialization and health care-seeking behaviourmay develop. This is already clear in the activedebates around current patterns of alcohol andother substance use,16–18 use of the Internet,19,20

changing sleep-wake patterns21 and reduced physi-cal activity.

TABLE 4. Some seriously unresolved issues

• What is the optimal point to commence clinical treatmentsfor mental ill-health or substance misuse in young people?

• To what extent can wider use of appropriate self-help,non-professionally delivered support, brief interventionsoutside clinical settings and/or e-health delivered informationor early intervention reduce the risk of progression to moreserious forms of mental ill-health?

• What are the optimal combinations or sequences of clinicaltreatments to deliver early in the course of mental-ill healthor substance misuse?

• To what extent does early intervention for one mental healthor substance misuse problem protect against thedevelopment of later other mental health, physical ill healthor substance misuse problems in later life?

• Does a simplistic ‘stepped care’ model for service deliveryresult in the best functional outcomes?

• Do we have any clinical, neuropsychological or otherbiomedical tools available to identify those with earlysymptoms who are at highest risk of progression to moresevere forms of mental ill-health?

• Will newly configured and more specialized mental healthservices for young people engage more effectively with thosewho have previously rejected clinical care as an option?

• Will new services delivered through new technologies –particularly those that are web-based – be as effective forthe purposes of early intervention as traditional clinicalservices?

• To what extent will we be able to solve the issues related toaccess to care through innovative use of new technologiesand new approaches to clinical service delivery?

• To what extent can we enhance the quality of long-termcare, and enhance the self-care component of long-termcare, through the use of new technologies and newapproaches to clinical service delivery?

TABLE 5. Priorities for reform

1 Substantial new investments in youth mental health servicesat a primary care level. These services need to beinterdisciplinary, collaborative, accessible andyouth-friendly5,6,25,31,48

2 Substantial new investments in early access to innovativespecialized care services for those with persisting difficultiesor onset of major mental disorders31,38–40,51

3 Enhanced access to new e-health based informational,self-care and clinical service applications42–44,50

4 Enhanced access to education and employment basedopportunities for supporting those with evolving as well asestablished mental ill health or substance misuse

5 Adoption of population-health based strategies to reduceexposure to alcohol and other substance misuse throughoutthe adolescent and early adult period.16–18

6 Major new infrastructure and recurrent investments in keylevels of basic, translational, clinical and population-healthbased research and development11,12

7 Annual and independent public reporting of key mentalhealth outcomes and impacts, and specifically those relatedto suicide, attempted suicide, unexplained accident andinjury, access to health care and rates of educational andemployment participation

8 Community-based prevention programs for common mentaldisorders52

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We are now well beyond simplistic lists of genetic,developmental or social risk factors or similarsimple lists of available population health, clinicalor health system interventions. We need activeresponses to these issues, and particularly newparadigms for population health program develop-ment and evaluation (see22), inclusive and relevantclinical trials,23 and health system development andevaluation (see24).

PRIORITIES IN REFORM

On the basis of the data available,24–26 the currentexperiences of those who are using services,25,27 theneeds of those who are currently excluded from ser-vices20,26 and the wider long-term health, social andeconomic impacts of failing to respond to the diffi-culties now faced by young people,28,29 it is critical topropose a priority list for reform (Table 5). Intrinsi-cally, such a list should relate to both a broader set of5 and 10-year goals or targets for mental healthreform.10,30 A set of specific goals for youth mentalhealth should be the subject of ongoing measure-ment and independent reporting back to the widercommunity, as well as key policy and professionalgroups (Table 6).

CONCLUSION

We are on the threshold of major advances in youthmental health. We now have a community that is

much more engaged, new models of service, newmeans for delivering services and a new basic andclinical science platform to support further innova-tion. In Australia, we have had clear recognition atthe highest levels of the need to invest substantialnew efforts in youth mental health.6,31 The tasks noware to share our efforts, test our ideas and supportthose who are willing to see the convergence of evi-dence in favour of a new and targeted agenda forreform. As so many have emphasized previously, thefuture mental wealth of our nations rests firmly onthese efforts.32

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3. Burgess PM, Pirkis JE, Slade TN, Johnston AK, Meadows GN,Gunn JM. Service use for mental health problems:findings from the 2007 National Survey of MentalHealth and Wellbeing. Aust N Z J Psychiatry 2009;43: 615–23.

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TABLE 6. Targets for 5- and 10-year reform impacts in Australia

5-year targets 10-year targets

1 That suicide rates among young persons fall to six per100 000/year

1 That suicide rates among young persons fall to four per100 000/year

2 That participation in education or employment for youngpersons with disabling mental disorders increase to 60%

2 That participation in education or employment for youngpersons with disabling mental disorders increase to 80%

3 That disability costs attributable to mental disorders in thoseaged 15–34 fall to 40%

3 That disability costs attributable to mental disorders in thoseaged 15–34 fall to 25%

4 That 40% of young men and 60% of young women withmental ill-health or significant substance misuse accessappropriate health care

4 That 70% of young men and 85% of young women withmental ill-health or significant substance misuse accessappropriate health care

5 That 60% of young persons with a first episode of a majorillness such as bipolar disorder or psychosis access carewithin 3 months of onset of defining symptoms

5 That 80% of young persons with a first episode of a majorillness such as bipolar disorder or psychosis access carewithin 3 months of onset of defining symptoms

6 That the experiences of care of young persons receivingmental health care are equivalent to those when the samepersons experience physical health care in 60% of cases

6 That the experiences of care of young persons receivingmental health care are equivalent to those when the samepersons experience physical health care in 90% of cases

7 That 60% of young persons identified in community surveyswith mental health difficulties report active movementtowards seeking appropriate informational or health careassistance within the same time frame as they would for aphysical health problem.

7 That 90% of young persons identified in community surveyswith mental health difficulties report active movementtowards seeking appropriate informational or health careassistance within the same time frame as they would for aphysical health problem.

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