- The Early Intervention and Youth Mental Health Service Reform Imperative
- Australia’s Innovation: Enhanced Primary Mental Health Care for Young People
- Future Directions for Youth Mental Health
Mental ill-health is a major health issue currently experienced by young people globally. The vast majority of mental disorders emerge prior to mature adulthood, with half developing by 14 years of age and three-quarters by 24 years (Kessler et al. 2005). Those aged between 10 and 24 years bear the largest burden of mental illness (Mokdad et al. 2016).
This pattern of onset and impact has led to mental illnesses being viewed as the “chronic diseases of the young” (Insel and Fenton 2005). Over the last decade, there has been growing recognition that the life stage of youth, that is the period of transition from childhood to young adulthood1 (12–25 years), is a critical window of opportunity for improving mental health outcomes (McGorry 2011; Fusar-Poli 2019).
In response to this, early intervention services with a priority focus on transition age youth have been implemented internationally. This was initiated in Australia through the creation of “headspace.” In this chapter, we provide an overview of promising youth mental health service innovations, with a specific focus on headspace. First, the rationale for youth-specific early intervention services such as headspace is described; second, the development, outcomes, and global impact of headspace are summarized; and third, the future directions of early intervention in youth mental health are discussed.
The Early Intervention and Youth Mental Health Service Reform Imperative
Although mental health is a major public health concern, the treatment gap for mental illness is excessively high (Patel et al. 2018). This is most apparent in young people who, despite constituting the age group with the highest incidence, prevalence, and burden of mental illness, have the worst access to mental health care (Burgess et al. 2009).
The timing of intervention plays a critical role in preventing the entrenchment of mental health symptoms and related negative impacts. Young people typically demonstrate a need for care prior to reaching the threshold for a traditional major psychiatric diagnosis (Rickwood et al. 2014) where distress, functional impairment, and early signs of mental illness are apparent, making early intervention at this time point crucial to preventing or reducing the severity of a full-threshold disorder (McGorry and van Os 2013). While some cases of mental illness are transitory, those that emerge early in life can commonly follow a course that is characterized by chronicity and multiple episodes of relapse (Gibbet al. 2010).
This can be associated with a range of adverse outcomes that include premature death, social isolation, poor functioning, and poor educational and vocational productivity (Gibb et al. 2010; Morgan et al. 2017; Walker et al. 2015). There is compelling evidence that the course and functional impacts of even the most serious forms of mental illness can be positively altered through early intervention (Correll et al. 2018; Killackey et al. 2019).
Young people’s poor access to mental health care reflects a range of individual and servicelevel barriers that are related to the design of available services and young people’s help-seeking behaviors. Seeking help for a mental disorder can be a challenging experience and a complex process for young people.
Their reluctance to seek help is influenced by factors such as reduced mental health literacy, a preference to solve their own problems, perceived stigma of mental illness, negative attitudes toward services, and confidentiality concerns (Rickwood et al. 2007). Prior to making contact with professional services, young people often begin the help-seeking process by seeking informal support from their social and family networks (Rickwood et al. 2015b).
Applying Early Intervention to Youth Mental Health Care
The current configuration of mental health care based on a pediatric-adult split sells adolescents and emerging adults short. Its failure to reflect the epidemiology of onset of mental illness creates a critical barrier to care that prevents access to early intervention. A pediatric model, which privileges the needs of younger children, can successfully focus on prevention and early intervention for the disorders that do emerge prepubertally, notably autism, conduct disorder, ADHD, and anxiety.
However, the surge of new morbidity from puberty through to the mid-20s, which encompasses all the syndromes that feature across the decades of adult life, means that a new, distinct youth-focused approach to mental health care is essential. The goal is to ensure that young people can access services and that the quality and continuity of care offered by services can effectively meet their clinical, developmental, and cultural needs.
This has led to the creation of a discrete youth mental health model of care that differs from those designed for children and older adults but with seamless linkages across streams (McGorry et al. 2007). Youth-specific services are required owing to the unique needs of young people and the complex and evolving pattern of morbidity and symptomatic fluidity that is characteristic of this population (McGorry et al. 2014).
The early stages of a mental state disorder in young people are often characterized by a range of co-occurring problems, including substance abuse and personality difficulties, which require an integrated approach to mental health care. In addition to responding to this heterogeneous pattern of clinical presentation, services should address the cultural and developmental needs that are unique to adolescents and young people, which are typically not catered for within the adult service stream (McLaren et al. 2013).
Australia’s Innovation: Enhanced Primary Mental Health Care for Young People
Headspace, the National Youth Mental Health Foundation, was established in 2006 with the mission to promote and support early intervention for young people aged 12–25 years with a range of mental disorders (McGorry et al. 2007). The headspace model of care is underpinned by ten service components (youth, family, and friends participation, community awareness, enhanced access, early intervention, appropriate care, evidence-informed practice, four core streams, service integration, and supported transitions) and six enabling components (national network, lead agency governance, consortia, multidisciplinary workforce, blended funding, and monitoring and evaluation) (Rickwood et al. 2019).
These core components currently represent best practice to deliver and reform youth mental health care (Rickwood et al. 2019). headspace is an enhanced primary care model that provides young people with integrated mental health, drug and alcohol, physical and sexual health, and vocational supports.
These four core streams of care are supplemented by headspace’s community awareness campaigns that enhance young people’s help-seeking behavior, facilitate the early identification of emerging mental health problems, and strengthen referral pathways into the service (McGorry et al. 2014). A key goal of the headspace model is to establish youth-friendly and highly accessible centers that target young people’s core health needs via a multidisciplinary care model with close connections to local specialist services and community organizations (Rickwood et al. 2019).
Global Progress in Early Intervention and Youth Mental Health
Beyond Australia, progress in youth mental health reform has expanded to other parts of the globe, with the UK, Ireland, Canada, the USA, Europe, and Asia adopting similar, culturally appropriatemodels (Hetrick et al. 2017). Available services include Jigsaw in Ireland (O’Keeffe et al. 2015), Youthspace in Birmingham (Vyas et al. 2014), ACCESS Open Minds in Canada (Malla et al. 2019), Foundry in British Columbia, @Ease in the Netherlands, allcove in the USA, and headspace in Denmark, Israel, and Iceland. Collectively, integrated models of care have yielded positive outcomes in terms of access to care, symptomatic and functional recovery, and client satisfaction (Hetrick et al. 2017).
Although youth models of care have predominately been implemented in high-resource settings, they can be adapted for low- and middle-resource settings to improve access to care and effectively meet the mental health needs of young people worldwide in a manner that is culturally appropriate and acceptable. A current area of development is designing a global framework for youth mental health care that supports the implementation of early intervention for young people across all resource settings (low, middle, and high). The global progress achieved thus far has been facilitated by a number of platforms, which have supported evidence-based reform through innovation in research and translation. These platforms include the International Association for Youth Mental Health, the International Youth Mental Health Research Network, IEPA: Early Intervention in Mental Health, Frayme, and the journal Early Intervention in Psychiatry.
Future Directions for Youth Mental Health
Despite the promising outcomes to date, the task of creating, evaluating, and scaling up youthfocused mental health care remains an ongoing challenge (McGorry 2019). Additional work is needed to realize the potential of early intervention for young people with mental ill-health and to reduce the significant unmet need experienced by this population globally. From an Australian perspective, the headspace model of care could be further strengthened through stronger national oversight to ensure integrative commissioning and additional funding streams to extend tenure of care, improve model fidelity, and support core streams (e.g., alcohol and other drug and vocational interventions) (McGorry et al. 2019).
There is also an urgent need for headspace to address the high and growing level of demand for services, which most headspace centers have struggled to meet due to underlying systemic issues (e.g., resource constraints, workforce availability, difficulty recruiting and retaining staff, and the physical constraints of centers) (headspace 2019). One solution to addressing this unmet need among young Australians is expanding the headspace model to effectively respond to the full spectrum of illness complexity and severity.
Although headspace was designed to address mild-to-moderate mental health concerns, considerable subset of clients present with higher levels of need (McGorry et al. 2014; Rickwood et al. 2014). Among the 40% of headspace clients who do not significantly benefit from treatment are young people with complex or severe forms of mental ill-health who require more specialized, intensive, and extended care than can be currently provided at headspace.
Author: Cristina Mei, Eoin Killackey, Andrew Chanen, and Patrick D. McGorry