Introduction: the problem
Mental and substance use disorders are among the most important health issues facing Australians. They are a key health issue for young people in their teenage years and early 20s and, if these disorders persist, the constraints, distress and disability they cause can last for decades (McGorry et al., 2007). Associated with mental disorders among youth are high rates of enduring disability, including school failure, impaired or unstable employment, and poor family and social functioning. These problems lead to spirals of dysfunction and disadvantage that are difficult to reverse. (McGorry et al., 2007). As over 75% of mental disorders commence before the age of 25 years, reducing the economic, geographical, attitudinal and service organisation barriers for adolescents and young adults is an essential first step in addressing mental health problems (Hickie and McGorry, 2007).
In Australia, rates of mental illness among young people is higher than for any other population group and represented the major burden of disease for young people with depression making the greatest contribution to this burden. In addition, youth suicide and self-harm have both steadily increased during the 1990s (Williams et al., 2005). 60% of all health-related disability costs in 1534-year-olds are attributable to mental health problems, and of the total disability years lived in Australia, 27% is attributable to mental disorders. Although most common mental disorders commence before 18 years of age, people aged 2544 years and 4564 years are more than twice as likely as those aged under 25 years to receive an active treatment when seen in general practice (Hickie et al., 2005).
Research has indicated that some mental health problems can be prevented through appropriate early intervention, and that the impact of existing mental illness can be mitigated through the early provision of appropriate services (Mental Health Policy and Planning Unit, ACT, 2006). It has been estimated that up to 60% of cases of alcohol or other substance misuse could be prevented by earlier treatment of common mental health problems (Hickie et al., 2005).
Despite the enthusiastic efforts of many clinicians around Australia, progress in service reform has plateaued, remains piecemeal and is frustratingly slow in contrast to what has been achieved in other countries, many of which began by emulating Australia. In addition, the specialist mental health system is seriously under-funded (McGorry and Yung, 2003). While Australias national health spending continues to grow past $72 billion the total recurrent mental health spending has consistently remained below 7% of this figure (Hickie et al., 2005). The need for coordinated national health and welfare services for people with mental health and substance misuse problems has been recognised by all Australian governments, but insufficient investment, lack of accountability, divided systems of government and changing health care demands resulted in a very patchy set of reforms (Hickie and McGorry, 2007; Vimpani, 2005).
Statistics regarding the problem
Close to one in five people in Australia were affected by a mental health problem within a 12-month period, according to the National Survey of Mental Health and Wellbeing. Young adults were particularly affected, with more than one-quarter of Australians aged 18 to 24 years suffering from at least one mental disorder over a 12-month period (Mental Health Policy and Planning Unit, ACT, 2006).
In Australia, the prevalence of mental health problems among children aged 412 years lies between 7% and 14%, rises to 19% among adolescents aged 1317 years, and increases again to 27% among young adults aged 1824. Therefore, up to one in four young people in Australia are likely to be suffering from a mental health problem, with substance misuse or dependency, depression or anxiety disorder, or some combination of these the most common issues (McGorry et al., 2007). It is therefore more likely that mental health problems will develop between the ages of 12 and 26 than in any other stage of life (Orygen Youth Health, 2009).
This situation also exists among Australian Indigenous communities, where the continuing grief and trauma resulting from the loss of traditional lands and cultural practices as a result of colonization, past policies of child removal and the destruction of traditional governance arrangements within Aboriginal communities, are an ever-present cultural reality that plays out in some of the worst developmental health and well-being outcomes in advanced industrial society (Vimpani, 2005).
Risk taking by young people
Studies show that psychosocial issues form a great burden of disease for young people, including intentional and unintentional injuries, mental disorders, tobacco, alcohol and other substance misuse, and unprotected sexual intercourse (Tylee et al., 2007). The pathways to substance misuse in young people involve complex interplay between individual biological and psychological vulnerability, familial factors and broader societal influences. The impact on family and society is often painful, destructive and expensive (Vimpani, 2005).
In 2005, nearly half of all deaths of young men and a third of young women aged 1534 years in NSW were due to suicide, transport accidents or accidental drug overdoses (418 persons; ABS, 2008b). In 2007, amongst young men in the age group 15-24 in NSW, the average age for first consumption of alcohol was around 15, and amongst women of the same age group, the average age for first use of alcohol was around 17 years. In addition to its potential direct health consequences, risky or high risk drinking can increase the likelihood of a person falling, or being involved in an accident or violence (ABS, 2008a). 71% of persons aged 14-19 and 89.4% of persons aged 20-29 were current drinkers. 27.6% of persons aged 14-19 (40.5% at the age of 20-29) were at risk of short term harm, while 10% (14.7% at the age of 20-29) were at risk of long term harm. Around 90% of Australian youth (aged 1824 years) have drinking patterns that place them at high risk of acute harm (Lubmen et al., 2007). On average, 25 percent of hospitalisations of 15-24 year olds occur as a result of alcohol consumption (Prime Minister of Australia, 2008).
Almost one-quarter (23%) of people aged 1524 years in Australia reported using illicit drugs during the last 12 months, around twice as high as the proportion of people aged 25 years and over (11%). Marijuana/cannabis was the most common drug used by 1524 year olds (18%), followed by ecstasy (9%), and meth/amphetamines and pharmaceuticals (both 4%).
Barriers to provision and use of health services
Primary-care health services are sometimes still not available. They may be inaccessible for a variety of reasons such as cost, lack of convenience or lack of publicity and visibility. Health services might not be acceptable to young people, however, even if available and accessible. Fear about lack of confidentiality (particularly from parents) is a major reason for young peoples reluctance to seek help, as well as possible stigma, fear of difficult questions. In addition, health professionals might not be trained in communicating with young people. If and when young people seek help, some may be unhappy with the consultation and determine not to go back. To ensure prevention and early intervention efforts, clinicians and public-health workers are increasingly recognising the pressing need to overcome the many barriers that hinder the provision and use of health services by young people, and to transform the negative image of health facilities to one of welcoming user-friendly settings (Tylee et al., 2007).
Spending in the area remains poor, and service access and tenure are actively withheld in most specialist mental health and substance misuse service systems until high levels of risk or danger are reached, or severe illness, sustained disability and chronicity are entrenched. Thus, just when mental health services are most needed by young people and their families, they are often inaccessible or unacceptable in design, style and quality. Moreover, numerous young people with distressing and disabling mental health difficulties struggle to find age-appropriate assistance. Young people with moderately severe non-psychotic disorders (eg, depression, anxiety disorders and personality disorders), and those with comorbid substance use and mental health issues, are particularly vulnerable. For many of these young people, if they survive (and many do not), their difficulties eventually become chronic and disabling (McGorry et al., 2007).
Another barrier is related to the manners in which young people seek help when they have a mental problem. The most recent national survey data for Australia show that only 29% of children and adolescents with a mental health problem had been in contact with a professional service of any type in a 12-month period. Some subgroups, such as young males, young Indigenous Australians and migrants may be even less likely to voluntarily seek professional help when needed. If young people want to talk to anyone, it is generally someone they know and trust and when they do seek professional help, it is from the more familiar sources family doctors and school-based counsellors. However, many young people at high risk of mental health problems do not have links to work, school, or even a family doctor (Rickwood, Deane and Wilson, 2007).
Furthermore, mental disorders are not well recognized by the public. The initial Australian survey of mental health literacy showed that many people cannot give the correct psychiatric label to a disorder portrayed in a depression or schizophrenia vignette. There is also a gap in beliefs about treatment between the public and mental-health professionals: the biggest gap is in beliefs about medication for both depression and schizophrenia, and admission to a psychiatric ward for schizophrenia (Jorm et al., 2006).
Existing resources: Knowledge, policy and programs
Existing knowledge: Manners of interventions
Prevention and early intervention programs are normally classified into four types: universal programs are presented to all regardless of symptoms; selective programs target children and adolescents who are at risk of developing a disorder by virtue of particular risk factors, such as being children of a depressed parent; indicated programs are delivered to students with early or mild symptoms of a disorder; and treatment programs are provided for those diagnosed with the disorder (Neil & Christensen, 2007). Universal prevention programs target all young people in the community regardless of their level of risk, and include economic measures, social marketing, and regulatory control and law enforcement initiatives, as well as a range of psychosocial programs (Lubmen et al., 2007).
In addition, interventions can be divided between promotion and prevention programs. Mental health promotion refers to activity designed to enhance emotional wellbeing, or increase public understanding of mental health issues and reduce the stigma surrounding mental illness. Prevention of mental illness may focus on at risk groups or sectors of the whole population. (Mental Health Policy and Planning Unit, ACT, 2006).
Source: Mental Health Policy and Planning Unit, ACT (2006).
Finally, collaborative care is typically described as a multifaceted intervention involving combinations of distinct professionals working collaboratively within the primary care setting. Collaborative care not only improves depression outcomes in months, but has been found to show benefits for up to 5 years (Hickie and McGorry, 2007).
The importance of early intervention
In the last two decades research demonstrated the high importance of early intervention to promote youth mental health and cope with mental disorders and substance misuse. Early intervention is required to minimise the impact of mental illness on a young persons learning, growth and development, thus improving the health outcome of those affected by mental illness. (Orygen Youth Health, 2009).
It was found that the duration of untreated psychosis (DUP) could be dramatically reduced by providing community education and mobile detection teams in an experimental study (McGorry, Killackey & Yung, 2007; McGorry et al., 2007). On the other hand, delayed treatment and prolonged duration of untreated psychosis is correlated with poorer response to treatment and worse outcomes. Thus, first-episode psychosis should be viewed as a psychiatric emergency and immediate treatment sought as a matter of urgency (McGorry and Yung, 2003).
The existing evidence also highlights the importance of prevention and early intervention programs on substance abuse. Such programs focus on delaying the age of onset of drug experimentation; reducing the number of young people who progress to regular or problem use; and encouraging current users to minimise or reduce risky patterns of use. Universal school-based drug education programs have been found to be effective in preventing and delaying the onset of drug use and reducing drug consumption (Lubmen et al., 2007).
Early andeffective intervention, targeting young people aged 1225 years, is a community priority. A robust focus on young peoples mental health has the capacity to generate greater personal, social and economic benefits than similar intervention in other age groups, and is therefore one of the best buys for future reforms (McGorry et al., 2007).
Importance of other players
During the early phases of a mental disorder, members of a persons social network (including parents, peers and GPs) can play an important role in providing support and encouraging appropriate help-seeking. For mental-health problems, young people tend to seek help from friends and family rather than health services. In developing countries, young people are even less willing to seek professional help for more sensitive matters (Tylee et al., 2007). As friends and family are often consulted first by young people, they constitute and important part of the pathway to professional mental health services (Rickwood, Deane and Wilson, 2007).
In a survey with young Australians and their parents, it was found that the most common response was to listen, talk or support the person, followed by listen, talk orsupport family and encourage professional help-seeking. Counsellor and GP/doctor/medical were the most frequently mentioned types of professional help that would be encouraged, but when young people were asked open ended questions about how they would help a peer, only a minority mentioned that they would encourage professional help. Among parents, encouraging professional help was a common response both in open-ended and direct questions (Jorm, Wright and Morgan, 2007).
General practice is essential to young peoples mental health and is often the point of initial contact with professional services. However, there is a need to improve the ability of GPs to recognise mental health problems in young people As well asensuring privacy and clearly explaining confidentiality. Finally, GPs can provide reassurance that it is common to feel distress at times, and that symptoms can be a normal response to stressful events (Rickwood et al., 2007).
For the small percentage of youth who do receive service, this typically occurs in a school setting. School-based mental health (SBMH) programs and services not only enhance access to services for youth, but also reduce stigma for help seeking, increase opportunities to promote generalization and enhance capacity for mental health promotion and problem prevention efforts (Paternite, 2005). There is compelling evidence of the effectiveness of a range of school-based interventions in primary and secondary schools for children and young people at risk of substance abuse (Vimpani, 2005). One study found that participation in a school-based intervention beginning in preschool was associated with a wide range of positive outcomes, including less depressive symptoms (Reynolds et al., 2009).
Best elements for SBMH include: (a) schoolfamilycommunity agency partnerships, (b) commitment to a full continuum of mental health education, mental health promotion, assessment, problem prevention, early intervention, and treatment, and (c) services for all youth, including those in general and special education. A strong connection between schools and other community agencies and programs also assists in moving a community toward a system of care, and promotes opportunities for developing more comprehensive and responsive programs and services (Paternite, 2005).
There are a number of examples of governmental policy and program to enhance youth mental health. The new Medicare-based scheme now includes a suite of measures designed to increase access to appropriate and affordable forms of evidence-based psychological care. Unfortunately, it largely reverts to traditional individual fee-for-service structures. There are no requirements for geographical distribution of services, despite the evidence of gross mal-distribution of mental health specialist services in Australia and the proven contribution of lack of mental health services to increased suicide rates in rural and regional communities (Hickie and McGorry, 2007).
Transformation is also occurring in primary care in Australia. GPs are increasing their skills, providing new evidence-based medication and psychological treatments, and beginning to emphasise long term functional outcomes rather than short-term relief of symptoms. Early-intervention paradigms depend on earlier presentation for treatment. Future progress now depends on development of an effective and accessible youth-health and related primary care network. (Hickie et al., 2005).
As for substance abuse, The National Campaign Against Drug Abuse (now known as the National Drug Strategy) was established in 1985. It is an inter-governmental and strategic approach based on national and state government cooperation and planning. The campaign has been adopted to bring together research and practice relevant to the treatment and prevention to protect the healthy development of children and youth (Williams et al., 2005).
There are several existing programs which address youth mental health and substance abuse. Knowing which programs exist may help us in understanding existing resources and knowledge, learning best practices, and recognising what else needs to be done.
* The National Youth Mental Health Foundation headspace: providing mental and health wellbeing support, information and services to young people aged 12 to 25 years and their families across Australia. www.headspace.org.au
* MindMatters is a national mental health initiative funded by the Australian Government Department of Health and Ageing. It is a professional development program supporting Australian secondary schools in promoting and protecting the mental health, social and emotional wellbeing of all the members of school communities. www.mindmatters.edu.au
* Mindframe: a national Australian Government’s program aimed at improving media reporting on mental health issues, providing access to accurate information about suicide and mental illness and portraying these issues in the news media and on stage and screen in Australia. www.mindframe-media.info
* The Personal Assessment and Crises Evaluation (PACE) clinic provides treatment for young people who are identified as being at ultra high risk. It involves facilitated groups using adult learning principles based on a curriculum addressing adolescent communication, conflict resolution and adolescent development. http://cp.oyh.org.au/ClinicalPrograms/pace
* The Gatehouse Project has been developed in Australia as an enhancement program for use in the secondary school environment. It incorporates professional training for teachers and an emotional competence curriculum for students and is designed to make changes in the social and learning environments of the school as well as promoting change at the individual level. www.rch.org.au/gatehouseproject
* Pathways to Prevention: a universal, early intervention, developmental prevention project focused on the transition to school in one of the most disadvantaged urban areas in Queensland.
* The Positive Parenting Program (Triple P), which has been implemented widely in Australia and elsewhere for parents of preschool children, has also been implemented for parents of primary school-aged children. http://www1.triplep.net
* The Family Partnerships training program, now established in several Australian states and already incorporated into maternal and child health and home visitor training, is designed to improve the establishment of an effective respectful partnership between health workers and their clients.
Other international programs:
* ARC (Availability, Responsiveness and Continuity): an organizational and community intervention model that was designed to support the improvement of social and mental health services for children. The ARC model incorporates intervention components from organizational development, inter-organizational domain development, the diffusion of innovation, and technology transfer that target social, strategic, and technological factors in effective childrens services.
* Preparing for the Drug Free Years (PDFY) is a universal prevention programme targeted at parents of pre-adolescents (aged 8 -14 years) that has been subjected to several large-scale dissemination and effectiveness studies across 30 states of the United States and Canada involving 120000 families.
This paper suggests that despite a wealth of knowledge and information on appropriate interventional methods, services to address youth mental health in Australia are not consistently provided and are often under-funded. New evidence is continuously available for professionals; however this knowledge has often failed to filter through to the community and those in need. As Bertolote & McGorry (2005) asserted, despite the availability of interventions that can reduce relapses by more than 50%, not all affected individuals have access to them, and when they do, it is not always in a timely and sustained way.
The major health problems for young people are largely preventable. Access to primary-health services is seen as an important component of care, including preventive health for young people. Young people need services that are sensitive to their unique stage of biological, cognitive, and psychosocial transition into adulthood, and an impression of how health services can be made more youth-friendly has emerged (Tylee et al., 2007).
Existing and new extended community networks, including business, schools, sporting bodies, government sectors, community agencies and the broader community are asked to play their part in mental health promotion and illness prevention. These networks will:
* bring together all service sectors and the broader community in closer collaboration in the promotion of mental health;
* exchange information about, and increase understanding of existing activities, and encourage new ones;
* develop and strengthen the mental health promoting aspects of existing activities; develop greater mental health promotion skills right across the community; and
* encourage an environment that fosters and welcomes new ideas, and supports adaptation and innovation to respond to a new environment (Mental Health Policy and Planning Unit, ACT, 2006).
As for substance misuse, despite acknowledgement of the substantial costs associated with alcohol misuse within Australia, there have not been serious attempts to reduce alcohol harm using the major levers of mass-marketing campaigns, accompanied by significant changes to alcohol price and regulatory controls. Young people continue to be given conflicting messages regarding the social acceptability of consuming alcohol (Lubmen et al., 2007).
According to the Mental Health Policy and Planning Unit (2006), ideas about the best strategies for supporting the mental health of the community are undergoing great change in Australia and internationally, with a growing focus on preventative approaches. Mental health promotion and prevention are roles for the whole community and all sectors of government. Although Australia has slipped behind in early intervention reform, it is now emerging that the situation can improve and that Australia can again be at the forefront of early intervention work. Here are some proposals as to how this can best be achieved:
Guaranteed access to specialist mental health services for a minimum period of 3 years post-diagnosis for all young people aged 1525 with a first-episode of psychosis. New funding is clearly required to support this.
Such funding must be quarantined into new structures, programmes and teams.
The child versus adult psychiatry service model split is a serious flaw for early intervention and for modern and appropriate developmental psychiatry models. It needs to be transcended by proactive youth-orientated models. Early detection and engagement can be radically improved through such reforms and specialist mental health care can also be delivered in a less salient and stigmatized manner.
McGorry et al. (2007) suggested four service levels that are required to fully manage mental illness among young people:
Improving community capacity to deal with mental health problems in young people through e-health, provision of information, first aid training and self-care initiatives;
Primary care services provided by general practitioners and other frontline service providers, such as school counsellors, community health workers, and non-government agency youth workers;
Enhanced primary care services provided by GPs (ideally working in collaboration with specialist mental health service providers in co-located multidisciplinary service centres) as well as team-based virtual networks;
Specialist youth-specific (1225 years) mental health services providing comprehensive assessment, treatment and social and vocational recovery services (McGorry et al., 2007).
Elements of successful programs (best practices)
Revising the vast research on preventing mental disorders and promoting mental health among youth, particularly in Australia, as well as examining some of the successful and effective programs in the field, the following items summarise elements of current best practice:
Holistic approaches and community engagement:
Adopt holistic approaches which integrate mental health promotion with other aspects of community and individual wellbeing
Balance between universal and targeted programmes and their relative cost-effectiveness.
Engage young people, the community and youth support services in working together to build the resilience of young people, and encourage early help and help seeking when problems occur
Community engagement with the youth, and youth engagement with the community
Outreach workers, selected community members and young people themselves are involved in reaching out with health services to young people in the community
Promote community-based health facility: including stand-alone units (which are generally run by non-governmental organisations or by private individuals or institutions), and units that are an integral part of a district or municipal health system (that are run by the government).
Access to services and information:
Make services more accessible to youth by collaborating with schools, GPs, parents etc.
Social marketing to reduce stigma and make information more accessible
Have more information online for young people with mental health issues, their families and peers. Promote understanding among community members of the benefits that young people will gain by obtaining health services
Improve convenience of point of delivery working hours and locations
Assure youth-friendly primary-care services
Have other players in the community involved in promotion of youth mental health, such as schools, GPs, and community centres
Ensure confidentiality and privacy (including discreet entrance)
Addressing inequities (including gender inequities) and easing the respect, protection, and fulfilment of human rights
Inter-sectoral and inter-organisational collaboration:
Enable organisations to work in partnership towards shared goals
Lead to multi agency, client centred service delivery and care
Research and support:
Provide support such as information and training for the community and for mental health carers and consumers to plan and participate in mental health promotion activity
Acknowledge formal and informal knowledge
Promoting a whole-of-government response to support optimal development health and well-being outcomes
Policies and procedures are in place that ensure health services that are either free or affordable to all young people