Elsevier

The Lancet Psychiatry

Volume 1, Issue 7, December 2014, Pages 559-568
The Lancet Psychiatry

Series
Cultures for mental health care of young people: an Australian blueprint for reform

https://doi.org/10.1016/S2215-0366(14)00082-0Get rights and content

Summary

Mental ill health is now the most important health issue facing young people worldwide. It is the leading cause of disability in people aged 10–24 years, contributing 45% of the overall burden of disease in this age group. Despite their manifest need, young people have the lowest rates of access to mental health care, largely as a result of poor awareness and help-seeking, structural and cultural flaws within the existing care systems, and the failure of society to recognise the importance of this issue and invest in youth mental health. We outline the case for a specific youth mental health stream and describe the innovative service reforms in youth mental health in Australia, using them as an example of the processes that can guide the development and implementation of such a service stream. Early intervention with focus on the developmental period of greatest need and capacity to benefit, emerging adulthood, has the potential to greatly improve the mental health, wellbeing, productivity, and fulfilment of young people, and our wider society.

Introduction

More than a quarter of the world's population is aged between 10 years and 24 years, and about 90% of these individuals live in low-income or middle-income countries.1 A strong focus on the health of young people is crucial, because their health now determines the health and prosperity for future generations worldwide. Many of the patterns of long-term health-related behaviours are initiated and become established during adolescence and early adulthood.2 This phase of life is also when most of the major adult-type mental disorders emerge.3 With the global reduction in mortality from communicable diseases, the non-communicable diseases are becoming more important, especially in less-developed countries. Mental ill health is now the most important health issue facing young people in both less-developed and more-developed countries4 and is the leading cause of disability in people aged 10–24 years, contributing 45% of the overall burden of disease in this age-group.5 Largely because the onset of mental illness peaks in emerging adulthood and subsequently affects the most productive years of life, it will pose the greatest threat to the gross domestic product (GDP) of both the developed and developing nations over the next 20 years, narrowly exceeding cardiovascular disease among the non-communicable diseases.4

In this Series paper we present the case for the urgent need for transformational reform of mental health services to better accommodate young people. Despite their manifest need and undoubted capacity to benefit, young people have the lowest rates of access to mental health care, largely because of poor awareness and help-seeking, structural and cultural flaws within the existing care systems, and a serious failure of governments to invest. We contend that early intervention and a priority focus on the developmental period of greatest need and capacity to benefit—emerging adulthood—have the potential to greatly improve the mental health, wellbeing, productivity, and fulfilment of young people, and our wider society, now and into the future. We discuss innovative service reforms that have led to the development and implementation of a nationwide youth mental health service, headspace, in Australia, which aims to improve access to evidence-based enhanced primary mental health care for all young Australians. With its focus on early and pre-emptive intervention in primary care and community settings, provided it is accompanied and backed by investment in the development of a complementary specialist tier of evidence-informed mental health care, this approach offers a useful blueprint for service reform in the broader international context and has already begun to influence and guide service reform and investment elsewhere.

Section snippets

The youth mental health imperative

The incidence of mental illness in young people is well documented as the highest of any age group.6 In the USA, the National Comorbidity Survey Replication3 showed that in 75% of people with psychiatric disorders, the onset was before the age of 24 years; the onset of most of the adult forms of mental illness falls within a quite discrete time band from the early teens to the mid-twenties, peaking in the early twenties. Furthermore, this study3 has shown that in the general population, the

Debate for service reorientation and a dedicated youth mental health care stream

Despite the obvious need, young people are reluctant to seek help from, or cannot access or engage with, existing health services.18 In Australia, young people have had worse access to mental health care than any other age-group; only 13% of young men and about 30% of young women with mental health issues access professional help.19 Thus, most young people who could benefit from mental health care did not receive it. Other large-scale studies, such as the US National Comorbidity Survey

Promotion of awareness, access, and acceptability

An essential first step to improve help-seeking behaviour and access to care is to promote awareness in young people and the wider community about mental health issues in young people and how to recognise and respond to them. First-line strategies, such as community education, self-help, and e-health, all have useful parts to play in raising awareness, developing an understanding of how best to respond to mental health issues as they arise, and how, when, and where to seek help. The idea of

Promotion of care appropriate to the stage of illness

Although up to 80% of young people experience mental ill health at some point during adolescence,7, 9, 12, 34 much of it is mild-to-moderate in nature. Typically, young people tend to present with a complex and fluctuating blend of symptoms, most commonly depression, anxiety, and other more non-specific symptoms including withdrawal, apathy, and sleep and appetite disturbance. Self-harm and substance misuse are prevalent in this age group. Over time these symptoms can either intensify,

New models for youth mental health services

Although care for most young people is best provided in the context of stigma-free, youth-friendly primary care or enhanced primary care structures, individuals with severe or established illness need access to specialised youth services for mental health. In the past few years, reform in the delivery of youth mental health services has been gaining ground, first in Australia, then the UK, Ireland, Canada, Denmark, and Asia, and lately the USA.16, 28, 30, 38, 39, 40, 41

In 2006, the Australian

The challenge of transformational reform

Mental health is undervalued in health care and in medical research. Despite its much greater projected effect on human suffering and productivity in the next 20 years, mental health continues to be seriously underfunded in comparison with cancer, cardiovascular disease, diabetes, and other non-communicable diseases. Meanwhile, health expenditures increase worldwide, with little rational guidance as we spend more and more on the final months of life in advanced old age. Most people agree that

Search strategy and selection criteria

This manuscript involved a systematic search for studies on the epidemiology, age of onset, and prevention and treatment of the adult-type mental disorders in adolescents and young adults between 12 years and 25 years of age using the Embase, PsycINFO and Medline databases. We also searched for papers that discussed youth mental health and mental health service development. Key search terms included adolescent, young adult, age of onset, depression, anxiety, psychosis, mania, mental health,

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