Integrated care models for youth mental health: A systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of integrated models of mental healthcare in enhancing clinical outcomes, quality of life, satisfaction with care and health service delivery outcomes in young people aged 12-25 years. A secondary objective was to identify common components of integrated mental health interventions.

METHODS

A systematic review and meta-analysis of studies published 2001-2023 that assessed clinical or health service use outcomes of integrated care, relative to treatment as usual, for any mental health condition in 12-25 years old accessing community-based care.

RESULTS

Of 11,444 titles identified, 15 studies met inclusion criteria and 6 studies were entered in the meta-analysis. Pooled effect size found integrated care was associated with a greater reduction in depressive symptoms relative to treatment as usual at 4-6 months (standardised mean difference = -0.260, 95% confidence interval = [-0.39, -0.13], p = 0.001). Of the seven studies reporting access or engagement, all reported higher rates of both in the intervention arm. The most frequent components of integration were use of a multidisciplinary team (13/15 studies), shared treatment planning (11/15) and workforce training in the model (14/15).

CONCLUSIONS

Integrated models of mental healthcare are associated with a small, but significant, increase in effectiveness for depressive symptoms relative to treatment as usual. Given integrated care may increase access and engagement, future research should focus on assessing the impact of integrated care in a wider range of settings and outcomes, including clinical and functional recovery, satisfaction with care and system-level outcomes such as cost-effectiveness.

Association of perceived inequality, relative deprivation and loneliness with the trajectory of anger in university students

OBJECTIVE

To examine the trajectory of anger and its psychosocial predictors (i.e., perceived social inequality, relative deprivation, and loneliness) as well as its association with anxiety and depression.

PARTICIPANTS/METHOD

Students (N = 365) completed an online survey three times over a one-year period.

RESULTS

Three trajectories of anger were identified by growth mixture modeling: low/stable (i.e., a low and stable anger over time; 88.0%), low/increasing (i.e., a low level of anger with an increasing trend; 6.7%), and moderate/decreasing class (i.e., a moderate level of anger with a decreasing trend; 5.3%). A greater perception of relative deprivation, but not of perceived social inequality, was associated with the low/increasing class. A greater level of loneliness was associated with the moderate/decreasing class. Symptoms of depression and anxiety were higher in the moderate/decreasing and low/increasing class than in the low/stable class.

CONCLUSIONS

These results suggest that interventions targeted at anger may benefit from addressing perceptions of relative deprivation and loneliness.

Evaluating changes in functioning and psychological distress in visitors of the @ease youth mental health walk-in centres

BACKGROUND

Highly accessible youth initiatives worldwide aim to prevent worsening of mental health problems, but research into outcomes over time is scarce.

AIMS

This study aimed to evaluate outcomes and support use in 12- to 15-year-old visitors of the @ease mental health walk-in centres, a Dutch initiative offering free counselling by trained and supervised peers.

METHOD

Data of 754 visitors, collected 2018-2022, included psychological distress (Clinical Outcomes in Routine Evaluation 10 (CORE-10)), social and occupational functioning (Social and Occupational Functioning Assessment Scale (SOFAS)), school absenteeism and support use, analysed with change indicators (first to last visit), and mixed models (first three visits).

RESULTS

Among return visitors, 50.5% were female, 79.4% were in tertiary education and 36.9% were born outside of The Netherlands (one-time visitors: 64.7%, 72.9% and 41.3%, respectively). Moreover, 29.9% of return visitors presented with suicidal ideations, 97.1% had clinical psychological distress levels, and 64.1% of the latter had no support in the previous 3 months (one-time visitors: 27.2%, 90.7% and 71.1%, respectively). From visit 1 to 3, psychological distress decreased (β = -3.79, 95% CI -5.41 to -2.18; P < 0.001) and social and occupational functioning improved (β = 3.93, 95% CI 0.51-7.36; P = 0.025). Over an average 3.9 visits, 39.6% improved reliably and 28.0% improved clinically significantly on the SOFAS, which was 28.4% and 8.8%, respectively, on the CORE-10, where 43.2% improved in clinical category. Counselling satisfaction was rated 4.5/5.

CONCLUSIONS

Reductions in psychological distress, improvements in functioning and high counselling satisfaction were found among @ease visitors, forming a basis for future research with a control group.

Evidence-based brief interventions targeting acute mental health presentations for children and adolescents: systematic review

BACKGROUND

Brief intervention services provide rapid, mobile and flexible short-term delivery of interventions to resolve mental health crises. These interventions may provide an alternative pathway to the emergency department or in-patient psychiatric services for children and young people (CYP), presenting with an acute mental health condition.

AIMS

To synthesise evidence on the effectiveness of brief interventions in improving mental health outcomes for CYP (0-17 years) presenting with an acute mental health condition.

METHOD

A systematic literature search was conducted, and the studies' methodological quality was assessed. Five databases were searched for peer-reviewed articles between January 2000 and September 2022.

RESULTS

We synthesised 30 articles on the effectiveness of brief interventions in the form of (a) crisis intervention, (b) integrated services, (c) group therapies, (d) individualised therapy, (e) parent-child dyadic therapy, (f) general services, (g) pharmacotherapy, (h) assessment services, (i) safety and risk planning and (j) in-hospital treatment, to improve outcomes for CYP with an acute mental health condition. Among included studies, one study was rated as providing a high level of evidence based on the National Health and Medical Research Council levels of evidence hierarchy scale, which was a crisis intervention showing a reduction in length of stay and return emergency department visits. Other studies, of moderate-quality evidence, described multimodal brief interventions that suggested beneficial effects.

CONCLUSIONS

This review provides evidence to substantiate the benefits of brief interventions, in different settings, to reduce the burden of in-patient hospital and readmission rates to the emergency department.

Evidence-based long term interventions targeting acute mental health presentations for children and adolescents: systematic review

Background

Long term intervention services have proven to be effective in improving mental health (MH) outcomes and the quality of life for children and young people (CYP).

Aim

To synthesize evidence on the effectiveness of long-term interventions in improving MH outcomes for CYP, 0-17 years, presenting with MH conditions.

Methods

A systematic search was carried out and the methodological quality of included long term MH intervention studies were assessed. Six databases were searched for peer-reviewed articles between January 2000 and September 2022.

Results

We found 30 studies that reported on the effectiveness of a range of long-term MH interventions in the form of (i) group therapy, (ii) multisystemic behavior therapy, (iii) general services, (iv) integrated services, (v) psychotherapy, (vi) intensive intervention services, (vii) comprehensive collaborative care, (viii) parent training, and (ix) home outreach service. Among the included studies, seven were rated as high level of evidence based on the National Health and Medical Research Council (NHMRC) levels of evidence hierarchy scale and seven were of moderate quality evidence. Others were rated as lower-quality evidence. Among the studies providing high quality evidence, most were reported for group therapy, general services, and psychotherapy studies demonstrating beneficial effects.

Conclusion

This systematic review provides evidence to demonstrate the benefits of a range of long-term interventions, in a range of settings, can be effective in improving MH outcomes for CYP and their families.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022323324.

A mixed-methods evaluation of the impacts of an online Carer wellbeing and connection program

Objective

To evaluate a facilitated, 90-min session, delivered for four weeks, Online Carer Wellbeing and Connection Program in Victoria, Australia.

Methods

One hundred and three carers took part in the evaluation. Eighty-six completed both pre- and post-program surveys evaluating program impacts on psychological distress, perceived loneliness, and social support. Qualitative interviews were conducted (n = 76) post-program for experiential data.

Findings

Paired samples t-tests showed significant decreases between pre- and post-program for psychological distress (M = 25.10, SD = 7.08; M = 22.00, SD = 6.57; t(85) = 4.88, p = 0.000), perceived loneliness (M = 6.69, SD = 1.89; M = 6.14, SD = 1.76; t(85) = 3.45, p = 0.000) and perceived social support (M = 8.31, SD = 2.48; M = 8.83, SD = 2.21; t(85) = -2.54, p = 0.013). Thematic analysis identified positive experiences and the mechanisms of action (or the ingredients for program success) as: 1. Delivery by a trained facilitator; 2. Provision of respite for person being cared for during meetings; 3. Technical assistance; 4. Online modality; 5. Inclusivity; 6. Diversity of experience; 7. Shared understanding; 8. Safety; 9. Emotional release; 10. Reflection, and; 11. Self-care practices.

Innovation

A model illustrating the mechanisms of action based on the findings of the mixed-methods evaluation is presented to support wider implementation and translation.

Conclusion

The online program effectively reduced psychological distress and loneliness and improved carer wellbeing.

The Effects of a Digital, Transdiagnostic, Clinically and Peer-Moderated Treatment Platform for Young People With Emerging Mental Health Complaints: Repeated Measures Within-Subjects Study

BACKGROUND

To address the growing prevalence of youth mental health problems, early intervention is crucial to minimize individual, societal, and economic impacts. Indicative prevention aims to target emerging mental health complaints before the onset of a full-blown disorder. When intervening at this early stage, individuals are more responsive to treatment, resulting in cost-effective outcomes. The Moderated Online Social Therapy platform, which was successfully implemented and proven effective in Australia, is a digital, peer- and clinically moderated treatment platform designed for young people. The Netherlands was the first country outside Australia to implement this platform, under the name Engage Young People Early (ENYOY). It has the potential to reduce the likelihood of young people developing serious mental health disorders.

OBJECTIVE

This study aims to investigate the effects on young people using the ENYOY-platform in relation to psychological distress, psychosocial functioning, and positive health parameters.

METHODS

Dutch-speaking young people with emerging mental health complaints (N=131) participated in the ENYOY-platform for 6 months in a repeated measures within-subjects study. Psychological distress, psychosocial functioning, and positive health parameters were assessed at baseline and 3, 6, and 12 months. Repeated measures ANOVA was conducted and adjusted for age, sex, therapy, and community activity. The Reliable Change Index and Clinically Significant Index were computed to compare the baseline with the 6- and 12-month measurements. The missing data rate was 22.54% and the dropout rate 62.6% (82/131).

RESULTS

The primary analysis (77/131, 58.8%) showed that psychological distress decreased and psychosocial functioning improved over time with large effect sizes (P<.001 in both cases; ηp2=0.239 and 0.318, respectively) independent of age (P=.76 for psychological distress and P=.48 for psychosocial functioning), sex (P=.24 and P=.88, respectively), therapy activity (P=.49 and P=.80, respectively), or community activity (P=.59 and P=.48, respectively). Similarly, secondary analyses (51/131, 38.9%) showed significant effects of time on the quality of life, well-being, and meaningfulness positive health parameters (P<.05; ηp2=0.062, 0.140, and 0.121, respectively). Improvements in all outcome measures were found between baseline and 3 and 6 months (P≤.001-.01; d=0.23-0.62) and sustained at follow-up (P=.18-.97; d=0.01-0.16). The Reliable Change Index indicated psychological distress improvements in 38% (39/102) of cases, no change in 54.9% (56/102) of cases, and worsening in 5.9% (6/102) of cases. Regarding psychosocial functioning, the percentages were 50% (51/102), 43.1% (44/102), and 6.9% (7/102), respectively. The Clinically Significant Index demonstrated clinically significant changes in 75.5% (77/102) of cases for distress and 89.2% (91/102) for functioning.

CONCLUSIONS

This trial demonstrated that the ENYOY-platform holds promise as a transdiagnostic intervention for addressing emerging mental health complaints among young people in the Netherlands and laid the groundwork for further clinical research. It would be of great relevance to expand the population on and service delivery of the platform.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-021-03315-x.

@ease peer-to-peer youth walk-in centres in The Netherlands: A protocol for evaluating longitudinal outcomes, follow-up results and cost-of-illness

AIM

Innovative youth mental health services around the globe vigorously work on increasing highly needed mental health care accessibility but their service users and care effectiveness have rarely been studied. The Dutch youth walk-in centres of @ease opened in 2018, with currently 11 locations at which free anonymous peer-to-peer counselling is offered to young people aged 12-25. The aim of this protocol is to outline the to-be-conducted research at @ease.

METHODS

Three studies are outlined: (1) an outcome evaluation of @ease visits using hierarchical mixed model analyses and change calculations, (2) a cost-of-illness study using calculations for costs of truancy and care usage among these help-seeking young people, with regression analyses for risk group identification, and (3) a follow-up evaluation at three, six and 12 months to assess long-term effects after ending @ease visits. Data provided by young people include demographics, parental mental illness, truancy, past treatment, psychological distress (CORE-10) and health-related quality of life (EQ-5D-5L). Social and occupational functioning (SOFAS), suicidal ideation and need for referral are rated by the counsellors. Questionnaires are filled out at the end of every visit and at follow-up via e-mail or text, provided permission is given.

DISCUSSION

Research regarding the visitors and effectiveness of the @ease services is fully original. It offers unique insights into the mental wellbeing and cost-of-illness of young people who may otherwise remain unseen while suffering from a high disease burden. The upcoming studies shed light on this unseen group, inform policy and practice and direct future research.

Sixteen years of innovation in youth mental healthcare: Outcomes for young people attending Australia's headspace centre services

Australia's headspace initiative is world-leading in nation-wide youth mental healthcare reform for young people aged 12 to 25 years, now with 16 years of implementation. This paper examines changes in the key outcomes of psychological distress, psychosocial functioning, and quality of life for young people accessing headspace centres across Australia for mental health problems. Routinely collected data from headspace clients commencing an episode of care within the data collection period, 1 April 2019 to 30 March 2020, and at 90-day follow-up were analysed. Participants came from the 108 fully-established headspace centres across Australia, and comprised 58,233 young people aged 12-25 years first accessing headspace centres for mental health problems during the data collection period. Main outcome measures were self-reported psychological distress and quality of life, and clinician-reported social and occupational functioning. Most headspace mental health clients presented with depression and anxiety issues (75.21%). There were 35.27% with a diagnosis: overall, 21.74% diagnosed with anxiety, 18.51% with depression, and 8.60% were sub-syndromal. Younger males were more likely to present for anger issues. Cognitive behavioural therapy was the most common treatment. There were significant improvements in all outcome scores over time (P<0.001). From presentation to last service rating, over one-third had significant improvements in psychological distress and a similar proportion in psychosocial functioning; just under half improved in self-reported quality of life. Significant improvement on any of the three outcomes was shown for 70.96% of headspace mental health clients. After 16 years of headspace implementation, positive outcomes are being achieved, particularly when multi-dimensional outcomes are considered. A suite of outcomes that capture meaningful change for young people's quality of life, distress and functioning, is critical for early intervention, primary care settings with diverse client presentations, such as the headspace youth mental healthcare initiative.

Self-Management Strategies in Youth With Difficulties Related to Anxiety or Depression: What Helps Them Feel Better

Anxiety and depressive disorders are the most prevalent mental health problems in adolescents, however, little is known about the strategies they use to deal with their difficulties and regain power over their symptoms. This exploratory study documented the self-management strategies used by adolescents to recover from difficulties related to anxiety and/or depression. Individual interviews were conducted in Montreal, Canada with 49 participants aged 11 to 18 years (28 girls, 20 boys, and 1 non-binary person from various cultural origins) after approval by the Institutional Review Board. Young people were questioned about the self-management strategies they put in place when they felt stressed, sad, or anxious. The data were coded according to the thematic analysis method using an inductive approach. Participants reported 73 self-management strategies, regrouped in four broad themes: (a) I think through; (b) I surround myself with people/animals; (c) I feel and manage my emotions; (d) I continue my daily activities. Their strategies emphasize the role played by their social network and the place of social media as a support in their recovery. Self-management is an empowering process that allows adolescents to take responsibility and to make decisions that foster their recovery.

Mental health mobile application self-help for adolescents exhibiting psychological distress: A single case experimental design

OBJECTIVES

The present demand for child and adolescent mental health services exceeds the capacity for service provision. Greater research is required to understand the utility of accessible self-help interventions, such as mobile apps. This study sought to investigate whether use of a mental health app, underpinned by CBT, led to changes in psychological distress amongst adolescents. Mechanisms of change were examined, specifically whether changes are attributable to cognitive strategies.

DESIGN

This study utilised a multiple-baseline single-case experimental design, tracking variables across baseline and intervention phases. Surveys assessing participant experience were also administered.

METHODS

Five participants with moderate-to-severe levels of psychological distress engaged with a CBT-based app over five weeks. Participants were recruited from both a well-being service and the general population. Supplementary weekly calls to participants offered clarification of app content.

RESULTS

A small overall effect of the intervention of psychological distress was evident; however, outcomes were dependent on the analysis conducted. The intervention appeared to promote an increase in use of adaptive cognitive strategies but not negative thinking styles. The CBT app did not promote changes in participant well-being. Participant feedback highlighted practical challenges of utilising the app.

CONCLUSIONS

The clinical benefits of app-based CBT were small, and a range of barriers to engagement were recognised. While further research is required, caution should be exercised in the interpretation of studies reporting on app effectiveness.

Engagement and outcomes of marginalised young people in an early intervention youth alcohol and other drug program: The Street Universities model

BACKGROUND

Early intervention alcohol and drug (AOD) programs for disadvantaged young people have the potential to substantially decrease the need for future intervention, however there is little research about how young people use these programs or the substance use and other outcomes of such programs. This paper uses data from an Australian AOD early intervention program, The Street Universities, to: describe young people's participation; examine changes in substance use and wellbeing over 90 days; and assess which young people are most positively impacted.

METHODS

Data come from a prospective study of new attendees, measuring retention in and attendance patterns in an 'engagement' program focussed on arts and lifestyle activities (n = 95), and a routine service dataset collected from seven years of therapeutic intervention (n = 3,893), measuring substance dependence (SDS), psychological distress (K10) and quality of life (EQoL).

RESULTS

Analysis reveals that young people were retained in the program at high proportion (63% at six months) and more than half of these returned at a frequency of weekly or more often. Young people participating in the therapeutic component of the program reported significant improvements in all key wellbeing indicators with SDS, K10 and EQoL scores significantly improving (at p < .001). These improvements occurred rapidly, within the first 30 days, and were maintained over the 90 day study period. Moreover, young people with the highest SDS and K10 scores and lowest quality of life at baseline experienced the most positive changes.

CONCLUSION

Aligning engagement program with therapeutic intervention can provide comprehensive support to disadvantaged young people, producing substantial improvements in AOD use, distress and wellbeing.

Clinical staging and the differential risks for clinical and functional outcomes in young people presenting for youth mental health care

BACKGROUND

Clinical staging proposes that youth-onset mental disorders develop progressively, and that active treatment of earlier stages should prevent progression to more severe disorders. This retrospective cohort study examined the longitudinal relationships between clinical stages and multiple clinical and functional outcomes within the first 12 months of care.

METHODS

Demographic and clinical information of 2901 young people who accessed mental health care at age 12-25 years was collected at predetermined timepoints (baseline, 3 months, 6 months, 12 months). Initial clinical stage was used to define three fixed groups for analyses (stage 1a: 'non-specific anxious or depressive symptoms', 1b: 'attenuated mood or psychotic syndromes', 2+: 'full-threshold mood or psychotic syndromes'). Logistic regression models, which controlled for age and follow-up time, were used to compare clinical and functional outcomes (role and social function, suicidal ideation, alcohol and substance misuse, physical health comorbidity, circadian disturbances) between staging groups within the initial 12 months of care.

RESULTS

Of the entire cohort, 2093 young people aged 12-25 years were followed up at least once over the first 12 months of care, with 60.4% female and a baseline mean age of 18.16 years. Longitudinally, young people at stage 2+ were more likely to develop circadian disturbances (odds ratio [OR]=2.58; CI 1.60-4.17), compared with individuals at stage 1b. Additionally, stage 1b individuals were more likely to become disengaged from education/employment (OR=2.11, CI 1.36-3.28), develop suicidal ideations (OR=1.92; CI 1.30-2.84) and circadian disturbances (OR=1.94, CI 1.31-2.86), compared to stage 1a. By contrast, we found no relationship between clinical stage and the emergence of alcohol or substance misuse and physical comorbidity.

CONCLUSIONS

The differential rates of emergence of poor clinical and functional outcomes between early versus late clinical stages support the clinical staging model's assumptions about illness trajectories for mood and psychotic syndromes. The greater risk of progression to poor outcomes in those who present with more severe syndromes may be used to guide specific intervention packages.

The role of digital tools in providing youth mental health: results from an international multi-center study

Since the traditional mental health system showed significant limitations in the early identification, diagnosis and treatment of the current new youth psychopathological trajectories, by substantially failing in targeting the needs of the current young generation, there is the demand to redesign and digitally adapt youth mental health care and systems. Indeed, the level of digital literacy and the level of digital competency and knowledge in the field of digital psychiatry is still under-investigated among mental health professionals, particularly in youth mental health. Therefore, we aimed at: (a) carrying out a post-hoc analysis of an international multi-centre study, to investigate the opinions of mental health professionals regarding the feasibility, efficacy and clinical experience in delivering digital mental health interventions (DMHIs) in youths; (b) providing a comprehensive overview on the integrated digitally-based youth mental health care models and innovations. Mental health professionals declared the lack of a formal training in digital psychiatry, particularly in youth mental health. Subjects who received a formal theoretical/practical training on DMHIs displayed a statistical trend towards a positive feasibility of digital psychiatry in youth mental health (p = 0.053) and a perceived increased efficacy of digital psychiatry in youths (p = 0.051). Respondents with higher Digital Psychiatry Opinion (DPO) scores reported a positive perceived feasibility of DMHIs in youths (p < 0.041) and are more prone to deliver DMHIs to young people (p < 0.001). Respondents with higher knowledge scores (KS) declared that DMHIs are more effective in youth mental health (p < 0.001). Overall, the digitalisation indeed allowed young people to keep in touch with a mental health professional, facilitating a more dynamic and fluid mental health care access and monitoring, generally preferred and considered more feasible by post-Millennial youngsters. Accordingly, our findings demonstrated that mental health professionals are more prone to offer DMHIs in youth mental health, particularly whether previously trained and knowledgeable on the topic.

A longitudinal study of headspace youth oriented mental health service satisfaction, service utilization and clinical characteristics

AIM

This study examined satisfaction with accessibility, staff attitudes, personal outcomes service components of youth-oriented mental health service, Headspace, and those components' associations with psychological distress and functional status at intake, service utilization patterns and demographic characteristics at middle and end of treatment.

METHODS

Data were collected between March 2016 and June 2018 from 112 participants (12-25 years) who consented and completed at least seven sessions at the Headspace youth integrated-care centre in Israel using the centre's registries and the Youth Service Satisfaction Scale.

RESULTS

Headspace participants attended an average of 12 sessions (SD = 3.12), they waited up to 2 weeks for their first intake (n = 57; 73%), after which most were offered a psychotherapy session (n = 80, 71%) within 2 months. Participants' satisfaction with Headspace was above the mid-point for all service aspects. The overall effect for time was not significant, F(1) = 1.14, p > .05. However, a significant increase in satisfaction with personal outcomes was found between the middle and the end of treatment, F(2,4) = 3.11, p < .05 compared to all other aspects. The length of waiting time, level of distress, number of sessions attended by parents and age were correlated with satisfaction. Correlations were found with waiting time, distress level, number of sessions attended by parents and age.

CONCLUSIONS

High levels of satisfaction with Headspace service aspects strengthens the evidence for areas of importance in designing youth mental health services: youth-friendly staff, general environment, accessibility and outcomes achievement.

Young help-seeker profiles in Israel: The case of the first Israeli headspace centre

AIM

To describe clinical and demographic characteristics of youths who seek help at the first Headspace centre in Israel and their families.

METHODS

A sample of 291 (65%) of the youths (12- to 25-year-olds) who applied to Headspace between March 2016 and June 2018 completed an assessment, including reasons for referral and clinical status; the Kessler Psychological Distress Scale, evaluating psychological distress; and the Strengths and Difficulties Questionnaire, measuring emotional and behavioural difficulties. Their families reported burden of care via the Burden Assessment Scale.

RESULTS

Of the sample, 75% were between the ages of 12 and 17 years (equal gender distribution); for 45%, Headspace was their first encounter with mental health services. Participants' most-reported referral source was school counsellors (27%), and presenting concern (51%) was emotional problems, mainly depression (18%) and anxiety (16%). Female and older participants had more emotional difficulties than did males and younger participants, respectively. Overall, most help-seekers expressed high distress levels upon entry, and their family's burden was associated with those levels.

CONCLUSIONS

This first study of the first Headspace centre in Israel sheds light on and broadens knowledge about young help-seekers of Headspace outside of Australia. It emphasizes the trend across all ages of help-seeking youths with high psychological-distress levels and the role of family and school staff in the help-seeking process. Establishing youth services that improve access and deliver early intervention to a widely underserved population at times of high distress can be a global trajectory.

The Impact of Community Mental Health Programs for Australian Youth: A Systematic Review

Australia has undergone significant youth mental health reform over the past 10 years, leading to numerous studies examining the effects of community-based mental health care programs for Australian youth. However, no synthesis of this literature currently exists. Therefore, this systematic review aimed to: (1) describe the types of community-based mental health programs that have been delivered to Australian youth in the past 10 years; and (2) examine their impact in improving young people’s mental health symptomology and psychosocial functioning. A systematic search of the peer-reviewed literature was conducted. Studies were included if they evaluated the extent to which such programs improved mental health symptomology (e.g., depression, anxiety, substance use) and/or psychosocial outcomes (e.g., social functioning, school engagement, employment) for Australian youth aged 10–25 years. Thirty-seven studies were included. Four types of community-based youth mental health care programs were identified: therapy (n = 16), case management (n = 9), integrated ‘one-stop-shop’ (n = 6) and lifestyle (n = 6) programs. The majority of therapeutic programs were effective in reducing mental health symptomology. Case management and integrated approaches consistently yielded significant improvements in both symptomology and psychosocial outcomes. Lifestyle programs were effective in alleviating depressive symptoms, but inconclusive for other outcomes. This review provides support for youth-friendly, systemic, multidisciplinary and integrated assertive outreach models of community mental health care to improve outcomes for young Australians experiencing mental health concerns. Several recommendations for future research are provided to strengthen the local evidence-base supporting community mental health programs to ultimately enhance young people’s life trajectory.

Designing and scaling up integrated youth mental health care

Mental ill-health represents the main threat to the health, survival and future potential of young people around the world. There are indications that this is a rising tide of vulnerability and need for care, a trend that has been augmented by the COVID-19 pandemic. It represents a global public health crisis, which not only demands a deep and sophisticated understanding of possible targets for prevention, but also urgent reform and investment in the provision of developmentally appropriate clinical care. Despite having the greatest level of need, and potential to benefit, adolescents and emerging adults have the worst access to timely and quality mental health care. How is this global crisis to be addressed? Since the start of the century, a range of co-designed youth mental health strategies and innovations have emerged. These range from digital platforms, through to new models of primary care to new services for potentially severe mental illness, which must be locally adapted according to the availability of resources, workforce, cultural factors and health financing patterns. The fulcrum of this progress is the advent of broad-spectrum, integrated primary youth mental health care services. They represent a blueprint and beach-head for an overdue global system reform. While resources will vary across settings, the mental health needs of young people are largely universal, and underpin a set of fundamental principles and design features. These include establishing an accessible, "soft entry" youth primary care platform with digital support, where young people are valued and essential partners in the design, operation, management and evaluation of the service. Global progress achieved to date in implementing integrated youth mental health care has highlighted that these services are being accessed by young people with genuine and substantial mental health needs, that they are benefiting from them, and that both these young people and their families are highly satisfied with the services they receive. However, we are still at base camp and these primary care platforms need to be scaled up across the globe, complemented by prevention, digital platforms and, crucially, more specialized care for complex and persistent conditions, aligned to this transitional age range (from approximately 12 to 25 years). The rising tide of mental ill-health in young people globally demands that this focus be elevated to a top priority in global health.

The psychometric characteristics of the Kessler Psychological Distress Scale (K6) in help-seeking youth: What do you miss when using it as an outcome measure?

This is the first study to describe psychometric properties of the Kessler Psychological Distress Scale (K6) in a large cohort of help-seeking young people presenting to primary mental health care services. The aim was to determine whether the K6 was appropriate for monitoring outcomes in such settings. 1067 young people were recruited from Australian headspace services. We examined dimensionality of the K6, measurement invariance, and how the K6 correlated with the the Patient Health Questionnaire-9 (PHQ-9)and the Generalised Anxiety Disorder-7 Scale (GAD-7). Standardised Response Mean (SRM) and Cohen's d effect size (ES) were used to examine 3-month stability of the K6. The best-fitting model was a two-factor model: (i) nervous and restlessness; and (ii) hopeless, worthless, depressed and effort. Measurement non-invariance was observed for sex and age groups. K6 strongly correlated with the PHQ-9 and GAD-7. The K6 was less sensitive to change compared to these other two measures. There was some support for the K6 being a screener for young people presenting to primary care; however, there issues arise with its use as an outcome measure. These issues include measurement non-invariance, concern about the dimensionality and focus of items, and its sensitivity to change.

Social and occupational outcomes for young people who attend early intervention mental health services: a longitudinal study

OBJECTIVE

To identify trajectories of social and occupational functioning in young people during the two years after presenting for early intervention mental health care; to identify demographic and clinical factors that influence these trajectories.

DESIGN

Longitudinal, observational study of young people presenting for mental health care.

SETTING

Two primary care-based early intervention mental health services at the Brain and Mind Centre (University of Sydney), 1 June 2008 - 31 July 2018.

PARTICIPANTS

1510 people aged 12-25 years who had presented with anxiety, mood, or psychotic disorders, for whom two years' follow-up data were available for analysis.

MAIN OUTCOME MEASURES

Latent class trajectories of social and occupational functioning based on growth mixture modelling of Social and Occupational Assessment Scale (SOFAS) scores.

RESULTS

We identified four trajectories of functioning during the first two years of care: deteriorating and volatile (733 participants, 49%); persistent impairment (237, 16%); stable good functioning (291, 19%); and improving, but late recurrence (249, 16%). The less favourable trajectories (deteriorating and volatile; persistent impairment) were associated with physical comorbidity, not being in education, employment, or training, having substance-related disorders, having been hospitalised, and having a childhood onset mental disorder, psychosis-like experiences, or a history of self-harm or suicidality.

CONCLUSIONS

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. Most functional trajectories were also quite volatile, indicating the need for dynamic service models that emphasise multidisciplinary interventions and measurement-based care.

Early Interventions for Clinical High-Risk State for Psychosis

The aim of this review was to discuss early intervention options for clinical high-risk states of psychosis, the limitations of the high-risk concept, and the importance of population-based approaches in preventing psychosis. Interventions for individuals at high risk of psychosis can be classified into two main categories: pharmacological and non-pharmacological. When selecting any of these intervention options, it should be taken into account that only a small proportion of individuals in the high-risk group will have a transition to clinical psychosis. Therefore, it is necessary to avoid aggressive interventions. Pharmacotherapies, particularly antipsychotics, are generally not considered as a treatment of choice for individuals at high risk of psychosis due to their potential side-effect profiles, whereas cognitive behavioral therapies and family-oriented therapies are the leading alternatives with virtually no side effects. However, meta-analyses have shown that none of the interventions are specifically more effective than needs-based treatment (including placebo) in preventing transition to psychosis. These interventions might not be effective in preventing transition to psychosis; however, they may improve the outcomes of psychosis. Accumulating evidence suggests that the targeted prevention approaches focusing on the clinical high risk of psychosis concept have major limitations in terms of the impact on reducing psychosis incidence in the general population compared to the population-based approaches. Recently, psychosis-focused prevention approaches have been replaced by easily accessible youth mental health centers that provide services for transdiagnostic conditions. Future studies on the efficacy of these community-based youth mental health services may provide guidance on how to prevent psychosis.

Depression Anxiety Stress Scale-10: A Brief Measure for Routine Psychotherapy Outcome and Progress Assessment

Routine outcome measurement and progress monitoring is well established to enhance quality assurance in clinical psychology service delivery but is not widely used in routine care. A major barrier to more widespread implementation is the lack of public domain, brief, psychometrically sound outcome measures that easily integrate into clinical information systems. The current study assessed a brief 10-item version of the widely used Depression Anxiety Stress (DASS)-42 scale, which we called the Depression Anxiety Stress-10 (DASS-10) scale. In two clinical samples of adults (n = 1036, 445 men, 591 women; and n = 1084, 493 men, 591 women), the DASS-10 had a replicable two-level factor structure, which at the lower level had two factors assessing stress-anxiety and depression, which each loaded onto a superordinate psychological distress scale. The items in the distress score discriminated between a clinical sample (n = 376) and a community sample (n = 379) and were sensitive to clinical change. The measure has the potential to make routine outcome measurement and progress monitoring more cost-effective to implement than existing measures, particularly when integrated with practice management software to make administration, scoring, and use easy.

A routine outcome measure for youth mental health: Clinically interpreting MyLifeTracker

AIM

MyLifeTracker is a session-by-session mental health outcome measure for young people aged 12 to 25 years. The aim of this study was to determine clinically significant change indexes for this measure that would identify developmentally appropriate thresholds. The study also aimed to determine expected change trajectories to enable clinicians to compare a client's progress against average rates of change.

METHODS

Participants comprised young people aged 12 to 25 years from both a clinical and a community sample from Australia. The clinical sample was 63 840 young people that attended a headspace centre. The non-clinical group was an Australian representative community sample of 4034 young people.

RESULTS

Clinically significant change indexes were developed for MyLifeTracker specific for age and gender groups by comparing clinical and non-clinical samples. Males and young people aged 12 to 14 years needed to reach higher scores to achieve clinically significant change compared to females and other age groups, respectively. MyLifeTracker expected change trajectories followed a cubic pattern for those with lower baseline scores of 0 to 50, whereas those with baseline scores of 51 and above had varying patterns. For those with lower baseline scores, expected change trajectories showed that stronger change was evident early in treatment, which then tapered off before accelerating again later in treatment.

CONCLUSIONS

The development of MyLifeTracker benchmarks allows the measure to be used for Feedback Informed Treatment by supporting treatment planning and decision-making. This information can help clinicians to identify clients who are not on track or deteriorating and identify when clients are improving.

W. M. J, Alvarez-Jimenez M, Nieman DH. ENgage YOung people earlY (ENYOY): a mixed-method study design for a digital transdiagnostic clinical - and peer- moderated treatment platform for youth with beginning mental health complaints in the Netherlands

BACKGROUND

The onset of mental disorders typically occurs between the ages of 12 and 25, and the burden of mental health problems is the most consequential for this group. Indicated prevention interventions to target individuals with subclinical symptoms to prevent the transition to clinical levels of disorders, even leading to suicide, have shown to be effective. However, the threshold to seek help appears to be high. Digital interventions could offer a solution, especially during the Covid-19 pandemic. This implementation study will investigate the digital indicated prevention intervention ENgage YOung people Early (ENYOY), the Dutch version of the original Moderated Online Social Therapy Platform (MOST+) from Australia. In addition, the relationship between stress biomarkers, symptoms and outcome measures of youth using the platform will be investigated in this study.

METHODS

The MOST+ platform will be adapted, translated and developed for the situation in the Netherlands in collaboration with a Youth Panel. A prospective cohort of 125 young people (16-25 years) with beginning mental health complaints will be on the platform and followed for a year, of which 10 participants will have an additional smart watch and 10 participants will be asked to provide feedback about the platform. Data will be collected at baseline and after 3, 6 and 12 months. Outcome measures are Psychological Distress assessed with the Kessler Psychological Distress Scale (K10), Social and occupational functioning (measures by the SOFAS), positive mental health indicators measured by the Positive Health Instrument, stress biomarkers with a smart-watch, website journeys of visitors, and feedback of youth about the platform. It will be a mixed-method study design, containing qualitative and quantitative measures.

DISCUSSION

This trial will specifically address young people with emerging mental health complaints, and offers a new approach for treatment in the Netherlands. Considering the waiting lists in (child and adolescent)-psychiatry and the increase in suicides among youth, early low-threshold and non-stigmatizing help to support young people with emerging psychiatric symptoms is of crucial importance. Moreover, this project aims to bridge the gap between child and adolescent and adult psychiatry.

TRIAL REGISTRATION

Netherlands Trial Register ID NL8966 , retrospectively registered on the 19th of October 2020.

How does reorganisation in child and adolescent mental health services affect access to services? An observational study of two services in England

BACKGROUND

Child and Adolescent Mental Health Services (CAMHS) in England are making significant changes to improve access and effectiveness. This 'transformation' variously involves easier access to services through a Single Point of Access (SPA), more integrated services within CAMHS and enhanced co-provision across education and third sector or non-profit organisations.

METHODS

A mixed-methods observational study was conducted to explore the process and impact of transformation over four years in two services. Ethnographic observations and in-depth interviews were conducted and Electronic Patient Records with over one million contacts analysed. Difference-in-differences analysis with propensity score matching to estimate the causal impact of the transformation on patient access was utilised.

OUTCOMES

Spend and staffing increased across both CAMHS. The SPA had growing rates of self-referral and new care pathways were seeing patients according to expected degree of psychopathology. Third sector partners were providing increasing numbers of low-intensity interventions. Although the majority of staff were supportive of the changes, the process of transformation led to service tensions. In the first year after transformation there was no change in the rate of new patients accessing services or new spells (episodes of care) in the services. However, by year three, the number of new patients accessing CAMHS was 19% higher (Incidence Rate Ratio: 1·19, CI: 1·16, 1·21) and the rate of new spells was 12% higher (Incidence Rate Ratio: 1·12, CI: 1·05, 1·20).

INTERPRETATION

Transformation investment, both financial and intellectual, can help to increase access to CAMHS in England, but time is needed to realise the benefits of reorganisation.

Schizophrenia polygenic risk scores in youth mental health: preliminary associations with diagnosis, clinical stage and functioning

BACKGROUND

The schizophrenia polygenic risk score (SCZ-PRS) is an emerging tool in psychiatry.

AIMS

We aimed to evaluate the utility of SCZ-PRS in a young, transdiagnostic, clinical cohort.

METHOD

SCZ-PRSs were calculated for young people who presented to early-intervention youth mental health clinics, including 158 patients of European ancestry, 113 of whom had longitudinal outcome data. We examined associations between SCZ-PRS and diagnosis, clinical stage and functioning at initial assessment, and new-onset psychotic disorder, clinical stage transition and functional course over time in contact with services.

RESULTS

Compared with a control group, patients had elevated PRSs for schizophrenia, bipolar disorder and depression, but not for any non-psychiatric phenotype (for example cardiovascular disease). Higher SCZ-PRSs were elevated in participants with psychotic, bipolar, depressive, anxiety and other disorders. At initial assessment, overall SCZ-PRSs were associated with psychotic disorder (odds ratio (OR) per s.d. increase in SCZ-PRS was 1.68, 95% CI 1.08-2.59, P = 0.020), but not assignment as clinical stage 2+ (i.e. discrete, persistent or recurrent disorder) (OR = 0.90, 95% CI 0.64-1.26, P = 0.53) or functioning (R = 0.03, P = 0.76). Longitudinally, overall SCZ-PRSs were not significantly associated with new-onset psychotic disorder (OR = 0.84, 95% CI 0.34-2.03, P = 0.69), clinical stage transition (OR = 1.02, 95% CI 0.70-1.48, P = 0.92) or persistent functional impairment (OR = 0.84, 95% CI 0.52-1.38, P = 0.50).

CONCLUSIONS

In this preliminary study, SCZ-PRSs were associated with psychotic disorder at initial assessment in a young, transdiagnostic, clinical cohort accessing early-intervention services. Larger clinical studies are needed to further evaluate the clinical utility of SCZ-PRSs, especially among individuals with high SCZ-PRS burden.

From Planning to Implementation of the YouthCan IMPACT Project: a Formative Evaluation

In order to improve the youth mental health system, there is an international movement toward developing community-based service hubs that provide integrated, collaborative care to youth. However, the implementation of multisystem collaboration is complex and can be hampered by barriers. This paper presents a formative evaluation of the YouthCan IMPACT integrated youth services project based on the Consolidated Framework for Implementation Research (CFIR), to identify facilitators and barriers to successful implementation. Results highlight that previous positive working relationships along with collaborative investment of resources from partnering organizations are essential to implement an integrated youth service model. In addition, it is important that representative members of all key stakeholder groups, including staff, youth, and caregivers, be involved in the development and execution of the project to ensure effective implementation. Attention to the facilitators and barriers to implementation may help teams seeking to implement highly collaborative, integrated models of service delivery for youth in the community.

Detection and intervention in emerging youth mental health issues: Outcomes from the first year of the CASPAR service

OBJECTIVE

There is a recognized gap in mental health service provision for youth, a population in whom emerging mental disorders are prevalent and recognized as a target for early intervention. Comprehensive Assessment Service for Psychosis and At-Risk (CASPAR) is a new, community-based service aiming to address the service gap between headspace and tertiary psychiatric services. CASPAR facilitates assessment and short-term early intervention in youth (aged 12-25 years) with emerging mental health issues. Demographic and clinical characteristics are described in all individuals receiving care from CASPAR in its first year of operation. Changes in psychological distress and psychosocial functioning over the course of a treatment episode are reported.

METHODS

Demographic and clinical data, including measures of functional impairment (Social and Occupational Functioning Assessment Scale [SOFAS]) and psychological distress (Kessler Psychological Distress Scale [K10]), were obtained at baseline and completion of episode of care for all clients.

RESULTS

92 young people (53.3% male, mean age 18.7 years) were included, of whom 20 (21.7%) disengaged before treatment endpoint. Clients who disengaged early were more likely to identify as lesbian, gay, bisexual and transgender+ (LGBT+). At follow-up, 61.1% showed improvements in social functioning (SOFAS) and 64.4% in psychological distress (K10).

CONCLUSIONS

The majority of clients showed improvements in psychological distress and functioning during an episode of care. LGBT+ youth were less likely to remain engaged with the service. The factors associated with initial and continued engagement with youth early intervention services require further examination, particularly in marginalized groups with high mental illness prevalence such as LGBT+ communities.

Predicting self-harm within six months after initial presentation to youth mental health services: A machine learning study

BACKGROUND

A priority for health services is to reduce self-harm in young people. Predicting self-harm is challenging due to their rarity and complexity, however this does not preclude the utility of prediction models to improve decision-making regarding a service response in terms of more detailed assessments and/or intervention. The aim of this study was to predict self-harm within six-months after initial presentation.

METHOD

The study included 1962 young people (12-30 years) presenting to youth mental health services in Australia. Six machine learning algorithms were trained and tested with ten repeats of ten-fold cross-validation. The net benefit of these models were evaluated using decision curve analysis.

RESULTS

Out of 1962 young people, 320 (16%) engaged in self-harm in the six months after first assessment and 1642 (84%) did not. The top 25% of young people as ranked by mean predicted probability accounted for 51.6% - 56.2% of all who engaged in self-harm. By the top 50%, this increased to 82.1%-84.4%. Models demonstrated fair overall prediction (AUROCs; 0.744-0.755) and calibration which indicates that predicted probabilities were close to the true probabilities (brier scores; 0.185-0.196). The net benefit of these models were positive and superior to the 'treat everyone' strategy. The strongest predictors were (in ranked order); a history of self-harm, age, social and occupational functioning, sex, bipolar disorder, psychosis-like experiences, treatment with antipsychotics, and a history of suicide ideation.

CONCLUSION

Prediction models for self-harm may have utility to identify a large sub population who would benefit from further assessment and targeted (low intensity) interventions. Such models could enhance health service approaches to identify and reduce self-harm, a considerable source of distress, morbidity, ongoing health care utilisation and mortality.

Expanding the search for emerging mental ill health to safeguard student potential and vocational success in high school: A narrative review

AIM

Young people experiencing mental ill health are more likely than their healthy aged peers to drop out of high school. This can result in social exclusion and vocational derailment. Identifying young people at risk and taking action before an illness is established or school dropout occurs is an important goal. This study aimed to examine evidence for the risk markers and at risk mental states of the clinical staging model (stage 0-1b) and whether these risk states and early symptoms impact school participation and academic attainment.

METHOD

This narrative review assembles research from both the psychiatry and education literature. It examines stage 0 to stage 1b of the clinical staging model and links the risk states and early symptoms to evidence about the academic success of young people in high school.

RESULTS

In accordance with the clinical staging model and evidence from education literature, childhood trauma and parental mental illness can impact school engagement and academic progress. Sleep disturbance can result in academic failure. Undifferentiated depression and anxiety can increase the risk for school dropout. Subthreshold psychosis and hypomanic states are associated with functional impairment and high rates of Not in Employment, Education, or Training (NEET) but are not recognized in the education literature.

CONCLUSION

Risk markers for emerging mental ill health can be identified in education research and demonstrate an impact on a student's success in high school. Clear referral protocols need to be embedded into school life to reduce risk of progression to later stages of illness and support school participation and success.

Factors affecting the implementation of an outcome measurement feedback system in youth mental health settings

Objective: Measurement feedback systems provide clinicians with regular snapshots of a client's mental health status, which can be used in treatment planning and client feedback. There are numerous barriers to clinicians using outcome measures routinely. This study aimed to investigate factors affecting the use of a measurement feedback system across youth mental health settings. Methods: The participants were 210 clinicians from headspace youth mental health services across Australia. They were surveyed on predictors and use of MyLifeTracker, a routine outcome measure. This was explored through three processes: looking at MyLifeTracker before session, using MyLifeTracker in treatment planning, and providing feedback of MyLifeTracker scores to clients. Results: Clinicians were more likely to look at MyLifeTracker before session, less likely to use it in treatment planning, and least likely to provide MyLifeTracker scores to clients. Each measurement feedback system process had a distinct group of predictors. Perceptions of MyLifeTracker's practicality was the only significant predictor of all three processes. Conclusion: Practically, organisations and supervisors can increase the use of measurement feedback systems through targeted supports.

Psychosis Risk and Development: What Do We Know From Population-Based Studies?

Recent years have seen an advent in population-based studies in children, adolescents, and adults that examine the prevalence, etiology, and developmental trajectories of diverse subclinical psychopathological symptoms that pose a risk for the later development of severe mental illnesses. It is increasingly recognized that most categorically defined psychiatric disorders occur on a spectrum or continuum, show high heterogeneity and symptom overlap, and share genetic and environmental risk factors. We discuss neurodevelopmental underpinnings of psychosis spectrum symptoms and review brain morphometric and functional alterations as well as genetic liability for psychosis in individuals experiencing psychotic symptoms (PSs) in the general population. With regard to brain structure and function, findings of qualitatively similar alterations in individuals experiencing subthreshold PSs and individuals with overt psychotic disorders support the notion of a psychosis continuum. However, genetic and epidemiological studies have emphasized the overlap of PSs and other psychiatric illnesses. In particular, PSs during adolescence appear to be a nonspecific precursor of different psychopathological outcomes. Given the evidence presented in this review, we argue that findings from population-based studies are appropriate to guide policy-making to further emphasize public health efforts. Broadly accessible mental health programs are promising to make a difference in the field of adolescent mental health. However, the specific efficacy of these programs warrants further study, and caution is advised to not overpathologize potentially transient occurrence of mental health problems.

Subjective cognitive functioning in relation to changes in levels of depression and anxiety in youth over 3 months of treatment

BACKGROUND

Subjective cognitive difficulties are common in mental illness and have a negative impact on role functioning. Little is understood about subjective cognition and the longitudinal relationship with depression and anxiety symptoms in young people.

AIMS

To examine the relationship between changes in levels of depression and anxiety and changes in subjective cognitive functioning over 3 months in help-seeking youth.

METHOD

This was a cohort study of 656 youth aged 12-25 years attending Australian headspace primary mental health services. Subjective changes in cognitive functioning (rated as better, same, worse) reported after 3 months of treatment was assessed using the Neuropsychological Symptom Self-Report. Multivariate multinomial logistic regression analysis was conducted to evaluate the impact of baseline levels of and changes in depression (nine-item Patient Health Questionnaire; PHQ9) and anxiety symptoms (seven-item Generalised Anxiety Disorder scale; GAD7) on changes in subjective cognitive function at follow-up while controlling for covariates.

RESULTS

With a one-point reduction in PHQ9 at follow-up, there was an estimated 11-18% increase in ratings of better subjective cognitive functioning at follow-up, relative to stable cognitive functioning. A one-point increase in PHQ9 from baseline to follow-up was associated with 7-14% increase in ratings of worse subjective cognitive functioning over 3 months, relative to stable cognitive functioning. A similar attenuated pattern of findings was observed for the GAD7.

CONCLUSIONS

A clear association exists between subjective cognitive functioning outcomes and changes in self-reported severity of affective symptoms in young people over the first 3 months of treatment. Understanding the timing and mechanisms of these associations is needed to tailor treatment.

Challenges during the transition from child and adolescent mental health services to adult mental health services

The transition from child and adolescent to adult mental health services for young people with mental health problems is of international concern. Despite the high prevalence of mental disorders during adolescence and their tendency to continue during adulthood, the majority of young people do not experience continuity of care. The aim of this review paper is to unravel the complexity of transitional mental healthcare to clinicians, policy makers and mental health service managers, and to address challenges to a smooth transition process at all levels.

Referral patterns to primary mental health services in Western Sydney (Australia): an analysis of routinely collected data (2005-2018)

Background

Regionally-specific approaches to primary mental health service provision through Primary Health Networks (PHNs) have been a feature of recent national mental health reforms. No previous studies have been conducted to investigate local patterns of primary mental health care (PMHC) services in Western Sydney. This study is designed to (i) understand the socio-demographic and economic profiles (ii) examine the inequalities of service access, and (iii) investigate the service utilisation patterns, among those referred to PMHC services in Western Sydney, Australia.

Methods

This study used routinely collected PMHC data (2005–2018), population-level general practice and Medicare rebates data (2013–2018) related to mental health conditions, for the population catchment of the Western Sydney PHN. Sex- and age-specific PMHC referrals were examined by socio-demographic, diagnostic, referral- and service-level factors, and age-specific referrals to PMHC services as a percentage of total mental health encounters were investigated.

Results

There were 27,897 referrals received for 20,507 clients, of which, 79.19% referrals resulted in follow-up services with 138,154 sessions. Overall, 60.09% clients were female, and median age was 31 years with interquartile ranged 16–46 years. Anxiety and depression were the predominant mental health condition, and 9.88% referred for suicidal risk. Over two-thirds of referrals started treatments during the first month of the referral and 95.1% of the total sessions were delivered by face to face. The younger age group (0–24) had greater referral opportunities as a percentage of total visits to a general practitioner and Medicare rebates, however demonstrating poor attendance rates with reduced average sessions per referral compared with older adults.

Conclusion

Children and young adults were more likely to be referred to PMHC services than older adults, but were less likely to attend services. Further research is needed to identify the strategies to address these differences in access to PMHC services to optimise the effectiveness of services.

Rethinking service design for youth with mental health needs: The development of the Youth Wellness Centre, St. Joseph's Healthcare Hamilton

AIM

This article describes the development and design of the Youth Wellness Centre (YWC), an innovative, youth-friendly centre providing mental health and addiction services for emerging adults aged 17 to 25 in Hamilton, Canada. We also report on demographic and clinical characteristics of clients to evaluate how the YWC is serving populations at increased risk of developing mental disorders.

METHODS

Data were extracted from clinic databases for 1520 youth at the YWC between March 2015 and 2018 to report on demographic characteristics, clinical profiles, primary presenting problems, service use and overall satisfaction with services.

RESULTS

Marginalized groups, particularly street-involved individuals and LGBTQ+ youth, are highly represented at the YWC, keeping with the centre's mandate of reaching at-risk populations. Youth at the YWC carry significant mental health burdens, with 80.8% having a history of suicidal ideation and 32.8% having a history of a substance use disorder. The primary route of referral is self-referral and the number of new clients has increased by nearly 20% in the first 3 years of operations. Overall satisfaction with the centre is on par with or slightly above provincial averages.

CONCLUSIONS

The YWC was developed to meet the mental health needs of transition-aged youth in Hamilton by providing early intervention, system navigation and transition services. The success of the YWC in reaching high-risk youth is demonstrated by the significant proportion of clients reporting demographic and clinical risk factors associated with increased risk for development of mental disorders. The increasing referrals to the YWC highlight the ongoing need for similar services.

Improved patient-reported outcomes after interprofessional training in mental health: a nonrandomized intervention study

BACKGROUND

Collaborative interprofessional practices are essential in caring for people with complex mental health problems. Despite the difficulties of demonstrating positive impacts of interprofessional education (IPE), it is believed to enhance interprofessional practices. We aimed to assess impacts on patient satisfaction, self-reported psychological distress and mental health status in a psychiatric ward.

METHODS

We conducted a nonrandomized intervention study with patient satisfaction, psychological distress, and health status as outcomes. Mental health inpatients were referred to either an interprofessional training unit (intervention group) or to a conventionally organized ward (comparison group). Outcomes were assessed using the Short Form Health Survey (SF-36), the Kessler Psychological Distress Scale (K10), and the Client Satisfaction Questionnaire (CSQ-8).

RESULTS

The intervention group included 129 patients, the comparison group 123. The former group reported better mental health status than the latter; the postintervention mean difference between them being 5.30 (95% CI 2.71-7.89; p = 0.001; SF-36), with an effect size of 0.24. The intervention group patients also scored higher on satisfaction (mean difference 1.01; 95% CI 0.06-1.96; p = 0.04), with an effect size of 0.31. The groups' mean scores of psychological distress were identical.

CONCLUSION

Our results support the hypothesized value of interprofessional training: intervention group patients reported higher scores regarding mental health status and satisfaction than did comparison group patients. As IPE interventions have rarely involved patients and fewer have taken place in practice settings, further research into both the processes and the long-term effects of IPE in mental healthcare is needed.

TRIAL REGISTRATION

The study was registered in ClinicalTrials.gov: NCT03070977 on March 6, 2017.

Cohort profile: the Brain and Mind Centre Optymise cohort: tracking multidimensional outcomes in young people presenting for mental healthcare

PURPOSE

The Brain and Mind Centre (BMC) Optymise cohort assesses multiple clinical and functional domains longitudinally in young people presenting for mental health care and treatment. Longitudinal tracking of this cohort will allow investigation of the relationships between multiple outcome domains across the course of care. Subsets of Optymise have completed detailed neuropsychological and neurobiological assessments, permitting investigation of associations between these measures and longitudinal course.

PARTICIPANTS

Young people (aged 12-30) presenting to clinics coordinated by the BMC were recruited to a research register (n=6743) progressively between June 2008 and July 2018. To date, 2767 individuals have been included in Optymise based on the availability of at least one detailed clinical assessment.

MEASURES

Trained researchers use a clinical research proforma to extract key data from clinical files to detail social and occupational functioning, clinical presentation, self-harm and suicidal thoughts and behaviours, alcohol and other substance use, physical health comorbidities, personal and family history of mental illness, and treatment utilisation at the following time points: baseline, 3, 6, 12, 24, 36, 48, and 60 months, and time last seen.

FINDINGS TO DATE

There is moderate to substantial agreement between raters for data collected via the proforma. While wide variations in individual illness course are clear, social and occupational outcomes suggest that the majority of cohort members show no improvement in functioning over time. Differential rates of longitudinal transition are reported between early and late stages of illness, with a number of baseline factors associated with these transitions. Furthermore, there are longitudinal associations between prior suicide attempts and inferior clinical and functional outcomes.

FUTURE PLANS

Future reports will detail the longitudinal course of each outcome domain and examine multidirectional relationships between these domains both cross-sectionally and longitudinally, and explore in subsets the associations between detailed neurobiological measures and clinical, social and functional outcomes.

Right care, first time: a highly personalised and measurement-based care model to manage youth mental health

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people.

High Intensity Interval training (HIIT) for people with severe mental illness: A systematic review & meta-analysis of intervention studies- considering diverse approaches for mental and physical recovery

There is a mortality gap of 15 to 20 years for people with severe mental illness (SMI - psychotic spectrum, bipolar, major depressive disorders). Modifiable risk factors include inactivity and low cardiorespiratory fitness (CRF). Exercise can improve mental and physical outcomes; optimal type and intensity of exercise for people with SMI has yet to be determined. High Intensity Interval training (HIIT) is an exercise with distinct cardio-metabolic advantages in other disease populations compared to traditional moderate intensity continuous training (MCT). We investigated the feasibility and efficacy of HIIT for people with SMI. Major electronic databases were searched, identifying HIIT studies for adults experiencing SMI.Data on feasibility, safety, study design, sample characteristics, and physical and psychological outcomes were extracted and systematically reviewed. Meta-analyses were conducted within group, pre and post HIIT interventions, and between group, to compare HIIT with control conditions. Nine articles were identified including three pre/post studies, one non randomised and five randomised trials, (366 participants, 45.1% female). HIIT appears as feasible as MCT, with few safety concerns. Following HIIT, there was a moderate improvement in CRF and depression. There was no difference between HIIT and MCT for adherence or CRF.HIIT improved depression more than MCT.

Improving Mood with Physical ACTivity (IMPACT) trial: a cluster randomised controlled trial to determine the effectiveness of a brief physical activity behaviour change intervention on depressive symptoms in young people, compared with psychoeducation, in addition to routine clinical care within youth mental health services-a protocol study

INTRODUCTION

Depression is highly prevalent and the leading contributor to the burden of disease in young people worldwide, making it an ongoing priority for early intervention. As the current evidence-based interventions of medication and psychological therapy are only modestly effective, there is an urgent need for additional treatment strategies. This paper describes the rationale of the Improving Mood with Physical ACTivity (IMPACT) trial. The primary aim of the IMPACT trial is to determine the effectiveness of a physical activity intervention compared with psychoeducation, in addition to routine clinical care, on depressive symptoms in young people. Additional aims are to evaluate the intervention effects on anxiety and functional outcomes and examine whether changes in physical activity mediate improvements in depressive symptoms.

METHODS AND ANALYSIS

The study is being conducted in six youth mental health services across Australia and is using a parallel-group, two-arm, cluster randomised controlled trial design, with randomisation occurring at the clinician level. Participants aged between 12 years and 25 years with moderate to severe levels of depression are randomised to receive, in addition to routine clinical care, either: (1) a physical activity behaviour change intervention or (2) psychoeducation about physical activity. The primary outcome will be change in the Quick Inventory of Depressive Symptomatology, with assessments occurring at baseline, postintervention (end-point) and 6-month follow-up from end-point. Secondary outcome measures will address additional clinical outcomes, functioning and quality of life. IMPACT is to be conducted between May 2014 and December 2019.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Melbourne Human Research Ethics Committee on 8 June 2014 (HREC 1442228). Trial findings will be published in peer-reviewed journals and presented at conferences. Key messages will also be disseminated by the youth mental health services organisation (headspace National Youth Mental Health Foundation).

TRIAL REGISTRATION NUMBER

ACTRN12614000772640.

Are Psychological Distress and Resilience Associated with Dietary Intake Among Australian University Students?

University students report unhealthy diets and experience poorer mental health than the general population. This study explores the association between psychological distress and resilience with dietary intake in a sample of Australian university students. Cross-sectional data from the University of Newcastle Student Healthy Lifestyle Survey 2017 were analysed. Psychological distress (Kessler Scale), resilience (Brief Resilience Scale) and fruit, vegetable, soft drink, takeaway food and breakfast intakes (short diet questions) were assessed. Socio-demographic (e.g., gender), student (e.g., undergraduate/postgraduate) and health characteristics (e.g., physical activity) were captured. Multivariate linear regression models explored associations between psychological distress and resilience with dietary intake, with adjustment for potential confounders. Analysis included 2710 students (mean age 26.9 ± 9.5 years, 30.4% male). In adjusted models, lower psychological distress was associated with higher fruit (β = -0.37, p = 0.001) and vegetable (β = -0.37, p < 0.001) serves/day, more frequent breakfast consumption (p < 0.001) and less frequent soft drink and takeaway food consumption (p < 0.001). Higher resilience was associated with higher fruit (β = 0.03, p = 0.022) and vegetable (β = 0.06, p < 0.001) serves/day, more frequent breakfast consumption (p = 0.005), and less frequent soft drink (p < 0.001) and takeaway food consumption (p = 0.001). These results highlight a potential link between psychological distress and resilience with diet, and that further research in this area is warranted.