Published 26 August 2009, doi:10.1136/bmj.b3371
Cite this as: BMJ 2009;339:b3371

Head to Head

Should youth mental health become a specialty in its own right? No

¹ Integrated Mental Health Program, Royal Children’s Hospital, Parkville Victoria 3052, Australia

Mental illness often develops in adolescence and young adulthood. Patrick McGorry (doi:10.1136/bmj.b3373) believes the best way to ensure early treatment is to have dedicated services, but Peter Birleson argues that integration with existing systems is more important

Proponents of a youth model for specialist mental health services claim that it will improve access to services early in the course of an illness. But replacing current specialist mental health services for 0-17 year olds (paediatric psychiatry) and 18-64 year olds (adult psychiatry) with three subspecialties for 0-11 year olds, 12-24 year olds, and 26-64 year olds¹ ignores current models of service planning,^{2 3} reduces the critical mass of child and adolescent mental health services needed to adopt evidence based practice,^{.4 5} and complicates mental health services. It fragments current service links and is likely to increase transition problems.

Psychotic disorders, such as schizophrenia or bipolar disorder, have their peak incidence at 21 and 22 years respectively,⁶ and substance use disorder peaks at 21-23 years.⁷ But psychotic disorders are not exclusive to youth and occur in both childhood and maturity. Although many psychotic episodes do start in young people, and a youth culture has emerged, these are weak reasons for redesigning mental health services or constructing new service boundaries at 12 and 25 years. We now better understand the effect of interactions between genetics and environment in mental illness⁸ through the emergent science of developmental psychopathology,^{6 7 8} but this new knowledge seems to argue for more prevention, early intervention, and continuity of care at all ages, not service redesign.

Coordination with other services

As half of mental health disorders begin by age 14 years, and 75% have onset by 24 years of age, more investment in prevention and intervention early in life seems wise,^{6 7 8} provided efficacy and cost benefit can be established. But new mental health prevention and early intervention services are most sensibly provided through universal platforms (such as schools and primary health) to make them accessible, not by adding new specialist mental health services. We need systems of care that can identify problems early and channel them to the lowest effective level of care, reserving specialist services for those with the most severe problems.^{2 3 4 5} Developing these new systems will need interdepartmental planning and partnerships, not the creation of a new youth service.

If we set aside substance use disorder, the total rate of psychiatric disorder at each life stage varies little,⁹ although patterns of disorder change. Thus, current psychiatry subspecialties have developed to meet the needs of different populations. Children and adolescents are legally and socially dependent on their parents or guardians, so services must be developmentally appropriate and family systems centred. Paediatric psychopathology is heterogeneous, commonly accompanied by other conditions, has heterotypic continuity, and continues into adolescence. Current child and adolescent mental health services manage this by using multimodal interventions to address biological, psychological, and social domains concurrently,¹⁰ in partnership with parents and families. Treatment is developmentally nuanced and is contextually linked with other services for 0-17 year olds (such as education, paediatrics, child protection, and juvenile justice). These arrangements should continue.

Acting on evidence

Child and adolescent mental health services were slow to embrace evidence based practice because there are too few academic child psychiatrists and clinicians individualise interventions to target disorders, risk factors, and contexts. However, the application of evidence based practice in paediatric psychiatry is strengthening.⁵ Innovative evaluation models show that child and adolescent inpatient units reduce mental health problems and improve social functioning.¹¹ Many well designed controlled trials show that prevention is feasible with childhood psychiatric disorders, such as conduct disorder.¹² A Child and Adolescent Psychiatry Trials Network supports large multicentre studies for evaluating effectiveness of treatment for depression, attention deficit hyperactivity disorder, and obsessive compulsive disorder.⁵ Creating a youth specialty risks slowing the rise of evidence based practice, which needs to develop a critical mass.

In Melbourne, a pilot service for 0-25 year olds in 1997 was developed between my hospital’s child and adolescent mental health services and Orygen Youth Health. In this arrangement, 0-14 year olds were seen by the hospital services and Orygen Youth Health saw 15-24 year olds. Sadly, conflict over resource allocation and the most appropriate models of care caused the partnership to break down, but this age division at 15 years remains. In recent years, local community consultation identified problems of access, discontinuity, and lack of integration with other services for adolescents. Although transition at 15 years old works for some adolescents, others are excluded because the youth health service has different entry criteria from the child and adolescent service and uses a different model of care that triages referrals into time limited and disorder related clinics.

Transition problems can be reduced by using a standard age cut-off point, adopting identical entry criteria, and developing compatible models of care,¹³ but the optimal time for transition between services seems to be the age of legal consent—18 years. Earlier transition complicates care. Services for youth or young adults can be improved by stronger partnerships and formal links between child and adult services to build a youth subspecialty within adult services that offers continuing care for vulnerable youth with developmental problems,¹⁴ those with disabling non-psychotic disorders, and youth at high risk who need outreach services. Integrating and strengthening our current system of care, by building primary and secondary mental health care within other sectors, and building collaborations for youth makes more sense than subdividing child and adolescent services.

Cite this as: BMJ 2009;339:b3371

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Competing interests: PB works for a child and adolescent mental health service that will be adversely affected by building youth specific mental health services.

References

1. McGorry PD. The specialist youth mental health model: strengthening the weakest link in the public mental health system. Med J Aust 2007;187(suppl 7):s53-6.[Web of Science][Medline]
2. National Health Advisory Service. Child and adolescent mental health services— together we stand. London: HMSO, 1995.
3. Stroul BA, Friedman RM. A system of care for children and adolescents with severe emotional disturbance. Washington, DC: National Technical Center for Child Mental Health, Georgetown University Child Development Center, 1996.
4. Kelvin RG. Capacity of tier 2/3 CAMHS and service specifications: a model to enable evidence-based service development. Child Adolesc Mental Health 2005;10:63-73.[CrossRef]
5. March JS, Szatmarii P, Bukstein O, Chrisman A, Kondo D, Hamilton JD, et al. AACAP 2005 research forum: speeding the adoption of evidence-based practice in pediatric psychiatry. J Am Acad Child Adolesc Psychiatry 2007;46:1098-110.[CrossRef][Web of Science][Medline]
6. Kessler RC, Aminger GP, Aguilar-Gaxiola S, Alonso J, Lee S. Age of onset of mental disorders: a review of recent literature. Current Opin Psychiatry 2007;20:359-64.[CrossRef]
7. Kim-Cohen J, Caspi A, Moffit TE, Harrington H, Milne BJ, Poulton R. Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective longitudinal cohort. Arch Gen Psychiatry 2003;60:709-17.[Abstract/Free Full Text]
8. Rutter M, Moffit TE, Caspi A. Gene-environment interplay and psychopathology: multiple varieties but real effects. J Child Psychol Psychiatry 2006;47:226-61.[CrossRef][Web of Science][Medline]
9. Lansford JE, Erath S, Yu T, Pettit GS, Dodge KA, Bates JE. The developmental course of illicit substance use from age 12-22: links with depressive anxiety and behaviour disorders at age 18. J Child Psychol Psychiatry 2008;49:877-85.[CrossRef][Web of Science][Medline]
10. American Academy of Child and Adolescent Psychiatry. Practice parameter: child and adolescent mental health care in community systems of care. J Am Acad Child Adolesc Psychiatry 2007;46:184-299.
11. Green J, Jacobs B, Beecham J, Dunn G, Krull L, Tobias C, et al. Inpatient treatment in child and adolescent psychiatry—a prospective study of health gains and costs. J Child Psychol Psychiatry 2007;48:1259-67.[Web of Science][Medline]
12. Conduct Problems Prevention Group. Fast track randomized controlled trial to prevent externalizing psychiatric disorders: findings from grades 3 to 9. J Am Acad Child Adolesc Psychiatry 2007;46:1250-62.[CrossRef][Web of Science][Medline]
13. Vostanis P. Patients as parents and young people approaching adulthood: how should we manage the interface between mental health services for young people and adults? Current Opin Psychiatry 2005;18:449-54.
14. McCarthy S, Asherson P, Coghill D, Hollis C, Murray M, Potts L, et al. Attention-deficit hyperactivity disorder: treatment discontinuation in adolescents and young adults. Br J Psychiatry 2009;194:273-7.[Abstract/Free Full Text]

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