Published 26 August 2009, doi:10.1136/bmj.b3373
Cite this as: BMJ 2009;339:b3373

Head to Head

Should youth mental health become a specialty in its own right? Yes

¹ Orygen Youth Health Research Centre, University of Melbourne, Melbourne, Australia

Mental illness often develops in adolescence or young adulthood. Patrick McGorry believes the best way to ensure early treatment is to have dedicated services, but Peter Birleson (doi:10.1136/bmj.b3371) argues that integration with existing systems is more important

Even in developed countries, access to and quality of mental health care lags way behind that for mainstream health care.¹ This gap is widest for young people, who have to deal with the full force of emerging mental and substance use disorders as they struggle to make the increasingly complex transition from childhood to independent adulthood. As we strive to scale up mental health services worldwide,² there is no better place to invest.³

Mental illnesses are the chronic diseases of young people.⁴ Seventy five per cent of mental disorders emerge for the first time before the age of 25.⁵ There is a dramatic surge in incidence beginning after puberty, peaking in the early 20s.⁵ It is a curious paradox that better physical health in young people has been accompanied by steadily worsening mental health.^{6 7 8} A youth mental health system could reduce the long term financial and human costs associated with illnesses that disable and shorten the lives of so many young people.

Specific needs

Expertise in development is essential for working with children, young people, and their families, yet our workforce is not well equipped. Sweeping demographic changes over the past half century have fundamentally altered the nature of development for young people, posing more complex challenges and developmental tasks.⁹ In developed countries at least, a period of emerging adulthood can now be distinguished from both childhood and truly independent adulthood.^{9 10} Mental disorders, even of moderate severity, can delay or derail career plans and affect relationships with family and peers, which are vital for support during this transition.¹¹ Emerging adulthood has evolved its own culture and requires treatment models that differ substantially from those suitable for children and older adults. Similar challenges face other agencies, such as drug and alcohol, forensic, housing, and vocational services.¹²

As with paediatrics, child psychiatry has focused on younger children, with attention declining from mid-adolescence.^{13 14} This means that the surge of new morbidity between the ages of 15 and 25 is paired with the worst access to services^{1 14}; the system is weakest where it needs to be strongest.¹⁵ Child psychiatry’s attempts to give better services to adolescents have been unsuccessful.^{12 13} On the other side of the divide, adult services fail to engage or provide access to most young people who experience even severe mental disorders.¹³ Despite sharply rising incidence and prevalence, there is a precipitous decline in access in late adolescence.¹⁴ Consequently many of those with the greatest need typically fall between the child and adult services or feel like they do not belong.^{14 16} Access to and engagement in standard primary care is equally problematic for young people.¹⁷

Tailored service

We should aim for a solution that strengthens rather than weakens the already fragile field of psychiatry. Investing in the existing paediatric/adult model will fail to do this. The age of 18 is a poor boundary for service transition.^{13 14 15} Epidemiological evidence, developmental perspectives, safety, cost effectiveness, and, not least, the preferences of young people¹⁶ and their families should guide the selection of transition zones in mental health care, rather than second order legal or educational traditions. A stronger and more distinct stream of care for young people, perhaps similar in concept to what has emerged as geriatric psychiatry, would be one of the best ways to spend the mental health budget since it would help to ensure that more people get early intervention.³ Treating in the early stages of any disorder is the most effective and cost effective strategy to avert long term disease burden, and evidence is emerging that this is also true in psychiatry.¹⁸

Creation of a youth mental health service could strengthen and extend our existing models of care. The Orygen Youth Health service for 15-25 year olds in Melbourne has achieved excellent outcomes over 13 years. Recent policy and reform initiatives in Australia have strongly endorsed substreams for 0-12 and 12-25 year olds with flexible transition zones,¹⁹ and a similar approach is being explored in Ireland²⁰ and Canada.²¹ The creation of a stronger subspecialty and model of youth mental health could potentially assure the future of both child and youth psychiatry. Child and adolescent psychiatry has struggled to gain appropriate resources, but extending the subspecialty to include the age group with peak incidence could help ensure funding and make it much more viable worldwide. For sustainable progress, youth mental health must be based on the growing evidence and include staff with distinct clinical skills, youth participation, integration of drug and alcohol and vocational expertise, and early intervention. Such reform has started in Australia (www.headspace.org.au, www.oyh.org.au) and in Ireland (www.headstrong.ie) with new nationwide services for 12-25 year olds. Elsewhere, early intervention services for psychosis,²² existing child and adolescent services, and transition age youth services²³ can help to form the foundations. Alliances rather than turf wars will be essential to meet this global public health challenge.

Cite this as: BMJ 2009;339:b3373

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Competing interests: PMcG is director of headspace, the National Youth Mental Health Foundation, funded by the Australian federal government, and also of Headstrong: the National Youth Mental Health Foundation of Ireland. He has not received fees for either of these roles, but Orygen Youth Health Research Centre has received funding for clinical and educational activities from the Australian government to support headspace and other youth mental health initiatives. PMcG has received funds from Astra Zeneca, Eli Lilly, Pfizer, and Janssen-Cilag to conduct investigator initiated clinical trials in psychotic and mood disorders, and support for the staging of and attendance at conferences and educational activities.

References

1. Australian Bureau of Statistics. National survey of mental health and wellbeing: summary of results. Canberra: Australian Bureau of Statistics, 2008.
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4. Insel TR, Fenton WS. Psychiatric epidemiology: it’s not just about counting anymore. Arch Gen Psychiatry 2005;62:590-2.[Free Full Text]
5. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005;62:593-602.[Abstract/Free Full Text]
6. Rutter M, Smith D, eds. Psychosocial disorders in young people. Chichester: Wiley, 1995.
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8. Eckersley RM. The health and well-being of young Australians: present patterns and future challenges. Int J Adolesc Med Health 2007;19:217-27.[Medline]
9. Arnett JJ. Emerging adulthood. The winding road from the late teens through the twenties. New York: Oxford University Press, 2004.
10. Graham P. The end of adolescence. New York: Oxford University Press, 2004.
11. Masten AS, Burt KB, Roisman GI, Obradovic J, Long JD, Tellegen A. Resources and resilience in the transition to adulthood: continuity and change. Dev Psychopathol 2004;16:1071-94.[CrossRef][Web of Science][Medline]
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14. Pottick KJ, Bilder S, Vander Stoep A,Warner LA, Alvarez MF, et al. US patterns of mental health service utilization for transition-age youth and young adults. J Behav Health Serv Res 2008;35:373-89.[CrossRef][Web of Science][Medline]
15. McGorry PD. The specialist youth mental health model: strengthening the weakest link in the public mental health system. Med J Aust 2007;187(7 suppl):S53-6.[Web of Science][Medline]
16. Tonin V. Young people seeking mental health care. Lancet 2007;369:1239-40.[CrossRef][Web of Science][Medline]
17. Rickwood DJ, Deane FP, Wilson CJ. When and how do young people seek professional help for mental health problems? Med J Aust 2007;187(7 suppl):S35-9.[Web of Science][Medline]
18. Mihalopoulos C, Harris M, Henry L, Harrigan S, McGorry P. Is early intervention for psychosis cost-effective over the long term? Schizophr Bull 2009 9 Jun [Epub ahead of print].
19. Victorian Government Health Information. Because mental health matters: Victorian mental health strategy 2009-2019. , www.health.vic.gov.au/mentalhealth/reformstrategy/thestrategy.htm.
20. Bates T, Illback RJ, Scanlan F, Carroll L. Somewhere to turn to, someone to talk to. Dublin: Headstrong,2009.
21. Kutcher S, Davidson S. Mentally ill youth: meeting service needs. CMAJ 2007;176:417-9.[Free Full Text]
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