Intended for healthcare professionals


Adolescents and young adults who are not in employment, education, or training

BMJ 2013; 347 doi: (Published 18 September 2013) Cite this as: BMJ 2013;347:f5270
  1. Jan Scott, professor of psychiatry1,
  2. David Fowler, professor of clinical psychology2,
  3. Pat McGorry, professor of youth mental health3,
  4. Max Birchwood, research director4,
  5. Eoin Killackey, associate professor3,
  6. Helen Christensen, executive director5,
  7. Nicholas Glozier, professor of psychiatry6,
  8. Alison Yung, professor of psychiatry7,
  9. Paddy Power, consultant in youth mental health8,
  10. Merete Nordentoft, professor of psychiatry9,
  11. Swaran Singh, head of department10,
  12. Elisa Brietzke, professor of psychiatry11,
  13. Simon Davidson, professor of child and adolescent psychiatry12,
  14. Philippe Conus, professor of psychiatry13,
  15. Frank Bellivier, professor of psychiatry14,
  16. Richard Delorme, professor of child and adolescent psychiatry15,
  17. Iain Macmillan, consultant psychiatrist16,
  18. John Buchanan, head of department17,
  19. Francesc Colom, clinical psychologist18,
  20. Eduard Vieta, professor of psychiatry18,
  21. Michael Bauer, head of department19,
  22. Phillip McGuire, head of department20,
  23. Kathleen Merikangas, head of department21,
  24. Ian Hickie, director22
  1. 1Department of Academic Psychiatry, Wolfson Unit, Institute of Neuroscience, Newcastle University, Newcastle NE4 6BE, UK
  2. 2Psychology Department, Sussex University, Brighton, UK
  3. 3Orygen Youth Mental Health Research Centre, University of Melbourne, Melbourne, Australia
  4. 4YouthSpace, University of Warwick, Warwick, UK
  5. 5Black Dog Institute, University of New South Wales, Sydney, Australia
  6. 6Brain and Mind Research Institute, University of Sydney, Sydney, Australia
  7. 7Institute of Brain, Behaviour, and Mental Health, University of Manchester, Manchester, UK
  8. 8Young Adult Service, St Patrick’s Mental Health Services, Dublin, Ireland
  9. 9OPUS Early Intervention Services, University of Copenhagen, Copenhagen, Denmark
  10. 10Department of Mental Health and Wellbeing, University of Warwick, Warwick, UK
  11. 11PRISMA Early Intervention Services, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
  12. 12Ontario Centre of Excellence for Child and Youth Mental Health, Ottawa, Canada
  13. 13Department of Psychiatry CHUV, Lausanne University, Switzerland
  14. 14Department of Adult Psychiatry and Addictions, University Denis Diderot, Paris, France
  15. 15Department of Child and Adolescent Psychiatry, Robert Debre University Hospital, Paris, France
  16. 16Early Intervention in Psychosis Service, NTW NHS Trust, Sunderland, UK
  17. 17Workplace Research Centre, Business School, University of Sydney, Australia
  18. 18Institute of Neurosciences, IDIBAPS-CIBERSAM, University of Barcelona, Barcelona, Spain
  19. 19Department of Psychiatry and Psychotherapy, Technische Universitat Dresden, Dresden, Germany
  20. 20Section for Psychosis Studies, Institute of Psychiatry, London, UK
  21. 21Genetic Epidemiology Research Branch, National Institute of Mental Health, USA
  22. 22Brain and Mind Research Institute, University of Sydney, Australia
  1. jan.scott{at}

Their problems are more than economic

The term NEET (not in employment, education, or training) refers to economically inactive adolescents and young adults.1 2 During economic crises, youth unemployment rises faster and recovers more slowly than general unemployment.1 In 2012, there were 7.5 million 15-24 year old (13% of the age group) and 6.5 million 25-29 year old (20%) economically inactive young people in the European Union. Together, they cost €153bn (£131bn; $204bn) in welfare benefits and lost productivity—1.2% of EU gross domestic product.2 International publications confirm global rates of 10-20% youth unemployment and highlight that the optimal solution is to increase retention in education and training.1 2 3 4 5

Prolonged economic inactivity has profound effects on mental health: the risks of depression (odds ratio 2.7), alcohol or substance misuse (3.4), and suicidal attempts (3.6) are significantly increased in economically inactive young people versus their economically active peers.3 However, action plans fail to recognise subgroups within the economically inactive population who are functionally impaired because of evolving or pre-existing mental disorders. During economic downturns, these people are especially disadvantaged and risk lifelong social exclusion and economic marginalisation unless their ill health is recognised early and their needs targeted more directly.4 5

Preventing or limiting economic inactivity alone could reduce rates of common mental disorders by 8-17%,6 but it would not completely solve the problem of the threefold greater risk of severe mental disorders in this group.3 The explanation for this is complex, but it is noteworthy that the peak age of onset of a first manic severe depressive or psychotic episode is 15-25 years. The early phases of these disorders are characterised by impaired academic performance, change in social behaviours, and increasing absences from school or work.7 8 9 Because functional decline often precedes the appearance of overt clinical symptoms, many young people may become economically inactive before their illness is recognised.4

To date, no policy document shows adequate awareness of this common illness trajectory. Consequently, there are few specific recommendations regarding screening or monitoring within the economically inactive population for these emerging problems, or “best practice” models for support and treatment. This is inexcusable, because once disengaged from the “system” it is usually one to four years before these young people access mental health services.4 7 8 9 By then the critical period for modifying the course of severe mental disorders has passed and prospects for meaningful occupational or social rehabilitation are greatly reduced.4 7 8 9

What’s to be done? The crucial first step is to raise awareness of the overlap between functional decline, mental disorders, and risk of economically inactive status (and the adverse effects of such a status). Next, policies need to promote systematic multilevel approaches that value both mental health and social assessments and offer guidance on the most relevant employment programmes and age appropriate health services. Coordination between social, vocational, and treatment programmes is essential. Currently, this is hampered by the “siloing” of support and care services for young people.

Early identification of underlying mental disorders is important,7 8 9 and is a policy objective in the United Kingdom and elsewhere. Youth friendly health service models—such as “headspace” in Australia, “headstrong” in Ireland, and “youthspace” in the UK—increase levels of engagement in economically inactive young people who present with common mental health problems.7 8 These operate at the primary-secondary care interface and encourage self referral and referral through schools, primary care, social services, and other agencies. The services prioritise vocational and clinical recovery, using targeted age appropriate interventions, functional remediation, and coordinated support for high risk groups during the transition from school to further education or work.7 8 These can be augmented by new e-health programmes, including those focused on self management and vocational matters, as well as peer support.

Young people with severe mental disorders are less likely than any other disability group to be included in, or to benefit from, mainstream government employment programmes.9 10 11 12 However, traditional health and social services pay insufficient attention to overcoming the “double whammy” of economic inactivity and severe mental disorder. For example, only 15% of people with a first episode of psychosis managed by community mental health teams achieve “vocational recovery,” compared with 52% of those managed by early intervention in psychosis services, which adopt a broader model and engage more effectively with young people.4 7 8 Before they are ready or able to take up offers of work and education programmes, economically inactive young people with complex problems require individualised interventions, such as cognitive behavioural models, which can help them deal with symptoms, distress, hopelessness, social withdrawal, and age related developmental problems.4

We would also advocate the wider dissemination of individual placement and support for these young people. Many studies internationally show that this programme is clinically effective,9 10 11 12 13 that this more individualised approach offers faster transition to employment and education (the “place and train” approach), and is acceptable to young adults.9 10 11 Evidence indicates that this approach achieves significantly better educational and employment outcomes than traditional rehabilitation (69% placed in education or employment v 35%),9 without increasing symptoms or relapses, and that the programme is cost neutral if a third of people who are offered it enter the workforce.9 10 11 12 13

Given the association between austerity and illness,14 it is not surprising that one of the most vulnerable economic groups (15-25 year olds) have serious health problems. However, mental rather than physical disorders are the chronic illnesses of young adults,15 and approaches for economically inactive young people need to acknowledge this. Although a robust evidence base for the ideal service is lacking, we believe that the rationale for service reform is evident and that several initiatives are promising. Investment is needed to clarify who will benefit most from which intervention and how to target those economically inactive young people with the greatest mental health needs. We suggest that just maintaining the status quo—providing more of what does not work, with a lack of coordinated action—makes no sense clinically, socially, or economically.


Cite this as: BMJ 2013;237:f5270


  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: All authors are active in research or clinical work (or both) relating to people with psychological problems or severe mental disorders, many of whom are unemployed. The authors have wide ranging opinions on the matters discussed, but we focus on the evidence regarding any changes to current policies that could be helpful, and the editorial does not represent any particular political or commercial group. Several authors (for example, KM, MBi, RD, FB, PM, AY, SD, IM, JB) had no other disclosures, their completed ICMJE forms and those of all other authors are available from JS (the first author) on request. In additional we highlight that most authors have current grants from national or international research bodies that are directly related to the themes of this editorial (for example, social or vocational recovery grants: DF, EK; early identification of severe mental disorders: PM, MN, JS, IH, NG, SS, MBa; cognitive rehabilitation or psychological therapies: FC, EV, HC) and some have past grants on these issues (for example, PC, PP, EB). Some universities have received unrestricted educational grant funding from drug companies for work that may link to early onset/early interventions after submissions by authors (for example, EV, MBa, PM, IH). Some authors have received funds to support attendance at international academic conferences, or have received personal payments from drug companies for “speaker bureau” talks or for attending advisory boards. However, none of these engagements or activities are associated with the topics covered in this editorial.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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