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Although mental health issues are the key health concern for young people, contributing 45% of the total burden of disease for those aged 10-24 years, young people have the poorest access to mental health care. Current service approaches are insufficient, poorly designed and not well supported. Transformational reform of mental health care is needed, based on principles of evidence-informed care, early intervention, and a focus on the developmental period of greatest need and capacity to benefit from investment: emerging adulthood. The most appropriate care models for this period place emphasis on offering care that is appropriate to early stages of illness, pre-emptive in nature, and with a strong preventive focus. This sits best with a clinical staging approach, which distinguishes earlier and milder clinical phenomena from those that accompany illness progression and chronicity. This provides a clinically useful framework that is sensitive to risk/benefit considerations and facilitates the selection of earlier, safer interventions, and favours a preventive or pre-emptive treatment approach. In this chapter, rapidly emerging examples of modern, stigma-free cultures of care designed and operated with young people themselves are described. This includes headspace and technologically enhanced service delivery models. Future directions for youth services are also described.
For over a decade a transdiagnostic clinical staging framework for youth with anxiety, mood and psychotic disorders (linked with measurement of multidimensional outcomes), has been utilised in over 8,000 young people presenting to the enhanced primary (headspace) and secondary care clinics of the Brain and Mind Centre of the University of Sydney. This framework has been evaluated alongside a broad range of other clinical, neurobiological, neuropsychological, brain imaging, circadian, metabolic, longitudinal cohort and controlled intervention studies. This has led to specific tests of its concurrent, discriminant and predictive validity. These extensive data provide strong preliminary evidence that: i) varying stages of illness are associated with predicted differences in a range of independent and objectively measured neuropsychological and other biomarkers (both cross-sectionally and longitudinally); and, ii) that earlier stages of illness progress at variable rates to later and more severe or persistent disorders. Importantly, approximately 15-20% of those young people classed as stage 1b or ‘attenuated’ syndromes at presentation progress to more severe or persistent disorders. Consequently, this cohort should be the focus of active secondary prevention trials. In clinical practice, we are moving to combine the staging framework with likely pathophysiological paths (e.g. neurodevelopmental-psychotic, anxiety-depression, circadian-bipolar) to underpin enhanced treatment selection.
Transition from at-risk state to full syndromal mental disorders is
underexplored for unipolar and bipolar disorders compared with
Prospective, trans-diagnostic study of rates and predictors of early
transition from sub-threshold to full syndromal mental disorder.
One-year outcome of 243 consenting youth aged 15–25 years with a
sub-syndromal presentation of a potentially severe mental disorder.
Survival analysis and odds ratio (OR) for predictors of transition
identified from baseline clinical and demographic ratings.
About 17% (n=36) experienced transition to a major
mental disorder. Independent of syndromal diagnosis, transition was
significantly more likely in individuals who were NEET (not in education,
employment or training), in females and in those with more negative
psychological symptoms (e.g. social withdrawal).
NEET status and negative symptoms are modifiable predictors of illness
trajectory across diagnostic categories and are not specific to
transition to psychosis.