Integrated Mental Health Services for the Developmental Period (0 to 25 Years): A Critical Review of the Evidence

Abstract

Background: The developmental period from 0 to 25 years is a vulnerable time during which children and young people experience many psychosocial and neurobiological changes and an increased incidence of mental illness. New clinical services for children and young people aged 0 to 25 years may represent a radical transformation of mental healthcare. Method: Critical, non-systematic review of the PubMed literature up to 3rd January 2019. Results: Rationale: the youngest age group has an increased risk of developing mental disorders and 75% of mental disorders begin by the age of 24 and prodromal features may start even earlier. Most of the risk factors for mental disorders exert their role before the age of 25, profound maturational brain changes occur from mid-childhood through puberty to the mid-20s, and mental disorders that persist in adulthood have poor long-term outcomes. The optimal window of opportunity to improve the outcomes of mental disorders is the prevention or early treatment in individuals aged 0 to 25 within a clinical staging model framework. Unmet needs: children and young people face barriers to primary and secondary care access, delays in receiving appropriate treatments, poor engagement, cracks between child and adult mental health services, poor involvement in the design of mental health services, and lack of evidence-based treatments. Evidence: the most established paradigm for reforming youth mental services focuses on people aged 12-25 who experienced early stages of psychosis. Future advancements may include early stages of depression and bipolar disorders. Broader youth mental health services have been implemented worldwide, but no single example constitutes best practice. These services seem to improve access, symptomatic and functional outcomes, and satisfaction of children and young people aged 12-25. However, there are no robust controlled trials demonstrating their impact. Very limited evidence is available for integrated mental health services that focus on people aged 0-12. Conclusions: Children and young people aged 12-25 need youth-friendly mental health services that are sensitive to their unique stage of clinical, neurobiological, and psychosocial development. Early intervention for psychosis services may represent the starting platform to refine the next generation of integrated youth mental health services.

Keywords: 0 to 25; development; mental health; mental health services; model of care; prevention; youth.

Figure 1

Ranges of onset age for common psychiatric disorders. Data from the National Comorbidity Survey Replication study (13), a nationally representative epidemiological survey of mental disorders. The majority of those with a mental disorder have had the beginnings of the illness in childhood or adolescence. Some anxiety disorders such as phobias and separation anxiety and impulse-control disorders begin in childhood, while other anxiety disorders such as panic, generalized anxiety and post-traumatic stress disorder, substance disorders, and mood disorders begin later, with onsets rarely before early teens. Schizophrenia typically begins in late adolescence or the early 20s [adapted from Ref. (13)].

Figure 2

Putative model of the onset and progression of psychosis in relation to non-purely genetic risk factors and developmental processes affected by the disorder. Sociodemographic and parental risk factors and perinatal risk factors have been implicated during the preclinical phase, usually observed from birth to infancy, childhood, and early adolescence. Additional later factors occurring during later adolescence and early adulthood can trigger the onset of attenuated psychotic symptoms, functional impairment, and help-seeking behavior, which constitute the CHR-P stage. The diagnosis of psychosis, which operationally corresponds to the first episode of psychosis, is usually made during the adolescence or early adulthood, with a peak from 15 to 35 years. Once diagnosed, psychosis usually follows a fluctuating course punctuated by acute exacerbation of psychotic crises superimposed upon a background of poorly controlled negative, neurocognitive, and social cognitive symptoms. The pink boxes represent the risk factors for psychosis (16). FEP, First Episode Psychosis; CHR-P, Clinical High Risk for Psychosis.

Figure 3

Onset and progression of psychosis in relation to the developmental processes affected by the disorder [adapted from Ref. (25)]. During the premorbid and clinical high risk for psychosis neurodevelopmental phases, risk reduction strategies can exert the highest impact for course alteration. During the early fully recover/late incomplete recovery and chronicity phases, rescue and restorative strategies can have the highest impact on course alteration.

Figure 4

Clinical staging of psychotic disorders. Unpublished figure courtesy of Paolo Fusar-Poli. The age bounds indicated are only descriptive. Stage 0 (premorbid) is followed by the clinical high-risk stage 1 for psychosis and then by stage 2 (early fully recover). Stage 3 describes a late/incomplete recovery and stage 4 is the chronic phase of psychotic disorders. Substages 1a–c and 3a–c are also indicated in the figure.

Figure 5

The needs of young people and their families are the main drivers of the Headspace integrated mental health model for children and young adults. Headspace has 10 service components (youth participation, family and friends participation, community awareness, enhanced access, early intervention, appropriate care, evidence informed practice, four core streams, service integration, and supported transitions) and six enabling components (national network, lead agency governance, consortia, multidisciplinary workforce, blended funding, and monitoring and evaluation). Through implementation of these core components, Headspace aims to provide easy access to one-stop, youth-friendly mental health, physical and sexual health, alcohol and other drug, and vocational services for young people across Australia [from Ref. (71)].