Future Directions for Early Childhood Prevention of Mental Disorders: A Road Map to Mental Health,Earlier

Mental disorders are the predominant chronic diseases of youth, with substantial life span morbidity and mortality. A wealth of evidence demonstrates that the neurodevelopmental roots of common mental health problems are present in early childhood. Unfortunately, this has not been translated to systematic strategies for improving population-level mental health at this most malleable neurodevelopmental period. We lay out a translational Mental Health, Earlier road map as a key future direction for prevention of mental disorder. This paradigm shift aims to reduce population attributable risk of mental disorder emanating from early life, by preventing, attenuating, or delaying onset/course of chronic psychopathology via the promotion of self-regulation in early childhood within large-scale health care delivery systems. The Earlier Pillar rests on a “science of when to worry” that (a) optimizes clinical assessment methods for characterizing probabilistic clinical risk beginning in infancy via deliberate incorporation of neurodevelopmental heterogeneity, and (b) universal primary-care-based screening targeting patterns of dysregulated irritability as a robust transdiagnostic marker of vulnerability to life span mental health problems. The core of the Healthier Pillar is provision of low-intensity selective intervention promoting self-regulation for young children with developmentally atypical patterns of irritability within an implementation science framework in pediatric primary care to ensure highest population impact and sustainability. These Mental Health, Earlier strategies hold much promise for transforming clinical outlooks and ensuring young children’s mental health and well-being in a manner that reverberates throughout the life span.     

Comorbidity: Coexisting substance use and mental disorders in young people

Young people with comorbid disorders (coexisting mental health and substance use disorders) present with particular issues that can be difficult for service providers, and for the community as a whole, to respond to. They tend to fall between the cracks of mental health services and substance use services, with the outcome often being ineffective treatment, or no treatment at all, for the young people concerned, and increasing conflict, ideological clashes and blame between agencies. There is urgent need for better communication and development of protocols between mental health services and substance use services for young people; both need to recognise and respect their differing expertise, develop coordinated treatment plans and convey this information to the wider helping services sector. Cross-training is necessary for professionals in the mental health and substance use fields.     

Treatment with youth who have committed sexual offences: Extending the reach of systemic interventions through collaborative partnerships

Delivery of high‐quality mental health services to clients in regional and remote areas in Australia presents significant challenges. Griffith Youth Forensic Service (GYFS) provides specialised, state‐wide assessment and systemic treatment services for young people in Queensland who have committed sexual offences. In an effort to provide equitable, ecologically valid services, GYFS clinicians recruit local para/professionals as collaborative partners in interventions. The success of GYFS interventions relies partly on the skills, knowledge and confidence of collaborative partners to work effectively. This study examines (a) the effectiveness of collaborative partnerships in enhancing knowledge, skills and confidence, and (b) the perspectives of collaborative partners regarding the collaborative model. Participant self‐reports (n = 47 collaborative partners) indicated that skills, knowledge and confidence were significantly increased over the collaboration, were maintained for 1 year, and that increased knowledge, skills and confidence were associated with perceived improvements in client outcomes.     

How can health services effectively meet the health needs of homeless people?

BACKGROUND: Homelessness affects many people in contemporary society with consequences for individuals and the wider community. Homeless people experience poorer levels of general physical and mental health than the general population and there is a substantial international evidence base which documents multiple morbidity. Despite this, they often have problems in obtaining suitable health care. AIM: To critically examine the international literature pertaining to the health care of homeless people and discuss the effectiveness of treatment interventions. DESIGN OF STUDY: Review and synthesis of current evidence. METHOD: Medline (1966-2003), EMBASE (1980-2003), PsycINFO (1985-2003), CINAHL (1982-2003), Web of Science (1981-2003) and the Cochrane Library (Evidence Based Health) databases were reviewed using key terms relating to homelessness, intervention studies, drug misuse, alcohol misuse and mental health. The review was not limited to publications in English. It included searching the internet using key terms, and grey literature was also accessed through discussion with experts. RESULTS: Internationally, there are differing models and services aimed at providing health care for homeless people. Effective interventions for drug dependence include adequate oral opiate maintenance therapy, hepatitis A, B and tetanus immunisation, safer injecting advice and access to needle exchange programmes. There is emerging evidence for the effectiveness of supervised injecting rooms for homeless injecting drug users and for the peer distribution of take home naloxone in reducing drug-related deaths. There is some evidence that assertive outreach programmes for those with mental ill health, supportive programmes to aid those with motivation to address alcohol dependence and informal programmes to promote sexual health can lead to lasting health gain. CONCLUSIONS: As multiple morbidity is common among homeless people, accessible and available primary health care is a pre-requisite for effective health interventions. This requires addressing barriers to provision and multi-agency working so that homeless people can access the full range of health and social care services. There are examples of best practice in the treatment and retention of homeless people in health and social care and such models can inform future provision.     

The impact of co-occurring mood and anxiety disorders among substance-abusing youth

BACKGROUND: Co-occurring mood and anxiety disorders are highly prevalent amongst substance-using young adolescents, and have been associated with a range of adverse outcomes. Few studies however have examined the impact of affective disorders in samples of older adolescents and young adults attending youth drug treatment services. METHODS: One hundred young people (mean age 19.4 years) were recruited from two youth drug treatment services in Melbourne, Australia. A structured interview and questionnaires assessing drug use, psychopathology, risk-taking behaviours and quality of life were administered at a mutually convenient location. RESULTS: Fifty percent of the sample met criteria for at least one current mental health disorder. Excluding individuals with a current psychotic illness (n=3), 49% met criteria for a current mood or anxiety disorder, with 68% reporting a lifetime history. There were high rates of current Major Depressive Disorder (MDD; 27%) and Post-traumatic Stress Disorder (PTSD; 26%) within the sample. Participants with these disorders were more likely to have a higher number of comorbid disorders, report more substance-related problems and a poorer quality of life. LIMITATIONS: Cross-sectional design, lack of biological assays. CONCLUSIONS: In older adolescence and emerging adulthood, young drug users with comorbid affective disorders have greater mental health and substance use morbidity than those with substance use problems alone. These findings have important clinical implications for the management and rehabilitation of young people with substance use disorders.     

Digital mental health outcome monitoring for a structured text-based youth counselling intervention: Demographic profile and outcome change

Background

Digital mental health interventions comprise a potentially effective and accessible form of support for young people, particularly at times when traditional face-to-face service delivery is reduced, as in the COVID-19 pandemic.

Aims

This study assessed the demographic profile of young people using a digital mental health support service and evaluated outcome change over the course of a structured online counselling intervention (synchronous text-chat sessions with a practitioner).

Materials and Methods

The data were collected from 23,260 young people aged between 10 and 25 years engaging with the intervention between April 2019 and June 2021.

Results

Young people accessing these services had high levels of mental health needs, particularly those identifying with non-binary gender identity. Service users were mostly female, with equitable rates of access for young people from racialised communities. Overall outcome change demonstrated small effect sizes according to the YP-CORE (0.19) and CORE-10 (0.38), which increased to a moderate level when young people remained engaged with a dedicated practitioner for at least seven sessions (0.38, 0.58). Regression analysis illustrated the effect of the number of sessions on outcome change, but this can be also influenced by other variables such as age and gender.

Discussion and Conclusion

Further research is required to explore ways to engage with young people using digital web-based services for a longer period and to collect and analyse single-session outcome data.     

Adverse experiences,mental health,and substance use disorders as social determinants of incarceration

This study describes how incarcerated people understand: (a) Adverse experiences, mental health, and substance use disorders as determinants of incarceration, (b) the role of gender in impacting this understanding, and (c) strategies to prevent incarceration. Ecosocial theory provides a theoretical framework. Open-ended interviews were conducted (December 2016–January 2017) with recently incarcerated adults in Massachusetts state prisons. Participants described determinants of incarceration and incarceration prevention strategies. Interviews were coded thematically using inductive and deductive approaches. Thirty participants, evenly split by gender, reported themes across four levels: Society (lacking basic needs, discrimination), community (neighborhood factors), interpersonal (trauma), and individual (social isolation, mental health, substance use). However, there were variations in themes by gender. Proposed prevention strategies included early access to quality individualized cross-system services. In conclusion, findings highlight how investing in social and community building services could prevent incarceration. Policies can support these services by redirecting funding.     

Reducing the burden of affective disorders: is evidence-based health care affordable?

BACKGROUND: Affective disorders remain the leading cause of disability burden despite the availability of efficacious treatment. A wider dissemination of evidence-based health care is likely to impact this burden, however the affordability of such a strategy at the population level is unknown. This study calculated the cost-effectiveness of evidence-based health care for depression, dysthymia and bipolar disorder in the Australian population, and determined whether it was affordable, based on current mental health-related expenditure and outcomes for these disorders. METHODS: Cost-effectiveness was expressed in costs per years lived with disability (YLDs) averted, a population health summary measure of disability burden. Data from the Australian National Survey of Mental Health and Wellbeing, in conjunction with published randomized trials and direct cost estimates, were used to estimate the 1-year costs and YLDs averted by current health care services, and costs and outcomes for an optimal strategy of evidence-based health care. RESULTS: Current direct mental health-related health care costs for affective disorders in Australia were 615 million dollars (1997-98 Australian dollars). This treatment averted just under 30,000 YLDs giving a cost-effectiveness ratio of 20,633 dollars per YLD. Outcome could be increased by nearly 50% at similar cost with implementation of an evidence-based package of optimal treatment, halving the cost-effectiveness ratio to 10,737 dollars per YLD. LIMITATIONS: The method to estimate YLDs averted from the literature requires replication. The costs of implementing evidence-based health care have not been estimated. CONCLUSIONS: Evidence-based health care for affective disorders should be encouraged on both efficacy and efficiency grounds.     

One-month prevalence of depression and other DSM-IV disorders among young adults.

BACKGROUND: We aimed to provide prevalence data on depression and other current mental disorders, impairment, need of psychiatric care and use of mental health services among young adults. METHODS: Based on a semi-structured clinical interview, current DSM-IV disorders, impairment, need of psychiatric care and use of mental health services were evaluated in a sample of 20-24-year-old young urban adults (N = 245), mean age 21.8, screened from a baseline population of 706. One-month prevalence estimates for disorders were calculated by the double sampling method, using various additional criteria to identify cases. RESULTS: One in four young adults (23.8%) suffered from a current mental disorder, the most prevalent being depressive (10.8%), anxiety (6.9%), substance use (6.2%) and personality disorders (6.0%). Prevalence estimates varied substantially according to the use of additional diagnostic criteria. Impairment (GAF < 61) together with DSM-IV symptom criteria produced an overall disorder prevalence of 10.3%, and 5.5% for depression. Prevalences were higher for females than males, except for alcohol abuse and personality disorders. Current co-morbidity was found in 39% of subjects with any disorder, and in more than half of those with depression. One-third of subjects with a current disorder reported an associated contact with psychiatric services and 16% had an ongoing contact. CONCLUSIONS: Our findings support the use of additional criteria to produce clinically relevant prevalence data. Co-morbidity should receive special attention due to its amplification of both need for psychiatric care and severity of impairment. Finally, our results show disturbed young adults to be severely undertreated.     

A randomised controlled trial to test the feasibility of a collaborative care model for the management of depression in older people

BACKGROUND: Depression is the most common mental health disorder in people aged over 65 years. Late-life depression is associated with chronic illness and disability. AIM: To investigate the feasibility of a collaborative care model for depression in older people in a primary care setting. DESIGN OF STUDY: Randomised controlled trial with 16-weeks follow up. SETTING: A primary care trust in Manchester. METHOD: Participants were 105 people aged 60 years or older who scored 5 or more on the Geriatric Depression Scale; 53 were randomly allocated to an intervention group and 52 to a usual care group. The intervention group received care managed by a community psychiatric nurse who delivered an intervention comprising a facilitated self-help programme with close liaison with primary care professionals and old-age psychiatry according to a defined protocol. The usual care group received usual GP care. A nested qualitative study explored the views of the health professionals and patients regarding the acceptability and effectiveness of the intervention. RESULTS: The main outcome measure was recovery from depression. Patients in the intervention group were less likely to suffer from major depressive disorder at follow up compared with usual care (0.32, 95% confidence = interval = 0.11 to 0.93, P = 0.036). The qualitative component of the study demonstrated the acceptability of the intervention to patients. CONCLUSION: A model of collaborative care for older people with depression, used in a primary care setting with a facilitated self-help intervention is more effective than usual GP care. This study demonstrates that the implementation of a collaborative care model is feasible in UK primary care and that the intervention is effective and acceptable to patients.     

Adapting and testing telephone-based depression care management intervention for adolescent mothers

This phase 1 clinical trial combined qualitative and quantitative methods to modify a collaborative care, telephone-based, depression care management intervention for adolescent mothers and to determine the acceptability, feasibility, and initial efficacy of the intervention in a sample of adolescent mothers (n = 97) who were recruited from a Teen Parent Program. Outcomes included measures of depressive symptoms, functioning, and use of mental health services. Acceptability of the intervention was demonstrated, but feasibility issues related to the complex life challenges confronting the adolescent mother. Although only four adolescent mothers received mental health treatment, there was a trend for improved depressive symptoms over time. Results of the study provide data for the need of further refinement of the intervention before a large clinical trial is conducted for adolescent mothers with symptoms of depression.     

Do Online Mental Health Services Improve Help-Seeking for Young People? A Systematic Review

Background

Young people regularly use online services to seek help and look for information about mental health problems. Yet little is known about the effects that online services have on mental health and whether these services facilitate help-seeking in young people.

Objective

This systematic review investigates the effectiveness of online services in facilitating mental health help-seeking in young people.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, literature searches were conducted in PubMed, PsycINFO, and the Cochrane library. Out of 608 publications identified, 18 studies fulfilled the inclusion criteria of investigating online mental health services and help-seeking in young people aged 14-25 years.

Results

Two qualitative, 12 cross-sectional, one quasi-experimental, and three randomized controlled trials (RCTs) were reviewed. There was no change in help-seeking behavior found in the RCTs, while the quasi-experimental study found a slight but significant increase in help-seeking. The cross-sectional studies reported that online services facilitated seeking help from a professional source for an average of 35% of users. The majority of the studies included small sample sizes and a high proportion of young women. Help-seeking was often a secondary outcome, with only 22% (4/18) of studies using adequate measures of help-seeking. The majority of studies identified in this review were of low quality and likely to be biased. Across all studies, young people regularly used and were generally satisfied with online mental health resources. Facilitators and barriers to help-seeking were also identified.

Conclusions

Few studies examine the effects of online services on mental health help-seeking. Further research is needed to determine whether online mental health services effectively facilitate help-seeking for young people.     

Modelling the population cost-effectiveness of current and evidence-based optimal treatment for anxiety disorders

BACKGROUND: The present paper describes a component of a large population cost-effectiveness study that aimed to identify the averted burden and economic efficiency of current and optimal treatment for the major mental disorders. This paper reports on the findings for the anxiety disorders (panic disorder/agoraphobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder and obsessive compulsive disorder). METHOD: Outcome was calculated as averted 'years lived with disability' (YLD), a population summary measure of disability burden. Costs were the direct health care costs in 1997-8 Australian dollars. The cost per YLD averted (efficiency) was calculated for those already in contact with the health system for a mental health problem (current care) and for a hypothetical optimal care package of evidence-based treatment for this same group. Data sources included the Australian National Survey of Mental Health and Well-being and published treatment effects and unit costs. RESULTS: Current coverage was around 40% for most disorders with the exception of social phobia at 21%. Receipt of interventions consistent with evidence-based care ranged from 32% of those in contact with services for social phobia to 64% for post-traumatic stress disorder. The cost of this care was estimated at dollar 400 million, resulting in a cost per YLD averted ranging from dollar 7761 for generalized anxiety disorder to dollar 34 389 for panic/agoraphobia. Under optimal care, costs remained similar but health gains were increased substantially, reducing the cost per YLD to < dollar 20 000 for all disorders. CONCLUSIONS: Evidence-based care for anxiety disorders would produce greater population health gain at a similar cost to that of current care, resulting in a substantial increase in the cost-effectiveness of treatment.     

Can gender differences in the prevalence of mental disorders be explained by sociodemographic factors?

Summary Background and aims: Epidemiological studies throughout the world consistently reported higher rates of depression and anxiety disorders in women, whereas men consistently show higher rates of substance and antisocial disorders. The present study examined factors potentially contributing to these gender differences using general population data.Methods: The sample was drawn from population registries (N=4181) and can be regarded as representative for the adult German population aged 18–65. Mental disorders (DSM-IV) were assessed with a diagnostic interview (CIDI) carried out by clinically trained interviewers. A range of sociodemographic variables was analysed within men, within women, and between genders.Results: The prevalence of common mental disorders (mood, anxiety, substance use and somatoform disorders) is higher among females, with the exception of substance use disorders. Young age was related to substance disorders both in women and in men. Not being married and being unemployed were associated with increased rates of mental disorders in both sexes, but in men stronger than in women. Being retired was associated with depression only in women, whereas belonging to a higher social class, working fulltime and having children appeared to be protective factors for men only. Other sociodemographic factors (concerning education, employment and family status) were not associated with increased rates of mental disorders both in women and men.Conclusion: Overall the emotional advantages or disadvantages of marital status, employment status, number of children, parenthood and social class apply equally to men and women. We cannot explain the female preponderance in most mental disorders by detecting specific unfavourable patterns of sociodemographic correlates, suggesting that determinants of gender differences in common mental disorders are still far from being understood.     

What depressive symptoms are associated with the use of care services? Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

Background: Depression is generally regarded as a serious, incapacitating illness. Although effective treatment strategies are available, timely recognition remains a stumbling block. We investigated the rates of health service uptake among depressed people and the specific depressive symptoms associated with service use, after adjustment for other illness characteristics and sociodemographic variables. Methods: In a representative sample (n=7076) of the Dutch adult population, we identified 1572 subjects with lifetime major or minor depression, using the Composite International Diagnostic Interview. Results: The majority (73%) of subjects with depression had sought specialised mental health care, or to a lesser extent primary care. As expected, those with more severe (vegetative), complex (anxiety-comorbid) or dangerous symptoms (suicidal ideation) were more likely to be treated in the specialised mental health sector. However, subjects with comorbid substance use dependence were less likely to receive care, especially primary care, and those with more education were more likely to receive specialised care, even after adjustment for illness characteristics. Limitations: The use of lifetime measures of depression and service use may have introduced slight recall bias, but it made the assessments less vulnerable to selection bias for chronic cases and to misclassification of subjects with some lifetime treatment experience. Conclusions: Although care for people with depression is readily accessible in the Netherlands, people with less education and people with comorbid substance use dependence remain unnecessarily out of reach of the care services. Primary care services need to be strengthened to enable the broad-scale application of stepped-care strategies.     

Outpatient mental health care, self-help groups, and patients' one-year treatment outcomes

OBJECTIVE: To examine the association between the duration and amount of outpatient mental health care, participation in self-help groups, and patients' casemix-adjusted one-year outcomes. METHODS: A total of 2,376 patients with substance use disorders, 35% of whom also had psychiatric disorders, were assessed at entry to treatment and at a one-year follow-up. Information about the duration and amount of outpatient mental health care was obtained from a centralized health services utilization database. RESULTS: Patients who obtained regular outpatient mental health care over a longer interval and patients who attended more self-help group meetings had better one-year substance use and social functioning outcomes than did patients who were less involved in formal and informal care. The amount of outpatient mental health care did not independently predict one-year outcomes. CONCLUSIONS: The duration of outpatient mental health care and the level of self-help involvement are independently associated with less substance use and more positive social functioning. The provision of low intensity treatment for a longer time interval may be a cost-effective way to enhance substance abuse and psychiatric patients' long-term outcomes.     

Psychotherapy alone versus collaborative psychotherapy and psychiatric care in the treatment of depression and anxiety in patients with cancer: A naturalistic,observational study

Objective

At present, there is a paucity of naturalistic studies directly comparing the effectiveness of psychotherapy alone versus collaborative psychotherapy and psychiatric care in the management of depression and anxiety in patients with cancer. This study tested the hypothesis that collaborative psychiatric and psychological care would lead to greater reductions in depression and anxiety symptoms in patients with cancer compared with psychotherapy alone.

Methods

We analyzed treatment outcomes of 433 adult patients with cancer, of which 252 patients received psychotherapy alone and 181 patients received collaborative psychotherapy and psychiatric care. Longitudinal changes in depressive (i.e., PHQ-9) and anxiety symptoms (GAD-7) were examined between groups using latent growth curve modeling.

Results

After controlling for treatment length and psychotherapy provider effects, results indicated collaborative care was more effective than psychotherapy alone for depressive symptoms (γ₁₂ = −0.13, p = 0.037). The simple slope for collaborative care was −0.25 (p = 0.022) and the simple slope for psychotherapy alone was −0.13 (p = 0.006), suggesting collaborative care resulted in greater reductions in depressive symptoms compared with psychotherapy alone. In contrast, there were no significant differences between psychotherapy alone and collaborative psychotherapy and psychiatric care in reducing anxiety symptoms (γ₁₂ = −0.08, p = 0.158).

Conclusions

Collaborative psychotherapy and psychiatric care may individually address unique aspects of mental health conditions in patients with cancer, namely depressive symptoms. Mental healthcare efforts may benefit from implementing collaborative care models where patients receive psychiatric services and psychotherapy to effectively address depressive symptoms in the treatment of this patient population.     

Meeting the Mental Health Needs of Older Adults in Primary Care: How Do We Get the Job Done?

Most elderly persons in the United States with mental health problems such as depression receive no attention or care. Those who receive treatment generally do so in primary care settings, where disorders like depression have a hard time competing with other common and chronic medical problems. Typically, mental illnesses are under-recognized and under-treated in elderly persons attending primary care clinics. The experience of the PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) study is briefly described, indicating that depression, for example, can be treated successfully in primary care elderly using the type of multidisciplinary collaborative care model advocated by Speer and Schneider (2003 ; this issue). The challenge now facing all of us is to create a consumer- and family-driven demand for good mental health services in geriatric clinics and a political consensus to reimburse such services fairly. Recent improvement in Medicare reimbursement for mental health services to victims of Alzheimer's dementia provides a basis for hope.     

Integrating health and mental health services in schools: psychologists collaborating with primary care providers

This article reviews recent trends, developments and empirical support for the expansion of psychological practice to include school-based treatment and management of serious and chronic medical conditions, including somatization, in collaboration with primary health care providers. Trends and developments reviewed include (a) the expansion and integration of health, mental health, social and community services in schools, (b) the rapid growth of school-based health centers (SBHCs), (c) psychology's increased involvement in the collaborative treatment of chronic and serious medical disorders, (d) recent federal and state legislative initiatives, and (e) cost-driven marketplace changes. Lack of empirical data specific to collaborative psychologist-health care provider collaboration in schools and SBHCs, particularly around somatization, is discussed. Ethical and legal, professional, and reimbursement issues that must be addressed if psychologists are to practice in this emergent arena are identified. This article calls for research to document both the clinical effectiveness and cost-efficacy of collaborative psychologist-primary care provider intervention in schools and SBHCs.     

‘THE LONG GOODBYE’: COGNITIVE ANALYTIC THERAPY WITH CARERS OF PEOPLE WITH DEMENTIA

This paper discusses the use of Cognitive Analytic Therapy (CAT) with carers of people with dementia and raises the wider issue of service delivery and provision of psychological therapy services to carers. Carers experience loss and emotional pain ( McCurry, 2008 ; Miesen, 2006a ; Woods et al., 2003 ) while providing full‐time care to the person with dementia who has complex and changing needs. This frequently results in major depression and anxiety, increasing the possibility of referral to mental health services. Treating carers’ distress is vital not only for their mental health but to enable them to continue in their caring role, without which the current care system would collapse. This need is being addressed in Newham by the tertiary psychology service, Psychotherapy for Older Adults (PTOA), set up in 2006–07 to accept referrals of people over 65 with mental health problems. This paper outlines how the PTOA is well placed to identify and treat carers. We propose that CAT is an effective and flexible therapy in this setting, and illustrate this with a case study. Further research and models for psychotherapeutic service delivery for carers are required.