The Medical journal of Australia
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The development of evidence-based ("collaborative care") mental health services in primary care for young people with anxiety, depression and alcohol or other substance misuse is a major challenge. Data from two clinical audits of selected Australian general practices (1998-1999 and 2000-2002) were analysed to explore actual experiences of care among people aged 16-25 years. Syndromal (1998-1999: 31.0% [n = 1849/5957]; 2000-2002: 37.8% [n = 148/392]) and subsyndromal (1998-1999: 27.4% [n = 1635/5957]; 2000-2002: 29.1% [114/392]) mental disorders are very common among young people presenting to general practitioners. ⋯ Only rarely is pharmacological treatment alone provided (1998-1999: 2.2% [n = 117/5236]; 2000-2002: 3.2% [n = 12/370]). New systems of primary care for young people need to be based on proven collaborative care models and encourage presentations for care, increase detection rates, and promote access to information and effective e-health services. Improved access to specific psychological treatments should remain a priority.
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Despite mental disorders being the dominant health issue confronting young people, youth mental health is yet to be recognised as a discrete, unified program area; responsibility for young people's mental health is currently split across multiple levels of government. Public specialist mental health services have followed a paediatric-adult split in service delivery, mirroring general and acute health care. The pattern of peak onset and the burden of mental disorders in young people means that the maximum weakness and discontinuity in the system occurs just when it should be at its strongest. ⋯ At the primary and community level, headspace: the National Youth Mental Health Foundation, is a national response to this and aims to provide better access, engagement and enhanced multidisciplinary care for young people across Australia. The specialist mental health service level should be complemented by youth-specific specialist mental health services for young people, aged 12-25 years, which would strengthen the existing system with a better targeted stream of care, providing access to integrated mental health, substance use, and vocational-recovery services. Alternative approaches to creating this capacity should be urgently developed and evaluated, and sustained reform informed by evidence as well as values.
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The impact on family members of mental illness in a young person is intensely distressing. Symptoms that they cannot understand, and the stigma surrounding mental illness may lead to families feeling isolated in their distress. Family carers are reassured by talking with other families who have experienced the same or similar situations. ⋯ Medical practitioners need to appreciate the importance of ensuring that families receive information and emotional support to help them cope effectively. Difficulties in helping family carers, often around perceived confidentiality restraints, need to be overcome so that collateral damage--family breakdown, persistence of symptoms, and behavioural maladjustments--can be reduced. Families who are supported can become advocates for improvements to mental health services for young people.
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headspace, Australia's national youth mental health initiative, was created in 2006 in response to the recognition that the existing health system needed to be much more accessible and effective for young people with mental and substance use disorders. With funding of more than $54 million from the Australian Government, a carefully constructed and selected system of 30 "communities of youth services", or integrated service hubs and networks, across the nation is being established, supported by programs for community awareness, workforce training and evidence-based resource material. headspace aims to improve access, and service cohesion and quality, and ultimately health and social outcomes, for young people aged 12-25 years experiencing mental illness and related substance use problems. Within the Council of Australian Governments framework, this will require synergistic planning with, and co-investment on behalf of, state and territory governments, as well as the support and involvement of local communities and the wider Australian society.
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Diagnosis in psychiatry continues to struggle to fulfil its key purposes, namely to guide treatment and to predict outcome. A clinical staging model, widely used in clinical medicine, could improve the utility of diagnosis in psychiatry, especially in young people with emerging disorders. Clinical staging has immediate potential to improve the logic and timing of interventions in psychiatry, as it does in many complex and potentially serious medical disorders. ⋯ In this way, a clinicopathological framework could be progressively constructed. Clinical staging, with restructuring across and within diagnostic boundaries and explicit operational criteria for extent and progression of disorder, should be actively explored in psychiatry as a heuristic strategy for developing and evaluating earlier, safer, and more effective clinical interventions, and for clarifying the biological basis of psychiatric disorders. Young people with emerging mental and substance use disorders could be the main beneficiaries.