Are we serious about youth mental health? “Not so far”

AUSTRALIA’S international reputation for “world’s best policy, world’s worst implementation” is getting in the way of equitable, effective youth mental health care, and it’s time for health leaders and policy makers to “get serious”, says one of the country’s leading experts.

“The Prime Minister often asks, ‘how good is Australia’,” said Professor Ian Hickie, co-Director, Health and Policy, of the University of Sydney’s Brain and Mind Centre.

“Well, I’d like to know. How good is Australia? Are we good, or are we just actually pretty average?”

Professor Hickie is co-author of a Supplement published by the MJA, detailing a new proposed model of care to manage youth mental health. According to the authors the model:

“… explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people.”

In an accompanying editorial published in the Journal itself, Professor Hickie wrote that:

“… we still do not deliver effective care, early in the course of illness, to most young people with anxiety, depression, or alcohol or other substance misuse.”

The “highly personalised approach” of the proposed model was achieved through the integration of three core concepts, Professor Hickie wrote:

• a multidimensional assessment and outcomes framework that includes social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory;
• clinical stage — differentiating immediate treatments from secondary prevention strategies; and
• three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian).

The measurement-based component of the model would be achieved by “linking individual care to the use of more sophisticated real-time health information technologies that can enhance immediate and continuous clinical decision-making”.

“This new model emphasises not simply early access to assessment but also rapid and ongoing provision of stage-appropriate and effective, often multidisciplinary team-based, interventions,” wrote Professor Hickie.

“It argues for the need to move beyond stepped care, where care typically proceeds from less intensive to more intensive, only after failure to respond to the initial offering, to staged care with the aim of delivering the right level of care, the first time.”

In an exclusive InSight+ podcast, Professor Hickie challenged governments and health leadership to step up to the challenge of producing a world-class youth mental health care framework.

“The challenge is to be serious about this area which has never had a genuine seat at the table,” he said.

“Now it is the responsibility of decision makers and of clinical leaders to get serious. You see people like Simon Judkins, president of the Australian College of Emergency Medicine very clearly taking that leadership role.

“I wish we could say the same about some of the mental health professionals.

“We need to see our psychologists, our psychiatrists, our GPs, particularly the medical leadership, get serious – say ‘yes, we’re going to change these systems and we’re going to work with more complex systems’. And then be very prepared to partner with education, with employment, with other sectors that can make a big difference,” he said.

“[Australia is] very good on the design phase.

“We’re very slow and often hopeless on implementation, because to implement means we’d have to do things differently to the way that we’ve historically done them.

“And we are very slow to change our profession-led health systems.”

Professor Hickie said the proposed new model was designed to bring together elements of the current system to create truly personalised treatment for complex conditions in young people before they became chronic adult disorders.

“We are great talkers about what we could do, what we would do, or more importantly, what you should do, but we’re rarely there in the teams that we need to form a genuine partnership with you,” he said.

“Our model brings together a number of complex elements, makes them clear, makes them transparent for the person and tracks with the young person and their family, together with the assistance of technology, whether [the treatment] is really [working] or not.

“Is it working? And most importantly, if it’s not working, what are the other real options for you as we learn more about you, not about which diagnosis it is.

“In the youth area, you can spend all your life and probably all your money going from one practitioner to another who will rediagnose you and provide another set of explanatory models and then make recommendations as a consequence of that, often which are generic and on average, they’re not bad, but they’re just not relevant to you on an ongoing basis,” he said.

Professor Hickie said cancer care was a leading example of how individualised care for children and youth was working.

“Every individual child in Australia with cancer is now having their cancer genotyped, has their own team devoted to them and their own therapy devoted and entirely personalised around the genetic signature of their cancer,” he said.

“Very high levels of complexity and team-based care, and we say, ‘oh, of course we will do that to save a child’s life’.”

On 31 October, the Productivity Commission released its Mental Health Draft Report. Its draft recommendation 5.9 states:

“The Australian, State and Territory Governments should reconfigure the mental health system to give all Australians access to mental healthcare, at a level of care that most suits their treatment needs (in line with the stepped care model), and that is timely and culturally appropriate.”

Professor Hickie said that one of the biggest problems with the Australian system was that health system research “remains grossly underfunded”.

“We spend the most on a health system and research the least how to make that system work, and then we’re surprised when we don’t see mental health.

“We love a good review. We love to have a good look at it and come to the conclusion that you know what, it’s poorly coordinated, it doesn’t meet personalised needs, it’s not person-centric.

“That’s the problem, what’s the solution?

“The model we describe in the MJA supplement [highlights] the key elements in straightforward terms; the interrelationships between them and then poses the question: as a clinician, are you really serious? As a service are you serious about doing it?

“The investment issue for our governments is, are they serious about the investment?. To which the answer is, so far, not very.”