Mind that child!

For many years, the importance of mental health and its impact on the Global Burden of Disease have been highlighted. Many mental health problems start in childhood or adolescence, and the paucity of health services to deal with these problems has been a matter for much hand-wringing, often without much action. In a recent comment in The Lancet, the need for action was again trumpeted, with the welcome news of a joint meeting between the World Bank and the World Health Organization (WHO) in April 2016 to tackle the important global economic effect of depression and anxiety (Summergrad, 2016). It is encouraging, therefore, to see the importance accorded to child and adolescent mental health problems in Australia with the funding of the large and important epidemiological study reported in this issue.

The survey, Young Minds Matter, was run by the Telethon Kids Institute at the University of Western Australia. Like the 1998 National Survey of Health and Well-Being (Sawyer et al., 2001), this is an epidemiological study of high calibre. The survey of 6310 families selected randomly from across Australia included a face-to-face diagnostic interview with parents and carers of 4- to 17-year-olds and a self-report questionnaire completed by young people aged 11–17 years in participating households. The investigators have used a careful design to maximise the generalisability of findings for the Australian population. They have over-sampled 16- to 17-year-olds to increase the chances of collecting good data on risk behaviours and to compensate for the frequent poor response rates in this age group. Measures included a computer-assisted personal interview with the primary caregiver of the index child, incorporating robust measures such as the Diagnostic Interview Schedule for Children (DISC IV) and the Strengths and Difficulties Questionnaire. Domains encompass family characteristics, demographics of the parents, mental health of the parents, function of the child and service use. The self-report for the 11- to 17-year-olds incorporates the Strengths and Difficulties Questionnaire, the DISC IV major depressive disorder module, questions on youth risk behaviours, presence of psychosis and measures of self-esteem. Major omissions include problematic substance use and eating disorders, both of which are relatively common and important, particularly in Western societies. This was a pragmatic decision made to limit the already large demand for data from participants and is understandable.

The response rate in the survey was somewhat disappointing at 55%, but this is in line with reduced response rates in many surveys internationally. More encouragingly, 89% of young people aged 11–17 years whose parents took part in the survey completed the youth section of the survey.

There are some interesting findings. The overall rates of disorder are remarkably similar between the two surveys (13.9% in the second national survey and 14% in the first) and also similar to international rates. The second survey includes not only major depressive disorder, conduct disorder and attention-deficit hyperactivity disorder but also anxiety disorders (social phobia, separation anxiety disorder, generalised anxiety disorder and obsessive–compulsive disorder). The survey included both 30-day and 12-month prevalence of disorder, and a comparison of the two rates gives a measure of the persistence of disorder. This proves to be high for all disorders (Lawrence et al., this issue). The disability related to disorders in also high, for example, non-attendance rates at schools. We again have data showing the importance of mental health problems, with disorders that are common, persistent and disabling.

Following the first survey, it is encouraging to see the report of increased access to services for young people who have mental health problems from roughly a quarter in the first national survey to well over half in the second survey. Even more importantly, nearly 90% of young people with serious mental health problems reported accessing mental health services in Young Minds Matter. This may reflect the success of initiatives such as the Better Access programme. Since the introduction of this programme, there has been a threefold increase in children and adolescents receiving Medicare-funded mental health services, an impressive increase in community-based ‘headspace’ and ‘kidspace’ centres (Johnson et al., this issue) which increased from 10 in 2006 to 100 by 2016 (Jorm, 2015) and an increased investment in Australia in mental health promotion and prevention programmes in school. Schools now play a big part in service delivery with nearly three-quarters of young people with moderate severity of mental health problems accessing support through schools. However, it is important to ensure that these services are having the impact they should on mental health problems in young people. The prevalence rates have not shown a change over time, which is disappointing. The effectiveness of headspace is apparently modest with only 21% showing clinically significant improvement. The infrastructure for young people is in place, young people are accessing the services, it appears the right treatments are being delivered, but perhaps the dose may be too low (Jorm, 2015). Measuring clinical improvement from the services and a return to function for young people accessing them must surely be a focus in the future.

The Internet is an important potential resource. As reported in this survey, young people and their parents are turning to the web for information about mental health problems at increasing rates, and some are accessing online self-help or therapist-assisted services (Johnson et al., this issue). Internationally, there is interest in the use of technology to improve access to psychological therapies. While use of the Internet can be problematic, with compulsive use and cyberbullying, it is also a potential force for good, but there is a bewildering proliferation of apps and websites to support mental health, little evaluation of effects and often poor uptake (Christensen et al., 2009). If we could learn to capitalise on strategies that have led to the phenomenon of Pokemon Go, which has been so much in the news recently, there is potential to have a major positive impact on the mental health of young people.

Self-harm and suicide continue to be of concern. Two papers from the survey (Zubrick et al. a, Zubrick et al. b) highlight the clear association between mental health problems, self-harm without suicide intent and suicidal behaviours. Young people who report self-harm have an increased risk of suicidal behaviours, especially when they also have a mental disorder. For example, of young people who reported having had a depressive disorder, 10% of those without self-harm had attempted suicide, whereas nearly 50% of those who had deliberately harmed themselves four times or more had attempted suicide. It is important not to underestimate the importance of self-harm, both in clinical services and in any suicide-prevention strategies.

The very clear link of the importance of socio-demographic factors is clearly outlined (Lawrence et al., this issue). Solo parent families, step- and blended families, parental unemployment and renting accommodation are all clearly linked to poorer mental health in children and young people. Attempts to address problems of mental illness in children and young people should not be limited to service development but also to ensure adequate supports for parents to function effectively.

New Zealand has not had the advantages of large epidemiological surveys such as Young Minds Matter. While we have data from excellent longitudinal studies, the young people in these reports were born in the early 1970s. Reports from the Youth 2000 national cross-sectional studies of the health and well-being of secondary school students provide some data on mental health, but not the extensive and in-depth data presented from the Young Minds Matter survey. New Zealand has the dubious distinction of having one of the highest youth suicide rates in the Organisation for Economic Co-operation and Development (OECD) with rates almost double those in Australia. Data from the Youth 2000 series allow us to compare Australian and New Zealand rates of suicide attempts over the past 12 months between the countries, and these show double the risk in New Zealand with rates of suicide attempts of 2.4% in Australia compared with 4.5% in New Zealand (Clark et al., 2013). The Prime Minister in New Zealand launched large youth mental health project in 2012, and it will be interesting to see what impact this initiative has on improving the mental health of adolescents in New Zealand.

Across both countries, we continue to struggle to provide help for children and adolescents with mental health problems. This excellent set of papers reminds us that the job is not yet done. There has been a major advance in development of services in Australia (and some initiatives in New Zealand as well). Young people and their families are accessing these at far greater rates, but the impact on rates of disorder is not evident. It is important to ensure now that the services deliver care that leads to the best clinical outcomes possible.