Cognitive screening: A significant unmet need in youth mental health

To the Editor

Cognitive impairments are common in mental illness, often emerge prior to full-threshold disorder, frequently persist despite clinical symptom stabilisation and predict ongoing functional difficulties. Accordingly, international experts, Australian primary care clinicians and recommendations from Australia’s National Mental Health Commission have emphasised the need for better availability of neuropsychological assessment for people with mental health concerns, particularly young people (Allott et al., 2018). However, neuropsychological assessment is a highly limited resource in public mental health and primary care clinicians report only moderate confidence in their ability to detect cognitive difficulties (Allott et al., 2018). Furthermore, many young people do not experience cognitive impairments, with significant heterogeneity between and within psychiatric disorders.

Cognitive screening signals whether further comprehensive assessment is required to assist diagnosis and management. However, accepted cognitive screening tools for adults, such as the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA), may not be sensitive to the nature and extent of cognitive impairment in younger people with emerging or full-threshold mental health conditions. These tools are typically used in older populations (i.e. 55+) with known or suspected organic neuropathology. Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG) has been validated in psychiatric populations, but again only in adults (Walterfang et al., 2006).

The lack of a validated cognitive screening tool in youth is a clinical unmet need. A psychometrically robust cognitive screening tool for young people with mental illness may assist in early identification of deficits within a normative developmental framework, prompting streamlined referral for comprehensive assessment. Screening may also raise awareness about broad cognitive abilities, guiding therapeutic management. The ideal screening tool would be brief (e.g. <30 minutes), adequately normed, sensitive to the diverse range of cognitive difficulties experienced in young people with mental health concerns and administered by health practitioners of various professions (Roebuck-Spencer et al., 2017). Evaluation of the feasibility and validity of existing tools used in adult samples is a critical first step. This should occur prior to recommendations for any routine clinical use in youth samples, and whether modification(s) is required or whether a new screening tool must be developed.

We are not proposing that cognitive screening replace the role of neuropsychological assessment in youth mental health. However, a research priority is the development and validation of a youth-specific cognitive screening tool to encourage referrals for rapid assessment and/or assist the management of cognitive issues when assessment cannot be obtained, supporting recovery-oriented, person-centred stepped care.