Youth Mental Health Should Be a Top Priority for Health Care in Canada

Abstract

In this article we have provided a perspective on the importance and value of youth mental health services for society and argued that advancing youth mental health services should be the number one priority of health services in Canada. Using the age period of 12–25 years for defining youth, we have provided justification for our position based on scientific evidence derived from clinical, epidemiological and neurodevelopmental studies. We have highlighted the early onset of most mental disorders and substance abuse as well as their persistence into later adulthood, the long delays experienced by most help seekers and the consequence of such delays for young people and for society in general. We have also provided a brief review of the current gross inadequacies in access and quality of care available in Canada. We have argued for the need for a different conceptual framework of youth mental disorders as well as for a transformation of the way services are provided in order not only to reduce the unmet needs but also to allow a more meaningful exploration of the nature of such problems presenting in youth and the best way to treat them. We have offered some ideas based on previous work completed in this field as well as current initiatives in Canada and elsewhere. Any transformation of youth mental health services in Canada must take into consideration the significant geographic, cultural and political diversity across the provinces, territories and indigenous peoples across this country.

The Canada Health Accord, ¹ signed by all provinces and territories, is a major achievement for improvement and equity in health care in Canada. The accord obliges all governments in the country to incorporate mental health and addictions with a specific focus on youth, until now largely neglected, in any future service development for the health and well-being of Canadians. This is in step with a worldwide awakening to the importance of mental health and addictions in recent years, as shown by several indicators, including the World Health Organization’s statement ‘there is no health without mental health’ ² ; a global declaration to sign an accord on mental health based on human rights ³ ; the enormous economic implications of mental illness (World Health Forum) ⁴ ; and significant progress in science through clinical, epidemiological, and neuroscience-based investigations.

A recent editorial in the CJP has highlighted concerns regarding neglect of mental health services in Canada while pointing out opportunities for improving access to mental health services in general under the relatively more positive current political climate. ⁵ These authors have advocated for scaling up of successful existing mental health programs, support for evidence-based interventions, creation of a national clearinghouse for treatment recommendations, development of technology to improve access to care, use of measurement in delivering care, and a better integration of specialist and primary care. Another editorial has gone further in making specific recommendations for creating access to psychotherapy for common mental disorders in primary care as well as for specific community programs for the seriously mentally ill. ⁶

Youth mental health is the starting point of overall mental health, from a societal and scientific perspective, and we argue that it should be Canada’s number one priority for mental health care in the near future incorporating most of the above recommendations.

Societal Perspective

‘Youth’, the age group 12 to 25 years, encompasses early adolescence and emerging adulthood. ⁷ Adolescence is a period of social and developmental turmoil as youth try to negotiate several challenges, including transition into multiple social roles from the limited and dependent roles of childhood and simultaneous formation of distinct identities. Key in mental health is the concept of transitional youth, the age group starting in adolescence and moving into adulthood. ‘Emerging adulthood’ is a relatively recently recognized phenomenon of delayed social and personal independence observed among young people ⁸ that has some implications when discussing youth mental health.

From this broader perspective, arguments to support attention to youth mental health (YMH) and addictions run to the very core of the social and economic well-being of all societies. ⁹ The contribution to loss of gross domestic product (GDP), resulting from mental health and addictions, is reportedly on par with cardiovascular disorders. ⁴

Unlike physical health problems, most (75%) mental disorders have their first onset before the age of 25. ¹⁰ Mental disorders surge during the transition between childhood and emerging adulthood ¹⁰ and have long-lasting health, social, and economic impacts on individuals, their families, and society. ^{11 –13} While most noncommunicable medical disorders usually begin later and have their highest prevalence in or after middle age, mental health problems in youth start early and compound the longer-term picture of the former through comorbidity and shared risk factors. ^{14 –16}

Older generations at times express clichéd concerns about young people’s capacity to manage the future (concerns expressed about Generation X and more recently about the Millennial Generation). There is no real basis for these concerns; every society relies on its youth to maintain continuity of the economic and social order. Millennials, for example, make up a substantial proportion (1 in 6) of the workforce today. ¹⁷ In high-income countries like Canada, changing social demographics help to focus the challenge. The relatively small proportion of the population (15%-20%) under 25 years of age ¹⁸ will need to sustain an increasingly aging population, so the health of the youth, crucially dependent on their mental health, has never been more important. In Indigenous communities in Canada, a higher proportion of the population is under 25 years old (40%-50%), ¹⁹ and they experience higher rates of mental health problems with even more limited access to care than non-Indigenous youth. ²⁰ Attending to the physical, mental, and social development of children and youth is vital to survival of Indigenous communities in Canada. Not doing so is not just a lost opportunity for social and economic development but also a potential societal disaster.

Early onset of mental illness and delay in or lack of access to adequate interventions frequently result in a downward spiral of disadvantage and suffering for young people and their families, leading eventually also to serious leakage from economic and societal or social development. Youth with untreated mental illness are likely to miss opportunities for education and employment, reflected in the claim that mental disorders represent 60% to 70% of disability-adjusted life years (DALYs) among young people. ²¹ Given the nature of DALYs, the future impact is probably an underestimate. Investment in prevention and early intervention makes great economic sense. ²²

Scientific Perspective

The incidence, prevalence, and distributions of mental health problems are not matched by the current availability and efficacy of care. Formal studies ^{23 –25} show that 20% of youth experience symptoms of mental disorders and at least 50% of these warrant intervention. ^26,27 Depression and anxiety, the 2 most common disorders, most often have their onset in childhood and adolescence, while schizophrenia first appears in the postpubertal period. Anxiety and impulse-control disorders reach their peak incidence relatively early, with 75% of cases appearing prior to the age of 21 and 15 years, respectively. ^24,28 Major mental disorders such as major depression, bipolar disorder, and psychotic disorders that begin early mostly continue through adult life.

Given their age at onset of such disorders, delays and missed opportunities for intervention are alarming. Such long delays for first intervention extend from 1 to 2 years for psychoses, 6 to 8 years for mood disorders, and 9 to 23 years for anxiety disorders. ^24,29 Delays result in poorer outcomes when treatment is eventually provided. Treatment delay in cases of psychosis has a long-lasting effect on clinical as well as social outcomes ^{30 –32} ; early intervention services that combine state-of-the-art treatment interventions and reduction of delay in treatment through open and rapid access in psychosis reduce many of these negative consequences, including suicide. ^{33 –37} The evidence for effectiveness of early intervention services is well established ³⁷ and is beginning to extend to interventions at presyndromal stages in those regarded as being at clinical high risk for psychosis. ³⁷ Delays in intervention for even milder disorders or subthreshold symptoms may complicate future presentation of mental disorders as often untreated earlier stages progress to more severe and complex problems through increasing functional deficits, comorbidity of substance abuse, or simply progression of underlying pathological phenomena. ³⁸ Delayed treatment can be associated with dire consequences that are difficult to attribute directly to the actual delays—suicide, traffic accidents, missed employment opportunities, crime, and poor physical health.

The Canadian Community Health Survey-Mental Health confirms a high incidence and prevalence of mental health problems among youth, as well as poor or late access to care. ³⁹ Suicide is the second cause of death among 15- to 24-year-olds ⁴⁰ in Canada; this is the third highest youth suicide rate in the industrialized world. ⁴¹ Among Indigenous men and women, suicide rates are respectively 5 and 7 times higher than the Canadian average. ^42,43 The recent crisis facing the country, with deaths from drug overdoses of fentanyl reaching epidemic proportions, has also largely involved youth under 25 years of age. ^44,45

Recent work in developmental neuroscience indicates that adolescence is a crucial developmental period. During the first 3 decades of life, brain development and maturation occur through dynamic and highly complex neural remodeling, involving changes in structure and connectivity. ^{46 –50} This provides the backdrop for enhanced vulnerability, during which environmental changes can disrupt behavioural adjustments and result in what we understand as mental disorders. Relatively small deviations in the developmental trajectories of normal brain development may provide the opportunity for increased risk for these disorders during this period. ⁵¹

Youth mental health has a bearing on the rest of health care. Individuals with mental disorders have a shorter life expectancy than do members of the general population; they have increased risk of later, as well as high comorbidity with concurrent, physical health problems. Youth mental health problems act on physical health through several mechanisms. Mental health problems are associated with higher rates of smoking and substance abuse, nutritional disorders (like obesity), and sexually transmitted diseases. These comorbid risks are themselves associated with risk of health problems like diabetes, cardiovascular and respiratory problems, cancer, and dementia. ^{52 –58} In addition, most mental disorders and many noncommunicable medical disorders (like diabetes, coronary artery disease) share many environmental risk factors, including childhood and intergenerational trauma, ⁵⁹ social and material deprivation, ⁶⁰ parental substance abuse, ⁶¹ and parental history of mental disorders. ⁶²

Current Services Are Inadequate for Mental Health Problems of Youth

Our overall response to youth mental health has been inadequate and inappropriate. The challenges continue: high incidence and prevalence, extreme delays in appropriate care even in the face of suicidal behaviour, high rates of disengagement even after accessing services, ⁶³ the largely institutional and biomedical nature of care available and high use of hospital emergency services, ⁶⁴ lack of involvement of youth and families, and, not least, the difficulties encountered in transitioning from child-focused care to the adult system of care. ⁶⁵ The latter issue was also highlighted in a recent Canadian report. ⁶⁶

The current configuration of child-adolescent and adult mental health services as 2 separate systems poses a major impediment to responding adequately to demands of youth mental health problems. The current system is also inadequate in dealing with new cases of mental disorders that present with a large variation of severity ranging from full-fledged diagnosable disorders to subthreshold states, often requiring immediate attention for their distress and reduced functioning. The response of specialized mental health care is thwarted by its divisions into silos, despite wide recognition of the high degree of comorbidity. ^67,68 A consequence of this inability of specialized mental services to address youth mental health, which does nothing to improve matters, is a prevailing culture of pessimism associated with dealing mostly with longstanding mental disorders and disabilities. Although several recommendations of how to manage transitions from child-adolescent to adult mental health services have been articulated, ⁶⁶ an obligatory transition in mental health services at 18 years of age may be considered problematic in itself, given the nature and course of mental disorders.

Primary health care is a theoretical avenue to address youth mental health, but in practice, this caters to physical illness for young children and older adults, offering woefully inadequate structure and resources to respond to mental health problems of the youth. It is time to rethink our approach to the onset of mental disorders, the need for early intervention, and the urgent transformation of services to serve the unique needs of youth (11-25 years).

Opportunities for Change

The challenge of youth mental health calls for very different models of illness than are available from current categories applied to adult mental disorders. Such response needs to be based on a sound understanding of the developmental course and epidemiology of mental disorders. Recent research has revealed earlier, subthreshold states of symptoms and behaviours do not meet the threshold for diagnosis and yet are accompanied by an array of social, health, and functional difficulties. ^{69 –74} This suggests earlier stages may be symptomatically milder but may require interventions directed at improving functioning. It is important to address functioning deficits directly in individuals with subthreshold symptoms without the need for a diagnosable disorder, thus interrupting a potentially vicious cycle. Even subthreshold symptom-related impairment impedes functioning. While resolution of symptoms is important to improve functioning, interventions aimed at improving functioning may enable the person to use personal and social resources when confronted with symptoms of a mental disorder at a later date. While presenting symptoms and distress of some youth may resolve without any specific intervention, early mental disorders may also transform into a different category of disorder over time. This raises the possibility that a general mental disturbance has the potential to develop into a variety of disorders ranging from mood disorders to psychosis. ^{75 –77} These earlier stages of mental illness are likely to be amenable to generic and usually less noxious interventions, preventing progression into more severe states. Examples are emerging that support a staging model of a variety of mental disorders. ^78,79

The past 2 decades of research have seen major successes in scaling up of early intervention services for a first onset of psychosis ^{80 –86} in many countries, including some but not all parts of Canada. This benefit has not been extended to Indigenous or remote communities. There is increasing recognition that early intervention and prevention of psychosis alone may be too narrow a focus, and the knowledge accumulated may be applicable to youth mental disorders of all levels of severity. ⁸⁷ A focus on youth mental health services might offer a platform for large-scale examination of at-risk and subthreshold states of mental disorders.

What Is being Proposed as a Solution?

There has been increasing momentum in several countries to develop and transform youth mental health services to address these pressing issues. Recent developments in Canada include greater attention to mental illness in general and to youth mental health in particular, at the federal, provincial, and territorial levels of government policy, as well as in service development and research in service and academic sectors. Canada is joining a global movement to improve mental health services for youth through efforts from the Mental Health Commission of Canada such as the framework developed for child and youth mental health services, ⁸⁸ many regional service (e.g., YouthCan Impact in Ontario; Foundry in British Columbia) interventions, and a more recent investment in service transformation research and evaluation as exemplified in the first Strategy of Patient Oriented Research (SPOR) launched recently in the field of youth mental health (see http://www.cihr-irsc.gc.ca/e/45854.html, www.accessopenminds.ca, or www.tramcan.ca). Any single model of YMH service transformation is unlikely to be feasibly implemented across the geographic, political, and cultural diversity of this country. The only way to address such challenges is to pilot test variations of a model of transformation adapted to contextual realities of such diversity before scaling it up or implementing a service format imported from another country.

A recent editorial has argued that the child and youth mental health framework, Evergreen, ⁸⁸ created for the Mental Health Commission of Canada, can be used to ‘move forward an agenda that could advance child and youth mental health services’. ⁸⁹ This agenda incorporates 4 domains of promotion, prevention, intervention, and ongoing care and research and evaluation. Certain interventions for improving mental health literacy, especially incorporated within school-based programs, have shown some impact on mental health literacy, knowledge about mental illness, and stigma among high school students. However, the extensive problems associated with improving mental health care for youth require a much larger system-based transformation, and any such transformation will be required to show the impact on outcomes in individual functioning and mental distress as well as a larger impact on service utilization and productivity.

It is not our intention to describe in detail any particular systemic approach to transformation of youth mental health services. Suffice it to say that a small number of countries (e.g., Australia, Ireland) have embarked on large-scale transformations of their youth mental health services. Headspace in Australia ⁹⁰ and Jigsaw and Headstrong in Ireland ⁹¹ have been set up as ‘new’ systems of care in the form of an enhanced-level primary care where a multitude of health and social services are available to the young person in addition to mental health services. The evidence for the effectiveness of Headspace is mixed, ⁹² although there is little doubt that it has significantly improved access for youth to mental health services in a youth-friendly environment. ⁹²

For Canada, we do not propose the setting up of a new system of care but creation of a truly transformed system of youth mental health care embedded within the current larger system. The essential principles of this transformation need to be based on addressing what is hindering access to timely adequate and appropriate services for young people (12-25 years old) presenting with the entire range of mental health problems, as reviewed briefly above. Such a service should be designed specifically for—and with—youth and must address multiple health needs (physical, sexual, and mental), substance use, and emerging mental disorders. The services must be able to address social needs of youth experiencing mental distress, while being sensitive to their cultural, historic, and geographic realities. These services must be easily accessible to youth and their families without need for a referral and include the provision of dropping in to receive the service. These services should promptly use evidence-informed approaches that are commensurate with young people’s preferences (e.g., involving information technology, peer support, access to brief psychotherapy, or counselling), without having to negotiate a complex and multilayered system of entry to appropriate care. Thus, such a service must be connected both vertically to other (specialist) services and horizontally to other health and social services. The former will indeed need its own transformation for how it responds to needs of the youth with more serious mental health problems and how it uses evidence-based interventions as advocated in recent editorials. ^5,6,89

In addition to providing access to youth in the general population, these services must pay special attention to those who are at high risk of mental disorders, including homeless youth; youth who are or have been in child-youth protection; urban and nonurban (reserves) Indigenous youth, including the Inuit who live in particularly isolated parts of the country; and immigrants and refugees. Building a solid youth mental health service will ensure not only a reduction in suffering of young people and their families but also a physically and mentally healthy future adult population and with that a healthy social and economic future for Canada. This is only possible if there is a commitment from all levels of government, academia, and service provision to regard youth mental health services as a top priority.