Youth Mental Health Services: Promoting Wellness or Treating Mental Illness?

Youth are society’s vital asset and their mental health is a priority for us all. ^1,2 The importance of youth mental health (YMH) services is now well recognized both in Canada and elsewhere, ^{3 –5} based on several observations. These include the following: early adolescence and young adulthood is the period of highest incidence of and greatest impact from mental health and substance use (MHSU) disorders, ^6,7 a recent increase in rates of mental disorders and suicide in youth, ⁸ and the majority of youth with mental health problems go without adequate and timely care. ⁹

New models of service such as early intervention in psychosis (EIP) have been successfully scaled up in many jurisdictions, having first demonstrated clinical, social, and economic benefits through rigorous research. ¹⁰ The larger value of scaling up such innovation for a single mental disorder is obviously limited, despite having provided inspiration for early intervention in a range of mental disorders. ^{11 –15} What is now required is a significant transformation of YMH services to improve outcomes for the entire range of mental disorders. ^4,16 Such transformation needs to be based on existing evidence while at the same time should be expected to generate new knowledge, just like that seen in the case of EIP. The enthusiasm about YMH has received support from all levels of government in Canada. ^17,18 Many provincial health services are beginning to take steps to improve YMH services as a policy priority.

While such interest and enthusiasm are most welcome, several social, cultural, scientific, philosophical, and political trends may influence how these new services are being structured and offered. One of these trends is the label “wellness” being presented as the face of these services. The trend to supplant “wellness” for mental health services is apparent in some new community-based YMH services as well as in student health services in postsecondary institutions. Positioning these services as “wellness centers,” while well-meaning, may not serve adequately those who seek relief and recovery from distress and functional impairments associated with MHSU disorders, while also weakening the potential impact of promotion of mental wellness.

The term “wellness” is semantically attractive as is its implicit purpose; however, subsuming the newly transformed services under the banner of wellness needs a careful examination from an epistemic and a practical perspective. Wellness has an essential place in creating mentally healthy individuals and communities and must be supported to improve health and outcomes for the entire population. It cannot, however, replace treatment of MHSU disorders. In this report, we argue that promoting wellness is very different from treating emerging and prevalent MHSU disorders among youth, that each requires a special system equipped with a set of disciplines and skills for their operations, and that each must involve evidence-informed practices and be supported as different funding envelopes. It is not our intention to engage in a philosophical or scientific discussion around the concept of wellness but to focus on its practical implications for mental health services. We also acknowledge that the indigenous concept of wellness may be quite different and more inclusive than the one we address here.

“Wellness” in the Context of Mental Health Services

Wellness

The Oxford dictionary describes wellness as “a state of being in good health as an actively pursued goal.” According to the World Health Organization, wellness is “a state of complete physical, mental and social well-being and not merely absence of disease or infirmity.” ¹⁹ While such a state is highly desirable for individuals and as part of creating a healthy society, it does not, by itself, make any reference to treatment of MHSU disorder for which an individual is seeking help.

The wellness trend has also become prominent in the everyday lives of young people through their use of social media. The Ontario Student Drug Use and Health Survey reported that 86% of students visit social media sites daily and about 20% spent 5 hr or more per day. ²⁰ The wellness trend on social media revolves around the idea of “buying wellness.” With these sites playing such a significant role in the lives of young people, it is likely that the former have an impact on the youths’ understanding of mental health care. Social media influencers (SMIs) are paid to help shape the purchases of young people, in particular, through social media platforms. Many SMIs that promote wellness, including those who self-identify as mental health advocates, share ads featuring products they have been paid to promote to young people as the solution to their mental distress. With mental health and wellness being attributed to taking baths, applying face masks, and purchasing essential oils, there is a risk of young people believing that mental health issues do not need proper intervention, but rather, like the SMIs they follow, they should become well simply by purchasing a product or taking part in a “wellness activity.” While such wellness activities are not bad practices for purposes of prevention of distress and maintaining mental wellness, they are not available to everyone nor do they address the needs of someone facing actual mental distress.

Wellness can indeed be promoted by generic actions directed at groups of individuals or communities through addressing issues of individual, social, and cultural identities; improving individual and collective resilience; promotion of healthy lifestyles through exercise and nutrition; building social safety nets for those who are vulnerable for reasons such as poverty, immigration, gender, ethnicity, and social problems; and promoting a healthy, respectful, and inclusive culture in school environments. These actions are also likely to reduce vulnerability to mental disorders by addressing some of the known risk factors for mental disorders as part of primary prevention. ²¹ The latter, while essential, is unlikely to have a large enough impact on incidence of mental disorders, at least for the foreseeable future. We will, therefore, continue to need a system of easily accessible care for new (incident) and prevalent cases of MHSU disorders and at the same time undertake a rigorous examination of the impact of wellness strategies on the future incidence of mental disorders in youth.

“Mental health services” must, on the other hand, provide assessment and treatment for the entire range of MHSU disorders. Young people with first onset of an MHSU disorder (incidence cases) and those with an existing disorder (prevalent cases) need rapid and unencumbered access to services that provide a thorough assessment followed by evidence-informed appropriate care. The latter most often comprises psychological interventions such as, different forms of psychotherapy and, less often, psychopharmacological treatment, depending on the nature of the presenting problem. A significant proportion will, however, require specialized care. In addition, other services are often needed to support youth with MHSU problems as they receive treatment for their primary MHSU problem. These include employment or educational support, housing, physical health, and nutrition services. In order to make such variety of services accessible to youth, appropriate professional and peer-support workforce with adequate skills within a single easily and rapidly accessible youth-friendly service are required. ²² Most large-scale service transformation initiatives designed to achieve these objectives are centered on the primary theme of mental health. ^23,24 The skills and interventions required to provide such services are different from those that promote wellness. Nevertheless, those who require and receive mental health services also need strategies to pursue a sense of well-being. This goes beyond the relief of symptoms and distress and equips the persons to lead healthy fulfilling lives once their presenting MHSU problems are treated. These supports to promote well-being for those in care are best delivered at an individual level within the framework of the service structure as part of their journey toward recovery. Indeed, even youth with serious mental disorders such as psychosis report an enhancement of their psychological well-being and personal growth following successful treatment, often in an EIP service. ^25,26

Labeling and Branding Mental Health Services as “Wellness” Centers

There appears to be an increasing trend to launch, what are designed and funded to be, YMH services under the title of “wellness centers or hubs”. ^{27 –30} There are possibly several reasons for such a shift of language for labeling of these services and their subsequent communication to youth seeking services for MHSU problems.

Low rates of treatment for YMH problems are presumed to reflect poor help-seeking behavior on the part of the individual needing help due to lack of acknowledgment of the presence of an MHSU problem, shame, stigma, or embarrassment. While there are indeed delays in youth seeking help, there are, in fact, equally long and often longer, delays in getting access to appropriate care once a young person (or family) starts seeking help. ^31,32 Such systemic delays are associated with the complexities of the prevailing service system. While it is possible “wellness” may convey a more positive message to the hesitant young person seeking help for an MHSU problem, he or she may not necessarily understand what is being offered by a service that is marketed as a “wellness” center, and the sources of systemic delays may remain unchanged.

The use of the term “wellness” as the primary focus of a treatment service may imply not only a change in the purpose of mental health services but also in our conception of mental illness. The concept of well-being may be used as a way to avoid a series of conceptual, epistemic, and moral conundrums related to defining mental disorders and interventions to treat them. It is possible, and indeed likely, that some new services labeled as “wellness centers” indeed provide adequate assessment and treatment of mental disorders (e.g., Youth Wellness Hubs of Ontario ³⁰ ), integrated with other supportive services alluded to above. However, the label of the service as a “wellness center” will unlikely convey this directly to the young person seeking service for an MHSU problem. This new vocabulary may give the impression that the issues related to concept of wellness and that of a mental disorder in need of treatment have been settled, when, in fact, they still need to be understood as equally valid and complementary but not entirely overlapping.

It is equally possible that a “wellness center” may concentrate on generic health promotion interventions to the exclusion of assessment and treatment of mental disorders, either due to an inherent shift in the philosophy or conceptual framework of those in charge or due to a workforce that is trained primarily in promoting wellness and not in treating mental disorders. Indeed, a web-based search of the term “wellness” often reveals places that provide yoga, meditation, and other interventions that are obviously designed to assist people with enhancing their physical, spiritual, and possibly psychological well-being. These, however, have a relatively limited role as part of treatment of MHSU disorders. Creating labels such as “wellness” is likely to cause confusion for the young person regarding what is required to help them to deal with an MHSU problem. This could lead to neglect of appropriate treatment for youth presenting with MHSU disorders, especially those with greater severity that require highly skilled interventions.

An additional risk of subsuming YMH services under “wellness” banner is that the two essential components of a good mental health system (health promotion and treatment) are now being squeezed out of the same source of public funds that are already woefully inadequate for providing services to a very large population of youth with untreated MHSU problems. Not attending to their specific treatment needs rapidly will lead to continuation of long delays in treatment and high levels of untreated prevalence of major depressive, anxiety, eating, substance use and psychotic disorders, all with peak onsets during early adolescence and young adulthood. ⁷ The substantial consequences of untreated prevalence are only too well known and include increasing rates of attempted and completed suicide, ^33,34 unemployment, ³⁵ and long-term disability. ^{36 –39} The newly launched YMH services must focus on providing rapid and optimum care to youth with emerging and prevalent MHSU disorders along with promoting their recovery and well-being.

Conclusions

In Canada and elsewhere, we are at the cusp of real and substantial progress in mental health through a new and principled focus on transforming youth mental services and making them readily accessible to an increasing number of youth in need. In order to achieve our goals, we must advocate for separating two principal, albeit, equally important and overlapping domains of an improved mental health care system, that is, promoting wellness and providing treatment. This can only be achieved through building these two parts of the system concurrently and not with one subsuming the other but in close collaboration. This will need to be supported by separate envelopes of funding. Improving mental wellness needs to involve strategies and interventions that follow other public health initiatives and should be designed and delivered at a national scale as well as incorporated locally into the newly transformed YMH services for greater impact. Generic programs such as increasing awareness and knowledge of mental disorders among the population and how to recognize mental disorders early, facilitating healthy lifestyles through better nutrition and exercise, and reducing stigma associated with seeking help are just some examples of activities that need a national approach. On the other hand, many specific interventions for promoting wellness such as improving help-seeking, local community development, improving social and educational environments, and reducing bullying in schools will need to be adapted to local cultural and geographical conditions and delivered locally. For local impact, these should be integrated within a transformed service so as to form part of care provision.

In order to achieve a balance between wellness (mental health promotion) and mental health service delivery (assessment, treatment, and recovery) objectives, new and relatively bold funding mechanisms may need to be considered. We recommend that, at the very least, the design and operation of generic wellness promotion activities described above be funded separately, preferably from Federal agencies such as Health Canada in coordination with funding of mental health services directed at treatment of mental disorders. The latter would continue to be funded from provincial and territorial health resources. Aspects of mental health promotion that are more appropriately delivered locally (see above) should be made available to the newly transformed YMH services and funded through the same Federal sources. In order to avoid problems associated with different layers of funding and given the gravity of YMH problems, we recommend the creation of a pan-Canadian fund for YMH with proportionate contributions from Federal as well as Provincial and Territorial governments and managed according to national standards that are currently being established through multiple service transformation initiatives. ¹⁶ Such a mechanism would also incorporate an evaluation framework currently being developed across the major YMH service transformation initiatives ^40,41 in Canada.

Irrespective of funding, mental wellness and YMH service delivery must both be informed by evidence and supported by a multidisciplinary workforce with adequate and specific skills. Having raised expectations through a new and exciting movement in YMH system, we must avoid diluting either of the two essential components of a mental health system, that is, wellness and timely treatment of mental illness. The history of mental health services over the past 70 years is a graveyard of broken promises and missed opportunities with incomplete and derailed reforms. Consequences of such failures include homelessness and further erosion of an already diminished quality of life for the seriously mentally ill, historically, starting with the period following deinstitutionalization. ^42,43

Mental health reforms are usually proposed based on ample scientific evidence and require a well-trained workforce to implement them. Often these opportunities have, however, been frittered away through misguided or inadequately funded policies without any evaluation of adherence to the principles and evidence on which such reforms are based. It is imperative that this time we get it right for the sake of our youth for whom the most common health problem is that of mental health. We have enough evidence to show that both promotion of wellness and treatment of mental disorders are equally important. Pretending that they are interchangeable and that the euphemistic use of “wellness” can assume provision of mental health services would be simply wrong. A good public mental health strategy must have both.