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World Psychiatry 21:1 - February 2022 61
FORUM – BUILDING NEW SYSTEMS OF YOUTH MENTAL HEALTH CARE: A GLOBAL FRAMEWORK
Designing and scaling up integrated youth mental health care
Patrick D. McGorry, Cristina Mei, Andrew Chanen, Craig Hodges, Mario Alvarez-Jimenez, Eóin Killackey
Orygen, National Centre of Excellence in Youth Mental Health; Centre for Youth Mental Health, University of Melbourne, Parkville, VIC, Australia
Mental ill-health represents the main threat to the health, survival and future potential of young people around the world. ere are indications
that this is a rising tide of vulnerability and need for care, a trend that has been augmented by the COVID-19 pandemic. It represents a global
public health crisis, which not only demands a deep and sophisticated understanding of possible targets for prevention, but also urgent re-
form and investment in the provision of developmentally appropriate clinical care. Despite having the greatest level of need, and potential to
benet, adolescents and emerging adults have the worst access to timely and quality mental health care. How is this global crisis to be ad-
dressed? Since the start of the century, a range of co-designed youth mental health strategies and innovations have emerged. ese range from
digital platforms, through to new models of primary care to new services for potentially severe mental illness, which must be locally adapted
according to the availability of resources, workforce, cultural factors and health nancing patterns. e fulcrum of this progress is the advent
of broad-spectrum, integrated primary youth mental health care services. ey represent a blueprint and beach-head for an overdue global
system reform. While resources will vary across settings, the mental health needs of young people are largely universal, and underpin a set of
fundamental principles and design features. ese include establishing an accessible, “soft entry” youth primary care platform with digital sup-
port, where young people are valued and essential partners in the design, operation, management and evaluation of the service. Global progress
achieved to date in implementing integrated youth mental health care has highlighted that these services are being accessed by young people
with genuine and substantial mental health needs, that they are beneting from them, and that both these young people and their families are
highly satised with the services they receive. However, we are still at base camp and these primary care platforms need to be scaled up across
the globe, complemented by prevention, digital platforms and, crucially, more specialized care for complex and persistent conditions, aligned
to this transitional age range (from approximately 12 to 25 years). e rising tide of mental ill-health in young people globally demands that
this focus be elevated to a top priority in global health.
Key words: Youth mental health, integrated mental health care, primary care platforms, global mental health, early intervention, prevention,
digital platforms
(World Psychiatry 2022;21:61–76)
People aged 10-24 years make up a
quarter of the world’s population1. Men-
tal ill-health represents the number one
threat to the health, well-being and pro-
ductivity of these people, with 50% of men-
tal disorders rst emerging before 15 years
of age and 75% by 252. Mental disorders
are extremely common in young people,
with more than 50% impacted by the age
of 253-5.
is landscape appears to be changing
for the worse. Young people have expe-
rienced disproportionately worse men-
tal health outcomes since the start of the
COVID-19 pandemic6, with 74% reporting
that their mental health has worsened dur-
ing this period7. Well before the pandemic,
substantial evidence indicated that young
people were facing a rising tide of mental
ill-health, including anxiety, depressive
symptoms, psychological distress and sui-
cide8-12.
Mental ill-health accounts for a stag-
gering 45% of the overall burden of disease
in those aged 10-24 years13 and, through
suicide, is the second most common cause
of death14. The consequences of this are
enormous, affecting young people, their
families and community, as well as the
economy at a local, national and global
level.
Adolescence and the transition to adult-
hood is a dynamic and developmentally
sensitive period. Mental ill-health dur-
ing this life stage disrupts a range of mile-
stones, including identity and relationship
formation, educational and vocational
attainment, nancial independence, and
achieving autonomy.
Key demographic changes have trans-
formed this threat into what has been
termed a “perfect storm”15. Although child-
hood mortality has fallen dramatically over
the past century, the birth rate is dropping
and the human lifespan is lengthening.
is increases greatly the dependence of
society on the health and productivity of
young people. We simply cannot aord the
loss of productivity wrought by prevent-
able, untreated or poorly treated mental
ill-health in young people. More than ever,
we need to prevent or reduce premature
death and disability in young people to
enable them to shoulder the burden of the
dependent older population.
Furthermore, because mental ill-health
in young people is a potent yet largely ig-
nored risk factor for age-related physical
illnesses later in life16, eective treatment
of mental ill-health in youth will help to
reduce the total burden of disease in older
people. Responding eectively to this “per-
fect storm” will deliver enormous benets
not only to young people but to people
across the lifespan and the whole of society.
THE DEVELOPMENTAL
CHALLENGE
e journey from childhood to mature
adulthood is now more complex and pro-
tracted than ever before, as a result of the
changing social construction of the tran-
sition, the extension of the lifespan, the
later age of marriage and childbirth, and
a raft of other destabilizing social, techno-
logical and economic changes in society,
including globalization, rising inequality
and climate change17,18. All this has intro-
duced new features into the landscape of
the developmental process, which have
been captured under the rubric “emerging
adulthood”19.
62 World Psychiatry 21:1 - Februar y 2022
The voices of young people confirm
how different it is to be a young person
navigating the transition to mature adult-
hood now than it was even 20 years ago,
and provide deep insights into how society
and health care systems should respond20.
Young people’s journey to maturity is ac-
companied by increased levels of instabil-
ity and risk20, which helps to explain why
we are facing this public health crisis.
e journey involves several key phas-
es, beginning even prior to birth, with early
childhood a particularly crucial stage dur-
ing which key risk and protective factors
inuence life chances and trajectories of
opportunity. However, the period from pu-
berty to mature adulthood is also of enor-
mous importance, with dramatic external
changes in biological maturity, mirrored
by less visible changes in brain structure
and function, in psychological develop-
ment and in social and vocational pro-
gress17.
The challenge of evolving a sense of
self, of individuating from one’s family of
origin and establishing a life and family of
one’s own is daunting, and stress, frustra-
tion, risk and loss are ambient within the
ecosystem of growth. The philosopher J.
Campbell characterized the “Hero’s Jour-
ney” as a monomyth with deep relevance
to the human condition21, and this is a
metaphor which is useful in normalizing
the level of challenge and threat that we
all face during the struggle for maturity. It
creates the space for a “positive psychol-
ogy” perspective, that is a strength-based
stance to distress and struggle during the
transition to adulthood. It also allows us to
accept and see value in a soft border, a ex-
ible boundary between mental health and
mental ill-health during the struggle, and
to validate a role not only for the “scaold-
ing” of the family and the social network
surrounding the young person, but also for
mental health professionals and treatment
of mental “injury” and illness.
This concept navigates the space be-
tween the concern about labelling com-
mon experiences as abnormal and recog-
nizing the crucial need for help and sup-
port, including expert medical and pro-
fessional help under certain conditions.
Finally, while it confronts and accepts the
extent of the threats and challenges and
the possibility of defeat, it holds out the
hope of ultimate success even in the dark-
est times. ese are all valuable elements
for a positive, modern day approach to the
mental health care of young people.
THE ECONOMIC IMPERATIVE
From a socioeconomic perspective, e -
merg ing adulthood is a crucial period for
“mental wealth”. Mental wealth is dened
as an individual’s cognitive and emotional
re sources that provide the foundation for
educational and vocational success, high
quality of life and signicant contribution
to society22,23. e development of mental
wealth during emerging adulthood has
impacts across the life course and, if dis-
rupted, may perpetuate a cycle of poverty,
homelessness or crime24,25. Mental ill-
health in youth, therefore, inuences the
social cohesion and productivity of the
whole community.
Society invests heavily in nurturing
young people from birth to the threshold of
productive life. If they become disabled or
die during this transition, or even if they fail
to reach their potential and underachieve,
there is a serious and widespread erosion
of productivity. e World Economic Fo-
rum rst recognized this in 2011, when it
discovered that mental illness makes the
largest contribution to loss of gross domes-
tic product among all non-communicable
diseases, accounting for 35% of the global
economic burden, followed by cardiovas-
cular disease (33%), cancer (18%) and dia-
betes (4%)26.
e World Economic Forum estimated
that by 2030 mental ill-health alone would
account for a loss of US$16 trillion in global
economic output. is impact is specical-
ly because of its timing of onset in young
people and consequently its extended im-
pact across the decades of productive adult
life. Most young people do not receive
evidence-based care in a timely or quality
way, hence much of the burden of mental
illness, while avertable, is not averted, re-
sulting in chronic, persistent and disabling
illness across the productive decades of
adult life, causing enormous suering and
weakening economies and societies.
In terms of economic participation, the
employment landscape is rapidly evolv-
ing and young people are facing one of the
most disruptive workforce changes, due to
economic developments in automation,
globalization and collaboration27. Seventy
percent of young people are currently en-
tering the labour market in roles that will
likely be obsolete or radically transformed
over the next decade27. e young work-
force has been casualized, and is highly in-
secure. Inequality is rising steadily across
the world and even increased during the
COVID-19 pandemic28.
e future job market will place a high
premium on skilled labor27, meaning that
educational participation and success will
be critical. Forty-eight percent of people
who develop a severe form of mental ill-
ness fail to complete high school29 and the
erosion of educational attainment surges
further within higher education. Com-
pared to their peers, young people with
mental illness are nearly twice as likely not
to be in education, employment or train-
ing (NEET)30, reducing both the workforce
and tax base. Together with an ageing pop-
ulation, a declining youth workforce and
tax base will likely increase the burden on
the working population, raise expenditure
on long-term health care31, and reduce
economic growth.
While the economic impacts of men-
tal ill-health are clear and overwhelming,
adequate investment in mental health, in-
cluding for young people, has been grossly
neglected worldwide, especially in non-
WEIRD (Western, Educated, Industrial-
ized, Rich and Democratic) countries32,33.
is state of aairs reects a combination
of factors, including morbidity and mor-
tality from communicable diseases, wide-
spread poverty as well as lack of political
will and stability, and limited infrastruc-
ture. e inuence of the COVID-19 pan-
demic on this mindset will be interesting
to analyze.
e economics of mental health extend
beyond the need for funding. Inaction
or insufficient investment comes with a
range of avertable and long-lasting costs,
including lost productivity, loss of earnings
and welfare dependency, that impact all
of society34-36. Early diagnosis and treat-
ment is one proven strategy to mitigate
the social and economic impact of mental
World Psychiatry 21:1 - February 2022 63
disorders which can be scaled up37. The
costs of inaction fall heavily on govern-
ments and economies, highlighting that
policy-makers cannot aord to underfund
youth mental health. Return on invest-
ment analysis enables decision-makers to
compare investments in the youth mental
health system37 with those in other areas of
the health system and the economy.
CURRENT STATUS OF MENTAL
HEALTH CARE FOR YOUNG
PEOPLE
To understand why such an obvious
public health opportunity has been over-
looked until recently, we need to examine
the history and evolution of mental health
care. It is only relatively recently that adult
mental health care evolved from the alien-
ist era of stand-alone psychiatric institu-
tions to join the mainstream of general
health care. is is a process by no means
complete across the globe. Even where this
has occurred, it has often been poorly de-
signed and funded, and has continued to
focus almost exclusively on the extremely
acute or the prevalent cases, that is middle-
aged people with chronic, persistent and
disabling illnesses.
Young adults, where the bulk of inci-
dent cases emerge, were not placed at a
premium, as are incident cases in cancer
and other major non-communicable dis-
ease elds. Rather, they and their families
found that they had to “prove chronicity”
to “deserve” and justify access to a model
of care characterized by a blend of the “soft
bigotry of low expectations”, the “clinicians’
illusion”38 and a culture of neglect and low
morale. Early intervention has been a very
hard sell in psychiatry39-41.
If we now turn to child psychiatry, its
origins are quite different. The sub-spe-
cialty originally arose from the child guid-
ance movement, and initially focused on
younger children. While in recent decades
its focus has reached up to include ado-
lescents and it is now labelled “child and
adolescent psychiatry”, it has adhered to a
paediatric model in which the boundary
with adult health care is set at 18 years on
legal, rather than health and developmen-
tal grounds.
e epidemiology of mental illness and
the developmental needs of young people
demand a radically dierent approach in
psychiatry42,43. Mental illness is the mirror
image of physical illness, with the greatest
need for care located during the period
of maximum physical health, at least in
modern globalized societies. Further-
more, while adult psychiatry has strug-
gled for parity within health systems, child
and adolescent psychiatry has faced an
even greater challenge to establish itself,
and remains seriously underdeveloped
and underfunded. Even in the prosper-
ous European Union, child and adoles-
cent mental health services are sparse or
invisible, except in a very small number of
countries44.
e result of the weak and divergent evo-
lution of these two traditions within psychi-
atry is that adolescents and young adults,
despite having the greatest level of need,
have the worst access to timely, quality spe-
cialized mental health care. e same ap-
plies to primary mental health care which,
just like specialized care, is poorly designed
and culturally ill-equipped to engage and
respond to mental ill-health in young peo-
ple, who typically do not seek or access
help from traditional primary care provid-
ers45. Young people are well able to explain
why current health and mental health ser-
vices simply do not appeal to or work for
them20.
In summary, the health system has been
designed to meet the needs of people with
physical illness, which means a dominant
focus on young children and older adults.
Mental health care has been “shoehorned”
into this system with little foresight, logic or
equity. e paediatric model of care simply
does not work for mental health, as recent
research has shown46,47. Not only the ma-
jority of young people fail to gain access at
all or do so only after long delays but, even
for those who do, an appropriate transition
from child and adolescent mental health
services to adult care is rarely achieved48.
Access and quality for the 19-25 age group
is also very poor.
The different origins and cultures of
these care systems, funding neglect and
the fact that the transition is demanded at
the worst possible point in time are jointly
responsible for young people’s low rates
of service access and engagement. Young
people and their families are forced to nav-
igate a new and often quite dierent sys-
tem before they are ready and when they
are least able to do so. Barriers to accessing
appropriate care, or reluctance to engage
with developmentally inappropriate ser-
vices, are strong contributors to a majority
of young people not accessing or receiving
mental health care when needed.
e success of the early psychosis mod-
el and its “proof of concept” for early inter-
vention49 has encouraged the wider appli-
cation of early diagnosis and specialized
treatment for the full range of emerging
disorders in young people50-52. e early
psychosis model delivers timely, compre-
hensive evidence-based intervention from
the earliest stages of psychotic illnesses
with the necessary “scaffolding” assem-
bled and supported so that young people
maximize their chances of recovery. Con-
sistent evidence supports its cost-eective-
ness53,54, and the embedding of specialist
education and employment services, such
as Individual Placement and Support55, of-
fers long-term economic benets37.
The early psychosis model has dem-
onstrated, as with other non-communi-
cable diseases, that early detection and
pre-emptive stage-linked treatment will
improve prognosis and reduce disability
and disengagement. From initial service
development in the early 1990s, there are
now early psychosis intervention services
established in many countries across the
world52,56-61.
While the principles of early interven-
tion, co-design, and holistic biopsycho-
social care could be translated from early
psychosis to the full spectrum of mental ill-
health in young people, it was clear to us,
as we began this task in 2001, that the scale
of unmet need and the epidemiology of
mental illness demanded a more complex
and tiered or staged approach. In any given
region or catchment area, the incidence of
psychosis is dwarfed by the total incidence
of mental disorders in young people. is
includes anxiety, mood disorders, eat-
ing disorders, personality disorders, and
substance use disorders, and blends of
these dimensions. Specialist services alone
would inevitably fail to address the scale of
the problem.
64 World Psychiatry 21:1 - Februar y 2022
Early intervention demands rapid and
smooth access to care and this all pointed
to the essential value of a high volume pri-
mary care model43. It has been recognized
for some time by the World Health Organi-
zation that the fulcrum of mental health
care across the globe needed to shift to
and focus on primary care62. ere are so
many advantages in pursuing this as the
entry portal: reduced stigma, greater band-
width and capacity, and genuine feasibility
across most health care contexts, includ-
ing low- and middle-resource settings, in
terms of cost and workforce. However, the
problem we immediately faced in high-
resource settings, such as Australia, was
that general practice and standard primary
care was not seen by young people as a set-
ting to seek help for mental ill-health and
related distress. Nor was this setting youth
friendly or suciently skilled or resourced
to respond20.
BUILDING A SYSTEM OF YOUTH
MENTAL HEALTH CARE FOR
THE 21ST CENTURY
In response to the limitations and fail-
ures of the traditional mental health sys-
tem20, a broad-spectrum youth mental
health approach has emerged since the
turn of the century and is gaining trac-
tion in many high-resource settings63-65.
New models of integrated youth primary
mental health care have spread across the
globe65. The focus is now the age group
12-25 years, ending the harmful transition
point at 18 years.
This focus requires developmentally
and culturally appropriate design features
that acknowledge the complex and evolv-
ing biopsychosocial issues, recognizing
the developmental crises, uid symptom
patterns and comorbidity seen in this age
group42,43. is means that services must
be co-designed, accessible, with “soft en-
try” (i.e., no or very low barriers to entry),
community-based, non-judgmental and
non-stigmatizing, where young people
feel comfortable and have a sense of trust,
and their families and friends are includ-
ed66.
It also means that the center of gravity
must be located in the community, with an
enhanced primary care model, that a clini-
cal staging approach67 should be adopted,
and that secondary or more specialized
mental health care will have to restructure
and align to enable more intensive and
sustained, longer-term care.
An international network of academ-
ics, health professionals, educators, young
people, families and other leadership – the
International Association for Youth Mental
Health (www.iaymh.org) – was established
in 2010 to support this process of global re-
form. In 2019, the World Economic Forum
started a formal partnership with Orygen
to work with stakeholders worldwide to
develop a Global Framework for Youth
Mental Health68. is process involved lit-
erature reviews of the scientic evidence,
global surveys, face-to-face workshops
and extensive online and face-to-face con-
sultations with young people and other
key stakeholders from many different
countries and settings. A number of prin-
ciples were agreed upon and a framework
for dierent levels of health resources was
proposed.
The key principles underpinning the
implementation of youth mental health
care include: a) prevention and early in-
tervention; b) youth participation, respect,
empowerment and co-design; c) com-
munity engagement, education and con-
sultation; d) “soft entry” without stigma
or nancial barriers; e) choice regarding
options for access and for treatment and
care; f) family engagement and support; g)
scientic evidence as a key guide. e way
models of care can be deployed in dierent
resource setting is captured in Table1.
It has proven relatively easy to get a
global consensus around the principles to
guide youth mental health reform. Trans-
lating these principles into practice is a
more challenging step, but there has been
encouraging progress in recent years in
many parts of the world. ese advances
can be described within a comprehensive
framework including the following key el-
ements: a) community awareness; b) pre-
vention programs; c) volunteers, youth and
peer workers; d) digital mental health plat-
forms; e) educational settings and work-
places; f ) integrated primary youth mental
health care; g) specialist youth community
mental health care; h) residential care.
COMMUNITY AWARENESS
e rst step in reducing the burden of
mental ill-health in young people is to ed-
ucate the public in every society about the
nature and pattern of mental ill-health and
how it can be prevented, recognized, and
responded to safely and eectively as soon
as it emerges. Community awareness, anti-
stigma and mental health promotion pro-
grams have been successfully deliv ered in
many countries in recent years, though most
have been generic or adult focused69,70.
ere are many worldwide examples of
youth focused awareness campaigns, which
have been a mix of mental health promo-
tion and education on the warning signs
of emerging mental ill-health. Mental
Health First Aid71 has produced a version
for adolescents72 and this has recently
been evaluated73,74. There are sustained
benets for participants, but benets for
young people have been dicult to dem-
onstrate and the focus on under 18s is
asignicant limitation. “headspace Day”
in Australia is another example (https://
headspace.org.au/about-us/our-cam-
paigns/). ReachOut, which was one of the
first to use the power of the Internet to
reach young people, is one of the best ex-
amples. More recently, Batyr has comple-
mented an online approach with face-to-
face strategies in educational settings. Jack.
org in Canada is youth-led and delivers
nationwide programs and campaigns in
youth mental health awareness and pro-
motion. In the UK, YoungMinds is creating
a youth-led movement to improve mental
health awareness and the support avail-
able to children and young people. ese
programs are described with some more
details in the following sections.
ReachOut
Established in Australia in 1998, Reach-
Out is a web-based mental health promo-
tion, early intervention and prevention
service for young people aged 12-2575.
Co-design and youth participation have
been central to its development and de-
livery76.
ReachOut aims to improve young peo-
ple’s mental health literacy, resilience,
World Psychiatry 21:1 - February 2022 65
social connectedness, and help-seeking
behaviors through self-help information,
peer support forums and referral tools75,77.
It also oers support and resources to par-
ents and schools. e service is accessed
by more than 2 million people in Australia
annually78.
Nearly three-quarters of young people
accessing ReachOut are experiencing high
or very high levels of psychological dis-
tress75. A recent evaluation found that the
service is accessible and relevant to young
people, increases help-seeking behaviors,
and signicantly reduces depression, anxi-
ety, stress and risk of suicide78,79.
batyr
Launched in 2011, batyr is a preventive
mental health organization in Australia
that aims to reduce stigma and promote
help-seeking. e batyr model draws upon
a body of evidence highlighting the as-
sociation between disclosure, stigma and
well-being80.
batyr delivers educational workshops
on mental health in schools (batyr@
school), universities (batyr@uni) and
workplaces (batyr@work). Presenters are
trained through the Being Herd program,
a free two-day workshop that aims to em-
power young people (18-30 years) to share
their lived experience of mental ill-health.
The Being Herd program has trained
over 700 young people to date and has
been associated with improved well-being
in trainees as well as reduced self-stigma
and stigma towards others80. e batyr@
school program has reached over 200,000
young people across 352 secondary schools
in Australia.
An unpublished randomized controlled
trial found that batyr@school reduced stig-
ma and increased attitudes and intentions
to seek professional mental health care81.
These findings were maintained three
months after the program81. Both second-
ary and university students report that the
batyr programs are highly engaging (82%
and 85%, respectively) and increase the
likelihood of seeking mental health sup-
port (70% and 78%, respectively).
Jack.org
Recognizing an absence of programs
to train youth mental health advocates in
Canada, Jack.org was established in 2010
as a youth-led mental health promotion
and prevention initiative targeting young
people aged 15-24.
e organization aims to increase men-
tal health literacy, reduce stigma, and
improve help-seeking behaviors through
three core programs: Jack Talks (peer-
to-peer mental health presentations),
Chapters (community-based, youth-led
working groups), and Summits (youth-led
conferences). Online resources are also
available to educate young people on how
to support their peers.
In 2019, Jack.org reached over 170,000
young people, and 446 Jack Talks were pre-
sented by trained and certied speakers.
Eighty-seven percent of Jack Talks attend-
ees report that the presentation helped
Table 1 Delivering youth-specific mental health care across resource settings
COMMUNITY PRIMARY CARE SECONDARY CARE TERTIARY CARE
HIGH-RESOURCE
SETTINGS
Community education,
screening and early
detection programs
Prevention programs (e.g.,
anti-suicide, anti-bullying)
School, university and
workplace awareness and
early detection programs
Digital mental health
platforms
Integrated youth (12-25 years)
health and social care
platforms as “one-stop
shops”
School and university mental
health services
Digital interventions and
telehealth integrated with
primary care
Multidisciplinary youth
mental health systems
providing face-to-face
and online care closely
linked to primary care and
community platforms
Complementary integrated
digital platforms
A suite of specialized,
co-designed youth inpatient
and residential services
linked to acuity and stage
of illness
Home-based acute care
and assertive community
treatment
MEDIUM-RESOURCE
SETTINGS
Community education,
prevention, and
school-based programs
Digital mental health
platforms
Integrated youth health and
social care platforms as
“one-stop shops”
School and university mental
health services
Digital interventions and
telehealth integrated with
primary care
Multidisciplinary community
mental health teams
(face-to-face or online)
Complementary integrated
digital platforms
Inpatient services distinct
from adult facilities and
home-based acute care if
this is not feasible
LOW-RESOURCE
SETTINGS
Community education,
prevention, and
school-based programs
Digital mental health
platforms
Volunteer, peer or lay worker
programs (Friendship Bench
concept)
Digital interventions and
telehealth platforms
Primary care health
professionals, including
general practitioners and
volunteers, trained in youth-
friendly practice and mental
health skills, providing care
within community primary
care settings with face-to-
face, telehealth and digital
options
Home-based acute care
66 World Psychiatry 21:1 - Februar y 2022
them think more positively about mental
health.
YoungMinds
YoungMinds is a UK charity focused
on ensuring that all young people receive
the mental health support that they need
when they need it. It oers online support,
workshops and face-to-face training to
young people, parents, schools and profes-
sionals.
In 2019/2020, nearly 2.5 million UK us-
ers visited the YoungMinds website and
11,959 parents and carers contacted its
helpline, with 77% of parents reporting
that they modied their approach to sup-
port their child following advice from the
helpline82. An evaluation found that the
helpline is benecial to 88% of those who
use it83. In 2019/2020, YoungMinds pro-
vided in-house training to 70 schools and
organizations, with 97% of trainees rating
the course highly82. Training is delivered to
over 10,000 professionals each year.
YoungMinds also oers a agship three-
year activist program for young people
aged 14 to 25 with a lived experience of
mental ill-health, who campaign to raise
awareness of youth mental health. Ninety-
seven percent of activists reported better
knowledge of their mental health and 83%
felt more condent to speak about mental
health issues82.
PREVENTION PROGRAMS
Prevention is better than cure, and many
of the risk and protective factors for mental
ill-health are well characterized84. Howev-
er, there is evidence for a rise in incidence
and prevalence of mental ill-health in
young people and of suicide rates, especial-
ly in young women12,85. A role is suggested
of social media and new technologies, cli-
mate change and a range of socio-econom-
ic forces in undermining the mental health
and well-being of young people18,86.
Specific programs targeting some of
these risk factors, for example, anti-bully-
ing programs87, chatsafe to reduce risks of
suicide via an online strategy88, and resil-
ience programs in schools89,90, have some
value91. However, other risk factors are not
especially malleable and are more widely
social and economic in nature and scope
(e.g., climate change and social media).
Prevention is a concept that extends
across a spectrum and includes all stages
of care. Fusar-Poli et al92 recently reprised
in this journal the US Institute of Medicine
model of the spectrum of prevention in
mental health93, highlighting the distinc-
tion between universal, selective and in-
dicated prevention and confirming that
indicated prevention has been the most
promising avenue for progress in recent
years and has further potential94.
As with other major non-communica-
ble disease areas such as cancer, all aspects
of prevention and preventively oriented
treatment are valuable. However, what can
be delivered in the foreseeable future in
terms of universal prevention95,96 remains
uncertain. Preventive health care can op-
erate across the full spectrum, and unnec-
essary false dichotomies between classic
primary prevention and treatment merely
undermine consensus and momentum92.
“SOFT ENTRY”: INNOVATIONS
WITH VOLUNTEERS, YOUTH
AND PEER WORKERS
e extreme shortage of mental health
professionals in low-resource settings, and
the relative shortage due to high need and
inadequate funding in middle- and high-
resource settings, has driven valuable in-
novation.
e most famous example of this is the
Friendship Bench97, devised and imple-
mented in Zimbabwe. This concept has
been enhanced as a “Friendship Bridge”,
a flexible way of engaging marginalized
young people from a variety of cultural
backgrounds. Similarly, in some high-re-
source settings, youth mental health mod-
els have drawn upon students and other
young volunteers to facilitate engagement
and make it more informal and less of
a barrier (e.g., https://www.ease.nl and
https://headspace.dk).
The advent of paid peer workers in
youth mental health has similar goals and
benefits98,99. With appropriate training,
volunteers and peer workers can not only
help to absorb substantial need for care
at the front end of services, but also make
the experience of entering care less chal-
lenging and more welcoming, especially
for first time users, offer compassionate
support, and deliver simple therapeutic
interventions.
This is a component of youth mental
health care which can be developed in all
communities, and is in fact not a substitute
for scarce workforces, but adds substantial
value irrespective of the level of health -
nancing and resources.
DIGITAL MENTAL HEALTH
PLATFORMS
Young people are digital natives and the
digital world is a fundamental element in
their lives. While the establishment of in-
tegrated youth mental health services has
improved young people’s access to men-
tal health care (see below), the volume of
demand and workforce challenges have
highlighted the need to develop further
platforms that can adequately address the
scale and diversity of need. e delivery of
high quality mental health care through
digital technology is considered key to this
endeavour, emphasized by the COVID-19
pandemic100.
e integration of digital technologies
within youth models of care has several
advantages, including improved service
efficiency and access to care100,101, po-
tentially reducing the treatment gap in all
resource settings. While the use of digital
technologies in low- and medium-re-
source settings is acceptable, feasible and
potentially eective102, particular consid-
erations are needed regarding factors such
as language, culture, level of education,
access to technology, digital literacy, and
infrastructure103.
ere has been a rapid growth in digital
mental health research104 and, while there
have been challenges in the implementa-
tion and uptake of new digital technolo-
gies105,106, their integration within clinical
services has the potential to enhance en-
gagement107.
For anxiety and depression in young
people, a range of digital mental health
interventions are available108. These in-
World Psychiatry 21:1 - February 2022 67
volve text-messages (e.g., ReachOut, Rise
Up), computer games (e.g., SPARX), on-
line programs (e.g., MOST, MoodGYM),
video games (e.g., Maya), online courses
and chat groups (e.g., Master Your Mood),
and mobile apps (e.g., Mayo Clinic Anxiety
Coach). Interventions that involve supervi-
sion or regular contact with a therapist are
more likely to be eective than unsuper-
vised educational programs. Engagement
and retention are issues requiring atten-
tion108.
Promising platforms that combine face-
to-face mental health care with digital in-
terventions are described in the following
sections.
Moderated Online Social Therapy
(MOST)
Developed in Australia by a multidisci-
plinary team of clinical psychologists, de-
signers, young adult novelists, comic artists
and software engineers, Moderated Online
Social erapy (MOST) is a seamless digi-
tal solution adopting a user-centred design
model. It is safe, eective and valued by cli-
nicians, young people and families.
The intervention offers young people
continuous access to evidence-based ther-
apy and peer and clinical support from
any Internet-enabled device. All included
therapy has been adapted and enhanced
based on a decade of youth feedback and
usage data, to ensure that the young per-
son’s perspective is captured and the range
of interventions feels uniquely relevant to
their daily life. is therapy is embedded
within a supportive online community of
other young people working on their men-
tal health, aiming to shift the treatment
experience from one of isolation to one of
shared mission.
MOST combines guided therapy jour-
neys, targeted coping strategies, and men-
tal health tracking with a social network of
peers, providing an enriching therapeutic
environment where young people can
safely work towards their goals, take posi-
tive interpersonal risks, and broaden and
rehearse coping skills for long-term well-
being. Therapists work alongside face-
to-face clinicians to offer wrap-around
support to young people and provide ad-
vanced intervention tailoring. Specialist
vocational consultants further support
young people with work and study.
MOST seamlessly blends human and
digital support to facilitate rapid detection
and response to any indicators of risk or
relapse between scheduled clinician con-
tacts. It is an evolving model, and through
successive iterations it has been adapted
for a range of populations: first episode
psychosis109-111, ultra-high risk for psy-
chosis112, depression113, social anxiety114,
mental ill-health115, suicidal risk116, and
relatives117,118.
A recent randomized controlled trial110
in young people with psychosis demon-
strated that Horyzons (MOST version for
youth psychosis) was associated with a
5.5 times increase in the likelihood to nd
employment or enrol in education, as well
as half the rates of visits to emergency ser-
vices and hospital admissions due to psy-
chosis, compared with treatmentas usu-
al, over 18 months following discharge
fromspecialized youth psychosis servic-
es.
Synergy
Also in Australia, Synergy is a digital
platform that aims to enhance the health,
social and physical outcomes of young
people through the delivery of personal-
ized and measurement-based care119. e
platform is embedded within youth men-
tal health services and can be congured
to meet local needs.
Co-designed with end-users120,121, the
platform facilitates a number of key pro-
cesses, including multidimensional assess-
ment, allocation of clinical stage, feedback
of assessment results, shared decision-
making, and monitoring of change over
time119. A clinical trial of Synergy is current-
ly underway122.
The “digital clinic”
In the US, the “digital clinic” oers a hy-
brid model of mental health care, augment-
ing and extending services at the Beth Israel
Deaconess Medical Center in Boston with
a smartphone app107. e clinic has a core
focus on therapeutic alliance, measure-
ment-based care and shared decision-
making107.
Components of the clinic have been
specically designed to address key barri-
ers among patients and clinicians that re-
duce uptake and engagement with digital
mental health care107. ese components
include the Digital Opportunities for Out-
comes in Recovery Services (DOORS)123
and the Digital Navigator124,125 programs,
which provide digital literacy training to
patients with serious mental illness and
clinicians, respectively.
The mindLAMP (Learn, Assess, Man-
age, Prevent) app, a digital health platform
used by the clinic and designed in con-
sultation with end-users, is customized to
each patient and has the potential to ad-
vance youth mental health care126. Core
functions of the app include education,
assessment via surveys and sensors, digi-
tal phenotyping, self-management tools,
data sharing with patients, and clinician sup -
port.
e mindLAMP app can be adapted for
implementation in all resource settings126
and is currently being used by research-
ers and clinicians in over 20 sites globally.
Preliminary ndings of mindLAMP have
highlighted the feasibility and potential
utility of digital phenotyping to augment
clinical care, although individuals under
25 years were found to complete fewer ac -
tivities on the app than older individu-
als127.
SCHOOLS AND EDUCATIONAL
SETTINGS AND WORKPLACES
Educational settings oer the opportu-
nity to promote mental health and well-
being, to educate students and teachers
about mental ill-health and how to recog-
nize and respond to it, and to oer a pri-
mary care level of initial response128-130.
is logic extends beyond school settings
to university and other tertiary educational
settings, where greater recognition of the
opportunities for proactive youth mental
health care is emerging in many coun-
tries131-133.
ese settings are best regarded as com-
munity-based populations of most, but
68 World Psychiatry 21:1 - Februar y 2022
not all, young people in which a bespoke
primary care level system of care can be
formulated and linked to other resources,
including specialist care and digital mental
health platforms.
INTEGRATED PRIMARY YOUTH
MENTAL HEALTH CARE
Integrated health care134 is a widely
endorsed approach to optimizing health
care, in view of its capacity to meet multi-
ple health and social needs from a single
platform of care. Its adaptation to young
people has been at the vanguard of reform
in youth mental health care over the past
two decades in high-resource settings. As
a version of primary mental health care62,
it should be at the heart of global reform,
as a gateway to and component of staged
care65, and ultimately in all resource set-
tings62,68.
Although there were earlier examples
of this approach135, the trigger for global
spread can be traced back to 2004, when
the Australian government agreed to fund
a new program of enhanced primary care,
named headspace. is program was de-
signed by Orygen and partners, including
national professional organizations rep-
resenting general practice and psychol-
ogy136. Other countries soon followed, no-
tably Ireland and Canada50,137-139.
is wave of innovation in youth mental
health care is now spreading globally, with
at least 12 other countries adopting an in-
tegrated youth primary care model that is
adapted to, and often limited by, the local
cultural, health nance patterns and work-
force context. e success of the headspace
model, in particular, has seen its expansion
into Denmark, Israel, the Netherlands, and
Iceland. Similar programs under dierent
branding have also been established in Ire-
land, Canada, Singapore, and the US. New
Zealand and France had independently
developed a similar model of care a little
earlier.
Common features of these models in-
clude the following. First, there is a physi-
cal, developmental and cultural separa-
tion of youth mental health platforms
from those for both younger pre-pubertal
children and those for older adults, with
an overdue shifting of the upper boundary
of youth mental health care from 18 to 25
years.
Second, the value of youth participation
and co-design is a universal success factor
and has not only changed the culture, but
also increased trust, and greatly minimized
the stigma associated with help-seeking.
This has been enhanced by the creation
of trusted, stigma-free brands, something
which has not been previously achieved in
mental health care.
ird, the “one-stop shop” aspect of in-
tegrated care, from a single location with
high visibility in the heart of the local com-
munity, enables better multidisciplinary
care to occur, and helps to future-proof
the service against the risk of defunding, to
which more diuse wrap-around models,
based on fragmented funding streams, are
more vulnerable. is approach also mo-
bilizes local community support, includ-
ing from local political representatives, and
draws in collaborative support from other
services and agencies.
Fourth, a flexible or “light touch” ap-
proach to diagnosis, especially in the early
fluid stages of mental ill-health, and a
needs- and strengths-based stance, which
suits primary care, has been a common
feature across many settings and is con-
gruent with the staging model. Finally, a
critical success factor, which improves out-
comes, is ensuring model delity through
accreditation, continuous monitoring and
quality improvement, and trademark li-
censing strategies. This limits erosion of
the evidence-based aspects of care, often
justied under the guise of local adapta-
tion.
Common challenges that have emerged
are related to patterns of commissioning,
workforce, professional work practices,
and the lack of secure nancial channels to
support the model of care. A devolved pat-
tern of commissioning undermines the ca-
pacity to safeguard model delity. Many of
the examples so far struggle to attract and
retain the full range of professionals and
rely more heavily than is ideal on youth
volunteers and peer workers, invaluable
as these are in any youth mental health ap-
proach.
Even when the model has a good bal-
ance between youth volunteers/peerwork-
ers and mental health professionals at
the primary care level, the success of the
“soft entry” approach in enabling young
people with all levels of need to gain ac-
cess means that a cohort of young people
with more complex and enduring mental
health conditions are welcomed to enter
the service. However, the model currently
lacks the capacity, the skillsets and the
tenure to fully meet the needs of this sub-
set of young people and improve their out-
comes. We have used the term “missing
middle” to denote this cohort, since, due
to the underfunding and neglect within
specialist mental health care, even in high-
resource settings, they fail to gain access
to the next tier of care unless they reach
a threshold of acute and severe illness or
chronicity140.
Nevertheless, aording primary care ac-
cess at an early stage does at least highlight
the existence of this crucial group of young
people from whom spring the ranks of the
future severely mentally ill, and creates the
potential for earlier preventive treatment.
A hidden waiting list of people with a need
for care is brought out of the shadows and
ultimately must be responded to.
Examples of programs of integrated
primary youth mental health care are de-
scribed in more detail in the following sec-
tions.
New Zealand: Youth One Stop Shops
and Piki
New Zealand pioneered the establish-
ment of “Youth One Stop Shops” in 1994.
ese provide young people (aged 10-25)
with a range of accessible, youth-friend-
ly health, social and other services in a
“wrap-around” manner.
An evaluation of 14 services in 2009
revealed that occasions of service ranged
from 2,000 to 15,000 per area, with a mean
of 11,430141. While objective data regard-
ing improvements in access and health
were unavailable, young people (94%) and
stakeholders (89%) reported that the ser-
vice was eective in improving health and
well-being141.
Following successful pilot of Piki, a
youth mental health service for young peo-
ple aged 18 to 25, the New Zealand govern-
World Psychiatry 21:1 - February 2022 69
ment recently committed to a rollout of
youth-specic primary mental health and
addiction services for young people aged
12 to 24 years. Services in 13 locations have
been announced to date. These services
will be oered in a range of places, includ-
ing in Youth One Stop Shops and commu-
nity centres.
France: Maisons des Adolescents
e “Maisons des Adolescents” (MDAs),
which began in 1999 in Le Havre, France,
are integrated health care services for
young people with physical, psychologi-
cal or social problems. While the target age
range is 11 to 21 years, sites can extend this
to 25 years135. Operating under a common
brand across 104 locations and with a na-
tional oce in Rennes, each centre pro-
vides care to between 700 and 1,000 young
people each year, and the average number
of visits is between two and three.
Young people report that the service
contributes to their well-being, while pro-
fessionals are satised that the service re-
sponds to individual needs142. Services are
varied in the content they oer, which in-
cludes a “health and prevention space” for
listening and assessment, mobile teams for
hospital in-reach and also home and com-
munity outreach visits, arts and cultural
programs, vocational support, specialist
consultations and network meetings.
Steps have been taken recently to im-
prove regulation and standardization of
the model to optimize the care provided,
prioritize needs and adapt the approach to
new societal issues. As with other models,
there is evidence of tension between a light
touch “listening” stance and more thera-
peutic interventions.
Australia: headspace
headspace was funded and designed
in 2005 by the Australian government in
response to an extensive advocacy cam-
paign for reform and investment in a na-
tional youth mental health program, which
was motivated by low levels of awareness,
access and quality of mental health ser-
vices for young Australians. e campaign
gained bipartisan political support, and
government funding was secured to sup-
port the design and implementation of the
program initially within only ten Australi-
an communities from 200666. is has pro-
gressively been scaled up to 136 centres,
through a series of government funding
rounds, and aims to reach 164 communi-
ties by the end of 2023143.
Over 130,000 young Australians access a
range of services via headspace every year,
and over half of young people attending
headspace present with high or very high
levels of psychological distress144. By late
2020, headspace had supported 626,000
young people with over 3.6 million occa-
sions of service145.
e headspace model provides a youth-
friendly “one-stop shop” service for young
people to access a range of health and so-
cial programs, including mental health,
physical and sexual health, vocational and
educational support, and drug and alco-
hol education and interventions43,66. A na-
tional online support service (eheadspace)
is also available over extended hours,
where young people can chat with a men-
tal health professional online or by phone.
headspace also delivers mental health
programs in schools nationally, in partner-
ship with beyondblue (www.beyondblue.
org.au), which enhance mental health
literacy and skills among teachers and of-
fer suicide postvention support145. Online
work and study support is available to
complement face-to-face vocational (Indi-
vidual Placement Support) interventions.
headspace operates on an enhanced
primary care model, providing a multidis-
ciplinary team structure with close links
to local community supports (e.g., schools
and specialist mental health care). It is a
form of franchise with a national brand
which requires adherence to a measurable
template of care. Until 2016, the headspace
national oce commissioned a single lead
agency within a wider local consortium
at each site to deliver the service. Now 31
devolved regional primary health care
networks perform this function on behalf
of the Australian government, while the
national oce assesses adherence to the
model and controls the license and trade-
mark.
headspace has undergone two sepa-
rate independent evaluations146,147, which
showed major improvements in access for
young people, including for marginalized
groups, notably Indigenous andlesbian,
gay, bisexual, trans and intersex (LGBTI)
young people. More than 60% of young
people experience short-term improve-
ments148, and a follow-up study of those
who engage has shown sustained ben-
ets with high levels of satisfaction among
young people and families149. A third eval-
uation is in progress.
e current headspace funding model
is modest and supports only brief episodes
of care, yet open access is provided to all
young people, including the “missing mid-
dle”, the large cohort of young people who
need more intensive, sustained and com-
plex interventions but fail to access them.
In Victoria, specialist services are now be-
ing aligned with the 12-25 headspace age
range and will be substantially boosted150.
Early psychosis programs linked with head-
space exist in a number of regions of Aus-
tralia, also span the adolescent-young adult
age range, and can be expanded transdiag-
nostically to ll this gap.
e rising level of unmet need and the
widely known and trusted brand and entry
portal are now resulting in increasing wait-
lists151. Workforce shortage, and the rela-
tive nancial weakness of the model and
of the specialist back-up system of care, are
issues that must now be addressed. Fortu-
nately, political and community support
for headspace has led to a boost in invest-
ment in the 2021 federal budget.
headspace, as a disruptive and popu-
lar reform, and still a work in progress,
has had its critics, which to a degree have
been helpful in eliminating aws and im-
proving the model of care39,152-154. Finally,
the COVID-19 pandemic created obvious
challenges, generating an increased need
for care with reduced accessibility7. The
latter was buered by the federal govern-
ment’s support for telehealth and mobile
outreach.
Ireland: Jigsaw
In 2006, in the context of a national re-
form, concern about youth suicide, and
influence by headspace in Australia, the
70 World Psychiatry 21:1 - Februar y 2022
One Foundation created headstrong as the
national youth mental health foundation
of Ireland. Jigsaw became the publicly fac-
ing brand for the service and later the sin-
gle brand for the whole organization139,155.
Prior to its development, there was very
limited mental health access available to
young people in Ireland, particularly for
those with mild to moderate mental health
needs, with state funded child and ado-
lescent mental health services seriously
under-resourced and only able to provide
care to a small minority of young people
with more severe mental illness, and not
even up to the age of 18.
Jigsaw’s approach incorporates free
one-to-one clinical supports and brief
clinical interventions that are accessible to
young people when and where required.
Community and school based programs
are additional features.
e program has grown from ve pilot
sites in 2010155 to 14 services in 2020 (in-
cluding one digital service), with an ad-
ditional service opening in 2021. Services
have provided access and care to over
44,000 young people since 2007. e pro-
gram is highly accessible and signicantly
reduces psychological distress (62% aged
17-25 show a reliable and clinically sig-
nicant improvement), with high levels of
satisfaction among young people and their
parents156-158.
For a number of years, Jigsaw was only
funded by philanthropic sources, but even-
tually the national government came on
board, and in 2015 the program was in-
cluded in the national Health Service Ex-
ecutive annual service plan and received
signicant mainstream funding. is fund-
ing has grown year-on-year to support the
expansion of services, and the Health Ser-
vice Executive now funds the majority of
costs associated with service delivery.
e challenge, as in Australia, now in-
volves filling the gap between Jigsaw, as
the entry point to youth mental health care
with only brief and limited capacity, and
the specialist mental health services for
young people, which needs major reform
and investment to engage with the pri-
mary care reform. A stronger role for gen-
eral practitioners is hampered by the lack
of universal health care and government
funding for primary care in Ireland.
Canada: ACCESS Open Minds,
Foundry, Youth Wellness Hubs
Ontario, Aire ouverte
Youth mental health reform in Canada
followed a common pattern, with catalytic
leadership from philanthropy. The Gra-
ham Boeckh Foundation allocated sub-
stantial funding, in partnership with the
Canadian Institutes for Health Research,
to create ACCESS Open Minds, a pan-
Canadian network transforming mental
health care for young people in 16 diverse
communities (seven provinces and one
territory), with an emphasis on high-risk
populations (e.g., Indigenous communi-
ties)137,159.
e ACCESS Open Minds model is ad -
apt ed to local circumstances, reecting the
geographic, political and cultural diversity
in Canada. Key elements of service trans-
formation within each site include: sys-
tematic service planning; early case iden-
tification; rapid access; integrated youth
space; appropriate care; active youth and
family engagement; training of clinical
sta; and building research and evaluation
capacity137.
A total of 7,539 young people between
May 2016 and August 2020 have received
services with rapid access, high levels of
satisfaction and small to medium effect
size improvements in distress, symptoms,
and social and vocational functioning160.
A wide range of clinical and social ser-
vices are oered. In contrast to other mod-
els, the majority of young people are expe-
riencing moderate to severe conditions160,
and it is this subgroup that improves more
with the interventions that are provided. A
key feature has been the success achieved
with Indigenous communities, LGBTI
and ethnic minorities, in which trust and
ease of access has been demonstrated160.
Evaluation of ACCESS Open Minds is un-
derway161.
e widespread advocacy and support
from the Graham Boeckh Foundation has
led to several provincial integrated youth
services initiatives in Canada. These in-
clude Foundry in British Columbia, Youth
Wellness Hubs in Ontario, and Aire ou-
verte in Quebec.
Established in 2015, Foundry is a net-
work of service centers across British Co-
lum bia, offering low-barrier (i.e., self-refer ral,
walk-in and free) access to mental health,
substance use, general and sexual health
care, and social services. A team of care and
service providers work with each young
person, and services are appropriately tar-
geted to the young person’s level of need
using a stepped care approach.
Each Foundry centre is operated by a
lead agency that brings together local part-
ners, service providers, young people and
caregivers. During the rst two and a half
years, 4,783 young people accessed care
through six service locations. Eighty-one
percent of young people who accessed
the service had high or very high levels of
distress162. e model has improved out-
comes and ensured greatly improved ac-
cess to marginalized subgroups, including
Indigenous, LGBTI and others, and is con-
tinuing to expand across the province.
Youth Wellness Hubs Ontario was ini-
tiated following the development of three
integrated youth mental health services
launched in Toronto as part of YouthCan
IMPACT, a federally-funded randomized
controlled trial of the integrated youth
mental health service model compared to
treatment as usual in hospital-based out-
patient adolescent psychiatryservices163.
In 2017, the Government of Ontario ex-
panded the integrated youth services
model to six additional communities. Ini-
tial service delivery emphasized integra-
tion of existingmental health, substance
use, general health and social services,
provided in-kind, with modest funding
enhancement from government and phi-
lanthropy. These services unified under
the Youth Wellness Hubs Ontario umbrella
to form a network of ten integrated youth
services which was included in the Ontario
government’s strategic mental health plan
and secured permanent funding164. Work
is ongoing to expand the model and dem-
onstrate its feasibility, appropriateness and
outcomes in Ontario’s diverse communi-
ties.
In the province of Quebec, a network of
integrated youth services (“Aire ouverte”)
has also been established for young peo-
ple aged 12-25. Similar to the above, these
services aim to provide low-barrier and
easy access to a range of health and social
services. ere are currently three centres,
World Psychiatry 21:1 - February 2022 71
with others due to open throughout the
province.
Denmark: headspace
headspace Denmark was established
in 2013 as an initiative of Det Sociale Net-
værk, a non-governmental organization.
While based on and branded similarly to
the Australian model, the Denmark model
has been adapted to meet local needs.
headspace Denmark is a free support
and counselling service predominately
delivered by trained volunteers, including
young people, who work in pairs. e ser-
vice does not yet oer clinical treatment to
young people. Instead, it provides a young
person with “someone to talk to”. Approxi-
mately one in ve young people accessing
headspace Denmark are referred to other
services for treatment or specialized care.
At present, there are 28 centers in Den-
mark in 26 municipalities (in addition
to a nationwide anonymous video and
text-based chat service). e government
is now engaged and contributing funds.
rough continued state co-nancing, it is
anticipated that headspace Denmark will
expand to 32 centers in 2022, which will
establish it as a nationwide face-to-face
service with 50% coverage, and expand its
position as the largest preventive and men-
tal health-promoting civil society project
for vulnerable young people in Denmark.
Formal evaluation of headspace Denmark
is currently underway.
Introducing clinical expertise and, as
elsewhere, building a bridge with special-
ist clinical services for young people, will
be crucial challenges.
Iceland: Bergid headspace
Bergid headspace was established in
Iceland through the advocacy of S. Bergs-
dottir. Since 2019, this low-threshold sup-
port and counselling service operates in
Reykjavík, with outreach counselling avail-
able in other regions of Iceland in addition
to online. By the end of 2020, a total of 390
young adults had accessed its services.
A range of data, including self-report
questionaires, are collected. e average
number of sessions attended is four, but
young adults often return for subsequent
episodes of care. e average age of those
who sought services is 19 years, and 90%
of the individuals are from the capital area
around Reykjavik.
Israel: headspace
headspace Israel was established in 2014
in response to low help-seeking rates and
a lack of public health services for young
people with emerging mental ill-health.
Once again philanthropy, this time from
Australian sources, was instrumental in
the service being established. Commenc-
ing in Bat Yam, a second site in Jerusalem
has been added.
headspace Israel is a youth-friendly,
multidisciplinary enhanced primary care
model (“one-stop shop”), with close links
to locally available specialist services,
schools and other community organiza-
tions.
In its rst year of operation, headspace
Israel successfully increased the level of ac-
cessibility and familiarity of mental health
services available to young people, with
652 youth accessing the service in Bat Yam.
Netherlands: @ease
@ease, which began in January 2018 in
Maastricht and Amsterdam, is a walk-in
support and counselling service for young
people delivered mainly by trained volun-
teers (including psychology students and
young people).
Since @ease was established, it has
expanded to Rotterdam, Gröningen and
Heerlen. It has been complemented by an
online chat service and by psychiatric and
other professional support, and over 1,000
young people have accessed care to date.
United States: allcove
In the US, the allcove program, de-
veloped through the Stanford Psychiatry
Center for Youth Mental Health and Well-
being, has opened its rst two centers in
2021. Created through a collaboration with
Santa Clara County, the first two allcove
sites are in San José and Palo Alto.
Inspired and supported by headspace
Australia and Foundry, this US integrated
youth mental health model for young
people aged 12-25 years will include early
mental health care, primary medical care,
substance use services, peer and fam-
ily support, and supported education and
employment services.
e State of California has committed
seed funding for a further ve centers in
San Mateo, Sacramento, Los Angeles (two
centres) and Orange counties. Potential
expansion across ve other states is also in
progress.
Singapore: Community Health
Assessment Team (CHAT)
Established in 2009, and building on
the Singapore Early Psychosis Interven-
tion Programme, CHAT is a national youth
mental health check and outreach program
under the Institute of Mental Health165.
CHAT focuses on young people aged
16-30, and provides free, personalized care
in a non-stigmatizing environment. The
service comprises allied health profession-
als, doctors, administrative support, youth
mental health advocates, CHAT ambassa-
dors (a volunteer-based youth peer group),
an outreach function, webCHAT (an on-
line screening service), and on-site brief
support to young people with poor access
to specialist services166.
Over its rst decade of operation, 3,343
young people (54% of all referrals) received
a complete mental health assessment at
CHAT. Forty-seven percent experienced a
25% or higher reduction in distress, while
20% showed a 6-25% reduction166.
United Kingdom
While no systematic health care youth
mental health reforms have emerged so far
across the UK, the same issues have inu-
enced service provision through a system
of variable Youth Access centres at local
levels.
In several parts of the UK, notably Nor-
folk and Birmingham, specialist mental
72 World Psychiatry 21:1 - Februar y 2022
health services have restructured to ac-
commodate a youth mental health per-
spective with some success167-169. Further
reform is under consideration by the na-
tional government.
Hong Kong
e success of early psychosis reforms
in Hong Kong170-172 has prompted the aca-
demic and clinical leadership to explore
youth mental health reform more broadly,
and a series of surveys have been conduct-
ed to prepare for this.
e recent social unrest and the extreme
pressures mounting upon the young peo-
ple have underlined the crucial need for
better mental health support and access.
SPECIALIST COMMUNITY
MENTAL HEALTH CARE
In high-resource settings, youth-specif-
ic specialized community mental health
care is an essential back-up system for
the integrated primary care platforms for
young people. A key barrier that has to be
overcome is the paediatric model of child
and adolescent mental health services,
with its low level of resourcing and a transi-
tion point to adult mental health services
anchored at age 18, as discussed above.
A recent breakthrough in Victoria, Aus-
tralia150 will align the specialist mental
health services with the headspace net-
work’s age range (12-25 years) and enable
a common clinical governance system to
operate both tiers of care in a seamless
manner. This alignment and vertical in-
tegration will facilitate the operation of a
clinical staging approach to treatment, and
should enhance the eectiveness of care
and outcomes.
RESIDENTIAL CARE
In high-resource settings, a suite of
residential options for young people is
needed and possible, ranging from acute
inpatient care, with the alternative of in-
tensive home-based care or “hospital in
the home”, through subacute or recovery
oriented therapeutic programs and longer-
term residential care in the community.
It remains a work in progress to fund
and design these facilities in partnership
with young people and families. Such set-
tings need to be streamed separately from
young children and older adults, and must
be designed and operated with gender,
cultural and developmental maturity is-
sues at the forefront.
PARADIGM TENSIONS
Any change which seeks a paradigm
shift will encounter major challenges
and resistances, and these have indeed
emerged as the youth mental health reform
has unfolded. Some of these challenges are
conceptual and political; others are practi-
cal. Psychiatry has struggled to overcome
an intrinsic pessimism and lack of self-be-
lief, which has been perpetuated by stigma,
discrimination and low status within health
care and medical research.
Underfunding and the sense that men-
tal health care is at best a zero-sum game
or, at worst, a shrinking pie, leads dierent
areas of psychiatry to compete with one
another and undermines progress in any
one eld39,41,173. It is dicult to secure uni-
ty of purpose and mobilize a team eort
within mental health to achieve beach-
heads and objectives of any kind. Doubt
is introduced even when solid or highly
promising scientific evidence has been
assembled, for reasons and in ways that
we do not see happening in other areas of
health care40. Scepticism is a vital force in
an empirical and pragmatic eld like med-
icine, but it can be counter-productive and
harmful if excessive or motivated by inse-
curity, vested interest or a self-defeating
mindset.
A new paradigm of youth mental health
care can be seen as a threat to the status
quo, or alternatively as a way of strengthen-
ing both child and adult psychiatry. ere
are indications that child and adolescent
psychiatry at least is starting to embrace
the opportunity. Yet the recent reforms in
this area have not ourished through logic
and scientic evidence alone, essential as
these safeguards and guides assuredly are.
Nor have they been hampered by doubt
disguised as genuine critique.
A key success factor to date has been
consumer demand and support. Deter-
mined global leadership from a range of
clinical and academic pioneers has also
been a key feature. Economic arguments
are now adding strongly to the momen-
tum, since mental health care, largely due
to its timing in the life cycle, is the one re-
maining area of health care where major
return on investment is achievable.
CONCLUSIONS
Youth mental health care has the poten-
tial to be a transformational new paradigm,
one which could inspire societies to value
and develop much greater faith in mental
health care. e energy and optimism that
can be generated, if combined with a posi-
tive experience of care, better outcomes
and return on investment, are powerful
forces for change. We have argued here
for youth mental health care to assume its
place as a critical transitional zone within
a lifespan approach to mental health care.
is ultimately involves the creation of a
new professional eld, not merely new mod-
els of care.
e main feature of the emerging mod-
els of youth mental health care is shifting
and embedding the focus upon the tran-
sitional developmental stage from puberty
to independent adulthood, which extends
approximately from 12 to 25 years, though
the boundaries are exible and variable.
The engagement of young people and
families in the conception, design and
operation of the models, and the strong
community and political support they
have mobilized, are essential components
of their success. e reform has typically
been led by clinicians, academics and phi-
lanthropists. Politicians, however, waiting
for solutions to the pessimism and stag-
nation in mental health care, have often
been eager to support these optimistic ap-
proaches to early intervention and youth
mental health.
Features that reduce barriers to entry
and promote a normalizing and welcom-
ing entry portal, such as the use of volun-
teers and peer workers, a de-emphasis on
formal diagnosis and a focus on encourag-
World Psychiatry 21:1 - February 2022 73
ing help-seeking for mild and potentially
transient problems, can create tensions
with professionals from more specialized
settings. The under-resourcing of youth
mental health care and the understand-
ably defensive mindsets contribute to this
tension. In fact, if we can assemble the
necessary resources to build a exible and
proactive system of staged youth mental
health care powered by new workforces,
including a new sub-specialty of “youth
psychiatry”174, then this tension can be dis-
persed and seen for what it is – a false di-
chotomy, one of many in the mental health
eld.
ese new infrastructures of youth men-
tal health care are enabling the early stages
and boundaries of potentially serious men-
tal illness in young people to be understood
and mapped across the transdiagnostic
landscape for the rst time. ey allow nov-
el therapies to be explored and trialled, and
their safety, acceptability and eectiveness
to be explored and examined in a transdi-
agnostic setting175.
Critics have alleged that this strategy
produces harm through labelling and over-
medicalization of teenage angst and over-
treatment. In fact, with a needs-based ap-
proach, in which diagnosis is de-empha-
sized and treatment sequenced according
to clinical staging, with its intensity guided
by risk-benet balance considerations, the
opposite is true, and the hard data from all
these programs strongly support the need
for care that the help-seeking young peo-
ple manifest.
e high degree of unmet mental health
needs in young people worldwide demands
that youth mental health care be elevated
to an absolutely top priority in health care.
Global reform and adequate investment in
youth mental health will not only substan-
tially improve the health and lives of young
people, but will pay for itself and promote
mental wealth for all of society.
ACKNOWLEDGEMENTS
e authors are grateful to colleagues from youth men-
tal health services who provided service updates:
S.Adelsheim, S. Barbic, L. Benoit, S. Bergsdottir, E.
Chen, J. Duy, T. Hammershoy, W. Helfrich, J. Hen-
derson, S. Hetrick, S. Iyer, R. Klaassen, S. Leijdes-
dor, A. Malla, S. Mathias, S. Mejrup, A. O’Reilly, J.
Risom, D. Rickwood, S. Rosevear, J. Torous, J. Tre-
thowan, T. van Amelsvoort and S. Verma.
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DOI:10.1002/wps.20938
