Open Forum
A Clinical Staging Model for Early Intervention Youth Mental Health Services Shane P. M. Cross, B.Psych., M.Psych.(Clin.) Daniel F. Hermens, Ph.D. Elizabeth M. Scott, B.Sc., M.B.B.S. Antonia Ottavio, Dip.Hth.Sc., B.Nursing Patrick D. McGorry, M.D., Ph.D. Ian B. Hickie, M.D.
Transformational reforms in mental health services are providing more young Australians who experience mental health problems with access to high-quality care. However, the current diagnostic approach has low utility in the early stages of illness, causing uncertainty among clinicians in regard to matching clients’ needs with safe and effective interventions. The authors propose a clinical staging model that has the potential to better match illness stage to intervention. The model allows clinicians to provide more personalized and responsive care, especially to young people with attenuated syndromes (subthreshold disorders) who have a clear need for mental health care but who may not otherwise receive it. This approach can also assist clinicians in considering the potential trajectory of illness. Recent research using this framework has demonstrated the model’s prospective utility. The authors describe application of the model in an early intervention youth mental health service in Australia. (Psychiatric Services 65:939–943, 2014; doi: 10.1176/appi. ps.201300221) Except for Prof. McGorry, the authors are with the Brain and Mind Research Institute, University of Sydney, New South Wales, Australia (e-mail: shane.cross@ sydney.edu.au). Prof. McGorry is with the Centre for Young People’s Mental Health, Department of Psychiatry, University of Melbourne, Parkville, Victoria, Australia.
PSYCHIATRIC SERVICES
M
ental disorders most often have their onset in youth and represent a significant portion of the disease burden of young people (1). These findings logically lead to calls for safe interventions to be delivered as early as possible in the course of mental ill health so as to avoid the direct and indirect damage to young lives caused by mental disorders (2,3) and to avoid illness progression and improve functional outcomes (4,5). In response to this challenge, a developing network of early intervention primary-level mental health services for individuals aged 12 to 25 has recently been established across Australia—called “headspace” and funded by the federal government through the National Youth Mental Health Foundation (6). The program is just one example of international innovations in youth mental health care (7,8). A dual challenge for any early intervention mental health service is to develop the capacity to respond to very large numbers of young people with subsyndromal disorders (9,10) while also deciding which interventions to implement in the relative absence of evidence for approaches that are effective in this group (10). For this cohort of young people, the current psychiatric classification system (11) remains limited in regard to early and nonspecific forms of mental disorders (12–14). Interventions should be guided by diagnosis, yet current psychiatric diagnostic systems are limited in their application to young people with evolving, unclear, or mixed subsyndromal
' ps.psychiatryonline.org ' July 2014 Vol. 65 No. 7
presentations, which results in many young people receiving no care at worst or suboptimal care at best and which leaves many clinicians in primary care ambivalent about the utility of diagnosis (14,15). In our experience at the early intervention centers that we manage, young people often present for care with significant functional impairment and distress, even though their symptoms are subsyndromal (16,17). Further, various studies have shown that young people with subsyndromal depression (18), bipolar disorder (19), and psychosis (20) are at much higher risk of developing full-blown disorders in young adulthood. Rates of transition from subthreshold to full-blown disorders vary between syndromes and studies. Fergusson and colleagues (18) found that 27.4% of study participants transitioned from subsyndromal depression to major depression with one to two years and 33.3% within three to seven years. Axelson and colleagues (19) demonstrated that 45% of study participants converted from subthreshold bipolar disorder to either bipolar I or II within about one year. Despite the diagnostic ambiguity, young people with subthreshold disorders demonstrate a clear need for intervention. At present, however, there is a real tension between this clear need for intervention and a lack of knowledge in regard to the safest and most effective treatments and service structures. The clinical staging framework may assist in developing this knowledge base. Clinical staging is widely used in general medicine and is defined as 939
a more refined form of diagnosis, which serves as an adjunct to the traditional psychiatric diagnostic system (21). It seeks to place a person on a continuum of illness course so as to enable clinicians to select more effective and less harmful treatments. Its ultimate aim is to reduce the risk of progression to more severe forms of illness, or better still to bring about full remission (21). The clinical staging framework also proposes that the emergence of earlier stages of mental ill health represents a modifiable risk factor to progression to later and more serious stages of a mental disorder, thereby changing the focus of the clinician from treating the current episode to being mindful of the longer-term trajectory of illness. Recently, various staging models have been proposed for single DSMIV disorders (22). However, such approaches may not fully account for a critical aspect of clinical staging— that is, earlier stages of illness are often characterized by less severe and less specific clinical phenotypes. Common symptoms of anxiety and depression typically dominate these presentations, often at levels of symptomatology or impairment that do not reach thresholds for the assignment of specific mental disorders. The single-disorder approach, therefore, risks excluding many earlier presentations of illness that fail to meet criteria for a disorder or those that are characterized by very mixed symptomatology. Therefore, the utility of such models for health services planning is likely to be extremely limited. In addition, first-line (typically benign) interventions for early-stage illnesses would not differ greatly enough to warrant the complexity of a singledisorder staging approach, again severely restricting utility in real-world clinical settings. Hickie and colleagues (13) have recently developed an expanded staging model with detailed consensus criteria to incorporate a range of syndromes within a single model. The model comprises six stages: stage 0, asymptomatic individuals at risk of a disorder who have not yet presented for care; stage 1a, help-seeking individuals with mild symptoms and mild functional impacts; stage 1b, those with attenuated 940
syndromes, often with mixed or ambiguous symptomatology and moderate or severe functional impacts; stage 2, those with discrete disorders—that is, clear episodes of psychotic, manic, or severe depressive disorders; stage 3, those with a recurrent or persistent disorder; and stage 4, those with severe, persistent, and unremitting illness (13). Interrater reliability of this model has been shown to be good, with 90% concordance between experienced raters (k5.72) (13). Hickie and colleagues (12) built upon this staging framework and added another dimension associated with determining the type of pathophysiological pathway (for example, nonspecific anxiety, circadian anxiety, developmental anxiety, or a combinations of types that progresses, respectively, to discrete anxious-depression, bipolar spectrum disorder, psychotic disorder, or combinations). It is proposed that these pathways overlap substantially in early stages and may become more independent at later stages, which may lead to more specific and targeted interventions. Interventions can be somewhat stratified on the basis of what is seen to be minimally required at each stage, while also being tailored to the individual depending on what is known about a person’s biological, social, and psychological risk and protective factors (3) that may influence progression. The number of clients assigned to each stage in our early intervention clinic settings has varied across our studies (16,17,23), perhaps because of factors such as service location (inner city versus outer suburban) and differences in the range of services offered. At the outer-metropolitan, suburban Sydney site (headspace Campbelltown), which serves a population of more than 30,000 in the 12–25 age group and assists approximately 1,500 young people per year, at intake between 33% and 41% of young people were assigned to stage 1a, 38%240% were assigned to stage 1b, 11%–14% were assigned to stage 2, and 7%28% were assigned to stages 3 and above (16,23). Notably, a marked increase in symptom severity was observed between stage 1a and stages 1b and above, highlighting PSYCHIATRIC SERVICES
the clinical significance of better identifying this high-risk group (13). The follow-up data in the study by Hickie and colleagues also showed that despite receiving standard care in a multidisciplinary early intervention environment, a significant number of young people transitioned from lower to higher stages over time: 11% of stage 1a clients transitioned to 1b, 19% of stage 1b clients transitioned to stage 2 or greater, and 33% of clients progressed from stage 2 to a later stage (13). For young people in stage 1b who transitioned to a higher stage, 75% of all transitions occurred within 12 months of initial contact with the service. The observed key clinical features associated with transition from stage 1b to stage 2 were depressive disorders to bipolar-type disorders; attenuated psychotic syndromes to first-episode psychosis; and severe depression to the development of additional psychotic or hypomanic features, severe psychomotor change, or other significant psychological features, such as body image disturbance and abnormal eating behavior (13). The number of clients who achieved remission was not reported. “Transition down” rates were also not reported, because, as in all staging models, transition is unidirectional in that an individual may attain symptomatic or functional recovery but remains at the highest stage ever reached. Currently, the evidence base is incomplete for models of care in youth mental health services (10). In recognition of this and to test the model more thoroughly, we propose a service model with a new framework that uses clinical staging and is based on preliminary data obtained from these and other studies. Despite a relative lack of evidence regarding youth mental health care models, a number of integrated components have been identified and recommended (24) and have been incorporated into the overall model as outlined below.
Model description Entry and assessment A range of individual- and service-level barriers are known to prevent young people from accessing timely care. Centers in the headspace project are deliberately designed to reduce these
' ps.psychiatryonline.org ' July 2014 Vol. 65 No. 7
service level barriers while also addressing individual barriers, such as stigma and confidentiality concerns through community mental health promotion efforts (4–6,17,23). Under the proposed clinical staging model, assessment comprises more than just a brief initial screening assessment. It needs to be comprehensive at baseline to ensure not only that the young person is engaged with the service but also that an appropriate amount of information is collected to allocate the young person to the appropriate stage. It also serves as a point of comparison by which to measure progress in treatment. Measurement of progress is fundamentally important, because ongoing treatment decisions are based on progress (or lack thereof) from baseline. The intake procedure is crucial to engaging young clients in the process of receiving professional assistance for their mental health concerns and familiarizing them with concepts such as confidentiality and care planning collaboration. To minimize disruptions to the therapeutic relationship and maximize retention in the service, the clinician conducting the assessment becomes the clinician who coordinates ongoing care needs. By the end of the assessment, the young person and his or her caregivers receive psychoeducation about the presenting concerns and how to manage them in the interim, as well as a collaboratively devised initial assessment and treatment plan that is also shared with the referring professional if appropriate. The only staging decision required of the intake clinician at this point is whether the young person is likely to be at stage 1a or above. If the client is considered to be higher than stage 1a (a complex symptom profile or significant functional disability or both) or if the clinician is uncertain about the stage, then the client is referred for a more comprehensive assessment before being staged. This assessment battery is designed to cover the key clinical markers used to stage clients and to monitor progress in care. They include a clinical assessment (psychiatrist or senior mental health clinician incorporating certain psychometric measures), a medical assessment (including metabolic screening), and if PSYCHIATRIC SERVICES
available a brief neuropsychological assessment (including attention, memory, mental flexibility, and psychomotor processing speed). These specific domains of assessment are based on data collected in previous studies and have been shown to be helpful in discriminating between earlier and later stages of illness (13,16,23,25,26). [Further details about the assessment protocol are available in an online data supplement.] Staging review via consensus rating At the conclusion of the assessment process, all information is summarized and presented to a multidisciplinary team trained in the staging model in order to gain consensus on the proposed stage as matched against staging criteria (13). When a consensus is reached, a summary of the recommended interventions for that stage, along with the proposed future review dates, are provided to the client, whose engagement and treatment progress are monitored by the care coordinator. Intervention All clients (regardless of stage) are provided with a range of standard supports and interventions, which may include psychoeducation (clients and caregivers); interagency information sharing; deliberate self-harm and suicide risk management; family support; substance misuse reduction and harm minimization; educational or vocational support; and sufficient support or intervention for any persisting problems associated with a childhoodonset psychiatric disorder, developmental disorder, or childhood trauma. In order to manage limited service resources, stage 1a clients who have access to a computer with an Internet connection are encouraged to engage in online cognitive-behavioral therapy (CBT), supported by the care coordinator, before they undertake faceto-face psychological therapy, especially if they have not previously received CBT. For clients who agree to online CBT, the care coordinator arranges suitable follow-up to review their progress. Clients who decline to participate in online CBT—or if it is not indicated for other reasons—are
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referred to a therapist for face-to-face psychological intervention. At the conclusion of this brief intervention (usually up to ten therapy sessions), clients undergo a standard review and are reassessed if there has not been sufficient symptomatic and functional improvement. Clients assigned to stage 1b or above are offered a range of interventions aligned to their stage and type and are encouraged to stay connected with services for at least one year, given that most transitions to stage 2 occur within this time frame (13). Additional interventions and social supports are often required depending on the unique risk and protective factors of each client (3). Clients who are assigned to stage 2 and beyond and who have psychotic, manic, and severe depressive or anxiety disorders require a more intensive mix of interventions and supports, including but not limited to assertive case management, medication, CBT, psychosocial support, weight management, and vocational assistance. These interventions are often delivered directly by or in partnership with specialist secondary or tertiary level mental health services over the long term (two to five years is recommended), as outlined elsewhere (21). [Further details about the range of interventions by stage are available in the online supplement.] Review One of the primary strengths of this service model is its structured framework for client review and follow-up on the basis of stage of illness. Timelimited episodic care models tend to focus on short-term symptom and riskof-harm reduction, with less consideration of the longer-term risk of illness progression. Dropout rates are usually high in these treatment settings, with over a third of children and adolescents dropping out of or prematurely terminating from psychosocial interventions (27). It is therefore vital that a young person presenting for care and at risk of developing a serious mental illness in adulthood is kept engaged and connected to care— even via “soft” clinical methods such as social recovery programs—until they demonstrate significant clinical and functional improvement. 941
From stage 1b onwards, young people require a standard clinical review at least every three months. At a minimum, the review is a brief standard assessment of the client’s current mental state and psychosocial functioning. If the client remains symptomatic or functionally impaired, six-month medical, metabolic, and neuropsychological screens and yearly MRI scans (for clients at stage 1b and above) are recommended. These recommendations are based on recent evidence of differences between clients in stage 1b and in stages 2 and 3 in neuropsychological test performance (25,26) and neuroimaging (26,28). The review data and the overall clinical picture are presented to the multidisciplinary team at scheduled review dates to ensure that all clients at stage 1b and above are staged (and restaged) by consensus at regular intervals. The aim is to reduce premature dropout and monitor progress more objectively and routinely. Client care plans are then updated with interventions matching the reviewed stage. If a young person achieves remission (in this case defined by the relative absence of symptoms of mental ill health and achievement of premorbid levels of functioning), review is recommended three months later to ensure remission, and self-management and relapse prevention strategies are then provided. [A flow diagram illustrating clinical staging pathways is available in the online supplement.] Integration with higher-tier mental health services The use of a clinical staging model also provides an opportunity for clearer referral pathways between different service levels across the local mental health system, in particular with highertier specialist mental health services. In this way, primary-level early intervention mental health services can negotiate with the existing specialist mental health services in the community to ensure that all young people along the clinical staging spectrum are managed by using the most appropriate level of service, depending on clinical need, functional impairment, and risk profile, and by utilizing shared-care approaches when appropriate to better manage resources. It is critical that 942
young people at all levels of need receive the right intervention from the right service at the right time.
6. McGorry PD, Tanti C, Stokes R, et al: headspace: Australia’s National Youth Mental Health Foundation—where young minds come first. Medical Journal of Australia 187(suppl 7):S68–S70, 2007
Conclusions
7. McGorry PD, Bates T, Birchwood M: Designing youth mental health services for the 21st century: examples from Australia, Ireland and the UK. British Journal of Psychiatry Supplement 54:s30–s35, 2013
The application of the clinical staging model in an early intervention youth mental health service presents an opportunity to better manage and respond to the common and unique needs of individuals presenting at different points along the continuum of mental ill health. The model defined here is subject to evaluation within our services to determine its effectiveness in improving mental health and associated outcomes for young people. Acknowledgments and disclosures Funding for the headspace project comes from the Australian Government Department of Health and Ageing. The evaluation of these services was supported by an Australia Fellowship (464914) from the National Health and Medical Research Council to Prof. Hickie. Dr. Hermens is supported by a grant from the New South Wales Ministry of Health, Mental Health and Drug and Alcohol Office. Funding agencies had no role in the protocol design, report writing, and the decision to submit the report for publication. Dr. Hermens has received honoraria from Janssen-Cilag. Dr. Scott has received honoraria from Eli Lilly and Company and Servier and has served on an advisory board for Pfizer. Prof. McGorry has received research funds from AstraZeneca, Bristol-Myers Squibb, Eli Lilly and Company, and Janssen-Cilag. Prof. Hickie has served as a consultant or advisor for AstraZeneca, Bristol-Myers Squibb, Eli Lilly and Company, Janssen-Cilag, Roche, and Pfizer and has received honoraria from Pfizer, Servier, and AstraZeneca. The other authors report no competing interests.
References 1. Merikangas KR, Nakamura EF, Kessler RC: Epidemiology of mental disorders in children and adolescents. Dialogues in Clinical Neuroscience 11:7–20, 2009 2. McGorry P: Prevention, innovation and implementation science in mental health: the next wave of reform. British Journal of Psychiatry Supplement 54:s3–s4, 2013 3. Patel V, Flisher AJ, Hetrick S, et al: Mental health of young people: a global public-health challenge. Lancet 369:1302– 1313, 2007 4. Hickie IB: Youth mental health: we know where we are and we can now say where we need to go next. Early Intervention in Psychiatry 5(suppl 1):63–69, 2011 5. McGorry PD: The specialist youth mental health model: strengthening the weakest link in the public mental health system. Medical Journal of Australia 187(suppl 7): S53–S56, 2007
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8. McFarlane WR, Cook WL, Downing D, et al: Portland identification and early referral: a community-based system for identifying and treating youths at high risk of psychosis. Psychiatric Services 61:512– 515, 2010 9. Lewinsohn PM, Shankman SA, Gau JM, et al: The prevalence and co-morbidity of subthreshold psychiatric conditions. Psychological Medicine 34:613–622, 2004 10. Patton GC, Hetrick SE, McGorry P: Service responses for youth onset mental disorders. Current Opinion in Psychiatry 20:319–324, 2007 11. APA: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision. Washington, DC, American Psychiatric Association, 2000 12. Hickie IB, Scott J, Hermens DF, et al: Clinical classification in mental health at the cross-roads: which direction next? BMC Medicine 11:125, 2013 13. Hickie IB, Scott EM, Hermens DF, et al: Applying clinical staging to young people who present for mental health care. Early Intervention in Psychiatry 7:31–43, 2013 14. McGorry PD: Risk syndromes, clinical staging and DSM V: new diagnostic infrastructure for early intervention in psychiatry. Schizophrenia Research 120: 49–53, 2010 15. McGorry P, van Os J: Redeeming diagnosis in psychiatry: timing versus specificity. Lancet 381:343–345, 2013 16. Hamilton BA, Naismith SL, Scott EM, et al: Disability is already pronounced in young people with early stages of affective disorders: data from an early intervention service. Journal of Affective Disorders 131:84–91, 2011 17. Scott E, Naismith S, Whitwell B, et al: Delivering youth-specific mental health services: the advantages of a collaborative, multi-disciplinary system. Australasian Psychiatry 17:189–194, 2009 18. Fergusson DM, Horwood LJ, Ridder EM, et al: Subthreshold depression in adolescence and mental health outcomes in adulthood. Archives of General Psychiatry 62:66–72, 2005 19. Axelson DA, Birmaher B, Strober MA, et al: Course of subthreshold bipolar disorder in youth: diagnostic progression from bipolar disorder not otherwise specified. Journal of the American Academy of Child and Adolescent Psychiatry 50: 1001–1016, 2011 20. Yung AR, Stanford C, Cosgrave E, et al: Testing the Ultra High Risk (prodromal) criteria for the prediction of psychosis in
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a clinical sample of young people. Schizophrenia Research 84:57–66, 2006
services for young Australians. Medical Journal of Australia 196:136–140, 2012
21. McGorry PD, Hickie IB, Yung AR, et al: Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions. Australian and New Zealand Journal of Psychiatry 40:616–622, 2006
24. Catania LS, Hetrick SE, Newman LK, et al: Prevention and early intervention for mental health problems in 0–25 year olds: are there evidence-based models of care? Administration in Mental Health 10:6–19, 2011
22. Cosci F, Fava GA: Staging of mental disorders: systematic review. Psychotherapy and Psychosomatics 82:20–34, 2013
25. Hermens DF, Naismith S, Lagopoulos J, et al: Neuropsychological profile according to the clinical stage of young persons presenting for mental health care. BMC Psychology 1:1–8, 2013
23. Scott EM, Hermens DF, Glozier N, et al: Targeted primary care-based mental health
26. Lin A, Reniers RL, Wood SJ: Clinical staging in severe mental disorder: evi-
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dence from neurocognition and neuroimaging. British Journal of Psychiatry Supplement 54:s11–s17, 2013 27. Schwalbe C, Gearing R: The moderating effect of adherence-promoting interventions with clients on evidence-based practices for children and adolescents with mental health problems. American Journal of Orthopsychiatry 82:146–155, 2012 28. Lagopoulos J, Hermens DF, Naismith SL, et al: Frontal lobe changes occur early in the course of affective disorders in young people. BMC Psychiatry 12:4, 2012
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A Clinical Staging Model for Early Intervention Youth Mental Health Services Shane P. M. Cross, B.Psych., M.Psych.(Clin.) Daniel F. Hermens, Ph.D. Elizabeth M. Scott, B.Sc., M.B.B.S. Antonia Ottavio, Dip.Hth.Sc., B.Nursing Patrick D. McGorry, M.D., Ph.D. Ian B. Hickie, M.D.
Transformational reforms in mental health services are providing more young Australians who experience mental health problems with access to high-quality care. However, the current diagnostic approach has low utility in the early stages of illness, causing uncertainty among clinicians in regard to matching clients’ needs with safe and effective interventions. The authors propose a clinical staging model that has the potential to better match illness stage to intervention. The model allows clinicians to provide more personalized and responsive care, especially to young people with attenuated syndromes (subthreshold disorders) who have a clear need for mental health care but who may not otherwise receive it. This approach can also assist clinicians in considering the potential trajectory of illness. Recent research using this framework has demonstrated the model’s prospective utility. The authors describe application of the model in an early intervention youth mental health service in Australia. (Psychiatric Services 65:939–943, 2014; doi: 10.1176/appi. ps.201300221) Except for Prof. McGorry, the authors are with the Brain and Mind Research Institute, University of Sydney, New South Wales, Australia (e-mail: shane.cross@ sydney.edu.au). Prof. McGorry is with the Centre for Young People’s Mental Health, Department of Psychiatry, University of Melbourne, Parkville, Victoria, Australia.
PSYCHIATRIC SERVICES
M
ental disorders most often have their onset in youth and represent a significant portion of the disease burden of young people (1). These findings logically lead to calls for safe interventions to be delivered as early as possible in the course of mental ill health so as to avoid the direct and indirect damage to young lives caused by mental disorders (2,3) and to avoid illness progression and improve functional outcomes (4,5). In response to this challenge, a developing network of early intervention primary-level mental health services for individuals aged 12 to 25 has recently been established across Australia—called “headspace” and funded by the federal government through the National Youth Mental Health Foundation (6). The program is just one example of international innovations in youth mental health care (7,8). A dual challenge for any early intervention mental health service is to develop the capacity to respond to very large numbers of young people with subsyndromal disorders (9,10) while also deciding which interventions to implement in the relative absence of evidence for approaches that are effective in this group (10). For this cohort of young people, the current psychiatric classification system (11) remains limited in regard to early and nonspecific forms of mental disorders (12–14). Interventions should be guided by diagnosis, yet current psychiatric diagnostic systems are limited in their application to young people with evolving, unclear, or mixed subsyndromal
' ps.psychiatryonline.org ' July 2014 Vol. 65 No. 7
presentations, which results in many young people receiving no care at worst or suboptimal care at best and which leaves many clinicians in primary care ambivalent about the utility of diagnosis (14,15). In our experience at the early intervention centers that we manage, young people often present for care with significant functional impairment and distress, even though their symptoms are subsyndromal (16,17). Further, various studies have shown that young people with subsyndromal depression (18), bipolar disorder (19), and psychosis (20) are at much higher risk of developing full-blown disorders in young adulthood. Rates of transition from subthreshold to full-blown disorders vary between syndromes and studies. Fergusson and colleagues (18) found that 27.4% of study participants transitioned from subsyndromal depression to major depression with one to two years and 33.3% within three to seven years. Axelson and colleagues (19) demonstrated that 45% of study participants converted from subthreshold bipolar disorder to either bipolar I or II within about one year. Despite the diagnostic ambiguity, young people with subthreshold disorders demonstrate a clear need for intervention. At present, however, there is a real tension between this clear need for intervention and a lack of knowledge in regard to the safest and most effective treatments and service structures. The clinical staging framework may assist in developing this knowledge base. Clinical staging is widely used in general medicine and is defined as 939
a more refined form of diagnosis, which serves as an adjunct to the traditional psychiatric diagnostic system (21). It seeks to place a person on a continuum of illness course so as to enable clinicians to select more effective and less harmful treatments. Its ultimate aim is to reduce the risk of progression to more severe forms of illness, or better still to bring about full remission (21). The clinical staging framework also proposes that the emergence of earlier stages of mental ill health represents a modifiable risk factor to progression to later and more serious stages of a mental disorder, thereby changing the focus of the clinician from treating the current episode to being mindful of the longer-term trajectory of illness. Recently, various staging models have been proposed for single DSMIV disorders (22). However, such approaches may not fully account for a critical aspect of clinical staging— that is, earlier stages of illness are often characterized by less severe and less specific clinical phenotypes. Common symptoms of anxiety and depression typically dominate these presentations, often at levels of symptomatology or impairment that do not reach thresholds for the assignment of specific mental disorders. The single-disorder approach, therefore, risks excluding many earlier presentations of illness that fail to meet criteria for a disorder or those that are characterized by very mixed symptomatology. Therefore, the utility of such models for health services planning is likely to be extremely limited. In addition, first-line (typically benign) interventions for early-stage illnesses would not differ greatly enough to warrant the complexity of a singledisorder staging approach, again severely restricting utility in real-world clinical settings. Hickie and colleagues (13) have recently developed an expanded staging model with detailed consensus criteria to incorporate a range of syndromes within a single model. The model comprises six stages: stage 0, asymptomatic individuals at risk of a disorder who have not yet presented for care; stage 1a, help-seeking individuals with mild symptoms and mild functional impacts; stage 1b, those with attenuated 940
syndromes, often with mixed or ambiguous symptomatology and moderate or severe functional impacts; stage 2, those with discrete disorders—that is, clear episodes of psychotic, manic, or severe depressive disorders; stage 3, those with a recurrent or persistent disorder; and stage 4, those with severe, persistent, and unremitting illness (13). Interrater reliability of this model has been shown to be good, with 90% concordance between experienced raters (k5.72) (13). Hickie and colleagues (12) built upon this staging framework and added another dimension associated with determining the type of pathophysiological pathway (for example, nonspecific anxiety, circadian anxiety, developmental anxiety, or a combinations of types that progresses, respectively, to discrete anxious-depression, bipolar spectrum disorder, psychotic disorder, or combinations). It is proposed that these pathways overlap substantially in early stages and may become more independent at later stages, which may lead to more specific and targeted interventions. Interventions can be somewhat stratified on the basis of what is seen to be minimally required at each stage, while also being tailored to the individual depending on what is known about a person’s biological, social, and psychological risk and protective factors (3) that may influence progression. The number of clients assigned to each stage in our early intervention clinic settings has varied across our studies (16,17,23), perhaps because of factors such as service location (inner city versus outer suburban) and differences in the range of services offered. At the outer-metropolitan, suburban Sydney site (headspace Campbelltown), which serves a population of more than 30,000 in the 12–25 age group and assists approximately 1,500 young people per year, at intake between 33% and 41% of young people were assigned to stage 1a, 38%240% were assigned to stage 1b, 11%–14% were assigned to stage 2, and 7%28% were assigned to stages 3 and above (16,23). Notably, a marked increase in symptom severity was observed between stage 1a and stages 1b and above, highlighting PSYCHIATRIC SERVICES
the clinical significance of better identifying this high-risk group (13). The follow-up data in the study by Hickie and colleagues also showed that despite receiving standard care in a multidisciplinary early intervention environment, a significant number of young people transitioned from lower to higher stages over time: 11% of stage 1a clients transitioned to 1b, 19% of stage 1b clients transitioned to stage 2 or greater, and 33% of clients progressed from stage 2 to a later stage (13). For young people in stage 1b who transitioned to a higher stage, 75% of all transitions occurred within 12 months of initial contact with the service. The observed key clinical features associated with transition from stage 1b to stage 2 were depressive disorders to bipolar-type disorders; attenuated psychotic syndromes to first-episode psychosis; and severe depression to the development of additional psychotic or hypomanic features, severe psychomotor change, or other significant psychological features, such as body image disturbance and abnormal eating behavior (13). The number of clients who achieved remission was not reported. “Transition down” rates were also not reported, because, as in all staging models, transition is unidirectional in that an individual may attain symptomatic or functional recovery but remains at the highest stage ever reached. Currently, the evidence base is incomplete for models of care in youth mental health services (10). In recognition of this and to test the model more thoroughly, we propose a service model with a new framework that uses clinical staging and is based on preliminary data obtained from these and other studies. Despite a relative lack of evidence regarding youth mental health care models, a number of integrated components have been identified and recommended (24) and have been incorporated into the overall model as outlined below.
Model description Entry and assessment A range of individual- and service-level barriers are known to prevent young people from accessing timely care. Centers in the headspace project are deliberately designed to reduce these
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service level barriers while also addressing individual barriers, such as stigma and confidentiality concerns through community mental health promotion efforts (4–6,17,23). Under the proposed clinical staging model, assessment comprises more than just a brief initial screening assessment. It needs to be comprehensive at baseline to ensure not only that the young person is engaged with the service but also that an appropriate amount of information is collected to allocate the young person to the appropriate stage. It also serves as a point of comparison by which to measure progress in treatment. Measurement of progress is fundamentally important, because ongoing treatment decisions are based on progress (or lack thereof) from baseline. The intake procedure is crucial to engaging young clients in the process of receiving professional assistance for their mental health concerns and familiarizing them with concepts such as confidentiality and care planning collaboration. To minimize disruptions to the therapeutic relationship and maximize retention in the service, the clinician conducting the assessment becomes the clinician who coordinates ongoing care needs. By the end of the assessment, the young person and his or her caregivers receive psychoeducation about the presenting concerns and how to manage them in the interim, as well as a collaboratively devised initial assessment and treatment plan that is also shared with the referring professional if appropriate. The only staging decision required of the intake clinician at this point is whether the young person is likely to be at stage 1a or above. If the client is considered to be higher than stage 1a (a complex symptom profile or significant functional disability or both) or if the clinician is uncertain about the stage, then the client is referred for a more comprehensive assessment before being staged. This assessment battery is designed to cover the key clinical markers used to stage clients and to monitor progress in care. They include a clinical assessment (psychiatrist or senior mental health clinician incorporating certain psychometric measures), a medical assessment (including metabolic screening), and if PSYCHIATRIC SERVICES
available a brief neuropsychological assessment (including attention, memory, mental flexibility, and psychomotor processing speed). These specific domains of assessment are based on data collected in previous studies and have been shown to be helpful in discriminating between earlier and later stages of illness (13,16,23,25,26). [Further details about the assessment protocol are available in an online data supplement.] Staging review via consensus rating At the conclusion of the assessment process, all information is summarized and presented to a multidisciplinary team trained in the staging model in order to gain consensus on the proposed stage as matched against staging criteria (13). When a consensus is reached, a summary of the recommended interventions for that stage, along with the proposed future review dates, are provided to the client, whose engagement and treatment progress are monitored by the care coordinator. Intervention All clients (regardless of stage) are provided with a range of standard supports and interventions, which may include psychoeducation (clients and caregivers); interagency information sharing; deliberate self-harm and suicide risk management; family support; substance misuse reduction and harm minimization; educational or vocational support; and sufficient support or intervention for any persisting problems associated with a childhoodonset psychiatric disorder, developmental disorder, or childhood trauma. In order to manage limited service resources, stage 1a clients who have access to a computer with an Internet connection are encouraged to engage in online cognitive-behavioral therapy (CBT), supported by the care coordinator, before they undertake faceto-face psychological therapy, especially if they have not previously received CBT. For clients who agree to online CBT, the care coordinator arranges suitable follow-up to review their progress. Clients who decline to participate in online CBT—or if it is not indicated for other reasons—are
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referred to a therapist for face-to-face psychological intervention. At the conclusion of this brief intervention (usually up to ten therapy sessions), clients undergo a standard review and are reassessed if there has not been sufficient symptomatic and functional improvement. Clients assigned to stage 1b or above are offered a range of interventions aligned to their stage and type and are encouraged to stay connected with services for at least one year, given that most transitions to stage 2 occur within this time frame (13). Additional interventions and social supports are often required depending on the unique risk and protective factors of each client (3). Clients who are assigned to stage 2 and beyond and who have psychotic, manic, and severe depressive or anxiety disorders require a more intensive mix of interventions and supports, including but not limited to assertive case management, medication, CBT, psychosocial support, weight management, and vocational assistance. These interventions are often delivered directly by or in partnership with specialist secondary or tertiary level mental health services over the long term (two to five years is recommended), as outlined elsewhere (21). [Further details about the range of interventions by stage are available in the online supplement.] Review One of the primary strengths of this service model is its structured framework for client review and follow-up on the basis of stage of illness. Timelimited episodic care models tend to focus on short-term symptom and riskof-harm reduction, with less consideration of the longer-term risk of illness progression. Dropout rates are usually high in these treatment settings, with over a third of children and adolescents dropping out of or prematurely terminating from psychosocial interventions (27). It is therefore vital that a young person presenting for care and at risk of developing a serious mental illness in adulthood is kept engaged and connected to care— even via “soft” clinical methods such as social recovery programs—until they demonstrate significant clinical and functional improvement. 941
From stage 1b onwards, young people require a standard clinical review at least every three months. At a minimum, the review is a brief standard assessment of the client’s current mental state and psychosocial functioning. If the client remains symptomatic or functionally impaired, six-month medical, metabolic, and neuropsychological screens and yearly MRI scans (for clients at stage 1b and above) are recommended. These recommendations are based on recent evidence of differences between clients in stage 1b and in stages 2 and 3 in neuropsychological test performance (25,26) and neuroimaging (26,28). The review data and the overall clinical picture are presented to the multidisciplinary team at scheduled review dates to ensure that all clients at stage 1b and above are staged (and restaged) by consensus at regular intervals. The aim is to reduce premature dropout and monitor progress more objectively and routinely. Client care plans are then updated with interventions matching the reviewed stage. If a young person achieves remission (in this case defined by the relative absence of symptoms of mental ill health and achievement of premorbid levels of functioning), review is recommended three months later to ensure remission, and self-management and relapse prevention strategies are then provided. [A flow diagram illustrating clinical staging pathways is available in the online supplement.] Integration with higher-tier mental health services The use of a clinical staging model also provides an opportunity for clearer referral pathways between different service levels across the local mental health system, in particular with highertier specialist mental health services. In this way, primary-level early intervention mental health services can negotiate with the existing specialist mental health services in the community to ensure that all young people along the clinical staging spectrum are managed by using the most appropriate level of service, depending on clinical need, functional impairment, and risk profile, and by utilizing shared-care approaches when appropriate to better manage resources. It is critical that 942
young people at all levels of need receive the right intervention from the right service at the right time.
6. McGorry PD, Tanti C, Stokes R, et al: headspace: Australia’s National Youth Mental Health Foundation—where young minds come first. Medical Journal of Australia 187(suppl 7):S68–S70, 2007
Conclusions
7. McGorry PD, Bates T, Birchwood M: Designing youth mental health services for the 21st century: examples from Australia, Ireland and the UK. British Journal of Psychiatry Supplement 54:s30–s35, 2013
The application of the clinical staging model in an early intervention youth mental health service presents an opportunity to better manage and respond to the common and unique needs of individuals presenting at different points along the continuum of mental ill health. The model defined here is subject to evaluation within our services to determine its effectiveness in improving mental health and associated outcomes for young people. Acknowledgments and disclosures Funding for the headspace project comes from the Australian Government Department of Health and Ageing. The evaluation of these services was supported by an Australia Fellowship (464914) from the National Health and Medical Research Council to Prof. Hickie. Dr. Hermens is supported by a grant from the New South Wales Ministry of Health, Mental Health and Drug and Alcohol Office. Funding agencies had no role in the protocol design, report writing, and the decision to submit the report for publication. Dr. Hermens has received honoraria from Janssen-Cilag. Dr. Scott has received honoraria from Eli Lilly and Company and Servier and has served on an advisory board for Pfizer. Prof. McGorry has received research funds from AstraZeneca, Bristol-Myers Squibb, Eli Lilly and Company, and Janssen-Cilag. Prof. Hickie has served as a consultant or advisor for AstraZeneca, Bristol-Myers Squibb, Eli Lilly and Company, Janssen-Cilag, Roche, and Pfizer and has received honoraria from Pfizer, Servier, and AstraZeneca. The other authors report no competing interests.
References 1. Merikangas KR, Nakamura EF, Kessler RC: Epidemiology of mental disorders in children and adolescents. Dialogues in Clinical Neuroscience 11:7–20, 2009 2. McGorry P: Prevention, innovation and implementation science in mental health: the next wave of reform. British Journal of Psychiatry Supplement 54:s3–s4, 2013 3. Patel V, Flisher AJ, Hetrick S, et al: Mental health of young people: a global public-health challenge. Lancet 369:1302– 1313, 2007 4. Hickie IB: Youth mental health: we know where we are and we can now say where we need to go next. Early Intervention in Psychiatry 5(suppl 1):63–69, 2011 5. McGorry PD: The specialist youth mental health model: strengthening the weakest link in the public mental health system. Medical Journal of Australia 187(suppl 7): S53–S56, 2007
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8. McFarlane WR, Cook WL, Downing D, et al: Portland identification and early referral: a community-based system for identifying and treating youths at high risk of psychosis. Psychiatric Services 61:512– 515, 2010 9. Lewinsohn PM, Shankman SA, Gau JM, et al: The prevalence and co-morbidity of subthreshold psychiatric conditions. Psychological Medicine 34:613–622, 2004 10. Patton GC, Hetrick SE, McGorry P: Service responses for youth onset mental disorders. Current Opinion in Psychiatry 20:319–324, 2007 11. APA: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision. Washington, DC, American Psychiatric Association, 2000 12. Hickie IB, Scott J, Hermens DF, et al: Clinical classification in mental health at the cross-roads: which direction next? BMC Medicine 11:125, 2013 13. Hickie IB, Scott EM, Hermens DF, et al: Applying clinical staging to young people who present for mental health care. Early Intervention in Psychiatry 7:31–43, 2013 14. McGorry PD: Risk syndromes, clinical staging and DSM V: new diagnostic infrastructure for early intervention in psychiatry. Schizophrenia Research 120: 49–53, 2010 15. McGorry P, van Os J: Redeeming diagnosis in psychiatry: timing versus specificity. Lancet 381:343–345, 2013 16. Hamilton BA, Naismith SL, Scott EM, et al: Disability is already pronounced in young people with early stages of affective disorders: data from an early intervention service. Journal of Affective Disorders 131:84–91, 2011 17. Scott E, Naismith S, Whitwell B, et al: Delivering youth-specific mental health services: the advantages of a collaborative, multi-disciplinary system. Australasian Psychiatry 17:189–194, 2009 18. Fergusson DM, Horwood LJ, Ridder EM, et al: Subthreshold depression in adolescence and mental health outcomes in adulthood. Archives of General Psychiatry 62:66–72, 2005 19. Axelson DA, Birmaher B, Strober MA, et al: Course of subthreshold bipolar disorder in youth: diagnostic progression from bipolar disorder not otherwise specified. Journal of the American Academy of Child and Adolescent Psychiatry 50: 1001–1016, 2011 20. Yung AR, Stanford C, Cosgrave E, et al: Testing the Ultra High Risk (prodromal) criteria for the prediction of psychosis in
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dence from neurocognition and neuroimaging. British Journal of Psychiatry Supplement 54:s11–s17, 2013 27. Schwalbe C, Gearing R: The moderating effect of adherence-promoting interventions with clients on evidence-based practices for children and adolescents with mental health problems. American Journal of Orthopsychiatry 82:146–155, 2012 28. Lagopoulos J, Hermens DF, Naismith SL, et al: Frontal lobe changes occur early in the course of affective disorders in young people. BMC Psychiatry 12:4, 2012
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