Early Intervention in the Real World

Broadening the early intervention paradigm:a one stop shop for youthVivian Wing Woon Lee1 and Brendan Patrick Murphy1,2

1Early in Life Mental Health Service,Dandenong, and 2School of Psychologyand Psychiatry, Monash University,Melbourne, Victoria, Australia.

Corresponding author: Dr Vivian Lee,Early in Life Mental Health Service,Monash Medical Centre, 246 ClaytonRoad, Clayton, Vic 3168, Australia.Email: vwlee1@gmail.com

Received 24 April 2012; accepted 23March 2013

Abstract

Aim: Despite recognition of the earlyonset and disease burden of mentaland substance use disorders in youngpeople, poor access to services per-sists. A new youth outreach clinic,with principles consistent with theearly intervention paradigm andintake criteria not linked to presump-tive diagnostic status, was set upwithin an existing youth hub. Theservice development and early servicedelivery are described.

Methods: The particulars of the clinic,including location, service recipientsand service delivery structure, wereconceptualized and implemented. Aservice model based on secondary

and primary consultations and up tosix sessions of treatment was adoptedto maximize the number of referrersand clients the clinic could service.

Results: Twenty referrals werereceived by the clinic in the first 2months. The clients’ ages ranged from14 to 21 with just less than half under18 years of age. Clients had complexmixes of symptomatology that ful-filled multiple diagnoses.

Conclusions: The described model ofservice delivery can help improveaccessibility, fulfil gaps in currentyouth mental health delivery, andbuild the capacity of non-tertiarylevel services. This is consistent withthe early intervention paradigm.

Key words: access, capacity building, early intervention, servicedevelopment, youth mental health.

INTRODUCTION

There is increasing recognition that mental and sub-stance use disorders are key health issues for youngAustralians.1–3 Epidemiological data demonstratethat 75% of major psychiatric and substance usedisorders have their onset by age 24 years4 and thatthey account for over half of the total disease burdenamong those aged 15–24.5 Yet, for young people withemerging mental health difficulties, there remainhigh levels of unmet need, with poor access to andfragmentation of services.6

The last decade has seen healthy debate on themodel of service delivery that can best improve psy-chiatric services for youth.7,8 As early intervention isargued to be necessary for a range of mental andsubstance use disorders,9 a proposed model foraddressing the gap in youth mental health has beenbuilt around two linked components working closelytogether: an enhanced youth-orientated primary careservice and youth-specific psychiatric services.6,9

Across Australia, in metropolitan, regional, ruraland remote areas, there has been the developmentof ‘communities of youth services’10 within theframework of the National Youth Mental Health Ini-tiative in the form of ‘headspace’10 centres, provid-ing enhanced youth-orientated primary care. Theseintegrated youth service hubs and networks work insynergy with specialist area mental health services.10

The principal aim of headspace has been to providea highly accessible, more specialized and multidis-ciplinary model of care, and at the same time bridgethe schism between mental health and drugand alcohol services, through strategies such asco-location and common clinical governance.10 Todate, 40 headspace centres have been establishedaround Australia.11

The City of Greater Dandenong covers the outersouth-eastern suburbs of Melbourne. It has a sig-nificantly high proportion of young people, pro-jected to comprise 24.8% of the local population by2018.12 The area also has high cultural and ethnic

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diversity and significant numbers of newly arrivedrefugees and other migrants; it is the most culturallydiverse locality in Victoria with residents from 156different birthplaces making up 56% of its popula-tion.12 Profiling of young people in the municipalityindicates higher levels of disadvantage across allkey indicators compared with metropolitan Mel-bourne.12 While previous applications for funding ofa headspace centre were unsuccessful, the vision forand need of a service that linked youth-friendly,integrated and stigma-free community-based serv-ices with a youth-focused tertiary mental healthservice remained.

The opportunity for creating such an accessibleand integrated youth service in the City of GreaterDandenong, inspired by headspace ideals, came in2010. The area is serviced by Southern Health, whichis the largest public health service in Melbourne,providing comprehensive integrated health care tonearly 1.3 million people. Driven by relevant StateGovernment reforms13 and in response to a numberof internal service reviews, Southern Health under-took a major redevelopment of its mental healthprogram. Concurrent with changes within the adultmental health program, the Child and AdolescentMental Health Service, which previously saw chil-dren up to 18 years old, expanded into a new 0–25service. This new Early in Life Mental Health Service(ELMHS) has three specific streams: perinatal andinfant, child, and youth.

The youth stream aims to provide fully integratedand comprehensive specialist mental health serv-ices that dovetail seamlessly with community-basednon-tertiary level services. These include generalpractitioners, drug and alcohol services, youth com-munity support agencies, and private practitionerssuch as psychologists and psychiatrists. To this end,the youth stream comprises a number of new andexpanded specialist services including: a new,purpose-built youth inpatient unit; a Youth Preven-tion And Recovery Care Services unit serving as astep-up treatment option for young people from thecommunity or as step-down facilitating early dis-charge from hospital; a high-prevalence disordersclinic; an intensive mobile outreach service forpoorly engaged clients with serious mental healthproblems; an expanded neurodevelopmentalservice; and an early psychosis service with a con-tinuing care facility. It is crucial that these expandedspecialist mental health services integrate and workcollaboratively with existing local primary careyouth services. To facilitate this, a number of youthoutreach consultation and mental health promo-tion positions were created within the redevelop-ment to liaise with and support the non-tertiary

level providers seeing young people who do notpresent to specialist mental health services. In addi-tion, through extensive consultation with dozens ofkey stakeholders including Professor PatrickMcGorry of Orygen Youth Health1 and ProfessorTom Callaly, program medical director of mentalhealth services in Geelong – who established theintegrated young persons’ mental health service,Jigsaw14 – a new youth outreach clinic, inspired bythe headspace model, was conceptualized.

Although the core principles for the new clinicwere based on the headspace model themes ofaccessibility and the bridging of youth-focusedprimary care and specialist mental health services,there were some contrasts. The eventual vision forthe clinic developed out of a number of factorsincluding funding restraints, the particulars of theexisting youth primary care services, and the needto develop ongoing partnerships with them, that theclinic was outreach, rather than independent fromthe local public area mental health service, and theconcurrent expansion of the ELMHS at SouthernHealth.

A local integrated youth hub, Youth Stop (YStop),facilitated by the City of Greater Dandenong counciland servicing young people aged 12–25, alreadyexisted in the area providing a range of youth-orientated services, including drug and alcoholdetoxification and case management, general andspecialist counselling, social and educational sup-ports, financial advice and multicultural services(Table 1). Young people could attend this hub toaccess services without a referral or appointment.Further, it ran a range of social, leadership and advo-cacy, health, and mental health-oriented programsfor young people, for example, young mothers’groups and holiday activity programs, further increas-ing community presence. It provided the ideal settingfor the new youth mental health outreach clinic.

The uniqueness of this clinic, beyond co-locationwith existing youth services, lay in referrers andclients having direct access to a full-time psychiatryregistrar supported within the multidisciplinarytertiary mental health service and intake criterianot linked to diagnosis. Early access to relevantassessment irrespective of presumptive diagnosis isconsistent with the early intervention paradigm.15

The aims of the clinic were to: improve accessibilityto timely and expert psychiatric consultation;address current gaps within the primary and spe-cialist mental health service provisions to youths;and to support, collaborate with, and build thecapacity of existing non-tertiary level youth-oriented services. An added bonus was that it pro-vided a unique training position in a non-hospital

One stop shop for youth

438 © 2013 Wiley Publishing Asia Pty Ltd

setting for psychiatry trainees. As such, much of thefunding was secured through the Specialist Train-ing Program16 from the Department of Health andAging, which promotes medical training experi-ences in extended settings. This study provides adescription of the clinic.

METHODS

In the design phase, the particulars of the clinic weredetermined. The reason for and location of theclinic are described above. The timing of the set-upcorresponded to the expansion of the tertiarymental health service. Service recipients weredivided into clients and referrers. Clients are youthaged 12–25 attending YStop for whatever reason,and can be referred by any of the agencies there. Amix of conditions, including depression, anxiety,psychosis, self-harm, eating disorders, drug andalcohol problems, and personality disorders,were expected. The clinic hoped to capture thoseyoung people not currently linked to tertiary level

psychiatric services, who did not pose enoughacuity to be traditionally accepted, but who may betoo complex for, or not linked to, primary care.Referrals were only received from the agencieswithin YStop in the first phase of implementation, togauge demand and the clinic’s ability to meet it. Theservice was meant to complement the existingPrimary Mental Health Team servicing the area,which accepts referrals from general practitioners,and there are ongoing discussions about how thetwo can act synergistically.

Service delivery was structured to keep in mindboth the key aims of the service (accessibility, fulfill-ing gaps in current mental health delivery, capacitybuilding) and the limited resources. To this end, aservice model based on primary and secondaryconsultations with appropriate referrals being takenon for up to six sessions was used. This sought tomaximize the number of referrers and clients thatservice could be provided for in a timely manner.

Referring agencies were encouraged to directlycontact the psychiatry registrar based at YStop todiscuss de-identified cases as secondary consulta-tions. To encourage them, no paperwork on theirpart was required. Notes were made of each discus-sion by the registrar to keep track of recommenda-tions and a database of referrals kept to track activityof the service and for subsequent evaluation.Number of ‘contacts’ was also noted as per therequirements of the mental health branch of theDepartment of Health.

From the secondary consultation, either recom-mendations were made at that point or a primaryconsultation would occur. The concept of aprimary consultation for this clinic was fluid. Theclient, with the referrer present and any familymembers (as per client choice), would be assessedover one to three sessions and verbal feedback pro-vided. Importantly, for each young person assessed,a detailed letter summarizing history, mental stateexamination, formulation and recommendationsfor further treatment was sent to the referrer andothers involved, such as the general practitioner, toensure clear communication. Treatment planningwas individualized for each of the clients seen.For some, the psychiatric assessment alone wasenough to clarify the pertinent issues and containany anxiety in the system of non-tertiary level treat-ing services, and the client could continue to workwith the referrer. For others, recommendationswere made for further cross referrals within theyouth services at YStop. If appropriate, the psychia-try registrar could engage in brief treatment such assessions of family work or brief individual therapyusing psychoeducational or cognitive behavioural

TABLE 1. Youth Services at YStop

CMY: Centre for Multicultural YouthCase management and support for young people newly arrived

or are of refugee status. They also host a number ofhomework groups and workshops.

City of Greater Dandenong Youth ServicesA number of teams come under this service, offering general

and specialist counselling, mental health intervention, andsocial and recreational activities and options for youngpeople in the municipality.

Moira: Southern Directions Youth Services Post-Care ProgramTeam

Intensive case management and brokerage for young peopleleaving state care from age 18 to 21. They help transitionthe young person to private rental, employment, educationand ongoing support to avoid young people being exitedfrom care into homelessness.

SEADS: South Eastern Alcohol and Drug Service Youth TeamDrug and alcohol counselling for young people and their

families. They also provide education and training forschools, agencies, and the community, and has a supportedhousing component for young people considered at seriousrisk of homelessness while engaging in withdrawal fromsubstances.

SECASA: South East Centre Against Sexual AssaultCounselling for children, adults and families who are victims of

sexual assault.Smith Family: Education TeamFocus on connecting children and young people to school.

Provision of brokerage for school books, uniforms and schoolfees.

Windana: Youth Intake TeamProvide supported 7- to 14-day drug and alcohol detoxification

in a secure facility nearby. Also provide short-term casemanagement and referrals to other services.

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frameworks, alongside the referrer. In some cases,ongoing medication reviews could also occuralthough the client continued to work therapeuti-cally with the referrer. For the youth taken on for sixsessions, those who needed ongoing tertiary levelcare were referred directly to ELMHS. At all times,the psychiatry registrar was fully supported by themultidisciplinary team and consultant psychiatristswithin the tertiary service.

Regular meetings were held with the coordinatorof youth services at YStop and staff from the manyservices to promote collaborative relationships andencourage referrals. The services varied in themental health support they provided and the skillsets of the staff, who ranged from therapists offeringspecialist counselling, for example, sexual trauma oranger management, to drug and alcohol workers, toyouth workers running socially oriented group pro-grams. It was important that the clinic oriented itselfin such a way as to benefit each individual serviceprovider. The clinic also had a triaging function,working out from de-identified secondary consulta-tions which clients would benefit from being seendirectly, or be cross referred to other services, oreven need an urgent psychiatric response. Having asense of the backgrounds of the referrers helpedensure that the appropriate clients were seen in themost timely manner. To build the capacity of refer-rers, regular meetings with each of the individualservices were organized, to run like mini ‘clinicalreviews’ where team members took turns to presentcases to one another.

RESULTS

In the first 2 months, the clinic received 20 referrals,the majority in the latter weeks after the initialintroductory meetings and set-up of the regularclinical reviews. Just under half of all referrals camefrom the specialist counselling team who did workin anger management and liaison with youthjustice. The clients’ ages ranged from 14 to 21 witha mean age of 16.95, and 45% were under 18 yearsold. There was an equal split between men andwomen. All began as secondary consultations, with9 of the 20 cases proceeding to primary consulta-tion, reflecting the complexity of cases. To illustrate,one client presented with depression, grief issues,panic attacks, deliberate self-harm, disorderedeating and family conflict, whereas another youngperson engaged in heavy polysubstance abuse on abackground of years of depressive and anxietysymptoms, a history of trauma and periods ofdissociation.

DISCUSSION

The development and beginnings of a new youthoutreach clinic have been described. The principlesunderlying the establishment of this service were:accessibility to expert opinion for young peopleseeking assessment and treatment for mental andsubstance use disorders; fulfilling the gaps incurrent youth mental health delivery by forming adirect link between primary care services and thetertiary level mental health program; and buildingthe capacity of non-tertiary level service providerswho work with the majority of young people in thecommunity, aims consistent with an early interven-tion paradigm. Importantly, the clinic does notrequire a presumptive diagnosis for the youngperson to be referred. This addresses the issue thatdiagnosis is often complex and uncertain in theyouth population, and may not be an accurategauge of distress, impairment or need for support. Itis expected that this service model will furtherbroaden the early intervention paradigm beyondearly psychosis.

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