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Architecture of change: rethinking child and adolescent mental health

Article  in  The Lancet Psychiatry · September 2017

DOI: 10.1016/S2215-0366(17)30315-2

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3 authors:

Andrea Raballo Michele Poletti

Università degli Studi di Perugia Azienda Unità Sanitaria Locale Reggio Emilia
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Patrick D Mcgorry
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 Comment
Now is an exciting time for scientists interested in the
mental health effects of cannabis exposure. The study
by Agrawal and colleagues1 takes an important step
in disentangling the relationships between cannabis
use, depression, and suicidal thoughts and behaviours,
and I anticipate further research on this subject. The
hypotheses presented in Agrawal and colleagues1 are
not mutually exclusive, and should not be read as
such. Cannabis use is probably related to depression
and suicidal behaviours through a constellation of
mechanisms, including shared genetic predispositions,
worsened societal outcomes, and environmental
traumas resulting from cannabis use effecting mental
health outcomes, and also cannabis use directly
mediating depression and suicidal behaviours through
altered neurobiology. Successful social and medical
intervention strategies for suicide prevention and
reduction of cannabis use must consider and address
these hypotheses concurrently.
Laura M Huckins
Icahn School of Medicine, Psychiatric Genomics, New York, NY
10128, USA
laura.huckins@mssm.edu
I declare no competing interests.
Architecture of change: rethinking child and adolescent
mental health
The comprehensive, pan-European survey1 by the
MILESTONE Consortium on the architecture and
functioning of childhood and adolescent mental health
Jim Reed Photography/Science Photo Library
services (CAMHS) clearly indicates that there are more
differences than commonalities across European Union
countries. Besides the macroscopic heterogeneity, another
glaring problem is that “the organisation of services and
the distribution of resources are often not based on users’
perspectives and needs, as they should be”.1
Such heterogeneity and distance from users’ needs—
which is plausibly also true on a global scale —is even
more problematic as it fails to match the epidemiological
burden of disease2 or the natural pattern of emerging
mental disorders in young people. Indeed, young
people aged 12–25 years have the highest incidence and
prevalence of mental illness across the lifespan, while
also having the worst access to and engagement with
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1 Agrawal A, Nelson EC, Bucholz KK, et al. Major depressive disorder, suicidal
thoughts and behaviours, and cannabis involvement in discordant twins:
a retrospective cohort study. Lancet Psychiatry 2017; published online
July 24. http://dx.doi.org/10.1016/S2215-0366(17)30280-8.
2 Sherva R, Wang Q, Kranzler H, et al. Genome-wide association study of
cannabis dependence severity, novel risk variants, and shared genetic risks.
JAMA Psychiatry 2016; 73: 472–80.
3 Carey CE, Agrawal A, Bucholz KK, et al. Associations between polygenic risk
for psychiatric disorders and substance involvement. Front Genet 2016;
7: 149.
4 Silins E, Horwood LJ, Patton GC, et al, for the Cannabis Cohorts Research
Consortium. Young adult sequelae of adolescent cannabis use:
an integrative analysis. Lancet Psychiatry 2014; 1: 286–93.
5 Volkow ND, Baler RD, Compton WM, Weiss SR. Adverse health effects of
marijuana use. N Engl J Med 2014; 370: 2219–27.
6 Schreiner AM, Dunn ME. Residual effects of cannabis use on neurocognitive
performance after prolonged abstinence: a meta-analysis.
Exp Clin Psychopharmacol 2012; 20: 420–29.
7 ElSohly MA, Mehmedic Z, Foster S, Gon C, Chandra S, Church JC. Changes in
cannabis potency over the last 2 decades (1995–2014): analysis of current
data in the United States. Biol Psychiatry 2016; 79: 613–19.
8 Ahern J, Stuber J, Galea S. Stigma, discrimination and the health of illicit
drug users. Drug Alcohol Depend 2007; 88: 188–96.
9 Link BG, Struening EL, Rahav M, Phelan JC, Nuttbrock L. On stigma and its
consequences: evidence from a longitudinal study of men with dual diagnoses
of mental illness and substance abuse. J Health Soc Behav 1997; 38: 177–90.
10 Mark Anderson D, Hansen B, Rees DI. Medical marijuana laws, traffic
fatalities, and alcohol consumption. J Law Econ 2013; 56: 333–69.
11 Morris RG, TenEyck M, Barnes JC, Kovandzic TV. The effect of medical
marijuana laws on crime: evidence from state panel data, 1990–2006.
PLoS One 2014; 9: e92816.
12 Anderson DM, Rees DI, Sabia JJ. Medical marijuana laws and suicides by
gender and age. Am J Public Health 2014; 104: 2369–76.
mental health services compared with all other age
groups.3–5 Thus, the division of mental health care along
the paediatric or adult model, inspired by the traditional
organisation of somatic medicine, is unfortunate, as
this division cuts across the age when risk for mental
disorders peaks, with obvious consequences in terms of
undertreatment, discontinuity of care, and unmet needs.
Furthermore, the developmental and cultural challenges
of transition to adulthood also now span a much longer
period, and extend at least into the mid-to-late twenties
in developed countries and increasingly within countries
with rapidly developing economies. Fast-paced economic,
cultural, technological, demographic, and social
changes are responsible for this increase in challenge
duration. Mental health care provision to immigrant and
refugee youth is increasingly needed, and new morbid
phenomena are arising, such as social withdrawal with

internet addiction, cyberbullying, or hazardous social
games (eg, the so-called Blue Whale, a game played across
various social media platforms that allegedly encourages
some teenagers to attempt suicide).6,7 Hence, we cannot
postpone a radical review of the structure and resourcing
of health care for young people in transition from
childhood to adulthood any longer. To be sustainable, this
review should be guided by emerging research evidence
from the new youth mental health framework and
transnational standards of care, and should ultimately
be reflected in the development and implementation of
international guidelines for novel service systems, such
as are already being created and scaled up internationally.
This approach would reorient and strengthen national
health services and facilitate the integration of country-
specific approaches and traditions within a broader and
future-oriented framework. Clearly, such creation of
youth-friendly primary care platforms, and structural
redevelopment and enhancement of contemporary
CAMHS, represents an excellent value proposition for
governments concerned with spiralling costs of health
and social services, who are seeking a strong return on
investment. This proposition is also a huge opportunity to
bridge the serious gap between child–adolescent and adult
psychiatry. Bridging this gap might be achievable through
a framework shift that incorporates the full continuum
of service response within a promotion and prevention
framework for youth mental health. Indeed, besides the
quality and accessibility of youth mental health, a crucial
driving principle should be the stepwise gradient of
increasing intensity and specificity of treatment, inspired
by a developmentally informed clinical staging model.8,9
Youth mental disorders affect motor, cognitive,
language, learning, and behavioural development, with
lifelong consequences. Thus, timely identification in the
early phases is a major prerequisite for interventions
that aim to positively modify the natural course of
these disorders, with potentially exponential cascading
effects on long-term quality of life and socioemotional
functioning.8–10 Taking into account the developmental
stage of the person is essential in this sense, not only to
ensure a personalised or stratified treatment approach,
but also to promote smooth access pathways into
services and encourage participation and hope in families
and carers.1
Adoption of a transdiagnostic staging model
could provide a more suitable framework to capture
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Comment
developmental psychopathology and follow the
multiple longitudinal fluctuations from subsyndromal
to syndromal states and back, with related changes in
the intensity of the need of care.8,9
Moreover, such a model enables shifting of the
strategic focus from disease-specific interventions in
adulthood, to preventive low-threshold interventions
in adolescence, which could be key to reducing disease
burden and related costs in a global phase of increasing
demands and stable or deflating resources.10,11 Within
this perspective, enhancing resilience and targeting
transdiagnostic modulators, such as emotion regulation
and social skills, could be a good compromise between
timing and specificity of interventions.8–11 The substantial
framework shift from existing CAMHS and adult mental
health services—which basically provide delayed and
heavily restricted access to a small subgroup of people
with overt, severe, and complex disorders—is evident.
The emphasis in youth-oriented interventions should
move from symptom reduction and containment to
prevention, early intervention, and ultimately much
greater social and economic participation. The world
has changed substantially in the past three decades, yet
service organisation has remained largely unchanged,
embryonic, under-resourced, and mostly anchored
to the post-asylum era mission. In this sense, the
transnational heterogeneity, poor access, and flawed
transitions revealed by the MILESTONE survey1 suggest
that simple (although laudable) incremental change is
unlikely to go anywhere close to meeting the unique
developmental and socio-cultural needs of adolescents.
Rather, international mental health policies should be
much more ambitious and explore preventive strategies
that are better suited to the developmental pattern of
mental vulnerabilities across the lifespan. A viable and
overdue first step in this direction would be to reorient
primary care and existing services towards youth-specific
mental healthcare. 12
*Andrea Raballo, Michele Poletti, Patrick McGorry
Department of Psychology, Psychopathology and Development
Research, Norwegian University of Science and Technology
(NTNU), Trondheim N-7491, Norway (AR); Department of Mental
Health and Pathological Addiction, Reggio Emilia Local Health
Trust, Reggio Emilia, Italy (MP); and Orygen (The National Centre
of Excellence in Youth Mental Health) and Centre for Youth Mental
Health, University of Melbourne, Parkville, VIC, Australia (PM)
andrea.raballo@ntnu.no
 Comment
PM reports personal fees from Janssen Cilag and Lundbeck. PM has a patent
PCT/AU2008/001337 pending to Orygen Youth Health Research Centre. All
other authors declare no competing interests. This work was supported by the
Norwegian University of Science and Technology (NTNU) Onsager Fellowship
programme in Psychopathology and Development.
1 Signorini G, Singh SP, Boricevic-Marsanic V, et al. Architecture and
functioning of child and adolescent mental health services: a 28-country
survey in Europe. Lancet Psychiatry 2017; 4: 715–24.
2 Patton GC, Sawyer SM, Santelli JS, et al. Our future: a Lancet commission on
adolescent health and wellbeing. Lancet 2016; 387: 2423–78.
3 Eyre O, Thapar A. Common adolescent mental disorders: transition to
adulthood. Lancet 2014; 383: 1366–68.
4 Rice F, Eyre O, Riglin L, Potter R. Adolescent depression and the treatment
gap. Lancet Psychiatry 2017; 4: 86–87.
5 The Lancet Psychiatry. Hunting down an evidence base for adolescent
mental health. Lancet Psychiatry 2017; 4: 83.
6 Krausz RM, Choi F. Psychiatry’s response to mass traumatisation and the
global refugee crisis. Lancet Psychiatry 2017; 4: 18–20.
New policy and evidence on suicide prevention
Published Online Suicide prevention has rarely had such a high
May 23, 2017
http://dx.doi.org/10.1016/
public profile in the UK as in the past 6 months,
S2215-0366(17)30238-9 which have seen a series of publications covering
policy, practice, and research evidence. Perhaps
the key moment was in January, 2017, when UK
Prime Minister Theresa May launched an updated
national suicide prevention strategy in England,1 part
of a suite of announcements on mental health with
young people and social justice as prominent themes.
In her speech, May referred to the “shocking reality”2 of
13 suicides per day in England.
The updated national strategy emphasised two
things: the need for suicide prevention plans in every
Panel: Key elements of safer care in mental health services
1 Safer wards
• Removal of ligature points
• Reduction in absconding
• Skilled inpatient observation
2 Care planning and early follow-up after discharge from
hospital to community
3 No out of area admissions for acutely ill patients
4 24 h crisis resolution and home treatment teams
5 Community outreach teams to support patients who
might lose contact with conventional services
6 Specialised services for alcohol and drug misuse and dual
diagnosis
7 Multidisciplinary review of patient suicides, with input
from family
8 Implementation of National Institute for Health and
Clinical Excellence guidance on depression and self-harm
9 Personalised risk management, without routine checklists
10 Low turnover of non-medical staff
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7 Inkster B, Stillwell D, Kosinski M, Jones P. A decade into Facebook: where is
psychiatry in the digital age? Lancet Psychiatry 2016; 3: 1087–90.
8 McGorry P, van Os J. Redeeming diagnosis in psychiatry: timing versus
specificity. Lancet 2013; 381: 343–45.
9 Raballo A, Larøi F. Clinical staging: a new scenario for the treatment of
psychosis. Lancet 2009; 374: 365–67.
10 McGorry P, Nelson B. Why we need a transdiagnostic staging approach to
emerging psychopathology, early diagnosis, and treatment.
JAMA Psychiatry 2016; 73: 191–92.
11 Singh SP, Tuomainen H. Transition from child to adult mental health
services: needs, barriers, experiences and new models of care.
World Psychiatry 2015; 14: 358–61.
12 McGorry PD, Goldstone SD, Parker AG, Rickwood DJ, Hickie IB. Cultures for
mental health care of young people: an Australian blueprint for
reform. Lancet Psychiatry 2014; 1: 559–68.
locality, and the growing concern over non-fatal self-
harm in young people. The strategy also emphasised
the need to find ways to reduce male suicide, to
treat depression in primary care, to strengthen acute
mental health care, and to support families bereaved
by suicide. The original strategy,3 published in 2002,
had overseen a decrease in the national suicide rate,
which reached a historically low figure in 2006–07.
However, by 2012, when the strategy was relaunched,4
the suicide rate had increased following the worldwide
recession,5 when instability in the international
banking sector caused harm to the lives of vulnerable
people. Figures for 2015 and 2016 suggest that the
increase has reversed, the main reduction being in
men aged 40–60 years, the group in whom the post-
recession rise also occurred, but in 2016 there were
still 4540 suicides registered in England, with a male to
female ratio of three to one.6,7
The updated strategy drew on evidence from the
national confidential inquiry,8 whose 2016 report
presented an analysis of suicides by mental health
patients over the preceding 20 years up to 2014.
This report noted an increasing number of suicides
by patients with mental disorders, but a decreasing
patient suicide rate. Crisis teams were highlighted as a
priority for suicide prevention: around 200 suicides per
year occur in patients under crisis teams, three times
as many as in inpatient care. However, crisis teams
are not inherently unsafe; the national confidential
inquiry report also found improved patient safety
where 24 h crisis teams were established. The risk of