Variability in Clinical Outcomes for Youths Treated for Subthreshold Severe Mental Disorders at an Early Intervention Service
Abstract
Objective:
The study assessed the longitudinal clinical and functional outcomes of young people receiving early intervention services for subthreshold manifestations of severe mental disorders at a youth mental health service in Sydney, Australia.
Methods:
The six-month, prospective, longitudinal study collected data on clinical outcomes of 243 young people treated for subsyndromal presentations of putative major mental disorders. Reliable change index scores and effect sizes were calculated to compare results at baseline, three months, and six months for measures of symptoms (Brief Psychiatric Rating Scale [BPRS]), psychological distress (Kessler 10 [K10]), and social functioning (Social and Occupational Functioning Assessment Scale [SOFAS]).
Results:
There was variability in outcomes across each of the outcome measures, with 25%, 33%, and 23% of patients showing reliable improvement and 9%, 13%, and 5% showing reliable deterioration for the SOFAS, K10, and BPRS, respectively. Many individuals did not show linear improvement or deterioration, with reliable change within individuals varying significantly between the zero- to three-month and three- to six-month time points. After the analyses were controlled for covariates, baseline severity or impairment and number of sessions with a psychiatrist or psychologist contributed a small (4%−8%) but significant amount to the total variance in outcomes at six months.
Conclusions:
Most individuals did not show significant deterioration, and about one in four showed reliable improvement by six months. However, individual patterns of change were diverse, highlighting the importance of further research into factors that influence treatment outcomes among youths with subthreshold presentations of severe mental disorders.
Internationally there has been a growing emphasis on the provision of timely early intervention for mental disorders among young people. The vast majority of adult-pattern, major mental disorders have their onset during the developmental period between the ages of 12 and 25 (1). The incidence and prevalence of mental disorders in this age group is high (2), and mental disorders are associated with significant social and economic disability among young people (3). However, members of this age group also have relatively low rates of help seeking (4).
These factors have led to the introduction of several new models of health care provision that focus on greater engagement of young people with emerging, but often subsyndromal forms of mental disorder (5). In Australia, publicly funded youth mental health centers known as “headspace” (6) have been specifically designed to intervene early in the development of psychiatric symptoms. The goal of headspace is to provide holistic care, reduce secondary morbidity, and prevent or delay the onset of severe mental disorders and their associated adverse consequences. These centers provide easy-access, primary care–level services from a mix of professionals to address needs associated with mental health, general medical health, alcohol and other drug use, and education and employment support.
A focus on early intervention has also drawn attention to the need to develop a greater understanding of illness trajectories and how and when to intervene with youths presenting with a range of symptoms, impairments, or distress. Clinical staging models, adapted from those used routinely in general medicine (for example, in cardiovascular disease or cancer), have been proposed as a way for providers of youth mental health services to identify youths who are at highest risk of developing severe mental disorders and persistent disability (7). These models are especially helpful for classifying the clinical presentations of individuals seen in youth mental health services operating at the interface of primary and secondary care (8,9). In one such transdiagnostic staging model, outlined in Table 1, individuals are placed on a continuum, from help seeking for mild symptoms (stage 1a) to attenuated features of a severe disorder (stage 1b), discrete severe mood and psychotic syndromes that meet traditional diagnostic thresholds for a disorder (stage 2), recurrent illness (stage 3), or end-stage, unremitting (stage 4) illness (7,10,11). Inherent in the model is the concept that within each stage, individuals are at differential risk of progression to the next, more severe clinical stage over time. In an earlier longitudinal study, we demonstrated that approximately 19% of a transdiagnostic sample who met criteria for stage 1b at initial presentation progressed to stage 2 (met criteria for a major mental disorder) within 12 months (11). Preventing or delaying progression to stage 2, particularly among the groups at highest risk of early transition (stage 1b), is an important and measurable goal of youth services that are based on clinical staging models. The effectiveness of services can be tested by their relative capacity to reduce or delay clinical or functional deterioration among those identified as being at high risk of disease progression.
| Clinical stage | Description | Characteristics |
|---|---|---|
| Stage 0 | Non–help-seeking asymptomatic individuals with risk factors that increase the risk of mental illness | A range of factors that increase the risk of mental illness, including but not limited to family history of mental illness, childhood abuse, developmental disorder, perinatal trauma, childhood onset anxiety, and affective disorders |
| Stage 1a | Help-seeking individuals with presenting symptoms that are distressing but are not specific to one disorder, are of low to moderate severity, and have limited impact on functioning | Nonspecific anxiety or depressive symptoms of mild to moderate severity typically among help-seeking individuals, with mild functional impacts |
| Stage 1b | Individuals with attenuated syndromes of severe mental disorders, with moderate to severe functional effects | Development of attenuated syndromes of anxiety, depression, bipolar disorder, or psychosis or syndromes with mixed features. Diagnosis is often unclear, and where it is, comorbidity is common. Social, education, and employment functioning often moderately to severely impaired |
| Stage 2 | Individuals with discrete first-episode syndromes with major functional effects | Clear-cut, first-episode psychotic, manic, severe depressive or mixed syndromes, with severe symptoms and major social, educational, and employment effects |
| Stage 3 | Individuals with recurrent or persistent syndromes with ongoing severe functional effects | Syndrome has not remitted after 12 months, or there has been a recurrence of a previous stage 2 illness |
| Stage 4 | Individuals with syndromes that are severe, persistent, and unremitting | Syndrome persists for more than 2 years in spite of provision of a range of specialized interventions |
There is much variability in rates of individual patient treatment response to real-world clinical services, including deterioration, persistent but stable levels of problems, and clinically or statistically significant improvement. Additionally, there is discordance between the outcomes of efficacy trials of homogeneous, selected subpopulations and naturalistic studies, with the latter often reporting much poorer outcomes (12). For example, Warren and colleagues (13) showed that 24% of young people treated in a public community mental health service in the United States demonstrated statistically reliable deterioration in clinical outcomes over approximately six months, whereas 28% showed reliable improvement. Murphy and colleagues (14) reported a reliable deterioration rate of 16% over three months among patients in an outpatient child and adolescent psychiatry clinic.
To date, there have been two published studies reporting on the clinical and functional outcomes among young people attending services at headspace. The first was a short-term study of a large national sample of close to 10,000 young people (15). The study reported change in outcomes between first and last service visits (the mean duration of treatment was not reported), which varied between patients. Using statistically reliable improvement analysis (16) of measures of psychological distress (17) and social and occupational functioning (18), the study found that reliable improvement in psychological distress was demonstrated in 26% of patients and reliable improvement in social-occupational functioning was demonstrated in 31% of patients. Additionally, 8% and 16% of patients showed reliable deterioration in distress and functioning, respectively. However, no analysis of differences between severity-based subgroups was conducted (8).
The second study was conducted in a single headspace center and reported on the differential outcomes of 880 young persons by clinical stage (19). It showed that individuals with conditions characterized as stage 1b demonstrated the same degree of improvement between baseline and last (repeated) measurement on both the Kessler Psychological Distress Scale (K10) and the Social and Occupational Functioning Assessment Scale (SOFAS) compared with individuals with less severe conditions (stage 1a). However, given that individuals with conditions characterized as stage 1b typically began treatment with greater levels of distress and impairment, their final clinical outcomes over the same period were significantly poorer than individuals who began treatment at stage 1a. On the basis of this and related findings in this group (8,9,11,19,20), we developed a model of care that gave particular clinical attention within these settings to persons with clinical presentations characterized as stage 1b (21).
This study reports on the characteristics of patients with subsyndromal conditions characterized as stage 1b. It also reports on the longitudinal clinical and functional outcomes for these young people (as a group and as individuals) over a period of six months.
Methods
Participants and Procedure
With ethics approval granted by The University of Sydney Human Ethics Board, we obtained written informed consent from patients (or their guardians for those under age 18) to collect and use their deidentified data. Participants were ages 12 to 25, had conditions that met criteria for clinical stage 1b according to our published criteria (11) (Table 1), and attended headspace Campbelltown between January 2014 and June 2015. The Campbelltown facility is a youth mental health service located in outer metropolitan Sydney, Australia, that provides early intervention treatment. There were no differences in the care or treatment provided to youths who did or did not give informed consent to participate in the study.
As a specialized, primary-level service for young people, headspace provides services such as care coordination and support by allied health professionals; general medical services by general practitioners (primary care physicians); more specialized mental health services delivered by clinical psychologists and psychiatrists; and education, employment, and other social supports delivered by colocated specialist services. A key aspect of headspace services is the direct connection and ease of access to secondary-level specialist services, such as early psychosis services (5). The specific clinical model employed in this study involves a comprehensive mental health assessment by a senior psychologist or psychiatrist followed by consensus-based stage allocation by the assessing clinician and the multidisciplinary team. Interventions are matched to that stage, and outcomes are subject to routine monitoring by a multidisciplinary team. The results of monitoring guide reassessment of stage and, if indicated, alteration of the treatment plan. The clinical model has been previously described (21).
Data Collection
Demographic details (age and sex) and a subjective estimate of the age of onset of first disabling symptoms or psychological problems were collected by treating clinicians at service entry (baseline). At baseline, three months, and six months, clinicians also collected data on psychological distress (K10) (17), symptoms (Brief Psychiatric Rating Scale–Expanded [BPRS]) (22), and social and occupational functioning (SOFAS) (18); consensus-rated clinical stage (obtained from clinical team meetings); and the total number of sessions with a psychiatrist or psychologist attended by the patient. Possible scores on the K10 range from 10 to 50, with higher scores indicating a greater range and severity of psychological symptoms. Possible scores on the BPRS range from 0 to 168, with higher scores indicating a greater range and severity of clinician-rated psychiatric symptoms. Possible scores on the SOFAS range from 0 to 100, with higher scores indicating better social and occupational functioning.
Statistical Analyses
Analysis was performed by using SPSS, version 22.0, with statistical significance set at p<.05 (two-tailed) for all analyses. Outcomes were measured by using both effect size (ES) change and statistically reliable change. ES change was calculated in standardized units of change between the mean scores at baseline and at later time points, with the baseline standard deviation (SD) for the relevant measure used for standardization. Statistically reliable change was calculated by using the reliable change index (RCI) according to the methods set out by Jacobson and Truax (16). The methods compare the change between an individual's scores at service entry and later time points (in this case three and six months into treatment) with the standard error of measurement of the scale. The RCI, therefore, represents the smallest amount of change that is unlikely to be caused by statistical fluctuation or chance. Whereas other methods identify treatment differences between groups, RCI identifies treatment outcomes within individuals.
Outcomes are reported as means and SDs or as medians and interquartile ranges (IQRs), depending on the normality of distributions of the measure or subscale. We used an RCI of 7 points for the K10 and 10 points for the SOFAS (15). Because of a lack of normative data reported for the BPRS in this age group, we used the Jacobson and Truax method (16) to calculate an RCI for the BPRS on the basis of mean±SD scores for a control group reported by Hermens et al. (20), producing an RCI of 11 points.
Stepwise linear regression was used to examine the associations between clinical, social, and demographic variables at baseline and treatment intensity (number of psychiatry, psychology, or combined sessions) with final outcome scores.
Results
Of the 1,142 patients who attended the service during this time, 867 provided consent for their deidentified information to be used for research purposes. The eligible stage 1b sample comprised 243 patients with a mean±SD age of 18.1±3.0 years; 36% (N=87) were male. The remainder of the sample was not eligible for the study because their clinical presentation was not staged at 1b, with 529 (61%) rated as stage 1a and 95 (11%) rated as stage 2 or above. The mean age of onset of first disabling symptoms or psychological problems was 13.0±3.1 years, according to subjective estimates. Most (N=232, 95%) individuals attended sessions with both a psychiatrist or a psychologist over the six-month period, and the average number of sessions attended was 13.9±11.8. Those who consulted a psychologist only (N=240, 99%) or a psychiatrist only (N=233, 96%) attended 10.0±6.3 and 6.0±4.3 sessions, respectively.
Group-Level Change in Outcome Measures
Baseline scores for the SOFAS, K10, and BPRS were 61.1±8.8, 31.1±8.9, and 40.6±8.3, respectively. Table 2 and Figure 1 show that by six months, median ESs of .25, .46, and .56 were observed for functioning (SOFAS), symptoms (BPRS), and distress (K10), respectively. ESs for functioning and symptoms were slightly lower in the three- to six-month period compared with the zero- to three-month period. The sample was divided into quarters based on ES change at each time point. The degree of improvement for the top 25% of the sample was much higher than the degree of deterioration for the bottom 25% of the sample, with ESs exceeding 1.0 for functioning and symptoms and approaching 1.0 for distress.
| Measure and percentile | 0 to 3 months | 3 to 6 months | 0 to 6 months |
|---|---|---|---|
| K10 | |||
| 25 | –.45 | –.39 | –.32 |
| 50 | .23 | .30 | .25 |
| 75 | .79 | .87 | .93 |
| SOFAS | |||
| 25 | –.58 | –.42 | –.48 |
| 50 | .40 | .05 | .46 |
| 75 | 1.04 | .66 | 1.15 |
| BPRS | |||
| 25 | –.25 | –.19 | –.13 |
| 50 | .38 | .28 | .56 |
| 75 | 1.12 | .56 | 1.32 |
a
K10, Kessler Psychological Distress Scale; BPRS, Brief Psychiatric Rating Scale; SOFAS, Social and Occupational Functioning Assessment Scale
FIGURE 1. Box plot for the change in effect size between zero and three months and three and six months for the K10, BPRS, and SOFASa
aVertical lines represent the median effect sizes for the measurement at each time point. Open circles and asterisks represent individuals with scores that are greater than two and three standard deviations from the mean, respectively. K10, Kessler Psychological Distress Scale; BPRS, Brief Psychiatric Rating Scale; SOFAS, Social and Occupational Functioning Assessment Scale
Individual-Level Change in Outcome Measures
In terms of reliable change in scores on the K10, SOFAS, and BPRS, respectively, between baseline and six months, Table 3 shows that 13%, 9%, and 5%, of the sample deteriorated, 54%, 66%, and 72% showed no reliable change, and 33%, 25%, and 23% had scores indicating reliable improvement. The degree of change for individuals across and within each of the time periods for each measure varied. More patients exhibited reliable deterioration across all measures in the first three-month period than in the second three-month period, whereas more patients exhibited reliable improvement on the BPRS and SOFAS in the first three-month period than in the second three-month period (data not shown).
| Change category at 6 months | Change in outcome | N | % | |
|---|---|---|---|---|
| 0–3 months | 3–6 months | |||
| K10 | ||||
| Deterioration | Deterioration | Deterioration | 1 | 1 |
| Deterioration | Deterioration | No change | 15 | 6 |
| Deterioration | Deterioration | Improvement | 2 | 1 |
| Deterioration | No change | Deterioration | 6 | 2 |
| Deterioration | No change | No change | 7 | 3 |
| No change | Deterioration | No change | 6 | 3 |
| No change | Deterioration | Improvement | 16 | 7 |
| No change | No change | Deterioration | 1 | 0 |
| No change | No change | No change | 79 | 31 |
| No change | No change | Improvement | 5 | 2 |
| No change | Improvement | Deterioration | 17 | 7 |
| No change | Improvement | No change | 7 | 3 |
| Improvement | No change | No change | 10 | 4 |
| Improvement | No change | Improvement | 27 | 11 |
| Improvement | Improvement | Deterioration | 2 | 1 |
| Improvement | Improvement | No change | 35 | 14 |
| Improvement | Improvement | Improvement | 6 | 2 |
| SOFAS | ||||
| Deterioration | Deterioration | No change | 8 | 3 |
| Deterioration | Deterioration | Improvement | 1 | 0 |
| Deterioration | No change | Deterioration | 3 | 1 |
| Deterioration | No change | No change | 8 | 3 |
| Deterioration | No change | Improvement | 1 | 0 |
| No change | Deterioration | Deterioration | 3 | 1 |
| No change | Deterioration | No change | 7 | 3 |
| No change | Deterioration | Improvement | 9 | 4 |
| No change | No change | Deterioration | 12 | 5 |
| No change | No change | No change | 82 | 34 |
| No change | No change | Improvement | 29 | 12 |
| No change | Improvement | Deterioration | 4 | 2 |
| No change | Improvement | No change | 11 | 5 |
| No change | Improvement | Improvement | 4 | 2 |
| Improvement | Deterioration | Improvement | 1 | 0 |
| Improvement | No change | Deterioration | 3 | 1 |
| Improvement | No change | No change | 15 | 6 |
| Improvement | No change | Improvement | 7 | 3 |
| Improvement | Improvement | Deterioration | 3 | 1 |
| Improvement | Improvement | No change | 28 | 12 |
| Improvement | Improvement | Improvement | 4 | 2 |
| BPRS | ||||
| Deterioration | Deterioration | No change | 6 | 2 |
| Deterioration | No change | Deterioration | 4 | 2 |
| Deterioration | No change | No change | 1 | 0 |
| No change | Deterioration | No change | 6 | 2 |
| No change | Deterioration | Improvement | 7 | 2 |
| No change | No change | Deterioration | 1 | 0 |
| No change | No change | No change | 153 | 63 |
| No change | No change | Improvement | 1 | 0 |
| No change | Improvement | Deterioration | 1 | 0 |
| No change | Improvement | No change | 7 | 2 |
| Improvement | No change | No change | 12 | 5 |
| Improvement | No change | Improvement | 7 | 2 |
| Improvement | Improvement | No change | 37 | 15 |
a
K10, Kessler Psychological Distress Scale; BPRS, Brief Psychiatric Rating Scale; SOFAS, Social and Occupational Functioning Assessment Scale
Of the 21 patients who deteriorated on the SOFAS over six months, none had deteriorated at both the zero- to three-month and the three- to six-month periods. Eight of the 21 (38%) patients who showed overall deterioration by six months showed no reliable change at both the zero- to three-month and the three- to six-month periods. Forty-nine percent (N=79) of those who showed no change in the SOFAS at six months had scores reflecting either deterioration or improvement at one or both of the three-month measurement points. Thirty-five (57%) of those who improved in the SOFAS at six months improved reliably in the first three months.
The BPRS showed much less movement across change categories over time than the other measures, with 63% of patients showing no reliable change at all measurement points (0–3, 3–6, and 0–6 months). Sixty-six percent (66%) of those who improved at six months showed reliable improvement in the first three months.
On the K10, 25% of the sample who showed no change at six months either improved or deteriorated in the first three months, then experienced the opposite outcome (improved to deteriorated or deteriorated to improved) in the second three months. Fifty-eight percent and 54% of patients who deteriorated or improved (respectively) did so in the first three months.
Predicting Six-Month Scores
After the analyses were controlled for demographic and baseline symptoms and functioning, stepwise regression demonstrated that about 17% of the variance in K10 score (R=.421, adjusted R2=.170, F=25.60, df=2 and 238, p≤.001) and about 4% of the variance in BPRS score (R=.231, adjusted R2=.041, F=4.46, df=3 and 237, p=.005) were accounted for by number of sessions with a psychiatrist. [Details of final regression models and other significant covariates are available as an online supplement to this article.] Also, after the analyses were controlled for other factors, stepwise regression demonstrated that about 8% of the variance in SOFAS score at six months was predicted by total number of sessions with a psychiatrist and psychologist (R=.301, adjusted R2=.083, F=11.82, df=2 and 238, p≤.001).
Discussion
This study demonstrated that on average, young people who accessed an early intervention service for treatment of subthreshold manifestations of severe mental disorders and concurrent functional impairment showed varied symptomatic and functional outcomes over a six-month period. Although rates of reliable improvement were modest, they appear to be comparable with those reported in other studies of youth cohorts (13,15). However, rates of deterioration among patients in this study appear to be slightly lower than reported in other studies of youth cohorts. An important objective of early intervention services is to prevent worsening or deterioration, especially among those at greatest risk of progression to poorer functional or clinical outcomes or progression to full-threshold severe disorders. Whereas aiming for reliable improvement over time for patients is the most desirable goal, halting deterioration among those deemed to be at highest risk of deterioration is also a desirable goal. With this in mind, the finding that most of these at-risk patients experienced no reliable deterioration in distress, functioning, and symptoms over the six-month period can also be viewed as a worthy outcome. Longer-term tracking of these patients will help to determine if rates of reliable improvement rise with more time spent in treatment.
Furthermore, it is worth noting that the use of the RCI is recognized as being extremely conservative when it comes to measuring treatment outcome (23). Those categorized as having improved demonstrate unequivocal improvement, whereas those categorized as having experienced no change will include a mix of minimal improvers, minimal deteriorators, and patients who did not respond to treatment over the defined time period. For example, a variation of less than 10 points in either direction on the SOFAS (a range of 20 points) will still result in an allocation to the “no change” category. Future research, especially in other highly variable at-risk cohorts, could report on this greater range of individual outcome classifications over a longer period (23).
Direct comparison with findings from other research is not possible because of variability in patient (demographic information and clinical severity) and service-level characteristics across studies. The rates of deterioration at six months for this high-risk cohort on functioning (9%), distress (13%), and symptoms (5%) appear to be relatively lower than or equivalent to those reported elsewhere. On the basis of our own prior naturalistic follow-up of stage 1b patients who had received treatment as usual (11), however, we expected to see rates of clinical deterioration in this subgroup on the order of 20%. Although not directly examined in this study, it is possible that in addition to the interventions provided, the routine monitoring aspect of the service model may have contributed to these comparatively lower deterioration rates.
The value of routine outcome measurement (ROM) in these settings has been proposed previously and has been directly linked to improvements in patient outcomes of modest effect size (24,25). If some young people do, in fact, present to care with pretreatment negative illness trajectories, as is predicted by staging models, then proactive and objective monitoring of outcome is vital. This study showed that degrees of improvement or deterioration vary considerably between individuals, across and within different periods, and across various measures. As such, this study lends some support to using clinical models with embedded systematic ROM practices for individual patients. Such models have the capacity to be more responsive to changes within the individual, resulting in a more personalized approach to care.
There is some evidence that treatment intensity is related to clinical improvement among youths (15), although other studies have found no relationship between outcome and number of sessions (26). We found that a small amount of the variance in outcome was explained by treatment intensity (primarily a greater number of sessions with a psychiatrist or (for variance in functioning) with a psychiatrist and a psychologist). However, the findings from this low-resource study do not allow us to further clarify any associations between improvement and treatment intensity, given that intensity was crudely measured. Also, it is possible that the service model, the range and quality of interventions provided (such as medication or therapist adherence to cognitive-behavior therapy models), the physical environment, the therapeutic relationship, the coordination of care needs, and other factors had additional unmeasured effects on outcome. In line with previous findings, baseline severity and early symptomatic or functional change appear to be most strongly linked with later outcomes (12).
The lack of real-world outcome data regarding early intervention services makes the current observational study both timely and important. However, because the study had several limitations, it should be considered a starting point for further research. For example, the study featured a quasi-experimental design with a lack of a control or a comparison group. Instead, a prospective observational monitoring approach was employed, and both patient and clinician ratings of outcome were collated across a heterogeneous clinical sample. This approach is in contrast with a randomized controlled trial, which would have involved recruiting a more selected, homogeneous sample. Although our goal was to enhance generalizability of the findings, it is notable that we cannot be certain of how much the observed outcomes vary from naturalistic patterns of disease or illness progression that might have been observed in an untreated population. Also, some of the analyses demonstrated that the observed outcomes were not normally distributed. The sample size limited the extent to which this distribution could be examined, and either a larger cohort or longer follow-up period may be needed to determine the importance of this limitation. Treatment data were also limited to those that could be reliably collated via routine clinical practice, namely number of treatment sessions, rather than the type or quality of the intervention. Although number of treatment sessions has been used as a proxy measure of the intervention received, a more systematic assessment that includes markers of quality assurance is likely to shed more light on any associations between treatment (including use of medication) and outcomes.
Conclusions
Given that many nations are moving to develop and expand the early intervention services provided to youths with emerging mental disorders, this study provides an example of incorporating a stage-based service framework into clinical settings. A guiding principle of this approach is that resources are allocated according to individual needs (severity of symptoms and level of functional impairment) regardless of whether the patient’s condition meets subthreshold or threshold criteria for a major mental disorder. This approach, which is a foundation of general medicine, is relatively untested in mental health, but this study identifies both the potential importance and the difficulties of undertaking such research.
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References
1.
Kessler RC, Berglund P, Demler O, et al: Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62:593–602, 2005
2.
Insel TR, Fenton WS: Psychiatric epidemiology: it’s not just about counting anymore. Archives of General Psychiatry 62:590–592, 2005
3.
Gore FM, Bloem PJN, Patton GC, et al: Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet 377:2093–2102, 2011
4.
Rickwood DJ, Deane FP, Wilson CJ: When and how do young people seek professional help for mental health problems? Medical Journal of Australia 187(suppl):S35–S39, 2007
5.
McGorry PD, Goldstone SD, Parker AG, et al: Cultures for mental health care of young people: an Australian blueprint for reform. Lancet Psychiatry 1:559–568, 2014
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):S68–S70, 2007
7.
McGorry PD, Purcell R, Hickie IB, et al: Clinical staging: a heuristic model for psychiatry and youth mental health. Medical Journal of Australia 187(suppl):S40–S42, 2007
8.
Rickwood DJ, Telford NR, Parker AG, et al: Headspace—Australia’s innovation in youth mental health: who are the clients and why are they presenting. Medical Journal of Australia 200:1–4, 2014
9.
Scott EM, Hermens DF, Glozier N, et al: Targeted primary care–based mental health services for young Australians. Medical Journal of Australia 196:136–140, 2012
10.
Scott J, Leboyer M, Hickie I, et al: Clinical staging in psychiatry: a cross-cutting model of diagnosis with heuristic and practical value. British Journal of Psychiatry 202:243–245, 2013
11.
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
12.
Lambert MJ: Outcome in psychotherapy: the past and important advances. Psychotherapy 50:42–51, 2013
13.
Warren JS, Nelson PL, Mondragon SA, et al: Youth psychotherapy change trajectories and outcomes in usual care: community mental health versus managed care settings. Journal of Consulting and Clinical Psychology 78:144–155, 2010
14.
Murphy JM, Blais M, Baer L, et al: Measuring outcomes in outpatient child psychiatry: reliable improvement, deterioration, and clinically significant improvement. Clinical Child Psychology and Psychiatry 20:39–52, 2015
15.
Rickwood DJ, Mazzer KR, Telford NR, et al: Changes in psychological distress and psychosocial functioning in young people visiting headspace centres for mental health problems. Medical Journal of Australia 202:537–542, 2015
16.
Jacobson NS, Truax P: Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology 59:12–19, 1991
17.
Kessler RC, Andrews G, Colpe LJ, et al: Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine 32:959–976, 2002
18.
Goldman HH, Skodol AE, Lave TR: Revising axis V for DSM-IV: a review of measures of social functioning. American Journal of Psychiatry 149:1148–1156, 1992
19.
Cross SPM, Hermens DF, Hickie IB: Treatment patterns and short-term outcomes in an early intervention youth mental health service. Early Intervention in Psychiatry 10:88–97, 2016
20.
Hermens DF, Naismith SL, Lagopoulos J, et al: Neuropsychological profile according to the clinical stage of young persons presenting for mental health care. BMC Psychology 1:8, 2013
21.
Cross SP, Hermens DF, Scott EM, et al: A clinical staging model for early intervention youth mental health services. Psychiatric Services 65:939–943, 2014
22.
Lukoff D, Nuechterlein K, Ventura J: Manual for the expanded BPRS. Schizophrenia Bulletin 12:594–602, 1986
23.
Wise EA: Methods for analyzing psychotherapy outcomes: a review of clinical significance, reliable change, and recommendations for future directions. Journal of Personality Assessment 82:50–59, 2004
24.
Boswell JF, Kraus DR, Miller SD, et al: Implementing routine outcome monitoring in clinical practice: benefits, challenges, and solutions. Psychotherapy Research 25:6–19, 2015
25.
Bickman L, Kelley SD, Breda C, et al: Effects of routine feedback to clinicians on mental health outcomes of youths: results of a randomized trial. Psychiatric Services 62:1423–1429, 2011
26.
Bickman L, Andrade AR, Lambert EW: Dose response in child and adolescent mental health services. Mental Health Services Research 4:57–70, 2002
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Cover: Le Tournesol, by Edward Steichen, circa 1920. Tempera and oil on canvas. Gift of the Collectors Committee, National Gallery of Art, Washington, D.C. © Estate of Edward Steichen.
History
Received: 1 February 2017
Revision received: 27 April 2017
Revision received: 4 July 2017
Revision received: 1 September 2017
Revision received: 8 October 2017
Accepted: 1 November 2017
Published online: 16 January 2018
Published in print: May 01, 2018
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Authors
Funding Information
Prof. Hickie has received honoraria for educational seminars from Janssen-Cilag and Eli Lilly; has led a range of depression awareness and education and training programs supported by the pharmaceutical industry; has led projects for health professionals and the community supported by AstraZeneca, Eli Lilly, Pfizer, Servier, and Wyeth for the identification and management of depression and anxiety; is a member of the Medical Advisory Panel for Medibank Private and a board member of Psychosis Australia Trust; has an equity share in Innowell, which develops digital tools for assessment and management of common mental disorders; and has received financial support from Servier Pharmaceuticals for investigator-initiated studies of treatments for sleep-wake cycle disturbances among young people with mood disorders. The other authors report no financial relationships with commercial interests.
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