Targeting mental health care attributes by diagnosis and clinical stage: the views of youth mental health clinicians.

OBJECTIVES: To explore the potential utility of clinical stage and mental disorder categories as a basis for determining which attributes of youth mental health care should be offered to which groups of young people. METHODS: In June 2017, we conducted an online survey of youth mental health clinicians that collected information on the participants' background and areas of expertise, then presented vignettes describing young people with different stages of six mental disorders (disorder-based vignettes were matched to participants' area of expertise). For each vignette, participants were asked to give a quantitative estimate of the proportion of young people with similar mental health problems they thought would clinically benefit from each of twelve attributes of mental health care (other than pharmacological or individual psychological therapies). Survey results were analysed as independent, disorder-based samples, using standard statistical tests of significance, and as a stratified sample using mixed-effects models. RESULTS: A total of 412 clinicians working in 32 countries participated in both parts of the survey. Respondents represented a broad range of clinical disciplines, settings and areas of expertise. Their estimated proportions of young people who would benefit from the mental health care attributes varied by clinical stage and disorder (eg, a mean of 93% [interquartile range (IQR), 90%-100%] of young people with Stage 2 psychosis were estimated to benefit from case management with a multidisciplinary team; while only 15% [IQR, 1%-25%] of young people with Stage 1b generalised anxiety disorder were estimated to benefit from collection and processing of biological samples). Neither the background of the respondents nor the sex of the characters in the vignettes significantly influenced the results. CONCLUSION: A combination of clinical stage and disorder information might be an appropriate basis for ensuring that the right attributes of early intervention mental health care are provided to the right young people at the right time. Policy and research priorities include trialling novel services, preferences research among young people, strengthening service responses to subthreshold disorders and promoting high-fidelity collection of clinical stage data in youth mental health settings.

Identifying attributes of care that may improve cost-effectiveness in the youth mental health service system.

OBJECTIVE: To identify attributes of youth mental health care for which there is evidence of potential cost-effectiveness. STUDY DESIGN: We performed a literature review of economic evaluations that examined both costs and outcomes for attributes of youth mental health care other than pharmacological or individual psychological therapies for full-threshold disorders. DATA SOURCES: We searched the United Kingdom National Health Service Economic Evaluations Database for evaluations published to the end of 2014; and MEDLINE, Google Scholar and the citation lists of relevant publications for peer-reviewed studies published in English since 1997. DATA SYNTHESIS: Forty economic evaluations met inclusion criteria. Psychosis was the mental disorder with the most developed economic evidence base, with good evidence of cost-effectiveness for first-episode psychosis services. There was a developing cost-effectiveness evidence base for other disorders. The most common attributes of the interventions examined in the included studies were the location of services, engagement and support of families, assessment, prevention, early intervention, group delivery format and information provision. We used our findings to formulate a list of attributes of youth mental health care that may be acceptable to young people and potentially cost-effective. CONCLUSION: There is at least suggestive cost-effectiveness evidence for a range of attributes of youth mental health care. Further economic research is needed to substantiate most cost-effectiveness findings and to improve targeting of care among young people. Future economic evaluations should examine costs from both societal and health care perspectives and incorporate evidence regarding young people's preferences.

At the heart of an early psychosis centre: the core components of the 2014 Early Psychosis Prevention and Intervention Centre model for Australian communities.

OBJECTIVE: To describe the core components of the Early Psychosis Prevention and Intervention Centre service model as the template agreed with the Australian Federal Government for national upscaling. The Early Psychosis Prevention and Intervention Centre model of early intervention has two main goals: to reduce the period of time between the onset of psychosis and the commencement of treatment and to bring about symptomatic recovery and restore the normal developmental trajectory as early as possible. CONCLUSIONS: The Early Psychosis Prevention and Intervention Centre comprises three elements of service provision for young people experiencing a first episode of psychosis: (i) early detection; (ii) acute care during and immediately following a crisis; (iii) recovery-focused continuing care, featuring multimodal interventions to enable the young person to maintain or regain their social, academic and/or career trajectory during the critical first 2-5 years following the onset of a psychotic illness. It does this via a combination of 16 core components, which provide a flexible, comprehensive, integrated service that is able to respond quickly, appropriately and consistently to the individual needs of the young person and their family. Innovative service reforms, such as Early Psychosis Prevention and Intervention Centre, that recognise the value of early intervention are crucial to reducing the impact of serious mental illness on young people and their families and, ultimately, on our society.

The utility of a fidelity measure to monitor implementation of new early psychosis services across Australia.

AIM: Early psychosis delivery models have proliferated worldwide, but there is limited research into establishing model fidelity. In this context, this article aims to describe the development and implementation of a fidelity tool in a national network of early psychosis services across Australia-the headspace Early Psychosis program. METHODS: Following a detailed consultation process, and based on the Australian Early Psychosis model, an 80-item Early Psychosis Prevention and Intervention Centre Model Integrity Tool (EMIT) was developed along with predefined thresholds for fidelity. The tool was used to assess adherence to the model in six clusters of service sites across Australia. Ratings on the EMIT were informed by interviews with site staff and young people receiving the service, routinely collected data and site policies and procedures. RESULTS: All six clusters of headspace Early Psychosis programs participated in five fidelity assessments across a period of two and a half years. In the initial two visits, the average fidelity score was in the 'low' fidelity range (i.e., <75%). By the fifth fidelity visit, the network average improved to 92.35%, reflecting 'superior' fidelity. CONCLUSIONS: Results of the longitudinal fidelity assessments indicate the successful implementation of the Australian Early Psychosis model across the headspace Early Psychosis program. Utilisation of ongoing fidelity assessments has proved an effective method to improve and maintain adherence to the model.

Development of an implementation guide to facilitate the roll-out of early intervention services for psychosis.

AIM: Our aim was to develop an implementation guide that was informed by an analysis of context-specific barriers and enablers, behaviour change theory, as well as evidence about the effects of implementation interventions, for the establishment and scaling up of an early intervention model for psychosis (called Early Psychosis Prevention and Intervention Centre (EPPIC)). METHODS: We used a systematic approach involving four steps. First, the target behaviours of the EPPIC model for implementation were specified. Second, a consultation was undertaken to explore the barriers and enablers to undertaking these priority minimum standard clinical behaviours. Third, an implementation strategy that included a range of behaviour change techniques tailored to address the identified barriers was developed. Finally, a tool to assess whether those implementing the EPPIC model maintained fidelity to the implementation strategy was designed. RESULTS: We identified a range of barriers that could act to dilute the core components of the EPPIC model and compromise its implementation. An implementation strategy using theory and evidence-based strategies for behaviour change was designed to address these barriers. CONCLUSIONS: The process we used in the development of the implementation strategy provided a unique opportunity to consider the essential areas to cover, how to make information easily understandable and accessible while noting the complexity of issues involved in not only implementation, but also the scaling up of the EPPIC model for services.