Health through the eyes of youths: a qualitative study.

Background: Emerging definitions of health have suggested a shift in focus to one's ability to manage their health condition, function, and social determinants of health. The construct of health for youths with mental health and substance use disorders (MHSU) is complex and multi-dimensional with interplay between biological, behavioral, and social conditions. Expanding definitions of health is crucial in the measurement of health and evaluation of integrated youth services (IYS) systems for people with MHSU disorders. Hence, it is critical to understand the construct of health from the perspective of a young person living with a MHSU disorder. Methods: This study was conducted using inductive thematic analysis. Three focus groups were conducted from July to August 2017. Results: A total of 22 youths (17-24 years) took part in this study. Results showed that health is a multidimensional construct situated in the ecosystem of a person's environment. Health can be understood from two macro themes: Individual health and Determinants of health. It consisted of physical health, mental health, day-to-day functioning, and being in control of your own health condition. Systemic and social factors were factors that influenced the state of health. Conclusion: This study contributes to a conceptualization of good health in youth with MHSU disorders. This conceptualization can aid in the development of more accurate measures of health and functioning and the evaluation of mental health services for youth with MHSU.

Implementing Foundry: A cohort study describing the regional and virtual expansion of a youth integrated service in British Columbia, Canada.

AIM: Integrated youth services (IYS) have been identified as a national priority in response to the youth mental health and substance use (MHSU) crisis in Canada. In British Columbia (BC), an IYS initiative called Foundry expanded to 11 physical centres and launched a virtual service. The aim of the study was to describe the demographics of Foundry clients and patterns of service utilization during this expansion, along with the impact of the COVID-19 pandemic. METHODS: Data were analysed for all youth (ages 12-24) accessing both in-person (April 27th, 2018-March 31st, 2021) and virtual (May 1st, 2020-March 31st, 2021) services. Cohorts containing all clients from before (April 27th, 2018-March 16th, 2020) and during (March 17th, 2020-March 31st, 2021) the COVID-19 pandemic were also examined. RESULTS: A total of 23 749 unique youth accessed Foundry during the study period, with 110 145 services provided. Mean client age was 19.54 years (SD = 3.45) and 62% identified as female. Over 60% of youth scored 'high' or 'very high' for distress and 29% had a self-rated mental health of 'poor', with similar percentages seen for all services and virtual services. These ratings stayed consistent before and during the COVID-19 pandemic. CONCLUSIONS: Foundry has continued to reach the target age group, with a 65% increase in number of clients during the study period compared with the pilot stage. This study highlights lessons learned and next steps to promote youth-centred data capture practices over time within an integrated youth services context.

Infusing wellness opportunities into integrated youth services.

BACKGROUND: Appropriate health services and health promotion strategies for young people with mental health and substance use (MHSU) concerns are critical for recovery. Foundry, an integrated youth services (IYS) initiative for young people ages 12-24 in British Columbia (BC), Canada, has recently added leisure and recreational activities (referred to as the Wellness Program) into its services. The objectives of this study were to: (1) describe how the Wellness Program was implemented over a two-year period into IYS (2) provide an overview of what the Wellness Program is, who accessed the program since inception and initial evaluation results. METHODS: This study was part of the developmental evaluation of Foundry. A phased approach was used to implement the program at nine centres. Data was accessed from Foundry's centralized platform 'Toolbox' and included activity type, number of unique youth and visits, additional services sought, information about how youth found out about the centre, and demographics. Qualitative data was also accessed from focus groups (n=2) conducted with young people (n=9). RESULTS: Over the two-year period, 355 unique youth accessed the Wellness Program, with 1319 unique visits. Almost half (40%) of youth identified the Wellness Program as the first point of access to Foundry. A total of 384 different programs were offered targeting five wellness domains (physical, mental/emotional, social, spiritual, and cognitive/intellectual). The majority of youth identified as young girls/women (58.2%), 22.6% as gender diverse, and 19.2% as young men/boys. The mean age was 19 years, and most participants were between the ages of 19-24 years (43.6%). From the thematic analysis of focus groups, we found young people enjoyed the social aspect of the program with peers and facilitators, and identified program improvements that are being considered as the program grows. CONCLUSIONS: This study provides insight into the development and implementation of leisure-based activities (known as the Wellness Program) into IYS and can be used as a guide by international IYS initiatives. The initial reach of programs over two years is promising, and these programs are acting as a potential gateway for young people to access other health services.

Identifying early intervention opportunities for illicit stimulant use: A cross-sectional study of factors associated with illicit stimulant use among young people accessing integrated youth services in British Columbia, Canada.

INTRODUCTION: Illicit stimulant (cocaine and/or amphetamine) use among young people aged 12-24 is a public health priority given that substance use initiation tends to peak in this developmental period and significant associated immediate and long-term harms are associated with its use. Young people using stimulants must be engaged in services as early as possible to reduce these harms. To inform early intervention opportunities, this study aimed to identify the risk/protective factors associated with illicit stimulant use among young people. METHODS: We conducted a cross-sectional study on routinely collected self-reported data among young people accessing integrated youth services in British Columbia (Canada) between April 2018 and January 2022. Data were collected on young peoples' socio-demographic characteristics, and social, behavioral, and health profiles. Variable selection was guided by established risk/protective factors for substance use among young people. The study used multivariable logistic regression to identify risk/protective factors that were independently associated with past 30-day illicit stimulant use. RESULTS: The analytic sample included n = 5620 young people aged 12-24 and a total of 163 (2.9 %) reported past 30-day illicit cocaine and/or amphetamine use. Demographic characteristics that were independently associated with illicit stimulant use included older age (aOR = 1.27, 95 % CI = 1.17-1.38) and gender identity as man vs woman (aOR = 1.71, 95 % CI = 1.10-2.70). Social and environmental risk factors included recently witnessing or experiencing violence (aOR = 2.32, 95 % CI = 1.47-3.68) and higher past-year crime/violent behaviors score (aOR = 1.39, 95 % CI = 1.13-1.69). Finally, regular alcohol (aOR = 6.90, 95 % CI = 2.36-25.42), regular (aOR = 3.74, 95 % CI = 1.95-7.54) or social (aOR = 3.06, 95 % CI = 1.44-6.60) tobacco use, and lifetime hallucinogen (aOR = 3.24, 95 % CI = 1.8-5.91) and ecstasy/MDMA (aOR = 2.53, 95 % CI = 1.48-4.39) use were also statistically significant risk factors. CONCLUSIONS: These risk/protective factors support identification of young people who may benefit from further screening, assessment, and treatment for illicit stimulant use. This study also underscores the need to expand early intervention and harm reduction programs that can comprehensively respond to young peoples' stimulant use, health, and social needs.

Scoping review of stepped care interventions for mental health and substance use service delivery to youth and young adults.

AIMS: Many young people with mental health and/or substance use concerns do not have access to timely, appropriate, and effective services. Within this context, stepped care models (SCMs) have emerged as a guiding framework for care delivery, inspiring service innovations across the globe. However, substantial gaps remain in the evidence for SCMs as a strategy to address the current systemic challenges in delivering services for young people. This scoping review aims to identify where these gaps in evidence exist, and the next steps for addressing them. METHODS: A scoping review was conducted involving both peer-reviewed and grey literature. Eligible studies explored SCMs implemented in the various health care settings accessed by young people aged 12-24 seeking treatment for mental health and substance use challenges. After screening titles and abstracts, two reviewers examined full-text articles and extracted data to create a descriptive summary of the models. RESULTS: Of the 656 studies that were retrieved, 51 studies were included and grouped by study team for a final yield of 43 studies. Almost half of the studies were focused on the adult population (i.e., 18 and over), and most did not specify interventions for young people. Among the SCMs, substantial variability was found in almost every aspect of the models. CONCLUSIONS: Considering the current body of evidence, there is an urgent need for a consensus position on the definition, implementation, and outcome measures required for rigorously assessing the utility of SCMs for young people.

Implementing integrated-youth services virtually in British Columbia during the COVID-19 pandemic.

Objective: During the COVID-19 pandemic, Foundry responded to support youth across the province of British Columbia (BC), Canada, by creating a virtual platform to deliver integrated services to youth. In this paper, we report on the development of Foundry Virtual services, initial evaluation results and lessons learnt for others implementing virtual services. Methods and analysis: In April 2020, Foundry launched its virtual services, providing young people and their caregivers from across BC with drop-in counselling services via chat, voice or video calls. Foundry consulted with youth and caregivers to implement, improve and add services. Using Foundry's quality improvement data tool, we document service utilisation, the demographic profile of young people accessing virtual services, and how young people rate the quality of services accessed. Findings: Since launching, 3846 unique youth accessed Foundry Virtual services over 8899 visits, totalling 11 943 services accessed. The predominant services accessed were walk in counselling (32.5%), mental health and substance use services (31.4%), youth peer support (17.2%) and group services (7.3%). Over 95% of youth reported that they would recommend virtual services to a friend. Conclusion: In response to our early findings, we provide three recommendations for other implementers. First, engage the audience in which you intend to serve at every phase of the project. Second, invest in the needs of staff to ensure they are prepared and supported to deliver services. Last, imbed a learning health system to allow for the resources culture of continuous learning improvement that allows for rapid course adjustments and shared learning opportunities.

Foundry: Early learnings from the implementation of an integrated youth service network.

AIMS: To provide the first profile of the demographic and service characteristics of young people (aged 12-24 years) who access Foundry, a provincial network of integrated youth health and social service centres in British Columbia, Canada and to share early learnings about implementation and service innovation. METHODS: Using a retrospective chart review, we conducted a census of all young people accessing a Foundry centre in a 'proof of concept' phase. Six centres were assessed between October 2015 and March 2018. Data included demographics, mental health service access history, service type the youth was seeking, and information about how they found out about the centre. RESULTS: A total of 4783 young people presented during this proof of concept period, for a total number of 35 791 visits. The most frequently accessed category of service was mental health/substance use (57%) followed by physical health (25%). Young people were most likely to be female, aged 15-19, and White. Youth demographic characteristics showed an over-representation of Indigenous and LGBTQ2 youth and under-representation of males and youth aged 20-24. Youth were most likely to learn about Foundry from a friend (44%) or family member (22%). Most youth (58%) reported that they would have gone 'nowhere' if not for Foundry. CONCLUSIONS: Foundry is a model of integrated health and social services delivery, focused on early intervention, prevention and accessibility, driven by the needs and priorities of young people and their families. Leveraging international integrated youth health service evidence, the model addresses urgent priorities in Canadian health service delivery.

Distributive Leadership Within an Emerging Network of Integrated Youth Health Centres: A Case Study of Foundry.

BACKGROUND: Distributive leadership has been proposed as an effective means towards achieving integrated health services. This study draws from the case of Foundry, a network of integrated youth health centres in British Columbia, Canada, and explores the function and impact of distributive leadership in the context of a large-scale effort towards integrated service delivery for youth experiencing mental health and substance use challenges. METHODS: Qualitative data was obtained from a developmental evaluation of Foundry using a longitudinal, ethnographic approach. Over 150 participants involved in the development of six Foundry centres were interviewed individually or in focus groups. Purposive and theoretical sampling strategies were used to maximize the diversity of perspectives represented in the data set. RESULTS AND DISCUSSION: Distributive leadership was observed to be a facilitator for achieving service and system-level integration. Distributive leadership was effective in promoting streamlined service provision, and coordinating efforts towards optimized access to care. A new culture of leadership emerged through collaboration and relationship-building based on a common value system to prioritize youth needs. CONCLUSION: As Foundry, and other integrated youth services, continues to expand, distributive leadership shows promise in assuring diverse and coordinated input for integrating services.

Understanding the mental health and recovery needs of Canadian youth with mental health disorders: a Strategy for Patient-Oriented Research (SPOR) collaboration protocol.

BACKGROUND: While considerable progress is being made to understand the health and self-management needs of youth with mental health disorders, little attention has focused on the mental health and recovery needs that the youth themselves identify-this despite a national priority to incorporate patient-oriented research into the development and assessment of mental health services. To address this gap, estimates of the extent to which existing patient-reported outcome measures (PROMs)-originally developed for use amongst adult populations-are clinically meaningful and psychometrically fit for use among youth are needed. In tandem, a recovery profile for youth can be constructed incorporating the youth perspective of the services provided within a community mental health setting. METHODS/DESIGN: This study will utilize a mixed methods design incorporating qualitative focus group interviews and cross-sectional survey. Our process will begin with the hiring of a youth peer research partner who will provide lived experience expertise through all phases of the study. We will advertise, recruit, and conduct four focus groups with youth who receive services from the Foundry Vancouver Granville located in British Columbia, Canada. In the first two focus groups, we will recruit youth aged 15-18 years (n = 10). In the second two focus groups, we will recruit young adults aged 19-24 years (n = 10). In parallel, we will conduct a cross-sectional survey of the recovery and mental health needs of youth, informed by ten widely used and validated PROM. Thematic analysis techniques will guide the identification of predominant thematic trends in the qualitative focus group data. We will use Classical and Rasch measurement methods to test and analyze the reliability and validity of selected PROM measures for youth populations. DISCUSSION: The proposed study has the potential to produce a preliminary conceptual and measurement model for understanding the mental health and recovery needs of youth with mental health disorders. This evidence will inform how youth mental health services can grow, support, and sustain the capacity for a collaborative, interdisciplinary and innovative patient-oriented research environment. Findings will also contribute much needed evidence to improve the standard of care for youth who experience mental health disorders in Canada and beyond.

Treatment delay and pathways to care in early psychosis.

OBJECTIVE: To examine the treatment delay associated with community and inpatient pathways into care for persons experiencing a first episode of psychosis. METHODS: A total of 104 clients entering a specialized early psychosis intervention (EPI) program and their family members were assessed for help-seeking behaviours, psychiatric symptoms, level of functioning and duration of untreated psychosis (DUP). RESULTS: DUP (median = 30.5 weeks) was associated with younger age of onset, poorer engagement with the EPI program and more severe symptoms. Almost one-third of clients had four or more contacts before receiving antipsychotic medication or entering the EPI program and one in five received interventions not specifically indicated for psychosis. Referrals directly involving family members accounted for about 81% of hospital-initiated treatment (39% of all referrals) and 46% of community-initiated treatment (61% of all referrals). Community entry was associated with longer DUP, more time-seeking treatment, younger age of onset, younger age at referral, greater likelihood of receiving other medication or counselling before receiving antipsychotic medication, schizophrenia, less severe symptoms and less substance use in the previous year. Those with schizophrenia showed no differences across pathway type for time-seeking treatment, being provided interventions not specifically indicated for psychosis after onset or rates of substance use. CONCLUSIONS: Treatment delay and the provision of interventions not specifically indicated for psychosis may be increased in first-episode populations who are younger and have less severe symptoms. Improving literacy about early psychosis in both professionals and families merits greater attention.

Hippocampal volume and the brain-derived neurotrophic factor Val66Met polymorphism in first episode psychosis.

INTRODUCTION: Small hippocampi and impaired memory are common in patients with psychosis and brain-derived neurotrophic factor (BDNF) plays a critical role in hippocampal neuroplasticity and memory. A common BDNF allele (Val66Met) has been the focus of numerous studies but results from the few BDNF-imaging studies are complex and contradictory. The objective of this study was to determine the association between Val66Met and hippocampal volume in patients with first episode psychosis. Secondary analyses explored age-related associations and the relationship between Val66Met and memory. METHOD: Hippocampal volume and BDNF genotyping were obtained for 58 patients with first-episode psychosis and 39 healthy volunteers. Patients were recruited from an early psychosis program serving a catchment-area population. RESULTS: Hippocampal volume was significantly smaller in patients than controls (F(1,92)=4.03, p<0.05) and there was a significant group-by-allele interaction (F(1,92)=3.99, p<0.05). Hippocampal volume was significantly smaller in patients than controls who were Val-homozygotes but no group differences were found for Met carriers. Findings were not affected by diagnosis, antipsychotic medication, or age, and there was no change in hippocampal volume during a one-year follow-up. Val-homozygous patients had worse immediate and delayed memory than their Met counterparts. CONCLUSIONS: Results suggest the effects of the BDNF Val66Met allele may be different in patients with psychosis than in healthy adults. Hippocampal volume in patient and control Met allele carriers was very similar suggesting that illness-related factors have minimal influence in this group. In contrast, Val homozygosity was related to smaller hippocampi and poorer memory functioning only in patients with psychosis.

The assessment of symptom severity and functional impairment with DSM-IV axis V.

OBJECTIVE: The Global Assessment of Functioning scale (GAF) is included as axis V in the DSM-IV multiaxial diagnostic system. The GAF is simple to administer and routinely used in treatment planning and as a measure of program performance. The GAF assesses both symptom severity and functional impairment, but the resultant rating provides no information about the contribution of each of these domains. This study aimed to improve the clinical utility of the GAF by creating subscales. METHODS: The authors divided the scale into its two principal domains: descriptors of social and occupational functioning (SOFAS) and descriptors of symptoms (GAF minus SOFAS descriptors). These and other measures of symptoms and functioning were used to assess 407 patients while acutely psychotic and again after treatment. RESULTS: Symptom scores were of greater severity than functional impairment scores in most cases. Because of this, the GAF score tended to reflect symptom severity rather than functional impairment. The symptom rating was more strongly correlated with measures of positive symptoms, and the functional rating had higher associations with negative symptoms and functional impairment. Both scales were good indicators of clinical change. CONCLUSIONS: Findings indicate that GAF ratings for patients with psychosis tend to reflect symptom severity rather than functional impairment. Splitting the GAF into two parts resulted in greater discrimination for this patient group yet retained ease of administration.

Evaluation of a community mental health carepath for early psychosis.

PURPOSE: To implement a carepath for early psychosis across all community mental health centres through the Early Psychosis Intervention Programme in the Fraser South Area of British Columbia, Canada. METHODS: Prior to developing the carepath, chart reviews and interviews were performed to assess for adherence to published guidelines for early psychosis intervention. This assessment revealed the inadequacies of narrative recording and that core psychosocial interventions were inconsistently provided. The carepath developed included prompts for interventions and standardized assessments and ultimately replaced the charting system used in the mental health centres for early psychosis clients. RESULTS AND CONCLUSIONS: One-year evaluation revealed some improvements in clinical practice but also identified other areas that require further improvement. This project demonstrated that it is possible to successfully implement a carepath in community mental health and that doing so provides a standardized method for ongoing improvements in care.