Episode 54      18 min 37 sec
Adolescents and Mental Illness

Psychiatrist Prof Patrick McGorry discusses how evolving treatment modalities can address disturbing trends of increased mental illness in young adults and adolescents. With host Jacky Angus.

"Typically in psychiatry, people have only spent money when they have been forced to do it - in other words when people become quite disabled or quite acutely disturbed. We are trying to shift the focus to a more preventive model of care." - Professor Patrick McGorry




           



Professor Patrick McGorry
Professor Patrick McGorry

Professor Patrick McGorry is the Chair in Youth Mental Health, at the University of Melbourne, and is Executive Director of ORYGEN Youth Health. Patrick has an international reputation for developing systems for the early treatment of mental disorders in adolescents and young people. His interests also include the homeless, refugees and torture survivors, youth suicide and youth substance use.

Credits

Host: Jacky Angus
Producers: Kelvin Param and Eric van Bemmel
Audio Engineer: Craig McArthur
Theme Music performed by Sergio Ercole. Mr Ercole is represented by the Musicians' Agency, Faculty of Music
Voiceover: Paul Richiardi

Series Creators: Eric van Bemmel and Kelvin Param

Melbourne University Up Close is brought to you by the Marketing and Communications Division in association with Asia Institute.

View Tags  click a tag to find other episodes associated with it.

Download file Download mp3 (18 MB)

Adolescents and Mental Illness

VOICEOVER
Welcome to Melbourne University Up Close, a fortnightly podcast of research, personalities and cultural offerings of the University of Melbourne, Australia. Up Close is available on the web at upclose.unimelb.edu.au. That’s upclose.u-n-i-m-e-l-b.edu.au.

JACKY ANGUS
Hello, and welcome to Up Close, coming to you from the University of Melbourne, Australia. I’m Jacky Angus.  In today’s episode of Up Close we examine a disturbing social phenomenon, unrecognised levels of mental illness in young Australians between 12 and 25.  It’s been estimated that over 75 per cent of mental disorders begin before a person reaches the age of 25.  Despite this, over the last decade support services in this area have declined, and costs to those receiving care have increased by nearly 50 per cent.  While these statistics and key aspects of mental illness addressed today do reflect the Australian situation, there are universal implications here in terms of how to better deal with mental illness in young people.

Professor Patrick McGorry is a world renowned researcher and practitioner in the field of youth mental health.  In addition to his role as a teacher and researcher at the University of Melbourne he has led the way in innovative approaches to intervention and treatment.

Welcome to Up Close, Patrick McGorry.  First what are the major illnesses that you see?

PATRICK MCGORRY
In our Youth Mental Health Service in Melbourne, Australia we see a full range of emerging mental health problems and substance use problems in this age group, the teenagers and young adults.  It involves depression and anxiety, psychosis, drug and alcohol problems, eating disorders - the full range of things that people have talked about but often in blends.  You do not see people that fit neatly into diagnostic categories they’ve got mixtures of different clinical pictures.

JACKY ANGUS
Why are young people so vulnerable in this period?

PATRICK MCGORRY
Well it is a massive period of development in life from the social and personal right through to the brain development.  It is occurring from puberty obviously major physical and mental health changes from puberty through.  But it is continuing in a social and a biological sense right through to the mid-twenties.  I think in the past this period of transition from childhood to adulthood was often very socially determined and pretty much by when you left school and went to work and often it was very telescoped into a short period.

Even in developing countries these days if younger children start work they don’t have much of a period of adolescence or transition.  There is a social component to it but in the developed countries and increasingly in developing countries it is getting extended so that the period from puberty through to independent adulthood is much longer and does not really finish until the mid-twenties, which coincidentally and may be related is the period when the brain development is at its greatest.

We think this interaction between biological development which is obviously under genetic control to a significant degree and the environmental factors, the ecology of development, the social environment and the personal environment the interaction of those two things makes the young people very vulnerable to even quite subtle changes in mental health which then can escalate and become quite serious.

JACKY ANGUS
Of course we tend to think, nowadays, of youth as a period of beauty and romance.  I am just wondering why is it that mental illness is not recognised to such an extent.

PATRICK MCGORRY
That is a very good point.  I guess physical health in young people has improved a lot.  A lot of people more recently have been spouting gloom and doom about obesity and other physical health issues, but the physical health of teenagers and young adults has never been better.  Conversely there is this paradox where their mental health has never been worse.

I suppose we could say a quarter of young people in any given year in this age group would have a significant mental health problem.  That means that three quarters are fine and, as you say, bursting with health and succeeding and so on.  That is the conventional wisdom that young people are in great shape and a lot of the so-called experts in the field highlight that point.  People like Richard Eckersley, an Australian commentator in this area, has challenged this orthodoxy and pointed out that young people are like the miners' canaries of society and that means society is becoming a bit sick in some ways and we have seen lots of examples at the moment of that economically and socially.

The young people are the ones that show it up first and that certainly fits with the post‑war trends that mental health has been deteriorating at a time when physical and materialistic sort of health has been improving.

JACKY ANGUS
To what extent then - I know we are making some very general comments - to what extent is cultural difference really important in mental health and is it really significant?  You are talking about the developing countries there must be some places where mental health is a different construct obviously to the constructs we might have here in Australia.

PATRICK MCGORRY
Yes.  I think in developing countries mental health has been very much a neglected issue as it has been in our countries as well.  It is only very recently that mental health has started to get significant attention from the general public and from governments in terms of funding appropriate services.  We have still got a long way to go there.  But in developing countries it has been low priority and almost the last issue on the government’s agenda.

But there is no doubt mental illnesses occur in all cultures at approximately the same rates and especially the serious mental illnesses like psychoses and severe mood disorders.

JACKY ANGUS
Even among teenagers?

PATRICK MCGORRY
Yes among teenagers and just across the whole population.  It is something that affects all societies, and so, in that sense ,it is not a cultural construct.  It might be interpreted and understood in different ways in different cultures, which often is one of the factors that gets in the way of treatment.

JACKY ANGUS
I was going to ask you the differences between treatments.  What sorts of changes have you seen since the Seventies in terms of treating young people?

PATRICK MCGORRY
I started training in psychiatry in the early 1980s and I was absolutely horrified with the way people were treated generally, not just young people, but particularly young people, coming into treatment for the first time.  First of all only the most severely ill got any effective sort of treatment and even then it was only in the most extreme situations.  So, a young person would have to be floridly psychotic and maybe have made a suicide attempt or have become dis-inhibited or aggressive, so much so that they were able to be treated involuntarily under the Mental Health Act.  You can imagine the kind of environments and contexts they were brought into in those days.  It conjured up pictures of One Flew Over the Cuckoos Nest and all the horrors of that.

JACKY ANGUS
People in white coats?

PATRICK MCGORRY
Yes, exactly.  That is not to say that there were not a lot of well-meaning people who were trying to do their best and there were effective treatments at that time but they were very narrowly based and usually drug therapies only and very amateurish psychological sorts of treatments.

Now I think what has happened is that we have brought the drug therapies together with more modern forms of psychological and psychosocial treatment.  So, in the best settings you can get a very synergistic application of innovative and new drug therapies with more modern forms of psychological treatment.

JACKY ANGUS
So that means you run them together?

PATRICK MCGORRY
Yes.

JACKY ANGUS
You have mentioned drug therapy.  I mean, presumably, there has been enormous change in the pharmaceutical - treating people for mental illness - would you be confident about that?  It has been said that there was for example a revolution in the Sixties in terms of pharmaceutics.  Have there been new dramatic changes since then that mean that people have to take fewer drugs or are there better drugs?

PATRICK MCGORRY
I would say yes and no.  There has definitely been some advance in terms of the safety and tolerability of medications and new antipsychotics and new antidepressants have much lower levels of subjective side effects so they are easier to take.  One thing that is being looked at in the youth mental health context is neuro-protective treatment.  I mentioned that the brain is developing during this period of life and what we think might be happening with these mental illnesses and mental health problems is that this normal development goes wrong in a quite subtle sort of way and these are not gross brain changes by any means.  We are thinking of ways of strengthening neuro development hence the term neuro-protection.

JACKY ANGUS
Which means what exactly?

PATRICK MCGORRY
Well neuronal health just like any cells in the body, they do not have to die to not function properly.  So if they are under oxidative stress in the brain, they may not function as well with secondary effects on the motion and behaviour.  The sorts of things we are looking at are treatments like omega 3 fatty acids, other treatments which reduce levels of oxidative stress in the brain which are more subtle and have got much lower levels of side effects but actually might be more effective in preventively strengthening brain function.

That is the sort of thing we are looking at in a research sense to try to develop better biological and drug therapies.  Side by side with psychosocial interventions like for example, when a young person is recovering from a psychotic episode we try to get them back to school and back to work very early and provide enough support around them and enough education and awareness amongst their friends and teachers and family that they can actually resume their roles very quickly and they do not drop off the perch in terms of their normal development.

JACKY ANGUS
You're listening to Up Close coming to you from the University of Melbourne, Australia. I’m Jacky Angus and I’m talking to Professor Patrick McGorry.
Now I understand, Professor McGorry, that you are involved in ORYGEN which is a youth mental health programme which is a state initiative.  But can you tell us what ORYGEN involves?

PATRICK MCGORRY
Well the Origin Youth Health is a programme which is different in one fundamental way in that it is focused on early intervention and secondly it is focused on teenagers and young adults.  Most mental health services around the world have been focused on children and adolescents so 0 to 18 years and then 18 to 65 years.  So you have an adult programme and then you have a child and adolescent programme.  We think that is a very bad way to design services because most of the emerging morbidity in this area comes out in teenage and young adult periods.  So there is a big surge around that period.

You do not want to have a division - a separation of services right in the middle of that phase of life.  What we have developed is a programme for this age group which is youth friendly.  It has got youth participation and input into the programmes, the culture of the programme and the way it is run.  We do have inpatient units and again we could certainly do with a lot more financial and other kinds of support to run that in a better way.  But we also try to treat patients in the home setting so they do not have to come out of their natural environment into a hospital unit if that is at all possible.

JACKY ANGUS
And that involves the rest of the family, presumably too?

PATRICK MCGORRY
Yes, it involves the family as key supporters during that phase.  They need a lot of educational support to do that.  They need very frequent visits from expert clinicians during that phase. And you know inpatient care is very expensive, but this is also expensive to do that ,as you can imagine.

JACKY ANGUS
I was going to say that.

PATRICK MCGORRY
We have got some economic data showing that initially it is about the same cost as generic programmes but over time these programmes by intervening early and providing better care at the front end of the illness and the illness experience. It actually saves money over the next seven to eight years of care for the people who do go onto longer term care.

Actually, it is very cost effective. You get better outcomes and it ends up costing less but you do have to invest the money in this model of care. Typically in psychiatry, people have only spent money when they have been forced to do it - in other words when people become quite disabled or quite acutely disturbed.
We are trying to shift the focus to a more preventive model of care. And that has been quite successful because across many parts of the world we now have early psychosis programmes which are focused on early intervention for the psychotic range of disorders.

JACKY ANGUS
The really serious ones?

PATRICK MCGORRY
Yes, the more serious schizophrenia and those related illnesses.  We are trying to identify, at the earliest possible point, emerging mental disorders in teenagers and young adults and intervening in a multi-disciplinary way in the local community with a low stigma, youth friendly environment.

JACKY ANGUS
When you say intervention, what would that mean at the grassroots?  Would that mean education - linking in with Police and Corrective Services as well as education?

PATRICK MCGORRY
Yes.  I mean mental health care for young people involves much more than just the clinical service.  It involves all of the groups that you mention and more.  But we do want to be able to provide effective treatment for emerging depression or emerging psychosis too.  We are trying to bring two worlds together the youth friendly sort of environment, the ecology of care plus the clinical expertise to help people recover and get better.

JACKY ANGUS
In what particular areas would there be - I’m thinking of depression and substance misuse which I guess is more common in Australia than in other parts of the world?

PATRICK MCGORRY
Yes.  Psychotic disorders when people are experiencing perceptual disturbance, hearing voices for example and other psychotic symptoms.

JACKY ANGUS
You have talked about co-operation amongst professionals and educators. Is that what is usually meant by the term ‘collaborative care’? Can you explain that? I know that is very much a thing in the policy world that it would be useful to go about the whole business of mental health in that way.

PATRICK MCGORRY
Yes. I think collaboration or the other term that has probably got the same intent is multi‑disciplinaries.  There are so many facets of the young person’s life that they need interaction with - education, vocational aspects, the clinical part the subjective distress or the symptoms of the illness or the mental health problem. Offending behaviour is another common sort of phenomenon in this age group too and often overlaps with mental health problems so we have got to have input from Youth Justice and other sort of settings like that.

The other point to make here is that the agencies and the professionals that are working together to help the young people they are quite different from what you see in younger children, let us say pre-pubertal children or even older adults.  That is part of the justification for having a separate stream of care orientated around this age group.

JACKY ANGUS
Professor McGorry, I’d like to ask you what your current interests are because I know that you have a lot on your plate.

PATRICK MCGORRY
I think the main areas are trying to identify the very earliest signs of potentially serious disorders like schizophrenia that has been an interest for some time.  We are now able to identify young people with a greatly increased risk of early transition to first episode schizophrenia and other psychoses.

JACKY ANGUS
What age are we talking about here?

PATRICK MCGORRY
Again anywhere between mid-teens up to mid-twenties in this case is the peak period of risk in the life span.  A lot of young people do develop early warning signs of psychosis during that period.  Now many of those will not progress to a more persistent or severe psychotic illness, but they are at increased risk.  What we have been able to show is that if we do begin treating young people with those warning signs, particularly when they have already shown a significant degree of distress and functional impairment - they need clinical care of some sort and if we can offer preventive treatment at that point it reduces their risks of becoming psychotic and developing schizophrenia. That is an area that we have been working very hard on.  We are now trying to use safer and more acceptable treatments like omega 3 fatty acids, low dose lithium therapy, cognitive behaviour therapy.  These are treatments that young people will not really be adversely affected by in a negative way and which will have potentially very great benefits.
This is an area of research that has opened up internationally.  There are dozens of centres looking at this issue now and it is very promising and is a key area.

JACKY ANGUS
What are the global trends in this sort of research?

PATRICK MCGORRY
That is one of the key ones.  I think we are trying to drive structural reform and investment and the creation of a special professional field around the youth mental health area.  It is the peak period across the lifespan when mental health problems are emerging and in fact are at their peak.  It has not had an academic or professional basis for it and has been lumped in with child psychiatry or ignored.

There is great potential to develop that understanding and I suppose a theoretical basis for it in all levels whether it is brain development, social development or psychological development and treatment.  That is what we see is the real challenge for international mental health going forward in the next ten or twenty years.

JACKY ANGUS
Thank you very much for being on Up Close, Professor McGorry.

PATRICK MCGORRY
Thanks very much.

JACKY ANGUS
That was Professor Patrick McGorry from the University of Melbourne, Australia. More information on this episode including a full transcript and related links can be found at our website at upclose.unimelb.edu.au. We invite you to leave your comments on this or any other episode of Up Close.  To do this just click on the Add Comments link at the bottom of the screen.  Up Close is brought to you by the Marketing and Communications Division, in association with Asia Institute, at the University of Melbourne, Australia. Up Close is created and produced by Eric van Bemmel and Kelvin Param. Audio engineering by Craig McArthur.  Theme music performed by Sergio Ercole. This is Jacky Angus thanking you for joining us on Up Close. Until next time, cheerio.

VOICEOVER
You’ve been listening to Melbourne University Up Close, a fortnightly podcast of research, personalities and cultural offerings of the University of Melbourne, Australia. Up Close is available on the web at upclose.unimelb.edu.au, that’s upclose.u-n-i-m-e-l-b.edu.au. Copyright 2008 University of Melbourne.


show transcript | print transcript | download pdf