Formerly published as Epidemiologia e Psichiatria Sociale
PRESENTATION OF THE EDITORIALS
Mental health, natural and human made disasters:
lessons learnt and future needs.
Amaddeo F. & Tansella M.1
The great East Japan Earthquake in 2011; toward
sustainable mental health care system.
Suzuki Y. & Kim Y.7
The narrative epidemiology of L’Aquila 2009 earthquake.
Casacchia M., Pollice R. & Roncone R. 13
Are human made disasters different?
Sederer L.I. 23
ABC OF METHODOLOGY
Heterogeneity: the issue of apples, oranges and fruit pie
Purgato M. & Adams C.E.23
NEUROBIOLOGY OF PSYCHOSIS.
Functional MRI studies in disruptive behaviour disorders.
Bellani M., Garzitto M. & Brambilla P.27
The importance of secondary trauma exposure for
post-disaster mental disorder
Kessler R.C., McLaughlin K.A., Koenen K.C.,
Petukhova M., Hill E.D. & the WHO World Mental Health
Survey Consortium. 35
Age of onset of mental disorders and use of mental
health services: needs, opportunities and obstacles.
de Girolamo G., Dagani J., Purcell R., Cocchi A. & McGorry P.D. 47
No time to lose: onset and treatment delay for
What promotes and inhibits cooperation in
Mental Health Care across disciplines, services and
service sectors? A qualitative study
Bramesfeld A., Ungewitter C., Böttger D.,
El Jurdi J.,.Losert C. & Kilian R.63
Gender differences in public beliefs and attitudes
about mental disorder in western countries:
a systematic review of population studies
Holzinger A., Floris F., Schomerus G.,
Carta M.G.& Angermeyer M.C.73
The relationship between socio-economic status
and antidepressant prescription: a longitudinal survey
and register study of young adults
von Soest T., Bramness J.G., Pedersen W. & Wichstrøm L. 87
Personalised support delivered by support workers
for people with severe and persistent mental illness:
a systematic review of patient outcomes.
Siskind D. Harris M., Pirkis J. & Whiteford H.97
LETTERS TO THE EDITOR
Childhood depression and anxiety disorders in Serbia:
a psychometric study of four screening questionnaires
Stevanovic D. 111
Parents’ beliefs about actions they can take to prevent
depressive disorders in young people: results from an
Australian national survey
Hui Yap M.B. & Jorm A.F. 117
Cambridge Journals Online
For further information about this journal
please go to the journal website at:
VOLUME 21 ISSUE 01VOLUME 21ISSUE 01
Epidemiology and Psychiatric Sciences
20457960_21-1_20457960_21-1 25/01/12 7:35 PM Page 1
MICHELE TANSELLA, University of Verona, Italy
FRANCESCO AMADDEO, Verona, Italy
CORRADO BARBUI, Verona, Italy
ANTONIO LASALVIA, Verona, Italy
MIRELLA RUGGERI, Verona, Italy
CARLO A. ALTAMURA, Milano, Italy
MATTEO BALESTRIERI, Udine, Italy
FRANCESCO BARALE, Pavia, Italy
DOMENICO BERARDI, Bologna, Italy
MASSIMO BIONDI, Roma, Italy
FILIPPO BOGETTO, Torino, Italy
PAOLO BRAMBILLA, Udine, Italy
LUIS SALVADOR CARULLA, Cadiz, Spain
MASSIMO CASACCHIA, L’Aquila, Italy
ANDREA CIPRIANI, Verona, Italy
GIOVANNI DE GIROLAMO, Brescia, Italy
CARLO FARAVELLI, Firenze, Italy
SECONDO FASSINO, Torino, Italy
LUIGI GRASSI, Ferrara, Italy
LOUISE HOWARD, London, United Kingdom
SONIA JOHNSON, London, United Kingdom
RONALD C. KESSLER, Boston, USA
ANTONIO LORA, Milano, Italy
LORENZA MAGLIANO, Napoli, Italy
PATRICK MC GORRY, Melbourne, Australia
MARIO MAJ, Napoli, Italy
PIERLUIGI POLITI, Pavia, Italy
MARCO RIGATELLI, Modena, Italy
SJOERD SYTEMA, Groningen, The Netherlands
INTERNATIONAL ADVISORY BOARD
RENATO FIANCO, University of Verona, Italy
Epidemiology and Psychiatric Sciences is an international, peer-reviewed journal published quarterly. It provides updated data and scientific
information to epidemiologists, psychiatrists, psychologists, statisticians and other research and mental health workers primarily concerned with
public health and epidemiological and social psychiatry.
© Cambridge University Press 2012
COPYING This journal is registered with the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923. Organizations in the USA who
are also registered with C.C.C. may therefore copy material (beyond the limits permitted by sections 107 and 108 of US copyright law) subject to
payment to C.C.C. of the per-copy fee of $16.00. This consent does not extend to multiple copying for promotional or commercial purposes. Code
2045-7960/2012 $16.00. Organizations authorized by the Copyright Licensing Agency may also copy material subject to the usual conditions. ISI
Tear Sheet Service, 3501 Market Street, Philadelphia, Pennsylvania 19104, USA, is authorized to supply single copies of separate articles for
private use only. For all other use, permission should be sought from Cambridge or the American Branch of Cambridge University Press.
SUBSCRIPTIONS Epidemiology and Psychiatric Sciences (ISSN 2045 7960) is published four times a year in March, June, September and December
by Cambridge University Press, The Edinburgh Building, Shaftesbury Road, Cambridge CB2 8RU, UK/Cambridge University Press, 32 Avenue
of the Americas, New York, NY 10013–2473, USA. The subscription price (excluding VAT), which includes print and electronic access, of volume
21, 2012 is £190 (US $313 in USA, Canada and Mexico) for institutions; £76 (US $125 in USA, Canada and Mexico) for individuals ordering direct
from the Press and certifying that the journal is for their personal use. The electronic-only price available to institutional subscribers is £121 (US
$200 in USA, Canada and Mexico). Four parts form a volume. EU subscribers (outside the UK) who are not registered for VAT should add VAT at
their country’s rate. VAT registered subscribers should provide their VAT registration number. Orders, which must be accompanied by payment,
may be sent to any bookseller or subscription agent or direct to the publishers: Cambridge University Press, The Edinburgh Building, Shaftesbury
Road, Cambridge CB2 8RU, UK, or in the USA, Canada and Mexico, to Cambridge University Press, Journals Fulfi llment Department, 100 Brook
Hill Drive, West Nyack, New York 10994–2133. Japanese prices for institutions are available from Kinokuniya Company Ltd, P.O. Box 55, Chitose,
Tokyo 156, Japan.
Periodicals postage paid at New York, NY, and at additional mailing offi ces. POSTMASTER: send address changes in the USA, Canada and
Mexico to Epidemiology and Psychiatric Sciences, Cambridge University Press, 100 Brook Hill Drive, West Nyack, New York 10994–2133. Claims
for missing issues will not be entertained unless made immediately upon receipt of the subsequent issue.
INTERNET ACCESS This journal is included in the Cambridge Journals Online service which can be found at http://journals.cambridge.org/eps. For
further information on other Press titles access http://journals.cambridge.org/.
Enquiries about advertising should be sent to the Journal’s Promotion Department of the Cambridge or American Branch of Cambridge University
This journal issue has been printed on FSC-certifi ed paper and cover board. FSC is an independent, non-governmental, not-for-profit
organization established to promote the responsible management of the world’s forests. Please see www.fsc.org for information.
Printed by Latimer Trend, Plymouth, UK.
THOMAS BECKER, Ulm, Germany
MAX BIRCHWOOD, Birmingham, United
BRIAN COOPER, Heidelberg, Germany
PAOLA DAZZAN, London, United Kingdom
ROBERT E. DRAKE, Dartmouth, USA
JOHN GEDDES, Oxford, United Kingdom
SUSAN M. ESSOCK, New York, USA
SIR DAVID GOLDBERG. London, United Kingdom
HOWARD H. GOLDMAN, Baltimore, USA
ASSEN JABLENSKY, Perth, Australia
MARTIN KNAPP, London, United Kingdom
POVL MUNK-JORGENSEN, Aalborg, Denmark
CARMINE PARIANTE, London. United Kingdom
STEFAN PRIEBE, London, United Kingdom
BENEDETTO SARACENO, Ornex, France
NORMAN SARTORIUS, Geneva, Switzerland
AART SCHENE, Amsterdam, Netherlands
GRAHAM THORNICROFT, London, United
PETER TYRER, London, United Kingdom
JIM VAN OS, Maastricht, Netherlands
JOSE VAZQUEZ BARQUERO, Santander, Spain
MYRNA M. WEISSMAN, New York, USA
ULI WITTCHEN, Dresden, Germany
CHRISTA ZIMMERMANN, Verona, Italy
INSTRUCTIONS FOR CONTRIBUTORS
SCOPE Epidemiology and Psychiatric Sciences (EPS) is an international, peer-reviewed journal providing updated data and
scientific information to epidemiologists, psychiatrists, psychologists, statisticians and other research and mental health workers
primarily concerned with public health and epidemiological and social psychiatry. Priority is given to original research and
systematic reviews about mental health service research, aimed to improve the quality of everyday practice. EPS is published
quarterly (in March, June, September and December).
A full instructions to authors is available at: http://journals.cambridge.org/eps
EPS publishes the following article types:
● Presentation of the Editorials
● Special Articles
● Original Articles
The Editor will also consider Methodological Contributions, Systematic Reviews and Meta-analyses.
The following Sections may also appear in the journal:
● ABC of Methodology
● Neurobiology of Psychosis
All submissions must be in English. Occasionally Letters may be published in Italian.
All contributions are accepted for publication after external peer review.
SUBMISSION OF MANUSCRIPTS
All papers submitted for publication should be addressed to the Editor:
Professor Michele Tansella
Department of Public Health and Community Medicine
Section of Psychiatry and Clinical Psychology
University of Verona
Policlinico G.B. Rossi
Piazzale L.A. Scuro 10
37134 Verona, Italy
All submissions must be made electronically by email and include a covering letter. Submission of a paper will be held to imply
that contains original work that has not been previously published and that it is not being submitted for publication elsewhere.
● All submissions must follow the style guide for submissions available in the full author instruction guide available online.
● If you require any further guidance on creating suitable electronic figures, please visit http://dx.sheridan.com/guidelines/
digital_art.html. Here you will find extensive guidelines on preparing electronic figures and also have access to an online
preflighting tool where you can check if your figures are suitable for reproduction.
PROOFS AND OFFPRINTS Page proofs will be sent to the author designated to receive correspondence. Corrections other than
to printer's errors may be charged to the author. All papers are published in their final version in the FirstView page of EPS before
being printed. A final PDF will be sent to the corresponding author when the article is published.
Detailed instructions for authors can be found on the EPS website <journals.cambridge.org/eps>
20457960_21-1_20457960_21-1 25/01/12 7:35 PM Page 2
Age of onset of mental disorders and use of mental
health services: needs, opportunities and obstacles
G. de Girolamo1*, J. Dagani1, R. Purcell2, A. Cocchi3and P. D. McGorry2
1IRCCS Fatebenefratelli, Via Pilastroni 4, 25125 Brescia, Italy
2Department of Psychiatry, Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Australia
3A.O. Ospedale Niguarda Ca’ Granda, Programma 2000, Via Livigno, 3, 20128 Milan, Italy
Purpose of review. In this review, we provide an update of recent studies on the age of onset (AOO) of the major men-
tal disorders, with a special focus on the availability and use of services providing prevention and early intervention.
Recent findings. The studies reviewed here confirm previous reports on the AOO of the major mental disorders.
Although the behaviour disorders and specific anxiety disorders emerge during childhood, most of the high-prevalence
disorders (mood, anxiety and substance use) emerge during adolescence and early adulthood, as do the psychotic dis-
orders. Early AOO has been shown to be associated with a longer duration of untreated illness, and poorer clinical and
Summary. Although the onset of most mental disorders usually occurs during the first three decades of life, effective
treatment is typically not initiated until a number of years later. There is increasing evidence that intervention during the
early stages of disorder may help reduce the severity and/or the persistence of the initial or primary disorder, and pre-
vent secondary disorders. However, additional research is needed on effective interventions in early-stage cases, as well
as on the long-term effects of early intervention, and for an appropriate service design for those with emerging mental
disorders. This will mean not only the strengthening and re-engineering of existing systems, but is also crucial the
construction of new streams of care for young people in transition to adulthood.
Received 1 July 2011; Revised 4 October 2011; Accepted 28 October 2011
Key words: Age of onset (AOO), early intervention, prevention, DUP, treatment delay.
In all areas of medicine, the study of the age of onset
(AOO) of illnesses has attracted increasing interest
over time. As Kessler et al. (2007) observed, the study
of the AOO enables us to calculate the projected life-
time risk of disorders, and makes it possible to capture
the topography of onset and clarify disorder aetio-
pathogenesis, so that primary prevention, prevention
of secondary disorders and early intervention strat-
egies can be targeted in an efficient, timely and cost-
Epidemiological data about AOO, however, face sev-
eral problems: retrospective reports from community-
based surveys, typically of an incomplete range of dis-
orders, are often hampered by recall bias, making
uncertain the timing of the disorder onset, and retro-
spective measures of treated incidence samples even
for psychotic disorders are known to be incomplete.
Certainly for the mood, anxiety, substance use and per-
sonality disorders, where treated incidence and preva-
lence are low as a proportion of the total, AOO data
ascertained this way may be of uncertain accuracy.
Moffitt et al. (2010) provided a clear example of these
problems. The authors followed up the representative
1972–1973 Dunedin New Zealand birth cohort (n=
1037) to age 32 years (achieving a 96% retention), and
compared it with the National New Zealand Mental
Health Survey (NZMHS), as well as with two US
samples. The prevalence of lifetime disorder at the age
of 32 years approximately doubled in prospective as
compared with retrospective data for all four disorder
types. In the case of children and adolescents, Angold
et al. (1996) showed that when symptoms have persisted
longer than 3 months, the month of onset usually can-
not be accurately reported, while with symptoms last-
ing a year or more, even the year of onset is usually
This paper reviews recent studies about AOO, and
its relationship with treatment delay, with special
attention to studies that relate onset to the prospects
for prevention and early intervention.
* Address for correspondence: Giovanni de Girolamo, M.D., IRCCS
Fatebenefratelli, Via Pilastroni 4, Brescia, Italy.
Epidemiology and Psychiatric Sciences, page 1 of 11.
© Cambridge University Press 2011
When do disorders start?
Most mental disorders begin in adolescence and early
adulthood, with these disorders now revealed as the
major contributors to the burden of disease in young
people (Murray & Lopez 1996; McGorry et al. 2007a, b,
2008). In a recent Lancet paper, Gore et al. (2011)
described the Global Burden of Disease (GBD) in
young people analysing all-cause and cause-specific
disability-adjusted life-years (DALYs) across global
regions for people aged 10–24 years. They used data
from WHO’s 2004 GBD, and found that the total
number of incident DALYs in those aged 10–24 years
represents 15.5% of total DALYs for all age groups.
wasneuropsychiatric disorders (45%) and the main risk
factor was alcohol (7% of DALYs).
In the National Comorbidity Study Replication,
Kessler et al. (2005) found that half of all lifetime
cases started by the age of 14 years and three-fourths
by the age of 24 years. Later onsets were mostly of
comorbid conditions, with estimated lifetime risk of
any disorder at age 75 years (50.8%) only slightly
higher than observed lifetime prevalence (46.4%). The
patterns for mental and substance use disorders are
virtually the mirror image of those seen in the chronic
physical disorders, which prompted Insel & Fenton
(2005) to characterize mental disorders as the ‘chronic
diseases of the young’.
The case of mood and anxiety disorders
Epidemiological studies consistently indicate that
anxiety disorders are among the most prevalent men-
tal disorders among children, with cross-sectional
studies showing that up to 20% of paediatric patients
score above the identified clinical cut-offs for one or
more anxiety disorders (Rockhill et al. 2010). Anxiety
disorders have relatively equal
among young boys and girls, but then become more
common in females, with a 2:1–3:1 female preponder-
ance by adolescence (Rockhill et al. 2010).
Separation anxiety disorder (SAD), with prevalence
approximately 5% before puberty, represents the only
specific anxiety disorder that primarily occurs in chil-
dren and adolescents, but not in adults; social phobia
and generalized anxiety disorder (GAD) frequently
co-occur with it; the latter become more prevalent
during adolescence, again with rates around 5%.
While the overall rate of anxiety disorders changes
relatively little from childhood to adolescence, the
nature of disorder does, with SAD most common in
young children, whereas social phobia is most com-
mon in adolescence (Pine, 2009). In general, while
some anxiety disorders have a median AOO within
childhood (particularly specific phobias and separ-
ation anxiety), most of the high prevalence anxiety dis-
orders typically emerge during early adolescence and
In a 14-year follow-up of 1580 subjects aged 4–16
years (Roza et al. 2003), anxiety disorders were more
frequent than mood disorders until the age of 25
years, both in males and females. After the age of 25
years, the cumulative incidence of anxiety disorders
did not increase, in contrast to the cumulative inci-
dence of mood disorders. Adolescent onset of anxiety
disorders is also associated with more severe and dis-
abling forms of these illnesses (Paus et al. 2008).
The National Comorbidity Survey Replication-
Adolescent Supplement (NCS-A) reported prevalence
and onset data on 10 123 adolescents in the USA using
a modified version of the CIDI. Anxiety disorders
al disorders (19.1%), mood disorders (14.3%) and
substance use disorders (11.4%); the overall prevalence
for any disorder with severe impairment and/or
distress was 22.2%. The median AOO was 6 years for
anxiety disorders, 11 years for behaviour disorders, 13
years for mood disorders and 15 years for substance
use disorders. Given that the upper limit of the
sample was censored at 18 years, therefore excluding
later onsets,these figures
cautiously in terms of defining the span and focus of
prevention and early intervention efforts, which must
extend from childhood through to the mid-20s at
least on the basis of Kessler et al.’s findings (Kessler
et al. 2005).
In Germany, a prospective, longitudinal follow-up
study (over 7–10 years) evaluated 3021 participants
aged 14–24 years at baseline assessment. The AOO dis-
tributions of anxiety varied according to the type of
disorder, with social and specific phobias typically
emerging during childhood, compared to GAD and
panic disorder, which characteristically emerged in
adolescence and early adulthood. The latter pattern
of onset was similarly observed for depressive dis-
orders (Beesdo et al. 2010).
Several studies have examined correlations between
the AOO of depression and the course or nature of ill-
ness, with an earlier onset associated with more
chronic illness (Angst et al. 2009), a greater number
of depressive episodes among females, but not males
(Essau et al. 2010) and longer episode duration,
increased suicidality and need for hospitalization
(Korczak & Goldstein, 2009). In the large sample
(N =89 037) of the WMH Survey Initiative, data from
18 countries were analysed and the average AOO,
ascertained retrospectively, was 25.7 in the high-
income and 24.0 in low- to middle-income countries.
must be interpreted
2 G. de Girolamo et al.
high-income countries, younger age was associated
with higher 12-month prevalence (Bromet et al. 2011).
Of particular concern from an early intervention
perspective, the latency to treatment initiation was
found in one study to be significantly longer in those
with childhood (mean=12.9 years) and adolescent
onset (mean=6.3 years) compared to adult-onset
depression (mean=2.4 years) (Korczak & Goldstein,
2009). Given the well-documented adverse outcomes
associated with prolonged duration of untreated psy-
chosis (DUP) (Marshall et al. 2005), this finding under-
scores the need for greater early identification and
(Hetrick et al. 2008). Also intervening with subthres-
hold symptoms in adolescents might be effective in
reducingthe risk offull-syndrome
(Garber et al. 2009).
Another important area for early intervention, and
one in need of careful study of the AOO, is bipolar
disorder (Hamshere et al. 2009; Perlis et al. 2009;
Baldessarini et al. 2010; Tijssen et al. 2010). Several
studies have utilized large, multicentre samples, ran-
ging from 1369 (Hamshere et al. 2009) to 3658 (Perlis
et al. 2009) subjects, recruited to clinical trials or other
studies of bipolar disorder. Many onsets occurred in
the 20s of study subjects, and in all studies earlier
onsets showed greater severity and other defining
clinical characteristics. Tijssen et al. (2010) took a differ-
between 14 and 17 years and following them up for
up to 10 years. They found that experiencing (hypo)
manic symptoms is a common adolescent phenom-
enon that infrequently predicts (current) mental health
The case of substance use disorders
Epidemiological studies have consistently shown that
prevalence of alcohol and drug use and abuse
increases with age during adolescence and peaks in
early adulthood. Vega et al. (2002) compared lifetime
prevalence and age of first use (onset) for alcohol, can-
nabis and other drugs in six international sites. In their
sample (N =27 255), age of first use was similar across
study sites: in particular, alcohol use onset increased at
the age of 11 years, and the curve accelerated in mid-
adolescence to a peak age of 18 years. This was fol-
lowed by a rapid decrease in new onsets during
early adulthood (the early 20s) and a gradual tapering
off thereafter. Cannabis had a short but intense onset
period with rapid acceleration of first use between
mid- and late adolescence, then a rapid decrease
after the age of 16–18 years, while drugs other than
alcohol and cannabis had a longer onset curve, with
lower onset rates during adolescence, but new onsets
extending into middle adulthood (peak age of first
use in all sites occurred at the age of 18 years).
Degenhardt et al. (2008) assessed substance use dis-
orders using a large dataset from 17 countries partici-
pating in the WMH surveys (N =43 249). Results
shows a remarkable similarity in the AOO distributions
for specific types of drug across countries: the median
AOO for substances was: alcohol between 16 and 19
years for all countries (with the exception of South
Africa: 20 years), cannabis between 18 and 19 years
(except for Nigeria and Israel: 22 years; Lebanon: 21
years) and cocaine between 21 and 24 years.
Childhood and adolescent conduct disorder have
strongly been associated with both early initiation
and progression in different types of substance use
and abuse (Rutter et al. 2006; Goodman, 2010).
Indeed in a recent US study, Slade et al. (2008) found
that having a substance use disorder by the age of 16
years was associated with higher risk of incarceration
for substance-related offenses in early adulthood and
with more extensive criminal justice system involve-
ment, as compared with having no disorder or having
a disorder beginning at a later age.
In the 10-year prospective German study mentioned
earlier (N =3021), Behrendt et al. (2009) studied the
association of early substance use (e.g. alcohol, nic-
otine or cannabis) in adolescence and the risk of devel-
oping substance use disorders. Their findings show
that first alcohol use mainly occurred between the
age of 10 and 16 years, first nicotine use between the
age of 11 and 17 years and first cannabis use between
the age of 14 and 19 years; overall early substance use
was associated with an elevated risk of substance use
disorder for all the substances considered.
These findings again underscore the need for early,
targeted interventions for substance and alcohol-
related disorders among young people especially.
The case of psychotic disorders
Disorder-specific estimates of AOO distributions for
affective and non-affective psychotic disorders have
not been separately reported in any of the WMH sur-
veys, or in any other surveys of common mental dis-
orders, due to the under-representation of these cases
in community surveys.
In a Danish registry study (Thorup et al. 2007), two
cohorts were established by linking data from the
Danish Civil Registration System with data from the
Danish Psychiatric Central Register, which covers all
incident cases of schizophrenia from 15 to 71 years.
The authors estimated the gender- and age-specific
incidence rates of schizophrenia for people aged up
Age of onset of mental disorders and use of mental health services3
to 71 years. The median age at onset for males and
females was 27 and 29 years, respectively. Despite
their somewhat divergent findings, these studies that
cover most of an individual’s life span suggest that
the median AOO of schizophrenia for males is in the
late 20s and for females is in the mid-30s.
In the well-known ABC cohort study, Häfner et al.
(1998) found that, in a sample of 232 subjects with
(defined as the first psychotic symptom) by the age
of 21 years, 59% in the age range of 21–35 years and
only a fifth after the age of 35 years. A consistent result
of this study was a 3–4 years higher AOO for women
by any definition of onset, which was not explainable
by social variables, such as differences in the male–
female societal roles, but related perhaps to a protec-
tive effect of oestrogen (Häfner, 2003).
Data about the AOO also come from selected, rigor-
ous epidemiological studies on the incidence of schizo-
phrenia. In the well-known WHO multinational
DOSMED study (Jablensky et al. 1992), 70% of male
patients and almost 60% of female patients had illness
onset before 25 years of age.
Finally, in a recent study aimed at comparing the
long-term outcome in 723 consecutive first-episode
Amminger et al. (2011) found that the mean age of
patients with adult (e.g. after the age of 18 years)
onset was quite low (22.6 years). They found that indi-
viduals with an early onset who received early inter-
positive symptoms and significantly superior function-
ing on measures assessing global, social/occupational
and community functioning compared to patients
with adult-onset disorder, equally treated. Their find-
ings suggest that early detection and specialized treat-
specifically improve long-term functional outcome,
and to some extent symptomatic outcome in people
with early-onset schizophrenia
Meta-analytic evidence also indicates that younger
age at the onset of schizophrenia is associated with a
positive family history for psychosis (Esterberg et al.
2010) and that the AOO of psychosis for cannabis
users is 2.7 years younger than for non-users (Large
et al. 2011). Heavy use of cannabis in adolescence is
also associated with a substantial increase in the risk
of experiencing psychotic episodes (Kuepper et al.
2011). Moreover, in the Dunedin Longitudinal Study,
self-reported symptoms about delusional beliefs and
hallucinatory experiences at the age of 11 years were
significantly associated with an increased risk of devel-
oping a schizophrenia-spectrum disorder by the age of
26 years (Rutter et al. 2006).
range of 14–30 years),
as compared to
Studies conducted in minors recruited from child
psychiatric settings have emphasized a relationship
between the AOO of schizophrenia and the course of
illness, with earlier onset (before 18 years of age) poss-
ibly associated with a more chronic form of the dis-
order (for reviews, see Kyriakopoulos & Frangou,
2007; Vyas et al. 2011), and more severe cognitive def-
icits (Rajji et al. 2009), with impairments in general
intellectual ability (IQ), attention, executive function
and memory consistently found in early-onset cases
of schizophrenia (Frangou, 2010).
These findings support the view that severity of the
disease process may be associated with different ages
at onset; indeed late adolescence is likely to reflect a
critical period in brain development, making it particu-
larly vulnerable for the onset of psychopathology
(Walker et al. 2004; Paus et al. 2008).
However, the traditional reluctance of child and
adolescent psychiatrists to assign severe psychiatric
diagnoses to minors could contribute to an over-
representation of more severely ill chronic cases
(Krausz & Muller-Thomsen, 1993). This diagnostic
reluctance, combined with a hesitancy to prescribe
antipsychotic medication, inevitably increases the
DUP and may contribute to poorer outcome in people
with earlier onset. Therefore, such hesitancy, particu-
larly in many child and adolescent mental health ser-
vices, should be reassessed.
Social inequalities and individual resilience
In a project sponsored by the WHO Regional Office for
Europe, an expert group has summarized the evidence
on social determinants of health, and has identified 10
main variables that can affect people’s health (Marmot,
2005): among these, eight have a direct, and often pro-
found influence on people’s mental health, namely the
social gradient, stress, early life, social exclusion, work,
unemployment, social support and substance use.
Although there is no space for a thorough discussion
of all these factors, we point to the relevance of
Socio-Economic Status (SES) as potential risk factor
for a variety of mental health outcomes. For instance,
a growing body of meta-analytical work suggests
that higher incidence and worse outcomes of psychotic
disorders are associated with growing up in an urba-
nized area, being in a minority group position, using
cannabis and suffering from developmental trauma
(van Os et al. 2010).
The association between family Socio-Economic
Position (SEP) and mental health problems among ado-
lescents has been studied in a large cohort (N =2230)
enrolled in the TRAILS study: the authors found
that in early adolescence the risk of mental health
4 G. de Girolamo et al.
problems increased with decreasing SEP, particularly
in the case of externalizing problems (Amone-P’Olak
et al. 2009).Van Oort et al (2011)havestudied the associ-
ation between SES and emotional and behavioural
problems comparing a US cohort (N=833) and a
Dutch cohort (N =708) of youths. Although the health-
care systems differbetween
Netherlands, socio-economic disparities in emotional
and behavioural problems were similar: in both
countries, lower SES predicted cumulative prevalence
rates for externalizing problems (withdrawn and
In their review, Fryers et al. (2003) have identified
several studies providing evidence of an association
between markers of a less privileged social position
(especially unemployment, less education and low
income or poor standard of living) and higher preva-
lence of common mental disorders; moreover, they
have also shown that a low SES has a potential to wor-
sen mental disorders; a similar conclusion has been
drawn by Amaddeo & Jones (2007); the latter authors
have also stated that the precise factors linking SES
and service utilization are still unclear.
Although these social variables are of great impor-
tance in shaping individual exposure to risk factors
and enhancing healthy individual development, it is
open to discussion what should be the role of psychia-
trists and other mental health professionals in the
wider social context to promote societal changes: do
they have a direct duty to change (or promote the
directly linked to their profession? Or should they
mainly be concerned about the correct application of
their specific knowledge and skills, as it has been well
dant literature on social factors and mental health, the
work has never been well clarified (Carpenter, 2002).
The discussion so far has had a focus on social vari-
ables: on the other hand, the notion of resilience deals
with the individual ‘relative resistance to environ-
mental risk experiences, or the overcoming of stress
or adversity’ (Rutter, 2006). This author has eloquently
described the theoretical knots to be faced in conduct-
ing research on resilience. Luthar et al. (2006) have pro-
vided thoughtful inputs for this kind of investigations:
studies on resilience should assign priority to ‘factors
that are salient in that particular life context’, affecting
a large number of people; attention should be given ‘to
indices that are relatively malleable...., that tend to be
relatively enduring in a child’s life...., that are genera-
tive of other assets’. These authors have stressed that
an extensive body of research on childhood resilience
shows that ‘a strong, enduring relationship with at
least one caring adult’ meets all these criteria.
Specific interventions to increase resilience in chil-
dren and adolescents through parenting and early
interventions, and programmes for children at risk
for mental disorders such as those who have a men-
tally ill-parent or have suffered parental loss or family
disruption, have also shown to increase mental well-
being and decrease depressive symptoms and the
onset of depressive disorders (Saxena et al. 2006).
Research in this area has to be strengthened, both in
terms of better methodology and in clarity of
The continuity of psychopathogy
The research evidence reviewed abundantly here
demonstrate that a large proportion of mental dis-
orders commence in childhood, adolescence and
early adulthood. Some may argue that, in the context
of obvious maturational changes occurring at those
life stages, mental disorders can remit, paving the
road to a healthy adulthood. However, there is strong
evidence pointing to a high level of continuity between
childhood/adolescent and adult psychopathology.
Costello et al. (2003) analysed data on a representa-
tive sample of 1420 children aged 9–13 years at intake
and followed them up until 16 years, examining also
homotypic and heterotypic continuity. Their results
showed that at any time, 1 in 6 will have a psychiatric
disorder, and at least 1 in 3 will have experienced a
mental disorder by the age of 16 years. Moving from
childhood to adolescence, there was a rise in rates of
depression and social phobia in females, which was
not observed in males, while in middle adolescence
the increase in substance abuse in both sexes was dra-
matic. During this period there was also a modest
increase in panic disorder and GAD.
In another prospective investigation (N =1037),
Kim-Cohen et al. (2003) found that half of the individ-
uals who met criteria for a major DSM-IV diagnosis at
26 years, first had a diagnosable disorder at 11–15
years of age, and three-quarters had a first diagnosis
before 18 years. Adult disorders were generally pre-
ceded by their juvenile counterparts (e.g. adult anxiety
was preceded by juvenile anxiety: homotypic continu-
ity), and also by different disorders (e.g. heterotypic
Conduct disorders in childhood or adolescence are
strong markers of adult psychopathology: in a group
of 578 male and 674 female twins, McGue et al. (2006)
found that early adolescent problem behaviour ident-
ified a subset of youth at especially high (and general-
ized) risk for developing adult psychopathology.
In a cohort study, Reef et al. (2009) found that almost
one-fourth of 1365 children categorized as deviant
Age of onset of mental disorders and use of mental health services5
were still regarded as deviant at 24-year follow-up.
Out of all childhood problems, primarily anxious/
depressed problems, aggressive behaviour and delin-
quent behaviour showed the strongest associations
with adult psychopathology. Not surprisingly, the
strongest predictor for adult internalizing problems
were anxious and depressed problems in childhood,
and the best predictors for adult externalizing pro-
blems was childhood delinquent behaviour.
The current evidence about the continuity of psy-
chopathology highlights the strong need for effective,
early interventions in young people in order to foster
secondary and tertiary prevention and minimize the
risks of chronic, disabling courses of mental disorders.
Treatment delay and characteristics of adult
In the WMH Survey initiative, delay to treatment has
been carefully investigated cross nationally. Although
in some countries the majority of people with lifetime
disorders eventually make treatment contact with any
(health or non-health) helping agency, there is tremen-
dous between-country variation, less for mood dis-
orders (88.1–94.2%) than for anxiety (27.3–95.3%),
impulse control (33.9–51.8%), or substance disorders
(52.7–76.9%). However, delay among those who even-
tually made treatment contact was significant, ranging
from 6 to 8 years for mood disorders and 9–23 years
for anxiety disorders. In this large dataset, poor access
to treatment and delay among those who eventually
made treatment contact were both associated with
early AOO, being in an older cohort, and having
selected socio-demographic characteristics such as
being male, married and poorly educated (Wang
et al. 2005).
Christiana et al. (2000) used self-report data from
3516 members of advocate groups for patients with
anxiety or mood disorders in 11 European countries
to study time to initial professional help-seeking after
incident episodes. In all cohorts and all countries,
time for initial help-seeking was inversely related to ill-
Data about the socio-demographics of patients in
treatment in Italy are of particular interest, since this
country has closed all large Mental Hospitals starting in
1978, and since then embarked on providing a full net-
work of community-based services for patients with
mental disorders. We have comprehensive data from
two registries covering two large regional areas:
Lombardy (9 742.676 inhabitants) and Emilia-Romagna
(4 337.979 inhabitants). In Lombardy, the rate per 10
000 population of patients in treatment with any
public mental health service in 2005 (last year with
available data) was 72 for males and 80 for females
aged 15–24 years. The rates increased in parallel with
aging (e.g. 139 for males and 142 for females aged
25–34 years; 155 for males and 180 for females aged
35–44 years, etc.). Even the treatment rates of males and
females aged 65+ years were higher than rates for
young people aged 15–24 years (Lora, 2008). The same
report underlines that the percentage of new patients in
contact with services has been decreasing, while the
mean age of treated patients has been increasing. In the
Emilia-Romagna Region, rates of patients in treatment
at adult mental health services were 132.8 per 10 000
among people aged 18–24 years; however, treatment
rates were almost double for those aged 45–54 years
(226.6 per 10 000). Despite the peak AOO of mental
disorders being in adolescence and young adulthood,
patients in this region aged 18–34 years represent only
of older adult patients (Bignami et al. 2008).
Although these data are cross sectional, they show
that even in a country with extensive community men-
tal health services like Italy, access to treatment is high-
est among older patients, with people aged 18–30
years being the minority. This may either mean that
patients access treatment after a long delay since the
disorder onset, or that many patients show a chronic
course, despite having contacted services early: all
available data seem to point to the former option.
Treatment issues for youth psychopathology
As most mental disorders emerge in childhood, ado-
lescence and early adulthood, the state of Child And
Mental Health Services (CAMHS) should be of pri-
mary concern to any mental health professional. The
provision of CAMHS internationally is inconsistent,
with Shatkin & Belfer’s (2004) systematic survey find-
ing that only 7% (14 of 191) of countries worldwide
had a clearly articulated specific (e.g. stand-alone)
child and adolescent mental health policy. Similarly,
Costello et al. (2005) highlighted that in the US, one-
fourth of the youngest population receive one-ninth
of the treatment dollars.
A recent large US study examined the patterns of
mental health service use by young people (16–25
years) based on a nationally representative 1997
Client/Patient Sample Survey and on population data
from the US Census Bureau (Pottick et al. 2008). The
annual rate of use of inpatient, outpatient and residen-
tial services was 34/1000 for 16- and 17-year-olds, and
18/1000 for 18- and 19-year-olds, rates that are con-
siderably lower than the existing prevalence rates for
mental disorders at this age. This confirms a paucity
of service utilization just at the time when serious
6G. de Girolamo et al.
mental health problems are beginning to emerge
12-month rates of service use for mental health pro-
blems and disorders in the general Australian adult
population. Overall, 11.9% of the adult population
made use of any services for mental health problems
in a 12-month period and only 34.9% of people meet-
ing diagnostic criteria for mental-disorder-accessed
treatment services. However, people in the youngest
age group (16–24-year-old), who had the highest
rates of diagnosable mental disorder, concomitantly
had the lowest rates of service access and use.
In most developed countries, both child and adoles-
cent mental health service and adult services use rigid
age cut-offs to delineate service boundaries, which cre-
ate discontinuities in provision of care. In the US, a sur-
vey of transition provision (e.g. between CAMHS and
adult services) within 41 states found that a quarter of
child services and half of adult services offered no
transition support (Singh, 2009); in particular, many
16–18-year-olds failed to receive support and care
during this difficult transition period. Young people
with ongoing mental health problems who did not
meet criteria for serious mental disorders were specifi-
cally excluded from adult services (Costello et al. 2005).
Moreover research indicates that young people tend
to not seek professional help for mental health pro-
blems. Rickwood et al. (2007) found that young men
tend to be even more reluctant to seek help than
young women. Young people are generally more
inclined to seek help if they have some knowledge
about mental health issues and sources of help; feel
emotionally competent to express their feelings; and
have establishedand trusted
potential help providers (e.g. school counsellors).
Additional factors facilitating contact with services
and seeking professional help among young people
include the belief that mental health problems can
have adverse consequences, that treatment can help,
and that mental health problems have intra-psychic
causes (Vanheusden et al. 2008).
Using data from a large longitudinal study of Dutch
adolescents, Amone-P’Olack et al. (2010) investigated
the association between different indices of family
socio-economic position and use of mental health ser-
vices: they found that adolescents were particularly
more likely to use specialty mental health services
with increasing levels of maternal education, but
only when in the analyses the severity of mental pro-
blems was accounted for. Incomplete emotional lit-
eracy also appears to be an important barrier to
service use among young people, and is an adjunct
to mental health literacy. Specific beliefs about the
need for professional help appear to be particularly
et al. (2009)examined
strong barriers to seeking mental health care (Wilson
et al., 2011)
Policy planners should carefully consider these bar-
riers and facilitators in sketching new services for
children and adolescents. An example of a new
initiative that has taken such factors into account
is the Australian National Youth Mental Health
Foundation, called headspace. Created in 2006 in
response to the recognition that the existing health sys-
tem needed to be more accessible and effective for
young people aged 12–25 years, the Australian
Federal Government funded a network of initially 30
(soon to be 90) youth mental health services that are
specifically designed to be ‘youth-friendly’, to improve
access to treatment, particularly early intervention for
sub-threshold conditions in order to create greater
cohesion among service providers who work with
young people experiencing mental health problems
(including not only clinical staff but also drug and
alcohol services, youth workers and vocational/
employment support). Initial service use data show
that the headspace is improving access to care for
young people, including young males who constitute
40% of the treated population. Furthermore, the
majority of referrals to headspace comprise self-
referrals from young people, followed by family or
school counsellor referrals. Therefore, the bulk of head-
space clients are actively help seeking, and despite the
EI focus of the initiative, many already meet the diag-
nostic criteria for a psychiatric diagnosis or have high
levels of psychological distress that attest to their
need for care. That young people (both with and with-
out experiences of mental health services) actively par-
ticipate in shaping the design of headspace centres and
treatment services (including sitting on interview
panels to hire clinical and administrative staff) likely
explains some of the success of headspace being
regarded by young people as a youth-friendly and
appropriate service for their needs. Formal evaluation
will determine the impact of this initiative on improv-
ing health andsocial outcomes
for the target
Conclusion and implications: avertable burden,
coverage and timing of interventions
Prevention and early intervention are unquestionably
the keys to reduce the burden of disease among chil-
dren, adolescents and young people. Delay in the
start of treatment can have multiple deleterious conse-
quences, and mental health professionals should be
well aware of this.
Public education campaigns to improve mental
health literacy and help-seeking are the first step to
Age of onset of mental disorders and use of mental health services7
increase coverage and access (Wright et al. 2006; Joa
et al. 2008). Progressively scaling up the capacity of
the health system, both the primary and specialist
tiers of care, with easy access to care, assertive mobile
detection strategies for ‘hard to reach’ cases, and gen-
uine integration of multidisciplinary and age appropri-
ate care are achievable objectives.
The topography of onset and impact of disorder
means that if we are going to shrink the avertable bur-
den of mental disorders, reduce suffering and improve
productivity across the critical adult years of life, we
must build strong, stigma-free and effective systems of
care for children and young people up to the mid-20s
(McGorry et al. 2007b; Patton et al. 2007). This means
with but discrete in culture and expertise from systems
for younger children and older adults (McGorry, 2009).
This reform is gaining ground in Australia (McGorry
et al. 2007b, 2008; McGorry & Purcell, 2009), but similar
programmes should be implemented everywhere.
Prevention-oriented evidence-based programmes for
younger children are also critical (Dadds et al. 1997;
Sanders, 2008; Rapee et al. 2010). Investment in this
stage of life is essential to address the hard fact that
treatment delay is much more likely to occur if
the onset is in children or young people. AOO is a
vital statistic to guide our future mental health policies.
Amaddeo F, Jones J (2007). What is the impact of
socio-economic inequalities on the use of mental health
services? Epidemiologia e Psichiatria Sociale 16, 16–19.
Amminger GP, Henry LP, Harrigan SM, Harris MG,
Alvarez-Jimenez M, Herrman H, Jackson HJ, McGorry
PD (2011). Outcome in early-onset schizophrenia revisited:
findings from the Early Psychosis Prevention and
Intervention Centre long-term follow-up study.
Schizophrenia Research 131, 112–119.
Amone-P’Olak K, Ormel J, Huisman M, Verhulst FC,
Oldehinkel AJ, Burger H (2009). Life stressors as mediators
of the relation between socioeconomic position and mental
health problems in early adolescence: the TRAILS study.
Journal of the American Academy of Child and Adolescent
Psychiatry 48, 1031–1038.
Amone-P’Olak K, Ormel J, Oldehinkel AJ, Reijneveld SA,
Verhulst FC, Burger H (2010). Socioeconomic position
predicts specialty mental health service use independent
of clinical severity: the TRAILS study. Journal of the
American Academy of Child and Adolescent Psychiatry 49,
Angold A, Erkanli A, Costello EJ, Rutter M (1996). Precision,
reliability and accuracy in the dating of symptom onsets in
child and adolescent psychopathology. Journal of Child
Psychology and Psychiatry 37, 57–64.
Angst J, Gamma A, Rossler W, Ajdacic V, Klein DN (2009).
Long-term depression versus episodic major depression:
results from the prospective Zurich study of a community
sample. Journal of Affective Disorders 115, 112–121.
Baldessarini RJ, Bolzani L, Cruz N, Jones PB, Lai M, Lepri
B, Perez J, Salvatore P, Tohen M, Tondo L, Vieta E (2010).
Onset-age of bipolar disorders at six international sites.
Journal of Affective Disorders 121, 143–146.
Beesdo K, Pine DS, Lieb R, Wittchen HU (2010). Incidence
and risk patterns of anxiety and depressive disorders and
categorization of generalized anxiety disorder. Archives of
General Psychiatry 67, 47–57.
Behrendt S, Wittchen HU, Höfler M, Lieb R, Beesdo K
(2009). Transitions from first substance use to substance use
disorders in adolescence: is early onset associated with a
rapid escalation? Drug and Alcohol Dependence 99, 68–78.
Bignami R, Fioritti A, Lanciotti G, Pazzi L, Piazza A,
Verdini E (eds) (2008). Rapporto 2008: Dati del Sistema
Informativo dei Servizi di Salute Mentale dell’Emilia-Romagna
Anno 2007. Regione Emilia-Romagna: Bologna.
Bromet E, Andrade LH, Hwang I, Sampson NA, Alonso J,
de Girolamo G, de Graaf R, Demyttenaere K, Hu C, Iwata
N, Karam AN, Kaur J, Kostyuchenko S, Lépine JP,
Levinson D, Matschinger H, Mora ME, Browne MO,
Posada-Villa J, Viana MC, Williams DR, Kessler RC
(2011). Cross-national epidemiology of DSM-IV major
depressive episode. BCM Medicine 9, 90.
Burgess PM, Pirkis JE, Slade TN, Johnston AK, Meadows
GN, Gunn JM (2009). Service use for mental health
problems: findings from the 2007 National Survey of
Mental Health and Wellbeing. Australian and New Zealand
Journal of Psychiatry 43, 615–623.
Carpenter J (2002). Mental health recovery paradigm:
Christiana JM, Gilman SE, Guardino M, Mickelson K,
Morselli PL, Olfson M, Kessler RC (2000). Duration
between onset and time of obtaining initial treatment
among people with anxiety and mood disorders: an
international survey of members of mental health patient
advocate groups. Psychological Medicine 30, 693–703.
Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A
(2003). Prevalence and development of psychiatric
disorders in childhood and adolescence. Archives of General
Psychiatry 60, 837–844.
Costello EJ, Egger H, Angold A (2005). 10-year research
update review: the epidemiology of child and adolescent
psychiatric disorders: I. Methods and public health burden.
Journal of the American Academy of Child and Adolescent
Psychiatry 44, 972–986.
Dadds MR, Spence SH, Holland DE, Barrett PM, Laurens
KR (1997). Prevention and early intervention for anxiety
disorders: a controlled trial. Journal of Consulting and Clinical
Psychology 65, 627–635.
Degenhardt L, Chiu WT, Sampson N, Kessler RC, Anthony
JC, Angermeyer M, Bruffaerts R, de Girolamo G, Gureje
O, Huang Y, Karam A, Kostyuchenko S, Lepine JP, Mora
ME, Neumark Y, Ormel JH, Pinto-Meza A, Posada-Villa J,
Stein DJ, Takeshima T, Wells JE (2008). Toward a global
view of alcohol, tobacco, cannabis, and cocaine use:
8 G. de Girolamo et al.
findings from the WHO World Mental Health Surveys.
PLoS Medicine 5, e141.
Essau CA, Lewinsohn PM, Seeley JR, Sasagawa S (2010).
Gender differences in the developmental course of
depression. Journal of Affective Disorders 127, 185–190.
Esterberg ML, Trotman HD, Holtzman C, Compton MT,
Walker EF (2010). The impact of a family history of
psychosis on age-at-onset and positive and negative
symptoms of schizophrenia: a meta-analysis. Schizophrenia
Research 120, 121–130.
Frangou S (2010). Cognitive function in early onset
schizophrenia: a selective review. Frontiers in Human
Neuroscience 3, 79.
Fryers T, Melzer D, Jenkins R (2003). Social inequalities and
the common mental disorders: a systematic review of the
evidence. Social Psychiatry and Psychiatric Epidemiology 38,
Garber J, Clarke GN, Weersing VR, Beardslee WR, Brent
DA, Gladstone TR, DeBar LL, Lynch FL, D’Angelo E,
Hollon SD, Shamseddeen W, Iyengar S (2009). Prevention
of depression in at-risk adolescents: a randomized
controlled trial. Journal of the American Medical Association
Goodman A (2010). Substance use and common child mental
health problems: examining longitudinal associations in a
British sample. Addiction 105, 1484–1496.
Gore FM, Bloem PJ, Patton GC, Ferguson J, Joseph V,
Coffey C, Sawyer SM, Mathers CD (2011). Global burden
of disease in young people aged 10–24 years: a systematic
analysis. Lancet 377, 2093–2102.
Häfner H (2003). Gender differences in schizophrenia.
Psychoneuroendocrinology 28, 17–54.
Häfner H, Maurer K, Löffler W, an der Heiden W,
Munk-Jørgensen P, Hambrecht M, Riecher-Rössler A
(1998). The ABC Schizophrenia Study: a preliminary
overview of the results. Social Psychiatry and Psychiatric
Epidemiology 33, 380–386.
Hamshere ML, Gordon-Smith K, Forty L, Jones L, Caesar S,
Fraser C, Hyde S, Tredget J, Kirov G, Jones I, Craddock N,
Smith DJ (2009). Age-at-onset in bipolar-I disorder:
mixture analysis of 1369 cases identifies three distinct
clinical sub-groups. Journal of Affective Disorders 116, 23–29.
Hetrick SE, Parker AG, Hickie IB, Purcell R, Yung AR,
McGorry PD (2008). Early identification and intervention
in depressive disorders: towards a clinical staging model.
Psychotherapy and Psychosomatics 77, 263–270.
Insel TR, Fenton WS (2005). Psychiatric epidemiology: it’s
not just about counting anymore. Archives of General
Psychiatry 62, 590–592.
Jablensky A, Sartorius N, Ernberg G, Anker M, Korten A,
Cooper JE, Day R, Bertelsen A (1992). Schizophrenia:
manifestations, incidence and course in different cultures.
A World Health Organization ten-country study.
Psychological Medicine. Monograph Supplement 20, 1–97.
Joa I, Johannessen JO, Auestad B, Friis S, McGlashan T,
Melle I, Opjordsmoen S, Simonsen E, Vaglum P, Larsen
TK (2008). The key to reducing duration of untreated first
psychosis: information campaigns. Schizophrenia Bulletin 34,
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR,
Walters EE (2005). Lifetime prevalence and age-of-onset
distributions of DSM-IV disorders in the National
Comorbidity Survey Replication. Archives of General
Psychiatry 62, 593–602.
Kessler RC, Angermeyer M, Anthony JC, DE Graaf R,
Demyttenaere K, Gasquet I, DE Girolamo G, Gluzman S,
Gureje O, Haro JM, Kawakami N, Karam A, Levinson D,
Medina Mora ME, Oakley Browne MA, Posada-Villa J,
Stein DJ, Adley Tsang CH, Aguilar-Gaxiola S, Alonso J,
Lee S, Heeringa S, Pennell BE, Berglund P, Gruber MJ,
Petukhova M, Chatterji S, Ustün TB (2007). Lifetime
prevalence and age-of-onset distributions of mental
disorders in the World Health Organization’s World Mental
Health Survey Initiative. World Psychiatry 6, 168–176.
Kim-Cohen J, Caspi A, Moffitt TE, Harrington H, Milne BJ,
Poulton R (2003). Prior juvenile diagnoses in adults with
mental disorder: developmental follow-back of a
prospective-longitudinal cohort. Archives of General
Psychiatry 60, 709–717.
Korczak DJ, Goldstein BI (2009). Childhood onset major
depressive disorder: course of illness and psychiatric
comorbidity in a community sample. Journal of Pediatrics
Krausz M, Muller-Thomsen T (1993). Schizophrenia with
onset in adolescence: an 11-year follow up. Schizophrenia
Bulletin 19, 831–841.
Kuepper R, van Os J, Lieb R, Wittchen HU, Höfler M,
Henquet C (2011). Continued cannabis use and risk of
incidence and persistence of psychotic symptoms: 10 year
follow-up cohort study. British Medical Journal 342, d738.
Kyriakopoulos M, Frangou S (2007). Pathophysiology of
early onset schizophrenia. International Review of Psychiatry
Large M, Sharma S, Compton MT, Slade T, Nielssen O
(2011). Cannabis use and Earlier onset of psychosis: a
systematic meta-analysis. Archives of General Psychiatry 68,
Lora A (2008). Il Sistema di Salute Mentale della Regione
Lombardia. Regione Lombardia: Milano.
Luthar SS, Sawyer JA, Brown PJ (2006). Conceptual issues in
studies of resilience: past, present, and future research.
Annals of the New York Academy of Sciences 1094, 105–115.
Marmot M (2005). Social determinants of health inequalities.
Lancet 365, 1099–104.
Marshall M, Lewis S, Lockwood A, Drake R, Jones P,
Croudace T (2005). Association between duration of
untreated psychosis and outcome in cohorts of first-episode
patients: a systematic review. Archives of General Psychiatry
McGorry P (2009). Should youth mental health become a
specialty in its own right? Yes. British Medical Journal 339,
McGorry P, Purcell R (2009). Youth mental health reform and
early intervention: encouraging early signs. Early
Intervention in Psychiatry 3, 161–162.
McGorry P, Hazell P, Hickie I, Yung A, Chanen A, Moran J,
Fraser R (2008). The ‘youth model’ in mental health
services. Australasian Psychiatry 16, 136–137.
Age of onset of mental disorders and use of mental health services9
McGorry PD, Purcell R, Hickie IB, Jorm AF (2007a).
Investing in youth mental health is a best buy. Medical
Journal of Australia 187 (Suppl. 7), S5.
McGorry PD, Purcell R, Hickie IB, Yung AR, Pantelis C,
Jackson HJ (2007b). Clinical staging: a heuristic model for
psychiatry and youth mental health. Medical Journal of
Australia 187 (Suppl. 7), S40–S42.
McGue M, Iacono WG, Krueger R (2006). The association of
early adolescent problem behavior and adult
Psychopathology: multivariate behavioral genetic
perspective. Behavior Genetics 36, 591–602.
Moffitt TE, Caspi A, Taylor A, Kokaua J, Milne BJ,
Polanczyk G, Poulton R (2010). How common are
common mental disorders? Evidence that lifetime
prevalence rates are doubled by prospective versus
retrospective ascertainment. Psychological Medicine 40,
Murray CJ, Lopez AD (1996). The Global Burden of Disease.
World Health Organization: Geneva.
Patton GC, Hetrick SE, McGorry P (2007). Service responses
for youth onset mental disorders. Current Opinion in
Psychiatry 20, 319–324.
Paus T, Keshavan M, Giedd JN (2008). Why do many
psychiatric disorders emerge during adolescence? Nature
Reviews Neuroscience 9, 947–957.
Perlis RH, Dennehy EB, Miklowitz DJ, Delbello MP,
Ostacher M, Calabrese JR, Ametrano RM, Wisniewski
SR, Bowden CL, Thase ME, Nierenberg AA, Sachs G
(2009). Retrospective age at onset of bipolar disorder and
outcome during two-year follow-up: results from the
STEP-BD study. Bipolar Disorders 11, 391–400.
Pine DS (2009). Anxiety disorders in childhood and
adolescence. New Oxford Textbook of Psychiatry 2,
Pottick KJ, Bilder S, Vander Stoep A, Warner LA,
Alvarez MF (2008). US patterns of mental health service
utilization for transition-age youth and young adults.
Journal of Behavioral Health Services and Research 35,
Rajji TK, Ismail Z, Mulsant BH (2009). Age at onset and
cognition in schizophrenia: meta-analysis. British Journal of
Psychiatry 195, 286–293.
Rapee RM, Kennedy SJ, Ingram M, Edwards SL, Sweeney L
(2010). Altering the trajectory of anxiety in at-risk young
children. American Journal of Psychiatry 167, 1518–1525.
Reef J, Diamantopoulou S, Van Meurs I, Verhulst F, Van
Der Ende J (2009). Child to adult continuities of
psychopathology: a 24-year follow- up. Acta Psychiatrica
Scandinavica 120, 230–238.
Rickwood DJ, Deane FP, Wilson CJ (2007). When and
how do young people seek professional help for mental
health problems? Medical Journal of Australia 187,
Rockhill C, Kodish I, DiBattisto C, Macias M, Varley C,
Ryan S (2010). Anxiety disorders in children and
adolescents. Current Problems in Pediatric and Adolescent
Health Care 40, 66–99.
Rosen A (2006). The community psychiatrist of the future.
Current Opinion in Psychiatry 19, 380–388.
Roza SJ, Hofstra MB, Van Der Ende J, Verhulst FC (2003).
Stable prediction of mood and anxiety disorders based on
behavioral and emotional problems in childhood: A 14 year
follow-up during childhood, adolescence and young
adulthood. American Journal of Psychiatry 160, 2116–2121.
Rutter M (2006). Implications of resilience concepts for
scientific understanding. Annals of the New York Academy
of Sciences 1094, 1–12.
Rutter M, Kim-Cohen J, Maughan B (2006). Continuities and
discontinuities in psychopathology between childhood and
adult life. Journal of Child Psychology and Psychiatry 47,
Sanders MR (2008). Triple P-positive parenting program as a
public health approach to strengthening parenting. Journal
of Family Psychology 22, 506–517.
Saxena S, Jané-Llopis E, Hosman C (2006). Prevention of
mental and behavioural disorders: implications for policy
and practice. World Psychiatry 5, 5–14.
Shatkin JP, Belfer ML (2004). The global absence of child and
adolescent mental health policy. Child and Adolescent Mental
Health 9, 104–108.
Singh SP (2009). Transition of care from child to adult mental
health services: the great divide. Current Opinion in
Psychiatry 22, 386–390.
Slade EP, Stuart EA, Salkever DS, Karakus M, Green KM,
Ialongo N (2008). Impacts of age of onset of substance use
disorders on risk of adult incarceration among
disadvantaged urban youth: a propensity score matching
approach. Drug and Alcohol Dependence 95, 1–13.
Thorup A, Waltoft BL, Pedersen CB, Mortensen PB,
Nordentoft M (2007). Young males have a higher risk of
developing schizophrenia: a Danish register study.
Psychological Medicine 37, 479–484.
Tijssen MJ, van Os J, Wittchen HU, Lieb R, Beesdo K,
Mengelers R, Wichers M (2010). Prediction of transition
from common adolescent bipolar experiences to bipolar
disorder: 10-year study. British Journal of Psychiatry 196,
Vanheusden K, Mulder CL, van der Ende J, van Lenthe FJ,
Mackenbach JP, Verhulst FC (2008). Young adults face
major barriers to seeking help from mental health services.
Patient Education and Counseling 73, 97–104.
van Oort FV, van der Ende J, Wadsworth ME, Verhulst FC,
Achenbach TM (2011). Cross-national comparison of the
link between socioeconomic status and emotional and
behavioral problems in youths. Social Psychiatry and
Psychiatric Epidemiology 46, 167–172.
van Os J, Kenis G, Rutten BP (2010). The environment and
schizophrenia. Nature 468, 203–212.
Vega WA, Aguilar-Gaxiola S, Andrade L, Bijl R, Borges G,
Caraveo-Anduaga JJ, DeWit DJ, Heeringa SG, Kessler
RC, Kolody B, Merikangas KR, Molnar BE, Walters EE,
Warner LA, Wittchen HU (2002). Prevalence and age of
onset for drug use in seven international sites: results from
the international consortium of psychiatric epidemiology.
Drug and Alcohol Dependence 68, 285–297.
Vyas NS, Patel NH, Puri BK (2011). Neurobiology and
phenotypic expression in early onset schizophrenia. Early
Intervention in Psychiatry 5, 3–14.
10 G. de Girolamo et al.
Walker EF, Sabuwalla Z, Huot R (2004). Pubertal Download full-text
neuromaturation, stress sensivity and psychopathology.
Development and Psychopathology 16, 807–824.
RC (2005). Failure and delay in initial treatment contact after
first onset of mental disorders in the national comorbidity
survey replication. Archives of General Psychiatry 62, 603–613.
Wilson CJ, Bushnell JA, Caputi P (2011). Early access and
help seeking: practice implications and new initiatives.
Early Intervention in Psychiatry 5, 34–39.
Wright A, McGorry PD, Harris MG, Jorm AF, Pennell K
(2006). Development and evaluation of a youth mental
health community awareness campaign – The Compass
Strategy. BMC Public Health 6, 215.
Age of onset of mental disorders and use of mental health services11