In a report drawing on three different forms of economic analysis,
the World Economic Forum recently identified mental ill health as
being at least equal to cardiovascular disease as the principal threat
to gross domestic product (GDP) over the next two decades.1The
Lancet’s campaign for global mental health and the international
Grand Challenges in Mental Health initiative on research
priorities also underline the growing recognition that mental ill
health is the awakening giant of health and social reform.2,3
Although the costs of mental ill health are otherwise set to double
over the next 20 years, billions could be saved through a greater
emphasis on prevention and early intervention. The key reason
that mental ill health is as potently corrosive of economic growth
as it is of human happiness and potential is that ‘mental disorders
are the chronic diseases of the young’.4The distribution of such
disorders within the life cycle is the mirror image of physical
illness. Seventy-five per cent of mental disorders emerge before
the age of 25 years, about a quarter before the age of 12 years
and the rest in a steady surge of premature mortality, morbidity
and comorbidity through the emerging adult years.5There is
evidence that the mental health of young people is worsening,
prompting the evocative assertion that young people are the
‘miners’ canaries’ of society.6The rates of diagnosable mental
disorders during the period of transition between childhood and
adulthood can reach as high as 50%, with multiple or recurrent
disorders present in more than half of cases. Neither is this to
be dismissed as teenage angst or growing pains, since there are real
and lasting consequences for earning potential and educational
and social outcomes at age 30 years.7There have been major
changes in the developmental experience of the transition to
adulthood in recent decades, which have some positive aspects
but may also carry a hidden yet increasing cost.8,9In summary,
because mental disorders have their origins early in life, surge
disproportionately during the stage of transition from childhood
to adulthood and cast a long shadow through the decades of
peak social and economic productivity,10they now represent the
most urgent threat and potentially the greatest opportunity for
prevention and control among the non-communicable diseases,
a landscape otherwise arguably characterised by diminishing
returns in the developed world at least.
Prevention is always better than cure, but for many reasons it
remains aspirational in mental health. The feasibility of universal
prevention with whole populations has been seriously questioned
on the basis of power and the low malleability of risk factors.11
Poverty, social and economic inequality and trauma, abuse and
neglect make smoking and diet seem simple targets. Yet it may
not be mission impossible. The natural experiment reported in
the Great Smoky Mountains study, for example, showed that
income supplementation for American Indian families reduced
the prevalence of psychiatric disorders across adolescence.12
Selective prevention whereby risk factors are targeted within
high-risk subgroups is perhaps more within reach and is more
researchable. One example is interventions triggered by screening
for postnatal depression. When we move on to the firmer ground
of indicated prevention, the spectrum begins conceptually and
practically to merge with early intervention and treatment. The
definition of indicated prevention allows subthreshold clinical
features to be viewed as risk factors for fully fledged disorder.
The identification of clinically significant (and functionally
impairing) yet subthreshold disorder represents the frontier of
research and service reform in mental healthcare and has
challenged psychiatry to face the controversies and measure up
to the standards of the rest of healthcare. But is it really
‘prevention’? To label it so has misled some into believing that
those involved are asymptomatic and currently ‘not ill’. However,
in psychiatry, a person’s need for care demonstrably precedes
the threshold for meeting full criteria for diagnosis, at least in
terms of our current categorical diagnostic systems. Despite
warnings about the medicalisation of human distress by critics
appropriately concerned that diagnosis in some health systems
(especially in the USA) means prescription of medication, there
is a much greater risk of denying effective help and support to
large numbers of people, many of whose lives will be at risk as a
result of significant and sustained morbidity. Many more will lead
thwarted lives, with poor mental health contributing to the
erosion of their life chances. Indicated prevention, closely followed
by early detection of full-threshold disorder, is theoretically the
next best option after universal and selective prevention, and is
Prevention, innovation and implementation
science in mental health: the next wave
Although the corrosive effect of mental ill health on human
health and happiness has long been recognised, it is only
relatively recently that mental illness has been acknowledged
as one of the major threats to economic productivity
worldwide. This is because the major mental disorders
most commonly have their onset during adolescence and
early adulthood, and therefore have a disproportionate
impact on the most productive decades of life. With
the costs associated with mental ill health estimated
to double over the next two decades, a greater emphasis
on prevention and early intervention has become even
more imperative. Although prevention largely remains
aspirational for many reasons, early intervention is well
within our current reach and offers the potential to
significantly reduce the impact of mental ill health on
our health, happiness and prosperity in the immediate
Declaration of interest
The British Journal of Psychiatry (2013)
202, s3–s4. doi: 10.1192/bjp.bp.112.119222
Professor Patrick McGorry’s major interest is in youth mental health,
particularly early psychosis, and in designing effective healthcare services
for young people with emerging mental disorders.
practically much more achievable, with Cuijpers suggesting ways it
can be sharpened and enhanced.11We have since developed a
heuristic diagnostic framework, the clinical staging model, to
guide further research and reform along this frontier and either
side of it.13,14This model is attracting increasing support,15
although it must transcend the current diagnostic silos in terms
of treatment and biomarker research.
Innovation is a vital ingredient and a pressing need if we are to
shift the focus from the palliative legacy of traditional mental
healthcare to a proactive effort to limit the corrosive havoc that
mental disorders can wreak on the lives of those on the threshold
of productive life and beyond. We have only partially relinquished
the deterministic concepts of 19th-century psychiatry which
continue to influence the energy as well as the topography of
mental healthcare. Innovation is like an orchid, exquisitely
sensitive to context and environment,16and we need to under-
stand the innovation cycle as it applies in other fields. Innovation
involves new thinking, new models, new treatments – all of which
we desperately need. Innovators and early adopters need to be
nurtured as we seek progress in mental healthcare.
Even if there were to be no new treatment advance in the next
20 years, we could still substantially reduce what Andrews17
describes as the ‘avertable burden of disease’ by increasing the
scale and coverage of mental healthcare and re-engineering the
timing and culture of the provision of services. The related
innovations,18especially of service models, are particularly
relevant to this supplement. Evidence-based medicine (and its
forerunner the Cochrane Collaboration) has been a valuable
safeguard against ‘great and desperate cures’,19particularly in
psychiatry; however, it can also be misused to obstruct the
diffusion of genuine advances. As I have argued elsewhere,
Cochrane loses relevance when it is applied beyond the level of
Evidence-based healthcare, a cousin of evidence-based medicine,
simply cannot be a prisoner of Cochrane. The orchid of
innovation needs a range of nutrients to grow, and although
evidence is certainly one of these, a genuine need for change,
champions, context and new resources are others. Many flowers
will germinate and flourish in a particular setting, yet few will
disseminate to other fields in a systematic or franchised manner.
The scaling-up literature,21,22again a body of knowledge that cuts
across many fields of endeavour, bears witness to the key elements
that are required for success.
This supplement makes the case for a transformational reform
of mental healthcare based on the principles of early intervention,
and a priority focus on the developmental period of greatest need
and capacity to benefit from investment: the period of emerging
adulthood. This by no means argues against investments earlier
or later in life, which are also essential. Heartened by the highly
successful evidence-informed scaling up of early intervention in
psychosis across many hundreds of locations and numerous
national health systems since the mid-1990s, and the newly
emergent youth mental health models of the past 5 years, a
number of leaders, policy makers and service developers are
working to create an international momentum to address the
mental health needs of young people and their families. There
are already rapidly emerging examples of these modern stigma-
free cultures of care designed and operated with young people
themselves, and these are described in this supplement.23The
arguments for this type of transformational reform are resonating
strongly with the community and with policy makers while
attracting predictable resistance from middle management and
conservative elements within professional groups. These examples
of 21st-century clinical infrastructure will also facilitate some of
health services research.20
the population-based and universal programmes that may link
with mental health awareness and promotion activities and with
new internet-based technologies. If these new mind-sets and
reforms spread widely we might be able to reduce the impact of
mental ill health on our health, happiness and prosperity over
the next two decades.
Patrick McGorry, MD, PhD, FRCP, FRANZCP, Orygen Youth Health Research Centre,
University of Melbourne, Locked Bag 10, Parkville, Melbourne, VIC 3052, Australia.
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