Peer involvement and accessibility as key ingredients for 21st century youth mental health care services
McGorry et al1 emphasize the urgency and need to invest in (primary) mental health care services for young people. They have been an example in successfully leading the international youth mental health reform movement for many years, and managed to put youth mental health on the agenda of several policy makers worldwide, including the World Economic Forum. Moreover, they have been pioneers of an inclusive and co-designing approach with regards to service development and dissemination of their research.
The urgency of their plea has become even clearer since the COVID-19 pandemic has entered our lives. The ongoing crisis caused by the pandemic poses the greatest threat to mental health since the Second World War2 and painfully shows that our already overstretched (mental) health care system has little flexibility and reserve capacity for unforeseen circumstances. Young people have particularly suffered from this, as demonstrated by the increasing rates not only of loneliness, suicidality and referral to specialist services, but also of drop-out from education, with possible long-lasting consequences.
Crisis situations, however, may also stimulate creativity, resulting in innovative initiatives. During this pandemic, the already ongoing digitalization of our society has overcome its last persistent hurdles, with results that have indeed been promising3. This offers opportunities for implementation of mHealth interventions that are transdiagnostic and empowering, probably particularly suitable for the next generation of help-seeking (emerging) adults4, as they completely grew up in a digitalized world.
Increasing the accessibility of services, whether digital or face-to-face, is one of the crucial aspects of improving mental health care in young people. Despite great efforts and initiatives over the last decade, it remains challenging to reach young people, particularly those at risk for or with (emerging) mental disorders. This is partially due to the way traditional services have been operating, as McGorry et al1 point out.
Several barriers are experienced by young people when in search for help for mental health problems, including (self-)stigma, worries about finances, shame, limited mental health literacy, waiting lists, and not knowing where to go or who to turn to5. More awareness and promotion of good mental health is essential6. For example, there is a need for education on mental health in collaboration with schools7, something that has been largely ignored. Teaching on physical health is a normal part of our educational system, but this has not been the case for mental health.
Negative attitudes lead to late recognition and acceptance of mental health problems among those affected, resulting in seeking help only when these problems begin to escalate5. The period between the occurrence of first symptoms and related suffering until first contact with services can take up to several years. However, the first contact with health care services of a young person with mental health problems is often formally registered as the starting point of his/her journey. Mental health care professionals may thereby not always realize what journey an individual has already travelled at that point, and the amount of courage needed to step into the clinic for that first clinical assessment. Perhaps because of our focus on a medical approach of diagnosis and treatment, we may have given too little attention to the steps a young person has to make prior to reaching professional services.
To enhance early intervention, improving the accessibility of services for young people should be even higher on the agenda than it already is. McGorry et al1 mention co-design, peer involvement and soft entry as key elements for youth mental health services, and peer support as a valuable innovation. However, peer or youth volunteer support is mainly proposed as an alternative to professional care in low-income settings or described as a strategy to cope with the shortage of mental health care professionals in general. We would like to emphasize the value of peer support and youth volunteers on their own, not only as a cheap alternative but as a crucial ingredient for lowering the threshold to seek help and facilitate disclosure of difficult topics, including suicidality and sexual abuse. Peer support results in improvements on both quantitative and qualitative measures of recovery8, and peers represent an essential source of support for young people with mental health problems. Of course, there are some critical conditions for optimal implementation of peer support, including a clear role description of peer workers and non-peer staff, and sufficient training and supervision8.
When implemented well, peer support is one of the most promising elements that can increase the accessibility of youth mental health services. As McGorry et al1 point out, easy accessibility will not only attract young people with emerging mental disorders, but also young people with severe or chronic mental health problems not yet receiving appropriate help. To be able to serve young people in all stages of mental ill-health, well-organized and professionally supervised peer support should be thoroughly aligned with a broad spectrum of mental health care services.
As it may not be feasible to have this entire spectrum of services available at every youth walk-in centre, and possibly not desirable in terms of creating soft entry, we would rather speak of “first-stop” than “one-stop” shops. Deciding what services should be available on site, and who should be collaborative partners, is best done at a regional level, after close consideration of local available services and needs of young people in that specific area.
More research – qualitative as well as quantitative – into the value of peer support for accessibility and effectiveness of youth mental health services is needed. Moreover, increasing awareness amongst professionals and a change of (working) attitudes is necessary. Thus, not only the system has to change, but also our attitudes as people working in the system. In order to do this, we do need input from young people themselves, to help us make the necessary changes and see things we did not see before.
Finally, cross-domain, multidisciplinary approaches in designing integrated easy-access youth mental health services should be embraced, involving available social and educational resources. Mental health problems in young people often coexist with problems in other domains9. This requires collaboration with and learning from other professionals.
