Discussion
In the last decade, there has been significant reform in Australia to provide young people with appropriate, accessible, and youth-friendly mental health care in the community (McGorry & Mei,
2018). However, no synthesis of the local empirical literature surrounding such programs currently exists. Therefore, this review aimed to: (1) describe the types of community-based mental health programs that have been delivered to Australian youth in the past 10 years; and (2) examine their impact in improving young people’s mental health symptomology and psychosocial functioning. A total of 37 studies (
n = 13 controlled,
n = 24 pre-post) were identified, which evaluated four different types of community-based youth mental health programs: (1) therapy, (2) case management, (3) integrated ‘one-stop-shop’, and (4) lifestyle interventions.
The majority of the 37 studies evaluated a therapy program for young people with mild to moderate mental health concerns, which was delivered by a psychologist and typically underpinned by CBT principles and strategies. Most of the therapeutic programs yielded significant improvements in mental health symptoms, with decreased severity and presence of general psychological distress, depressive, anxiety, OCD and substance use symptomology observed over time (Farell et al.,
2012; Hudson et al.,
2015). This aligns with the extensive international evidence that CBT is a gold standard form of psychotherapy treatment to address these symptoms among young people (David et al.,
2018) and supports the application of CBT-based programs with Australian youth. The effectiveness of therapy programs may also be due to the tendency to include parents in the work (i.e., encouraging parents to attend group sessions or targeted sessions for parents to reinforce skill development and strategies at home, Havighurst et al.,
2015). Research supports parent participation in
youth mental health treatment to facilitate attendance, engagement, and symptom alleviation (Haine-Schlagel & Walsh,
2015). These findings demonstrate the importance of early psychological intervention for young people with mental health concerns to promote positive coping strategies and skills, which can potentially prevent longer-term impacts of a mental disorder (Malla et al.,
2016).
Notwithstanding these positive findings for therapeutic programs, it should be highlighted that when a controlled study design was used to evaluate the therapy programs, they did not yield any significant improvements among intervention participants compared to the comparison group (Hides et al.,
2011; Poole et al.,
2018; Wagner et al.,
2017). One explanation for this could be a result of the control groups often receiving a similar kind of therapeutic treatment to that of the intervention group (i.e., standard care that included psychotherapy, modified CBT), which in turn would have limited the treatment effect (Karlsson & Bergmark,
2014). Given this, it is difficult to ascertain whether therapy programs for youth yield significant improvements above and beyond that of standard care; future controlled trials of such programs (i.e., compared to alternative care) are needed as the existing supporting evidence relies heavily on pre-post evaluations (Schley et al.,
2018). Further, the large range in effect sizes across the therapy-based studies (i.e., small to large improvements in mental health symptoms) may reduce confidence in their findings. This large variability is likely due to differences in the types of psychotherapy delivered, sample sizes, implementation (i.e., frequency and duration of sessions, group verse individual sessions, etc.), and/or participant engagement across the various programs. However, due to the limited and inconsistent reporting of intervention fidelity and adherence, there remains uncertainty around the full impact of these factors. Therefore, greater transparency in the reporting of intervention activities, implementation, and engagement rates of community-based mental health programs is necessary. An additional drawback of the studies evaluating therapeutic interventions was the lack of examination of psychosocial outcomes (i.e., engagement in education, social relationships, etc.). While reduction in mental health symptomology can contribute to improved broader functioning (Fuhr et al.,
2014), this was rarely measured in the reviewed studies. For example, half of the therapy programs were delivered in a group format, which may have provided opportunities to create positive social connections, promote social skills, and foster positive prosocial development, as identified in international reviews (Garcia-Poole et al.,
2019; Gardner et al.,
2019), yet such outcomes were not assessed. As psychosocial functioning was rarely captured in the reviewed therapeutic studies (both in terms of the focus of the therapeutic intervention and as an evaluated outcome), it remains unclear whether psychotherapy alone can significantly improve young people’s psychosocial functioning.
Consistent with the international literature, both case management and integrated programs were shown to be associated with improvements in mental health symptomology and psychosocial functioning among young people with moderate to severe mental health concerns, with consistently large effect sizes (Daubney et al.,
2021; Green et al.,
2015). While they differed in mode of delivery, both of these types of models of community mental health care provided intensive, flexible, multidisciplinary, systemic (i.e., engaging with the systems within which the young person exists, such as family, school, peers), wrap-around holistic support that was tailored to each young person’s unique psychosocial needs (i.e., vocational support, social connections, independent skills building). These factors, in combination, have been identified as key components of youth mental health support (Hetrick et al.,
2017; Settipani et al.,
2019). The positive impact of these programs may also be due to their modes of delivery (i.e., assertive outreach or ‘one-stop-shop’ support), which sought to break down barriers associated with youth service access and engagement (Daubney et al.,
2021). This is consistent with the emerging international research supporting the assertive outreach model of case management (i.e., dedicated key worker delivering intensive and flexible outreach support, providing care coordination across various relevant services and systems) to address young people’s psychosocial goals (Vijverberg et al.,
2017; Wilson et al.,
2017). This assertive outreach model of community mental health care is particularly relevant for youth with severe and complex mental health presentations, as it is flexible, easily accessible, and actively engages and approaches young people in their own environment (Mantzouranis et al.,
2019; Vijverberg et al.,
2017). In contrast, integrated and center-based “hub-like” programs similarly address key barriers as support is delivered all at the one location (“one-stop-shop”), which provides streamlined support so that young people do not have to navigate a complex mental health system and referral pathways, yet it relies on their attendance at the center (Hetrick et al.,
2017; Woody et al.,
2019). Indeed, the current findings regarding integrated youth mental health services are consistent with a recent international review of one-stop-shop models of care, which also yielded significant improvements in young people’s psychological distress and psychosocial functioning (Settipani et al.,
2019).
The majority of the evidence supporting the case management and integrated programs was based on pre-post evaluations. The reliance on uncontrolled studies evaluating community-based mental health programs for youth has also been reported in international reviews (Farahmand et al.,
2012; Garcia-Poole et al.,
2019; Vijverberg et al.,
2017). Due to the uncontrolled nature of these studies, it is difficult to determine whether the observed improvements in mental health symptomology and psychosocial functioning can be solely attributed to the type of intervention, or due to other factors, such as time or characteristics of clients and treatment settings, which often cannot be distinguished from the effects of the intervention (Cuijpers et al.,
2017). Further, given the relatively similar effectiveness of both case management and integrated programs, and the lack of reporting of engagement/attrition rates and effect sizes (particularly for the integrated programs), it is difficult to specifically discern which mode of delivery is more effective, with future evaluation required. Finally, case management was the only type of program that evaluated hospitalizations, demonstrating its potential to reduce the burden on and need for acute mental health services among youth (Conrad et al.,
2017). Given that this is one of the key goals of community mental health care reform (McGorry et al.,
2018), future research should ensure that hospital admissions are more routinely assessed as a key outcome for such programs to ensure treatment sustainability.
Lifestyle interventions, which focused on exercise and physical activity, were found to consistently alleviate depressive symptoms, regardless of study design (McGuire et al.,
2021; Nasstassia et al.,
2017,
2019). This aligns with international studies suggesting exercise as a form of behavioral activation to address depressive symptoms (Wegner et al.,
2020). However, they did not yield improvements in any other symptoms or psychosocial functioning, with increases in weight and sedentary activity observed (Parker et al.,
2016; Pearce et al.,
2020). The authors attributed such findings to a lack of engagement. International exercise interventions for youth with mental health concerns have shown strong engagement with components of self-monitoring, positive reinforcement, or rewards (Pascoe et al.,
2020). Such adaptations for Australian programs may need to be considered to improve attrition. Further, while the relationship between unhealthy dietary patterns and poor mental health has been demonstrated in children and adolescents (O’Neil et al.,
2014), nutrition remains a neglected area of community-based mental health intervention with Australian youth. A notable example of a holistic lifestyle intervention comes from HEALing Matters—a trauma-informed, attachment-focused program that seeks to improve the healthy lifestyle behaviors of young people in out-of-home care (Pizzirani et al.,
2019). Further evaluation of community-based lifestyle programs promoting healthy nutrition and physical activity is required to clarify their application in the Australian youth community mental health sector.
Limitations
While this review has provided a synthesis of the Australian evidence-base of the types and impact of community youth mental health programs, key limitations of the literature must be acknowledged. First, the majority of the reviewed evidence-base relies heavily on low to medium-level quality pre-post evaluations with short-term follow-up (i.e., immediately post-program). The lack of controlled studies, particularly for the case management and integrated programs, makes it difficult to ascertain whether improvements in outcomes are due to the intervention itself, as the potential for bias in the reviewed studies is relatively high (Cuijpers et al.,
2017). Youth who meet criteria for such interventions are likely at high risk, experiencing severe or comorbid mental health concerns and complex psychosocial needs, requiring intensive support (Conrad et al.,
2017). Due to the ethical issues in randomizing such young people to an organic control group wherein no care is delivered, greater consideration needs to be applied to the delivery of comparative or alternative support. Further, it is recommended that future evaluation studies seek to implement longer-term follow-up so that potential conclusions can be made about the ongoing sustainability of community-based mental health programs on young people’s mental health symptomology and psychosocial functioning into adulthood. Second, there was a lack of community mental health programs that were co-designed or co-created by the young people themselves, or included peer support (i.e., support delivered by those with lived experiences). Only one study specifically described that young people with a lived experience of mental health concerns were involved in the design, development, or delivery of the program (Hall et al.,
2021). While peer support has become an integral part of adult community-based mental health service delivery (Shalaby & Agyapong,
2020), this has been largely neglected in the Australian literature for youth thus far. Including the voice of those with lived experiences empowers them as experts, helps to better understand their unique experiences, can overcome barriers to service access, and ensures that supports are specifically tailored to meet their needs (Mulvale et al.,
2016; Thabrew et al.,
2018). Therefore, future research must prioritize young people’s genuine involvement in the design, development, delivery, and evaluation of mental health programs.
Third, only one reviewed study specifically adopted a trauma-informed lens to support youth with mental health concerns (Klag et al.,
2016). Given the high rates of trauma exposure among those with moderate to severe mental health concerns, particularly for those involved in juvenile justice and child welfare systems (Kisiel et al.,
2017), it is vital that community mental health services are well-equipped to deliver trauma-informed support. Further, the lack of representation of Aboriginal and Torres Strait Islander youth, other culturally and linguistically diverse (CALD) youth, and LGBTQIA + young people, is a significant gap of the reviewed literature. Given the disproportionate rates of mental health concerns experienced by these populations (AIHW,
2020), there is a greater need for competency, sensitivity, acknowledgment and inclusion of cultural, ethnic, sexuality, and gender diversity among community-based mental health programs for Australian youth. Finally, there was a consistent lack of implementation evaluation and reporting across the included studies. This represents a significant limitation of the literature and compromises the quality of evidence presented as it is unknown whether such programs were delivered as intended. Similarly, numerous studies did not report the level of engagement or attrition throughout program duration, while many noted low engagement. This is consistent with previous international reviews that have also identified poor or a lack of reporting on implementation quality of such programs (Garcia-Poole et al.,
2019). Variations in implementation may have also contributed to the large ranges in effect sizes identified across the therapy-based studies, which has similarly been observed in international reviews (Vijverberg et al.,
2017). It is well established that when youth do not receive an intervention as intended, it can reduce the effectiveness of the program (Rojas-Andrade & Bahamondes,
2018). Evaluating implementation and uptake is also necessary when establishing or redeveloping mental health programs to avoid replication failure and ensure they effectively engage this population (Ervin et al.,
2014). It is necessary that future research focuses on assessing the implementation of youth mental health programs to ensure they are effectively engaging and meeting young people’s needs.
Implications
The findings of this review highlight the importance of providing youth-friendly, systemic, and integrated assertive outreach support to young people to improve both psychiatric symptoms and psychosocial functioning. Integrated assertive outreach models of community mental health care may overcome barriers to youth accessing support and facilitate the provision of individualized services to improve overall wellbeing. The findings also suggest that community mental health care should be tailored to the unique developmental needs of the young person, which aligns with the recent Inquiry into Mental Health recommendation for a greater focus on person-centered care (Commonwealth of Australia,
2020). Specifically, young people with more severe and complex mental health presentations may require more intensive and holistic support to address their psychosocial needs than therapy alone (McGorry et al.,
2018). These findings may also be used to adapt, design, and inform international models of community mental health care for youth. Indeed, the evidence-base provides a useful framework within which both local and international clinicians, health professionals, researchers and policy makers can be guided. The findings may also inform the (re)development and implementation of community mental health programs for youth, with greater focus on the provision of psychosocial support, as outlined in the Inquiry into Mental Health (Commonwealth of Australia,
2020), and particular attention needs to be directed at better supporting the mental health needs of our most vulnerable youth (i.e., out-of-home care, ATSI, CALD, LGBTQIA + etc.). Finally, in recognizing that the majority of reviewed studies provided support to young people aged 12–25, it is recommended that the current transition from youth to adult community mental health services is improved to overcome the widely documented barriers associated with the discontinuation of support at 18 and to ensure continuity of mental health care (Embrett et al.,
2016; Nguyen et al.,
2017). Ideally, the aim of youth services should be to reduce the need for transition into adult services (McGorry et al.,
2018). Therefore, it is necessary to strengthen integrated models of community mental health care for Australian youth across this broader age range. A summary of key recommendations to address existing limitations of the current evidence-base and guide future research and practice includes the following:
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Higher quality program evaluations (including appropriate control groups) with longer-term follow-up
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Greater transparency in the reporting of intervention activities, implementation, fidelity, and effect sizes
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Greater focus on the provision of psychosocial support and evaluation of psychosocial-related outcomes as part of community-based mental health programs
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Implementation and evaluation of community-based mental health programs that appropriately support diverse youth, including youth from out-of-home care, intergenerational disadvantage or low socioeconomic status, and youth that identify as ATSI, CALD, or LGBTQIA +
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Implementation and evaluation of trauma-informed approaches to community-based mental health support
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Prioritize young people’s genuine involvement in the design, development, delivery, and evaluation of mental health programs, including co-design and participatory approaches
The authors acknowledge that while some of this work may already be occurring in practice in the local context, it is underrepresented in the empirical literature. Further research across these areas may contribute to a more comprehensive and transparent evidence-base to inform the development and implementation of community mental health programs in Australia that yield sustained improvements in young people’s wellbeing.
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