Taking the Next Step Forward: Building a Responsive Mental Health and Addictions System for Emerging Adults

BACKGROUND

The Mental Health Commission of Canada (MHCC) has identified “youth transitions” as a significant area of mental health policy concern. Changing Directions, Changing Lives: The Mental Health Strategy for Canada (MHCC, 2012) recommends “remov[ing] barriers to successful transitions between child, youth, adult and seniors mental health services” (Sec. 3.3.5, p. 69). Taking the Next Step Forward: Building a Responsive Mental Health and Addictions System for Emerging Adults is a report produced by researchers from the Children’s Hospital of Eastern Ontario (CHEO) for the MHCC’s Knowledge Exchange Centre (KEC).1 It considers the current state of Canadian and international policies and programs that support youth with mental health problems and illnesses transitioning into adulthood, argues that our current approaches are substantially limited, and offers a framework for bettering these practices in Canada.

What do we mean in this context when we talk about “transitions?” Emerging adults (EA) who are engaged in child and adolescent mental health services must transition into adult services at a prescribed age. EA are not adequately supported during this transition, despite evidence that interventions at this stage will positively impact an individual’s lifetime trajectory of mental health. Additionally, EA requiring services for the first time are often not able to find, access, or recover within the adult mental health and addiction service sector. We therefore envision a seamless continuum of EA services, supported by policy that specifically addresses challenges throughout this time of transition. Emerging adults transitioning from child/adolescent mental health and addiction services to adult services disengage from service at a higher rate than other age cohorts. Although no longitudinal studies have been carried out in Canada, findings from the United States and the United Kingdom indicate that both treatment retention and successful engagement levels across the child to adult transition are concerning. Untreated mental health issues in early adulthood may indicate increased risk of developing severe and enduring mental health problems and at least 75 per cent of mental health problems and illnesses have an onset in childhood, adolescence, or young adulthood. Issues such as leaving school early, youth unemployment, youth justice involvement, bullying, and traumatic release from care are amplified for young adults with mental illnesses. Unaddressed mental health and substance use issues lead to underemployment and lack of workforce participation and they increase the human and economic burden of mental health problems and illnesses. Most alarmingly, suicide is the second leading cause of death for Canadian youth and one in five of all deaths among young adults age 15–24 are due to suicide. This stage of emerging adulthood is challenging for all; however, it is a particularly vulnerable stage for EA with mental health issues and addictions problems. Moreover, EA from specific populations have an even greater chance of experiencing poor outcomes during their transition into adulthood. These groups include children born in poverty; First Nations, Inuit, Métis, and newcomer EA; newcomer EA; EA involved with the justice and child welfare systems; EA with disabilities; and lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ) EA. Provincial/territorial policy leads and recent literature also underline significant lack of access and increased risks experienced by marginalized groups living in rural and remote areas. Many rural or remote EAs do not have access to primary care, let alone specialized or EA-responsive programs. EA with acute needs, or those requiring intensive services, must be transported out of rural jurisdictions. In remote locations, few specialized services are available locally beyond community supports, itinerant medical practitioners, and telemedicine.

WHAT HAVE WE LEARNED?

CURRENTLY IN CANADA:

• Promising models and best practices for EA do exist in various provinces and regions.
• Some youth-specific strategies have been developed, but few provinces or territories have implemented evidence-based approaches to transitions management or EA clinical service delivery approaches.
• No national government leadership, strategy, or pan-Canadian policy guidance exists to support policy makers, planners, and service providers working to support EA in transition.
• No province or territory has fully implemented transitional protocols for EA.
• No policy requiring that health authorities and providers follow protocols currently exists.
• No province or territory is tracking youth across this transition.
• No province or territory has mandated, designated community- or hospital-based specialist clinical services for EA, beyond First Episode Psychosis programs.
• EA are not seen as a distinct population from the policy, planning, funding, and/or service delivery perspective.

In relation to EA and their needs, current research, policy, and programming demonstrate that:

• Up to 52 per cent of young people engaging in the transition process disengage at a time when serious mental health problems or illnesses are most likely to occur.
• Connections with peers and families have been shown to support motivation to engage with services.
• As the brain matures, risk-taking behaviour decreases, and reasoning and capacity to modulate emotions increases. These neurobiological developments peak in the mid-20s.
• A high proportion of EA with mental health issues also use substances.
• Continued engagement with EA is key to improving their mental health outcomes, and for the development of responsive program models.
• Without access to needed assessment and treatment services, health, social, and employment outcomes are compromised, especially for the most vulnerable EA.
• Policy and dedicated funding with a clear priority on EA is important.
• A collaborative, cross-ministry policy approach responding to young people with mental health and addiction issues who are involved, or may need to be involved, with multiple systems and sectors of care is necessary.
• High-profile national champions with political influence and academic and clinical credibility have an impact.
• National research and training initiatives will drive program development.
• There is a need for nationally funded, evidence-based practice and clinical guidelines, based on EA-specific research.
• Collaborations between private and public funders can create change.