Series

Adolescent Health 3
Mental health of young people: a global public-health
challenge
Vikram Patel, Alan J Flisher, Sarah Hetrick, Patrick McGorry

Lancet 2007; 369: 1302–13 Mental disorders account for a large proportion of the disease burden in young people in all societies. Most mental
Published Online disorders begin during youth (12–24 years of age), although they are often first detected later in life. Poor mental
March 27, 2007 health is strongly related to other health and development concerns in young people, notably lower educational
DOI:10.1016/S0140-
achievements, substance abuse, violence, and poor reproductive and sexual health. The effectiveness of some
6736(07)60368-7
interventions for some mental disorders in this age-group have been established, although more research is urgently
See Comment page 1239
needed to improve the range of affordable and feasible interventions, since most mental-health needs in young people
See Perspectives page 1251
are unmet, even in high-income countries. Key challenges to addressing mental-health needs include the shortage of
This is the third in a Series of six
papers about adolescent health
mental-health professionals, the fairly low capacity and motivation of non-specialist health workers to provide quality
mental-health services to young people, and the stigma associated with mental disorder. We propose a population-based,
Department of Epidemiology
and Public Health, London youth focused model, explicitly integrating mental health with other youth health and welfare expertise. Addressing
School of Hygiene and Tropical young people’s mental-health needs is crucial if they are to fulfil their potential and contribute fully to the development
Medicine, London, UK of their communities.
(V Patel MRCPsych); Sangath
Centre, 841/1 Alto Porvorim,
Goa 403521, India (V Patel); Introduction responsibilities will be regarded as a child up to the age
Division of Child and
I would there were no age between ten and
of puberty. However, boys or girls who are employed
Adolescent Psychiatry and
three-and-twenty, or that youth would sleep out the rest; will no longer be regarded as children, even if they start
Adolescent Health Research
Institute, University of Cape
for there is nothing in the between but getting wenches work aged 6 years.4 In other societies, adolescence has
Town, Red Cross War Memorial with child, wronging the ancientry, stealing, fighting. been used to define the phase of sexual maturity before
Children’s Hospital,
William Shakespeare, The Winter’s Tale marriage: thus, once a girl or boy is married, she or he
Rondebosch, South Africa becomes an adult. The duration of adolescence has also
(Prof A J Flischer FCPsych [SA]);
Research Centre for Health
In this paper, we focus on the mental-health needs of increased substantially into early adulthood.5 Although
Promotion, University of young people aged 12–24 years. Adolescence is a fluid puberty might be considered a biological marker of the
Bergen, Norway (A J Flisher); concept: the traditional age-bound definition of this onset of adolescence, no set of clear biological markers
ORYGEN Research Centre, phase of life (10–19 years)1 is greatly influenced by social, is available to indicate its end.
Parkville, VIC, Australia
(S Hetrick MA,
environmental, and cultural factors. Puberty is Surprisingly, despite the hundreds of societies in which
Prof P McGorry FRANZCP); and considered by many as signifying the onset of a stage corresponding to adolescence has been identified,6
Department of Psychiatry, adolescence and this is often associated, in girls, with many investigators have questioned whether the notion
University of Melbourne, menarche; as the age of menarche fell, particularly in of adolescence is valid.7,8 The consensus, which we
Melbourne, VIC, Australia
(P McGorry)
the early part of the last century in developed countries,2 support, is to consider the health and developmental
Correspondence to;
the onset of adolescence also seemed to take place at a needs for two age-groups separately: children and young
Dr Vikram Patel younger age. In many cultures, for example in the people. Young people are those who are aged between 12
[email protected] Hmong culture of southeast Asia, the age of 12 or and 24 years.8 Developmentally, they are emerging adults,7
13 years denotes the end of childhood and the sexually mature, in the final stages of their educational
simultaneous onset of adulthood.3 In Bangladesh, a career or in the early stages of their employment career,
child who goes to school and has no economic or social and embarking on several socially accepted adult pursuits
including finding and keeping a job, romantic
relationships, and, in some cultures, using alcohol and
Search strategy and selection criteria tobacco. The confluence of these experiences helps
We searched two online databases: MEDLINE (1996 to contextualise the mental-health needs of young people.
current) and PSYCINFO (1995 to current). The search words Youth is the stage at which most mental disorders,
covered any aspects of the epidemiology, risk factors or often detected for the first time in later life, begin. Young
treatment of mental health or illness record for children, people have a high rate of self-harm, and suicide is a
adolescents or young people. An example of the search leading cause of death in young people. A strong relation
history for epidemiology was to use the following search tree: exists between poor mental health and many other health
Epidemiol* or statistic* or inciden*; AND adolesc* or child* or and development concerns for young people, notably
young; AND mental*; AND health or illness or disorder. Only with educational achievements, substance use and abuse,
publications in English language were searched. violence, and reproductive and sexual health. The risk
factors for mental disorders are well established, and

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substantial progress has been made in developing

Ages (years) Population size Prevalence
effective interventions for such problems. Yet, most
mental-health-service needs are unmet, even in wealthier Australia10 18–24 10 600 27%
societies, and the rate of unmet need is nearly 100% in Brazil11 7–14 1251 13%
many developing countries.9 Furthermore, there is a Netherlands12 13–18 780 8%
dearth of interventions to prevent mental disorders and Ethiopia13 1–15 3001 18%
promote mental health. We propose a youth-focused Hawaii14 13–19 619 26%
model for development of services and integration of USA (high risk Native Americans, Northern Plains 14–16 251 29%
Reservation)15
mental health with other youth health and welfare
India16 1–16 2064 13%
concerns; such a model explicitly acknowledges the
persistence of risk factors, and psychiatric disorders that USA17 13 1420 13%

often begin during childhood and adolescence, into 14 10%

adulthood. 15 14%
16 13%
Burden of mental disorders in young people USA (service recipients in California)18 12–15 1618 57%
Many investigators reporting prevalence rates of mental 16–18 52%
disorders in young people include children or older adults South Africa19 6–16 500 15%
in their samples. Furthermore, the prevalence rates have Switzerland20 1–15 1964 23%
not been stratified to enable the rates applicable to young UK21 13–15 2624 12%
people to be ascertained. To summarise the data for our USA22 9–17 1285 21%
age-group of interest is therefore difficult. We tried to Australia23 4–17 4500 14%
identify a set of community epidemiological studies
Studies included are population-based or school-based or based in non-mental-health-care settings.
undertaken since 1995 that included a substantial sample
of young people aged 12–24 years, and used structured Table 1: Selected studies of prevalence of mental disorders in young people, by country
diagnostic instruments to establish Diagnostic and
Statistical Manual of Mental Disorders or International had their first episode by 18 years.27 Recall bias is inherent
Classification of Diseases diagnoses (table 110–23). Rates of in this approach, such that older people are more likely to
mental disorders ranged from 8% (in the Netherlands) forget episodes of depression in their youth. This issue
to 57% (for young people receiving services in five sectors was addressed in a review28 of 26 studies of rates of
of care in San Diego, California, USA). The Australian depression in children and adolescents born in the 1960s
National Survey of Mental Health and Well Being23 reported to the 1990s. This meta-analysis, which included nearly
that at least 14% of adolescents younger than 18 years were 60 000 observations, showed no evidence to support the
diagnosable with a mental or substance use disorder in hypothesis that successive cohorts of children and
12 months and this figure rose to 27% in the 18–24 year adolescents report higher rates of depression, at least
age-group. Taking these studies10–23 together, at least one during the past 30 years. However, a similar review has
out of every four to five young people in the general not been undertaken specifically for young people,
population will suffer from at least one mental disorder in particularly those aged 18–24 years. Evidence is available
any given year, although much less information is available for an increase in the rate of conduct problems in young
on burden in developing countries and substantial people in the UK.29 This evidence comes from three birth
crosscultural variations are evident (see later). Another way cohorts (1958, 1970, and 1983–84), each of which included
to show the burden of mental disorders in young people is young people aged 15–16 years. A consistent increase in
through disability-adjusted life years (DALY).24 Five of the the proportion with severe conduct problems took place
ten leading causes of DALY in people aged 15–44 years are from the earlier to later cohorts.
mental disorders—unipolar depressive disorders, Apart from disability, mental disorders might also exact a
alcohol use disorders, self-inflicted injuries, schizophrenia, substantial burden on mortality in young people—in many
and bipolar affective disorder. In a study from Victoria, communities, youth is increasingly a period of heightened
Australia, mental disorders in young people aged risk of suicide.30 Suicide is a leading cause of death in
15–24 years contributed to 60–70% of the total DALY,25 young people in countries such as China31 and India.32 The
reinforcing the notion that mental disorders are the major Indian study ascertained cause of death in a rural
contributor to disease burden in this age-group.8 community of 108 000 people in south India during
Evidence is mixed for whether rates of mental disorders 10 years from 1992 to 2001. The investigators reported that
in young people have increased during the past few suicide accounted for a quarter of deaths in boys and
decades. For example, rates of depression in adolescence between half and three-quarters of deaths in girls aged
have been shown to have increased in the most recent 10–19 years.32 Evidence for whether suicide rates have
birth cohorts.26 However, much of the evidence in support changed over time is mixed. Rates have increased
of this conclusion is based on recall data, for example an (especially in boys) for most countries where data are
increase in the proportion of adults in recent cohorts that available from the mid-1950s until the early 1990s.33 This

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with mental disorder.39–41 Evidence for the pathways

Risk factors Protective factors
suggests that this association is complex and bidirectional:
Biological growing up in a poor household increases the risk of
Exposure to toxins (eg, tobacco, alcohol) in Age-appropriate physical development exposure to adversities such as scarcity of food, poor
pregnancy Good physical health nutrition, violence, inadequate education, and living in a
Genetic tendency to psychiatric disorder Good intellectual functioning
Head trauma
neighbourhood characterised by absence of social
Hypoxia at birth and other birth complications networks, all of which are risk factors for mental disorder.
HIV infection Conversely, mental disorder contributes to educational
Malnutrition underachievement, loss of employment, and increased
Substance abuse
Other illnesses health-care costs. Young people living in families with
Psychological
parental mental disorder42,43 or substance abuse,44 discord
between parents, marital violence, and breakdown, are at
Learning disorders Ability to learn from experiences
Maladaptive personality traits Good self-esteem greater risk of mental disorders. Unsurprisingly, violence
Sexual, physical, emotional abuse and neglect High level of problem-solving ability and child abuse are major risk factors;45 most sexual
Difficult temperament Social skills violence takes place in the context of trusting relationships
Social (for example, peers or relatives), whereas most violence
Family Inconsistent care-giving Family attachment in general takes place in the school or community; in
Family conflict Opportunities for positive involvement both instances, older peers are the most frequent
Poor family discipline in family
Poor family management Rewards for involvement in family
perpetrators.46 In married young people, husbands and
Death of a family member in-laws are the most common perpetrators of violence
School Academic failure Opportunities for involvement in and harassment of young women.47 Educational
Failure of schools to provide appropriate school life pressures, especially in the context of limited employment
environment to support attendance and Positive reinforcement from academic opportunities for out-of-school young people, is a risk
learning Inadequate or inappropriate provision achievement
of education Identity with school or need for factor for suicide and poor mental health.30,34 Some people
Bullying educational attainment are historically disadvantaged, notably the indigenous
Community Transitions (eg, urbanisation) Connectedness to community people of many countries, migrants from rural to urban
Community disorganisation Opportunities for leisure areas, internally displaced people and refugees.48 For
Discrimination and marginalisation Positive cultural experiences example, suicides in aboriginal people in Queensland,
Exposure to violence Positive role models
Rewards for community involvement Australia, between 1990 and 1997 contributed
Connection with community disproportionately to the suicide rate for the state as a
organisations whole, especially for young aboriginal males—though
Table 2: Selected risk and protective factors for mental health of children and adolescents, by domain38 only 4% of the population in this age-group, aboriginal
males contributed 16% of the suicide deaths.49 The central
theme is the lack of control that young people in these
trend has been attributed to increases in the rates of groups might have in their lives. Cultural factors are a
depression, increased firearm availability, the diminishing major influence on mental health, as evidenced by the
influence of the family, increased freedom, and increased large variations in the prevalence of mental disorder
exposure to alcohol and other drugs.34,35 However, since the between different cultures; for example, rates of mental
early 1990s, the rate of suicide in young people has disorder in young people of English origin in the UK are
decreased in countries in which youth suicide prevention four times greater than those of Indian origin.50 Some
programmes have been promoted, such as in the USA.34 cultural factors might be protective, for example parental
This decrease has been attributed by some investigators to involvement in young people’s decision-making and the
efforts to restrict access to handguns, increased use of tendency to form friendships within one’s cultural
antidepressant drugs, falls in rates of substance abuse and group,51 whereas others might have the opposite effect,
violence, and improved economic circumstances.34 such as restricted autonomy for women in decision
Whether the high rates of suicide in young people reported making.46 The emphasis on certain body shapes, fuelled
from India and China in recent years represents a rising by the fashion industry—which views young people as a
trend or an under-reporting bias in older studies is unclear; major market—is probably a factor in explaining the
some investigators have suggested that the risk is associated finding that eating disorders are more common in
with rapid social change.36 Injuries are another leading developed countries.7 New evidence suggests that the
cause of death in young people; here too, mental disorders, globalisation of the media is associated with an increase
notably substance abuse, are important risk factors.37 in eating disorders in societies in which they were
previously rarely seen.52
Risk factors Although the final pathway for mental disorders might
Good evidence is available in support of a multifactorial involve a neural basis, the precise nature of this neural
cause for mental disorders in young people (table 2). basis remains unclear. Reviews and reports of
Poverty and social disadvantage are strongly associated histological and brain-imaging studies support the

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notion that brain development, with changes in structure increased risk,56 and neuroanatomical abnormalities are
and cognition, is evident in youth.53,54 However, how associated with psychoses.57,58 Genetic and biological
these changes relate to mental disorders associated with factors interact with shared (such as family environment)
adolescence is uncertain. Strong evidence is available and non-shared (such as school) environmental factors,
for the contribution of genetic and biological factors, to modify the risk of mental disorders.59–61 For example,
particularly for depression, psychoses, and severe poor attachment and family discord affect the timing of
behaviour disorders. Adolescents who have a history of the onset of puberty, which in turn, could contribute to
difficult and disruptive behaviours from childhood have conflict with parents, low self-esteem and associations
a high rate of neurocognitive impairments.55 Neurological with deviant peers.6 A characteristic feature of the most
disorders, such as epilepsy, and developmental disorders, common mental disorders in young people is the sex
such as learning disabilities, are also associated with an differences: young women are 1·5–3 times more likely
to have depressive disorders and attempt self-harm,
Panel 1: An infant intervention with effects in adolescence74 whereas young men are several times more likely to
suffer from conduct or behaviour disorders and
In 1986–87, researchers identified a group of 129 infants schizophrenia.62 These variations might be due to
aged 9–24 months in Kingston, Jamaica, who were from very differences in the rates of exposure to biological and
poor families and had stunted growth. The infants were environmental risk factors and different interactions
randomly assigned one of four groups: control, between these factors in the sexes. An interaction
supplementation, stimulation, and both supplementation between genetic and environmental factors, for example,
and stimulation. The supplementation consisted of 1 kg might explain the increased risk of behaviour disorders
milk-based formula a week. The stimulation consisted of in boys.63 A differential rate in exposure to environmental
weekly home visits from trained community-health workers. factors may explain the enhanced risk of depression and
Both interventions were given for 2 years. The aim was to self-harm in young women; for example, the high rates
enhance interactions between mothers and their infants. This of gender based violence experienced by young
was achieved by demonstrating playing techniques, involving women.47,64
the mothers in play with the children, encouraging the We wish to emphasise that most young people do not
mothers to talk to their children, praise them, and give have any mental disorder—even most of those who face
positive reinforcement. Toys and picture books were left in severe adversities and multiple risk factors remain in good
the homes and mothers were encouraged to play with their mental health.6,7 Protective factors are crucial to
children on a daily basis. understanding how the effect of risk factors can be
In 2003, the researchers interviewed 103 of the participants, modified and even eliminated. Recent crossnational
80% of those enrolled in the trial. They reported that the research from the USA and China65 has shown the
children who had received stimulation in infancy were, as universal role of protective factors in mitigating the risks
adolescents, less anxious, had fewer symptoms of depression for risk behaviours (such as delinquency, problem
and better self esteem, and fewer attention problems than drinking, and substance abuse) in adolescents. These
their non-stimulated counterparts. Furthermore, participants factors were shown to account for a substantial proportion
given stimulation were less likely to have been suspended of the variation in problem behaviours in both settings;
from school or expelled than those not given stimulation. not only was the size of protection (and risk) similar, but
However, the programme did not affect self-reported the same measures of protection and risk were related to
antisocial behaviour or primary-caregiver-reported the problem behaviours in a similar way. In both settings,
oppositional behaviour, cognitive problems, or lack of protective factors played a powerful role in mitigating the
attention. effect of risk factors for problem behaviours, suggesting
Further research is needed to establish the reasons for the the importance of these factors in promoting mental
beneficial effects. The benefits might have been due to the health. Longitudinal studies have shown that factors such
direct effects of the activities; or the mother’s mental health as a sense of connection, low levels of conflict, and an
might have improved as a result of involvement in the environment in which the expression of emotions was
intervention, which in turn could have benefited their encouraged protected against development of behavioural
children; or the educational progress of the participants or emotional disorders.66,67 Social support might be an
might have been positively affected, with a consequent effect important psychosocial buffer in the face of other risk
on their mental health. This is the first study to show that factors.68–71 These studies, and others, suggest that
stimulation in early childhood produced improvement in consistent and engaging parenting styles, parents and
mental-health status in adolescence. The intervention friends who model health behaviour, being in fulltime
constituted mental-health promotion in that it enhanced the education in a school with a zero-tolerance policy towards
parenting capacity of the mothers, thus strengthening an bullying and the promotion of a learning atmosphere
important protective factor for mental health outcomes in where individual needs and interests are addressed, and
children and adolescents. involvement in community activities and religious
observance are protective.7,72 Perhaps the single most

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important factor for building resilience in youth is to these findings is that focus should be on early
enable parents to provide adequate psychosocial interventions that aim to prevent the progression of
stimulation during early childhood; a recent report on primary disorders and the onset of comorbid disorders.
resilience concluded that “the key to giving young people Although we do not know for certain whether
a good start in life is to help their parents”, because interventions for mental disorders in youth reduce the
people’s response to adverse situations are shaped by early costs attributable to the disorder, some studies indicate
life experiences.73 Evidence in support of this observation that this is the case.78,79
is now emerging from developing countries (panel 1).74 Furthermore many of the leading causes of DALY that
Developmental epidemiology offers an alternative are not directly due to mental disorder, have mental-health
model to the traditional approach to the study of risk dimensions. For example, young people with mental
factors (shown in many of the studies we have cited) disorders are at a higher risk of contracting HIV/AIDS
which compares groups of young people with mental than their peers without mental illness.80,81 For
disorders with those without such disorders. externalising disorders, the increased risk occurs partly
Developmental epidemiology aims to incorporate the through inadequate sexual communication skills and
principles of developmental psychopathology into susceptibility to peer norms that encourage sexual-risk
epidemiology.28 More specifically, the “task is to behaviour.80 For internalising disorders, on the other
understand the mechanisms by which developmental hand, factors such as low perceived self efficacy, decreased
processes affect risk of specific psychiatric disorders and assertiveness, and reduced ability to negotiate safe sex
to propose preventive strategies appropriate to the various are applicable.81,82 Additionally, mental-health conse-
stages of risk”28. This approach requires, among other quences exist for young people with HIV/AIDS; for
things, that attention is given to the timing of the onset example, a rate of depression of 44% was documented
of disorders and recognition that the relations between 6 months after diagnosis in American adolescents.83
causes and outcomes vary across the span of development Finally, mental-health consequences of disclosure of
to be addressed. Longitudinal studies that enrolled positive maternal HIV status also exist, living with an
cohorts from childhood, such as the National Longitudinal infected family member, and losing one or both parents
Study of Adolescent Health in the USA, the Dunedin as a result of an HIV-related cause.84 Evidence for the
Multidisciplinary Health and Development Study in New mental-health effects of being orphaned as a result of
Zealand, and the Birth to Twenty Study in South Africa, AIDS are inconsistent, partly because of the nature of the
provide important information about life-course risk and control groups. For example, a study of South African
protective factors for health outcomes in young people.6 10–19 year-olds85 aimed to address confounding factors
by including two control groups from the same
Public-health significance economically deprived communities—non-orphaned
The suffering, functional impairment, exposure to stigma adolescents and adolescents orphaned as a result of
and discrimination, and enhanced risk of premature causes other than AIDS. The study showed that AIDS
death that is associated with mental disorders in young orphans did not have more psychosocial difficulties than
people has obvious public-health significance. This other orphans.
significance is amplified, since mental disorders in young Comorbidity with other disorders can occur at three
people tend to persist into adulthood.28 Conversely, levels: with other mental disorders, with substance
mental disorders in adults often began in youth or abuse, and with chronic diseases. Young people with
childhood, as shown by the National Comorbidity Survey learning difficulties or schizophrenia are more likely to
Replication75 in the USA, which was the first study to develop behaviour or emotional disorders. Substance
examine the temporal concentrations of age of onset. abuse, which is addressed in more depth in paper 4 in
According to the results of this study, 75% of people with this Series,86 is a major risk factor for mental disorder.
a mental disorder had an age of onset younger than The use of alcohol, tobacco, and other drugs is correlated
24 years. Furthermore, the ages of onset for most with psychopathology, especially attention-deficit
disorders likely to persist into adult life, including hyperactivity disorder, psychoses, mood disorders, and
depressive and anxiety disorders, psychoses, substance anxiety disorders.87–90 The reasons for the correlations
use, and eating and personality disorders, fell within a are unclear: substance use can cause the psychopathology
narrow time frame, notably the 12–24 year age range. or vice versa, or both could be caused by other factors.
Since youth is the period of life when most people Chronic diseases in young people, such as diabetes, are
complete their academic career, establish themselves in associated with increased risk of mental disorders.91
the job market, and establish friendships and romantic Injuries and violence are important contributors to the
relationships, and since mental disorders might reduce burden of disease in young people. Mental disorders
the likelihood of these tasks being completed successfully, can predispose to exposure to violence as a perpetrator
mental disorders in young people have a substantial or victim.92 Externalising problems (especially
effect on economic and social outcomes that extend into hyperactivity and poor attention and concentration)
adulthood.76,77 The obvious public-health implication of before 13 years predict violence into early adulthood.93

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Mental disorders, such as depression, anxiety, and significant clinical benefit has been shown. Several trials
post-traumatic stress disorder can occur as a result of of psychotherapy in children and adolescents have been
exposure to violence.94,95 undertaken, with results providing evidence for
psychotherapy generally, with no one type clearly
Health-system responses established as superior to another.98 Very few studies exist
Treatments for mental disorders in young people have that have compared or combined these treatments, with
improved substantially during the past two decades with the notable exception of the US Treatment for Adolescents
safer and more effective drugs, more practical forms of with Depression Study.124 In this trial, 439 adolescents
psychosocial interventions, and reforms in service-delivery aged between 12 and 17 years were randomly assigned
models. Several meta-analyses96–98 have shown support for one of four treatments (fluoxetine, cognitive behavioural
individual, group, and family psychotherapies, particularly therapy, fluoxetine plus cognitive behavioural therapy, or
those with a behavioural or cognitive-behavioural placebo) and reported that the combination treatment
orientation, for a range of mental health and behavioural was more efficacious than the other treatments. On the
disorders. In terms of evidence for specific interventions basis of evidence from these studies, we recommend that
for specific disorders, some encouraging developments psychosocial treatments are used as first-line interventions
have taken place in early intervention in psychotic in mild cases, with selective-serotonin-reuptake
disorders in young people, in terms of early detection, inhibitors, preferably fluoxetine, being judiciously
phase-specific treatment, and health-services reform.99–104 reserved for patients for whom psychosocial treatment
The evidence base for the effectiveness of interventions in has not worked, or those with severe and complex
other disorders is limited and therefore less clear-cut. presentations.98
Some evidence is available from adult studies (which Despite the substantial evidence for the burden,
included young people) that psychological therapies are public-health importance, and the emerging evidence of
of benefit, particularly in reducing suicide-related the efficacy of psychosocial and pharmacological
behaviours and substance use, in borderline-personality treatments for mental disorders in young people,
disorder.105 Some evidence exists regarding antisocial or health-system responses to youth mental health have
conduct disordered youth offenders, for whom family and been inadequate. In 2002, a systematic review and
parenting interventions have been shown to be effective interviews with key informants showed that only 7% of
in reducing the time of incarceration.106 For eating countries in the world had a clearly articulated specific
disorders, trials and systematic reviews have not been child and adolescent mental health policy.125 Substantial
specific to adolescents and young adults; however, the variations exist between WHO regions (table 3) and
mean population ages of those with these disorders is between developing and developed countries; while
generally within the 12–24 year age-range. Cochrane 78% of countries in the high-income category have a
systematic reviews and meta-analyses indicate some child and adolescent mental-health policy, not one
evidence for benefit of antidepressants and combined low-income country does.126 Notably, these figures
antidepressant-psychological treatment in bulimia probably represent an overestimate for two reasons;
nervosa,107,108 but not for antidepressant use in anorexia first, national figures mask inequities in the distribution
nervosa,109 where family therapy might be an effective of services within countries (for example, with less
intervention.110,111 In bipolar disorder, a few randomised coverage in rural or disadvantaged areas); and second,
trials have shown benefits of the use of lithium, divalproex services tailored to young people are scarce even in
sodium, and quetiapine in adolescents for stabilisation of countries with child and adolescent mental-health
the acute episode.112–116 programmes. In most developing countries, very few
The evidence base for drug and psychotherapeutic child and adolescent mental-health services or resources
interventions for depression in adolescents is fairly are available, and even fewer that specifically cater for
meager. Evidence shows that tricyclic antidepressants are young people. Even in many developed countries,
not effective in child and adolescent depression.117 admission of adolescents to inpatient units for older
Although the use of selective-serotonin-reuptake adults is routine practice.
inhibitors in adolescents has been criticised35,118,119 on the
basis of the modest increase in suicidal ideation and Child and adolescent Child and adolescent Countries responding
suicide attempt shown in pooled data from registration mental-health policy mental-health plan to survey (n)

studies, most studies typically combined prepubertal Africa 33% 6% 15

children with adolescents, despite the different Americas 78% 45% 9
phenotypes and underlying origins of mood disorders in Southeast Asia 50% 63% 8
these age-groups.120,121 Conversely, although antidepressants Europe 96% 67% 25
are effective in adult depression, adolescents and young Eastern Mediterranean 100% 33% 3
adults are under-represented in studies of adult Western Pacific 67% 83% 6
depression. Some investigators have supported the use of
Table 3: Presence of child and adolescent mental-health policies and programmes by WHO region126
fluoxetine,119,122–124 for which a small but statistically

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Thus, most mental-health care for adolescents and self-harm, and sexual risk behaviours (panel 2135). The
young adults is typically delivered in community and beyondblue schools research initiative in Australia136 is
outpatient settings, often within the context of adult another example of a school-based intervention that seeks
services. In developed countries, encouraging to prevent depression in young people through a complex
development of child and adolescent mental-health intervention which addresses both individual and
services has taken place. However, such services have environmental risk factors. A related strategy would be to
emerged only fairly recently from an exclusive focus on educate the community to improve knowledge of the
younger children, and typically still struggle to manage onset phase of mental and substance use disorders in
young people in the middle and later stages of young people and how to seek help locally.137–139 Secondly,
adolescence, when adult patterns of disorders generally general practitioners and other primary care workers need
emerge, whereas adult services are mainly focused on to be educated to better engage young people, to recognise
older and more chronic patients, and exclude and neglect mental and substance use disorders, and to deliver simple
younger patients. Iatrogenic effects can take place when treatments, including supportive counselling, cognitive
adolescents and young adults are mixed with older behaviour therapy, and, where appropriate, psychotropic
chronically ill patients, including increased risks of drugs.140
suicide.127 Initial access and continuing participation of
young people in adult mental-health services is Panel 2: HealthWise: a school-based intervention to
problematic and is partly responsible for the long delays encourage positive free-time behaviour and reduce
in treating first episode psychosis.128,129 prevalence of risk behaviours
Even in fairly well resourced countries with established
child and adolescent mental health services and adult The aim of HealthWise is to engage young people in a 2-year
mental-health services, access to mental-health care is school-based curriculum that addresses important issues and
poor, especially for those in late adolescence and early choices they make. Many young people have much spare time,
adulthood.130 Since young people are mainly physically (ie, time not spent at school or work). During spare time,
healthy, they generally do not have a regular relation with young people are free to engage in activities including chores,
a general practitioner or other primary-health worker.131 sports, spending time with friends or family, and participating
When help is sought, it is either not available or is in faith-based activities. Such activities have the potential to
typically offered in settings that fail to engage the young produce positive outcomes, for example increased
person and their family and to deliver effective help.132 connectedness with peers and adults. However, spare time
Young people’s problems are often diagnostically also has the potential to result in unhealthy choices, such as
confusing, and often need multidisciplinary and consumption of alcohol, use of other drugs, such as
intersectoral responses. Engaging young people also marijuana, and participation in unsafe sexual practices.
requires a particular style and therapeutic skill and this is HealthWise is designed to encourage positive free-time
often lacking. For these reasons, a substantial gap exists behaviour and to reduce the prevalence of unhealthy
between efficacy and effectiveness in mental-health care behaviours. The programme consists of a set of activities to
for young people. help young people to: use their free time in ways that will
benefit themselves, their families and friends, and their
Implications for policy and practice community; develop specific skills to make good decisions,
Although mental and substance use disorders represent control their emotions (such as anxiety and anger), resolve
the major health problems affecting young people and conflicts, and overcome boredom; grasp specific facts about
youth is the period of life during which most mental the causes and effects of drug use and sexual risk behaviours;
disorders emerge, provision of mental-health services is learn specific techniques to avoid peer pressure and to take
weakest during adolescence and youth.133 Taking a responsible action in their spare time; and how to link with
population-health perspective, we advocate a continuum community resources.
of response with a series of levels, from the community HealthWise has several noteworthy features. First, it follows a
through to specialist services.134 Self-limiting disorders and comprehensive approach that addresses a wide range of
milder yet potentially serious disorders in an early stage aspects of how young people spend their time. This approach
might respond to simple measures, such as psychosocial helps identify the reasons why young people engage in
support, self-help strategies, and education typically in healthy and unhealthy behaviours, and teaches them to think
non-clinical settings. These interventions could be about their lives holistically. Second, it focuses on and
developed in youth-friendly ways and disseminated strengthens positive aspects of young people’s lives, with a
through community-based channels, such as educational view to increasing resilience. Third, it incorporates a
settings and the internet. Schools and colleges in particular community approach, introducing young people to members
offer a unique setting for mental health promotion in of their school and local communities who can assist them in
young people, via the emphasis on reducing risk factors making important decisions and helping solve problems. The
and strengthening protective factors, which are common effectiveness of Healthwise is being assessed in South Africa135
to several risk behaviours, such as substance abuse,

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Specialised and multidisciplinary care will be required Interventions to prevent mental disorders and promote
for young people who have multiple or complex needs. mental wellbeing must not be overlooked. Some
This care should ideally involve youth-friendly general evidence is available of the effectiveness of preventive
practitioners and other primary-health workers interventions for conduct disorder, depression, anxiety,
collaborating closely with mental-health and substance- eating disorders, and suicide and alcohol misuse.144 The
abuse professionals and an array of support agencies, bulk of this evidence is from high-income countries;
such as accommodation, educational, and employment however, isolated examples exist of successful preventive
services. In view of the poor access and engagement of interventions in low-income and middle-income
young people in traditional primary and specialist service countries, such as an intervention to combat youth
structures,131 a strong case exists for location of this substance-abuse in China.145 Similarly, evidence exists of
service mix within a single youth-friendly setting, ideally the success of mental-health-promotion interventions
under one clinical-management structure, for example, in high-income countries, although these interventions
a broader youth precinct for youth health and welfare, are generally confined to protective factors at the
where mainstream youth-oriented activities occur, such individual level rather than interpersonal relations,
as sports and leisure pursuits. This specialised culture, and structural factors, such as poverty.146 We
community care alongside generic primary care and in were unable to identify a single example of an
partnership with the tertiary mental-health system, is intervention targeted at young people in low-income
under active development in Australia through a new and middle-income countries that improved
Federal National Youth Mental Health Initiative. Some mental-health outcomes. However, an intervention in For more information on
investigators have successfully argued for integration of which stimulation was provided in infancy had a positive this Australian initiative see
http: //www.headspace.org.au
drug and alcohol services within this youth stream of effect on mental-health outcomes in late adolescence
care.141 Finally, the tertiary specialist system has an (panel 1).73
important part to play in the care of young people with There is far too little systematic research evidence for
potentially serious disorders and must be strengthened. the burden, risk factors, protective factors, and
Streamed tertiary care, such as now increasingly exists interventions and models of care for youth mental
for old-age psychiatry, is needed for young people, disorders from most parts of the world. Cultural
especially inpatient facilities, so that they are no longer differences can have a profound effect on how policies,
placed in older adult inpatient units. The development plans, and specific interventions are formulated and
of a distinct clinical and academic subspecialty of youth implemented. Major research questions that need to be
psychiatry, best seen as a strengthening of child and address include: what are the mental health needs and
adolescent psychiatry, would help to drive these reforms the patterns of risk and protective factors for mental
and aid workforce and skill development. disorders in young people in societies that are witnessing
In all regions of the world, major staffing and other rapid social and economic change? What are the
resource challenges and a scarcity of a clinical and mental-health needs of young people with other health
public-health evidence base, particularly for problems, particularly HIV/AIDS? What is the
childhood-onset disorders exists.142 The scarcity of effectiveness of integrating mental health into routine
specialist human resources for mental disorders,126 the youth health-care programmes? How do child and
poor awareness of mental disorders, and the stigma adolescent mental health services compare with
associated with them143 are major challenges for integrated mental health programmes? What is the effect
implementing the ideal programme for specialist youth of early-intervention programmes in youth on adult
mental-health services that we have discussed. In health outcomes? We strongly recommend the need for
low-resource settings, the realistic path is to integrate more pragmatic trials, in which the young people
mental-health programmes into general youth health included are representative of those seen in clinics, and
and welfare programmes, in particular those being where the outcomes measured are clinically and socially
developed to cater for specific youth issues, such as meaningful. We also call for more research investment to
education and reproductive and sexual health. Youth develop, implement, and assess preventive and promotive
health and welfare programmes are likely to be less youth mental-health interventions. However, although
stigmatised and more accessible to young people and investment in research on youth mental health is
they have the advantage of providing a range of important, it must not be at the expense of delaying
youth-friendly services under one roof. Mental-health investment in services for youth mental disorders, for
professionals, where available, would work as part of a which sufficient evidence is available of the epidemiology,
youth-health team, delivering specialist interventions public-health importance, and treatment effectiveness of
and building generic mental-health skills. At their most mental disorders in young people.
basic level, screening for high-risk groups, provision of
simple, evidence-based, psychosocial treatments, and Youth mental health matters in all countries
increasing awareness about mental health and illness, It is ironic that, although substantial investment has
should be within the reach of every youth programme. been made in mental-health promotion and interventions

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for young people in many developed countries, no Consortium called The Mental Health and Poverty Project: mental health
equivalent acknowledgement of mental health needs of policy development and implementation in four African countries
(contract number. RPC HD6 2005-2010). PM and SH are supported by a
young people exists in developing countries. The National Health and Medical Research Council Program Grant and the
priorities for young people seem to be different in rich National Youth Mental Health Foundation Grant, both from the
and poor countries. We disagree with this dualism. Young Australian Government, and by the Colonial Foundation. We thank
people in every society have mental health needs; it is Robert Goodman for his advice on parts of this review.
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