Young Adult Mental Health Overview

Maryann Davis, Ph.D.Research Associate ProfessorDirector: Transitions Research & Training CenterCenter for Mental Health Services ResearchDepartment of PsychiatryUniversity of Massachusetts Medical School

What is Mental Health?Diagnoses (DSM-IV or ICD-9)

◦ Not Cognitive Disorders (e.g. delirium, dementia) Substance-Related Disorders Due to a General Medical Condition Sleep Disorders Adjustment Disorders (clinically significant reaction to stressor)

◦ None of the disorders first diagnosed in childhood EXCEPT; Attention Deficit and Disruptive Behavior Disorders and Attachment Disorders

Most commonly ◦ Mood Disorders (e.g. Major Depressive Disorder)◦ Anxiety Disorders ( e.g. Generalized Anxiety

Disorder)Transitions RRTC

Public Health Burden

WHO’s 2004 Global Burden of Disease Study Goal of Gore et al., 2011; characterize the burden of

disease in young people around the world Identified sources of death and disability In young adulthood – unlike adulthood - the primary

public health burden is disability, not mortality In high income countries, over 80% of total disease

burden was attributable to disability

Gore, FM., Bloem, PJN, Patton, GC, Ferguson, J, Joseph, V, Coffey, C, Sawyer, SM, & Mathers, CD (2011). Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet, DOI:10.1016/S0140-6736(11)60512-6

Major Causes of Burden Due to DisabilityU.S. 15-24 Yr. Olds

Females 15-19

Females 20-24

Males 15-19 Males 20-240%

10%20%30%40%50%60%70%80%90%

100%

55.9 54.134.8 33.0

12.6 12.2 39.3 37.2

Mental Health Substance Use Other NeuropsychMaternal Conditions Injuries Other CommunicableOther Non Communicable HIV/TB

Data from WHO Global Burden of Disease: 2004 Update, retrieved 5/2/13

Gore, FM., Bloem, PJN, Patton, GC, Ferguson, J, Joseph, V, Coffey, C, Sawyer, SM, & Mathers, CD (2011). Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet, DOI:10.1016/S0140-6736(11)60512-6

Psychosocial Development Affects Treatment

Psychotherapy is a psychosocial process◦Unique cognitive and psychosocial

development of YA’s, and their life circumstances renders “child” or “adult” interventions likely inappropriate

Typical Changes in Family Relations

Family involvement in treatment changes across these ages; parents are important but youth also developing self-determination skills

Suicide: Example of important age differences in clinical targets

Younger vs. Older (Kaplan et al. AJPH, 2012, S131-137)

non alcohol substance problem with high blood alcohol at suicide relationship problemsfinancial and medical health problems

associated with impulsive/aggressive (McGirr et al., Psych Med, 2008, 407-417)

Transition Age Youth Most Quickly Lost from Treatment

Davis et al., (submitted)

Evidence of Treatment Efficacy in this Age Group

Clinical trials conducted across ages Sufficient sample size of young

adults Conduct analyses to detect age

differences • Clinical trials conducted within the

age group (e.g. college students, early episode psychosis)

Ages 18-24 Ages 25-30 Ages 31+

1.00 –

.90 –

.80 –

.70 –

.60 –

.50 –

.40 –

.30 –

ControlSE

Employment Intervention Demonstration ProgramSupported Employment Randomized Trial

Burke-Miller, J., Razzano, L., Grey, D., Blyler, C., & Cook, J.(2012). Supported employment outcomes for transition age youth and young adults. Psychiatric Rehabilitation Journal, 35, 171-179.

Any Competitive Employment

Treatment/service models with strong

research support are RARE in this age group

Common Themes of Developmental Adaptations

Youth Voice; all developing models put youth front and center, and provide tools to support that position

Involvement of Peers roles; several interventions try to build on the strength of peer influence

Struggle to balance youth/family; delicate dance with families, no clear guidelines

Emphasize in-betweeness; simultaneous working & schooling, living w family & striving for independence, finishing schooling & parenting etc.

AGE Birth Death

18-21

Yrs.CHILD SYSTEM ADULT SYSTEM

Child WelfareEducation

Juvenile Justice

Criminal Justice

Child Mental Health

Adult Mental Health

Medicaid Medicaid

Substance AbuseVocational RehabilitationHousing

Higher EducationMedical Health Medical Health

40.1% Disenrolled

61.2% Disenrolled

82.9% Disenrolled

66.4% Disenrolled

Medicaid Enrollment Category

56.8% Disenrolled

F&C/CHIP (n=382) Primary

Care Utilization

20.4% Disenrolled

DisabledFoster Care

Limited Coverage (n=794) Recently

Disenrolled

44.6% Disenrolled

Yes (n=168)

No (n=214)

Exact Age

50.9% Disenrolled

>22.6 (n=53)

71.4% Disenrolled

<22.6 (n=151) Exact Age

< 20.1 (n=85)

>20.1 (n=76)

Yes (n=227)

12.5% Disenrolled

No (n=567)

Medicaid Disenrollment Post Inpatient Mental Health Care(n=1,176)

Davis et al., Psych Serv, submitted

Affordable Care Act Enrollment will be simplified; single application

developed for Medicaid, CHIP and Exchange plans; Outreach to underserved populations such as

homeless youth Those uninsured for more than six months may be

eligible for federally-subsidized state high-risk insurance plans for those with pre-existing conditions;

Exchanges will offer a plan specifically for youth under age 21

Incomes up to 133% FPL can be eligible for Medicaid (state option),

Parent’s insurance up to age 26 option

Conclusions

1. Mental health, with substance use disorders are the most impairing health conditions of young adulthood

2. Young adults need age-tailored interventions3. Few interventions are evidence based for this age4. Numerous interventions are in development5. System is fragmented at the point of entry into

adulthood6. Fragmentation contributions to discontinuity7. ACA helps, but not sufficient8. Research needed to elucidate targets of interventions,

test interventions, test system interventions

AcknowledgementsFunding from NIMH (R01 MH067862-01A1, R34-MH081303-01, R34 MH081374-01, RC1MH088542-02), and NIDRR & SAMHSA (H133B090018), UMass Medical School’s Commonwealth Medicine

Visit us at: http://labs.umassmed.edu/TransitionsRTCThe content of this presentation does not necessarily reflect the views of the funding agencies, nor their endorsement

I have no conflicts of interest to disclose