an engagement and access model for healthcare delivery to adolescents with mood and anxiety concerns

Early Intervention in the Real World

An engagement and access model for healthcaredelivery to adolescents with mood and

anxiety concernseip_312 97..105

Erin Ross, Evelyn Vingilis* and Elizabeth Osuch

FEMAP, London, Canada

Corresponding author: Dr ElizabethOsuch, Department of Psychiatry, FEMAP,860 Richmond Street, LondonON N6A 3H8, Canada. Email:[email protected]

*Present address: Population andCommunity Health; Department of FamilyMedicine, 2nd Floor Rm 2711; ClinicalSkills Building, UWO LondonON N6A 5C1.

Received 25 January 2011; accepted 9September 2011

Abstract

Aim: Mood and anxiety disorderstypically begin during adolescence orearly adulthood. Yet services targetingthis population are frequentlylacking. This study implemented anoutreach, access and assessment pro-gramme for youth with these con-cerns. The data reported constitute anevaluation of this mental healthcaredelivery approach.

Methods: This evaluation includedspecification of both programme andimplementation theories throughcausal and programme logic modelsand formative (process) evaluation.Outreach focused on access points foryouth such as schools and familyphysicians’ offices. Concerned youthwere encouraged to self-refer. Partici-pants completed a semi-structuredclinical interview and symptom andfunction questionnaire package.

Results: Engagement sessions wereconducted and results involved 93youth. The majority of youth self-referred, a process not possible in

traditional physician-referral health-care systems. Interestingly, almosthalf had received prior treatment andover half had tried a psychiatric medi-cation. Yet participants had signifi-cant symptomatology: 81% reportedmoderate to severe depressive symp-toms; 95% reported high levels oftrait-anxiety. Functional impairmentwas substantial: on average, partici-pants missed 2.6 days of school/workand functioned at reduced levels on4.2 days in the week prior to assess-ment. Demographic details arepresented.

Conclusion: This study evaluated amental healthcare delivery systemthat identified individuals with sig-nificant distress and functionalimpairment from mood/anxietyconcerns and previous unsuccessfultreatment attempts, verifying thatthey were in need of mental healthservices. This approach provides amodel for outreach and assessmentin this population, where earlierintervention has the potential toprevent chronic mental illness anddisability.

Key words: adolescent, anxiety disorder, delivery of health care, mooddisorder, programme evaluation.

INTRODUCTION

Adolescence is a time of significant physiological,developmental and social change, and is, therefore,also a time of vulnerability regarding mental health.1

Interestingly, the majority of psychiatric disordershave their onset in adolescence and early adult-hood.2,3 Mood and anxiety disorders are some of the

most common mental health disorders and have alifetime prevalence of almost 21% and 29%, respec-tively.3 Untreated, mood and anxiety disorders havea high rate of recurrence and often becomechronic.4,5 It is predicted that, by 2020, depressionwill become the second leading cause of disability inthe world.6 This could have major health conse-quences. In Canada, suicide already has accounted

Early Intervention in Psychiatry 2012; 6: 97–105 doi:10.1111/j.1751-7893.2011.00312.x

First Impact Factor released in June 2010and now listed in MEDLINE!

© 2011 Blackwell Publishing Asia Pty Ltd 97

for 24% of all deaths among 15 to 24-year-olds,7 andin a retrospective analysis, 77% of youth suicidesinvolved depressed mood.8

Increasingly, health care is adopting early inter-vention models in a variety of potentially chronicconditions such as obesity, heart disease and diabe-tes with goals of preventing disability and early mor-tality, and reducing societal and healthcare costs.9–11

To date, few such programmes have been initiated,targeting common psychiatric disorders. Australiahas launched a nationwide depression initiative,‘beyondblue’,12 which focuses on awareness, educa-tion, prevention and early intervention in depres-sion. The Orygen Youth Health programme at theUniversity of Melbourne appears to be the bestdeveloped and most extensively studied initiativeaddressing early identification and intervention inpsychiatric disorders, generally. And although earlyidentification and intervention programmes forpsychosis are standard in many Canadian commu-nities and beyond,13–15 Australia appears to be one ofthe few countries that has expended this initiative toother psychiatric conditions. No early interventionprogrammes for mood/anxiety have been availablefor Canadian youth.

In order to receive a psychiatric assessment andtreatment in Canada, youth with mental healthconcerns must ordinarily first see their primarycare physician who must then refer to psychiatricspecialty services. A common alternative is to go tothe emergency department at the nearest hospitaland obtain a physician referral by that route. Suchprocesses could create barriers for youth to getmental health services early in the course of theirillness. Shortages of family physicians and the highvisibility of and discomfort with an emergencydepartment visit are obvious barriers to youth.Numerous other factors may also be involved inthe lack of appeal of traditional health accessroutes for youth with mental illnesses as theseresources are traditionally geared towards adultclients.16,17

A programme was developed in 2006 that beganto address this gap within the London Health Sci-ences Centre in London, Ontario. The programme isknown by the name of the ‘First Episode Mood andAnxiety Program’ (FEMAP), although this name isrecognized as a misnomer. That is, those youth‘arriving at the door’ are not necessarily experienc-ing their first episode of mood and/or anxiety symp-toms. The goal of FEMAP is to identify youth atcritical developmental life stages who are just begin-ning to depart from their expected developmentaltrajectory and intervene by providing outpatientcare before these youth become chronically dis-

abled from mental illness. Youth may or may notbegin to fall off their normal trajectory at the time oftheir true first episode of symptoms. This is reflectedby the fact that many youth with early mood and/oranxiety symptoms will recover spontaneously18,19

and, therefore, not all youth with such symptomsare in need of specialty services. Ideally, a mentalhealthcare programme for youth should enrol thosein need of specialty mental health services whereasit should not enrol those who will recover withoutsuch services.

This study provides a formative evaluation toassess whether the outputs (programme activitiesimplemented and target audience reached) ofFEMAP are being realized. Thus, the results of thisstudy allow us to determine if we could increasecontacts to mental health services by eliminatingthe traditional barrier – physician referral; andsecondly, whether or not the youth coming to thisprogramme were experiencing sufficient levels ofsymptoms/dysfunction to warrant the level of careprovided by a mental health specialty clinic. We alsoexamined the demographic characteristics of thispopulation to understand the population better andsee where possible gaps in community engagementmay have occurred.

METHODS

This study followed current procedures for thedesign and evaluation of complex health interven-tions through the initial specification of both theprogramme theory, as represented by the pro-gramme’s causal model, and implementationtheory as represented by the programme’s logicmodel.20–24 Programme logic models represent howa programme is to operate to achieve its outcomes,built on the theory and assumptions underlying theprogramme.22 A programme logic model links out-comes, both short- and long-term, with programmeactivities and with theoretical assumptions or prin-ciples to ensure that the outcomes can be realizedthrough the activities. The causal model of FEMAP isillustrated in Figure 1, whereas the logic model isillustrated in Figure 2.

As recommended for newly developed pro-grammes and as followed here, the second step ofprogramme evaluation is to conduct a formative(process) evaluation to assess whether the pro-gramme output activities were implemented andwhether the programme reached its target audi-ence.21,22,24 The current study sought to evaluate theactivities presented in the logic model of the firstphase of this mental healthcare delivery model

Program evaluation: mood and anxiety in youth

98 © 2011 Blackwell Publishing Asia Pty Ltd

involving access and assessment of youth (Fig. 2).This study received approval from the Office ofResearch Ethics for Human Subject Use of the Uni-versity of Western Ontario, which follows the provi-sions set forth by the Declaration of Helsinki. Allparticipants had the study described to them ver-bally and via a written Letter of Information. Afterreading the document and asking any questions,willing participants signed written, informedconsent to participate.

Implementation of programme activities

Education/Community engagement

Institutions chosen for outreach education andengagement were selected on the basis of theirregular inclusion of youth. Meetings were held withlocal secondary school boards, specifically groups ofguidance counsellors and other school healthcareworkers; post-secondary educational institutions’

FIGURE 1. Causal model of the First Episode Mood and Anxiety Program illustrating the two-phase, multi-step process of recovery foryouth with mood and/or anxiety disorders. Phase I illustrates the access and assessment components of the model; Phase II illustratesthe process of getting youth to the correct services, treating them and their recovery. Phase I is the focus of this report.

Youth with mood/anxiety symptoms

Youth self-identifyto FEMAP Assess youthPhase I

Provide treatment RecoveryPhase II

1 2

5Direct youth to

needed services

3 4

FIGURE 2. Logic model of the First Episode Mood and Anxiety Program illustrating the outputs and the short, medium and long-termoutcomes of the programme. A potential unintended consequence is also illustrated. The darker-shaded sections of the figure representthe components that are included in this process evaluation of the model. Lighter-shaded components of the model will be reportedin a future outcome evaluation.

Outcomes–ImpactOutputs

Activities ParticipationPhase I:

Conduct educationalsessions on mood/anxiety where youth are seen

Create intake process that allows for self-referral

Assess and identify: level of symptom severity; symptom clusters; level of youth functional impairment

Phase II:

Direct youth to needed services

Provide treatment

Youth aged 16–26 with concerns related to mood and/or anxiety

Short Medium LongIncreased access of youth with significantmood/anxietyconcerns to mental health services

Recovery from mood/anxietydisorders

Less time lost by youth in school/work due to mental health concerns

Fewer youth with mental illnesses going untreated

Fewer youth becomingdependent upon governmentservices because of exacerbation of untreated mood/anxietydisorders

Potential Unintended Consequences: Excessiveuse of psychiatric specialty services by youth who could be treated elsewhere less expensively

E. Ross et al.


student health care and psychological support ser-vices; community and hospital mental healthcaresystems working with youth; and family practicenetworks in the community. The family practicenetworks and some of the mental health agenciesdid not selectively serve the youth populationwhereas the educational agencies were youthfocused, though not exclusive to youth. A web pagewas also launched describing FEMAP with mentalhealth information and access information for theprogramme. Lastly, we engaged two high schools toparticipate in an art contest to create visual incen-tives to visit the web site for FEMAP. This wasintended to create awareness both in the schoolsthat held the contests and also to develop materialsthat would be attractive to youth to help themconnect with the programme. Other research teamactivities involving public outreach occurred duringthe time of the study and are noted below as theymay have played an important role in communityawareness about the programme.

Enrolment

An intake process was developed so that all youthwho contacted FEMAP during a 12-month periodfrom 2009 to 2010 were invited to participate if theymet the following eligibility criteria: (i) age 16 to 26;(ii) not currently under psychiatric care; and (iii)stable enough to complete the assessment. Youthwho presented with symptoms other than anxietyand/or depression were included in the study aspart of the goal of facilitating access to the correctservice even if those were not FEMAP. Youth withprior psychiatric care were excluded to eliminatethe inclusion of participants who were alreadyknown to warrant specialty services. Following apreliminary screening, an in-person intake assess-ment was conducted by a non-physician clinicalteam member (ER).

Assessment

An assessment process was developed that involveda semi-structured clinical interview and question-naire package. The package consisted of the follow-ing measures:

1. The SCID-I Screening Questionnaire25 (full SCIDnot administered). This helped to identify areasof possible psychiatric disorders.

2. The Beck Depression Inventory (BDI-II),26 a21-item self-report questionnaire measuringdepression symptom severity.

3. The Spielberger State-Trait Anxiety Inventory(STAI),27 a 40-item self-report questionnairemeasuring the severity of anxiety symptoms. Itseparates in-the-moment ‘state’ anxiety from themore permanent ‘trait’ anxiety the individualexperienced on a daily basis.

4. The Sheehan Disability Scale28 was administered,which is a 5-item measure assessing the level offunctional impairment across important lifedomains within the week prior to taking thequestionnaire.

A demographic screening questionnaire devel-oped by the investigators was also used to ask par-ticipants to briefly identify their emotional concerns,their psychiatric treatment history and basic demo-graphic information. All referenced measures exceptthat created by the investigators had been previouslyvalidated.29–34 The diagnostic symptom clusters towhich each participant belonged were decided onthe basis of their self-identified concerns, confirmedby their questionnaire results.

RESULTS

Formative evaluation of phase I activities

Education, community engagement

Outreach was made to four medical centres, eighteducational services or departments, and 10 com-munity agencies that work with youth. These con-tacts included 3 formal presentations describingFEMAP services; 10 informal in-person question-and-answer sessions about FEMAP; five telephonemeetings about how to refer and what services wereavailable; one in-kind service provision to increasecommunity connections to FEMAP (i.e. brieflyattending drop-in sessions for youth in a commu-nity programme for homeless youth); one school-based awareness (art) campaign, as mentionedpreviously; and two ongoing partnerships helpingto link FEMAP to community services. Coincidentalexposure resulted from three public talks by FEMAPmembers, two on marijuana use in youth and oneon mood and anxiety symptoms in youth; and twoarticles in the local newspaper featuring FEMAP. Inall direct community engagement communications,listeners were invited to refer any youth with moodand/or anxiety complaints to FEMAP directly.

Intake process

The first 93 participants are the subject of thispreliminary report. Referral sources of the 93



participants were as follows: 23% (n = 21) werereferred from educational institutions; 21.5%(n = 20) by family or friends; 20% (n = 19) by familydoctors; 13% (n = 12) from hospital programmes(i.e. specialty physicians); 13% (n = 12) from com-munity mental health services (viz., without a phy-sician); 5% (n = 5) through the Internet; 2% (n = 2)from the local paper or from public talks; and anadditional 2% (n = 2) were unable to recall how theyheard of the programme but self-referred. Thus,only 33% (n = 31) of participants utilized referral byany physician and only 20% (n = 20) by a primarycare physician.

Description of youth and assessment

Demographics. The average age of participants was19.8 years (SD 2.8). Thirty-two percent (n = 30) weremale. Youth were largely Caucasian (82%) with thenext largest categories ‘other’ (12%), Native Cana-dian (2%), Asian (2%), South Asian (1%) and ofAfrican origin (1%).

The majority of participants (54%; n = 50) wereliving with their families of origin (either with asingle parent or both parents). The rest had livingsituations as follows: 23% (n = 21) lived with at leastone roommate, either a significant other or just afriend(s); 4% (n = 11) lived alone; 1% (n = 1) lived ina homeless shelter; and 1% (n = 1) lived with aspouse and their children. As another indicatorof socio-economic status, parental educationalachievement is shown in Table 1. Some participantsdid not know their parents’ level of maximum edu-cation. On average, educational level of parents washigh, with both parents having engaged in somepost-secondary school education.

Treatment history. Most participants had had previ-ous treatment. Overall, 71% (n = 66) of participantsreported some form of previous mental health care.Specifically, 21.5% (n = 20) had tried psychotherapybut had never taken a psychiatric medication and50% (n = 46) had tried some psychiatric medicationin their lifetime for the symptoms concerning them.Of this latter group, 32 participants reported being

on a medication at the time they contacted FEMAPwhereas 14 reported taking medication in the pastbut not currently.

Psychiatric assessment. Participants were groupedinto primary diagnostic clusters based on theirmain presenting concern. Many of the participantspresented with symptoms of both anxiety anddepression. Where they described depression as theprimary concern with secondary anxiety, partici-pants were placed into the depressed cluster, andvice versa. The depression plus anxiety cluster rep-resents participants who had primary symptomsof both, with neither predominating. Fully 39%(n = 36) of participants showed this combinedpresentation of primary depression plus anxietysymptoms; 28% (n = 26) presented with primarydepression symptoms; 16% (n = 15) presented withprimary anxiety symptoms (sans post-traumaticstress disorder (PTSD)); 9% (n = 8) presented withcomplaints of bipolar disorder symptoms; and7% (n = 6) presented with PTSD symptoms. Theprimary diagnostic complaint was in an alternativecategory or indeterminate for 2% (n = 2) of partici-pants. Severity of depression and anxiety symptomsare detailed in Table 2. In addition, 68% (n = 58) ofparticipants reported any thoughts of suicide and15% (n = 14) endorsed wanting to kill themselves asevidenced by an affirmative response to either BDIfoil, ‘I would like to kill myself’, or ‘I would kill myselfif I had the chance’. As a full SCID was not conductedthe specific diagnoses of their mood and/or anxietydisorders were not available.

Functional status within three domains of lifefunction is shown in Table 3. In addition, onaverage, participants reported losing 2.6 days (SD2.6) of work or school in the week prior to beingstudied. They also reported being underproductiveat work or at school an average of 4.2 days (SD 2.7)that week.

DISCUSSION

This study collected and analysed data on the out-reach and assessment components of a mental

TABLE 1. Parents’ maximum levels of education (subject number in parentheses)

Parent Partial highschool or less

High schoolgraduate

Partial collegeor university

College oruniversity graduate

Graduatetraining

Unknown

Father 14% (13) 15% (14) 15% (14) 23% (21) 22% (20) 12% (11)Mother 8% (7) 29% (25) 20% (17) 27% (23) 16% (14) 8% (7)

E. Ross et al.


healthcare programme designed specifically foryouth with mood and/or anxiety concerns as a for-mative evaluation to determine whether the pro-gramme activities were implemented as intendedand whether the programme reached its intendedtarget audience. Importantly, the interventioninvolved removing the barrier of physician referralfor access to this specialty service within a socializedhealthcare system. The purpose of this interventionwas to increase the likelihood that youth with sig-nificant mental health symptoms within the moder-ate mental illnesses (mood and anxiety disorders)would seek needed services before they began todevelop significant functional interference in theirdevelopmental trajectory from those symptoms.One objective of the formative evaluation was toidentify if youth presenting to the programme were,in fact, ill enough to warrant a specialty mentalhealth service. In short, the question asked by thisstudy was whether the programme would increasecontacts by ‘all and only’ those youth who neededthe specialized psychiatric services of FEMAP.

Our results demonstrated that only 33% (n = 31)of the youth participating in this study were referredby their family doctors or another physician – tradi-tionally the only means of accessing psychiatric ser-vices in the current Canadian health care system.Thus, 67% (n = 62) of our participants would nothave reached FEMAP without the ability to self-refer. This suggests that the model demonstratedhere increased access to psychiatric services for this

population. It also suggests that outreach to educa-tional institutions and the public at large was aneffective method of reaching some youth as thecombination of educational institutions and family/friends (word of mouth) were the two major sourcesof self-referral. Thus, this service approach was suc-cessful in increasing the numbers of youth present-ing for specialized mental health services, theprogramme’s short-term outcome.

Demographically, the mean age of youth in thisstudy was just under 20 years and there were twiceas many female as male participants. The mean agein the younger part of the target range was likelyreflective of the engagement conducted in the localhigh schools, college and university. It can be morechallenging to find locations to conduct communityengagement that involve youth in the mid-20 agerange. The sex difference found here could berelated to known sex differences in some of themood35 and anxiety disorders36 or may be a functionof differences in help-seeking behaviour betweenthe sexes.37 Most of the youth in this study were Cau-casian, which reflects the population of London,Ontario.38

The majority of youth in this study were livingwith their families of origin, but a sizable minoritywere also living with a roommate of some sort. Thisimplies that these youth were not, by and large,socially isolated or otherwise disenfranchised.Another indicator of their socio-economic statuswas the level of parental education of their parents,

TABLE 2. Depression (Beck Depression Inventory score) and anxiety (Spielberger State/Trait Anxiety Inventory score) symptom severity(number of subjects in parentheses)

Measure Minimal or none Low/Mild score Moderate score Severe/High score Mean; SD

BDI-II† 6.5% (6) 12% (11) 20% (19) 61% (57) 32;12.6‘severe’

STAI – State‡ N.A. 13% (12) 20% (19) 67% (62) 55;12.6‘high’

STAI – Trait‡ N.A. 1% (1) 5% (5) 95% (88) 62;8.7‘high’

†BDI-II, Beck Depression Inventory, version II. Score ranges: not depressed 0–9; mild 10–19; moderate 20–29; severe 30–63.‡STAI, Spielberger State-Trait Anxiety Inventory. Score ranges: low 20–39; moderate 40–49; high 50+.

TABLE 3. Functional impairment across life domains (Sheehan Disability Scale scores) (subject number in parentheses†)

Area of disruption Minimal or none Low/Mild score Moderate score Severe/High score Mean; SD (range)

School/work 1% (1) 11% (10) 19% (18) 66% (61) 7; 2.7 (0–10) ‘markedly’Social 1% (1) 12% (11) 25% (23) 62% (58) 7; 2.5 (1–10) ‘markedly’Family 2% (2) 13% (12) 27% (25) 58% (54) 6.5; 2.8 (0–10) ‘moderately-markedly’

†Three participants were not in school or working for reasons unrelated to symptoms.



which tended to be high with 59% of fathers and58% of mothers having had some college or univer-sity education. This reflected a higher level of edu-cational achievement than the general Londonpopulation.38 The reason that our youth came fromsuch families may be the result of the agencieschosen for our community engagement. Presum-ably, youth from better educated parents are morelikely to stay in school, and therefore more likely tobe in contact with someone who had attended oneof the FEMAP outreach events at their educationalinstitution. We did, however, also connect with com-munity mental healthcare agencies that includedseveral homeless youth resources. Others have alsofound indicators of lower socio-economic status tobe associated with less help seeking for mentalillness symptoms.39 These results may mean thatother community engagement approaches arenecessary to connect with youth from less well-educated families.

The majority (71%) of youth in this study had hadsome previous form of mental health treatment byprimary care physicians or other non-psychiatristmental health treatment providers, and half hadbeen treated with medications for psychiatric symp-toms. This confirmed that this may not have trulyrepresented a ‘first episode’ or even a ‘first treatedepisode’ for most participants. The fact that mostyouth had been treated in another setting beforeseeing a specialized psychiatric service is positive,as a possible unintended consequence of this modelis that the self-referral option would lead individualswhose needs could be addressed by less intensive(and less expensive) services, would consumelimited mental healthcare resources. The majorityof mood and anxiety problems can, and should, beaddressed in a primary healthcare setting. Yet ourdata suggested that, for the individuals in this study,previous treatment attempts had been made andhad been unsuccessful. On average, the youth whocontacted FEMAP reported moderate to severesymptomatology and substantial functional impair-ment in spite of prior treatment.

The most common symptom clusters endorsedby these youth were the combination of anxiety anddepression, followed by depression alone. This isconsistent with epidemiological data suggestingthat depression in youth is frequently comorbidwith (and often preceded by) anxiety symptoms.40

Anxiety complaints were less common even whenconsidering the combination with depression. Thisis in contrast with data showing that anxiety symp-toms with or without depression are more commonthan depressive symptoms alone, including inyouth.41 This could be a function of the urgency that

youth and/or their families attribute to depressivesymptoms as opposed to anxiety symptoms, or todifferences in public awareness between them. Onlytwo subjects (2%) did not present with mood and/oranxiety complaints (including PTSD). This demon-strated that the education about the programmewas bringing about contact from youth with thecorrect symptom clusters. This was probably alsofacilitated by the fact that an early intervention andprevention programme for psychosis was alreadywell established in this community.

The endorsement of bipolar symptoms at presen-tation to the programme was 9%. As these symptomclusters were not based on a formal psychiatry diag-nosis, it is probable that there were individuals withbipolar disorder in the depression and depressionplus anxiety symptom cluster groups. This would beconsistent with previous findings that individualsare more likely to seek help for depressive thanmanic symptoms.42

The overall level of symptom severity of youth inthis study was high with severe levels of depressivesymptoms and clinically significant levels of anxiety,especially trait-anxiety. Suicidal thoughts wereendorsed by 68% of youth in this study, with 15% ofthese having endorsed some serious intent, but themajority having indicated that they would notcommit suicide in spite of suicidal thoughts. Thusyouth who, on initial presentation, could be consid-ered in need of acute inpatient services were not themajority of youth contacting FEMAP, though thispopulation was a small fraction of those who pre-sented. Again, this indicates that, by and large, com-munity engagement and education activities for thisstudy were successful at attracting those youth bestserved in an ambulatory setting.

Study participants reported a marked level of dys-function. School/work dysfunction is a probableindicator of the extent to which individuals weremoving ‘off track’ from their expected developmen-tal trajectories. On average, these youth reportedmissing 2.6 days of school/work in the week preced-ing enrolment and under-functioning on over4 days that week. Given the developmental stage ofthis age group, in secondary or post-secondaryschool or early in their work lives, their mentalillness symptoms were disrupting important forma-tive activities for their future. If such youth have towait 6 months or longer for treatment in the health-care delivery model currently the standard of care insome Canadian communities, they could lose asemester or potentially a full academic year. Ifemployed, they would have been missing work orunder-functioning on the job early in their work life,which would potentially have negative employment

E. Ross et al.


consequences in the long run. The symptom sever-ity scores endorsed by this population suggestedthat, indeed, the specialized service developed herewas the correct service for the population. That is,the individuals were in need of specialized servicesand there were few individuals whose symptomseverity and functional impairment suggested that aless intensive treatment programme was indicated.These points address our second component of theformative evaluation on whether the programmereached its intended target audience and the poten-tial unintended consequence of the healthcaredelivery model.

On the basis of the participants mean level ofsymptom severity and dysfunction, the youth in thisstudy appear to most closely correspond with thestage of illness defined by Hetrick et al. for depres-sion as stage 2.43 The symptom severity described atthis stage of illness is notable for moderate to severesymptoms and functional decline and a globalassessment of functioning between 30 and 50.43

Given that many of the individuals in this study hadhad prior treatment that was not completely effec-tive, however, it is possible that we were recruitingthese youth at even more advanced stages of illness,such as stage 3.43 This raises the likelihood that theefforts made by this project were insufficient toattract youth early enough to optimize truly ‘earlyintervention’ strategies. It is probable that suchefforts will need to be made that focus on youngerage groups and with a comprehensive approach toadvancing public mental health awareness relatedto the early phases of mood and anxiety disordersfor the population at large.17 Further studies inves-tigating prevention and early intervention in moodand anxiety disorders can address these questions.

The development, acceptance and funding ofearly intervention programmes for psychosisoccurred over a decade ago in the Canadian health-care system. Currently, no similar mandate exists formood and anxiety disorders, in spite of the fact thatthese are over 10 times more common and are moreeasily treatable back to a baseline level of function-ing than schizophrenia. The balance needed forsuch a programme includes removing barriers togetting help by youth although also not ‘casting thenet too wide’ and bringing in youth who could bebetter treated without specialized services. Theresearch described here addressed the initial stepsof treatment (community engagement, identifica-tion and assessment) within a specialized mood andanxiety programme for late adolescents and youngadults and showed promising results from such amodel. Perhaps most importantly, this studyshowed that the youth who accessed the pro-

gramme through the non-traditional means of self-referral outnumbered the traditional referrals 2 to 1,the majority had tried prior treatment, and theyouth contacting FEMAP reported high levels ofsymptom severity and functional impairment.These data suggest that the programme’s formativeevaluation was successful. Future studies shouldalso address treatment responses and long-termoutcomes, as per phase II of the logic modeldescribed.

ACKNOWLEDGEMENTS

No conflict of interest exists for this study for any ofthe authors. This project was funded by a grant fromthe Academic Health Services Centres AlternateFunding Plan Innovation Fund; and the Universityof Western Ontario, London Health Sciences Centreand the Saint Joseph’s Health Care System. Theauthors would like to thank the FEMAP team,including Drs Kathryn Macdonald and Sarah Arm-strong; Jo Anne DePace; Jennifer Barfett-Lloyd;Darlene Lounsbury; Andrew Wrath; and MelodyChow.

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