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Background: Many Canadian adolescents and young adults with mental health problems face delayed detection, long waiting lists, poorly accessible services, care of inconsistent quality and abrupt or absent inter-service transitions. To address these issues, ACCESS Open Minds, a multi-stakeholder network, is implementing and systematically evaluating a transformation of mental health services for youth aged 11 to 25 at 14 sites across Canada. The transformation plan has five key foci: early identification, rapid access, appropriate care, the elimination of age-based transitions between services, and the engagement of youth and families., Methods: The ACCESS Open Minds Research Protocol has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial, that are detailed in this paper. Additional components include qualitative methods and cost-effectiveness analyses. The services transformation is being evaluated at all sites via a minimum evaluation protocol. Six sites are participating in the stepped-wedge trial whereby the intervention (a service transformation along the key foci) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves, i.e., randomization was stratified by population size. Our primary hypotheses pertain to increased referral numbers, and reduced wait times to initial assessment and to the commencement of appropriate care. Secondary hypotheses pertain to simplified pathways to care; improved clinical, functional and subjective outcomes; and increased satisfaction among youth and families. Quantitative measures addressing these hypotheses are being used to determine the effectiveness of the intervention., Discussion: Data from our overall research strategy will help test the effectiveness of the ACCESS Open Minds transformation, refine it further, and inform its scale-up. The process by which our research strategy was developed has implications for the practice of research itself in that it highlights the need to actively engage all stakeholder groups and address unique considerations in designing evaluations of complex healthcare interventions in multiple, diverse contexts. Our approach will generate both concrete evidence and nuanced insights, including about the challenges of conducting research in real-world settings. More such innovative approaches are needed to advance youth mental health services research., Trial Registration Number: Clinicaltrials.gov, ISRCTN23349893 (Retrospectively registered: 16/02/2017).

Objectives: In low- and middle-income countries (LMIC), major mental disorders often remain untreated because of barriers related to access and resources. In rural areas and in conflict-ridden regions, the problem can be exacerbated by increased rates of mental illness and by reduced access to care. This paper describes a project designed to provide mental health services for major mental disorders among youth using a low-cost model in a rural district of the troubled Kashmir valley., Methods: We describe the geographic and political context, the guiding principles and adaptation of the service model (through partnership with a voluntary organization and use of technology), and the implementation of the model using Theory of Change framework. The core of the intervention was to train a pool of lay health workers (LHWs) to provide mental health services to young (aged 14-30 years) people with major mental disorders in their own communities, supported by clinical professionals., Results: Despite political turmoil and major floods, 40 (male and female) LHWs were trained. The LHWs efficiently engaged in case identification, basic interventions, and data collection on outcomes. Several different stakeholders were engaged in activities relevant to the objectives of the project; however, the use of technologies was moderated by several challenges, including access to internet services and patient preference for personal contact., Conclusions: This service model is applicable in an environment where protracted political and armed conflict, low resources, and geographical isolation make exclusive reliance on scarce professional services impractical.

Objectives: To report the outcomes of young people (aged 14-30 years) treated for major mental disorders in a lay health worker (LHW) intervention model in a rural district of conflict-ridden Kashmir, India., Methods: Over a 12-month follow-up, LHWs collected data on symptoms, functioning, quality of life and disability, and patients' and families' service engagement and satisfaction., Results: Forty trained LHWs (18 males and 22 females) identified 262 individuals who met the criteria for a diagnosis of a major mental disorder, connected them with specialists for treatment initiation (within 14 days), and provided follow-up and support to patients and families. Significantly more patients (14-30 years) were identified during the 14 months of the project than those in all age groups in the preceding 2 years. At 12 months, 205 patients (78%) remained engaged with the service and perceived it as very helpful. Repeated measures ANOVA showed significant improvements in scores on the global assessment of functioning (GAF) scale (F[df, 3.449] = 104.729, p < 0.001) and all 4 domains of the World Health Organization quality of life (WHOQOL) brief version (WHOQOL-BREF) of the survey-Physical F(df, 1.861) = 40.82; Psychological F(df, 1.845) = 55.490; Social F(df, 1.583) = 25.189; Environment F(df, 1.791) = 40.902, all ps < 0.001-and a decrease in disability (F[df, 1.806] = 4.364, p = 0.016). An interaction effect between time and sex was observed for the physical health domain of the WHOQOL-BREF., Discussion and Conclusions: Our results show that an LHW-based service model, implemented in a rural setting of a low-to-middle income region plagued by long-term conflict, benefits young people with major mental disorders. We discuss the implications of our findings in the context of similar environments and the challenges encountered.

Aim: Demands for mental health services in post-secondary institutions are increasing. This paper describes key features of a response to these needs: ACCESS Open Minds University of Alberta (ACCESS OM UA) is focused on improving mental health services for first-year students, as youth transition to university and adulthood., Methods: The core transformation activities at ACCESS OM UA are described, including early case identification, rapid access, appropriate and timely connections to follow-up care and engagement of students and families/carers. In addition, we depict local experiences of transforming existing services around these objectives., Results: The ACCESS OM UA Network has brought together staff with diverse backgrounds in order to address the unique needs of students. Together with the addition of ACCESS Clinicians these elements represent a systematic effort to support not just mental health, but the student as a whole. Key learnings include the importance of community mapping to developing networks and partnerships, and engaging stakeholders from design through to implementation for transformation to be sustainable., Conclusions: Service transformation grounded in principles of community-based research allows for incorporation of local knowledge, expertise and opportunities. This approach requires ample time to consult, develop rapport between staff and stakeholders across diverse units and develop processes in keeping with local opportunities and constraints. Ongoing efforts will continue to monitor changing student needs and to evaluate and adapt the transformations outlined in this paper to reflect those needs., (© 2019 The Authors Early Intervention in Psychiatry Published by John Wiley & Sons Australia, Ltd.)

Aim: This paper outlines the transformation of youth mental health services in Edmonton, Alberta, a large city in Western Canada. We describe the processes and challenges involved in restructuring how services and care are delivered to youth (11-25 years old) with mental health needs based on the objectives of the pan-Canadian ACCESS Open Minds network., Methods: We provide a narrative review of how youth mental health services have developed since our engagement with the ACCESS Open Minds initiative, based on its five central objectives of early identification, rapid access, appropriate care, continuity of care, and youth and family engagement., Results: Building on an initial community mapping exercise, a service network has been developed; teams that were previously age-oriented have been integrated together to seamlessly cover the age 11 to 25 range; early identification has thus far focused on high-school populations; and an actual drop-in space facilitates rapid access and linkages to appropriate care within the 30-day benchmark., Conclusions: Initial aspects of the transformation have relied on restructuring and partnerships that have generated early successes. However, further transformation over the longer term will depend on data demonstrating how this has impacted clinical outcomes and service utilization. Ultimately, sustainability in a large urban centre will likely involve scaling up to a network of similar services to cover the entire population of the city., (© 2019 The Authors Early Intervention in Psychiatry Published by John Wiley & Sons Australia, Ltd.)

Aim: This study describes how mental health services for youth are being transformed within the context of a semi-urban and rural region of Canada (Chatham-Kent, Ontario), based on the framework of ACCESS Open Minds (ACCESS OM), a pan-Canadian youth mental health research and evaluation network., Methods: Transformation has focused on the five key objectives of ACCESS OM, namely early identification, rapid access, appropriate care, continuity of care, and youth and family engagement. A community mapping process was conducted at the beginning of the transformation to help develop a comprehensive inventory of services, identify challenges and optimize partnerships to address the five key objectives., Results: The following strategies represent key elements in the transformation: coordination and partnerships between hospital, community and voluntary organizations, as well as different sectors of the community (e.g., Child and Youth Services, Education, Community Safety and Correctional Services, CSCS); working with local champions (e.g., Youth Diversion Officer and the Mental Health and Addictions Nurse in the school sectors); establishing a youth-friendly space in a central part of the community, where services are co-located and operate within an open-concept design; training of ACCESS Clinicians to conduct an initial assessment; engaging youth and family in service-level recruitment, planning, daily operations, and evaluation, including hiring of youth and family peer navigators; and, engaging the community through awareness and educational events., Conclusions: The success of this transformation needs to be measured on various outcome parameters, but it is notable that neighbouring communities are already beginning to implement a similar model., (© 2019 The Authors Early Intervention in Psychiatry Published by John Wiley & Sons Australia, Ltd.)

In this article we have provided a perspective on the importance and value of youth mental health services for society and argued that advancing youth mental health services should be the number one priority of health services in Canada. Using the age period of 12-25 years for defining youth, we have provided justification for our position based on scientific evidence derived from clinical, epidemiological and neurodevelopmental studies. We have highlighted the early onset of most mental disorders and substance abuse as well as their persistence into later adulthood, the long delays experienced by most help seekers and the consequence of such delays for young people and for society in general. We have also provided a brief review of the current gross inadequacies in access and quality of care available in Canada. We have argued for the need for a different conceptual framework of youth mental disorders as well as for a transformation of the way services are provided in order not only to reduce the unmet needs but also to allow a more meaningful exploration of the nature of such problems presenting in youth and the best way to treat them. We have offered some ideas based on previous work completed in this field as well as current initiatives in Canada and elsewhere. Any transformation of youth mental health services in Canada must take into consideration the significant geographic, cultural and political diversity across the provinces, territories and indigenous peoples across this country.

Aim: Based on prior research, we hypothesized that personal or family familiarity with psychosis would have a different effect on pathways to care as compared to personal or family familiarity with mental disorders., Methods: Caregivers of 32 patients receiving treatment for a first episode of psychosis at a specialized early intervention centre provided information regarding their familiarity with psychosis and mental disorders. Information on the duration of untreated psychosis (DUP) and on the duration of untreated illness (DUI) was collected from patients and their caregivers., Results: Although we found a trend in the direction of lowered DUP and longer DUI for those with personal or family familiarity with psychosis, these effects were not statistically significant. A trend was found for a higher DUI for those with personal or family familiarity with mental disorders in general, but this effect was not significant., Conclusion: We did not find that differential familiarity with mental disorders and by extension, personal or family familiarity, affected measures of delay in treatment of a first episode of psychosis. Trends in our findings in the hypothesized directions suggest that a larger sample size may reveal significant differential effects of previous experience with mental disorders in general and psychosis in particular on delay in help seeking during different phases of the illness., (© 2014 Wiley Publishing Asia Pty Ltd.)

Despite its initial promise, there has been both progress and some set backs in genetic studies of the major psychiatric disorders of childhood and adulthood. Finding true susceptibility genes may be delayed because the most genetically informative phenotypes are not being used on a regular basis in linkage analysis and association studies. It is highly likely that using alternative phenotypes instead of DSM diagnostic categories will lead more rapid success in the search for these susceptibility genes. The objective of this paper is to describe the different types of informative phenotypes that can be employed in psychiatric genetic studies, to clarify their uses, to identify several methodologic issues the design and conduct of linkage and association studies that use alternative phenotypes and finally to suggest possible solutions to those difficulties. This is a conceptual review with a focus on methodological issues that may arise in psychiatric genetics and examples are taken from the literature on autism, schizophrenia, bipolar disorder, and alcoholism.

Genetics has captured the imagination of the public, the interest of the media and a large place in the sciences. Since the discovery of the structure of DNA by Watson and Crick, the double helix has epitomized the main dogma of genetics: everything from the tiniest details of the human body to the most complex of behaviours is encoded in the genes. This belief has been strengthened by the tremendous success that has been achieved in cloning more than 1000 genes that cause simple Mendelian disorders. However, for complex disorders, particularly psychiatric conditions, the search for genes has been frustrating and has not yielded definitive results, although claims of gene discoveries are made regularly. In this article, we discuss the possible causes for these difficulties, along with some directions that may help in reducing these problems. We also consider the implications of psychiatric genetic research for individual and public health.