Background

Youth with mental health difficulties (MHD) experience a stark disparity in health outcomes compared to the general population. This mortality gap – ranging from 10 to 20 years for those with severe MHD – largely stems from preventable physical illnesses and provides an argument for focusing on physical health among individuals with MHD (Luciano et al. Reference Luciano, Pompili, Sartorius and Fiorillo2022). Given the link between earlier onset of MHD and greater physical health comorbidities throughout the life course, targeting the physical health of youth with MHD may help minimise the risk of disease burden through primary prevention efforts (Kirkbride et al. Reference Kirkbride, Anglin, Colman, Dykxhoorn, Jones, Patalay, Pitman, Soneson, Steare, Wright and Griffiths2024).

Sexual health is also an under-recognised but important component of overall health. As MHD often onset during the formative years of adolescence, this can affect youth’s confidence and skills to form healthy relationships (Thorsen and Pearce-Morris, Reference Thorsen and Pearce-Morris2016). Furthermore, youth with MHD may lack the knowledge to ensure safe sexual practices and can be more vulnerable to high-risk sexual behaviours and exploitation compared to their peers (Adan Sanchez et al. Reference Adan Sanchez, McMillan, Bhaduri, Pehlivan, Monson, Badcock, Thompson, Killackey, Chanen and O’Donoghue2019; Dworkin, Reference Dworkin2020; Nolan et al. Reference Nolan, O’Donoghue, Simmons, Zbukvic, Ratcliff, Milton, Hughes, Thompson and Brown2024).

The physical and sexual health services offered to youth with MHD, both in Ireland and internationally, needs reform to align with the growing evidence for holistic approaches to care (Ireland’s Department of Health, 2021; WHO, 2001). There is a critical need for these concerns to be addressed with young service users and relevant stakeholders to drive reform.

Physical health in mental health

The cause of the mortality gap is complex, possibly driven both by the MHD itself (Hermanns et al. Reference Hermanns, Ehrmann, Shapira, Kulzer, Schmitt and Laffel2022; Correll et al. Reference Correll, Robinson, Schooler, Brunette, Mueser, Rosenheck, Marcy, Addington, Estroff, Robinson, Penn, Azrin, Goldstein, Severe, Heinssen and Kane2014), and treatments, such as medication-induced metabolic syndrome (Vancampfort et al. Reference Vancampfort, Stubbs, Mitchell, De Hert, Wampers, Ward, Rosenbaum and Correll2015). Physical health concerns are influenced by health behaviours (e.g. diet quality, sedentary behaviours; Johnstad, Reference Johnstad2023; Solomou et al. Reference Solomou, Logue, Reilly and Perez-Algorta2022; Teasdale et al. Reference Teasdale, Ward, Samaras, Firth, Stubbs, Tripodi and Burrows2019); and social and structural factors (e.g. care accessibility; Green et al. Reference Green, Elwyn, Hill, Johnston-Ataata, Kokanović, Maylea, McLoughlan, Roberts and Thomas2023). Those with severe MHD also have a higher prevalence of chronic health conditions such as obesity, diabetes and hypertension (Public Health England, 2018), which are in turn driven by lifestyle and medication factors (Daré et al. Reference Daré, Bruand, Gérard, Marin, Lameyre, Boumédiène and Preux2019; Hert et al. Reference Hert, Correll, C., Bobes, Cetkovich-Bakmas, Cohen, Asai, Detraux, Gautam, Möller, Ndetei, Newcomer, Uwakwe and Leucht2011). These complex interactions make regular monitoring of physical health essential; however, monitoring of medication- and its side effects in Ireland remains inconsistent (Health Service Executive, 2012). This may be due to uncertainty about responsibility or communication challenges between primary and secondary care providers. Psychiatrists and psychiatric nurses may feel that chronic disease management is too specialised for them and need increased training to effectively manage chronic health conditions (Butler et al. Reference Butler, de Cassan, Turner, Lennox, Hayward and Glogowska2020). Conversely, primary care clinicians might find the complexity of comorbid physical and sexual health issues in MHD a challenge. Nonetheless, it is likely that General Practitioners (GPs) and GP nurses would remain more skilled than specialist mental health teams to deliver comprehensive physical health care, even after additional training for mental health teams.

Efforts have been made to address MHD and physical health issues, including the ‘Don’t Just Screen, Intervene’ and ‘Making Every Contact Count’ initiatives (Rodrigues et al. Reference Rodrigues, Nichol, Wilson, Charlton, Gibson, Finch, Haighton, Maniatopoulos, Giles, Harrison, Orange, Robson and Harland2024; Shiers and Taylor, Reference Shiers and Taylor2017). These approaches provide comprehensive cardiometabolic healthcare; however, implementation of similar initiatives will remain challenging without concerted efforts to collaborate between primary and secondary care. There has been a consistent call to action to support a shared model of care (SMC) for mental and physical health in Ireland. A recommendation from Sharing the Vision, Ireland’s latest national mental health policy, states “the physical health needs of all users of specialist mental health services should be given particular attention by their GP. A shared care approach is essential to achieve the best outcomes.” (Ireland’s Department of Health, 2021). Implementing a SMC between primary and secondary care to support collaborative patient care, from referrals to monitoring, offers a bridge to addressing both individual and system-level barriers and support comprehensive patient care.

Sexual health in mental health

Sexual health is an important aspect of overall health yet is often under-resourced within the healthcare system. Impacts of MHD on sexual health can include: MHD medication side effects on sexual functioning; impulsivity and higher rates of STIs; higher rates of unplanned pregnancies (Marcell et al. Reference Marcell, Burstein, Braverman, Adelman, Alderman, Breuner, Hornberger and Levine2017); and challenges with healthy romantic relationships (Thorsen and Pearce-Morris, Reference Thorsen and Pearce-Morris2016). For example, Liang et al. (Reference Liang, Bai, Hsu, Huang, Ko, Chu, Yeh, Tsai, Chen and Chen2020) found young people with MHD were 2.28 times more likely to contract STIs compared to controls (95%CI: 2.02 – 2.57; p < 0.05) while a meta-analysis identified females with MHD were 1.34 more likely to experience an unplanned pregnancy compared to those without MHD (95%CI: 1.08 – 1.67; Schonewille et al. Reference Schonewille, Rijkers, Berenschot, Lijmer, van den Heuvel and Broekman2022). Given these co-occurring concerns, it is important that care for youth with MHD includes their sexual health needs.

Barriers to addressing sexual health among youth with MHD include: fear of discrimination; desire for discretion when accessing sexual health services (Green et al. Reference Green, Elwyn, Hill, Johnston-Ataata, Kokanović, Maylea, McLoughlan, Roberts and Thomas2023; Henderson et al. Reference Henderson, Noblett, Parke, Clement, Caffrey, Gale-Grant, Schulze, Druss and Thornicroft2014); limited clinician training; cultural taboos; limited LGBT-focused education and services; and navigating youth consent to treatment (Gascoyne et al. Reference Gascoyne, Hughes, McCann and Quinn2016; Hendry et al. Reference Hendry, Snowden and Brown2018; Nolan et al. Reference Nolan, O’Donoghue, Simmons, Zbukvic, Ratcliff, Milton, Hughes, Thompson and Brown2024). An Australian service which has embedded sexual health education session within mental health services to promote holistic wellbeing shows promise in addressing these many of barriers (Nolan et al. Reference Nolan, O’Donoghue, Simmons, Zbukvic, Ratcliff, Milton, Hughes, Thompson and Brown2024). While this intervention could be replicated in other jurisdictions, there remains a lack of clarity regarding the clinical responsibility for sexual health within mental healthcare. It is important that youth feel able to access a sexual health clinic without stigma. The location of sexual health clinics also needs consideration, whether it is embedded within a mental health service or services facilitating access to sexual health screening and referrals to sexual health clinics (Rickwood et al. Reference Rickwood, Telford, Mazzer, Parker, Tanti and McGorry2015). Ireland’s National Sexual Health Strategy 2025 – 2035 has prioritised developing a sexual health services model (Department of Health, 2021). Co-producing models with youth and ongoing monitoring and evaluation will be essential to effective sexual health care models, particularly for those with MHD.

What’s next for implementing physical and sexual health care in mental health services?

There is a now critical need for a SMC in Ireland to improve both the physical and sexual health of youth with MHD. An Irish study from 2012 with collaboration between Irish GPs (n = 78) and mental health providers (n = 74) found only 25% of GP teams had a formalised link with mental health services and 30% reported an informal link (Health Service Executive, 2012); there is little evidence suggesting these collaborations have improved since. As the Health Service Executive delivers SMC for chronic conditions, it may be possible to replicate some components in a mental health model. The Chronic Disease Management programme, which currently has no mental health aspect, is well developed in primary care and offers annual blood monitoring and physical health screening for those with chronic physical diseases. This service highlights integration is possible when resources are prioritised. We argue a SMC for managing psychosocial factors and physical and sexual health for youth with MHD is possible and should be prioritised by Irish policymakers. This aligns with country’s health reform programme Sláintecare, which aims to deliver universal access to integrated care (Government of Ireland, 2025).

Implementation of an integrated physical, sexual and mental health SMC have been affected by system-level barriers, including siloed communication between providers, limited resources (e.g. funding, staffing, investment in information technology and integration infrastructure) and lack of national electronic patient medical records (Bowers, Reference Bowers2025; Darker, Reference Darker2013; Green et al. Reference Green, Elwyn, Hill, Johnston-Ataata, Kokanović, Maylea, McLoughlan, Roberts and Thomas2023).These barriers hamper the ability of clinical teams to access records across services (Darker, Reference Darker2013). These issues create further challenges to providing effective mental health care for individuals with dual diagnoses (e.g. addictions, neurodevelopmental disorders). Additionally, sexual health may require a distinct approach given the unique implementation barriers identified. There is a need to tease out whether physical and sexual health should be integrated into a single SMC, or have separate approaches, while being cognisant that both issues should be considered a priority.

A recent Irish Health Research Board grant “VISTA: VISion To Action for promoting mental health and recovery” aims to address many of the complex issues highlighted in this editorial by embedding public and patient involvement and implementation science to operationalise a range of recommendations from Sharing the Vision (Ireland’s Department of Health, 2021). Within VISTA we seek to accomplish this through development of an integrated care pathway to deliver a SMC to address the physical and sexual health of youth with MHD across primary and secondary care; embed service users, providers and managers in the co-design of SMC to ensure relevance and acceptability; and address gaps in physical and sexual health research with the aim of delivering tailored care pathways (https://vista-apro.eu).