Youth Mental Health: Early Intervention

The Need for Early Intervention

• Early intervention is important due to an increased risk of developing mental health problems
• Mental health problems are a leading cause of disability in young people worldwide
• Around 25% of 17-25 year olds have a mental health need
• Young adults are the least likely to access mental health services
• Impacts of poor mental health during youth can be severe, long-lasting, and worsen over time

Risk Factors for Poor Mental Health During Youth

• Being female is a risk factor
• Females aged 16-24 are 3 times more likely to experience mental illness than males
• Poverty is a risk factor and growing up in a poor household results in a three-fold increase in the risk of developing a mental illness
• Adverse childhood experiences increase the risk of experiencing mental illness later in life
• Trauma is also a risk factor

Impact of Poor Mental Health During Youth

• Poor mental health during youth can have severe and long-lasting negative impacts
• Undiagnosed mental illness during youth lead to increased risk of substance use, poor educational achievements, violence, abuse and poor sexual health
• Young people with mental illness are more likely to be not in employment, education or training (NEET) and receiving state benefits
• Those unable to access mental health care have reported dropping out of education/work
• NEET young adults are at risk of being socially excluded and being economically disadvantaged in the long-term
• They also have poorer psychological treatment outcomes than other young adults

Costs of Mental Health Problems

• The costs of mental health issues affects various areas
• Individuals face treatment fees, service payments, reduced learning capacity, potential work disability, lost earnings, suffering, treatment side-effects, risk of suicide plus stigma and social exclusion
• Families face costs with informal care-giving
• There's time off work plus reduced productivity and psychological distress
• Society's costs include reduced productivity and loss of lives
• Health system costs involve the provision of mental health and general care through taxation and insurance
• Costs to social services include local authority care, accommodation and social work
• Education services face costs for educational psychologists, special education, welfare officers, and the indirect costs with worse educational attainment
• Costs to the youth justice system include youth offending teams and youth custody
• There are additional costs outside of the individual that affect health services and wider society (education, criminal justice)
• CAMHS receive less than 1% of the total NHS budget, and only 8% of the total mental health budget is spent on CAMHS

Barriers to Accessing Mental Health Services

• A lack of available services is a barrier
• Service availability differs across the country, between rural vs. city
• CAMHS/AMHS transition boundary
• Long waiting lists impact most other barriers
• There are low levels of engagement with services, and young people feel their needs aren't met
• Stigma reported from peers, families, and communities of young people from ethnic minorities
• "family stigma" is associated with mistrust of the healthcare system due to experiences racism
• People in minoritized groups face barriers to accessing community-based mental health services
• Young people feel the public lacks awareness of less 'severe' mental health problems

Transition of Care

• Transition of care to a new service that occurs as part of the therapeutic process should be planned, involving the young person and their care team
• Transitions usually occurs at 16-18 years and are often poorly managed
• Young people can fall through the cracks between services
• Continued care at CAMHS (Child and Adolescent Mental Health Services) is less common in the UK due to lack of funding
• When a young person turns 18, they may stop receiving funding
• Patients may get discharged back to a GP for continued care, referred to talking therapies, or monitored for medication
• Only 4% of young people experience optimum transition

Factors Affecting Transition

• Young people with more severe mental illness are more likely to transition
• Adult services can have waiting lists of up to 6 months
• An estimated 2/3rds of young people are not referred to adult services despite still being unwell

The MILESTONE Project

• Project aims to understand and improve care for young people crossing the transition boundary between child and adult mental health services
• Over 1000 young people were followed up for 24 months, trialling intervention of ‘managed transition'
• Interrupted care results when young people leaving CAMHS don't want another service, or they are unwell but there is no service for them to transition to
• Ending up coming back, most likely in crisis in another service

Likelihood of Transition to AMHS

• Young people were more likely to transition to AMHS if they:
  • Were rated by their CAMHS clinician as being 'severely ill'
  • Had previously attempted suicide
  • Had higher scores on a measure of overall health and functioning
  • Had higher scores on a measure of independent behaviours
• The costs associated with poor transition are complex and hard to measure

Low Engagement Levels

• Young adults are the age group least likely to start care at IAPT once referred to treatment
• Only around 1/3rd referred to the service, complete a treatment course
• Inflexibility, often when it's remote, can make it hard to engagement
• Can't always be remotely with a video call
• May not be in an environment at home where they can access a phone call for therapy
• A poor experience in CAMHS can put people off accessing care
• These factors may deter them from future engagement with services
• Developing a good therapeutic relationship with someone in CAMHS and avoid starting again with a new clinician when transitioning to adult services is critical
• Services are often not ‘youth friendly' and do not have the resources to support those who do not engage

Stigma

• Stigma is reported from multiple sources like family, friends and general public
• Young people have reported feeling severe stigma for mental illness
• Public information campaigns have been used to try and reduce stigma associated with poor mental health e.g. Time to Change campaign
• Stigma is reported from families and communities of young people from ethnic minorities
• 'family stigma' is associated with mistrust of the healthcare system
• Young people in minoritised groups can experience barriers to accessing community-based mental health services
• The public lacks awareness of less 'severe' mental health problems

Early Support Hubs

• They are mental health and wellbeing centres that provide open access and flexible, early support for young people Offers community-based 'drop in' services as well as other interventions and support
• They feature a YIACS (Youth Information, Access and Counselling Services) model
  • Access includes self-referral, drop-in, outreach, and online/phone
  • Timely, local, and age-appropriate assessment
  • A diverse range of support under one roof, information, therapy, referrals, and youth work
  • Positive outcomes and experiences
  • Youth-friendly, stigma-free focus and tailored support including feedback opportunities

Positive Aspects of Early Support Hubs

• Individuals can walk in without a referral, improving access to support
• They offer care for young people aged 11-25 (though varies by service)

International Evidence on Support Hubs

Headspace (Australia)

• Most young people access services for anxiety and depression symptoms
• Around a third show significant improvements in psychological distress and psychosocial functioning
• Just over two-thirds of services users show significant improvements in either psychological distress, psychosocial functioning or self-reported quality of life
• Australia provides holistic support for young people aged between 12-25 years
• This includes mental, physical, and sexual health, as well as support on drugs, alcohol, employment and education
• Despite its success, the evidence is relatively small scale and needs more robust evidence to show any real benefits

Jigsaw (Ireland)

• The majority of young people show high level of distress when presenting to the service
• Majority report significant reductions in distress and improvements in wellbeing
• Jigsaw offers consultation services for parents, teachers and concerned adults.
• It advises on youth mental health and how to deal with complex systems
• Services made available are low cost and do not need professional referral.
• There is limited evidence for its model

Policy Context

• Charities such as Youth Access campaign for early support hubs, known as the “Fund the Hubs” campaign
• The DHSC (Department of Health and Social Care) has made around £8 million available to fund 24 existing hubs
• Hubs are spread across the country, focusing outside of London Hubs started a new service in April 2024, which will be funded for 12 months
• Funding depends on evaluation into its effectiveness, which will be led by the MHPRU (Division of Psychiatry, UCL).

Proposed Work Plan

• Evidence synthesis, qualitative and quantitative studies will be used to determine effectiveness of youth mental health services
• Evidence will use systematic review of innovations in early intervention for young people, in consultation with parents, young people in services
• Qualitative studies will focus on staff experiences, and service managers
• Data linkage will take place needing identifiable data, in anonymous format.
• Consent and data security practices must be collected as routine data and in anonymised format
• Data collection format templates for standardised data need to be used
• Methods for merging datasets need to be used
• Hubs also ask people to complete the following measures to see its effectiveness
• Well-being Measure (SWEMWBS)
• PHQ & GAD-7 (or RCADS) for over 18s
• Functioning (WSAS) → 6 questions and also a youth version
• 1-item loneliness question
• Objective social outcomes for those who attend drop ins only
• Quantitative data will rely on 26 young people webinars and findings to create data linkages.
• Service managers can make finding actionable.

Focus of Systematic Review

• Focus on what approaches deliver effective early MH, including improved access, reducing waiting times, mental health symptoms, social outcomes, well-being ,quality of life.
• Young people can rank what is most important and what to get out of MH, including mental health difficulties and symptoms for anxiety and depression.
• This includes cost, methods and acceptability.

Essential Reading Key points

• From "I’m just a long history of people rejecting referrals” explores experiences of young people that fell through mental healthcare
• Systemic barriers include not being deemed ‘ill enough’ for AMHS, inadequate service provision. e.g. coordination.
• Problems with quality of care involved inappropriate care at CAMHS, preparedness for the end of care, leading to a difficult transition.
• There is a reluctance to access care due to negative self-referred deterrent for those seeking further help.
• The key effects on young people included feeling abandoned, difficulty managing education, social life, health complications and parents experiences anxiety.

Recommendations from the research Include developments of new models of care, improve training and ensure crisis care is avalible, strengths and limitations.