Early Intervention in Youth Mental Health PDF

Early Intervention in Youth Mental Health Dr Becky Appleton Notes: The Need for Early Intervention 1. Increased risk of developing mental health problems 2. Leading cause of disability in young people worldwide 3. 25%...

Early Intervention in Youth Mental Health Dr Becky Appleton Notes: The Need for Early Intervention 1. Increased risk of developing mental health problems 2. Leading cause of disability in young people worldwide 3. 25% of 17-25 year olds have a mental health need 4. Young adults least likely to access mental health services Risk Factors for Poor Mental Health During Youth Being Female: Females aged between 16-24 are 3x more likely to experience mental illness than males (Mental Health Foundation, 2016) Poverty: Growing up in a poor household results in a three-fold increase in the risk of developing a mental illness (Green et al, 2005) Trauma: Adverse childhood experiences increase risk of experiencing mental illness in later life (Hughes et al, 2017) The Need for Early Intervention There is evidence to suggest that the impacts of having poor mental health during youth can be severe and long lasting, and these negative impacts have worsened over time. Having a diagnosed mental illness during youth led to an increased risk of substance use, poor educational achievements, violence, abuse and poor sexual health (Patel et al., 2007) Untitled 1  Young people with mental illness are more likely to not be in employment, education or training (NEET) and be receiving state benefits (Knapp et al., 2016) Those unable to access mental health care have reported dropping out of education/work (Appleton et al., 2020) NEET young adults are at risk of being socially excluded and being economically disadvantaged in the long-term (McDaid et al., 2022) Also have poorer psychological treatment outcomes than other young adults (Buckman et al., 2022)) Productivity Perspective Care Costs Other Costs Costs Reduced Suffering, learning Treatment Individual with capacity Treatment and Service fees side-effects, mental health (Future) work and payments Suicide, disorders/problems disability Stigma, Social (Future) lost exclusion earnings Time off work, Psychological Family and friends Informal care-giving Reduced hardship/carer productivity burden Reduced Society Loss of Lives Productivity Provision of mental health Health System care and general care (taxation and insurance) Local authority care and Social Services accommodation, social work Educational psychologists, special education costs, education welfare officers, Education Services indirect costs incurred from worse educational attainment Untitled 2  Productivity Perspective Care Costs Other Costs Costs Youth Justice Youth offending team, youth System custody There are additional costs of poor mental health in this demographic group, outside of the costs to the individual. Not only do costs fall to the health service, but also wider society, incl. the education and criminal justice system. CAMHS receive less than 1% of the total NHS budget, and only 8% of the total mental health budget is spent on CAMHS (Young Minds, 2018) Barriers A lack of available services Differs across the country As well as rural vs. city CAMHS/AMHS transition boundary Waiting lists → impacts most other barriers in this list Low levels of engagement → YP feel their needs aren’t met Stigma Reported from peers Reported from families and communities of young people from ethnic minorities Noted that ‘family stigma’ is often associated with mistrust of the healthcare system due to experiences racism in this setting Young people for minoritised groups can also experience barriers to accessing community-based mental health services. Young people can feel as though the public lacked awareness of less ‘severe’ mental health problems. Transition Untitled 3  The transfer of care to a new service which occurs as part of the therapeutic process Should be a planned process involving the YP and their care team Usually occurs at 16-18 years Often poorly managed Young people can fall through the cracks between services Continued care at CAMHS is less common in the UK due to lack of funding → when a YP turns 18, they may stop receiving funding for this individual May also be discharged back to GP for continued care Sometimes then referred to other services such as talking therapies As well as monitored for medication etc. Quality of Transition Previous research has found only 4% of young people experience optimum transition (Singh et al., 2010) Young people are more likely to transition if they have a more severe mental illness 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 Untitled 4  The MILESTONE Project Aimed 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 Trialled intervention of ‘managed transition’ Interrupted Care: YP at the point of leaving CAMHS didn’t want another service Or they were unwell but there was no service for them to transition to End up coming back, most likely in crisis Who Transitions? Untitled 5  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 Levels of Engagement Young adults are the age group least likely to start care at IAPT once they have been referred to treatment (Pettit et al., 2017) Around 1/3rd referred to the service, complete a course of therapy Inflexibility can be a barrier to engagement Usually remotely - e.g. a video call May not be in an environment at home where they can access a phone call for therapy Some young people may be put off accessing care in other services due to a poor experience in CAMHS (Appleton et al., 2020) May deter them from future engagement Untitled 6  May also have formed a good therapeutic relationship with someone in CAMHS and don’t want to start again with a new clinician when transitioning to adult services Services are often not ‘youth friendly’ and do not have the resources to support young people who do not engage Stigma Stigma can be reported from multiple sources e.g. family, friends and general public e.g. Kourgiantakis et al., 2023 Young people have particularly reported feeling more stigma for more severe mental illness Public information campaigns have been used to try to reduce stigma associated with poor mental health e.g. Time to Change Reported from families and communities of young people from ethnic minorities Noted that ‘family stigma’ is often associated with mistrust of the healthcare system due to experiences racism in this setting Young people for minoritised groups can also experience barriers to accessing community-based mental health services. Young people can feel as though the public lacked awareness of less ‘severe’ mental health problems. Early Support Hubs Mental health and wellbeing centres that provide open access, flexible, early support for young people Community-based, offering a ‘drop in’ service as well as other interventions and support Untitled 7  Can walk in without a referral - improving access to support Youth information, Access and Counselling Services (YIACS) model Generally offer care for young people aged 11-25 (although varies by service) International Evidence Headspace (Australia): the majority of young people access the service for support with symptoms of anxiety and depression around a third show significant improvements in psychological distress and psychosocial functioning just over two-thirds of service users show significant improvements in either psychological distress, psychosocial functioning or self-reported quality of life Headspace services in Australia are a model of integrated youth mental health service (Rickwood et al., 2019) which have received the most research interest to date. Headspace services provide holistic support for young people aged between 12-25 years, encompassing mental, physical, and sexual health. They also provide support on drugs and alcohol and for issues relating to employment and education. Relatively small scale evidence There is potential evidence for its benefits but need more robust evidence Jigsaw (Ireland): Most young people show severe levels of distress on presenting to the service Untitled 8  Majority report significant reductions in distress and improvements in wellbeing14 Jigsaw, a service delivery program that aimed to establish youth-friendly, community-based mental health support structures for young people across Ireland. Uniquely in the Irish system, Jigsaw provides a consultation service (which accounts for just under 30% of engagements) advising parents, teachers and other concerned adults about how to support youth mental health and/or how to navigate the complexities of the mental health system. To ensure rapid, easy and affordable access, services are provided at no cost at the point of delivery in youth-friendly service settings, and no professional referral is required. Limited evidence for this model The Policy Context Charities such as Youth Access have been campaigning for the widespread role out of 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 additional services at 24 existing hubs Spread across the country with a focus to be outside of London (as most focus is in London and the surrounding area) The hubs started their new service offering in April 2024, with funding for 12 months in the first instance Funding stipulates engagement with an evaluation into effectiveness (led by the MHPRU in the Division of Psychiatry, UCL). Proposed Work Plan Evidence Synthesis Qualitative Studies Quantitative Evaluation Systematic review Service managers Consultation of innovations in Clinicians Untitled 9  early intervention Parents for young people Young people Qualitative meta- who have used synthesis of young the services people’s experiences Umbrella review of early intervention approaches Systematic Review Primary Research Questions: What services or approaches to delivering early intervention mental health care are effective in: Improving access to, and reducing waiting times for mental health support Improving mental health symptoms Improving social outcomes or functioning, wellbeing, or quality of life for young people with anxiety, depressive and other common mental health difficulties? Secondary Research Questions: Cost effectiveness Methods used Acceptability Stage 1: Qualitative Data Limitations around capacity, not having private rooms, not knowing who’s coming and when. Though overwhelmingly positive → though could be sampling bias (staff provided service users for data collection) Untitled 10  Interviews: CYP: n=20 Staff: n=24 Managers: n=18 Quantitative: Consultation on Outcomes Young Person Webinar Stakeholder Webinar 26 young people 11 stakeholders Aim: to find out what outcomes Service are important to them managers/clinicians/academics Demographic data Aim: to operationalise findings from YP webinar Practicalities of data collection Explore possibilities of comparison with other datasets/data linkage Young people asked to rank what is most important and what they’d want to get out of the mental health service: 1. Well-being including personal wellbeing, getting along with others, and wellbeing and work/uni/school 2. Ability to do things at work/uni/school, at home or take part in hobbies 3. Progress towards goals that are set at the start of an intervention 4. Mental health difficulties/symptoms 5. Quality of your relationship with others Mural board exercise: Untitled 11  Evaluation Outcomes Hubs asked to ask young people to complete the following: Wellbeing Measure (SWEMWBS) PHQ & GAD-7 (or RCADS) → for over 18s, not as a diagnostic measure Functioning (WSAS) → 6 questions and also a youth version available 1-item loneliness question Objective social outcomes → for young people who attend drop ins only Some Challenges How to take consent and data security → collected as routine data and in anonymised format How to collect the data in hubs (e.g. what platforms do they use?) → created a format template for data collection for standardised data How to merge these datasets from different hubs? Untitled 12  Data linkage (needing identifiable data) Essential Reading: Read: “I’m just a long history of people rejecting referrals” experiences of young people who fell through the gap between child and adolescent mental health services Authors: Rebecca Appleton, Farah Elahi, Helena Tuomainen, Alastair Canaway, Swaran P. Singh Abstract: This study explores the experiences of young people who fall through the gap between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). It identifies systemic barriers and quality of care issues that contribute to this gap and examines the effects on young people and their families. Key Findings: 1. Systemic Barriers to Continuity of Care: Not being 'ill enough' for AMHS: Many young people were deemed not severely ill enough to qualify for AMHS, despite having ongoing clinical needs. Inadequate Service Provision: Some young people were offered lower-intensity support, which they found unsuitable, or no support at all. Lack of Joined-Up Care: Poor coordination between CAMHS and AMHS led to multiple transitions and delays in accessing care. 2. Problems with Quality of Care: Inappropriate Care at CAMHS: Some young people felt CAMHS did not adequately address their needs, leading to ongoing issues. Unprepared for Transition: Many young people were not adequately prepared for the end of CAMHS care, leading to difficulties in managing their mental health independently. Untitled 13  Reluctance to Access Further Care: Negative experiences and the need for self-referral deterred some young people from seeking further help. 3. Effects on Young People: Feeling Abandoned: Many young people felt abandoned by the system, leading to feelings of worthlessness and increased anxiety. Struggling to Manage: Without continued care, some young people struggled significantly, impacting their education, work, and social life. Medication Issues: Problems with accessing, changing, or stopping medication were common, leading to further health complications. 4. Effects on Parents: Emotional Impact: Parents experienced significant anxiety and frustration due to the lack of support for their children. Active Role in Care: In the absence of professional support, parents often took on significant caregiving responsibilities, including managing medication and seeking alternative care options. Methodology: Participants: 15 young people and 15 parents, representing 19 unique transition stories. Data Collection: Narrative interviews conducted by a trained researcher. Analysis: Thematic analysis to identify key themes and sub-themes. Conclusion: The study highlights significant gaps in the transition from CAMHS to AMHS, leading to negative outcomes for young people and their families. It calls for improved service provision and better coordination between child and adult mental health services to ensure continuity of care. Untitled 14  Recommendations: Develop new models of care to fill the gap between CAMHS and AMHS. Improve training for GPs in managing young people's mental health. Ensure appropriate crisis care is available for young people in need. Strengths and Limitations: Strengths: Rich data from long-term reflections, diverse participant experiences. Limitations: Potential response bias, high proportion of university students, and reliance on self-reported diagnoses. Ethical Compliance: Ethical approval obtained, informed consent from participants, and open access under Creative Commons Attribution 4.0 International License. Keywords: Transition, CAMHS, AMHS, Narrative research, Qualitative research Read: From early intervention in psychosis to youth mental health reform: a review of the evolution and transformation of mental health services for young people Abstract In this invited review, we explore the recent advancements in youth mental health services, focusing on the evolution and reform triggered by early intervention in psychosis (EIP) and the growing recognition of mental health challenges faced by young people. The review synthesizes developments across four countries—Australia, Ireland, the UK, and Canada—highlighting innovative service models, challenges, and the ongoing efforts to enhance youth mental health outcomes. By examining the current state of knowledge and practice, we aim to identify emerging issues and propose strategies for improving mental health services tailored to the unique needs of young individuals. Introduction Untitled 15  The landscape of youth mental health services has undergone significant transformation in recent years, fueled by the increasing awareness of mental health issues among young people and the critical need for reform. Mental disorders often manifest during adolescence and early adulthood, with studies indicating that approximately 75% of mental health conditions emerge by the age of 24. The urgency of addressing these challenges has prompted a shift towards early intervention strategies aimed at improving access to care and reducing the long-term impact of untreated mental health issues. Methodology This review draws upon existing literature and data from various jurisdictions, specifically Australia, Ireland, the UK, and Canada. We synthesized findings from recent studies, policy documents, and service evaluations to identify key trends, challenges, and innovations in youth mental health service delivery. Findings Australia Australia has pioneered a model of integrated youth mental health services through the establishment of headspace, the National Youth Mental Health Foundation. Launched in 2006, headspace provides accessible, youth- friendly centers offering a range of services, including mental health care, substance use support, and vocational assistance. The model encourages early intervention by using brief psychosocial therapies and a stepped- care approach tailored to the severity of the condition. Despite the successes of headspace, challenges remain, particularly in extending services to remote areas and addressing the needs of young individuals with complex mental health issues. Ireland In Ireland, the youth mental health movement gained momentum due to rising concerns about youth suicide rates and mental distress. The establishment of Headstrong and the Jigsaw program has been instrumental in creating community-based mental health support structures. Jigsaw centers provide primary mental health care and support Untitled 16  for individuals aged 12 to 25, reflecting a commitment to making services more accessible and youth-friendly. Although progress has been made, systemic challenges and funding constraints hinder the comprehensive implementation of youth mental health services in Ireland. United Kingdom The UK has recognized the need for improved transition between child and adult mental health services, as evidenced by various policy initiatives, including the Children’s and Young People’s Mental Health and Well-being Taskforce. These initiatives aim to create a more cohesive and responsive mental health care system. Promising local projects, such as the Birmingham youth mental health service, demonstrate significant improvements in engagement and service delivery. However, the transition from child-focused to adult-oriented services remains a critical area needing further development and research. Canada Canada’s approach to youth mental health reform is characterized by the establishment of the ACCESS network, a multi-site research initiative aimed at transforming youth mental health services. Funded by the Canadian Institutes of Health Research and philanthropic organizations, the ACCESS network seeks to address key service gaps, including early detection, timely access to care, and continuity of services across the age spectrum. The initiative emphasizes community engagement and culturally appropriate practices, particularly for Indigenous populations, to create a more inclusive and effective mental health care system. Discussion The review highlights several overarching themes and challenges faced by youth mental health services across the examined countries. Key issues include: 1. Service Penetration and Access: Despite advancements, many young individuals experiencing mental health issues remain untreated due to systemic barriers, stigma, and lack of awareness. Strategies to enhance mental health literacy within communities are essential to encourage help-seeking behaviors. Untitled 17  2. Transition Between Services: The transition from child and adolescent mental health services to adult services is often fraught with challenges, leading to disruptions in care. A more integrated approach, focusing on soft transitions, is necessary to ensure continuity and support for young individuals as they age. 3. Cultural Competence and Accessibility: Addressing the unique needs of diverse populations, including Indigenous youth and those from disadvantaged backgrounds, requires culturally competent service delivery models. Tailoring interventions to meet the specific context and needs of various communities is crucial for effective care. 4. Research and Evaluation: Ongoing research is vital to assess the effectiveness of new service models and inform policy decisions. Collaborative efforts between researchers, practitioners, and policymakers can facilitate knowledge translation and ensure that evidence-based practices are implemented. Conclusions The evolution of youth mental health services is a dynamic process shaped by innovative practices, advocacy, and a growing recognition of the unique challenges faced by young individuals. Countries like Australia, Ireland, the UK, and Canada are making strides toward reform, yet persistent gaps and challenges remain. To achieve meaningful improvements in youth mental health outcomes, a coordinated and comprehensive approach that integrates services, emphasizes early intervention, and addresses the diverse needs of young people is essential. The lessons learned from early intervention in psychosis can serve as a valuable foundation for ongoing efforts to transform youth mental health services globally. Keywords: Youth mental health, service delivery, early intervention, reform, Australia, Ireland, UK, Canada. Untitled 18