Adolescents who are frequent attenders to primary care: contribution of psychosocial factors

Profile and healthcare utilisation patterns of adolescent frequent attenders in Singapore primary care: a retrospective study

OBJECTIVES

Frequent attenders (FAs) visit healthcare settings at higher rates compared with the general population and use disproportionate amounts of healthcare resources. Frequent attendance (FA) has also been associated with greater morbidity and adverse socioeconomic circumstances. Our study aimed to describe the sociodemographic profile, clinical presentation, and healthcare utilisation patterns of adolescent FAs at polyclinics in Singapore and to determine the factors associated with adolescent FA.

DESIGN

Retrospective electronic database analysis.

SETTING

A cluster of eight state-subsidised public primary care clinics (polyclinics).

PARTICIPANTS

Multiethnic Asian adolescents aged 10-19 years who attended the eight polyclinics in 2021. FAs were defined as the top 10% of clinic attendees in terms of annual visit frequency.

RESULTS

In 2021, 34 645 adolescents attended the polyclinics for 75 902 visits. Visits were for acute (52.8%), chronic (26.2%) and preventive (27.7%) care. FAs attended ≥4 visits annually, accounting for 14.4% of adolescents and 42.5% of total attendances. Compared with non-FAs, FAs were older (OR 1.16, 95% CI 1.15 to 1.18, p<0.001), more likely to be of non-Chinese ethnicity, and have received financial aid (OR 1.68, 95% CI 1.58 to 1.79, p<0.001). FAs had more underlying psychiatric conditions (p<0.001) but presented less frequently with psychiatric complaints (p<0.001). FAs were more likely to be referred to emergency departments (p<0.001) and psychiatry clinics (p<0.001), to be prescribed potentially addictive medication (p<0.001), and had longer annual medical leave certification (7 days (IQR=4-11) vs 3 days (IQR=1-3, p<0.001)).

CONCLUSION

Adolescent FA was associated with increasing age, non-Chinese ethnicity and lower socioeconomic status. Despite having more underlying psychiatric conditions, adolescent FAs presented more frequently with acute physical complaints instead of psychiatric symptoms. Adolescent FAs had longer annual medical leave certification and greater healthcare utilisation indicated by more clinic visits and referrals to emergency departments and psychiatry clinics.

Pre-adolescents with multiple health complaints redeem more prescriptions: A follow-up study in the Danish National Birth Cohort

Aims: This study aimed to examine the association between multiple health complaints (MHC) in pre-adolescence and prescription redemption in adolescence. Methods: This was a nationwide population-based study based on the Danish National Birth Cohort for an average of 6.9 years (2010-2018). A total of 96,382 children were invited at the age of 11. A modified version of the Health Behaviour in School Children Symptom Checklist was dichotomised into the World Health Organization's definition of MHC (⩾2 complaints, each with a frequency of at least weekly, yes/no). The number of prescriptions was retrieved from Danish registries. Negative binomial regression estimated incidence rate ratios (IRRs) comparing children with MHC to children without. Prescription redemption was further stratified by psychiatric/somatic medication and into subtypes of prescriptions. Results: A total of 47,365 (49.1%) children participated (M_age=11.2 years, 52% girls). MHC were reported by 10.3%. The unadjusted IRR (MHC vs. no MHC) of all types of redemptions was 1.57 (95% confidence interval (CI) 1.49-1.64). Results were robust to adjustment for socio-demographic variables and somatic/psychiatric morbidity at baseline (IRR=1.47; 95% CI 1.40-1.54). Associations were especially strong for psychiatric medication (adjusted IRR=3.88; 95% CI 3.43-4.40) and were modified by neither sex nor maternal education. Conclusions: MHC in pre-adolescents predict prescription redemption. This implies that changes in MHC might be indicative of changes in public health. This requires further study, as the cause of a change in reporting of symptoms might also cause a change in treatment response. The latter determines whether prescriptions are treating ill-being or needlessly medicalising subjective symptoms.

Children as frequent attenders in primary care: a systematic review

Background

Frequent paediatric attendances make up a large proportion of a GP's workload. Currently, there is no systematic review on frequent paediatric attendances in primary care.

Aim

To identify the sociodemographic and clinical characteristics of children who attend primary care frequently.

Design & setting

A systematic review.

Method

The electronic databases MEDLINE, Embase, and PsycINFO were searched up to January 2020, using terms relating to frequent attendance in primary care settings. Studies were eligible if they considered children frequently attending in primary care (aged 0–19 years). Relevant data were extracted and analysed by narrative synthesis.

Results

Six studies, of fair quality overall, were included in the review. Frequent attendance was associated with presence of psychosocial and mental health problems, younger age, school absence, presence of chronic conditions, and high level of anxiety in their parents.

Conclusion

Various sociodemographic and medical characteristics of children were associated with frequent attendance in primary care. Research on interventions needs to account for the social context and community characteristics. Integrating GP services with mental health and social care could potentially provide a response to medical and psychosocial needs of frequently attending children and their families.

GP perceptions of community-based children's mental health services in Pennine Lancashire: a qualitative study

Background

GP satisfaction with specialist Child & Adolescent Mental Health Services (CAMHS) is often reported as low in the UK, and internationally.

Aim

To explore GP perceptions of local children’s mental health services and to understand their experiences of a novel GP-attached Primary Mental Health Worker (PMHW) service.

Design & setting

Qualitative research involving GPs in Pennine Lancashire.

Method

Semi-structured face-to-face interviews of GPs (n = 9) were carried out. Thematic analysis was undertaken.

Results

Themes identified included: 1) The role of the GP: most GPs perceived their role to be signposting and referring patients with mental health issues to specialist services, rather than offering care directly; 2) Clarity on help available: GPs were unclear about specialist CAMHS referral criteria and alternative resources available. GPs experienced communication challenges with specialist CAMHS; 3) Getting advice and support: PMHWs enabled GPs to have informal discussions, and to seek advice about children. Some GPs felt they could recognise problems earlier and were able to access help more quickly; and 4) Development needs: some GPs felt they required increased training in supporting children with mental health problems, and identified a need for further collaboration with schools and specialist CAMHS.

Conclusion

The study identified challenges that GPs face with accessing and utilising specialist CAMHS. GPs who had PMHWs based in their practices expressed increased satisfaction with these services. GP-attached PMHWs can potentially reduce the challenges faced by GPs in primary care by offering timely and accessible advice, and improving access to specialist CAMHS.

Stress, mental and physical health and the costs of health care in German high school students

Stress is a mind-body phenomenon, which affects both mental and physical health and is highly relevant to the health care system. Yet, knowledge on the costs of stress and related health problems in adolescence is missing. The present study addresses this gap by investigating direct health care costs in relation to stress, mental health problems and physical health in high school students. The sample comprised 284 pupils from four schools in Heidelberg (mean age 16.75 ± 0.64 years, 59.64% female). Self-reported health care utilization and medication intake within 1 month were translated into costs. We established correlative associations of the dichotomized overall costs (no vs. any) with stress, mental health problems and physical health within generalized structural equation models. In particular, mental health problems and physical health were examined as mediators of the association between stress and costs. An increase of stress by 1 SD corresponded increased chances for costs by OR 1.39 (Odds Ratio; 95% CI  0.13-0.53, p = 0.001). When mediators were analysed separately, both mental and physical health (problems) fully mediated the association. Yet, when examined together, only mental health problems acted as a mediator. Our results indicate the health economic relevance of stress-related mental health problems in high school students. The finding is meant to set the stage for further cost-of-illness studies of stress and related health problems, as well as economic evaluations. Longitudinal research is needed to allow conclusions on directionality.

Predictors of mental health service use among individuals with high psychological distress and mental disorders

This study identified predictors of mental health service use over 12 months among 746 individuals with mental disorders and high psychological distress from a catchment area in southwest Montreal, Quebec (Canada). Data collected in 2011 and 2014 were analyzed using Andersen's Behavioral Model of Health Services Use. A hierarchical logistic regression identified predictors of mental health service use. In all, 29% of participants reported using mental health services in the previous 12 months. Three key enabling variables predicted mental health service use: having a family doctor, previous experience with mental health services, and employment. Self-perception of mental health, stressful events, and unmet needs marginally (Needs factors: non-clinical variables) were also associated with the outcome variable. Mental health service utilization depends primarily on organization of the health system, and patient perceptions of its condition (non-clinical needs). Mental health policy should focus on increasing the availability of services and professionals, especially family doctors. Other measures for encouraging service use and overall population wellbeing include raising public awareness around the signs and symptoms of mental illness as a way to promote more rapid response to patient needs, and protecting workplace mental health by reducing stress and stigma toward individuals affected by mental distress.

Health Care Utilisation by Bullying Victims: A Cross-Sectional Study of A 9-Year-Old Cohort in Ireland

Children frequently refrain from disclosing being bullied. Early identification of bullying by healthcare professionals in children may prevent adverse health consequences. The aim of our study was to determine whether Health Care Utilisation (HCU) is higher in 9-year-olds who report being bullied and factors influencing type of HCU. The study consists of cross-sectional surveys of Child Cohort of Irish National Longitudinal Study of Children (Wave 1), 8,568 9-year-olds, and their carers. Being bullied was assessed by a self-reported questionnaire completed by children at home. HCU outcomes consisted of the following: visits to GP, Mental Health Practitioner (MHP), Emergency Department (ED), and nights in hospital by parent interview. Bivariate logistic regression and gender-stratified Poisson models were used to determine association. Victimisation by bullying independently increased visits to GP (OR 1.13, 95% confidence interval (CI): 1.03 to 1.25; p = 0.02), MHP (OR 1.31, 95% CI: 1.05 to 1.63; p = 0.02), though not ED visits (OR 0.99, 95% CI: 0.87 to 1.13; p = 0.8) or nights in hospital (OR 1.07 95% CI: 0.97 to 1.18; p = 0.2), adjusting for underlying chronic condition(s) and socio-demographic confounders. Victimised girls made higher GP visits (RR 1.14, 95% CI: 1.06 to 1.23; p < 0.001) and spent more nights in hospital (RR 1.10, 95% CI: 1.04 to 1.15; p < 0.001). Victimised boys were more likely to contact MHPs (RR 1.21, 95% CI: 1.02 to 1.44; p = 0.03). 9-year-old bullied subjects were more likely to utilise primary care services than non-bullied 9-year-olds. Different HCU patterns were observed according to gender and gender differences in the presentation of victimisation. Our findings may lead to the development of clinical practice guidelines for early detection and appropriate management of bullied children.

Importance of physical health and health-behaviors in adolescence for risk of dropout from secondary education in young adulthood: an 8-year prospective study

BACKGROUND

Education and health constitute two interlinked assets that are highly important to individuals. In Iceland, prevalence of dropout from secondary education poses a considerable problem. This 8-year prospective study assesses to what extent poor physical health and negative health-behaviors of Icelandic adolescents predict increased odds of dropout from secondary education.

METHODS

The sample included n = 201 Icelandic children who participated at age 15 (baseline) and again at age 23 (follow-up). Data included objective measurements of physical health and questionnaires assessing health-behaviors, education status, parental education, neighborhood characteristics, self-esteem, and depression. Independent t-tests and chi-square were used to assess differences in physical health and health-behaviors at follow-up stratified by education status. Ordinal regression models were conducted to assess whether physical health and health-behaviors at age 15 predicted increased odds of dropout from secondary education at age 23, independent of gender, parental education and psychological factors.

RESULTS

At age 23, 78 % of girls and 71 % of boys had completed a secondary education. Completion of a secondary education was associated with significant health benefits, especially among women. Women without a secondary education had lower fitness, more somatic complaints, higher diastolic blood pressure, less sports participation, and poorer sleep, whilst men without a secondary education watched more television. In logistic regression models somatic complaints during adolescence were associated with 1.09 (95 % CI: 1.02-1.18) higher odds of dropout from secondary education in young adulthood, independent of covariates. Health-behaviors associated with higher dropout odds included smoking (3.67, 95 % CI: 1.50-9.00), alcohol drinking (2.57, 95 % CI: 1.15-5.75), and time spent watching television (1.27, 95 % CI:1.03-1.56), which were independent of most covariates. Finally, mother's higher education was strongly associated with significantly lower dropout odds (OR 0.54, 95 % CI: 0.34-0.88) independent of father's education and psychological factors, whilst high self-esteem was independently associated with lower dropout odds (OR 0.91, 95 % CI: 0.85-0.98).

CONCLUSIONS

Completion of a secondary education yields substantial physical health benefits for young women, but not for men. Importantly, somatic complaints and negative health-behaviors among adolescent boys and girls adversely impact their educational outcomes later in life, and may have widespread consequences for their future prospects.

Resilience and corpus callosum microstructure in adolescence

BACKGROUND

Resilience is the capacity of individuals to resist mental disorders despite exposure to stress. Little is known about its neural underpinnings. The putative variation of white-matter microstructure with resilience in adolescence, a critical period for brain maturation and onset of high-prevalence mental disorders, has not been assessed by diffusion tensor imaging (DTI). Lower fractional anisotropy (FA) though, has been reported in the corpus callosum (CC), the brain's largest white-matter structure, in psychiatric and stress-related conditions. We hypothesized that higher FA in the CC would characterize stress-resilient adolescents.

METHOD

Three groups of adolescents recruited from the community were compared: resilient with low risk of mental disorder despite high exposure to lifetime stress (n = 55), at-risk of mental disorder exposed to the same level of stress (n = 68), and controls (n = 123). Personality was assessed by the NEO-Five Factor Inventory (NEO-FFI). Voxelwise statistics of DTI values in CC were obtained using tract-based spatial statistics. Regional projections were identified by probabilistic tractography.

RESULTS

Higher FA values were detected in the anterior CC of resilient compared to both non-resilient and control adolescents. FA values varied according to resilience capacity. Seed regional changes in anterior CC projected onto anterior cingulate and frontal cortex. Neuroticism and three other NEO-FFI factor scores differentiated non-resilient participants from the other two groups.

CONCLUSION

High FA was detected in resilient adolescents in an anterior CC region projecting to frontal areas subserving cognitive resources. Psychiatric risk was associated with personality characteristics. Resilience in adolescence may be related to white-matter microstructure.

Adolescent school absenteeism and service use in a population-based study

BACKGROUND

School absenteeism is linked to a range of health concerns, health risk behaviors and school dropout. It is therefore important to evaluate the extent to which adolescents with absenteeism are in contact with health care and other services. The aim of the current study was to investigate service use of Norwegian adolescents with moderate and high absenteeism in comparison to students with lower rates of absence.

METHODS

The study employs data from a population-based study from 2012 targeting all pupils in upper secondary education in Hordaland County, Norway (the youth@hordaland-survey). A total of 8988 adolescents between the ages of 16 and 18 were included in the present study. Information on service use was based on adolescent self-report data collected in the youth@hordaland-survey. Absence data was collected using administrative data provided by the Hordaland County Council.

RESULTS

High absence (defined as being absent 15% or more the past semester) was found among 10.1% of the adolescents. Compared to their peers with low absence (less than 3% absence the past semester), adolescents with high absence were more likely to be in contact with all the services studied, including mental health services (odds ratio (OR) 3.96), adolescent health clinics (OR 2.11) and their general practitioner (GP) (OR 1.94). Frequency of contact was higher among adolescents with moderate and high absence and there seems to be a gradient of service use corresponding to the level of absence. Still, 40% of the adolescents with high absence had not been in contact with any services.

CONCLUSIONS

Adolescents with high absence had increased use of services, although a group of youth at risk seems to be without such contact. This finding suggests a potential to address school absenteeism through systematic collaboration between schools and health personnel.

Psychosocial problems in adolescents associated with frequent health care use

BACKGROUND

The prevalence of somatic, mental and behavioural problems increases in puberty. Nevertheless, compared to adults, health service utilization by adolescents, and associated factors such as risky health behaviours, have been poorly explored. In order to improve health care services, there is a need for further research on adolescents frequently using primary health care.

OBJECTIVES

We aimed to investigate adolescents who seek help for health issues, and examine whether particular socio-economic or psychological factors predict frequent primary health care use.

METHODS

Finnish adolescents aged 13-18 years (N = 793) attending comprehensive, upper secondary and vocational schools participated in the study in 2005. Data were collected using a questionnaire that included the Youth Self Report (YSR), as well as questions on the psychosocial background of the adolescents and substance use. Data regarding the frequency of use of health services were gathered from medical records of the local public health care services.

RESULTS

Altogether, 288 in the sample had used primary health care services making a combined total of 1411 health care visits. Female gender associated with frequent primary health care use. Furthermore, a high level of alcohol consumption and mental health symptoms in girls, and increased self-reported somatic complaints in the YSR in boys were associated with frequent primary health care use. Attending upper secondary school was related to less frequent primary health care use.

CONCLUSION

Few adolescents frequently use primary health care, but they account for a considerable proportion of all adolescent health care visits. There are higher levels of alcohol consumption, as well as socio-economic, educational and gender differences among adolescent frequent primary health care users.

Primary care providers' initial treatment decisions and antidepressant prescribing for adolescent depression

OBJECTIVE

Adolescent depression is a serious and undertreated public health problem. Nonetheless, pediatric primary care providers (PCPs) may have low rates of antidepressant prescribing due to structural and training barriers. This study examined the impact of symptom severity and provider characteristics on initial depression treatment decisions in a setting with fewer structural barriers, an integrated behavioral health network.

METHODS

A cross-sectional survey was administered to 58 PCPs within a large pediatric practice network. PCP reports of initial treatment decisions were compared in response to 2 vignettes describing depressed adolescents with either moderate or severe symptoms. PCP depression knowledge, attitudes toward addressing psychosocial concerns, demographics, and practice characteristics were measured.

RESULTS

Few PCPs (25% for moderate, 32% for severe) recommended an antidepressant. Compared with treatment recommendations for moderate depression, severe depression was associated with a greater likelihood of child psychiatry referral (odds ratio [OR], 5.50; 95% confidence interval [CI], 2.47-12.2] p < .001). Depression severity did not affect the likelihood of antidepressant recommendation (OR, 1.58 [95% CI, 0.80-3.11] p = .19). Antidepressants were more likely to be recommended by PCPs with greater depression knowledge (OR, 1.72 [95% CI, 1.14-2.59] p = .009) and access to an on-site mental health provider (OR, 5.13 [95% CI, 1.24-21.2] p = .02) and less likely to be recommended by PCPs who reported higher provider burden when addressing psychosocial concerns (OR, 0.85 [95% CI, 0.75-0.98] p = .02).

CONCLUSION

PCPs infrequently recommended antidepressants for adolescents, regardless of depression severity. Continued PCP support through experiential training, accounting for provider burden when addressing psychosocial concerns, and co-management with mental health providers may increase PCPs' antidepressant prescribing.

Characteristics of paediatric frequent presenters to an Australian emergency medicine network

AIM

The study aims to describe the characteristics of paediatric emergency department (ED) patients defined as frequent presenters (FP) presenting to an Australian ED health service and compare these with a cohort of non-frequent presenters (NFP).

METHOD

A retrospective chart review utilising an electronic emergency medicine patient medical record database was performed on paediatric patients (18 years or younger) presenting to Monash Health EDs from March 2009 to March 2010. NFPs were defined as patients presenting five or less times and FPs as presenting eight or more times in the study period. Characteristics of both groups were described and compared.

RESULTS

During the 12-month study period, there were 130 paediatric FP patients with 839 admissions and 34,262 paediatric NFP patients with 46,043 admissions. FPs to the ED were more likely to be female, utilise the ambulance service to arrive at the hospital and more likely to be admitted to hospital. In particular, FPs were more likely to require admission for a mental health-related problem. They were also more likely to have a discharge diagnosis related to oncology, neurology, respiratory, endocrinology and psychiatric complaints, compared with NFP who were more likely to present with a diagnosis related to injury or trauma.

CONCLUSIONS

Paediatric FPs are a vulnerable population with complex multidisciplinary care needs. A holistic approach towards their needs is essential to understanding the reasons for their higher frequency of attendance. By considering all the elements of the child's well-being, the child and family need support to assist in integration with other non-ED service providers. By focusing on wellness and self-management, there is a potential to reduce the reliance on acute emergency care for ongoing chronic health problems.

Can use of healthcare services among 15-16-year-olds predict an increased level of high school dropout? A longitudinal community study

OBJECTIVES

To study associations between healthcare seeking in 15-16-year-olds and high school dropout 5 years later.

DESIGN

Longitudinal community study.

SETTING

Data from a comprehensive youth health survey conducted in 2000-2004, linked to data from national registries up to 2010.

PARTICIPANTS

13 964 10th grade secondary school students in six Norwegian counties.

MAIN OUTCOME MEASURE

Logistic regression was used to compute ORs for high school dropout.

RESULTS

The total proportion of students not completing high school 5 years after registering was 29% (girls 24%, boys 34%). Frequent attenders to school health services and youth health clinics at age 15-16 years had a higher dropout rate (37/48% and 45/71%), compared with those with no or moderate use. Adolescents referred to mental health services were also more likely to drop out (47/62%). Boys with moderate use of a general practitioner (GP) had a lower dropout rate (30%). A multiple logistic regression analysis, in which we adjusted for selected health indicators and sociodemographic background variables, revealed that seeking help from the youth health clinic and consulting mental health services, were associated with increased level of high school dropout 5 years later. Frequent attenders (≥4 contacts) had the highest odds of dropping out. Yet, boys who saw a GP and girls attending the school health services regularly over the previous year were less likely than their peers to drop out from high school.

CONCLUSIONS

Adolescents who seek help at certain healthcare services can be at risk of dropping out of high school later. Health workers should pay particular attention to frequent attenders and offer follow-up when needed. However, boys who attended a GP regularly were more likely to continue to high school graduation, which may indicate a protective effect of having a regular and stable relationship with a GP.

Sub-syndromal depression in adolescents attending primary care: frequency, clinical features and 6 months outcome

BACKGROUND

The nature of adolescent sub-syndromal depression has not been investigated in primary care.

AIMS

To document frequency, characteristics and 6 month outcome of sub-syndromal depression amongst adolescent primary care attenders.

METHOD

Primary care attenders (13-18 years) completed depression screening questionnaires (Mood and Feelings Questionnaires) at consultation and at 6 month follow-up. Those screening positive were interviewed with the K-SADS. Sub-syndromal depression was defined as high levels of depressive symptoms in the absence of depressive disorder.

RESULTS

Two hundred and seventy four questionnaires were completed at consultation: the estimated rate of sub-syndromal depression was 25 %. These young people were clinically intermediary between those without depressive symptoms and those with depressive disorder; at 6-months follow-up 57 % had persistent depressive symptoms and 12 % had developed a depressive disorder. Negative life events during the follow-up period and a positive family history of depression were the strongest predictors of symptom persistence and the development of depressive disorder, respectively.

CONCLUSION

Sub-syndromal depression is common and persistent, in adolescent primary care attenders and it deserves attention.

Associations between mental disorders and the common cold in adults: a population-based cross-sectional study

OBJECTIVE

To investigate the association between specific mental disorders and the common cold.

METHODS

Negative binomial regression analyses were applied to examine cross-sectional associations of a broad range of mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) employing the standardized Munich Composite International Diagnostic Interview, with the self-reported number of occurrences of the common cold during the past 12 months in a representative population sample of 4022 German adults aged 18-65 years.

RESULTS

After adjustment for covariates including age, gender, and marital and socioeconomic status, having any 12-month DSM-IV mental disorder (incidence rate ratio [IRR]=1.44, 95% confidence interval [CI]=1.29-1.60), any substance abuse or dependence (IRR=1.32, 95% CI=1.14-1.52), possible psychotic disorder (IRR=1.43, 95% CI=1.09-1.87), any mood disorder (IRR=1.35, 95% CI=1.16-1.56), any anxiety disorder (IRR=1.40, 95% CI=1.23-1.59), or any somatoform disorder (IRR=1.38, 95% CI=1.18-1.62) was shown to be positively associated with the number of occurrences of a cold during the past 12 months.

CONCLUSION

The presence of a DSM-IV mental disorder was associated with a 44% higher risk of having experienced a cold in the past 12 months. Further studies are needed to explore potential common risk factors for incidence of mental disorders and the common cold, since the pathway connecting them has not been fully determined.

Determinants of negative pathways to care and their impact on service disengagement in first-episode psychosis

PURPOSE

Although there have been numerous studies on pathways to care in first-episode psychosis (FEP), few have examined the determinants of the pathway to care and its impact on subsequent engagement with mental health services.

METHODS

Using a sample of 324 FEP patients from a catchment area-based early intervention (EI) program in Montréal, we estimated the association of several socio-demographic, clinical, and service-level factors with negative pathways to care and treatment delay. We also assessed the impact of the pathway to care on time to disengagement from EI services.

RESULTS

Few socio-demographic or clinical factors were predictive of negative pathways to care. Rather, service-level factors, such as contact with primary care providers, have a stronger impact on patterns of health service use across multiple indicators. Patients who were in contact with primary care had a reduced likelihood of negative pathways to care, but also had longer referral delays to EI services. Socio-demographic and clinical factors were more relevant for predicting subsequent engagement with EI services, and indicators of negative pathways to care were not associated with service disengagement.

CONCLUSIONS

Primary care providers may be an efficacious target for interventions aimed at reducing overall treatment delay. Increasing the uptake of primary care services may also reduce the likelihood of negative pathways to care. Our findings draw attention to the need for further investigations of the role that the primary care system plays in early intervention for FEP, and strategies for supporting service providers in this role.

General practitioner experience and perception of Child and Adolescent Mental Health Services (CAMHS) care pathways: a multimethod research study

OBJECTIVES

This is a pilot study with the objective of investigating general practitioner (GP) perceptions and experiences in the referral of mentally ill and behaviourally disturbed children and adolescents.

DESIGN

Quantitative analyses on patient databases were used to ascertain the source of referrals into Child and Adolescent Mental Health Services (CAMHS) and identify the relative contribution from GP practices. Qualitative semistructured interviews were then used to explore challenges faced by GPs in referring to CAMHS.

SETTING

GPs were chosen from the five localities that deliver CAMHS within the local Trust (Peterborough City, Fenland, Huntingdon, Cambridge City and South Cambridgeshire).

PARTICIPANTS

For the quantitative portion, data involving 19 466 separate referrals were used. Seven GPs took part in the qualitative interviews.

RESULTS

The likelihood of a referral from GPs being rejected by CAMHS was over three times higher compared to all other referral sources combined within the Cambridge and Peterborough NHS Foundation Trust. Interviews showed that detecting the signs and symptoms of mental illness in young people is a challenge for GPs. Communication with referral agencies varies and depends on individual relationships. GPs determine whether to refer on a mixture of the presenting conditions and their perceived likelihood of acceptance by CAMHS; the criteria for the latter were poorly understood by the interviewed GPs.

CONCLUSIONS

There are longstanding structural weaknesses in the services for children and young people in general, reflected in poor multiagency cooperation at the primary care level. GP-friendly guidelines and standards are required that will aid in decision-making and help with understanding the referrals process. We look to managers of both commissioning and providing organisations, as well as future research, to drive forward the development of tools, protocols, and health service structures to help aid the recognition and treatment of mental illness in young people.

Psychiatric disorders in children attending a Nigerian primary care unit: functional impairment and risk factors

BACKGROUND

There is dearth of data on the level of functional impairment and risk factors for psychiatric morbidity in children attending primary care services in developing countries like Nigeria. The risk factors for psychiatric morbidity and functional impairment in children attending the primary care unit of a teaching hospital in Ilorin, Nigeria was therefore investigated to obtain data that could be used in improving service provision by primary care physicians.

METHODS

A cross-sectional two-stage design was employed for the study. The first stage involved administration of the Child Behavior Questionnaire (CBQ) to 350 children while the children's version of the schedule for affective disorders and schizophrenia was used for the second stage involving 157 children, all high scorers on CBQ (score of ≥ 7) and 30% of low scorers (score < 7). Diagnosis of psychiatric disorders was based on DSM-IV criteria.In addition, the Children Global Assessment Scale was used to assess the functional status of the children (score of ≤ 70 indicates functional impairment) while the mothers' mental health status was assessed with the 12-item version of the General Health Questionnaire, a score of 3 or more on this instrument indicate presence of mental morbidity.

RESULTS

It was observed that 11.4% of the children had diagnosable psychiatric disorders and 7.1% were functionally impaired; and those with psychiatric disorders were more functionally impaired than those without. Thus, significant negative correlation was noted between CBQ scores and CGAS (r = 0.53; p < 0.001). Following logistic regression, younger age of children, frequent hospital attendance and maternal parenting distress independently predicted psychiatric morbidity while child psychopathology and maternal parenting distress predicted functional impairment.

CONCLUSIONS

Child psychiatric disorders are prevalent in the primary care unit studied. Many of the risk factors identified in the study population are modifiable. Collaborative efforts between psychiatrists and primary care physicians could therefore help to reduce level of risk and functional impairment and psychiatric morbidity among children attending the primary care unit studied. It could also help improve referral rates of difficult cases to the child and adolescent psychiatric unit of the hospital.