Service use in adolescents at risk of depression and self-harm: prospective longitudinal study

Self-reported psychological distress in childhood and mental health-related hospital attendance among young adults: a 12-year data linkage cohort study from England

PURPOSE

Investigating the relationship between self-reported mental health and secondary care utilisation can provide evidence on the link between population-level common mental conditions and clinical care; however, cohort studies with linked administrative data are rare. We explored the link between self-reported mental health in adolescence and mental health-related hospital attendance in young adulthood.

METHODS

Data from a nationally representative English cohort (Next Steps) were linked to NHS Hospital Episode Statistics. GHQ-12 assessed psychological distress in Next Steps at age 15; participants were followed up until their first mental health-related hospital presentations and outpatient treatments or were censored at the end of the study (age 27). Cox proportionate hazard models with survey weights estimated associations.

RESULTS

Out of 4058 young people, 19% reported high levels of distress at age 15. During the 12-year follow-up, 5.3%, 2.9% and 2.7% of the participants had at least one mental disorder, drug/alcohol misuse and self-harm presentation, respectively, and 4.2% had a mental health treatment in NHS hospitals. Higher GHQ-12 scores were associated with mental disorder presentations (HR = 1.10, 95% CI:1.04-1.16), and mental health treatments (HR = 1.14, 95% CI:1.08-1.20). Associations for hospital treatments were weaker for young people living in deprived areas, or if their main parent had lower education.

CONCLUSION

Adolescent psychological distress is associated with subsequent hospital attendance in young adulthood, but there might be treatment gaps in service utilisation among more disadvantaged individuals. Detecting youth with mental health difficulties may facilitate early intervention, improve life-course outcomes, and ultimately reduce secondary healthcare use.

Precision computerised cognitive behavioural therapy (cCBT) for adolescents with depression: a pilot and feasibility randomised controlled trial protocol for SPARX-UK

BACKGROUND

A serious game called SPARX (Smart, Positive, Active, Realistic, X-factor thoughts), originally developed in New Zealand and incorporating cognitive behavioural therapy (CBT) principles, has been shown to help reduce symptoms of depression and anxiety in adolescents with mild to moderate depression in studies undertaken in Australasia. However, SPARX has never been trialled in the United Kingdom (UK), and there have been issues relating to low engagement when it has been used in a real-world context.

AIMS

To conduct the first pilot and feasibility randomised controlled trial (RCT) in England to explore the use of SPARX in different settings. The trial will explore whether SPARX supported by an e-coach (assistant psychologists) improves adherence and engagement compared with self-directed (i.e. self-help) use. The trial results will be used to inform the optimal mode of delivery (SPARX supported vs. SPARX self-directed), to calculate an appropriate sample size for a full RCT, and to decide which setting is most suitable.

METHODS

Following consultation with young people to ensure study suitability/appropriateness, a total of 120 adolescents (11-19 years) will be recruited for this three-arm study. Adolescents recruited for the study across England will be randomised to receive either SPARX with human support (from an e-coach), self-directed SPARX, or a waitlist control group. Assessments will be conducted online at baseline, week 4, and 8-10-week post-randomisation. The assessments will include measures which capture demographic, depression (Patient Health Questionnaire modified for adolescents [PHQ-A]) and anxiety (Revised Child Anxiety and Depression Scale [RCADS]) symptomatology, and health-related quality-of-life data (EQ-5D-Y and proxy version). Analyses will be primarily descriptive. Qualitative interviews will be undertaken with a proportion of the participants and clinical staff as part of a process evaluation, and the qualitative data gathered will be thematically analysed. Finally, feasibility data will be collected on recruitment details, overall study uptake and engagement with SPARX, participant retention, and youth-reported acceptability of the intervention.

DISCUSSION

The findings will inform the design of a future definitive RCT of SPARX in the UK. If the subsequent definitive RCT demonstrates that SPARX is effective, then an online serious game utilising CBT principles ultimately has the potential to improve the provision of care within the UK's health services if delivered en masse.

TRIAL REGISTRATION

ISRCTN: ISRCTN15124804. Registered on 16 January 2023, https://www.isrctn.com/ISRCTN15124804 .

Adverse childhood experiences and depressive symptoms among adolescents during the COVID-19 pandemic: mediating roles of poor sleep quality and psychological inflexibility

Previous studies have found that adverse childhood experiences can lead to depressive symptoms. But the underlying mechanisms have not been determined. Guided by the 3-P model of insomnia and acceptance and commitment therapy, this study examined the mediating role of poor sleep quality and psychological inflexibility in the relationship between adverse childhood experiences and depressive symptoms during the COVID-19 pandemic. A total of 996 senior high school students in China (Mage = 16.57 years; SD = 1.03) completed the self-report measures of adverse childhood experiences, depressive symptoms, poor sleep quality, and psychological inflexibility. Multiple mediation analysis revealed that adverse childhood experiences were related to depressive symptoms through poor sleep quality and psychological inflexibility, serially. These findings point to potential targets in the prevention of and intervention in adolescent depressive symptoms.

Working with Young People at Risk of Suicidal Behaviour and Self-Harm: A Qualitative Study of Australian General Practitioners' Perspectives

General Practitioners (GPs) play a crucial role in the identification and support of young people at risk of suicidal behaviour and self-harm; however, no studies have explored GPs' perspectives, approaches, challenges, and resource needs when working with this cohort in an Australian setting. This was a qualitative study where fifteen GPs (Mage = 45.25 years) from multiple clinics in Western Australia took part in semi-structured interviews, and data were analysed thematically. Seven main themes were identified: (1) working with young people has its unique challenges; (2) screening and assessment tools can help to manage uncertainty and discomfort; (3) going beyond tools-the dialogue and relationship are most important; (4) there are limits to what we can offer in the time available; (5) the service access and referral pathways lack clarity and coordination; (6) the provision of mental health support should not fall on GPs alone; and (7) more comprehensive training in suicide and self-harm is needed. The findings highlight a number of opportunities to enhance care and better assist GPs working with young people who present with suicidal behaviour and self-harm, including considerations for conducting assessments, targeted resources such as training, and system and service improvements.

Community Outpatient Psychotherapy Engagement Service for Self-harm (COPESS): a feasibility trial protocol

Background

People who self-harm are at high risk for future suicide and often suffer considerable emotional distress. Depression is common among people who self-harm and may be an underlying driver of self-harm behaviour. Self-harm is often repeated, and risk of repetition is highest immediately after an act of self-harm. Readily accessible brief talking therapies show promise in helping people who self-harm, but further evaluation of these approaches is needed. A brief talking therapy intervention for depression and self-harm has been designed for use in a community setting. This mixed methods feasibility study with repeated measures will examine the feasibility and acceptability of the Community Outpatient Psychological Engagement Service for Self-Harm (COPESS) for people with self-harm and depression in the community, compared to routine care.

Methods

Sixty participants with a history of self-harm within the last six months, who are also currently depressed, will be recruited to take part in a feasibility single-blind randomised controlled trial (RCT). Participants will be randomised 1:1 to receive COPESS plus treatment as usual (TAU) or TAU alone. Recruitment will be via General Practitioners (GP) and self-referral. Assessment of feasibility and acceptability will be assessed via quantitative and qualitative methods including measures of recruitment and retention to the feasibility trial, participants’ experience of therapy, completion/completeness of outcome measures at relevant time-points and completion of a service use questionnaire.

Discussion

The results will indicate whether it is feasible to conduct a definitive full trial to determine whether COPESS is a clinically and cost effective intervention for people who self-harm in the community. Qualitative and quantitative data will in addition help identify potential strengths and/or challenges of implementing brief community-based interventions for people who self-harm.

Trial registration

NCT04191122 registered 9th December 2019.

Best practice when working with suicidal behaviour and self-harm in primary care: a qualitative exploration of young people's perspectives

OBJECTIVES

General practitioners (GPs) have a key role in supporting young people who present with suicidal behaviour/self-harm. However, little is known about young people's opinions and experiences related to GPs' practices for such presentations, and their decisions to disclose suicidal behaviour/self-harm to GPs. Additionally, existing guidelines for the management of suicide risk and/or self-harm have not incorporated young people's perspectives. This study aimed to explore young people's views and experiences related to the identification, assessment and care of suicidal behaviour and self-harm in primary care settings with GPs.

DESIGN, SETTING AND PARTICIPANTS

Two qualitative focus groups were conducted in Perth, Western Australia, with 10 young people in total (Mage = 20.67 years; range: 16-24). Data were collected using a semistructured, open-ended interview schedule and analysed using thematic analysis.

RESULTS

Five major themes were identified from the focus groups. (1) Young people wanted a collaborative dialogue with GPs, which included being asked about suicidal behaviour/self-harm, informed of treatment processes and having autonomy in decision making; (2) young people were concerned with a loss of privacy when disclosing suicidal behaviour/self-harm; (3) young people viewed labels and assessments as problematic and reductionist-disliking the terms 'risk' and 'risk assessment', and assessment approaches that are binary and non-holistic; (4) young people highlighted the importance of GPs' attitudes, with a genuine connection, attentiveness and a non-judgemental demeanour seen as paramount; and (5) young people wanted to be provided with practical support and resources, followed-up, and for GPs to be competent when working with suicidal behaviour/self-harm presentations.

CONCLUSIONS

Our study identified several concerns and recommendations young people have regarding the identification, assessment and care of suicidal behaviour/self-harm in primary care settings. Taken together, these findings may inform the development of resources for GPs, and support progress in youth-oriented best practice.

What do young people who self-harm find helpful? A comparative study of young people with and without experience of being looked after in care

BACKGROUND

Self-harm amongst young people is an increasing problem, with looked-after young people at higher risk. Despite this, little research exists on what young people who self-harm find helpful.

METHOD

One hundred and twenty-six 11-21 year olds (53 who had experience of the care system and 73 who did not) were recruited from the community and NHS. All participants had self-harmed in the past 6 months. Participants completed an Audio Computer-Assisted Self-interview (ACASI) regarding their views about the support they had received, how helpful it was, and what further help they felt they needed.

RESULTS

Looked-after young people reported the three most helpful sources of support were Child and Adolescent Mental Health Services (CAMHS), friends and pets and the least helpful were CAMHS, Accident and Emergency (A&E) and Social services. For non-looked-after young people, CAMHS, counselling and Harmless (user-led support service for self-harm) were most helpful and CAMHS, cognitive behavioural therapy (CBT) and general practitioner (GP) were the least. Compared with the other group, more looked-after young people had received help from A&E and CAMHS, whereas more non-looked-after young people had accessed GPs, parents, psychological therapies, self-help books and websites. More looked-after young people found support groups helpful, and more non-looked-after young people reported that distraction techniques, medication and their siblings were helpful.

CONCLUSION

Young people who self-harm have mixed views about CAMHS. Differences in the pattern of access and preferences for support between looked-after and non-looked-after young people should be reflected in service availability and commissioning.

KEY PRACTITIONER MESSAGE

Little is known about what young people who self-harm find helpful, particularly for looked-after young people. CAMHS was named amongst the most helpful and the least helpful services by both looked-after and non-looked-after young people. Social services and A&E were frequently cited amongst the least helpful sources of support. Young people report finding informal support helpful, including family and friends. There appears to be a need for explorations of the reasons behind the apparent negative perception of statutory services in young people, and what is required to shift that.

Self-harm presentation across healthcare settings by sex in young people: an e-cohort study using routinely collected linked healthcare data in Wales, UK

BACKGROUND

This study used individual-level linked data across general practice, emergency departments (EDs), outpatients and hospital admissions to examine contacts across settings and time by sex for self-harm in individuals aged 10-24 years old in Wales, UK.

METHODS

A whole population-based e-cohort study of routinely collected healthcare data was conducted. Rates of self-harm across settings over time by sex were examined. Individuals were categorised based on the service(s) to which they presented.

RESULTS

A total of 937 697 individuals aged 10-24 years contributed 5 369 794 person years of data from 1 January 2003 to 30 September 2015. Self-harm incidence was highest in primary care but remained stable over time (incident rate ratio (IRR)=1.0; 95% CI 0.9 to 1.1). Incidence of ED attendance increased over time (IRR=1.3; 95% CI 1.2 to 1.5) as did hospital admissions (IRR=1.4; 95% CI 1.1 to 1.6). Incidence in the 15-19 years age group was the highest across all settings. The largest increases were seen in the youngest age group. There were increases in ED attendances for both sexes; however, females are more likely than males to be admitted following this. This was most evident in individuals 10-15 years old, where 76% of females were admitted compared with just 49% of males. The majority of associated outpatient appointments were under a mental health specialty.

CONCLUSIONS

This is the first study to compare self-harm in people aged 10-24 years across primary care, EDs and hospital settings in the UK. The high rates of self-harm in primary care and for young men in EDs highlight these as important settings for intervention.

Experience of Self-Harm and Its Treatment in Looked-After Young People: An Interpretative Phenomenological Analysis

We report the first Interpretative Phenomenological Analysis examination of self-harm and experience of clinical services in young people in the public care system. Qualitative interviews with 24 looked-after young people were completed. Prevalent themes were 1) Changes in care placement, 2) Feelings of anger, 3) Not wanting/feeling able to talk, 4) Developing coping techniques, 5) Clinical services: A relational mixed bag (subthemes: feeling (i) patronized, not listened to, (ii) nothing being done, (iii) comfortable/able to talk). Placement change and anger were highly salient to self-harm in this group and experiences of clinical services depended on individual relationships with clinicians. Implications include increasing compassion in therapeutic relationships, recognizing and managing emotional dysregulation, and increasing support during placement changes.

General Practitioners' experience of child and adolescent suicidal ideation and behaviour - a survey

OBJECTIVES

A major cause of death in Irish men aged 15-24 is suicide and the rates for those aged 15-19 are amongst the highest in Europe. Despite concerns over suicidal ideation or behaviour, little research has been done in the Irish primary care context. We therefore aimed to carry out a study of Irish General Practitioners (GPs)' experience regarding suicidal ideation or behaviour in children and adolescents.

METHODS

The study design was a descriptive, cross-sectional, questionnaire survey. We randomly selected 480 GPs and invited them to participate via post.

RESULTS

In total, 198 GPs replied, representing a response rate of 41% with a sampling error of ±6.8%. In total, 184 of respondents (93%) saw more than 50 children and adolescent patients annually, however, presentations of suicidal ideation and behaviour were relatively rare, with 36% reporting seeing none, 58% seeing between one and five and 6% seeing more than five such presentations annually. In total, 119 (62%) of GPs reported a willingness to prescribe antidepressants for this age group. In total, 66% of GPs felt this was either 'always' or 'usually' a difficult patient group to manage, and the single most commonly reported difficulty by GPs was access to services [n=48 (33%)].

CONCLUSIONS

GPs reported that their management of children and adolescents with suicidal ideation or behaviour is often difficult. GPs play a key liaison role in the area of child and adolescent mental health, but our results indicate that GPs are also involved in the treatment of this patient group. However, ongoing education was not a priority according to GPs themselves.

GPs role identifying young people who self-harm: a mixed methods study

BACKGROUND

Self-harm is common among young people and is evident in increasingly younger age groups. Many young people who self-harm do visit their GP but do not access specialist support. GP's can find it challenging to raise and discuss this sensitive subject with young people during short consultations.

OBJECTIVE

To explore GP's capabilities, motivations and opportunities for discussing self-harm and to identify barriers to and enablers for proactively discussing self-harm with young people.

DESIGN AND SETTING

An exploratory, mixed methods study was designed comprising an online survey and a qualitative interview study with GPs in the South West of England.

METHODS

An online survey was completed by 28 GPs. Ten GPs took part by telephone, in semi-structured interviews. Quantitative data was analysed using descriptive statistical techniques and thematic analysis was used to analyse the qualitative data. Findings from the quantitative and qualitative analysis are synthesized to illustrate GPs' skills, knowledge and perceptions about young people who self-harm.

RESULTS

Experienced GPs may underestimate the prevalence of self-harm in young people, particularly in the 11-14 age range. While consultations with young people and their carers can be challenging, GPs acknowledge that it is their role to provide support for young people who self-harm. GPs would welcome training for themselves and other practice staff in talking to young people and practical information about self-harm.

CONCLUSION

All primary care staff who provide frontline support to young people should receive education and practical training in talking about self-harm.

Provision of mental healthcare for children and adolescents: a worldwide view

PURPOSE OF REVIEW

There has been increased attention towards the burden imposed by mental disorders on children and adolescents. The present overview explores the current state of child and adolescent mental healthcare provision around the globe.

RECENT FINDINGS

Current research indicates a concerning gap in the provision of care for the child and adolescent population. The disparities between need, demand and access to youth mental healthcare are likely to be even greater in low and- middle-income countries (LAMIC), where the proportion of children and adolescents in the population is higher. The scarcity of available resources for youth mental healthcare, especially in LAMIC, represents a major obstacle to decreasing the impact of mental disorders across the lifespan.

SUMMARY

Our review highlights the discrepancy between demands and availability of mental healthcare for youth populations throughout the world. We describe some of the potential contributors to the current state of youth mental healthcare, such as problematic access to services, implementation deficiencies and inadequacy of policies. Recent innovative strategies to reduce these barriers are also presented.