High integrity mental health services for children: focusing on the person, not the problem

Using Progress Feedback to Enhance Treatment Outcomes: A Narrative Review

We face increasing demand for greater access to effective routine mental health services, including telehealth. However, treatment outcomes in routine clinical practice are only about half the size of those reported in controlled trials. Progress feedback, defined as the ongoing monitoring of patients' treatment response with standardized measures, is an evidence-based practice that continues to be under-utilized in routine care. The aim of the current review is to provide a summary of the current evidence base for the use of progress feedback, its mechanisms of action and considerations for successful implementation. We reviewed ten available meta-analyses, which report small to medium overall effect sizes. The results suggest that adding feedback to a wide range of psychological and psychiatric interventions (ranging from primary care to hospitalization and crisis care) tends to enhance the effectiveness of these interventions. The strongest evidence is for patients with common mental health problems compared to those with very severe disorders. Effect sizes for not-on-track cases, a subgroup of cases that are not progressing well, are found to be somewhat stronger, especially when clinical support tools are added to the feedback. Systematic reviews and recent studies suggest potential mechanisms of action for progress feedback include focusing the clinician's attention, altering clinician expectations, providing new information, and enhancing patient-centered communication. Promising approaches to strengthen progress feedback interventions include advanced systems with signaling technology, clinical problem-solving tools, and a broader spectrum of outcome and progress measures. An overview of methodological and implementation challenges is provided, as well as suggestions for addressing these issues in future studies. We conclude that while feedback has modest effects, it is a small and affordable intervention that can potentially improve outcomes in psychological interventions. Further research into mechanisms of action and effective implementation strategies is needed.

Shifting Perspectives on the Challenges of Shared Decision Making in Mental Health Care

Although shared decision making (SDM) has become the most preferable way in doctor-patient communication, it is not fully implemented in mental health care likely due to the complex nature of psychiatric syndromes and treatments. In this review we provide a systematic overview of all perceived and reported barriers to SDM in the literature, acknowledging field-specific challenges, and offering perspectives to promote its wider use. We conducted a systematic search of the wider literature in different databases and included all publications mentioning specified barriers to SDM in psychiatric care. Relevant data and opinions were categorised into micro-, meso- and macro-level themes and put into clinical perspective. We derived 20 barriers to SDM from 100 studies and reports. Eight were on micro-level care delivery, seven involved meso-level issues, five concerned macro-level themes. The multitude of perceived and actual barriers to SDM underline the challenges its implementation poses in mental health care, some of which can be resolved while others are inherent to the nature of the care, with its long-term relationships, complex dynamics, and social consequences, all requiring a flexible approach. We present four perspectives to help change views on the potential of SDM in mental health care.

User satisfaction in child and adolescent mental health service: Comparison of background, clinical and service predictors for adolescent and parent satisfaction

BACKGROUND AND OBJECTIVE

To improve quality, child and adolescent mental health services (CAMHS) are expected to quantify families' views on healthcare with user satisfaction measures. As little is known about what influences satisfaction in CAMHS, this study aimed to examine predictors of adolescents' and parents' user satisfaction.

METHODS

Data from 231 adolescents and 495 parents in treatment at an outpatient clinic who returned a user satisfaction measure, the Experience of Service Questionnaire (ESQ), was analyzed. Registry data on background, clinical and service characteristics were predictors for the ESQ factors general satisfaction, satisfaction with care and satisfaction with environment.

RESULTS

In regression models, satisfaction with care for adolescents (r2  = .12) was significant and was predicted by low parent-self-reported mental health burden and low clinician-rated overall symptom burden at intake. For parents, regression models for general satisfaction (r2  = .07), satisfaction with care (r2  = .06) and satisfaction with environment (r2  = .08) were significant. Parents general satisfaction was predicted by higher levels of hyperactivity, less family stress and longer travelling distances to the service. Satisfaction with care for parents was predicted by higher levels of hyperactivity at intake and longer travelling distances. Satisfaction with environment for parents was more likely if the adolescents was a boy, with low levels of family stress and longer travelling distances.

CONCLUSION

Predictors for adolescent and parent user satisfaction in CAMHS differ. Hence, to improve quality CAMHS should enhance focus on collaborative practice with parents, and person-centred care for adolescents with moderate to severe mental health illness.

PATIENT OR PUBLIC CONTRIBUTION

Representatives from the hospitals' youth panel and the non-governmental organization called The Change Factory have been consulted regarding study design and results.

Adolescents' Experience during Brace Treatment for Scoliosis: A Qualitative Study

This study aimed to explore the subjective experiences of adolescents with scoliosis during brace treatment in order to understand their obstacles and make recommendations to enhance brace compliance. Using purposive sampling, 15 adolescents (2 males and 13 females) with scoliosis aged from 10 to 16 years old during brace treatment were recruited to participate in semi-structured in-depth interviews. The data were recorded, transcribed, and coded using thematic analysis with the qualitative software NVivo 10. Significant statements and phrases were organized into categories and themes to understand adolescents' experiences during brace treatment for scoliosis. In general, the adolescents acknowledged that compliance with brace treatment was essential to reduce or prevent the progression of spinal curvature and tried their best to comply with the treatment. Regarding their subjective experiences during brace treatment, three themes were identified and emerged as obstacles negatively affecting their brace compliance, including physical discomfort due to brace materials and design, reluctance caused by the brace's visual appearance, and passive patient participation during the treatment process. This study reveals insights into the experiences of adolescents with scoliosis during brace treatment and what they perceive as hindrances to compliance. In order to have better brace compliance, adolescents' feelings and difficulties during brace treatment should be recognized and addressed. Therefore, active patient participation throughout the treatment process, involving the co-design of a customized brace, psychosocial interventions, and personalized appearance style management should be considered and promoted to facilitate a more acceptable bracing experience to achieve better brace compliance.

‘More than just numbers on a page?’ A qualitative exploration of the use of data collection and feedback in youth mental health services

Objectives

This study aimed to explore current data collection and feedback practice, in the form of monitoring and evaluation, among youth mental health (YMH) services and healthcare commissioners; and to identify barriers and enablers to this practice.

Design

Qualitative semi-structured interviews were conducted via Zoom videoconferencing software. Data collection and analysis were informed by the Theoretical Domains Framework (TDF). Data were deductively coded to the 14 domains of the TDF and inductively coded to generate belief statements.

Setting

Healthcare commissioning organisations and YMH services in Australia.

Participants

Twenty staff from healthcare commissioning organisations and twenty staff from YMH services.

Results

The umbrella behaviour ‘monitoring and evaluation’ (ME) can be sub-divided into 10 specific sub-behaviours (e.g. planning and preparing, providing technical assistance, reviewing and interpreting data) performed by healthcare commissioners and YMH services. One hundred belief statements relating to individual, social, or environmental barriers and enablers were generated. Both participant groups articulated a desire to improve the use of ME for quality improvement and had particular interest in understanding the experiences of young people and families. Identified enablers included services and commissioners working in partnership, data literacy (including the ability to set appropriate performance indicators), relational skills, and provision of meaningful feedback. Barriers included data that did not adequately depict service performance, problems with data processes and tools, and the significant burden that data collection places on YMH services with the limited resources they have to do it.

Conclusions

Importantly, this study illustrated that the use of ME could be improved. YMH services, healthcare commissioners should collaborate on ME plans and meaningfully involve young people and families where possible. Targets, performance indicators, and outcome measures should explicitly link to YMH service quality improvement; and ME plans should include qualitative data. Streamlined data collection processes will reduce unnecessary burden, and YMH services should have the capability to interrogate their own data and generate reports. Healthcare commissioners should also ensure that they provide meaningful feedback to their commissioned services, and local and national organisations collecting youth mental health data should facilitate the sharing of this data. The results of the study should be used to design theory-informed strategies to improve ME use.

I'm not a diagnosis: Adolescents' perspectives on user participation and shared decision-making in mental healthcare

Background:

Adolescents have the right to be involved in decisions affecting their healthcare. More knowledge is needed to provide quality healthcare services that is both suitable for adolescents and in line with policy. Shared decision-making has the potential to combine user participation and evidence-based treatment. Research and governmental policies emphasize shared decision-making as key for high quality mental healthcare services.

Objective:

To explore adolescents’ experiences with user participation and shared decision-making in mental healthcare inpatient units.

Method:

We carried out ten in-depth interviews with adolescents (16-18 years old) in this qualitative study. The participants were admitted to four mental healthcare inpatient clinics in Norway. Transcribed interviews were subjected to qualitative content analysis.

Results:

Five themes were identified, representing the adolescents’ view of gaining trust, getting help, being understood, being diagnosed and labeled, being pushed, and making a customized treatment plan. Psychoeducational information, mutual trust, and a therapeutic relationship between patients and therapists were considered prerequisites for shared decision-making. For adolescents to be labeled with a diagnosis or forced into a treatment regimen that they did not initiate or control tended to elicit strong resistance. User involvement at admission, participation in the treatment plan, individualized treatment, and collaboration among healthcare professionals were emphasized.

Conclusions:

Routines for participation and involvement of adolescents prior to inpatient admission is recommended. Shared decision-making has the potential to increase adolescents’ engagement and reduce the incidence of involuntary treatment and re-admission to inpatient clinics. In this study, shared decision-making is linked to empowerment and less to standardized decision tools. To be labeled and dominated by healthcare professionals can be a barrier to adolescents’ participation in treatment. We suggest placing less emphasis on diagnoses and more on individualized treatment.

In the child's voice: The experiences of primary school children with social, emotional and mental health difficulties

In England schools are increasingly responsible for supporting children with Social, Emotional and Mental Health (SEMH) difficulties yet their voices are rarely represented. Through semi-structured interviews, the views of 11 children aged 6-11 years with SEMH difficulties were sought. Using thematic analysis two themes were identified - (1) social relationships and interactions, and (2) emotional and behavioural reactions. The children demonstrated that they were articulate and reflective about the impact their difficulties have in the learning environment. For some, they reported building and maintaining close reciprocal friendships which they felt enriched their time at school. It was concluded that children with SEMH difficulties need to feel safe and supported by adults to flourish in school. This work demonstrates the importance of taking a child-centred approach, allowing children to feel heard, understood and valued.

Embedding interagency working between schools and mental health specialists: A service evaluation of the Mental Health Services and Schools and Colleges Link Programme workshops

There is increasing focus on the need for schools to work more effectively with specialist mental health providers, but there have been historic challenges in embedding closer interagency working. This article reports the results of a service evaluation of a 2-day workshop designed to facilitate improved working between schools and children and young people's mental health services (CYPMHS). Mental health leads from 255 schools, mental health professionals and other key stakeholders all took part in one of 26 two-day workshops across the United Kingdom. The impact on interagency working was examined using changes in pre- and post-survey results, changes in self-reported aspects of interagency working and 10 local reviews of practice. The pre-post questionnaires showed improvements in interagency working (e.g. 55% of school leads reported being in 'monthly' or 'continuous' contact with the National Health Service (NHS) CYPMHS¹ at follow-up, compared with 24% at baseline). The group-completed CASCADE framework showed an overall increase in collaborative working, although some areas continued to report significant challenges such as in relation to common outcome measures. The local reviews found positive changes in interagency working, in terms of building relationships, improved communication and sharing good practice. This service evaluation of the workshops found some evidence of improved interagency working between schools and CYPMHS, but more controlled research is needed to consider generalisability and scalability.

Strategies not accompanied by a mental health professional to address anxiety and depression in children and young people: a scoping review of range and a systematic review of effectiveness

This Review reports on a scoping review followed by a systematic review to consider interventions designed to address or manage depression or anxiety in children and young people up to the age of 25 years without the need to involve mental health professionals. The scoping review identified 132 approaches, 103 of which referred to children or young people (younger than 25 years). These approaches included social interaction, engagement with nature, relaxation, distraction, sensory stimulation, physical activity, altering perceptions, engaging in hobbies, self-expression, and exploration. A systematic review of effectiveness studies from the literature identified in the scoping review found only 38 studies on seven types of intervention that met the inclusion criteria. 16 studies were based on cognitive or behavioural principles (15 on digital interventions and one on bibliotherapy), ten focused on physical exercise, five on light therapy, three on dietary supplements, two on massage therapy, one on online peer support, and one on contact with a dog. Most studies focused on adolescents or young adults. Evidence suggested that light therapy could be effective for season depression and that digital interventions based on attention bias modification are ineffective for anxiety. Mixed evidence was available on the effectiveness of computerised cognitive behavioural therapy for depression and anxiety, and of physical exercise for depression. All other studies had insufficient certainty to obtain even tentative conclusions about effectiveness. These results highlight the disparity between the extensive range of approaches identified in the scoping review and the restricted number and focus found in the systematic review of effectiveness of these approaches. We call for an expanded research agenda that brings evaluation rigour to a wide range of self or community approaches.