Tami Kramer

Process, outcome and experience of transition from child to adult mental healthcare : multiperspective study

BACKGROUND Many adolescents with mental health problems experience transition of care from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). AIMS As part of the TRACK study we evaluated the process, outcomes and user and carer experience of transition from CAMHS to AMHS. METHOD We identified a cohort of service users crossing the CAMHS/AMHS boundary over 1 year across six mental health trusts in England. We tracked their journey to determine predictors of optimal transition and conducted qualitative interviews with a subsample of users, their carers and clinicians on how transition was experienced. RESULTS Of 154 individuals who crossed the transition boundary in 1 year, 90 were actual referrals (i.e. they made a transition to AMHS), and 64 were potential referrals (i.e. were either not referred to AMHS or not accepted by AMHS). Individuals with a history of severe mental illness, being on medication or having been admitted were more likely to make a transition than those with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder. Optimal transition, defined as adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition, was experienced by less than 5% of those who made a transition. Following transition, most service users stayed engaged with AMHS and reported improvement in their mental health. CONCLUSIONS For the vast majority of service users, transition from CAMHS to AMHS is poorly planned, poorly executed and poorly experienced. The transition process accentuates pre-existing barriers between CAMHS and AMHS.

Transfers and transitions between child and adult mental health services

BACKGROUND Transfer of care from one healthcare provider to another is often understood as a suboptimal version of the process of transition. AIMS To separate and evaluate concepts of transfer and transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). METHOD In a retrospective case-note survey of young people reaching the upper age boundary at six English CAMHS, optimal transition was evaluated using four criteria: continuity of care, parallel care, a transition planning meeting and information transfer. RESULTS Of 154 cases, 76 transferred to AMHS. Failure to transfer resulted mainly from non-referral by CAMHS (n = 12) and refusal by service users (n = 12) rather than refusal by AMHS (n = 7). Four cases met all criteria for optimal transition, 13 met none; continuity of care (n = 63) was met most often. CONCLUSIONS Transfer was common but good transition rare. Reasons for failure to transfer differ from barriers to transition. Transfer should be investigated alongside transition in research and service development.

Training General Practitioners in the Identification and Management of Adolescent Depression within the Consultation: A Feasibility Study.

BACKGROUND Depressive disorders are common in adolescent general practice attenders. METHOD Adolescent attenders were screened/interviewed for depressive disorders, general practitioners (GPs) completed a checklist indicating recognition of psychopathology prior to and following GP training in the identification/management of adolescent depression. RESULTS One hundred and thirty consecutive adolescent attenders were screened before and 184 after training. Ten GPs completed the training. Psychiatric interviews with 38 adolescents with high depressive scores prior to and 44 following training identified 10 (26%) and 21 (48%), respectively, as clinically depressed. Sensitivity of GP identification improved from 2/10 (20%) to 9/21 (43%) without loss of specificity; predictive validity from 2/6 (33%) to 9/12 (75%). Adolescents interviewed appreciated the intervention. CONCLUSIONS Training GPs is feasible and may improve recognition of adolescent depression.

Assessment of Somatic Symptoms in British Secondary School Children Using the Children's Somatization Inventory (CSI)

OBJECTIVE To present normative and psychometric data on somatic symptoms using the Childrens Somatization Inventory (CSI) in a nonclinical sample of British young people, and to assess associations with stress and functional impairment. METHODS A total of 1,173 students (11- to 16-years old) completed the CSI and self-report psychopathology measures. RESULTS The median CSI total score was 12 (5, 23). Headaches, feeling low in energy, sore muscles, faintness, and nausea were most frequent. Girls scored higher than boys, and respondents aged 13-14 years lower than younger children. The CSI showed good internal consistency and exploratory factor analysis yielded three factors: pain/weakness, gastrointestinal, and pseudoneurological. A quarter of respondents reported somatic symptoms were made worse by stress. CSI scores were moderately significantly correlated with impairment and emotional symptoms. CONCLUSIONS The CSI, complemented by information on functional impairment and stress is an appropriate measure of recent somatic symptoms and somatization risk in young people for use in the UK.

Depressive symptoms amongst adolescent primary care attenders. Levels and associations.

Abstract.Background:Background High rates of depressive disorder have been documented amongst adolescents attending general practitioners (GPs) in urban areas. However, little is known about the associations of adolescent depression in primary care.Method:We completed a cross-sectional questionnaire survey of adolescents, their parents and general practitioners, following adolescent attendance at the surgery.Results:We found high levels of depressive symptoms to be present in adolescent attenders of a broad range of social backgrounds. Depressive symptoms were associated with the following demographic and contextual factors: older age, female gender and parental psychiatric symptoms. They were also associated with the presence of physical symptoms causing psychosocial impairment, with health risks (use of cannabis and exposure to drugs) and with use of services (both primary care and mental health services). Levels of depressive symptoms were similar in urban and suburban groups. However, associations of depressive symptoms with smoking, exposure to drugs, cannabis use and primary care attendance were demonstrated in the suburban group and not the urban group.Conclusion:Adolescent GP attenders have high levels of depressive symptomatology. GP recognition and intervention should have the potential to impact on adolescent depression and on associated risks.

‘Talking a different language’: an exploration of the influence of organizational cultures and working practices on transition from child to adult mental health services

BackgroundOrganizational culture is manifest in patterns of behaviour underpinned by beliefs, values, attitudes and assumptions, which can influence working practices. Cultural factors and working practices have been suggested to influence the transition of young people moving from child to adult mental health services. Failure to manage and integrate transitional care effectively can lead to young people losing contact with health and social care systems, resulting in adverse effects on health, well-being and potential.MethodsThe study aim was to identify the organisational factors which facilitate or impede transition of young people from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) from the perspective of health professionals and representatives of voluntary organisations. Specific objectives were (i) to explore organizational cultures, structures, processes and resources which influence transition from child to adult mental health services; (ii) identify factors which constitute barriers and facilitators to transition and continuity of care and (iii) make recommendations for service improvements. Within an exploratory, qualitative design thirty four semi-structured interviews were conducted with health and social care professionals working in CAMHS and AMHS in four NHS Mental Health Trusts and four voluntary organizations, in England.ResultsA cultural divide appears to exist between CAMHS and AMHS, characterized by different beliefs, attitudes, mutual misperceptions and a lack of understanding of different service structures. This is exacerbated by working practices relating to communication and information transfer which could impact negatively on transition, relational, informational and cross boundary continuity of care. There is also evidence of a cultural shift, with some positive approaches to collaborative working across services and agencies, involving joint posts, parallel working, shared clinics and joint meetings.ConclusionsCultural factors embodied in mutual misperceptions, attitudes, beliefs exist between CAMHS and AMHS. Working practices can exert either positive or negative effects on transition and continuity of care. Implementation of shared education and training, standardised approaches to record keeping and information transfer, supported by compatible IT resources are recommended, alongside management strategies which evaluate the achievement of outcomes related to transition and continuity of care.

The effect of organisational resources and eligibility issues on transition from child and adolescent to adult mental health services

Objectives To investigate the organisational factors that impede or facilitate transition of young people from child and adolescent (CAMHS) to adult mental health services (AMHS). Methods Thirty-four semi-structured interviews were conducted with health and social care professionals working in child and adult services in four English NHS Mental Health Trusts and voluntary organisations. Data were analysed thematically using a structured framework. Results Findings revealed a lack of clarity on service availability and the operation of different eligibility criteria between child and adult mental health services, with variable service provision for young people with attention deficit hyperactivity disorder, autism spectrum disorders and learning disabilities. High workloads and staff shortages were perceived to influence service thresholds and eligibility criteria. Conclusions A mutual lack of understanding of services and structures together with restrictive eligibility criteria exacerbated by perceived lack of resources can impact negatively on the transition between CAMHS and AMHS, disrupting continuity of care for young people.

Child and Adolescent Mental Health interface work with primary services: A survey of NHS provider trusts

BACKGROUND We document the extent, nature and predictors of interface work between secondary Child and Adolescent Mental Health (CAMHS) and primary services, through structured questionnaires sent to all Trusts with CAMHS in England (returned by 124/150 or 83%). RESULTS Two-thirds of CAMHS reported training and education to primary care services, about one-third a structured consultation service, one-fifth reported undertaking outpatient clinics in primary care settings and joint casework. One-third had developed primary mental health worker posts. Multiple regression analysis identified firstly specialist clinics within CAMHS, and secondly CAMHS size, as the strongest predictors of interface work across agencies. Interface work thus grows with more developed, larger CAMHS.

Testing the Feasibility of Therapeutic Identification of Depression in Young People in British General Practice

PURPOSE Depression in young people attending primary care is common and is associated with impairment and recurrence into adulthood. However, it remains under-recognized. This study evaluated the feasibility of training primary care practitioners (PCPs) in screening and therapeutic identification of adolescent depression, and assessed its effects on practitioner knowledge, attitudes, screening, and management. METHODS We trained PCPs in therapeutic identification of adolescent depression during general practice consultations. To assess changes in knowledge and attitudes, PCPs completed questionnaires before and after training. We ascertained changes in depression screening and identification rates in the 16 weeks before and after training from electronic medical records of young people aged 13-17 years. Post-training management of depression was recorded on a checklist. RESULTS Aspects of practitioner knowledge (of depression prevalence and treatment guidelines) and confidence (regarding depression identification and management) increased significantly (all p < .04). Overall screening rates were enhanced from .7% to 20% after the intervention and depression identification rates from .5% before training to 2% thereafter (29-fold and fourfold increases, respectively). Identification was significantly associated with PCP knowledge of prior mental health problems (Fishers exact test, p = .026; odds ratio, 4.884 [95% confidence interval, 1.171-20.52]) and of psychosocial stressors (Fishers exact test, p = .001; odds ratio, 17.45 [95% confidence interval, 2.055-148.2]). CONCLUSIONS The Therapeutic Identification of Depression in Young People program is a feasible approach to improving primary care screening for adolescent depression, with promising evidence of effectiveness. Further evaluation in a randomized trial is required to test practitioner accuracy, clinical impact, and cost benefit.

Psychological distress and mental health service contact of unaccompanied asylum-seeking children

BACKGROUND Evidence is emerging that psychological problems, particularly symptoms of depression and post-traumatic stress disorder, are more prevalent in unaccompanied asylum-seeking children (UASC) than their accompanied peers. However, little is known about help seeking and mental health service (MHS) utilization in this group, and how this relates to their psychological needs. This study aims to describe the level of psychological distress among a group of UASC and the pattern of MHS contact. METHOD Socio-demographic data on 71 UASC residing in London was obtained and self-report questionnaires were completed regarding trauma events (Harvard Trauma Questionnaire), general psychological distress [Strengths and Difficulties Questionnaire (SDQ)], post-traumatic stress symptoms (Impact of Event Scale), depressive symptoms (Birleson Depression Self-Rating Scale for Children) and contact with MHS (Attitudes to Health and Services Questionnaire). RESULTS UASC were mainly male (n = 48, 67.6%), Black African (n = 39, 54.9%) and their median age was 17 years (interquartile range = 15; 17). They had been living in the UK for a median of 18 months. Eight (11.3%) scored on the SDQ borderline/abnormal range for total symptoms, but this was 21 (29.6%) using the SDQ emotional subscale. Forty-seven (66.2%) were at high risk for post-traumatic stress disorder and nine (12.7%) at high risk for depressive disorder. Only 12 (17%) had MHS contact. Predictors of MHS contact were depressive symptoms and duration of time in the UK. CONCLUSIONS UASC had a high level of emotional symptoms, especially post-traumatic stress symptoms. However, only a small proportion of UASC were in contact with MHS. This suggests a high level of MHS under-utilization, and reasons for this are discussed.