Registered psychiatric service use, self-harm and suicides of children and young people aged 0-24 before and during the COVID-19 pandemic: a systematic review

BACKGROUND

The COVID-19 pandemic has impacted on psychiatric symptoms of children and young people, but many psychiatric services have been disrupted. It is unclear how service use, self-harm and suicide has changed since the pandemic started. To gain timely information, this systematic review focused on studies based on administrative data that compared psychiatric service use, self-harm and suicide before and during the pandemic among children and young people.

METHODS AND FINDING

A systematic review of studies published in English from 1 January 2020 to 22 March 2021 was conducted, using the Web of Science, PubMed, Embase and PsycINFO databases. Increases or reductions in service use were calculated and compared using percentages. Of the 2,676 papers retrieved, 18 were eligible for the review and they provided data from 19 countries and regions. Most studies assessed changes during the early phase of the COVID-19 pandemic, from March to July 2020, and three assessed the changes until October 2020. Fifteen studies reported a total of 21 service use outcomes that were quantitively examined. More than three-quarters of the 21 outcomes (81%) fell by 5-80% (mean reduction = 27.9%, SD = 35%). Ten of the 20 outcomes for psychiatric emergency department (ED) services reduced by 5% to 80% (mean = 40.1%, SD = 34.9%) during the pandemic. Reductions in service use were also recorded for ED visits due to suicide ideation and self-harm, referrals to secondary mental health services, psychiatric inpatient unit admissions and patients receiving treatment for eating disorders. However, there were also some increases. Suicide rate and the number of ED visits due to suicide attempts have increased, and there was an increase in the number of treatment sessions in a service that provided telemedicine.

CONCLUSION

Most of the studies showed reductions in the use of psychiatric services by children and young people during the early phase of the pandemic and this highlighted potential delays or unmet needs. Suicide rate has increased during the second wave of the pandemic. Further studies are needed to assess the pattern of service use in the later phases of the COVID-19 pandemic.

The role of migration in mental healthcare: treatment satisfaction and utilization

Migration rates increase globally and require an adaption of national mental health services to the needs of persons with migration background. Therefore, we aimed to identify differences between persons with and without migratory background regarding (1) treatment satisfaction, (2) needed and received mental healthcare and (3) utilization of mental healthcare.In the context of a cross-sectional multicenter study, inpatients and day hospital patients of psychiatric settings in Southern Germany with severe affective and non-affective psychoses were included. Patients' satisfaction with and their use of mental healthcare services were assessed by VSSS-54 and CSSRI-EU; patients' needs were measured via CAN-EU.In total, 387 participants (migratory background: n = 72; 19%) provided sufficient responses for analyses. Migrant patients were more satisfied with the overall treatment in the past year compared to non-migrant patients. No differences between both groups were identified in met and unmet treatment needs and use of supply services (psychiatric, psychotherapeutic, and psychosocial treatment).Despite a comparable degree of met and unmet treatment needs and mental health service use among migrants and non-migrants, patients with migration background showed higher overall treatment satisfaction compared to non-migrants. The role of sociocultural and migrant-related factors may explain our findings.

Characteristics and patterns of health and social service use by families with babies and toddlers in Germany

OBJECTIVES

In the field of family health, cross-sectoral collaboration is promoted to reach vulnerable groups and overcome the prevention dilemma. To understand the extent to which these measures counteract the effects of social inequality with respect to health and social service uptake, we aim to identify socio-economic, health-related and psychosocial characteristics and patterns that are associated with the (non-)use of services.

STUDY DESIGN

This was a German representative cross-sectional study of 6860 mothers with a child younger than 48 months who answered the written questionnaire during child developmental examinations at paediatric practices in 2015.

METHODS

Associations were measured using logistic regression, and characteristics of user patterns were analysed using latent class analysis.

RESULTS

Mothers using universal services were less likely to report psychosocial stress and had more likely more socio-economic resources than mothers who did not use these services. The selective services pregnancy counselling (18.2%) were predominantly used by mothers who considered abortion during pregnancy (Odds Ratio [OR] = 3.9), mothers who received social welfare benefits (OR = 2.4), single parents (OR = 1.6) and mothers without social support (OR = 1.5). Four patterns of service use were identified: multi-service users (5.6%), low-service users (22.5%), medical service users (30.5%) and medical and social service users (41.6%). Families with less socio-economic resources were found in both the low-service group and the multi-service group; multi-users were more likely to have children with adverse perinatal characteristics and parenting stress.

CONCLUSION

We discuss whether low-service users are hard to reach, whereas multi-users are difficult to supply. Overall, there is a need to strengthen early psychosocial support.

The dynamics of frailty development and progression in older adults in primary care in England (2006-2017): a retrospective cohort profile

BACKGROUND

Frailty is a common condition in older adults and has a major impact on patient outcomes and service use. Information on the prevalence in middle-aged adults and the patterns of progression of frailty at an individual and population level is scarce. To address this, a cohort was defined from a large primary care database in England to describe the epidemiology of frailty and understand the dynamics of frailty within individuals and across the population. This article describes the structure of the dataset, cohort characteristics and planned analyses.

METHODS

Retrospective cohort study using electronic health records. Participants were aged ≥50 years registered in practices contributing to the Oxford Royal College of General Practitioners Research and Surveillance Centre between 2006 to 2017. Data include GP practice details, patient sociodemographic and clinical characteristics, twice-yearly electronic Frailty Index (eFI), deaths, medication use and primary and secondary care health service use. Participants in each cohort year by age group, GP and patient characteristics at cohort entry are described.

RESULTS

The cohort includes 2,177,656 patients, contributing 15,552,946 person-years, registered at 419 primary care practices in England. The mean age was 61 years, 52.1% of the cohort was female, and 77.6% lived in urban environments. Frailty increased with age, affecting 10% of adults aged 50-64 and 43.7% of adults aged ≥65. The prevalence of long-term conditions and specific frailty deficits increased with age, as did the eFI and the severity of frailty categories.

CONCLUSION

A comprehensive understanding of frailty dynamics will inform predictions of current and future care needs to facilitate timely planning of appropriate interventions, service configurations and workforce requirements. Analysis of this large, nationally representative cohort including participants aged ≥50 will capture earlier transitions to frailty and enable a detailed understanding of progression and impact. These results will inform novel simulation models which predict future health and service needs of older people living with frailty.

STUDY REGISTRATION

Registered on www.clinicaltrials.gov October 25th 2019, NCT04139278 .

Pathways to mental health care in active military populations across the Five-Eyes nations: An integrated perspective

Military service is associated with increased risk of mental health problems. Previous reviews have pointed to under-utilization of mental health services in military populations. Building on the most recent systematic review, our narrative, critical review takes a complementary approach and considers research across the Five-Eyes nations from the past six years to update and broaden the discussion on pathways to mental healthcare in military populations. We find that at a broad population level, there is improvement in several indicators of mental health care access, with greater gains in initial engagement, time to first treatment contact, and subjective satisfaction with care, and smaller gains in objective indicators of adequacy of care. Among individual-level barriers to care-seeking, there is progress in improving recognition of need for care and reducing stigma concerns. Among organizational-level barriers, there are advances in availability of services and cultural acceptance of care-seeking. Other barriers, such as concerns around confidentiality, career impact, and deployability persist, however, and may account for some remaining unmet need. To address these barriers, new initiatives that are more evidence-based, theoretically-driven, and culturally-sensitive, are therefore needed, and must be rigorously evaluated to ensure they bring about additional improvements in pathways to care.

Help-Seeking Behavior and Treatment Barriers in Anxiety Disorders: Results from a Representative German Community Survey

Although effective therapies exist, treatment rates of anxiety disorders (AD) are low, raising the question why affected individuals do not receive treatment. We provide data from the nationally representative German Health Interview and Examination Survey-2011 (DEGS1) on the help-seeking behavior and perceived treatment barriers of 650 subjects with Diagnostic and Statistical Manual of Mental Disorders' (DSM-IV AD). Only 26% of all cases with AD in the community reported having had contact with mental health services because of their anxiety problems in their lifetime. 16% were currently receiving professional help, most frequently by psychotherapists (8%), psychiatrists (5%) and general practitioners (5%). 40% of all cases never even considered seeking help and 31% reported barriers to treatment, such as self-reliance (18%) or beliefs that treatments were ineffective (9%), unavailable (8%) or too stigmatizing (7%). Measures to increase treatment rates should thus target individual as well as public attitudes and health literacy to increase awareness of and access to evidence-based interventions.

Referral patterns to outpatient child and adolescent mental health services and factors associated with referrals being rejected. A cross-sectional observational study

BACKGROUND

Outpatient child and adolescent mental health services (CAMHS) are faced with the challenge of balancing increasing demands with limited resources. An additional challenge is high rejection rates of referrals which causes frustration for referring agents and families. In order to effectively plan and allocate available resources within CAMHS there is a need for up-to-date knowledge on referral patterns and factors associated with rejection of referrals.

METHODS

In this cross-sectional observational study we did a retrospective review of all referrals (n = 1825) for children (0-18) referred for assessment at the outpatient CAMHS of the North Denmark Region in 2018.

RESULTS

The most common referral reasons to CAMHS were attention deficit disorder (ADHD/ADD) (27.9%), autism spectrum disorder (22.4%), affective disorders (14.0%) and anxiety disorders (11.6%). The majority of referrals came from general practitioners, but for neurodevelopmental disorders educational psychologists were the primary referral source. Re-referrals constituted more than a third of all referrals (35.9%). Children in care were overrepresented in this clinical sample and had an increased risk (Adj. OR 2.54) of having their referrals rejected by CAMHS. Referrals from general practitioners were also associated with an increased risk of rejection (Adj. OR 3.29).

CONCLUSIONS

A high proportion of children with mental disorders have a repeated need for assessment by CAMHS. There is a need for future research on predictors of re-referral to outpatient services to identify potential targets for reducing re-referral rates as well as research on how to optimize service provision for children with a repeated need for assessment. General practitioners are the main gatekeepers to CAMHS and research on interventions to improve the referral process should be aimed towards general practitioners.

Predictors of community versus specialty mental health service use: a prospective cohort study

Child and adolescent mental health specialized services (CAMHS) are supposed to serve those who are most seriously disturbed and impaired. However, little is known about how children receiving treatment at different levels of care differ. The present study seeks to determine whether having a psychiatric disorder and resulting impairment measured in early childhood increases the odds of receiving help in CAMHS versus from community services during middle childhood or whether other factors (e.g., parenting stress, family functioning) also influence service utilization. A screen-stratified sample (n = 995 of the 2003-2004 birth cohorts) in Trondheim, Norway was assessed biennially from age 4-12 with semi-structured diagnostic interviews and recording of service use, family functioning, parental perceived need, and parenting stress. Behavioral disorders more strongly predicted CAMHS than community service use, whereas impairment predicted community service use. However, impairment increased the odds of receiving services in CAMHS if the parents perceived a need for help. Parental perceived need for help also increased the odds of CAMHS use independent of diagnosis and impairment. Having an emotional disorder, attention deficit/hyperactivity disorder (ADHD), parenting stress, previous service use, or family functioning did not predict service use at either level. Whereas children with behavioral disorders received help from CAMHS, children with emotional disorders did not receive services at either level. ADHD did not predict service use, indicating that young children with ADHD without comorbid disorders are not sufficiently detected. Efforts to detect, refer and treat emotional disorders and ADHD at the appropriate level should be increased.

Parent Distress Intolerance, Repetitive Negative Thinking, and Mental Health Service Use

While extensive evidence links service use for mental health problems to demographic variables and positive attitudes, studies have not explored the role of transdiagnostic risk factors, like distress intolerance (DI) and repetitive negative thinking (RNT). This study examined the relationship between parental DI and RNT on mental health treatment seeking for parents themselves and their children. Results suggest higher DI and RNT predict service use among parents (p < 0.05) but were not significantly associated with help seeking for their children, indicating that factors more proximal to the child may have greater influence when parents make treatment decisions for their children. Results also indicte that DI moderates the relationship between parent psychopathology and parent service use, such that parent psychopathology is significantly associated with service use for those with lower DI, but not at moderate or high levels of DI. Implications for marketing mental health information to parents and engaging them in treatment are discussed.

Service Use Among Transition-Age Youth with Autism Spectrum Disorder

This study explored predictors of service use among 174 transition-age youth (age 16-30) with an Autism Spectrum Disorder using Andersen's (J Health Soc Behav 36(1):1-10, 1995) healthcare utilization model. Family caregivers were interviewed about past 6-month use of 15 services. On average, youth used 6.1 and needed 3.2 additional services. Greater service use was associated with two predisposing (caregiver college educated, caregiver not married/partnered), two enabling (youth has Medicaid waiver, youth in high school), and one need factor (lower adaptive functioning). Use of specific services was most strongly related to enabling (Medicaid waiver, in high school) and need factors (lower adaptive functioning, comorbid mental health diagnosis). Findings provide a snapshot of the "service cliff" faced by families and highlight the need for additional research.

Trauma, PTSD, and complex PTSD in the Republic of Ireland: prevalence, service use, comorbidity, and risk factors

PURPOSE

This study represents the first assessment of the prevalence of trauma exposure, and Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD), ever conducted in the general population of the Republic of Ireland. Additionally, prevalence of past-year mental health service use, comorbidity with major depression and generalized anxiety, and risk factors associated with PTSD and CPTSD were assessed.

METHODS

A nationally representative sample of non-institutionalized Irish adults (N = 1020) completed self-report measures of trauma history, trauma-related psychopathology, mental health service use, and concurrent mental health problems.

RESULTS

Lifetime exposure to one or more traumatic events was 82.3%, and 67.8% reported experiencing two or more traumatic events. Males and females significantly differed in their frequency of exposure to eight of 16 traumatic events. The past-month prevalence for PTSD was 5.0% (95% CI 3.7%, 6.3%) and 7.7% (95% CI 6.1%, 9.4%) for CPTSD. Of those who screened positive for PTSD or CPTSD, 48.6% accessed mental health care in the past year. Comorbidity with major depression and generalized anxiety was high, especially among those with CPTSD. Several unique and shared risk factors for PTSD and CPTSD were identified.

CONCLUSION

Approximately one-in-eight Irish adults met diagnostic requirements for PTSD or CPTSD, and comorbidity with other disorders was high. History of interpersonal trauma and exposure to multiple types of trauma in different developmental periods were associated with CPTSD. Many individuals did not access mental health care revealing a substantial mental health treatment gap.

Risk and protective factors associated with mental health among female military veterans: results from the veterans' health study

Background

This study focuses on factors that may disproportionately affect female veterans’ mental health, compared to men, and is part of a larger study assessing the prevalence of mental health disorders and treatment seeking among formerly deployed US military service members.

Methods

We surveyed a random sample of 1,730 veterans who were patients in a large non-VA hospital system in the US. Based on previous research, women were hypothesized to be at higher risk for psychological problems. We adjusted our results for confounding factors, including history of trauma, childhood abuse, combat exposure, deployments, stressful life events, alcohol misuse, psychological resources, and social support.

Results

Among the veterans studied, 5% were female (n = 85), 96% were White (n = 1,161), 22.9% were Iraq/Afghanistan veterans (n = 398), and the mean age was 59 years old (SD = 12). Compared to males, female veterans were younger, unmarried, college graduates, had less combat exposure, but were more likely to have lifetime PTSD (29% vs. 12%.), depression (46% vs. 21%), suicidal ideation (27% vs. 11%), and lifetime mental health service use (67% vs. 47%). Females were also more likely to have low psychological resilience and to have used psychotropic medications in the past year. Using multivariate logistic regression analyses that controlled for risk and protective factors, female veterans had greater risk for lifetime PTSD, depression, suicidal thoughts, and for lifetime use of psychological services, compared to males. Since 95% of the population in this study were male and these results may have been statistically biased, we reran our analyses using propensity score matching. Results were consistent across these analyses.

Conclusion

Using a sample of post-deployment veterans receiving healthcare services from a large non-VA health system, we find that female veterans are at greater risk for lifetime psychological problems, compared to male veterans. We discuss these findings and their implications for service providers.

Trends in the utilization of youth primary healthcare services and psychological distress

Background

Psychological distress among young people is increasing in Northern Europe. According to established healthcare utilization theory, this will create a greater need for youth primary healthcare and subsequently lead to more help-seeking behavior by distressed young people. The aim of this study was to investigate the association between the use of youth primary healthcare services and psychological distress in times of increasing mental health problems and increased service need.

Methods

This study consisted of five waves of repeated annual cross-sectional data collected from young people (aged 13–19) living in Norway between 2014 and 2018 (n = 368,579). Population-weighted and design-adjusted generalized linear regression with a log-link was used to examine the use of youth primary healthcare services over time.

Results

We found that a large proportion of young people use primary healthcare services and that young people with high levels of psychological distress use primary healthcare services twice as much as their peers with low levels of psychological distress. In addition, between 2014 and 2018 both psychological distress and primary healthcare service utilization increased: psychological distress increased by 5% and total primary healthcare service use increased by 500 consultations per 1000 young people. Overall, psychological distress had a conditional association with youth primary healthcare service use and could account for between 16 and 66% of the change in the use of services between 2014 and 2018, depending on the service type. However, the absolute increase seen in the use of primary healthcare services was mainly driven by young people with low levels of psychological distress as opposed to young people with high psychological distress. This suggest a converging trend.

Conclusions

Our findings suggest that there might be serious barriers between need and help-seeking behavior for young people with high levels of psychological distress and that the pattern of utilization among young people with lower distress may indicate overuse, possibly as an inadvertent consequence of a newly introduced school absence policy. While further research is needed to confirm these findings, our work may inform healthcare providers and policy makers about primary healthcare utilization trends among young people.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06124-w.

Parent-perceived barriers to accessing services for their child's mental health problems

BACKGROUND

Many children and adolescents with impairing mental health disorders are not in contact with specialized child and adolescent mental health services (CAMHS). In order to close the service gap, it is important to increase our knowledge of barriers to access. The aim of this study was to investigate parent perceived barriers to accessing services for their child's mental health problems to identify potential areas for improvement of access to CAMHS.

METHOD

In this cross-sectional observational study 244 parents of children and adolescents referred to outpatient psychiatric assessment were interviewed using the Children's services interview regarding barriers to accessing child mental health services across healthcare, educational services and social services. Parent reported barriers were analyzed in relation to the child's age, referral reason, symptom duration and impairment of the child.

RESULTS

The most commonly reported barriers were lack of information about were to seek help (60.3%), the perception that professionals did not listen (59.8%) and professionals refusing to initiate interventions or provide referral to services (53.7%). Lack of knowledge, stigmatization and unavailability of services were common themes across barriers to help-seeking. Long symptom duration and parent rated impairment was associated with increased risk of reporting several barriers to help-seeking.

CONCLUSION

Parents seeking help for their child's mental health encounter numerous barriers that could explain part of the treatment gap and long duration of mental health problems in children prior to referral to CAMHS.

Screening and referral is not enough: a qualitative exploration of barriers to access and uptake of mental health services in patients with cardiovascular diseases

Background

Cardiovascular diseases (CVD) are commonly comorbid with mental health disorders, portending poorer cardiac prognosis. Despite the high prevalence of depression and anxiety, and guidelines recommending routine depression screening and referral, uptake of mental healthcare in CVD populations remains low. Reasons for the underutilisation of mental health and psychological services for this population remain largely unknown.

Methods

Thirteen CVD patients with clinically significant psychological symptoms (depression, anxiety and/or stress) participated in one-on-one in-depth semi-structured interviews. Data were analysed using inductive thematic analysis.

Results

Barriers to uptake included the timing of referral and screening, with patients reporting a need for longer term follow-up. A lack of information provision and understanding around mental health and services, especially following cardiac-events were further barriers. A reluctance to report mental health or engage in services was also identified, with patients indicating a preference for informal peer support networks. A range of practical barriers such as mobility, transport and cost were also reported.

Conclusions

Longer term follow-up and routine mental health assessment may be beneficial to facilitate use of mental health services. Upskilling of practitioners around mental health may be a further avenue to promote information provision and enhance service use. Further focus on enhancing informal peer support may be a valuable initial approach for the CVD population. The implications for improving services and enhancing service use are discussed.

Counselling and psychotherapy service use in Chinese sexual minority populations: a nationwide survey

BACKGROUND

This study investigated the prevalence and factors associated with counselling and psychotherapy service use among Chinese sexual minority populations.

METHODS

A nationwide cross-sectional study was performed using snowball sampling method, which led to the inclusion of 18,193 participants. Participants' sociodemographic background, clinical, and psychological data were gathered. Multivariate logistic regression analysis was performed to explore any associated factors.

RESULTS

There were 2007 participants who had used counselling and psychotherapy service out of the total population. Among those who had used psychotherapy services, 80.2% participants perceived discrimination, 1.1% reported that they had been refused treatment by a counsellor and/or psychotherapist, 1.6% had experienced verbal harassment, and 8.4% reported that their counsellor and/or psychotherapist lacked knowledge and experience in treating sexual minorities. In addition, regression analyses indicated that those who were divorced/widowed, had religious beliefs, and those who had experienced discrimination, verbal harassment, and rejection for treatment by health professionals all had an increased likelihood of utilising counselling and psychotherapy service.

CONCLUSIONS

Service providers and policy makers in China should improve the quality and availability of counselling and psychotherapy services to address the mental health needs of sexual minority populations.

Does childhood mental health service use predict subsequent mental health service use during Latino youth transition to young adulthood? Evidence from the Boricua Youth Study

PURPOSE

Studies document the substantial underutilization of mental health services by US Latinos in young adulthood. Rates of service use are higher in childhood, raising questions about whether mental health service use during childhood may facilitate access to services later in life. This article examines the extent to which utilization of mental health services in childhood is predictive of utilization in young adulthood among US Latinos.

METHODS

Data come from the Boricua Youth Study, a longitudinal study of Puerto Rican youth at two sites (South Bronx, New York, and the standard metropolitan area of San Juan, Puerto Rico). Data were collected in three waves during childhood (ages 5-13; surveyed 1 year apart), with an approximately 11-year follow-up in young adulthood (ages 16-29). In childhood, parents reported on youth mental health service use (Waves 1-3). In Wave 4, as youth transitioned to young adults (N = 2004), they reported on their past year mental health service use.

RESULTS

Whereas 30.2% of parents reported their child received mental health services, only 3.5% of young adults reported mental health service use in the past year. After controlling for young adult disorders and their severity, childhood disorders were associated with increased likelihood of mental health service use in young adulthood. Childhood mental health service use was also associated with young adult service use; however, this association attenuated when controlling for childhood disorders.

CONCLUSION

Findings suggest the importance of specifically considering childhood disorders in understanding mechanisms for improving access to mental health services among Latino young adults.

Mental health status in veterans residing in rural versus non-rural areas: results from the veterans' health study

BACKGROUND

The majority of Veterans Affair (VA) hospitals are in urban areas. We examined whether veterans residing in rural areas have lower mental health service use and poorer mental health status.

METHODS

Veterans with at least 1 warzone deployment in central and northeastern Pennsylvania were randomly selected for an interview. Mental health status, including PTSD, major depression, alcohol abuse and mental health global severity, were assessed using structured interviews. Psychiatric service use was based on self-reported utilization in the past 12 months. Results were compared between veterans residing in rural and non-rural areas. Data were also analyzed using multivariate logistic regression to minimize the influence by confounding factors.

RESULTS

A total of 1730 subjects (55% of the eligible veterans) responded to the survey and 1692 of them had complete geocode information. Those that did not have this information (n = 38), were excluded from some analyses. Veterans residing in rural areas were older, more often of the white race, married, and experienced fewer stressful events. In comparison to those residing in non-rural areas, veterans residing in rural areas had lower global mental health severity scores; they also had fewer mental health visits. In multivariate logistic regression, rural residence was associated with lower service use, but not with PTSD, major depression, alcohol abuse, and global mental health severity score after adjusting confounding factors (e.g., age, gender, marital status and education).

CONCLUSIONS

Rural residence is associated with lower mental health service use, but not with poor mental health in veterans with former warzone deployment, suggesting rural residence is possibly protective.

Risk factors of hospitalization for any medical condition among patients with prior emergency department visits for mental health conditions

BACKGROUND

This longitudinal study identified risk factors for frequency of hospitalization among patients with any medical condition who had previously visited one of six Quebec (Canada) emergency departments (ED) at least once for mental health (MH) conditions as the primary diagnosis.

METHODS

Records of n = 11,367 patients were investigated using administrative databanks (2012-13/2014-15). Hospitalization rates in the 12 months after a first ED visit in 2014-15 were categorized as no hospitalizations (0 times), moderate hospitalizations (1-2 times), and frequent hospitalizations (3+ times). Based on the Andersen Behavioral Model, data on risk factors were gathered for the 2 years prior to the first visit in 2014-15, and were identified as predisposing, enabling or needs factors. They were tested using a hierarchical multinomial logistic regression according to the three groups of hospitalization rate.

RESULTS

Enabling factors accounted for the largest percentage of total variance explained in the study model, followed by needs and predisposing factors. Co-occurring mental disorders (MD)/substance-related disorders (SRD), alcohol-related disorders, depressive disorders, frequency of consultations with outpatient psychiatrists, prior ED visits for any medical condition and number of physicians consulted in specialized care, were risk factors for both moderate and frequent hospitalizations. Schizophrenia spectrum and other psychotic disorders, bipolar disorders, and age (except 12-17 years) were risk factors for moderate hospitalizations, while higher numbers (4+) of overall interventions in local community health service centers were a risk factor for frequent hospitalizations only. Patients with personality disorders, drug-related disorders, suicidal behaviors, and those who visited a psychiatric ED integrated with a general ED in a separate site, or who visited a general ED without psychiatric services were also less likely to be hospitalized. Less urgent and non-urgent illness acuity prevented moderate hospitalizations only.

CONCLUSIONS

Patients with severe and complex health conditions, and higher numbers of both prior outpatient psychiatrist consultations and ED visits for medical conditions had more moderate and frequent hospitalizations as compared with non-hospitalized patients. Patients at risk for frequent hospitalizations were more vulnerable overall and had important biopsychosocial problems. Improved primary care and integrated outpatient services may prevent post-ED hospitalization.

Predictors of study drop-out and service disengagement in patients at clinical high risk for psychosis

PURPOSE

Study drop-out during follow-up and service disengagement frequently occur in patients at clinical high risk for psychosis (CHR-P). However, little is known about their predictors. Therefore, we aimed to analyze the rate and reasons for drop-out and service disengagement in CHR-P patients and investigate their sociodemographic and clinical predictors.

METHODS

Data from 200 patients of the prospective Früherkennung von Psychosen (FePsy) study were analyzed with competing risks survival models, considering drop-out and transition to psychosis as competing events. To investigate whether symptoms changed immediately before drop-out, t tests were applied.

RESULTS

Thirty-six percent of patients dropped out within 5 years. Almost all drop-outs also disengaged from our service. Hence, study drop-out was used as a proxy for service disengagement. Patients with more severe baseline disorganized symptoms and a late inclusion into the study were significantly more likely to disengage. Immediately before disengagement, there was significant improvement in negative symptoms only.

CONCLUSION

A considerable proportion of CHR-P patients disengaged from our clinical study and service. Patients who were included during a later study period with more assessments disengaged more often, which might have been due to more frequent invitations to follow-up assessments and thereby increasing participation burden. Hence, our study provides a cautionary note on high-frequency follow-up assessments. Larger-scale studies evaluating predictors on multiple domains would help to further elucidate drop-out and disengagement.

Racial-Ethnic Differences in Service Use Patterns Among Young, Commercially Insured Individuals With Recent-Onset Psychosis

OBJECTIVE

The aim of this study was to investigate racial-ethnic differences in use of mental health services and antipsychotic medication in the year following the recent onset of a psychotic disorder and to examine the role of household income as a proxy for socioeconomic status.

METHODS

Deidentified administrative claims data from the OptumLabs Data Warehouse were used to identify 8,021 commercially insured individuals ages 14 through 30 with a recent-onset psychotic disorder (January 1, 2011, through December 31, 2015). The authors compared mental health service use among African-American (11.5%), Hispanic (11.0%), and non-Hispanic white (77.4%) individuals during the year following an index diagnosis and adjusted these analyses for household income.

RESULTS

The probability of any use of outpatient mental health services was lower among African-American (67.4%±1.4%) and Hispanic individuals (66.5%±1.5%) compared with non-Hispanic white patients (72.3%±0.6%; p<0.05 for each comparison). Among those who used services, African-American and Hispanic individuals had fewer mean outpatient mental health visits per year compared with non-Hispanic whites (9.7±0.7 and 10.2±0.7 versus 14.3±0.5, respectively, p<0.001 for each comparison). These racial-ethnic differences in service use remained after adjustment for household income.

CONCLUSIONS

Among young, commercially insured individuals using outpatient services following an index diagnosis of psychotic disorder, African Americans and Hispanics received less intensive outpatient mental health care than their non-Hispanic white counterparts. Amid the upsurge of early intervention programs, special attention should be paid to increasing access to mental health services for racial-ethnic minority groups.

Factors Associated with Perceived Continuity of Care Among Patients Suffering from Mental Disorders

This cross-sectional study identified variables associated with continuity of care among 327 patients with mental disorders receiving services from a variety of professionals in different Quebec settings. Based on the Andersen's Behavioral Model, a linear regression analysis was performed. Attention deficit and mood disorders were negatively associated with continuity of care, while substance use disorders and quality of life revealed positive associations. Consulting a psychologist was linked to weaker continuity of care whereas visiting a drug rehabilitation center, social support, and satisfaction with services were positively related. Fostering social support, comprehensive and integrated care, and facilitating access to psychologists could lead to improved continuity of care.

Early Intervention in Psychosis Treatment Components Utilization in Patients Aged Over 35

Early Intervention in Psychosis (EIP) services have been youth-focused since their inception. In England, recent National Institute for Health and Care Excellence (NICE) guidelines and new National Health Service (NHS) Standards for EIP recommend the expansion of the age acceptability criterion from 14-35 to 14-65. In the Cambridgeshire and Peterborough EIP service (CAMEO), we ran a service evaluation to assess the initial impact of this policy change. It aimed to elicit EIP treatment components utilization by patients with first-episode psychosis (FEP) aged over 35, in comparison with those under 35. We found that the over-35s required more contacts from EIP healthcare professionals, especially from care coordinators (coefficient = .239; Robust SE = .102; Z = 6.42; p = 0.019) and social workers (coefficient = 18.462; Robust SE = .692; Z = .016; p < 0.001). These findings indicate that FEP patients aged over 35 may present with more complex and sustained clinical/social needs. This may have implications for EIP service development and commissioning.

Falling between two systems of care: Engaging families, behavioral health and the justice systems to increase uptake of substance use treatment in youth on probation

Justice-involved youth (JIY) in the US have high rates of substance use (SU) problems, yet 50%-80% of these youth do not receive necessary services. There has been no systematic exploration of the use of treatment services for JIY that examines viewpoints across stakeholders in justice- and treatment-systems as well as the families. We conducted qualitative interviews and focus groups with n = 58, youth, their caregivers, SU treatment providers and probation officers in a Northeastern state. Interviews explored how families, staff- and system-level factors influence uptake of and retention in SU treatment services in youth on probation. We conducted a thematic analysis of all interview texts. Caregiver engagement is essential for youth treatment uptake and retention. Difficulties achieving caregiver engagement and agreement that treatment was necessary stemmed from distrust in the "system"; denial or minimization of youth's SU problem; relational barriers; and overburden and chaos within the family system. Structural barriers to service uptake were lack of available treatment options, SU agency practices and policies, and interagency collaboration between SU treatment agencies and probation. Enhancing family engagement at the point of referral to SU treatment is essential. Improvements in interagency collaboration and communication between SU treatment and probation agencies are necessary. Implications for policy and intervention are discussed.

Childhood bullying victimization, self-labelling, and help-seeking for mental health problems

PURPOSE

Previous research found sustained high levels of mental health service use among adults who experienced bullying victimization during childhood. This could be due to increased psychopathology among this group, but other factors, such as self-perception as having a mental health problem, might contribute to increased service use. Additionally, the relationship between informal help-seeking for mental health problems and bullying victimization is incompletely understood.

METHODS

The present study examined associations between the frequency of bullying victimization and both formal service use and informal help-seeking for mental health problems independent from psychopathology. Data on bullying victimization, service use, informal help-seeking for mental health problems, psychopathology, and self-labelling as a person with mental illness were collected among 422 young people aged 13-22 years.

RESULTS

In logistic regression models, controlling for past and current psychopathology and using no bullying victimization as the reference category, we identified a greater likelihood of mental health service use among persons who experienced frequent bullying victimization, as well as a greater likelihood of seeking informal help among persons who experienced occasional victimization. Increased self-identification as a person with mental illness completely mediated the positive association between frequent bullying victimization and mental health service use.

CONCLUSIONS

Our findings suggest that services to support persons who experienced frequent bullying victimization should focus on improving empowerment and self-perception. Additionally, there might be unserved need for formal support among those who experienced occasional bullying victimization.