Determinants of mental health service use among depressed adolescents

Closing the gap between screening and depression prevention: a qualitative study on barriers and facilitators from the perspective of public health professionals in a school-based prevention approach

BACKGROUND

The prevalence of depression has increased among adolescents in western countries. Prevention is needed to reduce the number of adolescents who experience depression and to avoid negative consequences, including suicide. Several preventive interventions are found to be promising, especially multi-modal approaches, for example combining screening and preventive intervention. However, an important bottleneck arises during the implementation of preventive intervention. Only a small percentage of adolescents who are eligible for participation actually participate in the intervention. To ensure that more adolescents can benefit from prevention, we need to close the gap between detection and preventive intervention. We investigated the barriers and facilitators from the perspective of public health professionals in screening for depressive and suicidal symptoms and depression prevention referral in a school-based setting.

METHODS

We conducted 13 semi-structured interviews with public health professionals, who execute screening and depression prevention referral within the Strong Teens and Resilient Minds (STORM) approach. The interviews were recorded, transcribed verbatim, and coded in several cycles using ATLAS.ti Web.

RESULTS

Three main themes of barriers and facilitators emerged from the interviews, namely "professional capabilities," "organization and collaboration," and "beliefs about depressive and suicidal symptoms and participation in prevention". The interviews revealed that professionals do not always feel sufficiently equipped in terms of knowledge, skills and supporting networks. Consequently, they do not always feel well able to execute the process of screening and prevention referral. In addition, a lack of knowledge and support in schools and other cooperating organizationorganizations was seen to hinder the process. Last, the beliefs of public health professionals, school staff, adolescents, and parents -especially stigma and taboo-were found to make the screening and prevention referral process more challenging.

CONCLUSIONS

To further improve the process of screening and prevention referral in a school-based setting, enhancing professional competence and a holding work environment for professionals, a strong collaboration and a joint approach with schools and other cooperating organizations and society wide education about depressive and suicidal symptoms and preventive intervention are suggested. Future research should determine whether these recommendations actually lead to closing the gap between detection and prevention.

A Social Media Website (Supporting Our Valued Adolescents) to Support Treatment Uptake for Adolescents With Depression or Anxiety: Pilot Randomized Controlled Trial

BACKGROUND

Adolescents with depression or anxiety initiate mental health treatment in low numbers. Supporting Our Valued Adolescents (SOVA) is a peer support website intervention for adolescents seen in primary care settings and their parents with the goal of increasing treatment uptake through changing negative health beliefs, enhancing knowledge, offering peer emotional support, and increasing parent-adolescent communication about mental health.

OBJECTIVE

This pilot study aimed to refine recruitment and retention strategies, refine document intervention fidelity, and explore changes in study outcomes (the primary outcome being treatment uptake).

METHODS

We conducted a 2-group, single-blind, pilot randomized controlled trial in a single adolescent medicine clinic. Participants were aged 12 to 19 years with clinician-identified symptoms of depression or anxiety for which a health care provider recommended treatment. The patient and parent, if interested, were randomized to receive the SOVA websites and enhanced usual care (EUC) compared with EUC alone. Baseline, 6-week, and 3-month measures were collected using a web-based self-report survey and blinded electronic health record review. The main pilot outcomes assessed were the feasibility of recruitment and retention strategies. Implementation outcomes, intervention fidelity, missingness, and adequacy of safety protocols were documented. Descriptive statistics were used to summarize mental health service use and target measures with 2-sample t tests to compare differences between arms.

RESULTS

Less than half of the adolescents who were offered patient education material (195/461, 42.2%) were referred by their clinician to the study. Of 146 adolescents meeting the inclusion criteria, 38 completed the baseline survey, qualifying them for randomization, and 25 (66%, 95% CI 51%-81%) completed the 6-week measures. There was limited engagement in the treatment arm, with 45% (5/11) of adolescents who completed 6-week measures reporting accessing SOVA, and most of those who did not access cited forgetting as the reason. Changes were found in target factors at 6 weeks but not in per-protocol analyses. At 12 weeks, 83% (15/18) of adolescents randomized to SOVA received mental health treatment as compared with 50% (10/20) of adolescents randomized to EUC (P=.03).

CONCLUSIONS

In this pilot trial of a peer support website intervention for adolescents with depression or anxiety, we found lower-than-expected study enrollment after recruitment. Although generalizability may be enhanced by not requiring parental permission for adolescent participation in the trials of mental health interventions, this may limit study recruitment and retention. We found that implementing education introducing the study into provider workflow was feasible and acceptable, resulting in almost 500 study referrals. Finally, although not the primary outcome, we found a signal for greater uptake of mental health treatment in the arm using the SOVA intervention than in the usual care arm.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03318666; https://clinicaltrials.gov/ct2/show/NCT03318666.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/12117.

Single-Session Interventions Embedded Within Tumblr: Acceptability, Feasibility, and Utility Study

Background

Existing mental health treatments are insufficient for addressing mental health needs at scale, particularly for teenagers, who now seek mental health information and support on the web. Single-session interventions (SSIs) may be particularly well suited for dissemination as embedded web-based support options that are easily accessible on popular social platforms.

Objective

We aimed to evaluate the acceptability and effectiveness of three SSIs, each with a duration of 5 to 8 minutes (Project Action Brings Change, Project Stop Adolescent Violence Everywhere, and REFRAME)—embedded as Koko minicourses on Tumblr—to improve three key mental health outcomes: hopelessness, self-hate, and the desire to stop self-harm behavior.

Methods

We used quantitative data (ie, star ratings and SSI completion rates) to evaluate acceptability and short-term utility of all 3 SSIs. Paired 2-tailed t tests were used to assess changes in hopelessness, self-hate, and the desire to stop future self-harm from before to after the SSI. Where demographic information was available, the analyses were restricted to teenagers (13-19 years). Examples of positive and negative qualitative user feedback (ie, written text responses) were provided for each program.

Results

The SSIs were completed 6179 times between March 2021 and February 2022. All 3 SSIs generated high star ratings (>4 out of 5 stars), with high completion rates (approximately 25%-57%) relative to real-world completion rates among other digital self-help interventions. Paired 2-tailed t tests detected significant pre-post reductions in hopelessness for those who completed Project Action Brings Change (P<.001, Cohen d_z=−0.81, 95% CI −0.85 to −0.77) and REFRAME (P<.001, Cohen d_z=−0.88, 95% CI −0.96 to −0.80). Self-hate significantly decreased (P<.001, Cohen d_z=−0.67, 95% CI −0.74 to −0.60), and the desire to stop self-harm significantly increased (P<.001, Cohen d_z=0.40, 95% CI 0.33 to 0.47]) from before to after the completion of Project Stop Adolescent Violence Everywhere. The results remained consistent across sensitivity analyses and after correcting for multiple tests. Examples of positive and negative qualitative user feedback point toward future directions for SSI research.

Conclusions

Very brief SSIs, when embedded within popular social platforms, are one promising and acceptable method for providing free, scalable, and potentially helpful mental health support on the web. Considering the unique barriers to mental health treatment access that many teenagers face, this approach may be especially useful for teenagers without access to other mental health supports.

Perceived Facilitators of and Barriers to Implementation of a Decision Support Tool for Adolescent Depression and Suicidality Screening: Focus Group and Interview Study

BACKGROUND

Screening Wizard (SW) is a technology-based decision support tool aimed at guiding primary care providers (PCPs) to respond to depression and suicidality screens in adolescents. Separate screens assess adolescents' and parents' reports on mental health symptoms, treatment preferences, and potential treatment barriers. A detailed summary is provided to PCPs, also identifying adolescent-parent discrepancies. The goal of SW is to enhance decision-making to increase the utilization of evidence-based treatments.

OBJECTIVE

This qualitative study aims to describe multi-stakeholder perspectives of adolescents, parents, and providers to understand the potential barriers to the implementation of SW.

METHODS

We interviewed 11 parents and 11 adolescents and conducted two focus groups with 18 health care providers (PCPs, nurses, therapists, and staff) across 2 pediatric practices. Participants described previous experiences with screening for depression and were shown a mock-up of SW and asked for feedback. Interviews and focus groups were transcribed verbatim, and codebooks were inductively developed based on content. Transcripts were double coded, and disagreements were adjudicated to full agreement. Completed coding was used to produce thematic analyses of the interviews and focus groups.

RESULTS

We identified five main themes across the interviews and focus groups: parents, adolescents, and pediatric PCPs agree that depression screening should occur in pediatric primary care; there is concern that accurate self-disclosure does not always occur during depression screening; SW is viewed as a tool that could facilitate depression screening and that might encourage more honesty in screening responses; parents, adolescents, and providers do not want SW to replace mental health discussions with providers; and providers want to maintain autonomy in treatment decisions.

CONCLUSIONS

We identified that providers, parents, and adolescents are all concerned with current screening practices, mainly regarding inaccurate self-disclosure. They recognized value in SW as a computerized tool that may elicit more honest responses and identify adolescent-parent discrepancies. Surprisingly, providers did not want the SW report to include treatment recommendations, and all groups did not want the SW report to replace conversations with the PCP about depression. Although SW was originally developed as a treatment decision algorithm, this qualitative study has led us to remove this component, and instead, SW focuses on aspects identified as most useful by all groups. We hope that this initial qualitative work will improve the future implementation of SW.

Predicting Mental Health Treatment Access Among Adolescents With Elevated Depressive Symptoms: Machine Learning Approaches

A large proportion of adolescents experiencing depression never access treatment. To increase access to effective mental health care, it is critical to understand factors associated with increased versus decreased odds of adolescent treatment access. This study used individual depression symptoms and sociodemographic variables to predict whether and where adolescents with depression accessed mental health treatments. We performed a pre-registered, secondary analysis of data from the 2017 National Survey of Drug Use and Health (NSDUH), a nationally representative sample of non-institutionalized civilians in the United States. Using four cross-validated random forest models, we predicted whether adolescents with elevated past-year depressive symptoms (N = 1,671; ages 12-17 years) accessed specific mental health treatments in the previous 12 months ("yes/no" for inpatient, outpatient, school, any). 53.38% of adolescents with elevated depressive symptoms accessed treatment of any kind. Even with depressive symptoms and sociodemographic factors included as predictors, pre-registered random forests explained < 0.00% of pseudo out-of-sample deviance in adolescent access to inpatient, outpatient, school, or overall treatments. Exploratory elastic net models explained 0.80-2.50% of pseudo out-of-sample deviance in adolescent treatment access across all four treatment types. Neither individual depressive symptoms nor any socioeconomic variables meaningfully predicted specific or overall mental health treatment access in adolescents with elevated past-year symptoms. This study highlights substantial limitations in our capacity to predict whether and where adolescents access mental health treatment and underscores the broader need for more accessible, scalable adolescent depression treatments.

Social experiences with mental health service use among US adolescents

BACKGROUND

Little is known about the associations of social experiences with mental health service use.

AIM

This study aimed to classify social experiences variables in the past year and examine the associations of selected variables in social experiences with mental health service use among US adolescents.

METHODS

A total of 13,038 adolescents (aged 12 to 17), of which 2208 received mental health services, were from the 2018 National Survey on Drug Use and Health. Multivariate logistic regression (MLR) analysis was conducted.

RESULTS

The overall prevalence of mental health service use was 16.1%. 44 variables on social experiences were grouped into 10 disjoint clusters and one variable from each cluster was selected for MLR analysis. Being female, African American, Hispanics, insured and having depression in the past year were associated with increased odds of mental health service use. Negative feelings about going to school, having a serious fight at school/work, active involvement in substance use help programs, knowledge of drug prevention, negative perceptions about the role of religious beliefs on life decisions were positively associated with mental health service use.

CONCLUSION

Mental health service use is associated with feelings about school and peers, perceptions about drug use, and involvement in activities.

Challenges during the transition from child and adolescent mental health services to adult mental health services

The transition from child and adolescent to adult mental health services for young people with mental health problems is of international concern. Despite the high prevalence of mental disorders during adolescence and their tendency to continue during adulthood, the majority of young people do not experience continuity of care. The aim of this review paper is to unravel the complexity of transitional mental healthcare to clinicians, policy makers and mental health service managers, and to address challenges to a smooth transition process at all levels.

Turning Back to Treatment: The Effect of Attendance and Symptom Outcomes on Subsequent Service Use

This study explored whether post-treatment symptom severity moderated the association between session attendance during an initial treatment episode and subsequent mental health service use. Data on attendance, symptom severity, and service use were gathered from an effectiveness trial testing a modular treatment for youth anxiety, depression, disruptive behavior, and traumatic stress. Multilevel logistic regression analyses showed a significant interaction between attendance and post-treatment symptom severity on subsequent service use, such that attendance significantly predicted subsequent service use when post-treatment symptom severity was in the normal range. Implications regarding the influence of treatment engagement on future help-seeking are discussed.

Assessment and treatment of depression in children and young people in the United Kingdom: Comparison of access to services and provision at two time points

Depression in young people is common and impairing. There have been significant service changes in the United Kingdom in the last decade, aiming to improve access to evidence-based interventions for depression. However, it is unclear whether youth with depression, first, access services and, second, receive appropriate interventions. In the current study, anonymised data from child and adolescent mental health services were extracted from a 1-year period at two time points (time 1: n = 770; time 2: n = 733). First, these were compared with prevalence and population data. Second, a subsample (n = 45 at each time point) was evaluated against National Institute for Clinical Excellence (NICE) guidelines. Approximately, one-quarter of the expected number of cases (according to population and prevalence data) were seen in the 12 to 18-years age group, and only 2% of expected cases were seen in the 0 to 11-years age group. This was consistent across time points. Adherence to NICE guidance was mostly good at both time points, but there were concerns raised by this evaluation, in particular the use of medication in this population. From time 1 to 2, there was an increase in use of questionnaire measures, but a decrease in the correct completion of risk assessments.

Factors Associated With Use of Mental Health and Substance Use Treatment Services by Justice-Involved Youths

OBJECTIVE

Nonincarcerated (community-supervised) youths who are first-time offenders have high rates of mental and substance use disorders. However, little is known about their use of psychiatric services (mental health and substance use) or factors associated with service use. This study examined the prevalence, determinants, and barriers to service use among community-supervised youths.

METHODS

Data were from a longitudinal study of mental health and substance use outcomes among adolescents ages 12-18 from a northeastern family court in which caregivers and youths completed assessments (N=423 dyads). The Behavior Assessment System for Children, Second Edition, assessed youths' psychiatric symptoms. The Child and Adolescent Services Assessment assessed service use and barriers. Family functioning and caregiver-adolescent communication were assessed with the McMaster Family Assessment Device and the Parent-Adolescent General Communication Scale, respectively. Multivariable regression analyses examined the cross-sectional relationship between youths' service use and determinants of use at baseline.

RESULTS

Of the 423 youths, 49% experienced psychiatric symptoms and 36% used psychiatric services in the past 4 months. The highest adjusted odds of service use were associated with youths' psychiatric symptoms and caregivers' history of a psychiatric diagnosis. The lowest odds were associated with caregivers' identifying as being from racial and ethnic minority groups. Caregiver-reported barriers to service use differed according to prior service use and by caregiver race-ethnicity.

CONCLUSIONS

Results suggest a need for interventions to increase access to and engagement in psychiatric services for community-supervised youths and the importance of caregiver factors in designing such interventions.

A Social Media Website (Supporting Our Valued Adolescents) to Support Treatment Uptake for Adolescents With Depression and/or Anxiety and Their Parents: Protocol for a Pilot Randomized Controlled Trial

Background

Few adolescents who experience depression or anxiety connect to mental health treatment. Supporting Our Valued Adolescents (SOVA) is a stakeholder-informed technology intervention that consists of 2 blog-format websites—one for adolescents and another for parents. SOVA is designed to intervene on targets, which may increase the mental health treatment uptake when adolescents with depression or anxiety are identified in primary care settings.

Objective

This study aims to describe the protocol for a pilot randomized controlled trial designed to refine recruitment and retention strategies, document intervention fidelity and implementation outcomes, and assess changes in health beliefs and knowledge, emotional or informational support, and parent-adolescent communication quality in adolescents and their parents.

Methods

Adolescents identified with symptoms of depression or anxiety, for which a health care provider recommends treatment, and their parents will be recruited from clinics where adolescents are seen for primary care. Adolescent-parent dyads will be randomized at 1:1 to both receive the SOVA websites and enhanced usual care or enhanced usual care alone. Baseline measures and 6-week and 3-month outcomes will be collected by Web-based self-report surveys and electronic health record review. The main pilot outcome is the 6-week study retention rate. Analyses will also assess changes in health beliefs and knowledge, emotional support, and parent-adolescent communication in both adolescents and their parents.

Results

The project was funded in 2017. Recruitment commenced in April 2018 and enrollment is ongoing, with completion anticipated at the end of 2019 with subsequent plans for data analysis and publication submission in early 2020.

Conclusions

The findings of this research will inform the design of a multisite hybrid effectiveness-implementation randomized controlled trial examining the effectiveness and optimal implementation strategies for using SOVA in community primary care settings.

Trial Registration

ClinicalTrials.gov NCT03318666; https://clinicaltrials.gov/ct2/show/NCT03318666

International Registered Report Identifier (IRRID)

PRR1-10.2196/12117

'Boost Camp', a universal school-based transdiagnostic prevention program targeting adolescent emotion regulation; evaluating the effectiveness by a clustered RCT: a protocol paper

BACKGROUND

The transition from childhood into adolescence can be considered as a critical developmental period. Moreover, adolescence is associated with a decreased use of adaptive emotion regulation strategies and an increased use of maladaptive emotion regulation strategies increasing the risk of emotional problems. Targeting emotion regulation is therefore seen as an innovative prevention approach. The present study aims to evaluate the effectiveness of Boost camp, an innovative school-based prevention program targeting ER, on adolescents' emotion regulation skills and emotional wellbeing. Also secondary outcomes and possible moderators will be included.

METHODS

The aim is to reach 300 adolescents (16 class groups, 6 schools) in their first year of high school. A clustered Randomized Controlled Trial (RCT) with two conditions, intervention (n = 150) and control (n = 150), will be set up. Adolescents in the intervention condition will receive 14 lessons over the course of 2 days, followed by Booster sessions, and will be compared with adolescents in a non-intervention control group. The outcomes will be measured by self-report questionnaires at baseline, immediately after Boost camp, and at three and 6 months follow-up.

DISCUSSION

Data-collection is planned to be completed in May 2018. Data-analyses will be finished the end of 2018. The presented paper describes the Boost camp program and the clustered RCT design to evaluate its effectiveness. It is expected that Boost camp will have beneficial effects. If found effective, Boost camp will have the potential to increase adolescent's ER and well-being, and reduce the risk to become adults in need. The trials is registered on the 13th of June 2017 in ISRCTN registry [ISRCTN68235634].

Research in the Integration of Behavioral Health for Adolescents and Young Adults in Primary Care Settings: A Systematic Review

Despite the recognition that behavioral and medical health conditions are frequently intertwined, the existing health care system divides management for these issues into separate settings. This separation results in increased barriers to receipt of care and contributes to problems of underdetection, inappropriate diagnosis, and lack of treatment engagement. Adolescents and young adults with mental health conditions have some of the lowest rates of treatment for their conditions of all age groups. Integration of behavioral health into primary care settings has the potential to address these barriers and improve outcomes for adolescents and young adults. In this paper, we review the current research literature for behavioral health integration in the adolescent and young adult population and make recommendations for needed research to move the field forward.

Trends and patterns of antidepressant use in children and adolescents from five western countries, 2005-2012

Following the FDA black box warning in 2004, substantial reductions in antidepressant (ATD) use were observed within 2 years in children and adolescents in several countries. However, whether these reductions were sustained is not known. The objective of this study was to assess more recent trends in ATD use in youth (0-19 years) for the calendar years 2005/6-2012 using data extracted from regional or national databases of Denmark, Germany, the Netherlands, the United Kingdom (UK), and the United States (US). In a repeated cross-sectional design, the annual prevalence of ATD use was calculated and stratified by age, sex, and according to subclass and specific drug. Across the years, the prevalence of ATD use increased from 1.3% to 1.6% in the US data (+26.1%); 0.7% to 1.1% in the UK data (+54.4%); 0.6% to 1.0% in Denmark data (+60.5%); 0.5% to 0.6% in the Netherlands data (+17.6%); and 0.3% to 0.5% in Germany data (+49.2%). The relative growth was greatest for 15-19 year olds in Denmark, Germany and UK cohorts, and for 10-14 year olds in Netherlands and US cohorts. While SSRIs were the most commonly used ATDs, particularly in Denmark (81.8% of all ATDs), Germany and the UK still displayed notable proportions of tricyclic antidepressant use (23.0% and 19.5%, respectively). Despite the sudden decline in ATD use in the wake of government warnings, this trend did not persist, and by contrast, in recent years, ATD use in children and adolescents has increased substantially in youth cohorts from five Western countries.

Systematic review of youth mental health service integration research

Quality mental health care is based on the integration of care across organisations and disciplines. The aims of this study were, first, to assess the extent, characteristics and reported outcomes of publications concerned with youth mental health service integration in Australia and internationally; and second, to investigate the study design quality of evaluative interventions and determine whether the studies report on the cost-effectiveness of the integration in order to inform the reform of youth mental health services by Queensland Health. A systematic search of the peer-reviewed literature and a narrative synthesis were undertaken of English language publications from 21 electronic databases. Inclusion criteria were: published 1998–2014 (inclusive); peer-reviewed research; focused on mental health services integration; reported data for youth aged 12–25 years. The methodological quality of evaluative interventions was assessed using the Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice Project (EPHPP). Twenty-five studies met the inclusion criteria: one (4%) was classified as a measurement research, 13 (52%) as descriptive, and 11 (44%) as interventions including five (45%) evaluative interventions. Four out of the five evaluative interventions reported positive effects of youth mental health service integration. Particular problems included ambiguity of definitions, absence of economic or cost analyses and insufficient consumer involvement. The methodological quality of the interventions was variable with, on average, a moderate level of selection bias and study design. Despite a slight increase in the number of studies in the last couple of years, there are important gaps in the evidence base for youth mental health service integration processes. The relatively small number of evaluative studies and lack of economic evaluations point to the need for additional research in this important area.

Parents' Role in Adolescent Depression Care: Primary Care Provider Perspectives

OBJECTIVE

To understand how primary care providers (PCPs) perceive barriers to adolescent depression care to inform strategies to increase treatment engagement.

STUDY DESIGN

We conducted semistructured interviews with 15 PCPs recruited from community pediatric offices with access to integrated behavioral health services (ie, low system-level barriers to care) who participated in a larger study on treating adolescent depression. Interviews addressed PCP perceptions of barriers to adolescents' uptake of care for depression. Interviews were audiorecorded, transcribed, and coded for key themes.

RESULTS

Although PCPs mentioned several adolescent barriers to care, they thought parents played a critical role in assisting adolescents in accessing mental health services. Important aspects of the parental role in accessing treatment included transportation, financial support, and social support. PCPs perceived that parental unwillingness to accept the depression diagnosis, family dysfunction, and trauma were common barriers. PCPs contrasted this with examples of good family support they believed would enable adolescents to attend follow-up appointments and have a "life coach" at home to help monitor for side effects and watch for increased suicidality when starting antidepressants.

CONCLUSIONS

In this PCP population, which had enhanced access to mental health specialists, PCPs primarily reported attitudinal barriers to adolescent depression treatment, focusing mainly on perceived parent barriers. The results of these qualitative interviews provide a framework for understanding PCP perceptions of parental barriers to care, identifying that addressing complex parental barriers to care may be important for future interventions.