Who is in the transition gap? Transition from CAMHS to AMHS in the Republic of Ireland

Practitioner Review: Continuity of mental health care from childhood to adulthood for youths with ADHD - who, how and when?

Many youths with attention-deficit/hyperactivity disorder (ADHD) experience significant long-term impairment and may develop concurrent mental and somatic health difficulties as adults. This is associated with burden and costs for the individual and society which could be prevented through continued support in youth. Yet, only few young people transition to adult mental health services for ongoing care in different countries worldwide. We provide an overview on current transition practices, highlighting the gaps in knowledge and the barriers to effective service transitioning, while considering the large geographical variation in available guidelines and service provision. For ease of use, this review is organized in a question-and-answer format covering different aspects of the transition process and considering both service users' and clinicians' perspectives. Consensus is needed to identify those that require continued care, the optimal timing to arrange transition, and the most suitable services. Finally, we discuss cost-effectiveness of transition practices, consider examples of best practice, and propose recommendations on how to improve transitional care, including the importance of service users' input into transition planning.

Identification and treatment of individuals with childhood-onset and early-onset schizophrenia

Approximately 8 % of patients with schizophrenia are diagnosed before age 18, and 18 % experience their first symptoms before age 18. This narrative review explores the management of patients with early-onset schizophrenia (EOS) and childhood-onset schizophrenia (COS) from diagnosis to their transition to adult care settings. Early diagnosis of schizophrenia in children and adolescents is essential for improving outcomes, but delays are common due to overlapping of symptoms with developmental phenomena and other psychiatric conditions, including substance use, and lack of clinicians' awareness. Once diagnosed, antipsychotic treatment is key, with specific second-generation agents generally being preferred due to better tolerability and their broader efficacy evidence-base in youth. Dosing should be carefully individualized, considering age-related differences in drug metabolism and side effect liability. Clinicians must be vigilant in detecting early non-response and consider switching or dose escalation when appropriate. Since early age of illness onset is a consistent risk factor for treatment-resistant schizophrenia (TRS), clinicians need to be competent in diagnosing TRS and using clozapine. Since COS and EOS are associated with cognitive deficits and impaired functioning, psychosocial interventions should be considered to improve overall functioning and quality of life. Good long-term outcomes depend on continuous treatment engagement, and successful transitioning from pediatric to adult care requires careful planning, early preparation, and collaboration between pediatric and adult clinicians. Targeting functional outcomes and quality of life in addition to symptom remission can improve overall patient well-being. Comprehensive evaluations, age-specific assessments, and targeted interventions are needed to address the unique challenges of EOS and COS.

Turning 18 in mental health services: a multicountry qualitative study of service user experiences and views

BACKGROUND

Worldwide, the division between Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) has frequently resulted in fragmented care with an unprepared, non-gradual transition. To improve continuity of care and other service transition experiences, service user input is essential. However, such previous qualitative studies are from a decade ago or focused on one mental disorder or country. The aim of the present study was to learn from service users' transition experiences and suggested improvements.

METHODS

Semi-structured interviews were held with young people aged 18-24 and/or parents/caregivers in the United Kingdom, Ireland, the Netherlands and Croatia. Inclusion was based on the experience of specialist mental health care before and after turning 18. Thematic analysis of transcribed and translated interview transcripts was performed using ATLAS.ti 9.

RESULTS

Main themes of service user experiences included abrupt changes in responsibilities, various barriers and a lack of preparation, communication and ongoing care. Young people expressed a great need for continuity of care. Their suggestions to improve transitional care included early and adequate preparation, joint working, improved communication from and between services, overlapping services, staying at CAMHS for longer and designated youth mental health teams.

CONCLUSIONS

Young people who experienced care before and after turning 18 suggested either altering the age limits of services or ensuring early preparation and communication regarding the transition and finding AHMS. This communication should include general changes when turning 18. Further considerations include increasing collaboration and overlap between CAMHS and AMHS.

Predictors of transfer and prognosis after transfer from child and adolescent mental health services to adult mental health services-a Danish nationwide prospective register-based cohort study

Onset of mental health disorder peaks during adolescence making continuity of care during this period of life crucial both to ensure a smooth treatment course and high quality of mental health services for adolescents. We aimed to examine which clinical and sociodemographic features predict transfer from child and adolescent mental health services to adult mental health services and if transfer is associated with prognosis. A Danish register study including all 16-17-year-olds with an outpatient contact in child and adolescent mental health services, who were discharged in the period of 1/1/06-10/05/15. Out of 27,170 Danish adolescents, 16% transferred to adult mental health services. Transfer was predicted by schizophrenia (OR 6.16; 95% CI 5.51-6.90) and personality disorders (OR 2.08; 95% CI 1.84-2.34), while hyperkinetic (OR 0.54; 95% CI 0.49-0.59) and pervasive developmental disorders (OR 0.42; 95% CI 0.31-0.58) decreased likelihood of transfer. Transfer was also substantially predicted by inpatient admission (OR 3.37; 95% CI 3.14-3.61) and psychiatric medication (OR 2.07; 95% CI 1.92-2.23). Transfer was associated with higher rates of inpatient admission to adult mental health services (IRR 5.83; 95% CI 4.37-7.77), more psychiatric emergency contacts (IRR 12.0; 95% CI 10.7-13.4), more convictions (IRR 1.40; 95% CI 1.23-1.59) and suicide attempts (IRR 5.70; 95% CI 4.72-6.90). Policy-makers and clinicians should push for improvements and open a discussion of how to ensure continuity of care for adolescents with psychiatric disorders.

Predictors of transitioning to adult mental health services and associated costs: a cross-country comparison

BACKGROUND

Young people are at risk of falling through the care gap after leaving child and adolescent mental health services (CAMHS) despite an ongoing need for mental health support. Currently, little is known about the predictors of transitioning to adult mental health services (AMHS), and associated healthcare and societal costs as young people cross the transition boundary.

OBJECTIVE

To conduct a secondary data analysis exploring predictors of transitioning or falling through the gap and associated costs.

METHODS

Data were used from a longitudinal study, which followed young people from seven European countries for 2 years after reaching their CAMHS boundary. Predictors of transitioning (including sociodemographic and clinical variables) and longitudinal resource use were compared for 488 young people who transitioned to AMHS versus those who fell through the gap.

FINDINGS

Young people were more likely to transition to AMHS if they were severely ill. Those from Italy, the Netherlands and the UK were more likely to fall through the gap than transition to AMHS. Healthcare costs fell for all young people over the study, with a sharper decrease for those who fell through the gap.

CONCLUSIONS

Total healthcare costs fell for all participants, indicating that the intensity of mental health support reduces for all young people as they cross the CAMHS boundary, regardless of clinical need.

CLINICAL IMPLICATIONS

It is important that alternative forms of mental health support are available for young people who do not meet the AMHS care threshold but still have mental health needs after leaving CAMHS.

A systematic review: Solutions to problems caused by age transition between eating disorder services

OBJECTIVE

This systematic review examines age transition issues specific to young people with eating disorders, including the extent of, and reasons for, problematic transition. Suggested solutions are examined, with focus on age-integrated services.

METHOD

PsycINFO, Medline and SCOPUS databases were searched on 4 April, 2022 using two inclusion criteria: (1) a peer-reviewed journal article in English, (2) focus on service transition caused by moving from childhood to adulthood for people with eating disorders. A narrative integration of the content was used.

RESULTS

Of the 17 non-overlapping studies located in the review, 6 involved quantitative data. Problematic transition between age-based services was indicated, where a substantial minority of young people who still require help lose contact with speciality services. A variety of reasons for this problematic transition were identified, including differing and sometimes adversarial cultures between age-based services. While a variety of solutions have been suggested, the least explored was the development of age integrated services; only 3 papers focussed primarily on this.

CONCLUSION

The consideration of the advantages of integration and the similarities between age-based services suggested that these potentially outweigh the barriers to integration. An implementation science research agenda is required to test this hypothesis.

Leaving child and adolescent mental health services in the MILESTONE cohort: a longitudinal cohort study on young people's mental health indicators, care pathways, and outcomes in Europe

BACKGROUND

The configuration of having separate mental health services by age, namely child and adolescent mental health services (CAMHS) and adult mental health services (AMHS), might be a barrier to continuity of care that adversely affects young people's mental health. However, no studies have investigated whether discontinuity of care in the transition period affects mental health. We aimed to discern the type of care young people receive after reaching the upper age limit of their CAMHS and examine differences in outcomes at 24-month follow-up between young people receiving different types of care.

METHODS

To assess mental health in young people from 39 CAMHS in eight European countries (Belgium, Croatia, France, Germany, Italy, Ireland, the Netherlands, and the UK), we did a longitudinal cohort study. Eligible young people were CAMHS users up to 1 year younger than the upper age limit of their CAMHS or up to 3 months older, if they were still in CAMHS. Information on mental health service use, mental health problems (ie, using the Health of the Nation Outcome Scale for Children and Adolescents, Youth Self-Report and Adult Self-Report, DSM-5, and ICD-10), and sociodemographic characteristics were collected using self-reported, parent-reported, and clinician-reported interviews and questionnaires. Mixed models were applied to assess relationships between baseline characteristics, mental health service use, and outcomes.

FINDINGS

The MILESTONE cohort included 763 young people. The participants were 60·0% female (n=458) and 40·0% male (n=305), 90·3% White (n=578), and had a mean age of 17·5 years (range 15·2-19·6 years). Over the 24-month follow-up period, 48 young people (6·3%) actively withdrew from the study. For young people, the higher their scores on the Health of the Nation Outcome Scale for Children and Adolescents (p=0·0009) and Youth Self-Report and Adult Self-Report (p=0·046), and who had a clinical classification of severe mental illness (p=0·0033), had suicidal thoughts or behaviours or self-harm (p=0·034), used psychotropic medication (p=0·0014), and had a self-reported or parent-reported need for continued treatment (p<0·0001) at baseline, were more likely to transition to AMHS or stay in CAMHS than to have care end. Overall, over the 24-month follow-up period, the mental health of young people improved, but 24·4% of young people reported an increase in problems calculated using the reliable change index, of whom 5·3% had a clinically relevant increase in problems. At 24-month follow-up, no differences in change in mental health problems since baseline were found between young people who used different types of care (CAMHS, AMHS, or no care).

INTERPRETATION

Although approximately half of young people reaching the upper age limit of their CAMHS stop using mental health services, this was not associated with a deterioration in their mental health. Young people with the most severe mental health problems are more likely to receive continued care. If replicated, our findings suggest investments in improving transitional care for all CAMHS users might not be cost-effective in times of rising health-care costs, but might be better targeted at a subgroup of young people with increasing mental health problems who do not receive continued treatment.

FUNDING

European Commission's 7th Framework Programme.

A child and adult psychiatrist discussion on the development of a youth mental health service

Purpose

Young people can often “fall through the gaps” between Child and Adolescent Mental Health services (CAMHS) and Adult Mental Health services (AMHS). This discursive viewpoint study aims to reflect a conversation among the authors on how CAMHS and AMHS psychiatry came together to develop and embed a UK community “Youth Mental Health Service”.

Design/methodology/approach

This reflective viewpoint study explores the perspectives of three of the lead CAMHS and AMHS psychiatrists from the implementation phase of a community youth mental health service. It explores, in a discursive way, these individuals’ views on some of the key facilitators and barriers in the development of the service that aimed to “bridge the gap” for young people.

Findings

These clinicians’ reflections recognise the importance of strong clinical leadership in enabling a youth/young adult model of mental health to be implemented. They also recognise how culture internal and external to a service has a key role to play in the success and sustainment of implementing an innovative model. This study describes a merging of CAMHS and AMHS psychiatry to meet the needs of young people in the most developmentally appropriate way.

Originality/value

This reflective study highlights the need for services and systems to think creatively about how they can allow flexibility for CAMHS and AMHS psychiatrists to learn and plan together, as well as gain experiences across the age ranges, to facilitate collaborative working that is developmentally appropriate and meets the needs of young people in a way that is accessible to them.

Transition care for adolescents and young adults with attention-deficit hyperactivity disorder (ADHD): A descriptive summary of qualitative evidence

The review presents a summary of available evidence about transition care of ADHD patients from all service users' perspectives. Common barriers, and suggestions for improvement ADHD of transition care, were extrapolated from qualitative research, including case notes studies, and were exposed. A comprehensive search of the PubMed, Embase, PsychInfo and Web of Science databases for articles published up to October 2021 was conducted to summarize recent evidence on the experiences of all stakeholders involved in the transition process. Reviews, other chronic conditions and different meaning of transition were excluded. Authors extracted data and assessed study quality independently. Findings were discussed taking into consideration barriers and suggestions from all service users' perspectives. Findings from 23 studies with different context and methods were collected and summarized. Most of the studies were conducted in UK, using interviews and questionnaires, and addressed to the physicians. The lack of information about ADHD as a condition and about transition process were the barriers most reported, while joint working and sharing transition protocols were the suggestions pointed out by all stakeholders. Despite different perspectives, all stakeholders exposed similar needs. The review reveals an evident need for defining and evaluating the effectiveness of transition programmes from child to adult ADHD services.

Addressing the Treatment and Service Needs of Young Adults with Attention Deficit Hyperactivity Disorder

The transition from adolescence to adulthood is a complex period in which multiple changes take place (education, work, independent living, and social relations). This stage is especially difficult for adolescents suffering from attention deficit hyperactivity disorder (ADHD), who have to move on from child and adolescent mental health services to adult mental health services. This review analyzes developmental and environmental risk and protective factors as well as critical variables such as executive functioning and self-monitoring that influence the course of ADHD in transitional age youth and guide the priorities for an optimal transition of care. The influence of the COVID-19 pandemic is also discussed. We reflect on the unmet needs for an optimal transition of care and propose practice and policy recommendations to achieve this goal.

Young people who have fallen through the mental health transition gap: a qualitative study on primary care support

BACKGROUND

Owing to poor continuity of care between child and adult mental health services, young people are often discharged to their GP when they reach the upper boundary of child and adolescent mental health services (CAMHS). This handover is poorly managed, and GPs can struggle to support young people without input from specialist services. Little is known about young people's experiences of accessing mental health support from their GP after leaving CAMHS.

AIM

To explore the experiences and perspectives of young people and the parents/carers of young people receiving primary care support after CAMHS and to identify barriers and facilitators to accessing primary care.

DESIGN AND SETTING

Qualitative study with young people and parents in two English counties: London and West Midlands.

METHOD

Narrative interviews were conducted with 14 young people and 13 parents who had experienced poor continuity of care after reaching CAMHS transition boundary. Data were analysed using reflexive thematic analysis.

RESULTS

Three themes were identified: unmet mental health needs, disjointed care, and taking responsibility for the young person's mental health care. Barriers included the perception that GPs couldn't prescribe certain medication, anxiety caused by the general practice environment, and having to move to a new practice at university. Young people's positive experiences were more likely to include having a long-term relationship with their GP and finding that their GP made time to understand their needs and experiences.

CONCLUSION

GPs could help to meet the unmet needs of young people unable to access specialist mental health services after leaving CAMHS. There is a need for comprehensive handover of care from CAMHS to GPs, which could include a joint meeting with the young person and a member of the CAMHS team. Future research should focus on interventions which improve continuity of care for young people after leaving CAMHS, and collaborative working across community mental health services.

Annual Research Review: A systematic review of mental health services for emerging adults - moulding a precipice into a smooth passage

BACKGROUND

The transition between child and adult services should aim to support young people into the next stage of their life in a way that optimises their function. Yet financial, organisational and procedural barriers to continuity of care often hamper smooth transition between child and adult services.

AIM AND METHOD

We reviewed studies of transition from child to adult mental health services, focusing on: (a) rates of referrals and referral acceptance; (b) barriers and facilitators of successful transition; (c) continuity of care during and post-transition and (d) service users' experience of transition. Studies were identified through systematic searches of electronic databases: PsycINFO, Medline, Embase and Child Development and Adolescent Studies.

FINDINGS

Forty-seven papers describing 43 unique studies met inclusion criteria. Service provision is influenced by previous history and funding processes, and the presence or absence of strong primary care, specialist centres of excellence and coordination between specialist and primary care. Provision varies between and within countries, particularly whether services are restricted to 'core' mental health or broader needs. Unsupportive organisational culture, fragmentation of resources, skills and knowledge base undermine the collaborative working essential to optimise transition. Stigma and young people's concerns about peers' evaluation often prompt disengagement and discontinuation of care during transition, leading to worsening of symptoms and later, to service re-entry. Qualitative studies reveal that young people and families find the transition process frustrating and difficult, mainly because of lack of advanced planning and inadequate preparation.

CONCLUSIONS

Despite increasing research interest over the last decade, transition remains 'poorly planned, executed and experienced'. Closer collaboration between child and adult services is needed to improve the quality of provision for this vulnerable group at this sensitive period of development.

Demographic, clinical, and service-use characteristics related to the clinician's recommendation to transition from child to adult mental health services

PURPOSE

The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians' advice to continue treatment at AMHS.

METHODS

Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians' transition recommendations.

RESULTS

Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS.

CONCLUSION

Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

Cohort profile: demographic and clinical characteristics of the MILESTONE longitudinal cohort of young people approaching the upper age limit of their child mental health care service in Europe

PURPOSE

The presence of distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) impacts continuity of mental health treatment for young people. However, we do not know the extent of discontinuity of care in Europe nor the effects of discontinuity on the mental health of young people. Current research is limited, as the majority of existing studies are retrospective, based on small samples or used non-standardised information from medical records. The MILESTONE prospective cohort study aims to examine associations between service use, mental health and other outcomes over 24 months, using information from self, parent and clinician reports.

PARTICIPANTS

Seven hundred sixty-three young people from 39 CAMHS in 8 European countries, their parents and CAMHS clinicians who completed interviews and online questionnaires and were followed up for 2 years after reaching the upper age limit of the CAMHS they receive treatment at.

FINDINGS TO DATE

This cohort profile describes the baseline characteristics of the MILESTONE cohort. The mental health of young people reaching the upper age limit of their CAMHS varied greatly in type and severity: 32.8% of young people reported clinical levels of self-reported problems and 18.6% were rated to be 'markedly ill', 'severely ill' or 'among the most extremely ill' by their clinician. Fifty-seven per cent of young people reported psychotropic medication use in the previous half year.

FUTURE PLANS

Analysis of longitudinal data from the MILESTONE cohort will be used to assess relationships between the demographic and clinical characteristics of young people reaching the upper age limit of their CAMHS and the type of care the young person uses over the next 2 years, such as whether the young person transitions to AMHS. At 2 years follow-up, the mental health outcomes of young people following different care pathways will be compared.

TRIAL REGISTRATION NUMBER

NCT03013595.

Factors associated with psychiatric admission and subsequent self-harm repetition: a cohort study of high-risk hospital-presenting self-harm

BACKGROUND

Individuals presenting to hospital with self-harm of high lethality or high suicidal intent are at high risk of subsequent suicide.

AIM

To examine factors associated with psychiatric admission and self-harm repetition following high-risk self-harm (HRSH).

METHOD

A cohort study of 324 consecutive HRSH patients was conducted across three urban hospitals (December 2014-February 2018). Information on self-harm repetition was extracted from the National Self-harm Registry Ireland. Logistic regression models examined predictors of psychiatric admission and self-harm repetition. Propensity score (PS) methods were used to address confounding.

RESULTS

Forty percent of the cohort were admitted to a psychiatric inpatient setting. Factors associated with admission were living alone, depression, previous psychiatric admission, suicide note and uncommon self-harm methods. History of emotional, physical or sexual abuse was associated with not being admitted. Twelve-month self-harm repetition occurred in 17.3% of cases. Following inverse probability weighting according to the PS, psychiatric admission following HRSH was not associated with repetition. Predictors of repetition were recent self-harm history, young age (18-24 years) and previous psychiatric admission.

CONCLUSION(S)

Findings indicate that psychiatric admission following HRSH is not associated with repeated self-harm and reaffirms the consistent finding that history of self-harm and psychiatric treatment are strong predictors of repetition.

The young adult service: An evaluation of a youth mental health service in the independent sector in Ireland

AIMS

Increasing concerns about the specific needs and rates of mental illness among young adults have spurred the development of youth mental health services. Yet few outcome studies exist. This study aims to evaluate a young adult service in an independent mental health sector in Ireland.

METHODS

This is a service evaluation using a retrospective, descriptive and naturalistic study design. Routine demographic, diagnostic and service usage data were collected at entry into the service. Outcomes were recorded at discharge from the service using the Clinical Global Impression (CGI) improvement scores. Factors associated with better or worse outcomes were analyzed.

RESULTS

Five hundred and sixty-seven young adults were assessed and managed during a 3-year period by the Young Adult Service. Their characteristics fell midway between adolescent and adult mental health service populations. They had high levels of Axis I & II co-morbidities reflecting the complex and fluid nature of emerging conditions in this age group. The majority (62.8%) had clinically improved by the end of follow-up. Outcomes were significantly better in those who were hospitalized, prescribed psychotropic medication, received 1:1 psychology sessions and attended a group-based psychology program or group program for specific disorders. One hundred and sixty-six patients (29.3%) dropped out of follow-up. Drop out was associated with longer time spent in the service, being treated solely in the community, without medication, not having a developmental disorder and not transferring from CAMHS.

CONCLUSIONS

This study demonstrates that it is possible to establish an effective youth mental health service with favourable outcomes within a broader mental health system. It provides a benchmark for similar services, bridging the gap between adolescent and adult mental health services.

A cross-cultural qualitative study of the ethical aspects in the transition from child mental health services to adult mental health services

BACKGROUND

Transitioning from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) raises novel ethical aspects for healthcare professionals, as well as for young people, their parents and carers.

METHOD

Focus groups were conducted in Croatia, Ireland and the United Kingdom with youth mental health groups and youth representatives with no mental health (MH) remit. One hundred and eleven participants, aged from 16 to 60 years, contributed to discussions.

RESULTS

Perpetuation of stigma, autonomy and decision-making were central themes as both enablers and deterrents of successful transition. The tension between professional (and at times parental) paternalism and young persons' growing autonomy was well captured in the themes; (a) desired practice, (b) who should decide, (c) the process of decision-making and (d) potential harm(s).

CONCLUSIONS

This study provides insight into the ethical values, particularly autonomy and collaboratively working, which people expect to underpin the transition between CAMHS and AMHS.

KEY PRACTITIONER MESSAGE

Engaging young people early in making decisions about their future care can enhance trust between practitioner and the young person. In addition to diagnosis, a number of factors (such as moving home; waiting lists and stigma) may need to be taken into account when considering the direction of future health care. When possible, alternatives to AMHS should be considered if considered by the young person to be a less-stigmatising treatment option.

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.

Trends in attention-deficit and hyperactivity disorder (ADHD) medications among children and young adults in Ireland: a repeated cross-sectional study from 2005 to 2015

OBJECTIVE

This study examined the prescribing patterns of attention-deficit hyperactivity disorder (ADHD) medications in Ireland between 2005 and 2015 in children, adolescents and young adults, and concomitant use of psychotropic medication.

DESIGN

Repeated cross-sectional study.

SETTING

Community setting using pharmacy claims data in Ireland.

PARTICIPANTS

Children and young adults aged 0-24 years.

PRIMARY AND SECONDARY OUTCOMES

Authorised medications used to treat ADHD during the study period, methylphenidate, dexamfetamine, lisdexamfetamine dimesylate and atomoxetine were extracted from a national pharmacy claims database. Dispensing of concomitant psychotropic medications including antipsychotics, anxiolytics, hypnotics/sedatives and antidepressants were examined.

RESULTS

The number on any ADHD medication ranged from 1913 in 2005 to 4853 in 2015, and the prevalence rate per 1000 eligible population aged <25 years increased significantly over time from 5.61 (95% CI 5.36 to 5.86) in 2005 to 8.36 (95% CI 8.13 to 8.60) in 2015 (p<0.0001). Negative binomial regression showed significant changes over time for ADHD prescribing (p<0.001), with significantly higher rates across the different age groups. The rates overall were three to five times higher in males. There was a significant increase in the percentage on concomitant antidepressants from 2% in 2005 to 6% in 2015 (p<0.001).

CONCLUSIONS

There were significantly higher rates of ADHD prescribing in children/adolescents and a significant increase in the coprescribing of antidepressants. The reasons for the increase are unclear but may reflect increasing awareness and diagnosis of the condition.

Protocol for the development and validation procedure of the managing the link and strengthening transition from child to adult mental health care (MILESTONE) suite of measures

Background

Mental health disorders in the child and adolescent population are a pressing public health concern. Despite the high prevalence of psychopathology in this vulnerable population, the transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) has many obstacles such as deficiencies in planning, organisational readiness and policy gaps. All these factors contribute to an inadequate and suboptimal transition process. A suite of measures is required that would allow young people to be assessed in a structured and standardised way to determine the on-going need for care and to improve communication across clinicians at CAMHS and AMHS. This will have the potential to reduce the overall health economic burden and could also improve the quality of life for patients travelling across the transition boundary. The MILESTONE (Managing the Link and Strengthening Transition from Child to Adult Mental Health Care) project aims to address the significant socioeconomic and societal challenge related to the transition process. This protocol paper describes the development of two MILESTONE transition-related measures: The Transition Readiness and Appropriateness Measure (TRAM), designed to be a decision-making aide for clinicians, and the Transition Related Outcome Measure (TROM), for examining the outcome of transition.

Methods

The TRAM and TROM have been developed and were validated following the US FDA Guidance for Patient-reported Outcome Measures which follows an incremental stepwise framework. The study gathers information from service users, parents, families and mental health care professionals who have experience working with young people undergoing the transition process from eight European countries.

Discussion

There is an urgent need for comprehensive measures that can assess transition across the CAMHS/AMHS boundary. This study protocol describes the process of development of two new transition measures: the TRAM and TROM. The TRAM has the potential to nurture better transitions as the findings can be summarised and provided to clinicians as a clinician-decision making support tool for identifying cases who need to transition and the TROM can be used to examine the outcomes of the transition process.

Trial registration

MILESTONE study registration: ISRCTN83240263 Registered 23-July-2015 - ClinicalTrials.gov NCT03013595 Registered 6 January 2017.

Identifying core components and indicators of successful transitions from child to adult mental health services: a scoping review

The aim of this scoping review was to identify the core components of interventions that facilitate successful transition from child and adolescent mental health services to adult mental health services. In the absence of rigorous evaluations of transition program effectiveness for transitioning youth with mental health care needs, these core components can contribute to informed decisions about promising program and intervention strategies. This review examined data from 87 peer-reviewed and non-academic documents to determine the characteristics that support the transition process and to identify opportunities for system and program improvement. Data were extracted and synthesized using a descriptive analytic framework. A major finding of this review is a significant lack of measurable indicators in the academic and gray literature. This review did identify 26 core components organized within the framework of the six core elements of healthcare transitions. Policy makers, practitioners, and administrators can use the core components to guide decisions about transition program and intervention content. Confirmation of the impact of these core program components on youth outcomes awaits the conduct of rigorous randomized trials. Future research also needs to explicitly focus on the development of indicators to evaluate transition programs and interventions.

Participatory development of a patient-clinician communication tool to enhance healthcare transitions for young people with 22q11.2

BACKGROUND

Individuals with the rare genetic disorder, 22q11.2 deletion syndrome (22q11.2ds), face particular challenges with transition from paediatric to adult health services due to complex physical and mental health care needs, often further complicated by intellectual disability (ID). To date, the lived experience of these young people navigating this complex journey has not been well researched.

AIM

The project sought to understand the lived experiences of young women with 22q11.2ds transitioning from child to adult health services and to elicit recommendations for improvement.

METHODS

Following ethical approval, six female participants, aged 19-35 years, were recruited through the family support organisation 22q11 Ireland. Adhering to participatory action research (PAR) principles, four full day sessions using creative research methodologies were conducted over a 4-month period.

RESULTS

Participants reported significant difficulties navigating transition between and within clinical services, and reported a lack of information transfer between healthcare services which required multiple retelling of their story. They expressed a low sense of confidence in new healthcare providers and reported ambivalence regarding their own agency and ability to manage clinical appointments without family or 'keyworker' support. Participants co-designed a patient-clinician communication tool to assist in information transfer and to capture salient features of any healthcare consultation.

CONCLUSIONS

There is a recognised need to strengthen transition pathways. This is especially true in this at risk group, given the poorer outcomes associated with transitions in youth with ID along with the additive effect of medical and mental health and learning difficulties that often co-occur in 22q11.2ds. A patient-clinician communication tool, designed by participants, offers a pragmatic approach to optimise healthcare transitions, support continuity of healthcare and personal autonomy.

Association of Primary Care Continuity With Outcomes Following Transition to Adult Care for Adolescents With Severe Mental Illness

IMPORTANCE

Adolescents with severe mental illness often age out of pediatric care without a clear transfer of care to adult services. The extent to which primary care provides stability during this vulnerable transition period is not known.

OBJECTIVE

To analyze the association between primary care continuity during the transition from pediatric to adult care and need for acute mental health services in young adulthood.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used linked health and demographic administrative data for all adolescents aged 12 to 16 years with severe mental illness ascertained by hospitalization for schizophrenia, eating disorder, or mood disorder between April 1, 2002, and April 1, 2014, in Ontario, Canada. Participants were followed up through March 31, 2017. Data were analyzed from July 2018 to January 2019.

EXPOSURES

Continuous primary care (same physician as baseline [age 12-16 years] always or sometimes), discontinuous primary care (visits to a primary care physician during the transition period who was not the patient's usual physician), and no primary care during the transition period (age 17-18 years).

MAIN OUTCOMES AND MEASURES

Mental health-related hospitalizations and emergency department visits in young adulthood (age 19-26 years) adjusted for sex, rurality, neighborhood income, mental illness type, and health service use before transition.

RESULTS

Among 8409 adolescents with severe mental illness (5720 [68.0%] female; mean [SD] age, 14.8 [1.2] years), 5478 (65.1%) had continuous primary care, 2391 (28.4%) had discontinuous primary care, and 540 (6.4%) had no primary care during the transition period. Youths with no primary care during transition were more likely to be male (57.2%), have lower socioeconomic status (31.5%), and have no usual primary care practitioner at baseline (25.6%). Compared with continuous care, patients with discontinuous and no primary care had an increased rate of mental health-related hospitalization in young adulthood (adjusted relative rate, 1.20; 95% CI, 1.10-1.30; and adjusted relative rate, 1.30; 95% CI, 1.08-1.56, respectively).

CONCLUSIONS AND RELEVANCE

In the context of decreasing outpatient specialist mental health visit rates following transition to adult care, ensuring adequate access to primary care during this vulnerable period may improve mental health outcomes in young adulthood.

Improving mental health pathways and care for adolescents in transition to adult services (IMPACT): a retrospective case note review of social and clinical determinants of transition

BACKGROUND

Poor transitions to adult care from child and adolescent mental health services may increase the risk of disengagement and long-term negative outcomes. However, studies of transitions in mental health care are commonly difficult to administer and little is known about the determinants of successful transition. The persistence of health inequalities related to access, care, and outcome is now well accepted including the inverse care law which suggests that those most in need of services may be the least likely to obtain them. We sought to examine the pathways and determinants of transition, including the role of social class.

METHOD

A retrospective systematic examination of electronic records and case notes of young people eligible to transition to adult care over a 4-year period across five Health and Social Care NHS Trusts in Northern Ireland.

RESULTS

We identified 373 service users eligible for transition. While a high proportion of eligible patients made the transition to adult services, very few received an optimal transition process and many dropped out of services or subsequently disengaged. Clinical factors, rather than social class, appear to be more influential in the transition pathway. However, those not in employment, education or training (NEET) were more likely (OR 3.04: 95% CI 1.34, 6.91) to have been referred to Adult Mental Health Services (AMHS), as were those with a risk assessment or diagnosis (OR 4.89: 2.45, 9.80 and OR 3.36: 1.78, 6.34), respectively.

CONCLUSIONS

Despite the importance of a smoother transition to adult services, surprisingly, few patients experience this. There is a need for stronger standardised policies and guidelines to ensure optimal transitional care to AMHS. The barriers between different arms of psychiatry appear to persist. Joint working and shared arrangements between child and adolescent and adult mental health services should be fostered.

Screening for attention deficit-hyperactivity disorder (ADHD) symptomatology in adult mental health clinics

OBJECTIVES

This study estimates the symptomatology of attention deficit-hyperactivity disorder (ADHD) in adult mental health services (AMHS) outpatient clinics.

METHODS

All consecutive patients attending any of the outpatients' clinics in Sligo/Leitrim AMHS were invited to participate. Participants completed the Adult ADHD Self-Report Scale (ASRS) and the Wender Utah Rating Scale (WURS) self-report. Clinical notes were reviewed to identify those with a pre-existing ADHD diagnosis.

RESULTS

From 822 attending the clinics, 62 did not meet inclusion criteria, 97 declined to participate and 29 had incomplete data in either of the screening scales, leaving 634 (77%) eligible for full study analysis. Mean age was 40.38 (s.d.: 12.85), and 326 (51.4%) were females. In total, 215 (33.9%) screened positive on the WURS for childhood onset ADHD and 219 (34.5%) participants scored positive on the ASRS. Applying a more stringent criteria of scoring above cut-offs on both scales, suggested 131 (20.7%) screened positive on both. Only three (2.3%) had a prior clinical diagnosis.

CONCLUSIONS

This preliminary study suggests the possibility of relatively higher rates of ADHD in a general AMHS than previously thought, however, given the possibility of overlapping symptoms with other major psychiatric disorders in adulthood and recall bias further research is needed before drawing firm conclusions.

Attaining the age threshold for adolescent mental health services: factors associated with transition of care in the independent sector in Ireland

OBJECTIVES

The transition from adolescent to adult mental health services (AMHS) is associated with disengagement, poor continuity of care and patient dissatisfaction. The aim of this retrospective and descriptive study was to describe the 'care pathways' in an independent mental health service when adolescents reach age 18 and to investigate the level of engagement of those who transitioned to independent AMHS.

METHODS

This is a retrospective, naturalistic and descriptive study in design. All patients discharged from the St Patrick's Adolescent Mental Health Service aged 17 years and 6 months and older, during a 3-year period between January 2014 and December 2016, were included. Electronic records were used to collect socio-demographic and clinical details and to determine engagement rates in adolescents who transferred to independent adult services.

RESULTS

A total of 180 patients aged over 17 years and 6 months were discharged from the adolescent service. Of these, 45.6% were discharged to their GP, 28.9% to public mental health services and 25.6% to independent mental health services. The majority who transitioned to independent AMHS went to a Young Adult Service, which had high engagement rates at 3 and 12 months post-transition.

CONCLUSIONS

In this independent mental health service, less than half of adolescents who reach the transition age are referred onto AMHS. Engagement rates were found to be high among those referred on to a specialised young adult service.

Transitioning from Adolescent to Adult Mental Health Services: An Integrative Literature Review

This article aims to present a review of the peer-reviewed, published literature related to the transition from adolescent mental health services to adult mental health services. Six databases (PubMED, Medline, PsycINFO, CINAHL, EMBASE, and Google Scholar) were searched for peer-reviewed, published literature on the transition from adolescent to adult mental health services. Articles on primary research were included in the review if they were published in English between 2000 and 2018, and if they were explicitly about alignment and/or transition between adolescent and adult mental health services. Fifty articles were included in the final review. The findings are discussed in two overarching streams of research from the literature: evaluations of transition arrangements, and the perspectives of various stakeholders (including consumers, carers, and health professionals). The results emphasise the problematic siloes of adolescent and adult mental health services. While there are still no randomised controlled trials on transition to assess transition pathways, our findings have implications to inform best practice in the sector. Given that transitioning to adult mental health services is seen as a point of vulnerability for young people, this review contributes to understandings about how services can offer better support during transition periods.

Outcomes of young people who reach the transition boundary of child and adolescent mental health services: a systematic review

When young people reach the upper age limit of child and adolescent mental health services (CAMHS), care should be transferred to an adult mental health service (AMHS) if they require ongoing support. However, many young people experience a significant disruption of their care during this transition, whilst others may fail to transition at all. Currently, there is no systematic appraisal of the international evidence regarding the outcomes of young people after transition. A systematic review was conducted which aimed to synthesise and review the existing research regarding outcomes after transition. We searched six databases from their inception until December 2017 for research relating to either the mental health or service use outcomes of young people after reaching their CAMHS age boundary. Results were synthesised narratively. The initial searches identified 18,287 papers, of which 213 were screened on full text. 13 papers were included in the review, representing 10 cohorts of young people who crossed the transition age boundary. No studies contained extractable data on mental health outcomes following transition, and therefore, this review focused only on service use outcomes. Results showed a quarter of young people transitioned to AMHS, with the other young people experiencing varied outcomes after leaving CAMHS and multiple transitions during this time. This review provides evidence for the varying service use outcomes of young people after reaching the upper age limit of CAMHS. However, longitudinal research into long-term outcomes is lacking, in addition to research regarding the mental health and functioning outcomes of young people following transition.Protocol registration The protocol for this systematic review has been registered with PROSPERO, ID number CRD42018085916.

Care experiences of young people with eating disorders and their parents: qualitative study

BACKGROUND

Perspectives of young people with eating disorders and their parents on helpful aspects of care should be incorporated into evidence-based practice and service design, but data are limited.AimsTo explore patient and parent perspectives on positive and negative aspects of care for young people with eating disorders.

METHOD

Six online focus groups with 19 young people aged 16-25 years with existing or past eating disorders and 11 parents.

RESULTS

Thematic analysis identified three key themes: the need to (a) shift from a weight-focused to a more holistic, individualised and consistent care approach, with a better balance in targeting psychological and physical problems from an early stage; (b) improve professionals' knowledge and attitude towards patients and their families at all levels of care from primary to 'truly specialist'; (c) enhance peer and family support.

CONCLUSIONS

Young people and parents identified an array of limitations in approaches to care for young people with eating disorders and raised the need for change, particularly a move away from a primarily weight-focused treatment and a stronger emphasis on psychological needs and individualised care.Declaration of interestNone.

ADHD: science, stigma and service implications

We are delighted to dedicate an edition of the Irish Journal of Psychological Medicine to the topic of attention-deficit hyperactivity disorder (ADHD). ADHD accounts for the majority of clinical presentations to Child and Adolescent Mental Health Services, both in terms of new assessments and ongoing attendances. Papers presented in this edition reflect on the evolving construct of ADHD, drawing from science, clinical practice and public opinion. Current and evidenced-based assessment and treatment practice guidelines are reviewed. International longitudinal studies allow us to understand the personal and societal cost, which can persist for many years post-diagnosis. Despite continuation to adulthood in many young people, follow on adult services are lacking. It is fitting that submissions, by way of personal reflections and opinion pieces, are also included from adult colleagues as they reflect on their experiences in this area. Given the recent development of a national clinical programme in ADHD in Ireland, coupled with a growing evidence for effective interventions, it is hoped that this special edition will highlight the need for appropriate and accessible ADHD treatments across the lifespan.

A systematic review of the literature on ethical aspects of transitional care between child- and adult-orientated health services

BACKGROUND

Healthcare policy and academic literature have promoted improving the transitional care of young people leaving child and adolescent mental health services (CAMHS). Despite the availability of guidance on good practice, there seems to be no readily accessible, coherent ethical analysis of transition. The ethical principles of non-maleficence, beneficence, justice and respect for autonomy can be used to justify the need for further enquiry into the ethical pros and cons of this drive to improve transitional care. The objective of this systematic review was therefore to systematically search for existing ethical literature on child- to adult-orientated health service transitions and to critically appraise and collate the literature, whether empirical or normative.

METHODS

A wide range of bioethics, biomedical and legal databases, grey literature and bioethics journals were searched. Ancestral and forward searches of identified papers were undertaken. Key words related to transition, adolescence and young adulthood, ethics, law and health. The timeframe was January 2000 to at least March 2016. Titles, abstracts and, where necessary, full articles were screened and duplicates removed. All included articles were critically appraised and a narrative synthesis produced.

RESULTS

Eighty two thousand four hundred eighty one titles were screened, from which 96 abstracts were checked. Forty seven full documents were scrutinised, leading to inclusion of two papers. Ancestral and forward searches yielded four further articles. In total, one commentary, three qualitative empirical studies and two clinical ethics papers were found. All focused on young people with complex care needs and disabilities. The three empirical papers had methodological flaws. The two ethical papers were written from a clinical ethics context rather than using a bioethical format. No literature identified specifically addressed the ethical challenges of balancing the delivery of transitional care to those who need it and the risk of pathologizing transient and self-limited distress and dysfunction, which may be normal during adolescence.

CONCLUSIONS

There is very little research on ethical aspects of transitional care. Most existing studies come from services for young people with complex care needs and disabilities. There is much scope for improvement in the amount and quality of empirical research and ethical analysis in this area.

Increasing rates of self-harm among children, adolescents and young adults: a 10-year national registry study 2007-2016

PURPOSE

Rates of hospital-treated self-harm are highest among young people. The current study examined trends in rates of self-harm among young people in Ireland over a 10-year period, as well as trends in self-harm methods.

METHODS

Data from the National Self-Harm Registry Ireland on presentations to hospital emergency departments (EDs) following self-harm by those aged 10-24 years during the period 2007-2016 were included. We calculated annual self-harm rates per 100,000 by age, gender and method of self-harm. Poisson regression models were used to examine trends in rates of self-harm.

RESULTS

The average person-based rate of self-harm among 10-24-year-olds was 318 per 100,000. Peak rates were observed among 15-19-year-old females (564 per 100,000) and 20-24-year-old males (448 per 100,000). Between 2007 and 2016, rates of self-harm increased by 22%, with increases most pronounced for females and those aged 10-14 years. There were marked increases in specific methods of self-harm, including those associated with high lethality.

CONCLUSIONS

The findings indicate that the age of onset of self-harm is decreasing. Increasing rates of self-harm, along with increases in highly lethal methods, indicate that targeted interventions in key transition stages for young people are warranted.

Managing the link and strengthening transition from child to adult mental health Care in Europe (MILESTONE): background, rationale and methodology

BACKGROUND

Transition from distinct Child and Adolescent Mental Health (CAMHS) to Adult Mental Health Services (AMHS) is beset with multitude of problems affecting continuity of care for young people with mental health needs. Transition-related discontinuity of care is a major health, socioeconomic and societal challenge globally. The overall aim of the Managing the Link and Strengthening Transition from Child to Adult Mental Health Care in Europe (MILESTONE) project (2014-19) is to improve transition from CAMHS to AMHS in diverse healthcare settings across Europe. MILESTONE focuses on current service provision in Europe, new transition-related measures, long term outcomes of young people leaving CAMHS, improving transitional care through 'managed transition', ethics of transitioning and the training of health care professionals.

METHODS

Data will be collected via systematic literature reviews, pan-European surveys, and focus groups with service providers, users and carers, and members of youth advocacy and mental health advocacy groups. A prospective cohort study will be conducted with a nested cluster randomised controlled trial in eight European Union (EU) countries (Belgium, Croatia, France, Germany, Ireland, Italy, Netherlands, UK) involving over 1000 CAMHS users, their carers, and clinicians.

DISCUSSION

Improving transitional care can facilitate not only recovery but also mental health promotion and mental illness prevention for young people. MILESTONE will provide evidence of the organisational structures and processes influencing transition at the service interface across differing healthcare models in Europe and longitudinal outcomes for young people leaving CAMHS, solutions for improving transitional care in a cost-effective manner, training modules for clinicians, and commissioning and policy guidelines for service providers and policy makers.

TRIAL REGISTRATION

"MILESTONE study" registration: ISRCTN ISRCTN83240263 Registered 23 July 2015; ClinicalTrials.gov NCT03013595 Registered 6 January 2017.

Transitioning from child and adolescent mental health services with attention-deficit hyperactivity disorder in Ireland: Case note review

In a context of international concern about early adult mental health service provision, this study identifies characteristics and service outcomes of young people with attention-deficit hyperactivity disorder (ADHD) reaching the child and adolescent mental health service (CAMHS) transition boundary (TB) in Ireland. The iTRACK study invited all 60 CAMHS teams in Ireland to participate; 8 teams retrospectively identified clinical case files for 62 eligible young people reaching the CAMHS TB in all 4 Health Service Executive Regions. A secondary case note analysis identified characteristics, co-morbidities, referral and service outcomes for iTRACK cases with ADHD (n = 20). Two-thirds of young people with ADHD were on psychotropic medication and half had mental health co-morbidities, yet none was directly transferred to public adult mental health services (AMHS) at the TB. Nearly half were retained in CAMHS, for an average of over a year; most either disengaged from services (40%) and/or actively refused transfer to AMHS (35%) at or after the TB. There was a perception by CAMHS clinicians that adult services did not accept ADHD cases or lacked relevant service/expertise. Despite high rates of medication use and co-morbid mental health difficulties, there appears to be a complete absence of referral to publicly available AMHS for ADHD youth transitioning from CAMHS in Ireland. More understanding of obstacles and optimum service configuration is essential to ensure that care is both available and accessible to young people with ADHD.

The interface between child/adolescent and adult mental health services: results from a European 28-country survey

Transition-related discontinuity of care is a major socioeconomic and societal challenge for the EU. The current service configuration, with distinct Child and Adolescent Mental Health (CAMHS) and Adult Mental Health Services (AMHS), is considered a weak link where the care pathway needs to be most robust. Our aim was to delineate transitional policies and care across Europe and to highlight current gaps in care provision at the service interface. An online mapping survey was conducted across all 28 European Countries using a bespoke instrument: The Standardized Assessment Tool for Mental Health Transition (SATMEHT). The survey was directed at expert(s) in each of the 28 EU countries. The response rate was 100%. Country experts commonly (12/28) reported that between 25 and 49% of CAMHS service users will need transitioning to AMHS. Estimates of the percentage of AMHS users aged under 30 years who had has previous contact with CAMHS were most commonly in the region 20-30% (33% on average).Written policies for managing the interface were available in only four countries and half (14/28) indicated that no transition support services were available. This is the first survey of CAMHS transitional policies and care carried out at a European level. Policymaking on transitional care clearly needs special attention and further elaboration. The Milestone Study on transition should provide much needed data on transition processes and outcomes that could form the basis for improving policy and practice in transitional care.

Protocol for a cohort study of adolescent mental health service users with a nested cluster randomised controlled trial to assess the clinical and cost-effectiveness of managed transition in improving transitions from child to adult mental health services (the MILESTONE study)

INTRODUCTION

Disruption of care during transition from child and adolescent mental health services (CAMHS) to adult mental health services may adversely affect the health and well-being of service users. The MILESTONE (Managing the Link and Strengthening Transition from Child to Adult Mental Healthcare) study evaluates the longitudinal course and outcomes of adolescents approaching the transition boundary (TB) of their CAMHS and determines the effectiveness of the model of managed transition in improving outcomes, compared with usual care.

METHODS AND ANALYSIS

This is a cohort study with a nested cluster randomised controlled trial. Recruited CAMHS have been randomised to provide either (1) managed transition using the Transition Readiness and Appropriateness Measure score summary as a decision aid, or (2) usual care for young people reaching the TB. Participants are young people within 1 year of reaching the TB of their CAMHS in eight European countries; one parent/carer and a CAMHS clinician for each recruited young person; and adult mental health clinician or other community-based care provider, if young person transitions. The primary outcome is Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) measuring health and social functioning at 15 months postintervention. The secondary outcomes include mental health, quality of life, transition experience and healthcare usage assessed at 9, 15 and 24 months postintervention. With a mean cluster size of 21, a total of 840 participants randomised in a 1:2 intervention to control are required, providing 89% power to detect a difference in HoNOSCA score of 0.30 SD. The addition of 210 recruits for the cohort study ensures sufficient power for studying predictors, resulting in 1050 participants and an approximate 1:3 randomisation.

ETHICS AND DISSEMINATION

The study protocol was approved by the UK National Research Ethics Service (15/WM/0052) and equivalent ethics boards in participating countries. Results will be reported at conferences, in peer-reviewed publications and to all relevant stakeholder groups.

TRIAL REGISTRATION NUMBER

ISRCTN83240263; NCT03013595 (pre-results).