Global prevalence of unmet need for mental health care among adolescents: A systematic review and meta-analysis

PURPOSE

Globally mental disorders affect a large number of adolescents. The unmet need for health care of mental health problems is common among adolescents. The aim of this systematic review and meta-analysis was to estimate the global prevalence of unmet needs of mental health care among adolescents.

METHODS

PubMed, Web of Sciences and Scopus, were searched by June 2018 using a pre-designed search strategy. The summary measure was the prevalence of unmet need for mental health care. The inverse variance method was used in meta-analysis, and the results were reported using the random-effects model at a 95% confidence interval (CI).

RESULTS

Out of 30,154 retrieved studies, 15 cross-sectional studies met the eligibility criteria and included in the meta-analysis. The included studies involved 51,309 participants, which 34,476 of them required the mental health care services. The overall pooled prevalence of unmet need for mental health care was 54.0% (95% CI: 41.0, 67.0; I² = 99.9%). Prevalence among adolescents with any mental disorder, general population of adolescents, and high-risk adolescents were 58.1 (46.8, 69.5), 51.4 (30.2, 72.7), and 31.0 (29.0, 33.0) respectively.

CONCLUSION

Based on the results of this systematic review a considerable proportion of adolescents with mental health problems, have not received the required mental health care.

Prevalence of Emotional and Behavioral Problems among School-Going Adolescents: A Cross-Sectional Study

Background

Adolescence is a period of several emotional, mental, and behavioral changes, and many adolescent problems are manifested in the form of emotional problems, conduct problems, hyperactivity, and peer-related problems. The objectives of the current study are to assess the prevalence of emotional and behavioral problems across gender and location. It analyzes the Strengths and Difficulties Questionnaire (SDQ) total score with sociodemographic details among school-going adolescents in Kollam district.

Materials and Methods

A cross-sectional study of 600 school-going adolescents between Class VIII to XII from the rural and urban areas in Kollam district was carried out using a cluster sampling method. A self-reported SDQ was administered to the respondents.

Results

The findings indicate that a little more than a tenth of school-going adolescents had emotional and behavioral problems and multiple regression analysis revealed a significant association in SDQ total score with the type of schools, settings, and socioeconomic status.

Conclusion

Early detection, periodical assessment, and intervention in the schools with the aid of mental health professionals can help adolescents in coping with different issues and for a healthy transition into adulthood.

The combined self- and parent-rated SDQ score profile predicts care use and psychiatric diagnoses

The Strengths and Difficulties Questionnaire (SDQ) is widely used, based on evidence of its value for screening. This evidence primarily regards the single informant total difficulties scale and separate difficulties subscales. We assessed to what degree adolescents' SDQ profiles that combined all self- and parent-rated subscales were associated with use of care and psychiatric diagnoses, and examined the added value thereof over using only a single informant and the total scale. Cluster analysis was used to identify common SDQ profiles based on self- and parent-reports among adolescents aged 12-17 in mental healthcare (n = 4282), social care (n = 124), and the general population (n = 1293). We investigated associations of the profiles with 'care use' and 'DSM-IV diagnoses', depending on gender. We identified six common SDQ profiles: five profiles with varying types and severities of reported difficulties, pertaining to 95% of adolescents in care, and one without difficulties, pertaining to 55% of adolescents not in care. The types of reported difficulties in the profiles matched DSM-IV diagnoses for 88% of the diagnosed adolescents. The SDQ profiles were found to be more useful for predicting care use and diagnoses than SDQ scores reported by the adolescent as single informant and the total difficulties scale. The latter indicated the presence of problems among 42-63% of the adolescents in care, missing a substantial number of adolescents with reported emotional difficulties and borderline problem severity. These findings advocate the use of combined self- and parent-rated SDQ score profiles for screening.

Mental Health Needs of Adolescents Assessed During the Years of Global Financial Crisis: a Systematic Review

Introduction:

Mental health issues during adolescence are common and worsen when financial crisis occur across the world. Identification of mental health needs as they are expressed by adolescents themselves is important for efficient mental health promotion interventions.

Aim:

This systematic review examined studies on the mental health needs among adolescents from their own perspective.

Methods:

Four databases were searched between 2008-2018, starting with 2008 when the global financial crisis began.

Results:

The seven studies that fulfilled the inclusion criteria used different data collection methods. Emotional and behavioral problems and hyperactivity were found, while adolescents’ own perceptions also showed positive indicators for mental health. Most studies focus on specific adolescent populations, while the general adolescent population needs more attention as a target group for mental health interventions.

Conclusion:

Interventions should address the needs as they are identified by adolescents in order to promote their mental health. Researchers should develop an instrument which assesses exclusively the adolescents’ mental health needs.

Adolescent Enrollment in Psychosocial Care: Do Parents Make a Difference?

Care for adolescents with emotional and behavioral problems (EBP) is frequently unequally distributed. Parents may play a role in the access to this care. Therefore, the aim was to explore the association between parental characteristics and their adolescent's enrollment in psychosocial care. We used data from the Care4Youth cohort study. Our sample consisted of 446 adolescents (mean age 13.22 years, 48% boys) and 382 parents (mean age 42.95 years, 14% males). EBP combined with enrollment created four groups: 1, no EBP/no care; 2, no EBP/care; 3, EBP/no care; 4, EBP/care. We assessed differences in parental characteristics among the groups. Group 2 had a significantly lower socioeconomic position (p < 0.01), more psychological distress (p < 0.001), poorer supervision (p < 0.001) and lower family social support (p < 0.05) than Group 1. Group 4 had a significantly lower socioeconomic position (p < 0.01) and poorer supervision (p < 0.001) than Group 1. Group 3 had significantly poorer supervision (p < 0.001) than Group 4. The poor supervision in Group 3 requires attention, as these adolescents receive no care. The quality of parental supervision should be addressed generally, e.g., by providing better parenting support and more parental training.

Barriers to help-seeking in Israeli Arab minority adolescents with mental health problems: results from the Galilee study

BACKGROUND

The Galilee Study assessed mental health service needs among Israeli Muslim and Druze adolescents and their mothers. Studies show that mothers of adolescents belonging to the Arab minority have much lower help-seeking rates than Jewish mothers. This paper examines mothers' structural and cultural barriers to help-seeking.

METHODS

All 9th grade students living in 5 towns representative of Muslim and Druze localities in northern Israel, were eligible for the study and 1639 (69.3%) obtained parental agreement and participated. Emotional or behavioral problem were assessed in the classroom using the Strengths and Difficulties Questionnaire. A total of 704 adolescent-mother dyads participated in the follow-up, and were interviewed at home, using the Development and Well Being Assessment inventory, the Composite Barriers to Help-Seeking Questionnaire, the General Health Questionnaire - 12, the Subjective Feelings of Discrimination Index and socio-demographic questions. Pearson χ2 test and multivariate binary logistic regressions were performed to analyze mothers' consultation rates by risk factors. Exploratory factor analysis was performed to identify underlying factors and assess construct validity of the Composite Barriers to Help-Seeking Questionnaire, and also mean scores and standard deviations for the distinct scales were calculated.

RESULTS

More mothers of adolescents with a mental disorder than those without a mental disorder consulted a professional or school source (39.7% vs. 20.5%; χ2 = 45.636; p = < 0.001). The most important barriers to help-seeking were those related to "Accessibility", followed by barriers related to the belief that "Treatment is detrimental" and to the possibility of "Reprisal by authorities". Barriers related to "Stigma" and "Distrust of professionals" had the lowest means scores. Differences by ethnicity/religion were found.

CONCLUSIONS

Structural barriers related to lack of access, were considered the main obstacle to help-seeking in this Israeli Arab minority population. Cultural barriers such as stigma were considered of secondary importance. Structural barriers could be reduced by increasing the number of accessible public mental health clinics in the minority localities, a responsibility of the Ministry of Health and the HMOs. Information campaigns and psychoeducation for parents would help reduce other barriers to mental health treatment.

Changes in mental health service use among 8-year-old children: a 24-year time-trend study

The use of children's mental health services has increased, but most children with psychiatric problems are still not in contact with these services. This time-trend study assessed changes in considered and reported service use over a 24-year period and studied the factors associated with it using four cross-sectional studies. Information was gathered on 8-year-old children living in the area covered by Turku University Hospital, Finland, at four time points: 986 children in 1989, 891 in 1999, 930 in 2005, and 942 in 2013. The same study design, methods and school districts were used each year and the participation rates varied between 86 and 95%. Parents and teachers completed questionnaires concerning the child's psychiatric symptoms and service use. The considered and reported service use increased continuously during the study period. In 1989, 2.4% of children had used services and in 2013 this was 11.0% (OR 5.0, 95% CI 3.1-8.0). Reported service use also increased among children with comorbid problems, from 18.3 to 50.7% (OR 5.0, 95% CI 2.1-12.0). Psychiatric problems and some family factors were associated with service use, but the increase was not explained by these factors. The increase in child mental health service use may reflect better public awareness of mental health problems, fewer barriers to accessing care and decrease of stigma. Although more children are using mental health services, there are still a large number of children with mental health problems who have not been in contact with services.

Enrolment of children in psychosocial care: problems upon entry, care received, and outcomes achieved

Psychosocial care systems have been designed so that specific problems are treated by specific care types. There is insufficient evidence as to which problem types are actually presented to the various care types. This study assessed types and severity of problems among children and adolescents upon enrolment in psychosocial care, compared to children not enrolled; also outcomes after 3 and 12 months, overall and per care type. We obtained data on a cohort of 1382 Dutch children aged 4-18 years (response rate 56.6%), included upon enrolment in psychosocial care, and on 443 not-enrolled children (response rate 70.3%), all from one region. Results showed that enrolled children had more problems than children not enrolled in care. In child and adolescent mental healthcare (CAMH), relatively many children had internalizing problems, and in child and adolescent social care (CASC) relatively many children had externalizing, parenting, family and multiple problems. Regardless of the type of problem, care duration in preventive child healthcare (PCH) was relatively short; and in CASC and CAMH longer. After 3 and 12 months, rates of problem solution were highest in PCH. These rates were also substantial among children not in care. To conclude, our findings show that the system of psychosocial care functions as intended regarding the distribution of problems across care types. Extended demarcation of clients by problem type and severity towards type and contents of care may further improve the system.

Time-to-treatment of mental disorders in a community sample of Dutch adolescents. A TRAILS study

AIMS

Timely recognition and treatment of mental disorders with an onset in childhood and adolescence is paramount, as these are characterized by greater severity and longer persistence than disorders with an onset in adulthood. Studies examining time-to-treatment, also referred to as treatment delay, duration of untreated illness or latency to treatment, and defined as the time between disorder onset and initial treatment contact, are sparse and all based on adult samples. The aim of this study was to describe time-to-treatment and its correlates for any health care professional (any care) and secondary mental health care (secondary care), for a broad range of mental disorders, in adolescents.

METHODS

Data from the Dutch community-based cohort study TRacking Adolescents' Individual Lives Survey (TRAILS; N = 2230) were used. The Composite International Diagnostic Interview (CIDI) was administered to assess DSM-IV disorders, the age of onset, and the age of initial treatment contact with any health care professional in 1584 adolescents of 18-20 years old. In total 43% of the adolescents (n = 675) were diagnosed with a lifetime DSM-IV disorder. The age of initial treatment contact with secondary care was based on administrative records from 321 adolescents without a disorder onset before the age of 10. Descriptive statistics, cumulative lifetime probability plots, and Cox regression analyses were used analyze time-to-treatment.

RESULTS

The proportion of adolescents who reported lifetime treatment contact with any care varied from 15% for alcohol dependence to 82% for dysthymia. Regarding secondary care, proportions of lifetime treatment contact were lower for mood disorders and higher for substance dependence. Time-to-treatment for any care varied considerably between and within diagnostic classes. The probability of lifetime treatment contact for mood disorders was above 90%, whereas for other mental disorders this was substantially lower. An earlier age of onset predicted a longer, and the presence of a co-morbid mood disorder predicted a shorter time-to-treatment in general. Disorder severity predicted a shorter time-to-treatment for any care, but not for secondary care. Time-to-treatment for secondary care was shorter for adolescents from low and middle socioeconomic background than for adolescents from a high socioeconomic background.

CONCLUSION

Although the time-to-treatment was shorter for adolescents than for adults, it was still substantial, and the overall patterns were remarkably similar to those found in adults. Efforts to reduce time-to-treatment should therefore be aimed at children and adolescents. Future research should address mechanisms underlying time-to-treatment and its consequences for early-onset disorders in particular.

Appropriate assessment of ethnic differences in adolescent use of psychotropic medication: multilevel analysis of discriminatory accuracy

OBJECTIVE

In the present study, we used a multilevel approach to investigate the role of maternal country of birth (MCOB) in predicting adolescent use of psychotropic medication in Sweden.

DESIGN

Using the Swedish Medical Birth Register we identified all 428,314 adolescents born between 1987 and 1990 and who were residing in Sweden in the year they turned 18. We applied multilevel logistic regression analysis with adolescents (level 1) nested within MCOBs (level 2). Measures of association (odds ratio) and measures of variance (intra-class correlation (ICC)) were calculated, as well as the discriminatory accuracy by calculating the area under the Receiver Operator Characteristic (AU-ROC) curve.

RESULTS

In comparison with adolescents with Swedish-born mothers, adolescents with mothers born in upper-middle, lower-middle and low-income countries were less likely to use psychotropic medication. However, the variance between MCOBs was small (ICC = 2.5 in the final model) relative to the variation within MCOBs. This was confirmed by an AU-ROC value of 0.598.

CONCLUSIONS

Even though we found associations between MCOB and adolescent use of psychotropic medication, the small ICC and AU-ROC indicate that MCOB appears to be an inaccurate context for discriminating adolescent use of psychotropic medication in Sweden.

Expectations of barriers to psychosocial care: views of parents and adolescents in the community

Parents with a child suffering from psychosocial problems frequently experience barriers to psychosocial care, which may hinder access. Expectations of barriers may have the same effect, but evidence is lacking. The aim of this study is to examine parents' and adolescents' expectations of barriers regarding psychosocial care for the child, along with associated child and family characteristics. We obtained data on an age-stratified random sample of school children/pupils aged 4-18 via questionnaires (N = 666; response rate 70.3 %). Expectations of barriers to psychosocial care were measured with the "Barriers to Treatment Participation Scale-Expectancies" questionnaire (BTPS-exp). Results showed that 64 % of the parents of children below age 12, 59 % of the parents of adolescents (age 12-18), and 84 % of the adolescents expected one or more barriers. Parents and adolescents expected barriers most frequently with respect to irrelevance of treatment. Mainly parents with low educational level and their adolescents expected barriers regarding treatment, and quite a few characteristics of parents of adolescents were associated with expecting multiple barriers regarding treatment demands and issues, for example, single parents, parents of lower educational level and of adolescent boys, and parents of adolescents with psychosocial problems. We conclude that adolescents especially, but also their parents and parents of younger children, expect major barriers to psychosocial care, which may greatly hinder appropriate care seeking. This evidence may support professionals and policymakers in their attempts to improve access to psychosocial care.

Enrolment of children and adolescents in psychosocial care: more likely with low family social support and poor parenting skills

Knowledge about determinants of child and adolescent enrolment in psychosocial care concerns only single types of care and usually only socio-demographic factors. The social environment is also a likely key determinant but evidence is lacking. The aim of this study was to examine the associations between family social support, parenting skills and child and adolescent enrolment in psychosocial care. We obtained data on 1,331 children (response rate 56.6%), 4-18 years old, enrolled in preventive child health care, and child and adolescent social care and mental health care because of psychosocial problems, and on 463 children (response rate 70.3%) not enrolled in psychosocial care. Results showed that enrolment in psychosocial care was associated with low family social support (odds ratio; 95%-confidence interval: 3.2; 2.4-4.4), and with poor parenting skills, i.e. poor supervision (1.5; 1.1-2.1) and inconsistent disciplining (1.5; 1.1-2.1). Children's psychosocial problems partially mediated the associations with family social support and completely with parenting skills. Children's problems did not moderate the associations. Positive parenting was not associated with care enrolment. We conclude that low family social support and poor parenting are important factors associated with enrolment, in particular because they are associated with more frequent occurrence of children's psychosocial problems. This implies that professionals and policymakers need to be aware that factors in children's social environment are related with enrolment in psychosocial care, in addition to children's psychosocial problems.

Help-seeking behaviour among Finnish adolescent males

BACKGROUND

Adolescent males have a low rate of seeking help for mental health problems. The onset for many psychiatric disorders occur during the adolescence. Previous studies have identified previous help seeking, parental opinion, parental divorce and suicidal thoughts as factors associated with contacting mental health services. Yet studies on the rate of use of mental health services remain few, as do studies concerning factors associated with use of mental health services.

AIMS

To study prevalence and risk factors of use of mental health services among Finnish adolescent males.

METHODS

Factors associated with use of mental health services during the preceding 12 months were studied in a general population sample of 4309 men attending military call-up in 2009. The mean age was 18.3 ± 0.45 years.

RESULTS

Within the previous 12 months, 3.2% of men had used mental health services and an additional 2.3% had considered contacting mental health services. Factors associated with service use were living alone, having a poor paternal relationship, having no contact with father, death of father, high internalizing symptoms, suicidal thoughts, regular smoking and use of illicit drugs. Frequent drunkenness was associated with mental health service use, whereas occasional use of alcohol was inversely associated with use of mental health services.

CONCLUSIONS

The rate of mental health service use among males in late adolescence is very low. The inability of young people to contact service providers should be addressed more efficiently.

CLINICAL IMPLICATIONS

A majority of the troubled men did not contact professionals for help, although approximately a quarter of the men had a self-perceived mental health problem. A major challenge is to find ways for mental health services to be made more accessible to adolescent males.

Discrepancies between adolescents' attributed relevance and experiences regarding communication are associated with poorer client participation and learning processes in psychosocial care

OBJECTIVE

To examine adolescents' attributed relevance and experiences regarding communication, and whether discrepancies in these are associated with clients' participation and learning processes in psychosocial care.

METHODS

Adolescents receiving psychosocial care (n=211) completed measures of communication in three domains: affective communication, information provision, and shared decision-making. Participation involved clients' attendance and adherence (professional-reported). Learning processes involved clients' improved understanding and improved confidence (client and professional-reported).

RESULTS

Important but less often experienced affective communication was associated with low adherence (odds ratio, 95% confidence interval: 2.8, 1.1-6.8), less improvement in understanding (3.7, 1.5-9.0), and less improvement in confidence (4.5, 1.8-11.6). If information provision or shared decision-making was important but less often experienced, adolescents were more likely to demonstrate less improvement in understanding (3.1, 1.1-8.5; 4.2, 1.7-10.8). The combination "less important but experienced" only had an effect regarding affective communication; these adolescents were more likely to demonstrate less improvement in confidence (6.0, 2.3-15.4).

CONCLUSION

Discrepancies between attributed relevance and experiences frequently occur. These discrepancies negatively affect adolescents' participation and their learning processes, although the pattern differs across communication domains.

PRACTICE IMPLICATIONS

Care professionals should pay considerable attention to their clients' communication preferences and adapt their communication style when necessary.

Priorities in the communication needs of adolescents with psychosocial problems and their parents

BACKGROUND

In patient-centred care, professionals should recognize their patient's needs and adapt their communication accordingly. Studies into patients' communication needs suggest priorities vary depending on sociodemographic characteristics, and type and severity of the complaints. However, evidence lacks on priorities in the communication needs of adolescents in psychosocial care and their parents.

OBJECTIVE

To assess adolescents' and parents' importance ratings concerning affective communication, information provision, shared decision-making, interprofessional communication and the degree to which client and care characteristics determine these.

METHODS

Adolescents aged 12-18 (n = 403) and one of their parents (n = 403) rated the importance of communication before the psychosocial care process started. Multivariable logistic regression analysis was applied to determine which characteristics were associated with the 25% lowest importance ratings for communication aspects.

RESULTS

Adolescents and parents considered affective communication to be the most important, with shared decision-making the least important. For adolescents, lower importance ratings were associated with dissatisfaction with prior care (OR 1.8), negative expectations (ORs 1.9-2.4), emotional problems (ORs 0.2-0.5) and low prosocial behaviour skills (ORs 2.0). For parents, low education (ORs 1.7-1.8), negative expectations (OR 0.4), adolescent's hyperactivity/inattention (ORs 0.4-0.5) and low prosocial behaviour skills (ORs 1.8-2.6) determined lower importance ratings.

CONCLUSIONS

Affective communication has highest priority for adolescents and their parents. Client and care characteristics are associated with client priorities in communication. Being attentive to clients' educational level, previous care experiences, current expectations and specific problem types might help professionals to adapt better to their clients' communication needs.

Adolescents' use of care for behavioral and emotional problems: types, trends, and determinants

OBJECTIVE

While adolescents use various types of care for behavioral and emotional problems, evidence on age trends and determinants per type is scarce. We aimed to assess use of care by adolescents because of behavioral and emotional problems, overall and by type, and its determinants, for ages 10-19 years.

METHODS

We obtained longitudinal data on 2,230 adolescents during ages 10-19 from four measurements regarding use of general care and specialized care (youth social care and mental healthcare) in the preceding 6 months, the Child Behavior Checklist (CBCL) and Youth Self-Report, and child and family characteristics. We analyzed data by multilevel logistic regression.

RESULTS

Overall rates of use increased from 20.1% at age 10/11 to 32.2% at age 19: general care was used most. At age 10/11 use was higher among boys, at age 19 among girls. Use of general care increased for both genders, whereas use of specialized care increased among girls but decreased among boys. This differential change was associated with CBCL externalizing and internalizing problems, school problems, family socioeconomic status, and parental divorce. Preceding CBCL problems predicted more use: most for mental health care and least for general care. Moreover, general care was used more frequently by low and medium socioeconomic status families, with odds ratios (95%-confidence intervals): 1.52 (1.23;1.88) and 1.40 (1.17;1.67); youth social care in case of parental divorce, 2.07 (1.36;3.17); and of special education, 2.66 (1.78;3.95); and mental healthcare in case of special education, 2.66 (1.60;4.51).

DISCUSSION

Adolescents with behavioral and emotional problems use general care most frequently. Overall use increases with age. Determinants of use vary per type.

Adolescents' utilisation of psychiatric care, neighbourhoods and neighbourhood socioeconomic deprivation: a multilevel analysis

Mental health problems among adolescents have become a major public health issue, and it is therefore important to increase knowledge on the contextual determinants of adolescent mental health. One such determinant is the socioeconomic structure of the neighbourhood. The present study has two central objectives, (i) to examine if neighbourhood socioeconomic deprivation is associated to individual variations in utilisation of psychiatric care in a Swedish context, and (ii) to investigate if neighbourhood boundaries are a valid construct for identifying contexts that influence individual variations in psychiatric care utilization. Data were obtained from the Longitudinal Multilevel Analysis in Scania (LOMAS) database. The study population consists of all boys and girls aged 13–18 years (N=18,417), who were living in the city of Malmö, Sweden, in 2005. Multilevel logistic regression analysis was applied to estimate the probability of psychiatric care utilisation. The results from the study indicate that the neighbourhood of residence had little influence on psychiatric care utilisation. Although we initially found a variation between neighbourhoods, this general contextual effect was very small (i.e. 1.6 %). The initial conclusive association between the neighbourhood level of disadvantage and psychiatric care utilisation (specific contextual effect) disappeared following adjustment for individual and family level variables. Our results suggest the neighbourhoods in Malmö (at least measured in terms of SAMS-areas), do not provide accurate information for discriminating adolescents utilisation of psychiatric care. The SAMS-areas appears to be an inappropriate construct of the social environment that influences adolescent utilisation of psychiatric care. Therefore, public health interventions should be directed to the whole city rather than to specific neighbourhoods. However, since geographical, social or cultural contexts may be important for our understanding of adolescent mental health further research is needed to identify such contexts.