Detecting emotional disorder in young people in primary care

Precision computerised cognitive behavioural therapy (cCBT) for adolescents with depression: a pilot and feasibility randomised controlled trial protocol for SPARX-UK

BACKGROUND

A serious game called SPARX (Smart, Positive, Active, Realistic, X-factor thoughts), originally developed in New Zealand and incorporating cognitive behavioural therapy (CBT) principles, has been shown to help reduce symptoms of depression and anxiety in adolescents with mild to moderate depression in studies undertaken in Australasia. However, SPARX has never been trialled in the United Kingdom (UK), and there have been issues relating to low engagement when it has been used in a real-world context.

AIMS

To conduct the first pilot and feasibility randomised controlled trial (RCT) in England to explore the use of SPARX in different settings. The trial will explore whether SPARX supported by an e-coach (assistant psychologists) improves adherence and engagement compared with self-directed (i.e. self-help) use. The trial results will be used to inform the optimal mode of delivery (SPARX supported vs. SPARX self-directed), to calculate an appropriate sample size for a full RCT, and to decide which setting is most suitable.

METHODS

Following consultation with young people to ensure study suitability/appropriateness, a total of 120 adolescents (11-19 years) will be recruited for this three-arm study. Adolescents recruited for the study across England will be randomised to receive either SPARX with human support (from an e-coach), self-directed SPARX, or a waitlist control group. Assessments will be conducted online at baseline, week 4, and 8-10-week post-randomisation. The assessments will include measures which capture demographic, depression (Patient Health Questionnaire modified for adolescents [PHQ-A]) and anxiety (Revised Child Anxiety and Depression Scale [RCADS]) symptomatology, and health-related quality-of-life data (EQ-5D-Y and proxy version). Analyses will be primarily descriptive. Qualitative interviews will be undertaken with a proportion of the participants and clinical staff as part of a process evaluation, and the qualitative data gathered will be thematically analysed. Finally, feasibility data will be collected on recruitment details, overall study uptake and engagement with SPARX, participant retention, and youth-reported acceptability of the intervention.

DISCUSSION

The findings will inform the design of a future definitive RCT of SPARX in the UK. If the subsequent definitive RCT demonstrates that SPARX is effective, then an online serious game utilising CBT principles ultimately has the potential to improve the provision of care within the UK's health services if delivered en masse.

TRIAL REGISTRATION

ISRCTN: ISRCTN15124804. Registered on 16 January 2023, https://www.isrctn.com/ISRCTN15124804 .

Reasons for non-participation of children and adolescents in a large-scale school-based mental health project

Background

Non-participation in mental health studies is an under-explored but very important topic. Investigating reasons for non-participation holds promise for the planning of future study designs and recruitment strategies. This study aimed at investigating reasons for children and adolescents (C&A) not participating in a school-based mental health research project.

Methods

Data collection took place within the school-based recruitment of a large-scale multi-site project ("ProHEAD-Promoting Help-seeking using E-technology for Adolescents") in Germany. Participants were N = 534 C&A aged ≥ 12 years attending secondary schools. The present cross-sectional study analyzed anonymous survey data of C&A who themselves or whose parents, respectively, did not provide written consent to participate in the mental health research project. The questionnaire consisted of 14 items covering potential reasons for non-participation, and four free text fields. Besides descriptive statistics, free text field answers were analyzed using qualitative content analysis.

Results

Students indicated an average of M = 2.94 (SD = 1.75) reasons for their non-participation in the project. In the descriptive analysis of indicated items, the three most frequently reported reasons for non-participation included students reporting to not be concerned by the topic "mental health" (n = 290, 54.3%), not having returned the consent form to the teacher (n = 175, 32.8%), and not having time for participation (n = 149, 27.9%). In the qualitative content analysis, the most frequently assigned categories were organizational reasons (n = 216, 57.1%), general disinterest in study participation (n = 139, 36.8%), and personal attitudes toward the topic "mental health" (n = 84, 22.2%), such as not being concerned with the topic "mental health" (n = 23, 6.1%) or being too concerned with the topic "mental health" (n = 16, 4.2%).

Conclusion

The study provides unique insights into reasons for C&A and their caregivers not participating in a large federally funded mental health research project. The results suggest that in order to increase participation rates, stigma should be reduced, parents as well as teachers should be involved where possible, and the use of incentives might be helpful. The study highlights the importance of assessing reasons for non-participation, especially in online intervention studies on mental health.

The impact of school-based screening on service use in adolescents at risk for mental health problems and risk-behaviour

Early detection and intervention can counteract mental disorders and risk behaviours among adolescents. However, help-seeking rates are low. School-based screenings are a promising tool to detect adolescents at risk for mental problems and to improve help-seeking behaviour. We assessed associations between the intervention "Screening by Professionals" (ProfScreen) and the use of mental health services and at-risk state at 12 month follow-up compared to a control group. School students (aged 15 ± 0.9 years) from 11 European countries participating in the "Saving and Empowering Young Lives in Europe" (SEYLE) study completed a self-report questionnaire on mental health problems and risk behaviours. ProfScreen students considered "at-risk" for mental illness or risk behaviour based on the screening were invited for a clinical interview with a mental health professional and, if necessary, referred for subsequent treatment. At follow-up, students completed another self-report, additionally reporting on service use. Of the total sample (N = 4,172), 61.9% were considered at-risk. 40.7% of the ProfScreen at-risk participants invited for the clinical interview attended the interview, and 10.1% of subsequently referred ProfScreen participants engaged in professional treatment. There were no differences between the ProfScreen and control group regarding follow-up service use and at-risk state. Attending the ProfScreen interview was positively associated with follow-up service use (OR = 1.783, 95% CI = 1.038-3.064), but had no effect on follow-up at-risk state. Service use rates of professional care as well as of the ProfScreen intervention itself were low. Future school-based interventions targeting help-seeking need to address barriers to intervention adherence.Clinical Trials Registration: The trial is registered at the US National Institute of Health (NIH) clinical trial registry (NCT00906620, registered on 21 May, 2009), and the German Clinical Trials Register (DRKS00000214, registered on 27 October, 2009).

Help-seeking attitudes and behaviours for mental health problems in adolescents before and during the first COVID-19 school closures in Germany

AIM

Comparing measures of psychological wellbeing and help-seeking in youths before and within the first school closures due to the coronavirus disease 2019 (COVID-19) pandemic enables a better understanding of the effects the pandemic has for those seeking professional help for mental health problems.

METHODS

Data were obtained from the Germany-based ProHEAD school study. Pre-lockdown and lockdown samples (n = 648) were compared regarding pupils' psychological wellbeing, help-seeking attitudes and help-seeking behaviour.

RESULTS

Participants from the lockdown sample showed greater positive attitudes towards seeking professional help, whereas psychological wellbeing and help-seeking behaviour remained stable.

CONCLUSIONS

Possible explanations may include an increased public discourse on mental health or self-selection bias for participation during lockdown.

Burden of non-communicable diseases among adolescents aged 10-24 years in the EU, 1990-2019: a systematic analysis of the Global Burden of Diseases Study 2019

BACKGROUND

Disability and mortality burden of non-communicable diseases (NCDs) have risen worldwide; however, the NCD burden among adolescents remains poorly described in the EU.

METHODS

Estimates were retrieved from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Causes of NCDs were analysed at three different levels of the GBD 2019 hierarchy, for which mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) were extracted. Estimates, with the 95% uncertainty intervals (UI), were retrieved for EU Member States from 1990 to 2019, three age subgroups (10-14 years, 15-19 years, and 20-24 years), and by sex. Spearman's correlation was conducted between DALY rates for NCDs and the Socio-demographic Index (SDI) of each EU Member State.

FINDINGS

In 2019, NCDs accounted for 86·4% (95% uncertainty interval 83·5-88·8) of all YLDs and 38·8% (37·4-39·8) of total deaths in adolescents aged 10-24 years. For NCDs in this age group, neoplasms were the leading causes of both mortality (4·01 [95% uncertainty interval 3·62-4·25] per 100 000 population) and YLLs (281·78 [254·25-298·92] per 100 000 population), whereas mental disorders were the leading cause for YLDs (2039·36 [1432·56-2773·47] per 100 000 population) and DALYs (2040·59 [1433·96-2774·62] per 100 000 population) in all EU Member States, and in all studied age groups. In 2019, among adolescents aged 10-24 years, males had a higher mortality rate per 100 000 population due to NCDs than females (11·66 [11·04-12·28] vs 7·89 [7·53-8·23]), whereas females presented a higher DALY rate per 100 000 population due to NCDs (8003·25 [5812·78-10 701·59] vs 6083·91 [4576·63-7857·92]). From 1990 to 2019, mortality rate due to NCDs in adolescents aged 10-24 years substantially decreased (-40·41% [-43·00 to -37·61), and also the YLL rate considerably decreased (-40·56% [-43·16 to -37·74]), except for mental disorders (which increased by 32·18% [1·67 to 66·49]), whereas the YLD rate increased slightly (1·44% [0·09 to 2·79]). Positive correlations were observed between DALY rates and SDIs for substance use disorders (r_s=0·58, p=0·0012) and skin and subcutaneous diseases (r_s=0·45, p=0·017), whereas negative correlations were found between DALY rates and SDIs for cardiovascular diseases (r_s=-0·46, p=0·015), neoplasms (r_s=-0·57, p=0·0015), and sense organ diseases (r_s=-0·61, p=0·0005).

INTERPRETATION

NCD-related mortality has substantially declined among adolescents in the EU between 1990 and 2019, but the rising trend of YLL attributed to mental disorders and their YLD burden are concerning. Differences by sex, age group, and across EU Member States highlight the importance of preventive interventions and scaling up adolescent-responsive health-care systems, which should prioritise specific needs by sex, age, and location.

FUNDING

Bill & Melinda Gates Foundation.

Twelve-month service use, suicidality and mental health problems of European adolescents after a school-based screening for current suicidality

Suicide is one of the leading causes of death in adolescents and help-seeking behaviour for suicidal behaviour is low. School-based screenings can identify adolescents at risk for suicidal behaviour and might have the potential to facilitate service use and reduce suicidal behaviour. The aim of this study was to assess associations of a two-stage school-based screening with service use and suicidality in adolescents (aged 15 ± 0.9 years) from 11 European countries after one year. Students participating in the 'Saving and Empowering Young Lives in Europe' (SEYLE) study completed a self-report questionnaire including items on suicidal behaviour. Those screening positive for current suicidality (first screening stage) were invited to an interview with a mental health professional (second stage) who referred them for treatment, if necessary. At 12-month follow-up, students completed the same self-report questionnaire including questions on service use within the past year. Of the N = 12,395 SEYLE participants, 516 (4.2%) screened positive for current suicidality and were invited to the interview. Of these, 362 completed the 12-month follow-up with 136 (37.6%) self-selecting to attend the interview (screening completers). The majority of both screening completers (81.9%) and non-completers (91.6%) had not received professional treatment within one year, with completers being slightly more likely to receive it (χ2(1) = 8.948, V = 0.157, p ≤ 0.01). Screening completion was associated with higher service use (OR 2.695, se 1.017, p ≤ 0.01) and lower suicidality at follow-up (OR 0.505, se 0.114, p ≤ 0.01) after controlling for potential confounders. This school-based screening offered limited evidence for the improvement of service use for suicidality. Similar future programmes might improve interview attendance rate and address adolescents' barriers to care.

Help-seeking duration in adolescents with suicidal behavior and non-suicidal self-injury

Prompt access to appropriate professional care for adolescents with self-harm thoughts and respective behaviors (suicidal behavior and non-suicidal self-injury [NSSI]) is crucial as both are associated with an increased risk of suicide in later life. The present study aimed to describe the duration from initial onset of thoughts and incidents of self-harm until first clinical presentation in children and adolescents and to identify factors affecting help-seeking duration. Onset of self-harm thoughts and behaviors, time of first clinical presentation, and psychiatric and demographic variables were obtained from n = 672 adolescents (11-19 years) from the Germany-based AtR!Sk (Ambulanz für Risikoverhalten & Selbstschädigung) cohort-study at an outpatient clinic for risk-taking and self-harm behaviors. In 22% of overall cases, the first self-harm thoughts and behaviors occurred after contact to professional care was already established. Focusing on actual help-seeking delay only, it took between M = 0.99 years (after first suicide attempt) and M = 1.98 years (after first thoughts of NSSI) until participants sought professional help. Overall, help-seeking duration and help-seeking delay were longer for participants with more severe psychopathology (i.e., BPD, depressive symptoms, general symptom severity). The findings revealed a substantial delay of receiving appropriate professional care in adolescents with self-harm thoughts and behavior. The correlation between treatment latency and higher psychopathology may emphasize the need of prompt treatment. A better understanding of barriers and facilitators to professional help will contribute to enhance measures of tailored support for young patients in their help-seeking process.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

General Practitioners' management of young people with mental health conditions in Australia

AIM

Detecting and diagnosing youth mental health issues can be challenging for General Practitioners (GPs) who are often the first to encounter them. One aim of this study was to understand the challenges GPs faced in identifying, treating and referring young people with mental health issues in Melbourne, Australia. A second aim was to identify gaps in GP knowledge and service provision in order to design a service and training program for GPs that addresses those gaps.

METHOD

A representative sampling method was used to invite GPs in south-east Melbourne to complete the study survey. Seventy-seven GPs completed the questionnaire consisting of 10 questions in 3 sections.

RESULTS

The results showed that GPs who consulted with young people more often had greater levels of confidence in identifying and treating their mental health issues but not referring. Forty-four percent identified the need for training in regards to youth mental health. GPs considered that the most effective care was provided in youth-friendly spaces but tended to primarily refer young people to private providers.

CONCLUSION

GPs need access to ongoing professional development and education programs on youth mental health, in particular more severe issues such as psychosis. Specialist youth mental health services such as CYMHS/CAMHS and headspace can offer GPs support in managing mental health issues in young people. However, there is a need to strengthen the link between GPs and specialist youth mental health service. Stronger links between services will ensure young people have timely and increased access to treatment.

Protocol for the Process Evaluation of the Online Remote Behavioural Intervention for Tics (ORBIT) randomized controlled trial for children and young people

BACKGROUND

Process evaluations are an important component in the interpretation and understanding of outcomes in trials. The Online Remote Behavioural Intervention for Tics (ORBIT) study is a randomized controlled trial evaluating the effectiveness of an Internet-delivered behavioural intervention (called BIP TIC) compared to an Internet-delivered education programme aimed at children and young people with tics. A process evaluation will be undertaken alongside the main trial to determine precisely how the behavioural intervention works and ascertain whether, and if so, how, the intervention could be successfully implemented in standard clinical practice. This protocol paper describes the rationale, aims, and methodology of the ORBIT trial process evaluation.

METHODS

The process evaluation will have a mixed-methods design following the UK Medical Research Council 2015 guidelines, comprising both quantitative and qualitative data collection. This will include analysing data usage of participants in the intervention arm; purposively sampled, semi-structured interviews of parents and children, therapists and supervisors, and referring clinicians of the ORBIT trial, as well as analysis of qualitative comments put into the online therapy platform by participants at the end of treatment. Qualitative data will be analysed thematically. Quantitative and qualitative data will be integrated in a triangulation approach, to provide an understanding of how the intervention works, and what resources are needed for effective implementation, uptake and use in routine clinical care.

DISCUSSION

This process evaluation will explore the experiences of participants, therapists and supervisors and referring clinicians of a complex online intervention. By contextualising trial efficacy results, this will help understand how and if the intervention worked and what may be required to sustain the implementation of the treatment long term. The findings will also aid in our understanding of factors that can affect the success of complex interventions. This will enable future researchers developing online behavioural interventions for children and young people with mental health and neurological disorders to gain invaluable information from this process evaluation.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials Number, ISRCTN70758207. Registered on 20 March 2018. ClinicalTrials.gov, NCT03483493. Registered on 30 March 2018.

Effectiveness of a Mental Health Service Navigation Website (Link) for Young Adults: Randomized Controlled Trial

BACKGROUND

Mental health and substance use disorders are the main causes of disability among adolescents and young adults yet fewer than half experiencing these problems seek professional help. Young people frequently search the Web for health information and services, suggesting that Web-based modalities might promote help-seeking among young people who need it. To support young people in their help-seeking, we developed a Web-based mental health service navigation website called Link. Link is based on the Theory of Planned Behavior and connects young people with treatment based on the type and severity of mental health symptoms that they report.

OBJECTIVE

The study aimed to investigate the effect of Link on young people's positive affect (PA) compared with usual help-seeking strategies immediately post intervention. Secondary objectives included testing the effect of Link on negative affect (NA), psychological distress, barriers to help-seeking, and help-seeking intentions.

METHODS

Young people, aged between 18 and 25 years, were recruited on the Web from an open access website to participate in a randomized controlled trial. Participants were stratified by gender and psychological distress into either the intervention arm (Link) or the control arm (usual help-seeking strategies). Baseline, immediate postintervention, 1-month, and 3-month surveys were self-reported and administered on the Web. Measures included the PA and NA scales, Kessler psychological distress scale (K10), barriers to adolescent help-seeking scale (BASH), and the general help-seeking questionnaire (GHSQ).

RESULTS

In total 413 young people were recruited to the trial (intervention, n=205; control, n=208) and 78% (160/205) of those randomized to the intervention arm visited the Link website. There was no evidence to support a difference between the intervention and control arms on the primary outcome, with PA increasing equally by approximately 30% between baseline and 3 months in both arms. NA decreased for the intervention arm compared with the control arm with a difference of 1.4 (95% CI 0.2-2.5) points immediately after the intervention and 2.6 (95% CI 1.1-4.1) at 1 month. K10 scores were unchanged and remained high in both arms. No changes were found on the BASH or GHSQ; however, participants in the intervention arm appeared more satisfied with their help-seeking process and outcomes at 1 and 3 months postintervention.

CONCLUSIONS

The process of prompting young people to seek mental health information and services appears to improve their affective state and increase help-seeking intentions, regardless of whether they use a Web-based dedicated youth-focused tool, such as Link, or their usual search strategies. However, young people report greater satisfaction using tools designed specifically for them, which may encourage future help-seeking. The ability of Web-based tools to match mental health needs with appropriate care should be explored further.

CLINICAL TRIAL

Australian New Zealand Clinical Trials Registry ACTRN12614001223628; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366731.

Promoting Help-seeking using E-technology for ADolescents with mental health problems: study protocol for a randomized controlled trial within the ProHEAD Consortium

BACKGROUND

The highest incidence and prevalence of mental health problems across the lifespan as well as the first onset of most long-term mental health conditions are reported for youths between 14 and 25 years of age. At the same time, only 25% of adolescents with mental health problems receive professional treatment. One explanation for poor treatment access in youths is their low help-seeking behavior. Barriers that can keep children and adolescents (C&A) from seeking professional help include a lack of perceived need, structural barriers, or stigma. Interventions based on e-technology might present an effective approach, overcoming these barriers by reducing stigma and providing low-threshold access with enhanced reach, ultimately facilitating help-seeking for mental health problems among youths.

METHODS

The study is designed as a multi-center, randomized controlled trial. In total, an estimated number of n = 1,500 C&A with mental health problems, drawn from a school-based sample of n = 15,000 pupils attending school grades 6 to 13 (≥ 12 years of age), recruited in five regions of Germany, will be randomized either to an intervention (ProHEAD online) or a control condition. C&A in the intervention group will receive online access to tailored information and individual advice on where to seek professional help for their specific needs close to their place of living, case reports of and interaction with peers, as well as the opportunity for online and telephone counseling. C&A in the control intervention will receive a recommendation to seek help and online information on where to find professional help. All participants will be asked to complete questionnaires concerning their help-seeking behavior at baseline, during the intervention (monitoring), and also at a 1 and 2 year follow-up. The primary endpoint is the number of C&A seeking conventional face-to-face professional help in the real-world setting within 1 year after their initial screening.

DISCUSSION

The trial will investigate if an Internet-based intervention can increase professional help-seeking in C&A with mental health problems. With its randomized controlled design and large-scale school-based sampling, the study aims to overcome the shortages of previous research. The intervention has the potential to narrow the treatment gap in C&A and to ultimately improve the mental health care system.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00014685 . Registered on 7 July, 2018.

Adolescents consulting general practitioners for psychological problems-a nationwide, register-based study in Norway

BACKGROUND

Psychological problems are increasing among adolescents, but little is known about the role of GPs in this area.

OBJECTIVES

This study aims to investigate the frequency of GP consultations with a psychological diagnosis in adolescence and predictors for such help seeking.

METHODS

Nationwide longitudinal register-based study investigating GP consultations among adolescents aged 13-17 years (N = 123 516) in Norway. First, all GP consultations within the study population were identified from the national GP claims register for 2006-11. Second, adolescents with a first-time consultation with a psychological diagnosis at age 15-16 years were identified, and prior GP consultations, prior somatic diagnoses, parental education and GP and GP-practice characteristics were assessed as possible predictors for seeking help.

RESULTS

From age 13 to 17 years, 15.3% of girls and 13.0% of boys had ≥1 GP consultation with a psychological diagnosis. In total, 6.8% of girls and 4.8% of boys consulted a GP for the first time with a psychological problem at age 15-16 years. For both sexes, number of prior GP consultations and a prior diagnosis of headache and abdominal pain predicted consulting with an internalizing problem (depression, anxiety and stress). A prior headache diagnosis predicted consulting for behavioural problems. Psychological diagnoses were more often found among adolescents with lower parental education. There were only minor associations with GP characteristics.

CONCLUSIONS

Norwegian adolescents often consult a GP and one in seven had a GP-diagnosed psychological problem at age 13-17. Policies to improve mental health care for adolescents should include strengthening of GP services.

Training General Practitioners to Detect Probable Mental Disorders in Young People During Health Risk Screening

PURPOSE

The purpose of the study is to investigate whether a training intervention increases general practitioners' (GPs) detection sensitivity for probable mental disorders in young people.

METHODS

Forty general practices were randomized to an intervention (29 GPs) or comparison arm (49 GPs). Intervention GPs participated in 9 hours of interactive training on youth-friendly care, psychosocial health risk screening, and responding to risk-taking behavior with motivational interviewing approaches, followed by practice visits assisting with integration of screening processes and tools. Youth aged 14-24 years attending GPs underwent a computer-assisted telephone interview about their consultation and psychosocial health risks. Having a "probable mental disorder" was defined as either scoring high on Kessler's scale of psychological distress (K10) or self-perceived mental illness. Other definitions tested were high K10; self-perceived mental illness; and high K10 and self-perceived mental illness. Psychosocial health risk screening rates, detection sensitivity, and other accuracy parameters (specificity, positive predictive value, and negative predictive value) were estimated.

RESULTS

GPs' detection sensitivity improved after the intervention if having probable mental disorder was defined as high K10 score and self-perceived mental illness (odds ratio: 2.81; 95% confidence interval: 1.23-6.42). There was no significant difference in sensitivity of GPs' detection for our preferred definition, high K10 or self-perceived mental illness (.37 in both; odds ratio: .93; 95% confidence interval: .47-1.83), and detection accuracy was comparable (specificity: .84 vs. .87, positive predictive values: .54 vs. .60, and negative predictive values: .72 vs. .72).

CONCLUSIONS

Improving recognition of mental disorder among young people attending primary care is likely to require a multifaceted approach targeting young people and GPs.

Facilitating mental health help-seeking by young adults with a dedicated online program: a feasibility study of Link

OBJECTIVE

To explore the feasibility of a dedicated online youth mental health help-seeking intervention and to evaluate using a randomised controlled trial (RCT) study design in order to identify any modifications needed before commencement of the full-scale RCT.

DESIGN

A pilot RCT with 1:1 randomisation to either the intervention or comparison arm.

SETTING

An online study conducted Australia-wide.

PARTICIPANTS

18-25 year olds living in Australia were recruited via social media.

INTERVENTION

Link is a dedicated online mental health help-seeking navigation tool that matches user's mental health issues, severity and service-type preferences (online, phone and face-to-face) with appropriate youth-friendly services. The comparison arm was usual help-seeking strategies with a link to Google.com.

MAIN OUTCOME MEASURES

The primary outcome was the number of acceptability and feasibility criteria successfully met. Intervention and study design acceptability and feasibility were assessed by nine criteria. Secondary outcomes, via online surveys (at baseline, 1 week and 1 month) measured service use, help-seeking intentions, psychological distress, barriers to help-seeking, attitudes towards mental health help-seeking, mental health literacy, satisfaction and trust.

RESULTS

Fifty-one participants were randomised (intervention: n=24; comparison: n=27). Three out of four of the intervention and two out of five of the study design criteria were met. Unmet criteria could be addressed by modifications to the study design. Qualitative analysis demonstrated that Link was useful to participants and may have increased their positive experiences towards help-seeking. There were no observable differences between arms in any outcome measures and no harms were detected.

CONCLUSION

Generally, the Link intervention and study design were acceptable and feasible with modifications suggested for the four out of nine unmet criteria. The main trial will hence have shorter surveys and a simpler recruitment process, use positive affect as the primary outcome and will not link to Google.com for the comparison arm.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry, ACTRN12614000386639.

Does screening for and intervening with multiple health compromising behaviours and mental health disorders amongst young people attending primary care improve health outcomes? A systematic review

BACKGROUND

Adolescence and young adulthood are important developmental periods. Screening for health compromising behaviours and mental health disorders during routine primary care visits has the potential to assist clinicians to identify areas of concern and provide appropriate interventions. The objective of this systematic review is to investigate whether screening and subsequent interventions for multiple health compromising behaviours and mental health disorders in primary care settings improves the health outcomes of young people.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, literature searches were conducted in Medline, PsycINFO, Scopus and Cochrane Library databases (Prospero registration number CRD42013005828) using search terms representing four thematic concepts: primary care, young people, screening, and mental health and health compromising behaviour. To be eligible for inclusion, studies had to: include a measure of health outcome; include at least 75 % of participants aged under 25 years; use a screening tool that assessed more than one health domain; and be conducted within a primary care setting. Risk of bias was assessed using the Quality Rating Scale.

RESULTS

From 5051 articles identified, nine studies fulfilled the inclusion criteria and were reviewed: two randomised controlled trials (RCTs), one pilot RCT, two clustered RCTs, one randomised study with multiple intervention groups and no control group, one cluster RCT with two active arms, one longitudinal study and one pre-post study. Seven studies, including two RCTs and one clustered RCT, found positive changes in substance use, diet, sexual health or risky sexual behaviour, alcohol-related risky behaviour, social stress, stress management, helmet use, sleep and exercise. Of only two studies reporting on harms, one reported a negative health outcome of increased alcohol use.

CONCLUSIONS

There is some evidence that the use of screening and intervention with young people for mental health disorder or health compromising behaviours in clinical settings improves health outcomes. Along with other evidence that young people value discussions of health risks with their providers, these discussions should be part of the routine primary care of young people. Further quality studies are needed to strengthen this evidence.

Risk-behaviour screening for identifying adolescents with mental health problems in Europe

Indicated prevention of mental illness is an important public health concern among youth. The aim of this study was to establish a European school-based professional screening among adolescents, which included variables on both a broad range of risk-behaviours and psychopathology; and to investigate the indicative value of adolescent risk-behaviour and self-reported psychopathology on help-seeking and psychological problems that required subsequent mental healthcare. A two-stage professional screening approach was developed and performed within the multi-centre study "Saving and Empowering Young Lives in Europe" (SEYLE). The first stage of screening comprised a self-report questionnaire on a representative sample of 3,070 adolescents from 11 European countries. In the second stage, students deemed at-risk for mental health problems were evaluated using a semi-structured clinical interview performed by healthcare professionals. 61 % of participants (n = 1,865) were identified as being at-risk in stage one. In stage two, 384 participants (12.5 % of the original sample) were found to require subsequent mental healthcare during semi-structured, clinical assessment. Among those, 18.5 % of pupils were identified due to screening for psychopathology alone; 29.4 % due to screening for risk-behaviours alone; and 52.1 % by a combination of both. Young age and peer victimization increased help-seeking, while very low body mass index, depression, suicidal behaviour and substance abuse were the best predictors of referral to mental healthcare. Screening of risk-behaviours significantly increased the number of detected students requiring subsequent mental healthcare. Screening of risk-behaviours added significant value in identifying the significant amount of European pupils with mental health problems. Therefore, attention to adolescent risk-behaviours in addition to psychopathology is critical in facilitating prevention and early intervention. Identifying factors that increase compliance to clinical interviews are crucial in improving screening procedures.

GPs' responses to adolescents presenting with psychological difficulties: a conceptual model of fixers, future planners, and collaborators

BACKGROUND

Psychological difficulties are common in adolescents yet are not often addressed by GPs. Anxiety and uncertainty about professional practice, with a reluctance to medicalise distress, have been found among GPs. GP involvement in this clinical area has been shown to be influenced by how GPs respond to the challenges of the clinical consultation, how they view young people and their perception of their health needs, and a GP's knowledge framework.

AIM

To explore the relationship between the above three influences to develop an overarching conceptual model.

DESIGN AND SETTING

Qualitative study based in 18 practices in the north east of England. The practices recruited included rural, urban, and mixed populations of patients predominantly living in socioeconomically disadvantaged communities.

METHOD

Theoretical sampling was used to guide recruitment of GP participants continuing until theoretical saturation was reached. Data were analysed using the constant comparative method of grounded theory and situational analysis.

RESULTS

In total 19 GPs were recruited: 10 were female, the age range was 29-59 years, with a modal range of 40-49 years. Three levels of analysis were undertaken. This study presents the final stage of analysis. GP 'enactment of role' was found to be the key to explaining the relationship between the three influencing factors. Three role archetypes were supported by the data: 'fixers', 'future planners', and 'collaborators'.

CONCLUSION

The role of GPs in managing adolescent psychological difficulties is unclear. Policy advocates a direct role but this is unsupported by education and service delivery. GPs adopt their own position along a continuum, resulting in different educational needs. Better preparation for GPs is required with exploration of new, more collaborative models of care for troubled adolescents.

Life-time prevalence and psychosocial correlates of adolescent direct self-injurious behavior: a comparative study of findings in 11 European countries

OBJECTIVES

To investigate the prevalence and associated psychosocial factors of occasional and repetitive direct self-injurious behavior (D-SIB), such as self-cutting, -burning, -biting, -hitting, and skin damage by other methods, in representative adolescent samples from 11 European countries.

METHODS

Cross-sectional assessment of adolescents was performed within the European Union funded project, Saving and Empowering Young Lives in Europe (SEYLE), which was conducted in 11 European countries. The representative sample comprised 12,068 adolescents (F/M: 6,717/5,351; mean age: 14.9 ± 0.89) recruited from randomly selected schools. Frequency of D-SIB was assessed by a modified 6-item questionnaire based on previously used versions of the Deliberate Self-Harm Inventory (DSHI). In addition, a broad range of demographic, social, and psychological factors was assessed.

RESULTS

Overall lifetime prevalence of D-SIB was 27.6%; 19.7% reported occasional D-SIB and 7.8% repetitive D-SIB. Lifetime prevalence ranged from 17.1% to 38.6% across countries. Estonia, France, Germany, and Israel had the highest lifetime rates of D-SIB, while students from Hungary, Ireland, and Italy reported low rates. Suicidality as well as anxiety and depressive symptoms had the highest odds ratios for both occasional and repetitive D-SIB. There was a strong association of D-SIB with both psychopathology and risk-behaviors, including family related neglect and peer-related rejection/victimization. Associations between psychosocial variables and D-SIB were strongly influenced by both gender and country. Only a minor proportion of the adolescents who reported D-SIB ever received medical treatment.

CONCLUSION

These results suggest high lifetime prevalence of D-SIB in European adolescents. Prevalence as well as psychosocial correlates seems to be significantly influenced by both gender and country. These results support the need for a multidimensional approach to better understand the development of SIB and facilitate culturally adapted prevention/intervention.

Do online mental health services improve help-seeking for young people? A systematic review

Background

Young people regularly use online services to seek help and look for information about mental health problems. Yet little is known about the effects that online services have on mental health and whether these services facilitate help-seeking in young people.

Objective

This systematic review investigates the effectiveness of online services in facilitating mental health help-seeking in young people.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, literature searches were conducted in PubMed, PsycINFO, and the Cochrane library. Out of 608 publications identified, 18 studies fulfilled the inclusion criteria of investigating online mental health services and help-seeking in young people aged 14-25 years.

Results

Two qualitative, 12 cross-sectional, one quasi-experimental, and three randomized controlled trials (RCTs) were reviewed. There was no change in help-seeking behavior found in the RCTs, while the quasi-experimental study found a slight but significant increase in help-seeking. The cross-sectional studies reported that online services facilitated seeking help from a professional source for an average of 35% of users. The majority of the studies included small sample sizes and a high proportion of young women. Help-seeking was often a secondary outcome, with only 22% (4/18) of studies using adequate measures of help-seeking. The majority of studies identified in this review were of low quality and likely to be biased. Across all studies, young people regularly used and were generally satisfied with online mental health resources. Facilitators and barriers to help-seeking were also identified.

Conclusions

Few studies examine the effects of online services on mental health help-seeking. Further research is needed to determine whether online mental health services effectively facilitate help-seeking for young people.

The Strengths and Difficulties Questionnaire (SDQ): the factor structure and scale validation in U.S. adolescents

The Strengths and Difficulties Questionnaire (SDQ) is one of the most commonly used instruments for screening psychopathology in children and adolescents. This study evaluated the hypothesized five-factor structure of the SDQ and examined its convergent validity against comprehensive clinical diagnostic assessments. Data were derived from the National Comorbidity Survey - Adolescent Supplement (NCS-A), a nationally representative sample of U.S. adolescents aged 13 to 18 years. Parents/parent surrogates (n=6,483) was asked to complete a self-administered questionnaire including the SDQ and DSM-IV comprehensive diagnostic information on the participating adolescents. Confirmatory factor analysis (CFA) was conducted to assess the factor structure of the SDQ. The five-factor solution of the SDQ (including emotional, conduct, hyperactivity-inattention, peer relationship, and prosocial) provided a satisfactory fit to the data, and was invariant across sex, age, race/ethnicity and income subgroups. SDQ scores predicted a significantly increased probability of meeting criteria for a DSM-IV disorder, with better prediction for behavior disorders than for mood disorders. Decreasing the SDQ cutoffs to the 80th percentile significantly increased the sensitivity from 39% to 63% for the SDQ Total Difficulties Score, with an expected decrease in specificity from 93% to 87%. This work confirms the five-factor structure of the SDQ in an ethnically and sociodemogrpahically diverse community sample of adolescents. Our findings strengthen empirical evidence for the use of the parent-reported SDQ as a screening tool for DSM-IV behavioral and emotional disorders in adolescents identified in the general population.

Universal mental health screening in pediatric primary care: a systematic review

OBJECTIVE

Universal mental health screening in pediatric primary care is recommended, but studies report slow uptake and low rates of patient follow-through after referral to specialized services. This review examined possible explanations related to the process of screening, focusing on how parents and youth are engaged, and how providers evaluate and use screening results.

METHOD

A narrative synthesis was developed after a systematic review of 3 databases (plus follow-up of citations, expert recommendations, and checks for multiple publications about the same study). Searching identified 1,188 titles, and of these, 186 full-text articles were reviewed. Two authors extracted data from 45 articles meeting inclusion criteria.

RESULTS

Published studies report few details about how mental health screens were administered, including how clinicians explain their purpose or confidentiality, or whether help was provided for language, literacy, or disability problems. Although they were not addressed directly in the studies reviewed, uptake and detection rates appeared to vary with means of administration. Screening framed as universal, confidential, and intended to optimize attention to patient concerns increased acceptability. Studies said little about how providers were taught to explore screen results. Screening increased referrals, but many still followed negative screens, in some cases because of parent concerns apparently not reflected by screen results but possibly stemming from screen-prompted discussions.

CONCLUSIONS

Little research has addressed the process of engaging patients in mental health screening in pediatric primary care or how clinicians can best use screening results. The literature does offer suggestions for better clinical practice and research that may lead to improvements in uptake and outcome.

Screening for adolescent depression in paediatric care: validity of a new brief version of the Center for Epidemiological Studies Depression Scale

BACKGROUND

The study assessed the criterion validity of the 15-item version of the Center for Epidemiological Studies Depression Scale (CES-D-15) as a screening instrument in paediatric care.

METHOD

A total of 327 patients (13-16 years) completed the CES-D-15 and a diagnostic interview serving as gold standard diagnosis for validation.

RESULTS

Receiver operating characteristics yielded an overall accuracy of area under the curve (AUC) = .90 (95% CI [.85, .95]) for the detection of any depressive disorder. At the optimal cut-off point of 14, sensitivity (.85) and specificity (.84) were good.

CONCLUSIONS

The CES-D-15 is a promising tool for paediatricians to enhance the recognition rate of juvenile depression.

Can general practice help address youth mental health? A retrospective cross-sectional study in Dublin's south inner city

AIMS

With general practice potentially having an important role in early intervention of mental and substance use disorders among young people, we aim to explore this issue by determining the prevalence of psychological problems and general practice/health service utilization among young people attending general practice.

METHODS

A retrospective cross-sectional study of patients attending three general practices in Dublin city.

RESULTS

Among a sample of young people (mostly women, 44% general medical services (GMS) eligible), we observed considerable contact with general practice, both lifetime and for the 2 years of the study. The mean consultation rate was 3.9 consultations in 2 years and psychosocial issues (most commonly stress/anxiety and depression) were documented in 35% of cases. Identification of psychosocial issues was associated with GMS eligibility, three or more doctor consultations, and documentation of smoking and drinking status.

CONCLUSIONS

Psychosocial issues are common among young people attending general practice and more work on their epidemiology and further identification in general practice are advocated.

The prevention access and risk taking in young people (PARTY) project protocol: a cluster randomised controlled trial of health risk screening and motivational interviewing for young people presenting to general practice

BACKGROUND

There are growing worldwide concerns about the ability of primary health care systems to manage the major burden of illness in young people. Over two thirds of premature adult deaths result from risks that manifest in adolescence, including injury, neuropsychiatric problems and consequences of risky behaviours. One policy response is to better reorientate primary health services towards prevention and early intervention. Currently, however, there is insufficient evidence to support this recommendation for young people. This paper describes the design and implementation of a trial testing an intervention to promote psychosocial risk screening of all young people attending general practice and to respond to identified risks using motivational interviewing.

MAIN OUTCOMES

clinicians' detection of risk-taking and emotional distress, young people's intention to change and reduction of risk taking.

SECONDARY OUTCOMES

pathways to care, trust in the clinician and likelihood of returning for future visits. The design of the economic and process evaluation are not detailed in this protocol.

METHODS

PARTY is a cluster randomised trial recruiting 42 general practices in Victoria, Australia. Baseline measures include: youth friendly practice characteristics; practice staff's self-perceived competency in young people's care and clinicians' detection and response to risk taking behaviours and emotional distress in 14-24 year olds, attending the practice. Practices are then stratified by a social disadvantage index and billing methods and randomised. Intervention practices receive: nine hours of training and tools; feedback of their baseline data and two practice visits over six weeks. Comparison practices receive a three hour seminar in youth friendly practice only. Six weeks post-intervention, 30 consecutive young people are interviewed post-consultation from each practice and followed-up for self-reported risk taking behaviour and emotional distress three and 12 months post consultation.

DISCUSSION

The PARTY trial is the first to examine the effectiveness and efficiency of a psychosocial risk screening and counselling intervention for young people attending primary care. It will provide important data on health risk profiles of young people attending general practice and on the effects of the intervention on engagement with primary care and health outcomes over 12 months.

TRIAL REGISTRATION

ISRCTN16059206.

Child and adolescent mental health care in Dutch general practice: time trend analyses

Background

Because most children and adolescents visit their general practitioner (GP) regularly, general practice is a useful setting in which child and adolescent mental health problems can be identified, treated or referred to specialised care. Measures to strengthen Dutch primary mental health care have stimulated cooperation between primary and secondary mental health care and have led to an increase in the provision of social workers and primary care psychologists. These measures may have affected GPs' roles in child and adolescent mental health care. This study aims to investigate the identification and treatment of child and adolescent mental health problems in general practice over a five-year period (2004-2008).

Methods

Data of patients aged 0-18 years (N ranging from 37716 to 73432) were derived from electronic medical records of 42-82 Dutch general practices. Time trends in the prevalence of recorded mental health problems, prescriptions for psychotropic medication, and referrals to primary and secondary mental health care were analysed.

Results

In 2008, 6.6% of children and 7.5% of adolescents were recorded as having mental health problems; 15.2% of these children and 29.4% of these adolescents were prescribed psychotropic medication; 18.9% of these children and 22.9% of these adolescents were referred, mainly to secondary mental health care. Between 2004 and 2008, the percentages of children (chi-square: 22.06; p < 0.001) and adolescents (chi-square: 9.15; p = 0.003) who were diagnosed with mental health problems increased. An increase was also found in the percentage of children who were prescribed psychostimulants (chi-square: 8.29; p = 0.004). Prescriptions for antidepressants decreased over time in both age groups (children: chi-square: 6.80; p = 0.009; adolescents: chi-square: 13.52; p < 0.001). The percentages of children who were referred to primary (chi-square: 6.98; p = 0.008) and secondary mental health care (chi-square: 5.76; p = 0.02) increased over the years, whereas no significant increase was found for adolescents.

Conclusions

Although GPs' identification of mental health problems and referrals to primary mental health care have increased, most referrals are still made to secondary care. To further strengthen primary mental health care, effective short-term interventions for child and adolescent mental health problems that can be applied in general practice need to be developed.

Predicting future depression in adolescents using the Short Mood and Feelings Questionnaire: a two-nation study

BACKGROUND

Adolescence is a key life period for the development of depression. Predicting the development of depression in adolescence through detecting specific early symptoms may aid in the development of timely screening and intervention programmes.

METHODS

We administered the Short Mood and Feelings Questionnaire (SMFQ) to 5769 American and Australian students aged 10 to 15 years, at two time points, separated by 12 months. We attempted to predict high levels of depression symptoms at 12 months from symptoms at baseline, using statistical approaches based upon the quality, as well as the quantity, of depression symptoms present. These approaches included classification and regression trees (CART) and logistic regression.

RESULTS

A classification tree employing four SMFQ items, such as feelings of self-hatred and of being unloved, performed almost as well as all 13 SMFQ items at predicting subsequent depression symptomatology.

LIMITATIONS

Depression was measured using a self-report instrument, rather than a criterion standard diagnostic interview.

CONCLUSION

Further validation on other populations of adolescents is required: however the results suggest that several symptoms of depression, especially feelings of self-hatred, and being unloved, are associated with increased levels of self-reported depression at 12 months post baseline. Although screening for depression can be problematic, symptoms such as the ones above should be considered for inclusion in screening tests for adolescents.

What is the role of general practice in addressing youth mental health? A discussion paper

BACKGROUND

Mental and substance use disorders are a leading cause of morbidity among young people. Policy and clinical services in Ireland are endeavouring to address these twin issues.

AIMS

To review the emerging literature on the role of general practice in addressing youth mental health and to discuss the implications of this literature for further research, education and service delivery.

METHODS

We conducted a review of 'PubMed' and a web search of relevant national/international primary/mental healthcare agencies and professional bodies.

RESULTS

Although general practice has an important role in addressing youth mental health, there are challenges in how young people seek help. Specifically, young people do not engage with healthcare agencies and many factors which act as barriers and enablers in this regard have been identified. The detection and treatment of mental and substance use disorders by GPs can be improved and implementing interventions to improve screening and early intervention are likely to be valuable.

CONCLUSIONS

General practice is a central agency in addressing youth mental health and complex multifaceted interventions (education, clinical guidelines, and promoting awareness) are likely to support its role. Further research exploring this issue is a priority.

What are the major drivers of prevalent disability burden in young Australians?

OBJECTIVE

To examine age and sex differences in the leading causes of prevalent disability in young Australians.

DESIGN, SETTING AND PARTICIPANTS

We analysed data from the 2003 Australian Burden of Disease and Injury Study, which estimated the prevalent disability burden attributable to 170 diseases and injuries, for younger adolescents (10-14 years), older adolescents (15-19 years) and young adults (20-24 years).

MAIN OUTCOME MEASURES

The broad categories of disease and injury that are the main contributors to prevalent disability and the 10 leading disease and injury causes of prevalent disability, according to sex and age group.

RESULTS

Total prevalent disability rates are lowest in younger adolescents and highest in young adults. Mental disorders are the largest "contributor" to disability in young Australians, and anxiety and depressive disorders are the leading single cause. In young males, autism and attention deficit hyperactivity disorder cause similar levels of disability as do anxiety and depression. In young females, eating disorders are the second leading cause of mental disorder disability. Alcohol use disorders and schizophrenia make important contributions to disability in young adult males. Asthma is the most prominent cause of physical disability in all three age groups.

CONCLUSIONS

There are substantial changes in both the pattern and level of disability burden across the three age groups that we studied. The increase in total prevalent disability that occurs from early adolescence to young adulthood should focus attention on the delivery of accessible and youth friendly health care as well as the effectiveness of transitions from child health services to adult health services.