Scoping review of stepped care interventions for mental health and substance use service delivery to youth and young adults

Screening and Follow-Up Treatment Practices for Suicide Risk in Adolescent Primary Care: A Retrospective Chart Review

Universal depression screening in adolescent primary care often encompasses questions about suicide risk. We conducted a retrospective chart review of well-child visits where adolescents (ages 13-17.9) had endorsed self-injurious thoughts and behaviors or suicidal ideation. The goal was to investigate primary care providers' follow-up actions, including documentation, further assessment, and referrals. Over 3-quarters of the progress notes showed evidence of further assessment, and two-thirds documented same-day actions, including mental health referrals, emergency department referrals, safety plans, medication changes, primary-care follow-up, and talking to parents. Actions varied by depression severity. Cases without interventions often had justifications. Owing to the variety of possible meanings and severity underlying positive screens, providers implemented an array of interventions, using clinical judgment to tailor actions to patients' individual needs and preferences. From these observations, we propose that standardized guidelines for suicide risk screening and follow-up should involve a clinical assessment and individualized treatment planning.

Brazilian Scale for Evaluation of Mental Health Care Needs: Additional Evidence

OBJECTIVE

To investigate validity evidence of the Brazilian Scale for Evaluation of Mental Health Care Needs (CuidaSM).

METHODS

This is a psychometric study, which seeks additional evidence of internal structure. Data collection was carried out in 11 Primary Health Care (PHC) services , which implement the Health Care Planning (HCP) methodology, distributed across the five Brazilian regions. The preliminary version of CuidaSM, containing a block self-referred by the user and another block evaluated by PHC professionals, was applied to users aged 18 or over who attended the PHC services for consultation with a higher education professional. The techniques of confirmatory factor analysis and network analysis were used to investigate validity evidence. For the primary data of the confirmatory factor analysis, the factorial loads and the item's predictive power (R2) were used. Six model adjustment indices were adopted and reliability was measured by three indicators using Bayesian estimation.

RESULTS

A total of 879 users participated in the study. By confirmatory factor analysis, factorial loads ranged from 0.43 to 0.99 and R2 from 0.19 to 0.98. Both the primary indicators and the model adequacy indices were established at satisfactory and consistent levels. The network analysis showed that the items were appropriately associated with their peers, respecting the established dimensions, which again indicates the sustainability and stability of the proposed model.

CONCLUSIONS

The study findings confirm a consistent and reliable model of the instrument, through a combination of techniques. Considering the importance of using solid instruments in clinical practice, CuidaSM is a promising tool for population-based management and network care organization, aligned with HCP proposals.

Acceptability and utility of digital well-being and mental health support for university students: A pilot study

AIM

To assess the acceptability and explore the utility of a novel digital platform designed as a student-facing well-being and mental health support.

METHODS

An adapted version of i-spero® was piloted as a student-facing well-being support and as part of routine university-based mental health care. In both pathways, student participants completed baseline demographics and brief validated measures of well-being and mental health. Weekly measures of anxiety (GAD-7) and depression (PHQ-9) and a Week 8 Experience Survey were also scheduled. Integrated mixed methods analysis was used to assess acceptability and explore the utility of these platforms.

RESULTS

Students in the well-being (n = 120) and care pathways (n = 121) were mostly female and between 19 and 22 years of age. Baseline screen positive rates for anxiety and depression were high in both the well-being (68%) and care pathways (80%). There was a substantial drop in adherence over Week 1 (50% well-being; 40% care) followed by minor attrition up to Week 8. Anxiety and depressive symptom levels improved from baseline in students who dropped out after Week 1 (p ≤ .06). The student experience was that i-spero® improved their emotional self-awareness, understanding of progress in care, and knowledge about when to seek help. Most students agreed (>75%) that i-spero® should form part of regular university student wellness support.

CONCLUSIONS

Digital well-being and mental health support seems acceptable to university students; however, engagement and persistence are areas for further development. Such digital tools could make a positive contribution to an evidence-based stepped approach to student well-being and mental health support.

Provider perceptions of the anticipated benefits, barriers, and facilitators associated with implementing a stepped care model for the delivery of addiction and mental health services in New Brunswick: a mixed-methods observational implementation study

BACKGROUND

Providers who work within addiction and mental health (A&MH) services in New Brunswick (NB), Canada completed training in Stepped Care 2.0 and One-at-a-Time (OAAT) therapy as part of a provincial practice change initiative to implement a provincial stepped care model. The present study aimed to identify: (1) the perceived acceptability and feasibility of the SC2.0 model; (2) the perceived benefits, barriers, and facilitators to implement SC2.0 in practice; and (3) perceived impacts on clinical practice.

METHODS

This is a mixed-methods observational implementation study. Quantitative surveys were completed after training courses. Open-ended responses were collected after completion of SC2.0 training. A subset of providers who completed surveys were asked to participate in semi-structured interviews. Descriptive statistics were used to describe results from surveys. Open-ended responses and semi-structured interviews were compiled and thematically synthesized in an iterative process using a grounded theory framework. Quantitative and qualitative data were triangulated to build an in-depth understanding of provider perceptions.

RESULTS

316 providers completed surveys and responded to open-ended prompts. Interviews were completed with 28 of those providers. SC2.0 was deemed to be acceptable, a suitable fit, and feasible to implement. Perceived benefits included: (1) timely access to services; (2) increased practice efficiency; and (3) increased availability of services. Perceived barriers included: (1) insufficient availability of resources to populate a SC2.0 continuum of care; (2) provider complacency with their current practice; and (3) difficulty for clients to accept and adjust to change.

CONCLUSIONS

Identifying the perceived benefits, facilitators, and barriers to adopting stepped care in practice can lead to targeted implementation strategies and the collection of data that can inform continuous improvement cycles.

Guiding Principles for Implementing Stepped Care in Mental Health: Alignment on the Bigger Picture

Stepped care models are a mental healthcare delivery framework in which a continuum of support allows selection of a range of interventions to match a client's evolving needs and preferences. Currently in use in multiple settings worldwide, stepped care has the potential to provide a needed advance for the development of comprehensive mental health systems. However, definitions of stepped care lack consistency, resulting in differing interpretations reflected in variable implementation, ultimately limiting its replicability, utility and potential for impact. To help foster greater alignment in research and practice, we propose a set of principles for stepped care which can provide guidance on how to bridge multiple mental health services together, reduce fragmentation, and respond to the full breadth of mental health needs along a continuum of care in diverse settings. We hope that articulating these principles will foster discussion and spur mental health stakeholders to translate them into actionable standards.

"They are always focusing on the person who is doing the worst": Exploring how crisis shapes young people's pathways in and out of supportive housing in Vancouver, Canada

Housing instability, homelessness, and mental health among young people who use drugs in Vancouver, Canada, and elsewhere have increasingly been framed through a language of crisis. The declaration of overlapping housing, mental health, and addictions crises in our own setting has prompted a wide range of interventions, including the rapid expansion of supportive housing programs that include integrated housing-based substance use and mental health care. There is growing evidence demonstrating that these models are effective at stabilizing people who are experiencing protracted housing instability, mental health, and substance use related health concerns. We recount stories of three young people who have lived in supportive housing to argue that achieving the relative stability afforded by these interventions is partially contingent on maintaining a delicate balance between being in a state of "too much" or "too little" in crisis. These stories demonstrate two key findings. First, being in crisis has made these young people visible to housing, substance use, and mental health programs that may not otherwise be available to them. Secondly, entering periods of protracted or intense mental health crisis may reopen pathways into unstable housing and homelessness by activating undesirable institutional responses that conflict with young people's desire for self-determination in relation to their care. This study underscores that supportive housing should be part of a broader youth focused system of housing and care that seeks to address the needs of young people before they enter states of crisis.

Impact of Cultural and Linguistic Maintenance on Mental Health Outcomes in Migrant Adolescents: Protocol for a Scoping Review

BACKGROUND

There is no consensus on how the disruption or maintenance of heritage culture and language affect mental health outcomes in adolescents with a migrant (also known as "immigrant" or "international migrant") background. Even though previous literature reviews have investigated the association between acculturation and mental health in migrants, none have explicitly focused on adolescents.

OBJECTIVE

The aim of the scoping review described in this protocol is to understand (1) the focus, scope, and nature of quantitative empirical research investigating heritage cultural maintenance, including linguistic maintenance, and mental health outcomes in adolescents with a migrant background worldwide and (2) the potential effects of cultural and linguistic maintenance or disruption on migrant adolescent mental health outcomes.

METHODS

A total of 11 key electronic health, medical, social science, and language databases (APA PsycArticles Full Text; Embase Classic+Embase; Ovid MEDLINE All and Epub Ahead of Print, In-Process, In-Data-Review and Other Non-Indexed Citations and Daily; Ovid MEDLINE All; APA PsycInfo; University of Melbourne full-text journals; Science Citation Index Expanded; Social Sciences Citation Index; Arts & Humanities Citation Index; Scopus; Linguistics and Language Behavior Abstracts) were searched. Databases were searched without time restrictions from the beginning of their coverage. Publication date, location, and quantitative study design (except for literature reviews) were not restricted; however, the search was only conducted in English. Data from included studies will be extracted using a template with predefined data items, and results will be summarized in a structured, narrative summary.

RESULTS

A search was conducted on April 20, 2021, returning 2569 results. We are currently at the final stages of screening titles and abstracts of our search results, which will be followed by a full-text review and the data extraction of included studies. We expect to submit the full review for publication by the end of 2023.

CONCLUSIONS

The scoping review aims to provide a better understanding of existing research on the association between cultural (including linguistic) maintenance and mental health in migrant adolescents. It will help identify gaps in the existing literature and develop hypotheses that could inform future research, eventually facilitating the development of targeted prevention initiatives and improving migrant adolescents' well-being.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40143.

Adverse Childhood Experiences and Mental Health among Students Seeking Psychological Counseling Services

Recent years have seen a marked rise in the number of students accessing University Psychological Counseling (UPC) services, and their concerns have been increasingly severe. This study aimed to examine the impact of cumulative adverse childhood experiences (ACEs) on mental health in students who had approached counseling services (N = 121) and students who had no experience with counseling services (N = 255). Participants completed an anonymous online self-report questionnaire measuring exposure to adverse childhood experiences (ACE-Q), psychological distress (General Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9), personality traits (PID-5), and coping strategies. We found that students who approached UPC services scored higher on cumulative ACEs than the non-counseling group. While ACE-Q score was a direct positive predictor of PHQ-9 (p < 0.001), it did not predict GAD-7. Moreover, the results supported the existence of a mediation effect of avoidance coping, detachment, and psychoticism on the indirect effects of ACE-Q score on PHQ-9 or GAD-7. These results underlined the importance of screening for ACEs in a UPC setting because it can help identify students at higher risk for developing mental and physical health problems and provide them with early interventions and support.

A Relational Agent Intervention for Adolescents Seeking Mental Health Treatment: Protocol for a Randomized Controlled Trial

BACKGROUND

Unmet pediatric mental health (MH) needs are growing as rates of pediatric depression and anxiety dramatically increase. Access to care is limited by multiple factors, including a shortage of clinicians trained in developmentally specific, evidence-based services. Novel approaches to MH care delivery, including technology-leveraged and readily accessible options, need to be evaluated in service of expanding evidence-based services to youths and their families. Preliminary evidence supports the use of Woebot, a relational agent that digitally delivers guided cognitive behavioral therapy (CBT) through a mobile app, for adults with MH concerns. However, no studies have evaluated the feasibility and acceptability of such app-delivered relational agents specifically for adolescents with depression and/or anxiety within an outpatient MH clinic, nor compared them to other MH support services.

OBJECTIVE

This paper describes the protocol for a randomized controlled trial evaluating the feasibility and acceptability of an investigational device, Woebot for Adolescents (W-GenZD), within an outpatient MH clinic for youths presenting with depression and/or anxiety. The study's secondary aim will compare the clinical outcomes of self-reported depressive symptoms with W-GenZD and a telehealth-delivered CBT-based skills group (CBT-group). Tertiary aims will evaluate additional clinical outcomes and therapeutic alliance between adolescents in W-GenZD and the CBT-group.

METHODS

Participants include youths aged 13-17 years with depression and/or anxiety seeking care from an outpatient MH clinic at a children's hospital. Eligible youths will have no recent safety concerns or complex comorbid clinical diagnoses; have no concurrent individual therapy; and, if on medications, are on stable doses, based on clinical screening and as well as study-specific criteria.

RESULTS

Recruitment began in May 2022. As of December 8, 2022, we have randomized 133 participants.

CONCLUSIONS

Establishing the feasibility and acceptability of W-GenZD within an outpatient MH clinical setting will add to the field's current understanding of the utility and implementation considerations of this MH care service modality. The study will also evaluate the noninferiority of W-GenZD against the CBT-group. Findings may also have implications for patients, families, and providers looking for additional MH support options for adolescents seeking help for their depression and/or anxiety. Such options expand the menu of supports for youths with lower-intensity needs as well as possibly reduce waitlists and optimize clinician deployment toward more severe cases.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05372913; https://clinicaltrials.gov/ct2/show/NCT05372913.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44940.

The Longitudinal Youth in Transition Study (LYiTS) Cohort Profile: Exploration by Hospital- Versus Community-Based Mental Health Services

OBJECTIVES

Youth face numerous challenges in receiving coordinated and continuous mental health services, particularly as they reach the age of transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). The Longitudinal Youth in Transition Study (LYiTS) follows youth prospectively as they cross this transition boundary to better understand their transition pathways and resulting symptoms and health service use outcomes. The current paper presents the baseline profile description for the LYiTS cohort and additionally examines differences in symptoms and functioning and health service utilization between youth receiving services at hospital- versus community-based CAMHS.

METHODS

A cross-sectional design was used. A sample of 237 16-18-year-old youth recruited from outpatient CAMHS at two hospitals and two community sites completed self-report measures at their first of four annual assessments. A latent profile analysis was conducted to identify symptomology profiles, and youth were compared on symptoms and health service use between hospital- and community-based sites.

RESULTS

Four distinct symptomology profiles were identified (subclinical, moderate internalizing, moderate externalizing, and high symptomology). Symptom profiles and functioning levels reported by youth were no different across both types of organization, although there were differences detected in health service utilization, such as type of provider seen and use of medications.

CONCLUSIONS

These findings suggest that there is little difference in symptomology between youth accessing hospital versus community-based CAMHS. With growing interest in understanding the effectiveness and cost-effectiveness of different models of mental health care, these findings provide a new understanding of the clinical and service use profiles of transition-aged youth that will be explored further as this cohort is followed across the CAMHS to AMHS transition boundary.

Predictors of outcome after a time-limited psychosocial intervention for adolescent depression

Research on the predictors of outcome for early, community-based, and time-limited interventions targeted for clinical depression in adolescents is still scarce. We examined the role of demographic, psychosocial, and clinical variables as predictors of outcome in a trial conducted in Finnish school health and welfare services to identify factors associating to symptom reduction and remission after a brief depression treatment. A total of 55 12–16-year-olds with mild to moderate depression received six sessions of either interpersonal counseling for adolescents (IPC-A) or brief psychosocial support (BPS). Both interventions resulted in clinical improvement at end of treatment and 3- and 6-month follow-ups. Main outcome measures were self-rated BDI-21 and clinician-rated Adolescent Depression Rating Scale (ADRSc). Latent change score (LCS) models were used to identify predictors of change in depressive symptom scores and clinical remission at end of treatment and 3- and 6-month follow-ups over the combined brief intervention group. Symptom improvement was predicted by younger age and having a close relationship with parents. Both symptom improvement and clinical remission were predicted by male gender, not having comorbid anxiety disorder, and not having sleep difficulties. Our results add to knowledge on factors associating with good treatment outcome after a brief community intervention for adolescent depression. Brief depression interventions may be useful and feasible especially for treatment of mild and moderate depression among younger adolescents and boys, on the other hand clinicians may need to cautiously examine sleep problems and anxiety comorbidity as markers of the need for longer treatment.

Characterizing mental health related service contacts in children and youth: a linkage study of health survey and administrative data

BACKGROUND

To inform the provision and organization of care, and to improve equitable access to mental health services for children and youth, we must first characterize the children and youth being served, taking into consideration factors related to mental health need. Our objective was to use a population-based survey linked with health administrative data to estimate mental health related contacts and determine socio-demographic correlates, after adjusting for factors related to mental health need.

METHODS

Data from the 2014 Ontario Child Health Study (OCHS) were linked at the individual level to health administrative databases from Ontario's Ministry of Health and Long-Term Care (MOHLTC). Mental health related service contacts were identified in the 6-months prior to the OCHS survey date. Service contacts with physicians were obtained from health administrative data, and non-physician service contacts from survey data (parent-report).

RESULTS

21.7% of Ontarian children (4-11 years) and youth (12-17 years) had at least one mental health related contact in the 6-months prior to their OCHS survey date (18.8% non-physician, 8.0% physician, 5.2% both). Children and youth contacting both physician and non-physician services (ref. contact with physician or non-physician services alone) had higher mean symptom ratings of mental disorders across all classes of disorder. After adjusting for total symptom ratings, children and youth with immigrant parent(s) (ref. non-immigrant) (Prevalence Ratio: 0.65, 95% CI 0.55, 0.75) were less likely to have any mental health related service contact.

CONCLUSIONS

Results indicate that children and youth with the highest mental health symptom ratings are more likely to have contact with multiple providers across sectors. As such, the coordination of care across and within sectors are critical components of mental health related services for children and youth. Our results indicate that the greatest disparities in mental health related service contacts may exist for children and youth with immigrant parent(s) and that targeted outreach efforts are required to reduce barriers to care and improve equitable access to mental health related services for children and youth in Ontario.

Gaming My Way to Recovery: A Systematic Scoping Review of Digital Game Interventions for Young People's Mental Health Treatment and Promotion

Nearly all young people use the internet daily. Many youth with mental health concerns, especially since the Covid-19 pandemic, are using this route to seek help, whether through digital mental health treatment, illness prevention tools, or supports for mental wellbeing. Videogames also have wide appeal among young people, including those who receive mental health services. This review identifies the literature on videogame interventions for young people, ages 12-29, and maps the data on game use by those with mental health and substance use problems, focusing on evidence for the capacity of games to support treatment in youth mental health services; how stakeholders are involved in developing or evaluating games; and any potential harms and ethical remedies identified. A systematic scoping review methodology was used to identify and assess relevant studies. A search of multiple databases identified a total of 8,733 articles. They were screened, and 49 studies testing 32 digital games retained. An adapted stepped care model, including four levels, or steps, based on illness manifestation and severity, was used as a conceptual framework for organizing target populations, mental health conditions and corresponding digital games, and study results. The 49 selected studies included: 10 studies (20.4%) on mental health promotion/prevention or education for undiagnosed youth (Step 0: 7 games); 6 studies (12.2%) on at-risk groups or suspected mental problems (Step 1: 5 games); 24 studies (49.0%) on mild to moderate mental conditions (Steps 2-3: 16 games); and 9 studies (18.4%) focused on severe and complex mental conditions (Step 4: 7 games). Two interventions were played by youth at more than one level of illness severity: the SPARX game (Steps 1, 2-3, 4) and Dojo (Steps 2-3 and 4), bringing the total game count to 35 with these repetitions. Findings support the potential integration of digital games in youth services based on study outcomes, user satisfaction, relatively high program retention rates and the potential usefulness of most games for mental health treatment or promotion/prevention. Most studies included stakeholder feedback, and involvement ratings were very high for seven games. Potential harms were not addressed in this body of research. This review provides an important initial repository and evaluation of videogames for use in clinical settings concerned with youth mental health.