Integrated collaborative care teams to enhance service delivery to youth with mental health and substance use challenges: protocol for a pragmatic randomised controlled trial

Health through the eyes of youths: a qualitative study

Background

Emerging definitions of health have suggested a shift in focus to one's ability to manage their health condition, function, and social determinants of health. The construct of health for youths with mental health and substance use disorders (MHSU) is complex and multi-dimensional with interplay between biological, behavioral, and social conditions. Expanding definitions of health is crucial in the measurement of health and evaluation of integrated youth services (IYS) systems for people with MHSU disorders. Hence, it is critical to understand the construct of health from the perspective of a young person living with a MHSU disorder.

Methods

This study was conducted using inductive thematic analysis. Three focus groups were conducted from July to August 2017.

Results

A total of 22 youths (17-24 years) took part in this study. Results showed that health is a multidimensional construct situated in the ecosystem of a person's environment. Health can be understood from two macro themes: Individual health and Determinants of health. It consisted of physical health, mental health, day-to-day functioning, and being in control of your own health condition. Systemic and social factors were factors that influenced the state of health.

Conclusion

This study contributes to a conceptualization of good health in youth with MHSU disorders. This conceptualization can aid in the development of more accurate measures of health and functioning and the evaluation of mental health services for youth with MHSU.

What do justice-involved youth want from integrated youth services? A conjoint analysis

Background

Many youth in the criminal justice system are affected by mental health and/or substance use (MHS) challenges, yet only a minority receive treatment. One way to increase access to MHS care is integrated youth services (IYS), a community-based model of service delivery where youth can access evidence-based treatment for their MHS problems and other wellbeing needs, in one location. However, it is unknown what IYS services justice-involved youth prioritize.

Objective

This study explored what components of IYS justice-involved youth deem to be the most important in meeting their MHS service needs, in comparison with non-justice-involved youth, by conducting a secondary analysis of data gathered from a larger Ontario-wide study.

Method

Using a conjoint analysis, n = 55 justice-involved youth, and n = 188 non-justice-involved youth, completed thirteen choice tasks representing different combinations of IYS.

Results

Both justice-involved and non-justice-involved youth exhibited preferences for a broad range of core health services, including mental health services, substance misuse counseling, medication management, and physical or sexual health services. They also preferred a broad range of additional support services, in addition to fast access to care in a community setting that specializes in mental health services, with the incorporation of e-health services. Justice-involved youth prioritized working with a trained peer support worker to learn life skills and help them with the services they need. The importance of youth playing a leadership role in making decisions within IYS organizations was also a distinguishing preference among justice-involved youth.

Conclusions

Tailoring IYS to meet the service preferences of justice-involved youth may enhance service utilization, potentially leading to better outcomes for justice-involved youth and their communities.

Can Implementing New Services Organization Models to Better Meet the Needs of Young People Bring About Practice Changes? Analysis of an Experiment in Québec

The research question addressed in this article is: Can implementing new services organization models to better meet the needs of young people bring about practice changes? More precisely, we examine the effects of a new model called Aire Ouverte (AO) which is implemented gradually across Quebec since 2019. This new model involves public sector and community organizations. To grasp practices' change, we use cultural historical activity theory (CHAT) and employ a qualitative approach. Beyond a precise description of work activities, we gained an inside view of how the actors involved represented their practice and context. Our results show that practice changes seen by actors are in line with the object of the intervention, that is, responding rapidly to the expressed needs of young people. The development of new tools, flexible functioning, strengthening of interprofessional and intersectoral collaboration, involvement of young people in decision-making, all should contribute to improving response to their needs. This being said, a critical look at practice changes reveals a challenge in aligning the design and objective of AO with the needs of some young people. We noted also a poor alignment of effective collaborative practices between levels of care and the practices sought from intersectoral collaboration.

Evaluation of an automated matching system of children and families to virtual mental health resources during COVID-19

BACKGROUND

Children and their families often face obstacles in accessing mental health (MH) services. The purpose of this study was to develop and pilot test an electronic matching process to match children with virtual MH resources and increase access to treatment for children and their families during COVID-19.

METHODS

Within a large observational child cohort, a random sample of 292 families with children ages 6-12 years were invited to participate. Latent profile analysis indicated five MH profiles using parent-reported symptom scores from validated depression, anxiety, hyperactivity, and inattention measures: (1) Average Symptoms, (2) Low Symptoms, (3) High Symptoms, (4) Internalizing, and (5) Externalizing. Children were matched with virtual MH resources according to their profile; parents received surveys at Time 1 (matching process explanation), Time 2 (match delivery) and Time 3 (resource uptake). Data on demographics, parent MH history, and process interest were collected.

RESULTS

128/292 families (44%) completed surveys at Time 1, 80/128 families (63%) at Time 2, and a final 67/80 families (84%) at Time 3, yielding an overall uptake of 67/292 (23%). Families of European-descent and those with children assigned to the Low Symptoms profile were most likely to express interest in the process. No other factors were associated with continued interest or uptake of the electronic matching process. Most participating parents were satisfied with the process.

CONCLUSIONS

The electronic matching process delivered virtual MH resources to families in a time-efficient manner. Further research examining the effectiveness of electronically matched resources in improving children's MH symptoms is needed.

Associations over the COVID-19 pandemic period and the mental health and substance use of youth not in employment, education or training in Ontario, Canada: a longitudinal, cohort study

BACKGROUND

The economic shutdown and school closures associated with the COVID-19 pandemic have negatively influenced many young people's educational and training opportunities, leading to an increase in youth not in education, employment, or training (NEET) globally and in Canada. NEET youth have a greater vulnerability to mental health and substance use problems, compared to their counterparts who are in school and/or employed. There is limited evidence on the association between COVID-19 and NEET youth. The objectives of this exploratory study included investigating: longitudinal associations between the COVID-19 pandemic and the mental health and substance use (MHSU) of NEET youth; and MHSU among subgroups of NEET and non-NEET youth.

METHODS

618 youth (14-28 years old) participated in this longitudinal, cohort study. Youth were recruited from four pre-existing studies at the Centre for Addiction and Mental Health. Data on MHSU were collected across 11 time points during the COVID-19 pandemic (April 2020-August 2022). MHSU were measured using the CoRonavIruS Health Impact Survey Youth Self-Report, the Global Appraisal of Individual Needs Short Screener, and the PTSD Checklist for DSM-5. Linear Mixed Models and Generalized Estimating Equations were used to analyze associations of NEET status and time on mental health and substance use. Exploratory analyses were conducted to investigate interactions between sociodemographic characteristics and NEET status and time.

RESULTS

At baseline, NEET youth were significantly more likely to screen positive for an internalizing disorder compared to non-NEET youth (OR = 1.92; 95%CI=[1.26-2.91] p = 0.002). No significant differences were found between youth with, and without, NEET in MHSU symptoms across the study time frame. Youth who had significantly higher odds of screening positive for an internalizing disorder included younger youth (OR = 1.06, 95%CI=[1.00-1.11]); youth who identify as Trans, non-binary or gender diverse (OR = 8.33, 95%CI=[4.17-16.17]); and those living in urban areas (OR = 1.35, 95%CI=[1.03-1.76]), compared to their counterparts. Youth who identify as White had significantly higher odds of screening positive for substance use problems (OR = 2.38, 95%CI=[1.72-3.23]) compared to racialized youth.

CONCLUSIONS

Our findings indicate that sociodemographic factors such as age, gender identity, ethnicity and area of residence impacted youth MHSU symptoms over the course of the study and during the pandemic. Overall, NEET status was not consistently associated with MHSU symptoms over and above these factors. The study contributes to evidence on MHSU symptoms of NEET youth.

Youth Wellness Hubs Ontario: Development and initial implementation of integrated youth services in Ontario, Canada

AIM

The need for youth-friendly early intervention services to meet the mental health, substance use, primary care, and other social needs of adolescents and young adults is well-documented. This article describes Youth Wellness Hubs Ontario, a province-wide initiative in Ontario, Canada to build and implement a one-stop-shop model of integrated youth services.

METHODS

We describe the development of Youth Wellness Hubs Ontario, in the context of global youth mental health system transformation, as well as pan-Canadian youth mental health system change. We also describe Youth Wellness Hubs Ontario's values and services.

RESULTS

The demonstration phase of Youth Wellness Hubs Ontario was initiated in 2017-2018. Youth Wellness Hubs Ontario is co-created with youth for youth aged 12-25 years old across diverse community contexts. Youth Wellness Hubs Ontario centres engagement and equity, and offers developmentally-appropriate services in an integrated, community-based walk-in format. As an initiative committed to continuous learning and quality improvement, Youth Wellness Hubs Ontario offers evidence-based and evidence-generating services, and measurement-based care. Youth Wellness Hubs Ontario is supported by backbone resources with expertise in implementation science, health equity, Indigenous practices, youth and family engagement, evaluation, and knowledge translation. In 2020 Youth Wellness Hubs Ontario secured sustainable funding for the first 10 locations and scale-up began in 2021, with 10 additional locations in development.

CONCLUSIONS

Youth Wellness Hubs Ontario demonstrates the feasibility of integrated mental health and substance use early intervention services, offered in the context of a broad range of health and social services.

Youth substance use service provider’s perspectives on use and service access in ontario: time to reframe the discourse

Background

Age is a critical factor in substance use and related outcomes, with adolescence being a particularly sensitive period. Early initiation of substance use has been linked with higher risk for developing substance use disorders. In Ontario, Canada, substance use is common among youth, yet treatment is underutilized, suggesting the potential for an unmet need in terms of substance use care. Despite these challenges, there is limited research examining factors that contribute to youth substance use and youth-specific barriers to substance use care. To fill this knowledge gap, this study sought to include the unique perspectives of service providers who work directly with youth to examine these issues.

Methods

We used a cross-sectional mixed-methods design to examine factors that contribute to substance use among youth and identify youth-specific barriers to substance use among a sample of 54 Ontario-based youth service providers. Data collection included an online survey completed by all study participants followed by qualitative interviews of a subsample of 16 participants. Data analysis included basic frequency tabulations for survey results and thematic qualitative analyses to identify common themes.

Results

Licit substances were identified as the most commonly used among youth, where 94% of respondents identified cannabis use and 81% identified alcohol use. Thematic analyses identified the role of dominant substance use discourses in normalizing certain substances (i.e., cannabis and alcohol) while also endorsing stigmatizing beliefs and sentiments. According to youth service providers, the intersection of these two discourses simultaneously lead to an increase in substance use while deterring youth from seeking substance use care.

Conclusions

Normalization and stigmatization are two dominant discourses around youth substance use, with important implications for public health interventions. Key public health strategies, as identified by participants, to reduce the overall negative effect of these factors include the need to reframe substance use discourse, from a moral failing to a public health issue and to educate youth about the impacts of use. To accomplish this goal educational campaigns to raise awareness around the health effects of use and address stigmatization are needed. Educational reforms are also needed to ensure that these programs are integrated into the school system.

A Longitudinal Cohort Study of Youth Mental Health and Substance use Before and During the COVID-19 Pandemic in Ontario, Canada: An Exploratory Analysis

BACKGROUND

Youth mental health appears to have been negatively impacted by the COVID-19 pandemic. The impact on substance use is less clear, as is the impact on subgroups of youth, including those with pre-existing mental health or substance use challenges.

OBJECTIVE

This hypothesis-generating study examines the longitudinal evolution of youth mental health and substance use from before the COVID-19 pandemic to over one year into the pandemic among youth with pre-existing mental health or substance use challenges.

METHOD

A total of 168 youth aged 14-24 participated. Participants provided sociodemographic data, as well as internalizing disorder, externalizing disorder, and substance use data prior to the pandemic's onset, then every two months between April 2020-2021. Linear mixed models and Generalized Estimating Equations were used to analyze the effect of time on mental health and substance use. Exploratory analyses were conducted to examine interactions with sociodemographic and clinical characteristics.

RESULTS

There was no change in internalizing or externalizing disorder scores from prior to the pandemic to any point throughout the first year of the pandemic. Substance use scores during the pandemic declined compared to pre-pandemic scores. Exploratory analyses suggest that students appear to have experienced more mental health repercussions than non-students; other sociodemographic and clinical characteristics did not appear to be associated with mental health or substance use trajectories.

CONCLUSIONS

While mental health remained stable and substance use declined from before the COVID-19 pandemic to during the pandemic among youth with pre-existing mental health challenges, some youth experienced greater challenges than others. Longitudinal monitoring among various population subgroups is crucial to identifying higher risk populations. This information is needed to provide empirical evidence to inform future research directions.

Youth and family members make meaningful contributions to a randomized-controlled trial: YouthCan IMPACT

BACKGROUND

There are growing calls to engage service users in research about issues relevant to them. Youth and family members can make meaningful contributions to research projects, improving quality and relevance. However, more information is needed on the contributions that youth and family members can make to various study designs.

OBJECTIVE

This paper describes the contributions that youth and family members have made to a multi-site pragmatic randomized-controlled trial, YouthCan IMPACT, and the way project-based engagement learnings accelerated change at the institutional level and beyond.

RESULTS

Youth and family members were full members of the project team, including the project's core governance and working groups. They contributed to project leadership, as funding co-applicants and as equal members of the governance team. They were also engaged in study design. Youth defined the primary outcome measure and contributed to decisions on all secondary measures. The service pathway was co-designed with youth and family members; for example, they guided the inclusion of peer support and a family member intervention as core service components. Study implementation contributions included ensuring a youth- and family-friendly research process and training research staff on working with youth and family members. Knowledge translation activities have included youth and family members as co-presenters and manuscript co-authors. The learnings from this trial have been leveraged to expand youth and family engagement at the institution and beyond.

CONCLUSIONS

Youth and family members make substantial contributions to complex research projects, including randomized-controlled trials, thereby improving project design, study implementation, associated interventions, and knowledge translation.

Characterization of multilevel influences of mental health care transitions: a comparative case study analysis

PURPOSE

Mental health care transitions are increasingly prioritized given their potential to optimize care delivery and patient outcomes, especially those focused on the transition from inpatient to outpatient mental health care. However, limited efforts to date characterize such mental health transition practices, especially those spanning multiple service setting contexts. Examination of key influences of inpatient to outpatient mental health care transitions across care contexts is needed to inform ongoing and future efforts to improve mental health care transitions. The current work aims to characterize multilevel influences of mental health care transitions across three United States-based mental health system contexts.

METHODS

A comparative multiple case study design was used to characterize transition practices within the literature examining children's, non-VA adult, and VA adult service contexts. Andersen's (1995) Behavioral Health Service Use Model was applied to identify and characterize relevant distinct and common domains of focus in care transitions across systems.

RESULTS

Several key influences to mental health care transitions were identified spanning the environmental, individual, and health behavior domains, including: community capacity or availability, cross-system or agency collaboration, provider training and experience related to mental health care transitions, client care experience and expectations, and client clinical characteristics or complexity.

CONCLUSIONS

Synthesis illustrated several common factors across system contexts as well as unique factors for further consideration. Our findings inform key considerations and recommendations for ongoing and future efforts aiming to plan, expand, and better support mental health care transitions. These include timely information sharing, enhanced care coordination and cross setting and provider communication, continued provider/client education, and appropriate tailoring of services to improve mental health care transitions.

Foundry: Early learnings from the implementation of an integrated youth service network

AIMS

To provide the first profile of the demographic and service characteristics of young people (aged 12-24 years) who access Foundry, a provincial network of integrated youth health and social service centres in British Columbia, Canada and to share early learnings about implementation and service innovation.

METHODS

Using a retrospective chart review, we conducted a census of all young people accessing a Foundry centre in a 'proof of concept' phase. Six centres were assessed between October 2015 and March 2018. Data included demographics, mental health service access history, service type the youth was seeking, and information about how they found out about the centre.

RESULTS

A total of 4783 young people presented during this proof of concept period, for a total number of 35 791 visits. The most frequently accessed category of service was mental health/substance use (57%) followed by physical health (25%). Young people were most likely to be female, aged 15-19, and White. Youth demographic characteristics showed an over-representation of Indigenous and LGBTQ2 youth and under-representation of males and youth aged 20-24. Youth were most likely to learn about Foundry from a friend (44%) or family member (22%). Most youth (58%) reported that they would have gone 'nowhere' if not for Foundry.

CONCLUSIONS

Foundry is a model of integrated health and social services delivery, focused on early intervention, prevention and accessibility, driven by the needs and priorities of young people and their families. Leveraging international integrated youth health service evidence, the model addresses urgent priorities in Canadian health service delivery.

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

AIMS

Many young people with mental health and/or substance use concerns do not have access to timely, appropriate, and effective services. Within this context, stepped care models (SCMs) have emerged as a guiding framework for care delivery, inspiring service innovations across the globe. However, substantial gaps remain in the evidence for SCMs as a strategy to address the current systemic challenges in delivering services for young people. This scoping review aims to identify where these gaps in evidence exist, and the next steps for addressing them.

METHODS

A scoping review was conducted involving both peer-reviewed and grey literature. Eligible studies explored SCMs implemented in the various health care settings accessed by young people aged 12-24 seeking treatment for mental health and substance use challenges. After screening titles and abstracts, two reviewers examined full-text articles and extracted data to create a descriptive summary of the models.

RESULTS

Of the 656 studies that were retrieved, 51 studies were included and grouped by study team for a final yield of 43 studies. Almost half of the studies were focused on the adult population (i.e., 18 and over), and most did not specify interventions for young people. Among the SCMs, substantial variability was found in almost every aspect of the models.

CONCLUSIONS

Considering the current body of evidence, there is an urgent need for a consensus position on the definition, implementation, and outcome measures required for rigorously assessing the utility of SCMs for young people.

International perspective on integrated care models in child and adult mental health

The dearth of child and adolescent mental health services (CAMHS) is a global problem. Integrating CAMHS in primary care has been offered as a solution. We sampled integrated care perspectives from colleagues around the world. Our findings include various models of integrated care namely: the stepped care model in Australia; shared care in the United Kingdom (UK) and Spain; school-based collaborative care in Qatar, Singapore and the state of Texas in the US; collaborative care in Canada, Brazil, US, and Uruguay; coordinated care in the US; and, developing collaborative care models in low-resource settings, like Kenya and Micronesia. These findings provide insights into training initiatives necessary to build CAMHS workforce capacity using integrated care models, each with the ultimate goal of improving access to care. Despite variations and progress in implementing integrated care models internationally, common challenges exist: funding within complex healthcare systems, limited training mechanisms, and geopolitical/policy issues. Supportive healthcare policy, robust training initiatives, ongoing quality improvement and measurement of outcomes across programs would provide data-driven support for the expansion of integrated care and ensure its sustainability.

Designing and scaling up integrated youth mental health care

Mental ill-health represents the main threat to the health, survival and future potential of young people around the world. There are indications that this is a rising tide of vulnerability and need for care, a trend that has been augmented by the COVID-19 pandemic. It represents a global public health crisis, which not only demands a deep and sophisticated understanding of possible targets for prevention, but also urgent reform and investment in the provision of developmentally appropriate clinical care. Despite having the greatest level of need, and potential to benefit, adolescents and emerging adults have the worst access to timely and quality mental health care. How is this global crisis to be addressed? Since the start of the century, a range of co-designed youth mental health strategies and innovations have emerged. These range from digital platforms, through to new models of primary care to new services for potentially severe mental illness, which must be locally adapted according to the availability of resources, workforce, cultural factors and health financing patterns. The fulcrum of this progress is the advent of broad-spectrum, integrated primary youth mental health care services. They represent a blueprint and beach-head for an overdue global system reform. While resources will vary across settings, the mental health needs of young people are largely universal, and underpin a set of fundamental principles and design features. These include establishing an accessible, "soft entry" youth primary care platform with digital support, where young people are valued and essential partners in the design, operation, management and evaluation of the service. Global progress achieved to date in implementing integrated youth mental health care has highlighted that these services are being accessed by young people with genuine and substantial mental health needs, that they are benefiting from them, and that both these young people and their families are highly satisfied with the services they receive. However, we are still at base camp and these primary care platforms need to be scaled up across the globe, complemented by prevention, digital platforms and, crucially, more specialized care for complex and persistent conditions, aligned to this transitional age range (from approximately 12 to 25 years). The rising tide of mental ill-health in young people globally demands that this focus be elevated to a top priority in global health.

Engaging young people within a collaborative knowledge mobilization network: Development and evaluation

Background

It is critical that mental health systems place a focus on prevention and early intervention focused on young people while integrating youth voice to guide priority directions.

Objective

This study was designed to better understand how youth advisories can be utilized to influence strategic directions within integrated knowledge mobilization networks operating within the youth mental health system.

Design

To support this objective, we reviewed the detailed stages of development in establishing a youth advisory within a national network designed to support the integration of youth services. We also engaged the advisory in a participatory evaluation process that examined the extent to which the network had created processes to include youth voice in decision‐making.

Results

Results from the surveys identified moderate to high levels of individual engagement as well as strong development of processes and procedures that support the inclusion of youth voice across the network.

Discussion

Major successes and challenges are presented and discussed with respect to the development of the advisory. The findings are useful for youth advocates and adult allies working to support youth engagement (YE) in knowledge mobilization to enhance the mental health services system. This study also contributes to research and evaluation efforts examining YE and represents an exemplar methodology for evaluating YE efforts at the system level.

Patient or Public Contribution

Young people as mental health service users and youth mental health advocates were involved in the design, data collection, analysis and interpretation of the data as well as the preparation of this manuscript.

Social determinants of health and depression in adults presenting to the emergency department: Implications for family medicine

OBJECTIVE

To estimate the extent to which social determinants of health (SDH) predict levels of depression in adults presenting to the emergency department (ED) with an acute mental health crisis.

DESIGN

Secondary data analysis.

SETTING

St Paul's Hospital, an urban tertiary care hospital in Vancouver, BC.

PARTICIPANTS

Patients 19 years and older presenting to the ED with an acute mental health crisis.

MAIN OUTCOME MEASURES

Responses to demographic questionnaires focused on SDH and to measures of self-perceived health and depression. Relationships between depression and SDH were described using t tests and χ ² tests. The extent to which SDH variables predicted depression scores, as measured by the Patient Health Questionnaire-9 (PHQ-9), was determined using linear regression.

RESULTS

The primary study had 202 participants. Data for the 156 (77%) participants who completed the PHQ-9 were assessed in this secondary analysis. In this sample, 60% of participants identified as men, 37% as women, and 4% as other. The mean (SD) age was 39.1 (13.8) years, with most participants identifying as white (65%) or Indigenous (18%). Thirty-seven percent had a high school diploma or less education, and 72% reported being unemployed. Identifying as a woman, lack of access to clean drinking water, poor food security, feeling unsafe, little structured use of time, lack of a sense of community, and dissatisfaction with housing significantly predicted higher depression scores. Overall, 59% of respondents met the criteria for moderately severe or severe depression (PHQ-9 score ≥ 15), with 37% of those reporting thoughts of suicide nearly every day for the past 2 weeks.

CONCLUSION

This study demonstrates the importance of screening for both depression and SDH in the ED. Because the ED often does not have the capacity to address appropriate levels of follow-up for this population, this study has important implications for primary care. Developing a clear pathway of follow-up support for people with depression and SDH risk factors will be critical to optimize patient outcomes, promote patient safety, enhance patient satisfaction, and optimize the use of resources between the ED and primary care.

Youth in a pandemic: a longitudinal examination of youth mental health and substance use concerns during COVID-19

OBJECTIVE

This study analyses longitudinal data to understand how youth mental health and substance use are evolving over the course of the COVID-19 pandemic, which is critical to adjusting mental health response strategies.

SETTING

Participants were recruited from among existing participants in studies conducted in an urban academic hospital in Ontario, Canada.

PARTICIPANTS

A total of 619 youth aged 14-28 years participated in the study (62.7% girls/young women; 61.4% Caucasian).

MEASURES

Data on mood, substance use and COVID-19-related worries were collected over four time points, that is, every 2 months beginning in the early stages of the pandemic in April 2020. Latent class analyses were conducted on the longitudinal data to identify distinct groups of youth who have different trajectory profiles of pandemic impact on their mood, substance use and COVID-19-related worries.

RESULTS

For the majority of participants, mood concerns increased early in the pandemic, declined over Canada's summer months and subsequently increased in autumn. Among the youth with the highest level of mood symptoms at the beginning of the pandemic, increases in mental health concerns were sustained. Substance use remained relatively stable over the course of the pandemic. COVID-19-related worries, however, followed a trajectory similar to that of mood symptoms. Girls/young women, youth living in urban or suburban areas, in larger households, and with poorer baseline mental and physical health are the most vulnerable to mental health concerns and worries during the pandemic.

CONCLUSIONS

Youth mental health symptom levels and concerns are evolving over the course of the COVID-19 pandemic, in line with the evolution of the pandemic itself, and longitudinal monitoring is therefore required. It is also essential that we engage directly with youth to cocreate pandemic response strategies and mental health service adaptations to best meet the needs of young people.

Impacts of the COVID-19 pandemic on youth mental health among youth with physical health challenges

AIM

To examine mental health in conjunction with physical health during the COVID-19 pandemic among youth with physical health conditions compared to those without.

METHODS

A cross-sectional survey of 622 youth aged 14 to 28 was conducted. Analyses were conducted to understand the changes in mental and physical health among youth in four groups: (a) participants with a friend or family member diagnosed with COVID-19, (b) participants with symptoms associated with COVID-19, (c) participants with atopic conditions (asthma and allergies), and (d) participants with other preexisting physical health conditions.

RESULTS

Many participants with physical health concerns met screening criteria for an internalizing disorder, which was significantly higher than the rate found among participants without physical health conditions. Significantly greater declines in self-reported mental health were observed during the COVID-19 period compared to 3 months earlier among youth reporting physical health concerns compared to those without physical health concerns. Substance use does not appear to have been affected.

CONCLUSIONS

Mental health concerns are highly prevalent among youth with physical health concerns, and also appear to be exacerbated by the COVID-19 pandemic. Physical health concerns appear to constitute risk factors for heightened mental health responses to the pandemic situation. System planners striving to adapt mental health services to meet social/physical distancing recommendations are urged to consider youth with physical health conditions and ensure that adequate integrated mental health and physical health supports are available to them.

Service providers endorse integrated services model for youth with mental health and substance use challenges: findings from a discrete choice experiment

BACKGROUND

Given high rates of mental health and substance challenges among youth and substantial system access barriers, system innovation is required. Integrated youth services (IYS) models aim to transform youth mental health and substance use services by creating integrative, collaborative models of care in youth-friendly settings. This study examines service provider perspectives on the key service components to include in IYS models.

METHOD

A discrete choice experiment modeled service provider preferences for the service components of IYSs. The sample includes 388 service provider/agency leader participants (age 18+) from youth-serving organizations in Ontario. Importance scores and utility values were calculated for 12 attributes represented by four levels each. Latent class analysis identified subgroups of participants with different preferences.

RESULTS

The majority of participants were direct service providers working in larger organizations in the mental health and/or substance use sectors in large urban centers. Participants strongly endorsed service models that provide rapid access to the widest variety of culturally sensitive service options, with supplementary e-health services, in youth-focused community settings with evening and weekend hours. They prefer caregiver involvement in youth services and treatment decisions and support youth and family engagement. Latent class analyses reveal three segments of service providers: a Youth-Focused Service Accessibility segment representing 62.1% (241/388) of participants, a Service Options segment representing 27.6% (107/388) of participants, and a Caregiver Integration segment representing 10.3% (40/388) of participants. Within these segments, the degree of prioritization of the various service components differ; however, the overall endorsement of the service components remains largely consistent across classes for most attributes. The segments did not differ based on demographic or agency characteristics.

CONCLUSIONS

The core characteristics of IYS settings for youth with mental health and substance use challenges, i.e., rapid access to a wide range of youth-oriented services, are strong priorities of service providers and youth-serving agency leaders. These findings confirm that youth-oriented service providers endorse the importance and relevance of IYS models as a whole; strong service provider buy-in to the model is expected to facilitate development, implementation and scaling of IYS models. Hearing stakeholder perspectives, including those of service providers, youth, and caregivers, is essential to developing, effectively implementing, and scaling effective youth services.

Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation

BACKGROUND

Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis.

OBJECTIVES

To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events.

MAIN RESULTS

We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies.

AUTHORS' CONCLUSIONS

The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.

Youth Perspectives on Seeking Psychotherapy: A Concurrent Mixed Methods Study

OBJECTIVE

Psychotherapy is the recommended first line of treatment for depression among youth; however, few youth seek professional support. This study compares barriers and facilitators to seeking psychotherapy among both youth who have and have not seen a psychotherapist. The study further explores reasons youth discontinue psychotherapy.

METHODS

A concurrent mixed methods study design was used. Eligible participants completed a survey (N=104) and a subset of participants completed a semi-structured interview (N=60). The survey and interview data were analyzed concurrently using a triangulation design.

RESULTS

Surveys were conducted among youth who had experienced psychotherapy (N=53) and youth who had not (N=51). The majority of participants were female. Common reasons for not seeking psychotherapy included wanting to handle their problems on their own (87.6%), thinking their problems would improve on its own (87.6%), and not knowing who to see (74.3%). Several barriers were common across the two groups, including stigma, concerns about the therapeutic relationship, and a preference for self-management. Common facilitators included improving coping skills and addressing functional impairment. There was some overlap between the barriers to seeking psychotherapy and the reasons for discontinuing, although aging out of youth-oriented service also constituted a termination factor.

CONCLUSIONS

: As this study highlights the multiple factors that influence youth's psychotherapy-seeking behavior, a widespread, multi-level approach is needed to address barriers and facilitators at the individual level, but also at the community, policy, and organizational levels. Strategies such as increasing service availability and quality are needed to increase service seeking and improve retention.

Girls suffer: the prevalence and predicting factors of emotional problems among adolescents during upper secondary school in Norway

This longitudinal, quantitative survey examined factors predicting 1077 Norwegian adolescents` emotional problems during Upper Secondary School (grades I–III, approximately 16–19 years old) considering the following research question: “To what extent do students in Upper Secondary School experience emotional problems, and how are these problems predicted by gender, academic/social self-concept, coping beliefs, appearance pressure and school stress?”. The mentioned variables were scrutinized through analysis of frequencies, zero order correlations and structural equation modeling. Results verified previous findings that there was an increase in emotional problems for adolescents, especially among girls. Furthermore, the study results indicate that coping beliefs is a crucial factor when it comes to the perception of pressure and stress, and the subsequent development of emotional health problems.

'It reshaped how I will do research': A qualitative exploration of team members' experiences with youth and family engagement in a randomized controlled trial

Background

Engaging youth and family members as active partners in research and service design offers great promise in improving projects. In youth mental health, recent research has highlighted the value of youth and family engagement. However, research on the experience and impacts of engagement is sparse.

Objective

This study explores the project team's experience of youth and family engagement in the design and development of the YouthCan IMPACT randomized controlled trial and clinical service pathway design.

Design

Qualitative data collected using semi‐structured interviews and a focus group as part of the YouthCan IMPACT clinical trial were analysed to understand the impacts of engagement. Twenty‐eight team members were interviewed, including youth and family members. A qualitative content analysis was conducted, with a member checking process.

Results

Team members reported facilitators, barriers and impacts of youth and family engagement. Facilitators included a safe environment and strong procedures conducive to inclusion in co‐design. Barriers included logistical, structural and institutional constraints. Overall, team members found youth and family engagement to be valuable and to positively impact the research and service design process.

Discussion and Conclusions

Youth and family engagement played a critical role in research and clinical service pathway design. The team found that their involvement improved the quality of the research and service pathway through sustained and multifaceted engagement. Facilitators and barriers to engagement may serve to guide future engagement initiatives. Future research should evaluate the long‐term impact of early engagement and further focus on family engagement.

Patient/Public Contribution

Youth and family members were engaged in the data analysis and interpretation process.

From Planning to Implementation of the YouthCan IMPACT Project: a Formative Evaluation

In order to improve the youth mental health system, there is an international movement toward developing community-based service hubs that provide integrated, collaborative care to youth. However, the implementation of multisystem collaboration is complex and can be hampered by barriers. This paper presents a formative evaluation of the YouthCan IMPACT integrated youth services project based on the Consolidated Framework for Implementation Research (CFIR), to identify facilitators and barriers to successful implementation. Results highlight that previous positive working relationships along with collaborative investment of resources from partnering organizations are essential to implement an integrated youth service model. In addition, it is important that representative members of all key stakeholder groups, including staff, youth, and caregivers, be involved in the development and execution of the project to ensure effective implementation. Attention to the facilitators and barriers to implementation may help teams seeking to implement highly collaborative, integrated models of service delivery for youth in the community.

Distributive Leadership Within an Emerging Network of Integrated Youth Health Centres: A Case Study of Foundry

Background

Distributive leadership has been proposed as an effective means towards achieving integrated health services. This study draws from the case of Foundry, a network of integrated youth health centres in British Columbia, Canada, and explores the function and impact of distributive leadership in the context of a large-scale effort towards integrated service delivery for youth experiencing mental health and substance use challenges.

Methods

Qualitative data was obtained from a developmental evaluation of Foundry using a longitudinal, ethnographic approach. Over 150 participants involved in the development of six Foundry centres were interviewed individually or in focus groups. Purposive and theoretical sampling strategies were used to maximize the diversity of perspectives represented in the data set.

Results and Discussion

Distributive leadership was observed to be a facilitator for achieving service and system-level integration. Distributive leadership was effective in promoting streamlined service provision, and coordinating efforts towards optimized access to care. A new culture of leadership emerged through collaboration and relationship-building based on a common value system to prioritize youth needs.

Conclusion

As Foundry, and other integrated youth services, continues to expand, distributive leadership shows promise in assuring diverse and coordinated input for integrating services.

Patterns, contexts, and motivations for polysubstance use among people who inject drugs in non-urban settings in the U.S. Northeast

BACKGROUND

Polysubstance use (i.e., using ≥2 psychoactive substances concomitantly) is associated with increased morbidity and mortality and complicates drug treatment needs among people who inject drugs (PWID). We explored patterns, contexts, motivations, and perceived consequences of polysubstance use among PWID in small cities and towns in the U.S. Northeast.

METHODS

Between October 2018 and March 2019, we conducted semi-structured interviews with 45 PWID living outside of the capital cities of Rhode Island and Massachusetts recruited online and through community-based organizations. Written transcripts were coded inductively and deductively using a team-based approach and analyzed thematically.

RESULTS

All participants reported recent polysubstance use, with most using five or more classes of substances in the past three months. Polysubstance use often followed long personal drug use histories (i.e., years or decades of occasional drug use). Reasons for polysubstance use included obtaining synergistic psychoactive effects as a result of mixing drugs (i.e., using drugs to potentiate effects of other drugs) and managing undesirable effects of particular drugs (e.g., offsetting the depressant effects of opioids with stimulants or vice-versa). Polysubstance use to self-medicate poorly managed physical and mental health conditions (e.g., chronic pain, anxiety, and depression) was also reported. Inadequately managed cravings and withdrawal symptoms prompted concomitant use of heroin and medications for opioid use disorder, including among individuals reporting cocaine or crack as their primary "issue" drugs. Polysubstance use was perceived to increase overdose risks and to be a barrier to accessing healthcare and drug treatment services.

CONCLUSION

Healthcare services and clinicians should acknowledge, assess, and account for polysubstance use among patients and promote harm reduction approaches for individuals who may be using multiple drugs. Comprehensive healthcare that meets the social, physical, mental health, and drug treatment needs of PWID may decrease the perceived need for polysubstance use to self-medicate poorly managed health conditions and symptoms.

Impacts of COVID-19 on Youth Mental Health, Substance Use, and Well-being: A Rapid Survey of Clinical and Community Samples: Répercussions de la COVID-19 sur la santé mentale, l'utilisation de substances et le bien-être des adolescents : un sondage rapide d'échantillons cliniques et communautaires

OBJECTIVES

The current novel coronavirus disease of 2019 (COVID-19) pandemic presents a time-sensitive opportunity to rapidly enhance our knowledge about the impacts of public health crises on youth mental health, substance use, and well-being. This study examines youth mental health and substance use during the pandemic period.

METHODS

A cross-sectional survey was conducted with 622 youth participants across existing clinical and community cohorts. Using the National Institute of Mental Health-developed CRISIS tool and other measures, participants reported on the impacts of COVID-19 on their mental health, substance use, and other constructs.

RESULTS

Reports of prepandemic mental health compared to intrapandemic mental health show a statistically significant deterioration of mental health across clinical and community samples (P < 0.001), with greater deterioration in the community sample. A total of 68.4% of youth in the clinical sample and 39.9% in the community sample met screening criteria for an internalizing disorder. Substance use declined in both clinical and community samples (P < 0.001), although 23.2% of youth in the clinical sample and 3.0% in the community sample met screening criteria for a substance use disorder. Participants across samples report substantial mental health service disruptions (48.7% and 10.8%) and unmet support needs (44.1% and 16.2%). Participants report some positive impacts, are using a variety of coping strategies to manage their wellness, and shared a variety of ideas of strategies to support youth during the pandemic.

CONCLUSIONS

Among youth with histories of mental health concerns, the pandemic context poses a significant risk for exacerbation of need. In addition, youth may experience the onset of new difficulties. We call on service planners to attend to youth mental health during COVID-19 by bolstering the accessibility of services. Moreover, there is an urgent need to engage young people as coresearchers to understand and address the impacts of the pandemic and the short, medium, and long terms.

Measuring functional impairment: Preliminary psychometric properties of the Columbia Impairment Scale-Youth Version with youth accessing services at an outpatient substance use programme

AIM

Functional impairment is a key aspect of mental disorders, yet it is poorly defined and operationalized, particularly for youth. The Columbia Impairment Scale (CIS) has been indicated as a potentially useful measure to assess functional impairment. This study provides an initial psychometric evaluation of the CIS-Youth (CIS-Y) Version in a sample of youth accessing an outpatient substance use programme.

METHODS

The CIS-Y Version was administered to youth aged 15 to 24 years accessing an outpatient substance use programme in Ontario, Canada. Demographic data on age, sex, ethnicity and current occupational and/or educational status were also collected. Exploratory factor analysis (EFA) was used to identify what factor structure best fits our sample of youth.

RESULTS

The sample included 134 youth, with a mean age of 19.3 (SD = 2.1; range = 15-24). Over 34% of the sample had at least some item-level missing data, overwhelming this was item-level "not applicable" responses. The CIS-Y exhibited good internal consistency (α = .84), and EFA revealed that a one-factor structure was the best fit for the data.

CONCLUSIONS

Results suggest that continued use of the CIS-Y with populations of youth, including emerging adults, is warranted. The scale has good internal consistency, loads onto one factor and discriminates between groups known to have lower and higher functioning. Further research is recommended that uses larger and more varying samples, as well as research that investigates optimal coding of non-applicable responses.

Ranking evidence in substance use and addiction

Evidence-based medicine has consistently prized the epistemological value of randomized-controlled trials (RCTs) owing to their methodological advantages over alternative designs such as observational studies. However, there are limitations to RCTs that hinder their ability to study chronic and dynamic conditions such as substance use and addiction. For these conditions, observational studies may provide superior evidence based on methodological and practical strengths. Assuming epistemic superiority of RCTs has led to an inappropriate devaluation of other study designs and the findings they support, including support for harm reduction services, especially needle exchange programs and supervised injection facilities. The value offered by observational studies should be reflected in evidence-based medicine by allowing more flexibility in evidence hierarchies that presume methodological superiority of RCTs. Despite the popularity of evidence ranking systems and hierarchies, nothing should replace critical appraisal of study methodology and examining the suitability of applying a given study design to a specific research question.

Frayme: Building the structure to support the international spread of integrated youth services

AIM

Frayme is a Canadian-based international network designed to accelerate the adoption and scaling up of integrated youth services (IYS). This is done through the synthesis of evidence from a variety of sources and a commitment to integrated knowledge mobilization (KMb) to inform research policy and practice. Frayme is utilizing innovative approaches to stakeholder engagement (youth, families, policy makers, funders, researchers and practitioners) and KMb in order to co-design system change. The purpose of this article describes the overall Frayme strategy and presents findings from a participatory needs assessment implemented to inform policy-related priorities.

METHODS

The Frayme leadership team facilitated a participatory needs assessment with major stakeholder groups that applied a modified problem-solving activity. The needs assessment was on a designed to support diverse stakeholder perspectives on ways to improve knowledge mobilization of IYS. Qualitative data were analysed using a thematic analysis.

RESULTS

The four themes identified through the needs assessment were: (a) traditional scientific practices, (b) organizational obstacles, (c) change aversion, and (d) pre-established stakeholder hierarchies.

CONCLUSIONS

Through the recognition of these challenges, Frayme has developed a set of major objectives to inform projects, opportunities for knowledge sharing, implementation of evidence and scaling up of efforts. The Frayme integrated KMb model represents a unique applied example of an evidence-informed approach to practice collaboration in KMb to promote system change. The findings from this research also contribute to the expanding knowledge base with regard to complex evaluation and system transformation.

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

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

Cognitive behavioral therapy in adolescents with early-onset psychosis: a randomized controlled pilot study

Cognitive behavioral therapy for psychosis (CBT) is an effective treatment in adult patients with schizophrenia. However, no randomized controlled and blinded trial in adolescents with early-onset psychosis (EOP) has been conducted. Therefore, the present pilot study explores the acceptance, tolerability, feasibility, and safety of a modified CBT in adolescents with EOP. Twenty-five adolescents with EOP were randomized to either 9 months (20 sessions) of CBT + treatment as usual (TAU) or TAU alone. The primary endpoint was the PANSS-positive subscale (P1-7). Secondary endpoints included psychopathology, global functioning, and quality of life (QoL). Acceptance, tolerability, feasibility, and safety were assessed. Blinded assessments took place by the end of the treatment (9 months) and at 24-month follow-up. Despite improvements in both groups and lack of statistical significance between CBT + TAU and TAU regarding the primary endpoint, we observed between-group effect sizes of at least d = 0.39 in favor of CBT + TAU at post-treatment for delusions, negative symptoms, functioning and QoL after the intervention and effect sizes of at least d = 0.35 after 24 months. CBT in EOP was highly acceptable (73.5% agreed to randomization), well-tolerated (83.1% attendance rate, no drop-outs), and safe (one serious adverse event (SAE) in CBT + TAU in comparison with six SAEs in TAU). These findings suggest that CBT adapted to the needs of adolescents with EOP is a promising approach regarding negative symptoms, functioning, and QoL. CBT is a safe and tolerable treatment. However, due to the small sample size and the pilot character of the study, these conclusions are limited, and should be tested in a larger, adequately powered randomized controlled trial.

Digital Game Interventions for Youth Mental Health Services (Gaming My Way to Recovery): Protocol for a Scoping Review

Background

Digital or video games are played by millions of adolescents and young adults around the world and are one of the technologies used by youths to access mental health services. Youths with mental health problems strongly endorse the use of technologies, including mobile and online platforms, to receive information, support their treatment journeys (eg, decision-making tools), and facilitate recovery. A growing body of literature explores the advantages of playing digital games for improving attention span and memory, managing emotions, promoting behavior change, and supporting treatment for mental illness (eg, anxiety, depression, or posttraumatic stress disorder). The research field has also focused on the negative impact of video games, describing potential harms related to aggression, addiction, and depression. To promote clarity on this matter, there is a great need for knowledge synthesis offering recommendations on how video games can be safely and effectively adopted and integrated into youth mental health services.

Objective

The Gaming My Way to Recovery scoping review project assesses existing evidence on the use of digital game interventions within the context of mental health services for youths (aged 11-29 years) using the stepped care model as the conceptual framework. The research question is as follows: For which youth mental health conditions have digital games been used and what broad objectives (eg, prevention, treatment) have they addressed?

Methods

Using the methodology proposed by Arksey and O’Malley, this scoping review will map the available evidence on the use of digital games for youths between 11 and 29 years old with mental health or substance use problems, or both.

Results

The review will bring together evidence-based knowledge to assist mental health providers and policymakers in evaluating the potential benefits and risks of these interventions. Following funding of the project in September 2018, we completed the search in November 2018, and carried out data screening and stakeholder engagement activities during preparation of the protocol. We will conduct a knowledge synthesis based on specific disorders, treatment level and modality, type of service, population, settings, ethical practices, and user engagement and offer recommendations concerning the integration of video game technologies and programs, future research and practice, and knowledge dissemination.

Conclusions

Digital game interventions employ unique, experiential, and interactive features that potentially improve skills and facilitate learning among players. Digital games may also provide a new treatment platform for youths with mental health conditions. Assessing current knowledge on video game technology and interventions may potentially improve the range of interventions offered by youth mental health services while supporting prevention, intervention, and treatment.

International Registered Report Identifier (IRRID)

PRR1-10.2196/13834

Peer Support in Mental Health: Literature Review

BACKGROUND

A growing gap has emerged between people with mental illness and health care professionals, which in recent years has been successfully closed through the adoption of peer support services (PSSs). Peer support in mental health has been variously defined in the literature and is simply known as the help and support that people with lived experience of mental illness or a learning disability can give to one another. Although PSSs date back to several centuries, it is only in the last few decades that these services have formally evolved, grown, and become an integral part of the health care system. Debates around peer support in mental health have been raised frequently in the literature. Although many authors have emphasized the utmost importance of incorporating peer support into the health care system to instill hope; to improve engagement, quality of life, self-confidence, and integrity; and to reduce the burden on the health care system, other studies suggest that there are neutral effects from integrating PSSs into health care systems, with a probable waste of resources.

OBJECTIVE

In this general review, we aimed to examine the literature, exploring the evolution, growth, types, function, generating tools, evaluation, challenges, and the effect of PSSs in the field of mental health and addiction. In addition, we aimed to describe PSSs in different, nonexhaustive contexts, as shown in the literature, that aims to draw attention to the proposed values of PSSs in such fields.

METHODS

The review was conducted through a general search of the literature on MEDLINE, Google Scholar, EMBASE, Scopus, Chemical Abstracts, and PsycINFO. Search terms included peer support, peer support in mental health, social support, peer, family support, and integrated care.

RESULTS

There is abundant literature defining and describing PSSs in different contexts as well as tracking their origins. Two main transformational concepts have been described, namely, intentional peer support and transformation from patients to peer support providers. The effects of PSSs are extensive and integrated into different fields, such as forensic PSSs, addiction, and mental health, and in different age groups and mental health condition severity. Satisfaction of and challenges to PSS integration have been clearly dependent on a number of factors and consequently impact the future prospect of this workforce.

CONCLUSIONS

There is an internationally growing trend to adopt PSSs within addiction and mental health services, and despite the ongoing challenges, large sections of the current literature support the inclusion of peer support workers in the mental health care workforce. The feasibility and maintenance of a robust PSS in health care would only be possible through collaborative efforts and ongoing support and engagement from all health care practitioners, managers, and other stakeholders.

Rethinking service design for youth with mental health needs: The development of the Youth Wellness Centre, St. Joseph's Healthcare Hamilton

AIM

This article describes the development and design of the Youth Wellness Centre (YWC), an innovative, youth-friendly centre providing mental health and addiction services for emerging adults aged 17 to 25 in Hamilton, Canada. We also report on demographic and clinical characteristics of clients to evaluate how the YWC is serving populations at increased risk of developing mental disorders.

METHODS

Data were extracted from clinic databases for 1520 youth at the YWC between March 2015 and 2018 to report on demographic characteristics, clinical profiles, primary presenting problems, service use and overall satisfaction with services.

RESULTS

Marginalized groups, particularly street-involved individuals and LGBTQ+ youth, are highly represented at the YWC, keeping with the centre's mandate of reaching at-risk populations. Youth at the YWC carry significant mental health burdens, with 80.8% having a history of suicidal ideation and 32.8% having a history of a substance use disorder. The primary route of referral is self-referral and the number of new clients has increased by nearly 20% in the first 3 years of operations. Overall satisfaction with the centre is on par with or slightly above provincial averages.

CONCLUSIONS

The YWC was developed to meet the mental health needs of transition-aged youth in Hamilton by providing early intervention, system navigation and transition services. The success of the YWC in reaching high-risk youth is demonstrated by the significant proportion of clients reporting demographic and clinical risk factors associated with increased risk for development of mental disorders. The increasing referrals to the YWC highlight the ongoing need for similar services.

Towards Integrated Youth Care: A Systematic Review of Facilitators and Barriers for Professionals

To overcome fragmentation in support for children and their families with multiple and enduring problems across life domains, professionals increasingly try to organize integrated care. However, it is unclear what facilitators and barriers professionals experience when providing this integrated care. Our systematic review, including 55 studies from a broad variety of settings in Youth Care, showed that integrated care on a professional level is a multi-component entity consisting of several facilitators and barriers. Findings were clustered in seven general themes: ‘Child’s environment’, ‘Preconditions’, ‘Care process’, ‘Expertise’, ‘Interprofessional collaboration’, ‘Information exchange’, and ‘Professional identity’. The identified facilitators and barriers were generally consistent across studies, indicating broad applicability across settings and professional disciplines. This review clearly shows that when Youth Care professionals address a broad spectrum of problems, a variety of facilitators and barriers should be considered.

Registration PROSPERO, registration number CRD42018084527.

An integrated approach to meet the needs of high-vulnerable families: a qualitative study on integrated care from a professional perspective

BACKGROUND

To meet the needs of high-vulnerable families with severe and enduring problems across several life domains, professionals must improve their ability to provide integrated care timely and adequately. The aim of this study was to identify facilitators and barriers professionals encounter when providing integrated care.

METHODS

Experiences and perspectives of 24 professionals from integrated care teams in the Netherlands were gathered by conducting semi-structured interviews. A theory-driven framework method was applied to systematically code the transcripts both deductively and inductively.

RESULTS

There was a consensus among professionals regarding facilitators and barriers influencing their daily practice, leading to an in depth, thematic report of what facilitates and hinders integrated care. Themes covering the facilitators and barriers were related to early identification and broad assessment, multidisciplinary expertise, continuous pathways, care provision, autonomy of professionals, and evaluation of care processes.

CONCLUSIONS

Professionals emphasized the need for flexible support across several life domains to meet the needs of high-vulnerable families. Also, there should be a balance between the use of guidelines and a professional's autonomy to tailor support to families' needs. Other recommendations include the need to improve professionals' ability in timely stepping up to more intensive care and scaling down to less restrictive support, and to further our insight in risk factors and needs of these families.

Youth underrepresentation as a barrier to sexual and reproductive healthcare access in Kasulu district, Tanzania: A qualitative thematic analysis

OBJECTIVES

Representation of the key groups in community-level healthcare decisions is a prerequisite for accountable and responsive primary healthcare systems. However, meaningful representation requires both the presence of individuals who represent the key community groups and their capacity to influence the key healthcare plans and decisions. Our study explored how the underrepresentation of the youth in health facility committees, the decentralized community- and facility-level healthcare decision-making forums affects youth access to sexual and reproductive health services.

METHODS

A multisite case study involving focus group discussions, interviews, and meeting observation was conducted in eight primary healthcare facilities in Kasulu, a rural district in Tanzania. Inductive thematic analysis was used to identify the key emerging themes.

RESULTS

Five major themes were identified in connection with youth underrepresentation and limited access to sexual reproductive health as a 'taboo' phenomenon in the communities. These were: numbers do not matter, passive representation, sociopolitical gerontocracy, economic vulnerability, and mistrust and suspicion.

CONCLUSIONS

Gradual emancipatory and transformative efforts are needed to normalize the representation of the youth and their concerns in formal community-level decision-making institutions.

From Research to Practice: The Importance of Appropriate Outcome Selection, Measurement, and Reporting in Pediatric Mental Health Research

Results of randomized controlled trials (RCTs) and, ideally, the synthesis of RCT results into meta-analyses, drive both clinical and policy decision making about health care interventions and inform new avenues for research. Selection of the right health outcomes to measure, analyze, and report on when designing a trial therefore is key in ensuring that the research will be useful and will have maximum impact.^1-3 As in many areas of medicine, wide variability exists in pediatric mental health research as to which outcomes are selected, how they are measured, and how they are reported. Variability in outcome selection and measurement may stem from various factors, including a tendency to select what is feasible or historical to measure rather than a focus on what is important to measure and how best to measure it. The resulting variability limits comparing and combining the results from different trials addressing a similar question in meta-analyses, hindering the translation of research to practice.^1,2 The objective of this article is to highlight the importance of outcome selection, measurement, and reporting in the translation of research to clinical practice.

Examining partnerships within an international knowledge translation network focused on youth mental health promotion

Background

Systems transformation for health promotion, involving engagement from multiple disciplines and levels of influence, requires an investment in partnership development. Integrated youth service is a collaborative model that brings organisations together to provide holistic care for youth. Frayme is an international knowledge translation network designed to support the uptake and scaling of integrated youth service. Social network analysis (SNA) is the study of relationships among social units and is useful to better understand how partners collaborate within a network to achieve major objectives. The purpose of this paper is to apply SNA to the Frayme network in order to (1) examine the level and strength of partnerships, (2) identify the strategies being employed to promote the main objectives and (3) apply the findings to current research in youth mental health and system transformation.

Methods

The PARTNER tool includes a validated survey and analysis software designed to examine partner interconnections. This tool was used to perform the SNA and 51 of the 75 partners completed the survey (14 researchers, 2 advisory groups and 35 organisations). A network map was created and descriptive frequencies were calculated.

Results

The overall network scores for the Frayme network were 20.6% for density, 81.5% for centralisation and 71.7% for overall trust. The Frayme secretariat received a 3.84 out of a possible 4 for value. In addition, the youth and family advisories each received a value score of 4 and all Leadership Team organisations received a score of 2.97 or above.

Conclusions

The Frayme secretariat links many partners who would otherwise be disconnected and acts as a significant conduit for novel information. Frayme may have the opportunity to enhance value perceptions among broader network members by profiling individual organisations and the potential leveraging opportunities that might exist through their work. These findings increase understanding with respect to the mechanisms of network development and will be helpful to inform partnership development in the future. In addition, they contribute to the literature with respect to knowledge translation practice as well as the scaling of collaborative interventions within youth mental health.

Community Interventions to Promote Mental Health and Social Equity

(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).

Trends in mental health system transformation: Integrating youth services within the Canadian context

The current mental health services system in Canada is fragmented and transitions between the youth and adult mental health systems have been identified as needing significant improvement. Integrated Youth Services (IYS) are designed to be adaptable and developmentally appropriate as well as to promote seamless transitions, including during emerging adulthood. This article provides an overview of recent developments in Canadian mental health system transformation to promote the integration of services and the holistic promotion of youth well-being. We offer an overview of the current state of knowledge related to best practices in IYS in Canada and highlight areas for future development. We also introduce Frayme, a Canadian-based international knowledge translation platform designed to connect organizations working in the youth services system to accelerate the implementation of IYS.

Key attributes of integrated community-based youth service hubs for mental health: a scoping review

BACKGROUND

Community-based, integrated youth service hubs have the potential to address some of the longstanding issues with mental health services for youth, including problems with access and system fragmentation. Better understanding of these approaches, particularly efforts to create a single point of entry to comprehensive, evidence-based services through youth service hubs, is needed to help guide future implementation and evaluation. This scoping review identifies the key principles and characteristics of these models of care, as well as the state of the literature, particularly with regard to implementation and replicability.

METHOD

Electronic databases and grey literature sources were searched for material from 2001 to 2019, with diverse search terms capturing the concept of "integrated" or "one-stop shop" youth mental health services. Title/abstract and full text review were conducted, as well as additional focused searching. After screening 4891 texts at the title/abstract level and 496 at the full-text level, 110 documents were included for data extraction.

RESULTS

Several integrated care hub models for youth mental health services and related frameworks were identified internationally, largely in high-income countries. Common principles included an emphasis on rapid access to care and early intervention, youth and family engagement, youth-friendly settings and services, evidence-informed approaches, and partnerships and collaboration. Program characteristics also revealed similarities (e.g., providing evidence-informed or evidence-based services in youth-friendly spaces), with some differences (e.g., care coordination methods, types of service providers), potentially attributable to lack of available information about key ingredients. Outcome research was limited, with few rigorous evaluations of youth outcomes. Moreover, sufficient information for replication, community evaluation of feasibility or actual implementation was rarely provided.

CONCLUSION

Internationally, integrated youth service hubs were found to share common key principles, while providing comprehensive services to youth with mental health difficulties. There is a great need for common language and measurement framework to facilitate replication, rigorous evaluation of outcomes, knowledge exchange, and dissemination of findings.

Integrated Mental Health Services for the Developmental Period (0 to 25 Years): A Critical Review of the Evidence

Background: The developmental period from 0 to 25 years is a vulnerable time during which children and young people experience many psychosocial and neurobiological changes and an increased incidence of mental illness. New clinical services for children and young people aged 0 to 25 years may represent a radical transformation of mental healthcare. Method: Critical, non-systematic review of the PubMed literature up to 3rd January 2019. Results: Rationale: the youngest age group has an increased risk of developing mental disorders and 75% of mental disorders begin by the age of 24 and prodromal features may start even earlier. Most of the risk factors for mental disorders exert their role before the age of 25, profound maturational brain changes occur from mid-childhood through puberty to the mid-20s, and mental disorders that persist in adulthood have poor long-term outcomes. The optimal window of opportunity to improve the outcomes of mental disorders is the prevention or early treatment in individuals aged 0 to 25 within a clinical staging model framework. Unmet needs: children and young people face barriers to primary and secondary care access, delays in receiving appropriate treatments, poor engagement, cracks between child and adult mental health services, poor involvement in the design of mental health services, and lack of evidence-based treatments. Evidence: the most established paradigm for reforming youth mental services focuses on people aged 12-25 who experienced early stages of psychosis. Future advancements may include early stages of depression and bipolar disorders. Broader youth mental health services have been implemented worldwide, but no single example constitutes best practice. These services seem to improve access, symptomatic and functional outcomes, and satisfaction of children and young people aged 12-25. However, there are no robust controlled trials demonstrating their impact. Very limited evidence is available for integrated mental health services that focus on people aged 0-12. Conclusions: Children and young people aged 12-25 need youth-friendly mental health services that are sensitive to their unique stage of clinical, neurobiological, and psychosocial development. Early intervention for psychosis services may represent the starting platform to refine the next generation of integrated youth mental health services.

What makes mental health and substance use services youth friendly? A scoping review of literature

BACKGROUND

There are increasing calls to make mental health and substance use services youth friendly, with hopes of improving service uptake, engagement and satisfaction. However, youth-friendliness in this area has not been clearly defined and there is a lack of information about the characteristics that make such services youth friendly. The purpose of this scoping review was to examine the literature available on youth-friendly mental health and substance use services in order to identify the characteristics, outline the expected impacts, and establish a definition.

METHODS

A scoping review of seven databases and grey literature sources was conducted. Twenty-eight documents were retained as relevant to the research questions. Relevant data from these documents was extracted, analyzed and presented to stakeholders, including youth, caregivers and service providers to validate and refine the results.

RESULTS

Youth-friendly mental health and substance use services include integrated, inclusive, confidential and safe organization and policy characteristics; bright, comfortable, environment with informational materials; welcoming and genuine service providers with appropriate communication and counselling skills; an accessible location; minimal wait times; and individualized and innovative approaches. All areas in which youth friendliness should be implemented in a mental health and substance use service organization had a core value of youth voice.

CONCLUSION

Improving the youth friendliness of mental health and substance use services includes incorporating youth voice in organization, policy, environment, service providers, and treatment services, and has implications for treatment uptake, engagement and satisfaction. Further research is required to determine the impact of youth friendliness in such services.

Community Interventions to Promote Mental Health and Social Equity

PURPOSE OF REVIEW

We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

RECENT FINDINGS

There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

The service-seeking profiles of youth reporting a legal mandate or perceived coercion for substance use treatment

INTRODUCTION

There is paucity of research on treatment-related coercion in youth: most research focuses on adult populations and legally mandated treatment. This study aims to examine the service-seeking profiles of youth with substance misuse issues who report a legal mandate or perceived coercion to enter treatment.

METHODS

Differences between youth who were legally mandated and not legally mandated, and differences between youth reporting high and low perceived coercion, were examined for demographic characteristics, mental health and substance use profiles, motivation, and readiness to change.

RESULTS

Compared to participants reporting low perceived coercion, those experiencing high perceived coercion reported more substance use problems, greater mental health needs, and greater external and introjected motivation. Legally mandated youth reported fewer mental health issues, lower identified motivation, and greater readiness to change than those reporting no legal mandate.

DISCUSSION

Many youth who present for substance use services report experiencing a sense of coercion, which suggests the potential importance of considering youth-centered strategies for involving youth in treatment planning and the development of treatment goals. Youth seeking treatment also have multiple intersecting needs which may benefit from a collaborative and integrative approach.

Early Adolescent Substance Use and Mental Health Problems and Service Utilisation in a School-based Sample

OBJECTIVE

This paper reports on substance use, mental health problems, and mental health service utilisation in an early adolescent school-based sample.

METHOD

Participants were 1,360 grade 7 and 8 students from 4 regions of Ontario, Canada. Students completed an in-class survey on mental health and substance use. The sampling strategy and survey items on demographics, substance use, service utilisation, and distress were adapted from the Ontario Student Drug Use and Health Survey. Internalising and externalising mental health problems were assessed using the Global Assessment of Individual Needs - Short Screener. Distress was defined as fair or poor self-rated mental health.

RESULTS

Rates of internalising and/or externalising problems above the threshold exceeded 30%; yet, fewer than half had received mental health services in the past 12 mo. Substance use was associated with increased odds of internalising and externalising problems above the threshold and distress. Youth using cannabis had 10-times the odds of exceeding the threshold for internalising or externalising problems. The use of substances other than alcohol or cannabis was associated with increased odds of fair or poor self-rated mental health among grade 8 students. Of the youth who confirmed at least a substance use problem, most also reported mental health problems; this association was stronger among girls than boys.

CONCLUSIONS

Early adolescent substance use was associated with concurrent self-reported mental health problems in a non-clinical sample. The low levels of service utilisation reported highlight the need for improved access to early identification and intervention to prevent the development of concurrent disorders.