Service provision for depressed children and youth: a survey of the scope and nature of services in Ontario

Talking 'Bout Better outcomes for Adolescent Depression: Youth and Caregiver Perspectives on an Integrated Care Pathway for Depression

BACKGROUND

Depression is a common condition among adolescents, with rates continuing to rise. A gap exists between evidence-based recommendations for the treatment of depression and clinical practice. Integrated Care Pathways (ICPs) can help address this gap, but to date no study has examined how young people and their caregivers experience ICPs and whether these pathways are an acceptable form of care. This study used focus groups with adolescents, caregivers, and service providers to examine experiences of an ICP.

METHODS

Six individual interviews with service providers, four focus groups with youth, and two focus groups with caregivers were completed. Data was analyzed consistent with Braun & Clarke's Thematic Analysis Framework within an interpretivist paradigm.

RESULTS AND CONCLUSION

The study demonstrated that ICPs are acceptable to youth and their caregivers and that ICPs facilitate shared decision making between youth/caregivers and care providers. Findings also indicated that youth are willing to engage with ICPs particularly when there is a trusted clinician involved who helps interpret and tailor the ICP to the young person's experience. Further questions include how to best integrate these into the overall system and how to further tailor these pathways to support youth with diagnostic complexity and treatment resistance.

An Integrated Care Pathway for depression in adolescents: protocol for a Type 1 Hybrid Effectiveness-implementation, Non-randomized, Cluster Controlled Trial

INTRODUCTION

Our group developed an Integrated Care Pathway to facilitate the delivery of evidence-based care for adolescents experiencing depression called CARIBOU-2 (Care for Adolescents who Receive Information 'Bout OUtcomes, 2nd iteration). The core pathway components are assessment, psychoeducation, psychotherapy options, medication options, caregiver support, measurement-based care team reviews and graduation. We aim to test the clinical and implementation effectiveness of the CARIBOU-2 pathway relative to treatment-as-usual (TAU) in community mental health settings.

METHODS AND ANALYSIS

We will use a Type 1 Hybrid Effectiveness-Implementation, Non-randomized Cluster Controlled Trial Design. Primary participants will be adolescents (planned n = 300, aged 13-18 years) with depressive symptoms, presenting to one of six community mental health agencies. All sites will begin in the TAU condition and transition to the CARIBOU-2 intervention after enrolling 25 adolescents. The primary clinical outcome is the rate of change of depressive symptoms from baseline to the 24-week endpoint using the Childhood Depression Rating Scale-Revised (CDRS-R). Generalized mixed effects modelling will be conducted to compare this outcome between intervention types. Our primary hypothesis is that there will be a greater rate of reduction in depressive symptoms in the group receiving the CARIBOU-2 intervention relative to TAU over 24 weeks as per the CDRS-R. Implementation outcomes will also be examined, including clinician fidelity to the pathway and its components, and cost-effectiveness.

ETHICS AND DISSEMINATION

Research ethics board approvals have been obtained. Should our results support our hypotheses, systematic implementation of the CARIBOU-2 intervention in other community mental health agencies would be indicated.

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.

Youth Perspectives on Integrated Youth Services: A Discrete Choice Conjoint Experiment

OBJECTIVE

Integrated youth services (IYS) are an emerging model of care offering a broad range of mental health and social services for youth in one location. This study aimed to determine the IYS service characteristics most important to youth, as well as to determine whether different classes of youth have different service preferences, and if so, what defines these classes.

METHODS

Ontario youth aged 14-29 years with mental health challenges were recruited to participate in a discrete choice experiment (DCE) survey. The DCE contained 12 attributes, each represented by 4 levels representing core characteristics of IYS models. To supplement the DCE questions, demographic information was collected and a mental health screener was administered. Preferences were examined, latent class analyses were conducted, and latent classes were compared.

RESULTS

As a whole, participants endorsed the IYS model of service delivery. Among 274 youth, there were three latent classes: 1) the Focused Service (37.6%) latent class prioritized efficient delivery of mental health services. 2) The Holistic Services (30.3%) latent class prioritized a diverse array of mental health and social services delivered in a timely fashion. 3) The Responsive Services (32.1%) latent class prioritized services that matched the individual needs of the youth being served. Differences between classes were observed based on sociodemographic and clinical variables.

CONCLUSIONS

IYS is an acceptable model of care, in that it prioritizes components that reflect youth preferences. The differences in preference profiles of different groups of youth point to the need for flexible models of service delivery. Service design initiatives should take these preferences into account, designing services that meet the needs and preferences of a broad range of youth. Working locally to co-design services with the youth in the target population who wish to be engaged will help meet the needs of youth.

CARIBOU-1: A pilot controlled trial of an Integrated Care Pathway for the treatment of depression in adolescents

Background

To co-ordinate a multidisciplinary team in the delivery of guideline recommendations using a measurement-based care framework, our group previously developed a care pathway for the treatment of depression in adolescents. Core components of the pathway were: assessment, education, cognitive-behavioural therapy, a caregiver intervention group, a medication algorithm, and monthly measurement-based care "team reviews" with the adolescent present. The aim of this study was to test the feasibility of conducting a controlled clinical trial of the pathway.

Method

We conducted a 20-week pilot controlled clinical trial of the care pathway relative to treatment as usual. Participants were adolescents (age 14-18) with a primary diagnosis of Major Depressive Disorder recruited from one of two outpatient psychiatric clinics at academic hospitals. Site of presentation was the method of allocation. Thirty-five youth were allocated to the pathway and 31 were allocated to treatment as usual. As this is a pilot study, trial feasibility outcomes were of primary interest, including clinician fidelity to the care pathway.

Results

Our target sample size was recruited over a 15-month time interval. Clinician fidelity and adolescent engagement in the care pathway components on a priori checklists were high (95% and 80%, respectively). We collected baseline and 20-week endpoint data for our primary outcome of the Children's Depression Rating Scale - Revised (CDRS-R) for 83% of the sample. On linear mixed effects modelling, we observed a linear decrease in CDRS-R across 4-week intervals up to the 20-week endpoint in both groups (β = -2.07; 95% CI -3.14 to -1.01).

Conclusion

A controlled clinical trial of a complex, multi-component intervention for the treatment of depression in adolescents is feasible. Given the need to find optimal strategies to deliver effective care for adolescents with depression, a definitive randomized controlled trial of the pathway is warranted.Trial is registered at Clinicaltrials.gov: NCT03428555.

Demographic and Clinical Presentations of Youth using Enhanced Mental Health Services in Six Indigenous Communities from the ACCESS Open Minds Network

OBJECTIVE

In many Indigenous communities, youth mental health services are inadequate. Six Indigenous communities participating in the ACCESS Open Minds (AOM) network implemented strategies to transform their youth mental health services. This report documents the demographic and clinical presentations of youth accessing AOM services at these Indigenous sites.

METHODS

Four First Nations and two Inuit communities contributed to this study. Youth presenting for mental health services responded to a customized sociodemographic questionnaire and presenting concerns checklist, and scales assessing distress, self-rated health and mental health, and suicidal thoughts and behaviors.

RESULTS

Combined data from the First Nations sites indicated that youth across the range of 11-29 years accessed services. More girls/women than boys/men accessed services; 17% identified as LBGTQ+. Most (83%) youth indicated having access to at least one reliable adult and getting along well with the people living with them. Twenty-five percent of youth reported difficulty meeting basic expenses. Kessler (K10) distress scores indicated that half likely had a moderate mental health problem and a fourth had severe problems. Fifty-five percent of youth rated their mental health as fair or poor, while 50% reported suicidal thoughts in the last month. Anxiety, stress, depression and sleep issues were the most common presenting problems. Fifty-one percent of youth either accessed services themselves or were referred by family members. AOM was the first mental health service accessed that year for 68% of youth.

CONCLUSIONS

This report is the first to present a demographic and clinical portrait of youth presenting at mental health services in multiple Indigenous settings in Canada. It illustrates the acceptability and feasibility of transforming youth mental health services using core principles tailored to meet communities' unique needs, resources, and cultures, and evaluating these using a common protocol. Data obtained can be valuable in evaluating services and guiding future service design. Trial registration name and number at Clinicaltrials.gov: ACCESS Open Minds/ACCESS Esprits ouverts, ISRCTN23349893.

Severe and complex youth depression: Clinical and historical features of young people attending a tertiary mood disorders clinic

AIM

The concept of severe and complex youth depression has evolved from clinical experience. Here we conducted a file audit study to evaluate supporting data for the construct.

METHODS

A retrospective file audit was undertaken with 84 consecutively discharged patients over 6-months from Orygen's Youth Mood Clinic (YMC; 50% female).

RESULTS

Over a third (36.9%) were disengaged from vocation and education, with exposure to traumatic events common (84.5%). Almost all patients (91.7%) reported past 2-week suicidal ideation at clinic entry. Hospital emergency departments were the most frequent referral source (31.0%). Most (72.6%) had received previous mental health treatment. Multimorbidity was frequently observed. The presence of a substance use disorder, or ≥ 3 comorbidities were both associated with a greater likelihood of prior suicide attempt.

CONCLUSIONS

These data highlight the clinical needs associated with severe and complex depression. Findings have implications for youth experiencing mood disorders attending tertiary and community mental health settings.

Prioritizing core components of successful transitions from child to adult mental health care: a national Delphi survey with youth, caregivers, and health professionals

Youth accessing mental health care often experience a disruption in care as they attempt to transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). Few studies have evaluated interventions seeking to improve the experience and outcomes of CAMHS-AMHS transitions, in part due to lack of consensus on what constitutes best practices in intervention success. As such, the aim of this study was to engage patients, caregivers, and clinicians to prioritize core components of successful CAMHS-AMHS transitions which can be used in the design or evaluation of transition interventions. As such, a Delphi study was conducted to determine core components of successful CAMHS-AMHS transitions. Guided by the principles of patient-oriented research, three balanced expert panels consisting of youth, caregivers, and clinicians ranked and provided feedback on the importance and feasibility of core components of CAMHS-AMHS transitions. Components endorsed as feasible or important with ≥ 70% agreement from any panel moved to the next round. As a result, a list of 26 core components of CAMHS-AMHS transitions has been refined which can be used in the design, implementation, or evaluation of interventions intended to improve transition experiences and outcomes for youth in mental health care. Youth and families were engaged in an expert advisory role throughout the research process, contributing their important perspectives to the design and implementation of this study, as well as interpretation of the findings.

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.

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.