What are "good outcomes" for adolescents in public mental health settings?

Ethnic differences in treatment outcome for children and young people accessing mental health support

Children and Young People (CYP) from minoritized ethnic backgrounds experience structural inequalities in Children and Young People's Mental Health Settings (CYPMHS). This mixed methods study explores whether CYP's ethnicity is associated with their treatment outcomes (operationalised as 'measurable change') from CYPMHS. A multilevel multi-nominal regression analysis, controlling for age, gender, referral source, presenting difficulty, case closure reason, suggests that CYP from Asian backgrounds (OR = 0.82, CI [0.70, 0.96]) and Mixed-race (odds ratio (OR) = 0.80; 95% CI [0.69, 0.92]) are less likely to report measurable improvement in mental health difficulties compared to White British CYP. Three themes from a thematic analysis of semi-structured interviews with 15 CYP from minoritized ethnic backgrounds focused on views and experiences of ending mental health support are also presented. CYP view personalised support and the right therapist as conducive to good endings and valued a range of outcomes pertaining to empowerment. Experiences of stigma and inequalities may begin to explain the less positive outcomes experienced by Asian and Mixed-race CYP found in the regression analysis. The implications of these findings and future areas of research are suggested.

Understanding change - developing a typology of therapy outcomes from the experience of adolescents with depression

Outcome measures mostly focusing on symptom reduction to measure change cannot indicate whether any personally meaningful change has occurred. There is a need to broaden the current understanding of outcomes for adolescent depression and identify whether holistic, interlinked patterns of change may be more clinically meaningful.

To create a typology of therapy outcomes based on the experiences of adolescents with depression.

Interview data from 83 participants from a clinical trial of the psychological treatment of adolescent depression was analysed using ideal type analysis.

Six ideal types were constructed, reflecting different evaluations of the holistic impact of therapy: "I've worked on my relationships", "With the insight from therapy, and feeling validated, I can cope with life challenges better", "My mood still goes up and down", "If I want things to change, I need to help myself", "Therapy might help, but it hasn't been enough", and "I don't feel therapy has helped me".

Assessing change using outcome measures may not reflect the interconnected experience for adolescents or the contextual meaning of symptom change. The typology developed offers a way of considering the impact of therapy, taking into account how symptom change is experienced within a broader perspective.

Perceptions of mental health providers of the barriers and facilitators of using and engaging youth in digital mental-health-enabled measurement based care

Objectives

Increased rates of mental health disorders and substance use among youth and young adults have increased globally, furthering the strain on an already burdened mental health system. Digital solutions have been proposed as a potential option for the provision of timely mental health services for youth, with little research exploring mental health professional views about using such innovative tools. In Alberta, Canada, we are evaluating the implementation and integration of a digital mental health (dMH) platform into existing service pathways. Within this paper we seek to explore mental health professionals' perceptions of the barriers and facilitators that may influence their utilization of digital MH-enabled measurement-based care (MBC) with the youth who access their services.

Methods

A qualitative, descriptive methodology was used to inductively generate themes from focus groups conducted with mental health professionals from specialized mental health services and primary care networks in Alberta.

Results

As mental health professionals considered the barriers and facilitators of using dMH with youth, they referenced individual and family barriers and facilitators to consider. Providers highlighted perceived barriers, including: first, cultural stigma, family apprehension about mental health care, and parental access to dMH and MBC as deterrents to providers adopting digital platforms in routine care; second, perceptions of increased responsibility and liability for youth in crisis; third, perception that some psychiatric and neurodevelopmental disorders in youth are not amenable to dMH; fourth, professionals contemplated youth readiness to engage with dMH-enabled MBC. Participants also highlighted pertinent facilitators to dMH use, noting: first, the suitability of dMH for youth with mild mental health concerns; second, youth motivated to report their changes in mental health symptoms; and lastly, youth proficiency and preference for dMH options.

Conclusions

By identifying professionals' perceptions of barriers and facilitators for youth users, we may better understand how to address misconceptions about who is eligible and appropriate for dMH through training and education.

Trust in Therapeutic Work With Adolescents With and Without Personality Disorders: A Transference-Focused Therapy Perspective

Trust is central to successful therapeutic work with adolescents, but establishing trust can be challenging, especially with adolescents with personality disorders. We present our understanding of trust in working with adolescents with and without personality disorders. We draw on complementary and overlapping perspectives, namely the attachment model, Kernberg's object relations model, and Fonagy's mentalization model. In Kernberg's object relations conceptualization, difficulties in trust experienced by patients with borderline personality disorders result from paranoia associated with splitting and identity diffusion. In Fonagy's mentalization model, epistemic trust is rooted in early experiences of being responded to and understood. We outline how techniques used in transference-focused psychotherapy for adolescents promote the development of the adolescent's capacity to trust by facilitating identity integration, thus reducing paranoia. Finally, we use two clinical case illustrations to demonstrate how trust unfolds in working with adolescents with and without personality disorders.

What treatment outcomes matter most? A Q-study of outcome priority profiles among youth with lived experience of depression

Interest in youth perspectives on what constitutes an important outcome in the treatment of depression has been growing, but limited attention has been given to heterogeneity in outcome priorities, and minority viewpoints. These are important to consider for person-centred outcome tracking in clinical practice, or when conducting clinical trials targeting specific populations. This study used Q-methodology to identify outcome priority profiles among youth with lived experience of service use for depression. A purposive sample of 28 youth (aged 16-21 years) rank-ordered 35 outcome statements by importance and completed brief semi-structured interviews eliciting their sorting rationales. By-person principal component analysis was used to identify outcome priority profiles based on all Q-sort configurations. Priority profiles were described and interpreted with reference to the qualitative interview data. Four distinct outcome priority profiles were identified: "Relieving distress and experiencing a happier emotional state"; "Learning to cope with cyclical distressing emotional states"; "Understanding and processing distressing emotional states"; and "Reduced interference of ongoing distressing emotional states with daily life". All four profiles prioritised improvements in mood and the ability to feel pleasure but differed in the level of importance assigned to learning coping skills, processing experiences, and the reduced interference of depression with life and identity. As part of a person-centered approach to care delivery, care providers should routinely engage young people in conversation and shared decision-making about the types of change they would like to prioritise and track during treatment, beyond a common core of consensus outcomes.

A novel application of the Lego® Serious Play® methodology in mental health research: Understanding service users' experiences of the 0-19 mental health model in the United Kingdom

AIM

The 0-19 model is an example of a service that has been retransformed in line with UK's recent policies. However, there is limited qualitative research exploring young people's experiences with the accessibility and acceptability of retransformed models through more participatory qualitative approaches. This study aimed to understand service users' experiences of accessibility and acceptability with the 0-19 model and its service provision. In addition, we also aim to outline the process and application of the Lego® Serious Play® methodology to the context of children and young people's mental health research and reflect on the usefulness of this novel approach and its potential for further research use.

METHODS

A qualitative methodology based on the Lego® Serious Play® approach was used to investigate service users' perceptions of the accessibility and acceptability of the 0-19 model. This novel approach is viewed as a facilitator of engagement, which also stimulates critical thinking and reflective practice. All interviews were thematically analysed.

RESULTS

Seven participants constructed 14 models and provided metaphorical narratives for them besides engaging in group discussions. Thematic analysis of the participants' models and narratives resulted in six identified themes: accessibility, doors into the unknown, let it out, overcoming obstacles, less is sometimes better and satisfaction with the 0-19 model and its provision.

CONCLUSION

Participants in this study perceived the 0-19 model as acceptable and, to a degree, accessible. Participants identified a range of barriers to accessibility, such as inconvenient locations, long waiting and inflexible working times.

The effective delivery of digital CBT: a service evaluation exploring the outcomes of young people who completed video conferencing therapy in 2020

Despite its impressive evidence base, there is a widening access gap to receiving cognitive behavioural therapy (CBT). Video conferencing therapy (VCT) offers an effective solution for logistical barriers to treatment, which has been salient throughout the Coronavirus pandemic. However, research concerning the delivery of CBT via VCT for children and young people (CYP) is in its infancy, and clinical outcome data are limited. The aim of this service evaluation was to explore the effectiveness of a VCT CBT intervention for CYP referred from Child and Adolescent Mental Health Services (CAMHS) in the UK. A total of 989 records of CYP who had completed CBT via VCT in 2020 with Healios, a digital mental health company commissioned by the National Health Service (NHS), were examined to determine changes in anxiety, depression and progress towards personalised goals. Routine outcome measures (ROMs) were completed at baseline and endpoint, as well as session by session. Feedback was collected from CYP and their families at the end of treatment. There was a significant reduction in symptoms of anxiety and depression and significant progress towards goals, with pre- to post-effect sizes (Cohen’s d) demonstrating medium to large effects (d=.45 to d=−1.39). Reliable improvement ranged from 31 to 80%, clinical improvement ranged from 33 to 50%, and 25% clinically and reliably improved on at least one measure; 92% reported that they would recommend Healios. This service evaluation demonstrates that Healios’ CBT delivered via VCT is effective for CYP receiving it as part of routine mental health care.

Key learning aims

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Monitoring and Measurement in Child and Adolescent Mental Health: It's about More than Just Symptoms

Routine outcome monitoring (ROM) provides information to practitioners and others providing healthcare support to demonstrate the impact of interventions and for service evaluation [...].

Chronic pain and masculine identity: life-world interviews with men at a South African Pain Clinic

PURPOSE

The purpose was to investigate experiences of men who were living with chronic pain in relation to masculine identity and their experiences of treatment at a Chronic Pain Clinic in South Africa.

METHODS

A purposive sample of 14 male patients from an outpatient Chronic Pain Clinic participated in the study in 2019. Qualitative inquiry followed a life-world dialogical interview approach. Respondent validation interviews further engaged participant perspectives. Team data analysis, thematic network diagrams and tabulations were used for analysis of the interview data. .

RESULTS

The respondents described multiple challenges of the journey to chronic pain, living with chronic pain, experiences of treatment contexts, ways of coping and the experience of living with chronic pain in relation to masculinity. Three typologies were identified: (1) aligning with hegemonic ideals, (2) a yielding masculinity or (3) an adjusted masculine identity. The findings revealed how masculine identity was positioned by the perceptions of others, interpersonally and within the individual.

CONCLUSIONS

Healthcare practitioners and public health can be responsive to the gendered context of living with difficult and long-term pain conditions. Treatment should be supportive and inclusive..

Understanding the illness representations of young people with anxiety and depression: A qualitative study

BACKGROUND

Many young people with anxiety or depression drop out of treatment early, and/or leave treatment without showing measurably improved symptom levels. To enhance treatment engagement and effectiveness, it is critical to better understand how young people's perceptions of the symptoms, causes, consequences, treatability, and course of their anxiety and depression influence engagement.

AIM

This study aimed to provide a qualitative account of illness perceptions among youth with anxiety and depression by applying the Common Sense Model of Self-Regulation (CSM), which was developed in physical health contexts.

METHODS

Semi-structured interviews were conducted with 26 young people (aged 16-24, 73% female) with a history of anxiety and/or depression. Interviews were analysed using a combination of theory- and data-driven analysis techniques, consisting primarily of deductive thematic analysis.

RESULTS

The five themes broadly mapped onto the dimensions of the CSM, suggesting parallels in how mental and physical health problems are perceived. Anxiety and depression were viewed as non-linear, relapsing and remitting, but lifelong conditions, with a fluctuating and complex path to recovery and coping. Youth described pervasive negative impacts on their lives, but also described some positive aspects.

IMPLICATIONS

Better understanding of young people's illness beliefs has the potential to open a range of intervention possibilities by prioritizing young people's illness perceptions over the clinician's understanding and the supposed objective condition severity and trajectory. Although this study supported a common structure of illness beliefs, the content of these beliefs was idiosyncratic and specific to anxiety and depression, suggesting the need to develop a valid tool to measure illness perceptions in this group.

PRACTITIONER POINTS

Our findings suggest that illness perceptions are complex, highly idiosyncratic, and specific to youth anxiety and depression. Given the complexity of these beliefs and the known association with important treatment- and health-related outcomes, it is important that clinical formulation incorporates young people's illness belief models, including their perceptions of symptoms, cause, timeline to recovery, consequences, and personal and treatment control. To increase help-seeking, treatment engagement and adaptive coping strategies, therapy should work to a shared understanding of illness beliefs. Increasing congruence between the belief models of young people, families, and clinicians may serve to improve treatment benefits and address the unmet mental health needs of young people.

Barriers and Facilitators in Adolescent Psychotherapy Initiated by Adults-Experiences That Differentiate Adolescents' Trajectories Through Mental Health Care

Mental health problems start early in life. However, the majority of adolescents fulfilling the criteria for mental health disorders do not receive treatment, and half of those who do get treatment drop out. This begs the question of what differentiates helpful from unhelpful treatment processes from the perspective of young clients. In this study, we interviewed 12 young people who entered mental health care reluctantly at the initiative of others before the age of 18. Their journeys through mental health care varied significantly despite sharing the same starting point. Our analyses resulted in a model of three trajectories. We describe relational and structural facilitators and obstacles within each trajectory and have formulated narratives highlighting core experiences differentiating them. Trajectory 1 (I never saw the point - Being met as a case) was characterized by a rapid loss of hope, leading the adolescents to conclude that mental health care was not worth the investment. Trajectory 2 (I gave it a go, but nothing came of it - Being met by a therapist representing a rigid and unhelpful system) was characterized by a lingering hope that never materialized into a constructive therapeutic process despite prevailing efforts by both therapists and adolescents. Trajectory 3 (Something good came of it - Being met by a therapist who cares and wants to help) was characterized by genuine meetings, allowing the therapist to transform from an unsafe stranger into a safe, competent, and benevolent adult. We discuss how our results have implications for understanding agency displayed by adolescent clients in therapy, therapist flexibility and authenticity, service organization, and attributional processes influencing clinical judgment and therapeutic processes when adolescent psychotherapy has a difficult starting point (i.e., initiated by adults).

Physical Morbidity and Mental Health Care Among Young People

PURPOSE

This epidemiological study examined associations between morbidity status and mental health care use among young people.

METHODS

Data come from individuals aged 15-29 years (n = 5,630) in the Canadian Community Health Survey-Mental Health (2012). Physical health problems were measured using a standard checklist. The Composite International Diagnostic Interview assessed 12-month mental health and substance use problems. Individuals were asked which types of mental health care they had received in the past year. Logistic, ordinal, and multinomial regression models were computed and the method of variance estimates recovery was used to compare estimates.

RESULTS

Individuals with comorbid physical health problems had higher odds of mental health care use for those with mental (odds ratio [OR] = 12.54 [7.07, 22.25]) and substance use problems (OR = 2.97 [1.75, 5.05]). While these estimates were higher than for individuals without physical comorbidity, differences were not statistically significant. For mental health care needs not being met, associations were found for individuals with mental (OR = 2.56 [1.24, 5.26]) or substance use problems only (OR = 2.48 [1.06, 5.82]).

CONCLUSIONS

Odds of perceiving the need for and using mental health care were high in individuals with a physical comorbidity, but similar to those with mental health or substance use problems only. Young people with a physical comorbidity were less likely to report that their mental health needs are not being met compared to those with mental health or substance use problems only. Research is needed to understand barriers and facilitators faced by young people with mental health or substance use problems as they navigate the health system.

A comprehensive mapping of outcomes following psychotherapy for adolescent depression: The perspectives of young people, their parents and therapists

As mental health systems move towards person-centred care, outcome measurement in clinical research and practice should track changes that matter to young people and their families. This study mapped the types of change described by three key stakeholder groups following psychotherapy for depression, and compared the salience of these outcomes with the frequency of their measurement in recent quantitative treatment effectiveness studies for adolescent depression.Using qualitative content analysis, this study identified and categorized outcomes across 102 semi-structured interviews that were conducted with depressed adolescents, their parents, and therapists, as part of a randomized superiority trial. Adolescents had been allocated to Cognitive-Behavioral Therapy, Short-Term Psychoanalytic Psychotherapy, or a Brief Psychosocial Intervention.The study mapped seven high-level outcome domains and 29 outcome categories. On average, participants discussed change in four domains and six outcome categories. The most frequently discussed outcome was an improvement in mood and affect (i.e., core depressive symptoms), but close to half of the participants also described changes in family functioning, coping and resilience, academic functioning, or social functioning. Coping had specific importance for adolescents, while parents and therapists showed particular interest in academic functioning. There was some variation in the outcomes discussed beyond these core themes, across stakeholder groups and treatment arms.Of the outcomes that were frequently discussed in stakeholder narratives, only symptomatic change has been commonly reported in recent treatment studies for adolescent depression. A shift towards considering multiple outcome domains and perspectives is needed to reflect stakeholder priorities and enable more nuanced insights into change processes.

Impact of the implementation of the safewards model on the social climate on adolescent psychiatric wards

The Safewards model was created to reduce conflict and containment in psychiatric inpatient units. The model suggests alternative methods for containment and aims to create a safer hospital experience for both patients and staff. The evaluation of this model has provided evidence that it might be implemented on adolescent psychiatric wards. This study evaluated the impact of the implementation process of the Safewards model on the social climate of adolescent psychiatric inpatient wards by using the Essen Climate Evaluation Schema questionnaire. The study was carried out on six closed wards of one Finnish hospital district. Data were collected at baseline (42 adolescent inpatients and 134 staff members) and after the implementation of the model (39 inpatients and 115 staff members). The data were analysed using the Mann-Whitney U-test. The findings of this preliminary study indicate that inpatients' experience of patient cohesion and therapeutic hold and staff members' experience of safety on adolescent psychiatric wards might be improved by the implementation of the Safewards model on adolescent psychiatric wards.

Moving Toward Connectedness - A Qualitative Study of Recovery Processes for People With Borderline Personality Disorder

Borderline personality disorder (BPD) is a mental health disorder estimated to affect 1–2% of the general population. As a group, people with BPD endure a high degree of suffering, often leading to suicide attempts, self-harm, and suicide. Comparatively few studies explore the first person perspective of the person suffering from any mental health disorder. This might be especially problematic for people diagnosed with BPD, as this particular diagnosis is followed by stigma potentially making help seeking harder and helping relationships more vulnerable. We interviewed 12 female participants recently diagnosed with BPD in-depth about their experiences with recovery and treatment, and used a stepwise reflective approach to rigorously analyze the data. Results show an overarching theme of working toward connectedness, with four constituent sub-themes. We discuss the findings with regard to empirical work, recovery and autonomy, and the risk of epistemic injustice that people with BPD risk facing.

Review: What Outcomes Count? A Review of Outcomes Measured for Adolescent Depression Between 2007 and 2017

OBJECTIVE

Measurement of treatment outcomes in childhood depression has traditionally focused on assessing symptoms from the clinician's perspective, without exploring other outcome domains or considering young people's perspectives. This systematic review explored the extent to which multidimensional and multi-informant outcome measurements have been used in clinical research for adolescent depression in the past decade and how patterns have evolved over time.

METHOD

Embase, Medline, and PsycINFO were searched, and studies that were published from 2007 through 2017 and assessed the effectiveness of treatments or service provision for adolescent depression were included. Of 7,483 studies screened, 95 met the inclusion criteria and were included for data extraction and analysis.

RESULTS

Ten outcomes domains were identified, 2 of which were assessed on average using 4 outcome measures. Most studies (94%) measured symptoms, followed by functioning (52%). Other domains such as personal growth, relationships, quality of life, and service satisfaction were each considered by less than 1 in 10 studies. Youth self-report was considered by 54% but tended to focus on secondary outcomes. Multidimensional and multi-informant measurements were more frequent in studies published since 2015.

CONCLUSION

Recent clinical research continues to prioritize symptoms measurement based on clinician report and has not yet fully embraced multidimensional and multi-informant approaches. In the context of significant policy shifts toward patient-centered and evidence-based care, measuring what matters most to patients has become a priority, but this is not yet widely reflected in clinical research.