“I’m just a long history of people rejecting referrals” experiences of young people who fell through the gap between child and adult mental health services

The paediatric-adult split in mental health care necessitates young people to make a transition between services when they reach the upper end of child and adolescent mental health services (CAMHS). However, we know that this transition is often poor, and not all young people who require ongoing support are able to continue care in adult mental health services (AMHS). These young people are said to have fallen through the gap between services. This research aimed to explore the reasons why young people fall through the gap between CAMHS and AMHS, and what effect his has had on them and their families. Narrative interviews were conducted with 15 young people and 15 parents, representing 19 unique transition stories. Themes were identified collaboatively using thematic analysis. Reasons for falling through the gap were grouped into systemic problems and problems with the quality of care received. Effects of alling through the gap were grouped into separate themes for young people (feeling abandoned; struggling to manage without continued care; problems with medication) and parents (emotional impact of care ending; parents taking an active role in the young person’s care). To our knowledge, this is the firt qualitative study that has focused only on the experiences of young people who have fallen through the gap between services. This research adds novel findings o existing literature regarding barriers to transition and the effectsof discontinuity of care

Understanding why young people fall through the gap between child and adult mental health services and the associated impact and costs for young people, society, and the health service

This thesis explores the causes and effects of discontinuity of care at the upper age boundary of child and adolescent mental health services (CAMHS). We investigate why young people (YP) fall through the gap between child and adult services and the effect this has on their mental health, functioning, and associated healthcare and societal costs. Mixed methods were used. A systematic review explored service use outcomes of young people after leaving CAMHS. Longitudinal data from 488 young people with an anxiety or depressive disorder, a neurodevelopmental disorder, or a personality disorder was analysed using multiple regression methods to examine predictors of transitioning, mental health and functioning outcomes, and resource use. Narrative interviews with thematic analysis was conducted with 15 YP and 15 parents of YP who fell through the gap. The results of all data analyses were synthesised using a Pillar Integration Process to generate new insights from the data. The most common reason for falling through the gap was being deemed ‘not ill enough’ to access adult services. The current service structure does not meet the mental health needs of all YP, and several reported being unable to access mental health care or medication when needed. Falling through the gap caused frustration and anxiety for YP and parents, and some YPs struggled to manage without specialist mental health care. Those who were most ill typically used more health care resources. This thesis sheds light on the causes and consequences of children falling through the gap between services. It concludes with seven recommendations for clinical practice and mental health policy to improve care for young people at the CAMHS transition boundary

Men don't talk about their health, but will they CHAT? The potential of online holistic needs assessment in prostate cancer

Men don't talk about their health is a familiar trope. Evidence suggests that in the United States (US) and in the United Kingdom (UK) this is indeed the case. A survey of five hundred men in the US over the age of eighteen reported only 7% discussing their health with their peers [1]. Only 42% of men surveyed were prepared to consult a health care professional over a worrying symptom

Review: Systematic review and metasynthesis of qualitative literature on young people's experiences of going to A&E/emergency departments for mental health support

Background: There has been an increase in children and young people attending emergency departments for mental health reasons, including self‐harm. Patients often report having poor experiences when attending emergency departments for mental health support. However, there has yet to be a review exploring the experiences of young people. Our aim in this study was to synthesise qualitative literature on young people's experiences of going to emergency departments for mental health support. Methods: A systematic review and metasynthesis were conducted. Five databases and grey literature were searched for relevant studies. Five articles met study criteria and were analysed using an iterative process of thematic synthesis. Results: The synthesis yielded four overarching themes: (a) emergency departments' inability to meet the mental health needs of young people, (b) emergency departments exacerbating patient distress, (c) patients feeling like a burden or undeserving of treatment and (d) consequences of poor emergency department experiences. Conclusions: These findings (based on a still very limited literature) highlight the role that emergency departments have in relation to being a key point of contact with young people who self‐harm. To properly engage with patients, emergency departments need to have the resources to provide compassionate care and follow clinical guidelines regarding assessments

A systematic review of influences on implementation of supported self-management interventions for people with severe mental health problems in secondary mental health care settings

PURPOSE: There is robust evidence for offering supported self-management interventions for people with severe mental illness (SMI) throughout secondary mental health services, but their availability remains patchy. The aim of this systematic review is to synthesise the evidence on barriers and facilitators to implementing self-management interventions for people with SMI in secondary mental health care settings. METHODS: The review protocol was registered with PROSPERO (CRD42021257078). Five databases were searched to identify relevant studies. We included full-text journal articles with primary qualitative or quantitative data on factors which affect the implementation of self-management interventions for people with SMI in secondary mental health services. The included studies were analysed using narrative synthesis, using the Consolidated Framework for Implementation Research and an established taxonomy of implementation outcomes. RESULTS: Twenty-three studies from five countries met eligibility criteria. The barriers and facilitators identified in the review were mainly on the organisational level, but included some individual-level influences. Facilitators included high feasibility, high fidelity, a strong team structure, sufficient number of staff, support from colleagues, staff training, supervision, the presence of an implementation champion and adaptability of the intervention. Barriers to implementation include high staff turnover, staff shortage, lack of supervision, lack of support for staff delivering the programme, staff struggling with their increased workload, a lack of senior clinical leadership, and programme content perceived as irrelevant. CONCLUSION: The findings from this research suggest promising strategies to improve implementation of self-management interventions. For services providing support for people with SMI, organisational culture should be considered, as well as the adaptability of interventions

New models of care in general practice for the youth mental health transition boundary

Mental illness represents the highest proportion of disease burden for children and young people in the UK.1 However, despite this, young people can struggle to access timely and appropriate mental health care. One particular barrier to continuity of care occurs when young people reach the upper age limit (usually 18 years) of child and adolescent mental health services (CAMHS). If they require ongoing specialist support, their care should be transferred to an adult mental health service (AMHS), through a purposeful and planned transfer of care known as ‘transition’. However, only around a quarter of young people transition to AMHS,2 and in the absence of specialist adult mental health care, GPs often become involved in the young person’s care ‘by default’.3 Although GPs become responsible for the young person’s care after they leave CAMHS, they may not have the necessary skills and resources to manage complex mental health difficulties in young peopl

Promoting integrated care in prostate cancer through online prostate cancer-specific holistic needs assessment : a feasibility study in primary care

Purpose This study assessed the feasibility of implementing a novel model of integrated prostate cancer care involving an online prostate cancer-specific holistic needs assessment (sHNA) and shared digital communication between patients and their healthcare professionals (HCPs). The sHNA produces a semi-automated care plan that is finalised in consultation between the patient and their practice nurse. Methods Men living with and beyond prostate cancer were invited to participate in a 9-month non-randomised cluster controlled feasibility study. The intervention group was asked to complete the sHNA on three occasions. Data were collected using Patient Reported Outcome Measures (PROMs) at baseline, 10 and 24 weeks, and 9 months. Outcomes included recruitment, retention, acceptability, and engagement with the sHNA and PROMs. Results Fourteen general practices (8 intervention and 6 control), and 41 men (29 intervention and 12 control) participated. Initial patient engagement with the sHNA was high, with all but one receiving practice nurse-led follow-up and an individualised care plan. The sHNA proved useful in identifying ‘red flag’ symptoms, and helping practice nurses decide when to seek further medical care for the patients. There was a high level of acceptability for patients and HCPs. However, integration of care did not occur as intended because of problems linking hospital and general practice IT systems. Conclusion While the study demonstrated the feasibility of implementing the sHNA, it did not meet the a priori progression criteria; as such, undertaking a definitive randomised controlled trial is not appropriate until the identified methodological and technical issues have been addressed

Outcomes of young people who reach the transition boundary of child and adolescent mental health services: a systematic review

When young people reach the upper age limit of child and adolescent mental health services (CAMHS), care should be transferred to an adult mental health service (AMHS) if they require ongoing support. However, many young people experience a significant disruption of their care during this transition, whilst others may fail to transition at all. Currently, there is no systematic appraisal of the international evidence regarding the outcomes of young people after transition. A systematic review was conducted which aimed to synthesise and review the existing research regarding outcomes after transition. We searched six databases from their inception until December 2017 for research relating to either the mental health or service use outcomes of young people after reaching their CAMHS age boundary. Results were synthesised narratively. The initial searches identified 18,287 papers, of which 213 were screened on full text. 13 papers were included in the review, representing 10 cohorts of young people who crossed the transition age boundary. No studies contained extractable data on mental health outcomes following transition, and therefore, this review focused only on service use outcomes. Results showed a quarter of young people transitioned to AMHS, with the other young people experiencing varied outcomes after leaving CAMHS and multiple transitions during this time. This review provides evidence for the varying service use outcomes of young people after reaching the upper age limit of CAMHS. However, longitudinal research into long-term outcomes is lacking, in addition to research regarding the mental health and functioning outcomes of young people following transition.Protocol registration: The protocol for this systematic review has been registered with PROSPERO, ID number CRD42018085916

Perspectives of young people who access support for mental health in primary care : a systematic review of their experiences and needs

Background: There is an increasing demand for mental health support in primary care, especially for young people. To improve mental health support for young people in general practice, the needs of young people must be considered. Aim: To explore the experiences of young people (aged 12–25 years) on receiving mental health care in primary care and identify the needs of young people who present with mental health concerns. Design and setting: A systematic review and narrative synthesis. Method: This was a systematic review and narrative synthesis. Six databases were searched for literature relating to young people’s experiences of receiving mental health care in primary care. Additional handsearching and manual internet searching were conducted. Narrative synthesis was employed. Results: Five papers and a further two reports from manual internet searching were found, resulting in the inclusion of 1823 young people from four different countries (UK, US, Ireland, and Canada) for synthesis. The synthesis generated four themes: the centrality of a trusting relationship; showing empathy and taking concerns seriously; being given time to talk; and barriers to accessing mental health support in primary care. Conclusion: Young people need a trusting relationship to discuss sensitive issues. To enable high-quality and effective mental health consultations with young people and the development of trust, GPs require unhurried consultations and the ability to maintain continuity of care

Development of a conceptual framework to guide description and evaluation of social interventions for people with serious mental health conditions

People with serious mental health conditions face social exclusion and have poorer social outcomes compared to the general population in several areas of life. Social exclusion also negatively impacts mental health. Promising models of support to improve social outcomes for people with serious mental health conditions have been described in the literature and proliferate in practice, but typologies of support are not clearly established and a robust evidence base for effective approaches is lacking in many areas. We conducted a scoping review of relevant literature and consulted with experts in the field to identify models to improve social circumstances across eight life domains, with the aim of developing a conceptual framework to distinguish the main broad approaches to improving the social circumstances of people with serious mental health conditions. We also sought to explore which approaches have been used in models within each life domain. This work was conducted in collaboration with a group of expert stakeholders, including people with lived experience of accessing mental health services. We developed a conceptual framework which distinguishes sources and types of support, allowing description of complex interventions to improve the social circumstances of people with serious mental health problems, and providing a framework to guide future service development and evaluation