Children with mental health disorders have lower symptoms of depression 3 years after contact with mental health services

Commentary on: Neufeld SA, Dunn VJ, Jones PB, et al. Reduction in adolescent depression after contact with mental health services: a longitudinal cohort study in the UK. Lancet Psychiatry 2017;4:120–127.

What is already known about this topic

Adolescence is a critical period for the development of depression with prevalence rates rising sharply from childhood to early adulthood.¹ Many adult depressive disorders have their first onset in adolescence² with longer episode duration being the strongest predictor of future problems.³ In addition to increasing the risk of later mental health problems, adolescent depression is associated with significant educational and social impairment and is a major risk factor for suicide.¹ Providing effective early interventions to shorten the duration of episodes and potentially reduce the impact on later life is therefore important.³ This study explores this question and compares the effects of contact at age 14 with child mental health services in those with and without diagnosed mental health disorders on symptoms of depression 3 years later.⁴

Methods of the study

In a longitudinal repeated-measures cohort study, 1238, 14-year-old adolescents attending 18 UK secondary schools and their primary caregivers were assessed at baseline, 18 and 36 months with mental health diagnosis being confirmed by the Schedule for Affective Disorders and Schizophrenia for School-Aged Children—Present and Lifetime version. Self-report symptoms of depression were assessed by the Mood and Feelings Questionnaire at each time point with mental health service contact being assessed in the year before baseline.

What this paper adds

• This study uses robust statistical analysis to control for the possible confounding effects of differences in symptoms and background factors among service users and non-users at baseline and over time in those with and without a diagnosed mental health disorder.

• At baseline, 126 (11%) adolescents were assessed as having a current mental health disorder. Of these, 48 (38%) reported contact with mental health services over the previous 12 months with 26 (54%) having contact with specialist child and adolescent mental health services.

• Adolescents  with a mental health disorder (aged 14) who did not have contact with mental health services were seven times more likely to report symptoms of depression at age 17 than those with a disorder who did have contact with services (adjusted OR: 7.38. 1.73–31.50, p=0.0069).

• Sixteen adolescents were accessing mental health services at baseline who did not fulfil criteria for a mental health diagnosis. Including these in the analysis failed to show that contact with mental health services had an effect on symptoms of depression at age 17 suggesting that longer-term improvements were limited to those who fulfilled diagnostic criteria.

Limitations

• Assessment of service use relied on retrospective self-report and was not independently confirmed by clinical records.

• The disorder and service contact group (n=48) presented with a range of diagnosis and it is unclear whether the reduction in depressive symptoms was related to a particular diagnostic group.

• The components of mental health interventions for different disorders vary and as such it is not possible to determine the specific mechanisms which resulted in lower symptoms of depression at 36 months.

What next in research

Larger studies are required to explore the effects of specific diagnoses on outcomes and whether early contact results in improvements in other areas of functioning such as anxiety and general behaviour. These would also allow the identification of possible mechanisms underpinning these improvements and which specific or non-specific treatment factors are important.

Do these results change your practice and why?

Yes. This study highlights that the majority of adolescents with a mental health disorder do not access mental health services. Clinical services need to proactively reach out and engage with adolescents in schools and the community through initiatives such as mental health school in-reach programmes. Second, given the limited funding and capacity of specialist child mental health services, limited resources need to be used as effectively as possible. This study suggests that those who benefited from contact with mental health services presented with diagnosed disorders. Training those who work in school and community settings in the presentation and diagnostic criteria of mental health disorders would help to ensure that those with mental health disorders are more accurately identified and referred to specialist services.