Interventions to reduce wait times for adolescents seeking mental health services: a scoping review protocol

Abstract

Introduction

The demand for adolescent mental health services has increased significantly in recent years, leading to excessive wait times for adolescents seeking mental health services and poor mental health outcomes. Timely access to mental health services is critical to reducing the risk of symptom chronicity and progression to mental disorder. A better understanding of whether and how interventions to reduce wait times impact mental health outcomes is needed to guide mental health policymakers and service planners in their approach to reducing wait times.

Methods and analysis

The scoping review will use Arksey and O'Malley’s six-stage framework for scoping reviews and Rayyan to support screening, data extraction and evidence synthesis. The review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. We will search the Cochrane Library, EBSCOhost, MEDLINE (Ovid), PsycArticles (Ovid), PsycINFO (Ovid), EMBASE (Ovid), Web of Science, ProQuest and Scopus databases for peer-reviewed texts published in English between 1 January 2000 and 28 February 2023. We will also search Google Scholar for additional grey literature. To be eligible for inclusion, studies must focus on adolescent populations aged 13–18 years and report on interventions to reduce wait times for any mental health service except crisis and emergency services. Title, abstract and full-text screening will be done by two reviewers. We will extract data describing the interventions and their effects on wait times and adolescent mental health outcomes, and we will identify strengths and limitations in the evidence base to inform recommendations for future research. A youth advisory group with lived experience of mental health difficulties will be consulted throughout the review process.

Ethics and dissemination

Ethics approval is not required. Findings will be disseminated via peer-reviewed publications and presented at conferences.

Study registration

The protocol was registered with the Open Science Framework on 20 February 2023 (https://osf.io/qt4zy).

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This scoping review follows best practice and includes consultations with a youth advisory group, helping to ensure project relevance to key stakeholders in the field.

• The analysis will produce a catalogue of interventions to reduce wait times for adolescent mental health services and a summary of evidence in support of their effectiveness, which can guide stakeholders’ efforts to reduce wait times for their services.

• A limitation is that, in the existing literature, there are only a limited number of studies examining wait times for adolescent mental health services.

• Another limitation is the exclusion of non-English language articles.

Introduction

Adolescence, defined as the period from 13 to 18 years of age, is a crucial developmental period characterised by rapid social, emotional and physical change.¹ These changes correspond with increasingly complex social and emotional experiences that heighten vulnerability to mental health difficulties, such as anxiety, depression and substance use disorders.¹ The impacts of poor mental health during adolescence are far-reaching and include risky behaviours, educational difficulties, social exclusion, physical ill-health, harmful substance use, self-injury and suicidality.^{2 3} When left untreated, these mental health difficulties may persist into adulthood and have lasting individual and societal impacts.⁴ This is cause for concern as mental and substance use disorders are among the leading causes of disability for adolescents globally.⁵

The global burden of untreated mental disorders among children and youth up to 20 years of age is estimated to have increased by 14.9% between 1990 and 2019.⁶ Emerging evidence suggests that this burden further increased during the COVID-19 pandemic due to disrupted routines, fear of illness and loss, social isolation and increased cyberbullying.^{7 8} Indeed, a meta-analysis of 29 studies comprising 80 879 adolescents reported a doubling of anxiety and depression symptoms to current estimates of 25.2% and 20.5%, respectively.⁹ While not all adolescents experiencing these symptoms meet diagnostic criteria for mood or anxiety disorders, the peak age of onset for most mental disorders is 14.5 years,¹⁰ and longitudinal evidence demonstrates that symptoms of mental health difficulties in late adolescence persist into young adulthood.¹¹ Therefore, timely access to mental health services for adolescents experiencing mental health difficulties is critical to reducing the persistence and progression of these difficulties¹² and the long-term costs associated with untreated mental disorders.¹³

However, the increased demand for adolescent mental health services outweighs available resources, leading to excessive wait times for adolescents seeking mental healthcare.^{4 14} Long wait times for mental health services are associated with escalating mental health difficulties, declining quality of life, negative beliefs about mental health services, increasing reluctance to seek help and initiate treatment, and poorer treatment engagement once services are accessed.^15–17 Systematic reviews have identified several barriers to adolescents’ timely access to mental health services, the most significant being structural barriers such as service availability, cost and wait time.^{18 19} Given the impacts of wait times for adolescent mental health services, access to timely mental healthcare is considered an essential aspect of mental health service quality,^{20 21} and reducing wait times is a critical health system goal.^{18 22}

Various approaches to reducing mental health service wait times have been tested with many of these interventions focusing on managing therapeutic waitlists as a proxy for service wait time.^{23 24} Thomas et al²⁵ conducted a systematic review of interventions to manage waitlists across child, adolescent and adult mental health services. Five broad approaches to waitlist management were identified: walk-in models, triage processes, multidisciplinary care, patient-led approaches and service delivery changes, with varying evidence for their effectiveness.²⁵ However, findings from this review were not disaggregated by age, meaning their relevance and applicability to adolescent mental health services are unclear. Additionally, this review only presented evidence for the effect of these interventions on waitlists, with minimal examination of their effects on service wait times or patient outcomes.²⁴ A better understanding of how these interventions affect service wait times and mental health outcomes is needed to advocate for investment in and scale up of these interventions. To date, no systematic review has synthesised the literature on the types and efficacy of interventions designed to reduce wait times for adolescent mental health services. Therefore, a synthesis of the global literature on interventions to reduce wait times for adolescent mental health services is needed to guide mental health policymakers and service planners in their approach to reducing wait times.

The aim of the current scoping review is to systematically map the literature on interventions to reduce wait times for adolescent mental health services. Specifically, we will describe and critically examine the literature on types of interventions to manage wait times for adolescent mental health services—with the key outcomes of interest being the effects of these interventions on service wait times and adolescent mental health outcomes. The findings of this scoping review will identify gaps in current knowledge and research, with a view to outline directions for future research on wait times for adolescent mental health services and their impact on mental health outcomes.

Methods and analysis

We will conduct a systematic scoping review to identify and map the available evidence on interventions to reduce or manage wait times for adolescent mental health services. We have chosen to conduct a scoping review to capture the breadth of interventions available and identify gaps in the literature.^26–28 In conducting this review, we will use Arksey and O'Malley’s six-stage framework for scoping reviews.²⁹ These stages involve: identifying the research question; identifying relevant studies; study selection; data extraction; collating, summarising and reporting results; and stakeholder consultation to validate findings.

We will use Rayyan, a web application for systematic reviews,³⁰ to support screening, data extraction and evidence synthesis. The review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.³¹ The protocol was registered with the Open Science Foundation (OSF) on 20 February 2023 (https://osf.io/qt4zy).

The research question

Our scoping review is designed to answer the key overarching research question: What is known about the types and efficacy of interventions to reduce wait times for adolescent mental health services? This research question defined the broad framing of the population (adolescents waiting for mental health services), the concept (mental health service wait times) and the context (adolescent mental health services, defined broadly to include all types of therapeutic services offered to support adolescent mental well-being). Specifically, the objectives of this review are to:

1. Identify and describe interventions that have been developed, tested and/or implemented to reduce wait times for adolescent mental health services, including study details (eg, type, setting and method of evaluation).

2. Summarise evidence on the efficacy of these interventions to reduce wait times for adolescent mental health services and their effects on adolescent mental health outcomes.

3. Identify gaps in the current evidence relating to geographical coverage, types of interventions and evidence.

Identifying relevant studies

Our search strategy will be guided by the Peer Review of Electronic Search Strategies Checklist³² and developed in consultation with a health sciences librarian. The draft search strategy, optimised for the MEDLINE database, can be found in table 1. We will adopt a multistep approach to searching the literature. First, we will search electronic databases, including Cochrane Library, EBSCOhost, MEDLINE (Ovid), PsycArticles (Ovid), PsycINFO (Ovid), EMBASE (Ovid), Web of Science, ProQuest and Scopus, for primary, peer-reviewed texts published in English between January 2000 and February 2023. A cursory search identified relevant literature dating back to 2000³³; therefore, this time period was chosen so both contemporary and historical approaches to reducing wait times for adolescent mental health services could be captured.

Table 1.

Initial search strategy optimised for MEDLINE (Ovid)

	Search terms
1	(“wait* time*” or “unmet demand” or “wait* list*” or waitlist* or “intake time*” or “intake process*” or triage*).mp. [mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept) word, protocol supplementary concept) word, rare disease supplementary concept) word, unique identifier, synonyms]
2	((adolescen* or minor* or teen* or youth* or “missing middle” or child* or “young people” or “young person” or “young adult*” or pediatric* or paediatric*) adj5 (counsel* or psychotherap* or therap* or CAMHS or AMHS or “mental health” or “mental illness*” or “mental disorder*")).mp.(mp=title, book title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept) word, protocol supplementary concept) word, rare disease supplementary concept word, unique identifier, synonyms]
3	1 and 2
4	limit 3 to yr=“2000 - current”
5	Limit 4 to English language

Second, we will search for dissertations, theses, conference proceedings and additional grey literature using Google Scholar (limiting our search for each term to the first 10 pages of results). Finally, the reference lists of studies that meet inclusion criteria will be checked for additional studies, and we will use Spidercite (https://sr-accelerator.com/#/spidercite), Scopus and Web of Science to conduct forward and backward citation checks of included studies.

The search strategy will use Medical Subject Headings terms, Boolean logic and operators (‘and’, ‘or’ ‘not’), proximity operators and filters to improve precision. After an initial trial search on the MEDLINE database, the university’s health sciences librarian will review the search strategy to improve the precision of searches across various electronic databases. The search strategy will then be translated to be appropriate for each database.

Study selection

All articles identified through the searches will be imported into Rayyan for screening. After removing duplicates, study screening and selection will occur in two stages: first, title and abstract screening, and second, full-text review. All titles and abstracts will be double-screened. Two reviewers will independently screen and review the titles and abstracts of all identified publications against the following eligibility criteria:

1. The text is focused on adolescent populations between 13 and 18 years of age (or presents disaggregated data for a subgroup of the sample in the specified age range) with mental health concerns of any type (the population).

2. The text reports on the development, testing and/or implementation of an intervention to reduce wait times for any type of adolescent mental health service including primary care services, public and private services, and community-based services designed for youth (the concept).

3. The text reports on at least one outcome related to adolescent mental health service wait times and/or adolescent mental health outcomes (the context).

Studies focusing on wait times for crisis services, for example, emergency departments, drop-in mental health intervention services or mental health support phone lines, will be excluded as these services are not delivered by appointment and are not designed to provide ongoing mental healthcare and support; therefore, they are not within the remit of a mental health service that can be waited for. Texts, where any of the adolescent population is aged outside of 13–18 years, will be excluded unless there is age-disaggregated data within the eligible age bracket.

Eligible texts and those where the relevance is unclear based on the title and abstract will be included in the next stage of full-text review. All texts for full-text review will be double-screened for potential inclusion. Two reviewers will independently assess each full-text article against the inclusion criteria. Those that meet the inclusion criteria will be retained for data extraction. At both the title/abstract and full-text screening stages, discrepancies between reviewer decisions will be discussed and resolved by a senior author. Reasons for exclusion of full-text articles will be recorded and presented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

Data charting and extraction

The Rayyan web app for systematic reviews³⁰ will be used to store, organise, extract and record data. Data from eligible texts will be charted in line with the Joanna Briggs Institute template³⁴ for extracting study details, study characteristics and results. A draft data charting form has been developed (see online supplemental file 1). As per Levac et al’s²⁶ suggestions, two researchers will pilot the form by independently completing data charting for five texts and then meet with the research team to discuss challenges, uncertainties and discrepancies with the data extraction process. The data charting form will then be modified before the remainder of the literature is charted.

Collating, summarising and reporting of results

First, we will describe the included studies and the interventions they use to address wait times. Next, we will present a narrative synthesis of the effects of these interventions on wait times and adolescent mental health outcomes. We will report the quality of the included studies and report this in a separate table. Finally, we will identify strengths and gaps in the evidence base and present recommendations for future research on interventions to reduce wait times for adolescent mental health services. The details extracted will be displayed in tables, providing relevant information such as year of publication, study design, study population, intervention type and key findings.

Patient and public involvement

At three points, we will consult with our youth advisory group, comprising six young people aged 14–20 years who have lived experience of mental health difficulties and lengthy wait times for adolescent mental health services. The youth advisory group will be consulted for grey literature or other texts that we have missed, their views on the data extraction process and the variables, and their feedback on the findings. We will report this process using the GRIPP2 guideline.³⁵

Ethics and dissemination

This paper is a scoping review protocol; therefore, ethical approval is not required. We will store all information about the review on the OSF registry. The results of this scoping review will be published in peer-reviewed publications and presented to youth mental health consumer advisory groups and adolescent mental health providers at conferences and workshops. Through this review, we will produce a catalogue of interventions for reducing wait times for adolescent mental health services that we will also disseminate to mental health policymakers, service planners and providers to guide their efforts to reduce wait times for services.

Discussion

Our proposed scoping review aims to explore and summarise the available literature reporting on the development, testing and/or implementation of interventions to reduce wait times for adolescent mental health services, and the effects of these interventions on wait times for services and mental health outcomes. Although a recent systematic review²⁵ described waitlist management interventions for child, adolescent and adult mental health services, it relied on a proxy measure of wait time, did not examine patient outcomes and findings were not specific to adolescent mental health services. To address this gap and inform future wait time reduction efforts, our review will answer the research question, ‘What is known about the types and efficacy of interventions to reduce wait times for adolescent mental health services?’ The findings from this review will identify gaps within the current evidence to inform a larger project aimed at developing psychological interventions for adolescents who are waiting for mental health services.

The proposed scoping review has three key limitations. First, based on a previous systematic review,²⁵ we are aware that only a limited number of studies examining wait times for adolescent mental health services exist in the current literature. As such, the number of articles to be included in our proposed scoping review will likely be limited. If so, it will point to the need for further research on the topic of interventions to reduce wait times for adolescent mental health services globally. Second, the exclusion of articles written in languages other than English may introduce a bias towards well-resourced child and adolescent mental health systems and high-income countries. Third, we only plan to search major international databases. Only a small proportion of research from low-income and middle-income countries is published in indexed journals and captured by major databases.³⁶ Despite these limitations, the proposed scoping review will be the first to describe the types of interventions being used to manage wait times for adolescent mental health services, and the effects of these interventions on wait times and mental health outcomes. The findings from this review will be used to produce a catalogue of interventions to reduce wait times for adolescent mental health services, with a summary of the evidence for each listed intervention. Mental health policymakers and service planners could use the information generated through this review to guide their selection of strategies for reducing wait times for adolescent mental health services. The review will also identify gaps in the evidence base of initiatives to manage wait times for adolescent mental health services to which other researchers or stakeholders can respond.

Ethics statements

Patient consent for publication

Not required.