The mental health of young people: the view from primary care

SETTING THE SCENE

Children and young people’s (CYP) mental health services are the ‘Cinderella of the Cinderella services’ by being chronically underfunded and undervalued. Fifty per cent of mental illness begins prior to the age of 14 years and 75% by the age of 24 years.^1,2 Although effective treatments are available, less than one-half of those who need such treatment receive it.¹ Mental illness in CYP can have detrimental effects on educational, physical, and social development with enduring consequences into adulthood. Therefore it is crucial that CYP are able to access appropriate, welcoming, and effective mental health services when they need it.

CYP who present to their GP are twice as likely to have a mental health problem, which may manifest as physical health complaints (headache, abdominal pain, and poor sleep).³ Within general practice there is an excess of oppositional defiant disorders seen in pre-school children and emotional disorders exceeding conduct disorders in school children and adolescents. Mental health illness in adolescent surgery attenders is linked with increased intensity and impairment of physical symptoms and increased exposure to illicit drugs.⁴ A 2016 survey of 302 GPs reported that 78% of GPs are seeing more CYP with mental illness and 61% are seeing more young people self-harming than 5 years ago.⁵

THERE IS NO HEALTH WITHOUT MENTAL HEALTH

The No Health Without Mental Health report recognised that only a life course approach will allow us to successfully meet the mental health challenges of the future and emphasised the importance for the early years.⁶ The Future in Mind report highlights the pressing need (by 2020) for a whole-person approach, better access and support for front-line staff, adoption of innovative approaches, and a move away from the current tier system for Child and Adolescent Mental Health Services (CAMHS).³ Urgent calls for parity of esteem between physical and mental health services were made in the Five Year Forward View for Mental Health.⁷

To help in achieving the above, robust data are needed, with better information sharing, data collection, and transparency. Real strides in CYP mental health require not only national but also local leadership, with an impetus on multidisciplinary team working across all sectors. This has begun with NHS England’s local transformation plans incorporating local partners across the NHS, public health, social care, and youth justice and education sectors to improve CYP health and wellbeing services in localities.⁸

NEW WAYS OF WORKING IN PRIMARY CARE

Rising demand and workforce challenges in general practice require urgent development in innovative ways of working in primary care, where continuity of care and access are promoted. E-mail consultations, Skype, and telephone appointments are opportunities that need further exploration with CYP. Social prescribing schemes are defined as linking patients to non-medical sources of support within the community. These have been shown to improve the wellbeing of mental health patients in primary care with a focus on early intervention and prevention, and are provided by the third sector. They offer practical support and promote emotional health and wellbeing, physical activity, and positive parenting.⁹

INTEGRATED CROSS-CARE MODELS

Using templates developed by adult psychiatry there are a number of possible models of integrated primary, secondary, and wider health and social care services that could be considered. These include: coordinated home visits by GPs and mental health workers; shift of psychiatric clinics to health centres/surgeries; group discussions with primary care staff; and joint consultations. A CYP mental health service recently developed by Forward Thinking Birmingham for 25-year-olds offers integrated working, prioritising individual choice, integration, access, and prevention.¹⁰ The General Practice Forward View supports the development of integrated care models within primary care and identifies investment in practice-based therapists. The latter, although primarily focused on adults, may also help the practice to become more ‘psychologically aware’ and act as a blueprint for a model for CYP.¹¹

One service model that has been unequivocally successful is the management of young people experiencing a first episode of psychosis. Using a case management approach, early intervention teams have transformed the care of young people experiencing their first episode of psychosis. Providing practical and recovery-oriented care, care provision moves from service providers taking the lead in managing patient care to one in which the service user is supported to take an increasing role in identifying and managing their own health and social care needs.

We welcome the governmental commitment to invest £1.4 billion on CYP and perinatal mental health with additional funding for eating disorders. We feel that the focus has to be on early-intervention-based models in the community setting with evidence-based treatments and mental health promotion.⁷

THE ROLE OF PRIMARY CARE

GPs have said they want more training on CYP mental health problems, with the Royal College of General Practitioners recommending that all GP trainees in the future should receive specialist-led child health and mental health training.¹² This would undoubtedly aid GPs’ confidence in diagnosing and managing mental health problems in CYP. However, training needs to be based in relevant primary care settings. CYP mental health care requires expert generalism, the art of providing personalised, patient and family-focused care with utilisation of interpretive practice (going beyond protocol). This needs to be included within the GP training curriculum.¹³

The wider practice team has an important role in promoting positive mental health and wellbeing. The Royal College of Nursing has produced an educational toolkit on mental health in CYP that practice nurses will benefit from.¹⁴ Primary healthcare professionals (PHCPs) can improve their communication with CYP, through searching but sensitive enquiry about mental health in all presentations. It only requires one appropriately asked question to enable a CYP to disclose possible mental health symptoms. Once disclosure has occurred, the relationship can be developed over time and further management discussed. This will also help in de-stigmatising and normalising mental illness.

ACCESS

CYP find it difficult to access services.³ In an increasingly modernised and digital world, innovative and dynamic options are needed to encourage and retain engagement with CYP. GP surgeries could be more ‘youth friendly’, by involving CYP in patient participation groups, communicating practice news over social media (Twitter and Facebook), and increasing the use of digital technology as a means to connect with their CYP population.

The current tier system for CAMHS is inflexible and rigid. It requires CYP to fit into services instead of services responding to need, and some fall through the gaps. Waiting times are long and 89% of GPs have concerns over CYP being at risk of harm while waiting for specialist input.⁵ The THRIVE model offers an alternative approach to CAMHS, moving away from an escalator of severity to focusing on the needs and choices of CYP that places CYP and their families at the heart of service provision.¹⁵

MOVING FORWARD

The evolution of CYP mental health services in primary care has been slow. Primary care requires an integrated and collaborative approach between GP surgeries, secondary care, educational institutes, third-sector organisations, justice systems, and social services to provide holistic care in CYP mental health that is family oriented, evidence based, and culturally sound. The Well Centre (www.thewellcentre.org), which houses youth workers, counsellors, and doctors utilising a multidisciplinary theme, is a fantastic example of best practice and should be a template for similar schemes around the UK. However, more needs to be done and has to be supported by funding high-quality research into effective, acceptable, and affordable treatment options for CYP, investment in preventive and earlier-intervention approaches in collaboration with public health, and for finding ways to improve access of CYP to mental health services — all in partnership with CYP themselves.

Provenance

Commissioned; externally peer reviewed.

Further information

The resources for CYP mental health in the RCGP Mental Health Toolkit are tailored for PHCPs to use in the consultation and for learning: http://www.rcgp.org.uk/clinical-and-research/toolkits/mental-health-toolkit.aspx