Commentary: State of transitional care for emerging adults – reflections on Anderson et al.

Abstract

Transitional care at the boundary between child/adolescent and adult mental health services has received increased research attention over the past decade, many studies revealing similar unsatisfactory findings. The needs of service users and their parents/carers are the same across the world, and they are not being met. Outdated organisational structures and training agendas contribute to the difficulties at the boundary, which marks the end of specialist care for most young people attending child/adolescent mental health services. The review by Anderson et al. summarises the latest research in this area.

A key indicator and predictor of positive outcomes in youth mental health care is the relationship the young person has with their therapist, supporting an effective therapeutic alliance (Shirk, Karver, & Brown, 2011). For young people who struggle to talk to and trust therapists, practically strangers, achieving therapeutic alliance is an achievement on both sides and should be supported to ensure best outcomes (Stige, Barca, Lavik, & Moltu, 2021). However, the historical divide between child/adolescent and adult mental health services jeopardises therapeutic alliance and continuity of care. In many countries, service structures and fiscal constraints within the system dictate that young people exit child/adolescent mental services (CAMHS) around the age they become eligible for adult services (Signorini et al., 2018). This typically coincides with their 18^th birthday, and usually with major upheavals in their lives, linked to education, relationships, and/or living circumstances. Unsurprisingly, this is also the time when young people are most at risk of more serious mental illness. Service transformation, such as the new 0‐25 service model, that eradicates the need to disrupt an established therapeutic alliance at this juncture should be a key priority of mental health service reform. If this is unattainable, then supporting a smooth transition from child/adolescent to adult services should be prioritised for young people with continued mental health needs. This includes transition planning and a period of joint care between the two services, among other measures. A failed transition in these circumstances increases the likelihood of reconnecting with specialist mental health services further down the line and poorer mental health outcomes.

Mental health service transition outcomes and experiences have been a topic of research for over 20 years, with the first studies being published in the USA in the early 2000s, then in the United Kingdom, followed by the Republic of Ireland and France. The last decade has seen a significant increase in research in this field, encompassing a broader range of countries. The latest raft of studies associated with transition have been conducted under the umbrella of the MILESTONE project, an EU‐funded eight‐country programme of research carried out between 2014 and 2019 focusing on the child–adult mental health service interface across Europe (Tuomainen et al., 2018).

The first systematic reviews regarding mental health service transitions were by Paul, Street, Wheeler, and Singh (2015) and Mulvale et al. (2019), but the evidence base has grown since then. The systematic review by Anderson et al. (2022) is therefore welcome and timely as it captures the very latest published evidence. Unlike Appleton, Connell, Fairclough, Tuomainen, and Singh (2019) who focus on transition outcomes in the form of service destinations, the scope of Anderson’s et al. review is more comprehensive and covers rates of referrals, barriers, and facilitators of successful transition, continuity of care, and service user experiences of transition. Due to the number of studies that focus specifically on neurodevelopmental conditions, findings are presented for these separately from those focusing on (unspecified) mental health conditions.

Whilst research in service transition has increased, the review highlights that the majority of studies have been conducted in the UK. The first UK study on transition, the TRACK study, included a retrospective case note review (Singh et al., 2010), a relatively straightforward and effective method that captures young people with any diagnosis, including those with more severe mental illness, provided that electronic records are complete. The retrospective case note review method does not, however, capture young people who drop out or leave close to the service boundary. Several of the studies in the review by Anderson et al. use this method, with only a few studies prospectively following young people as they transitioned from CAMHS to adult services. The MILESTONE longitudinal cohort study followed up young people with any mental health diagnosis for 24 months, with main findings being published this year (2022) (Tuomainen et al., 2018). Anderson et al. included in their review Appleton’s substudy of the MILESTONE cohort, a mixed methods study (secondary data analysis of data from seven countries, qualitative interviews, economic analysis) of young people with anxiety, depressive, and personality disorders and neurodevelopmental disorders, including attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), designed to better understand why so many of these young people fail to transition to adult mental health services.

The main findings of Anderson’s et al. review are sobering. Despite the increase in research highlighting that transition‐related problems are widespread, affecting continuity of care in several countries, this has not translated into effective solutions to bridge the divide between child and adult mental health services for those with continued mental health needs. The authors call the problem a ‘leaky pipeline’, in which young people drop out of services before they even get referred to adult services, refuse referral to adult services, or fail to engage with the new services. Those with more severe presentations, including those in forensic medium secure services, are in the main ‘stream’, making the passage across to adult services, securing continuity of care.

Whilst there are country differences in relation to the likelihood of transitioning to adult services and the possibility of CAMHS in retaining young people beyond the boundary, the divide between adult and child psychiatry affects most countries (Signorini et al., 2018). Child psychiatry is a relatively new speciality/discipline, not even recognised as such in some countries, impacting training of psychiatrists. Mental health professionals in adult services are generally not trained in child and adolescent psychopathology, for example, ADHD, and those in child/adolescent services may not be well versed in severe mental disorders that emerge in late adolescence or early adulthood. These discrepancies may impact transition, especially in countries lacking training in transition. A systematic review focusing on psychiatry training in Europe showed that transition as a topic appears in the curricula in only two countries in Europe, Ireland and the UK (Tuomainen et al., 2018).

The distance between the child/adolescent and adult psychiatry is reflected in the physical distance between the two services, child/adolescent outpatient and inpatient services seldom sharing the same location or building with adult services. This physical distance contributes to the poor professional connection, communication, and collaboration between the services, as well as to the continued stigma regarding adult services among service users. The unknown or unfamiliar feeds fear; if no time or effort is put into alleviating these fears in advance of the service boundary, even young people qualifying for adult care, and their parents, will be more likely to refuse it. As a result, young people may rely on primary care services (e.g., their general practitioner or emergency services) to address particularly acute mental health needs. Primary care, however, is less well equipped to support these young people with complex needs (O'Shea & McHayle, 2021). Interestingly, however, Appleton’s economic analysis showed that young people who did not transition attended primary care and Accident and Emergency departments no more frequently than young people who successfully transitioned to adult services. The related qualitative study highlighted parents’ important role in supporting young people who no longer attend specialist services. Further research is needed to better understand parent support and primary care provision after discharge from CAMHS.

Anderson’s et al. review includes four studies that evaluated interventions designed to improve transition experiences and continuity of care, with three being relatively small‐scale and condition‐specific. The fourth is the first ever clinical trial of a scalable intervention, ‘Managed Transition’, aimed at improving mental health outcomes of young people who reach the mental health service boundary (Singh et al., 2021). At the core of Managed Transition is a structured assessment of young people for transition readiness and appropriateness, with feedback to clinicians via a report collating young person, parent/carer, and clinician scores. Considering that such an assessment has not been part of care processes in most countries, the intervention is a very practical and reasonable step to take, especially as it also reaches out to adult services. It promotes timely transition planning, and the involvement of the young person and parent/carer in decision making. In the cluster randomised trial, Managed Transition led to a small improvement in the overall mental health and wellbeing of young people 15 months after entry to the trial, as compared to usual care, irrespective of service destination. Compared to large‐scale service reform, the cost of Managed Transition is a drop in the ocean. However, it does not iron out many of the other problems at the service interface, uncovered by Anderson et al. and other authors (Signorini et al., 2018).

A seamless service for 0‐25‐year olds is on the agenda for community mental health services in the United Kingdom; early support hubs have been proposed as a solution to assist this venture for young people with low‐level mental health needs, offering a more flexible way forward (O'Shea & McHayle, 2021). However, a 0‐25 community mental health service does not eradicate the existing boundary in most inpatient settings or in other countries that do not have the same policy brief as in the United Kingdom or flexibility regarding the timing of transition (Signorini et al., 2018). It is highly desirable that the next systematic review in this field captures a greater number of robust studies evaluating the effectiveness of interventions designed to improve the experience and outcomes of transitional care.