Adolescence is considered the time of greatest risk for mental health problems to occur and 75% of mental disorders occur before age 24. It makes sense that intervening at an early age might have an important impact on prevention and recovery. However, young people are also the group least likely to seek help.

The authors of this review wanted to find out what young people themselves thought about mental health services, to work out what the barriers to engaging with services might be and to inform efforts to better engage with young people in need.

Methods

• They excluded studies before 2000, as they thought that views of the services older than that might not be relevant to understanding current perceptions of modern services.
• They also excluded studies conducted outside the UK and those not reporting primary data (for example, editorials which talked about the issue but didn’t include data collected from young people themselves).
• Studies were assessed for quality using the ‘weight of evidence’ criteria. These look at the study ‘integrity’ (was it well conducted?), the appropriateness of the design for answering the question at hand, and finally the relevance of the study.
• They conducted a thematic analysis to draw out common themes.
• The authors didn’t restrict the review to studies of young people who had actual experience of mental health services. They report that 625 participants had experience of services and 12,990 were sampled from the general population and “are assumed” to have no experience of mental health services.

This review was primarily made up of qualitative and mixed methods research.

Results

• 31 studies were included in the review, with a total sample of 13,605 participants (though the sample size ranged from 4 to 3,004)
• 21 of these studies were qualitative, 9 used mixed methods and only 1 was quantitative.
• Facilitators of engagement with services were interventions that promoted self-reliance and positive mental health workers who respected confidentiality. Young people also felt services needed to be more visible and offer treatment in a range of settings, for example at schools or through home visits.
• Negative factors included concerns about the stigma of being diagnosed with a mental health problem, a perceived medicalization of emotional problems by some professionals who limited treatment options to medication, and a lack of continuity of care which meant young people saw many different professionals.
• Only two studies specifically sought the views of young people from ethnic minority backgrounds. Only one study explored the views of people aged 18 years and over.
• The authors report in the discussion that many of the studies were judged to be of low quality, but there isn’t much detail given on this, or any breakdown for example on which ‘weight of evidence’ criterion was failed most often, or how these quality issues map onto the evidence itself (for example, were certain studies in certain settings typically of lower quality? Were the themes sensitive to quality issues at all, for example were certain themes more or less present in higher quality studies?)
• The authors do elaborate on one aspect of quality, relating to sampling, when they note that important groups (such as ethnic minorities and young people who have disengaged with services) seem to be neglected in the literature to date.

Interventions that promoted self-reliance were more likely to succeed in engaging young people.

Conclusions

The authors conclude with a plea for greater involvement of young people themselves in redesigning services to be more engaging and accessible:

In summary, young people have strong and consistent views of mental health services, both of the reasons for current poor engagement, and also how they could be improved. Engaging young people directly in service redesign as well as assessing the impact of service redesign on these barriers to engagement would be ways of ensuring that services are addressing the needs of young people, and are fit for purpose.

(For a great example of involving young people in designing mental health solutions, check out the Doc Ready website).

As with most reviews, what’s missing is perhaps more telling than what’s included. I was surprised to see that only one study spoke to participants over 18. It’s at this age that young people will have to transition from youth to adult services, which can be a very difficult experience. The authors pull this out as well, commenting on the need for “a single pathway of care across organizational and age boundaries.”

Also, as someone who previously did research in a youth forensic setting, I noted that only two studies included forensic samples. Mental health need is exceptionally high amongst young people in forensic settings, both in custody and the community, so I think there’s much to be done there, especially considering continuity or disruption between forensic services and mental health agencies.

This study calls for young people to be more directly engaged in service redesign.

Limitations

• Only a minority of the young people in the review had confirmed experience of mental health services. Although it’s undoubtedly important to consider the views of young people more broadly (to explore for example what kind of awareness the ‘general public’ of young people have about mental health), it could be argued that the direct experience of those who have actually used services is more valuable to informing the kind of redesign the authors advocate. The authors do however make reference in the results and discussion to cases where the two groups emphasised different issues or where they both shared the same concerns, and themselves highlight that exploring the views of young people who disengage from services will be crucial.
• I have mixed feelings about the decision to review both quantitative and qualitative data together. The results seem to predominantly focus on the qualitative data (perhaps as the majority of studies were qualitative) and it was unclear to me what the additional information about surveys and questionnaires adds. If the authors had focused on one type of study, they could also have then employed specific quality criteria appropriate for that method and perhaps reported quality issues in more detail. However, I can understand that the authors wanted to include all data they considered relevant, and perhaps broadening inclusion criteria in this way would help us get away from those reviews which end up discussing only a tiny portion of the published literature.

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