Characterised by symptoms such as low mood, irritability, low self-esteem, and suicidal thoughts, depression is a major public health issue affecting adolescents globally. Depressive disorders were listed as the leading cause of mental disorder disability-adjusted life-years (a measure of disease burden expressed as years of healthy life lost due to premature death or living with a disability) for 15-24 year old individuals in 2019 (GBD 2019 Mental Disorders Collaborators). Globally, it is estimated that 34% of adolescents aged 10-19 years old are at risk of developing depression (Shorey et al., 2021).

Being able to access mental health support has been reported to significantly reduce depressive symptoms in adolescents (Neufeld et al., 2017). While evidence-based guidelines for treatments are readily available in England (e.g., NICE guidelines), there is a lack of detailed reports on the specific pathways followed by children and adolescents seeking help for depression, including referral, treatment, and discharge. To assess effectiveness and adherence to treatment guidelines, it is crucial to understand how mental health services respond to depression in this population.

Currently, it is unclear whether adequate administrative data on child and adolescent depression pathways are systematically available at the NHS Trust level. To address this gap, Wickersham and colleagues (2023) aimed to provide an overview of the mental health service pathway for children and adolescents with depression in two NHS Trust services. Additionally, they sought to assess the availability and quality of the data pertaining to these pathways.

Methods

Data from two healthcare providers were used to investigate mental health service pathways for children and adolescents with depression: the Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), and the South London and Maudsley NHS Foundation Trust (SLaM).

De-identified electronic health records were searched to find referrals from 2015 to 2019 where children and adolescents under the age of 18 years old received a diagnosis for depression for the first time. Data was extracted for demographic and clinical characteristics (e.g., gender, ethnicity, age at referral, age at depression diagnosis, comorbidities), service pathway characteristics and timings, and intervention type.

Results

From the initial search, a total of 2,798 patients were identified (CPFT = 296, SLaM = 2,502). Patients were mostly female (CPFT = 79.3%, SLaM = 69.3%) and of white ethnic background (CPFT = 88.9%, SLaM = 57.9%), with a median age at first depression diagnosis of 16 (CPFT) and 15 (SLaM) years old. Anxiety disorders were the most frequent comorbidity in about a third of the sample (CPFT = 32.1%, SLaM = 29.9%), followed by eating disorders (CPFT = 20.3%, SLaM = 6.7%).

In terms of referrals:

• They were mostly made from primary care as part of a routine check (CPFT = 75.3%, SLaM = 84.8%), with other referrals qualified as urgent or priority (CPFT = 24.7%, SLaM = 15.2%).
• About half of the sample were seen within 1 month after first contact to health services was made (CPFT = 41.7%, SLaM = 48.8%), followed by 1-6 months after (CPFT = 58.3%, SLaM = 44.3%). Few waited longer (SLaM: 7-12 months in 5.3%, > 12 months in 1.6%).

Regarding treatment:

• The most commonly prescribed intervention was antidepressants (CPFT = 86.8%, SLaM = 42.7%), then sleeping pills (CPFT = 52.7%, SLaM = 25.1%), antipsychotics (CPFT = 30.7%, SLaM = 12.0%) and mood stabilisers (CPFT = 4.4%, SLaM = 2.2%).
• When a type of psychotherapy was recorded, the most common one was cognitive behavioural therapy (CBT) or dialectical behavioural therapy (DBT) (SLaM = 40.7%), with a median of 11 sessions attended, followed by arts therapies (SLaM = 17.4%) or group therapy (SLaM = 16.3%).

For discharge:

• Most referrals were closed at time of extraction (CPFT = 86.1%, SLaM = 98.4%), with the primary reason being that care had ended (CPFT = 65.1%, SLaM = 79.2%).
• Patients who were not discharged within 1 year of referral usually remained with a health service for more than 2 years (CPFT = 34.9%, SLaM = 16.4%).

Conclusions

This study provided an overview of the journeys that children and adolescents seeking help for depression take through two healthcare services in England. Patients were more often female, of white ethnicity, first referred for depression in mid-to-late adolescence, and experienced comorbid anxiety. While the general findings are as expected for this cohort, this study also highlighted how pathways can greatly vary based on individual needs and healthcare services. The systematic collection of data and standardisation of record systems utilised by providers is crucially needed to improve comparisons and generalisation of findings.

Strengths and limitations

This is the first publication to follow the journey of children and adolescents with depression through healthcare services in England. It provides a comprehensive overview of the mental health service pathway via electronic health records, exploring prevalence rates, referral sources, treatment modalities, timelines and more. This is an essential step in understanding who seeks help, but also in appraising the availability, reliability and quality of data stored through electronic health records. In addition, the paper highlights the importance of data quality and standardisation for accurately assessing mental health service provision. By acknowledging the variations in data recording systems between the two sites, the study emphasises the need for improved data collection practices to enhance the reliability and comparability of mental health service data.

While this study paints a clear picture of the journey of young people through health services, it also identifies a great deal of variation in service pathways experienced by children and adolescents with depression. Authors suggest that this variation could be linked to individual needs, and to socioeconomic differences in the populations served by each site. Another important aspect is that both sites used different electronic health records systems and data extraction tools, rendering comparisons difficult. Moreover, in the CPFT sample, de-identified free-text clinical notes were manually audited to access additional information. These observations emphasise the need to fully describe population and healthcare provider characteristics to allow appraisal of generalisability of findings.

There are some limitations to this research. As noted by the authors, this study aimed to describe pathways within healthcare services in two sites, and not to directly compare them. Findings are thus limited to two NHS Trusts in England, selected because the lead author had access to them while undertaking a placement, and are hardly generalisable to other areas, which may not be representative of mental health services in other regions or countries. The findings likely do not capture the full spectrum of service pathways and may not be applicable to different healthcare systems or populations with diverse sociodemographic characteristics.

Further, the study relies on electronic health records, which may be subject to errors or omissions in data recording (Feder, 2017). The accuracy of structured diagnosis fields and the availability of certain information could vary across sites, potentially introducing biases and limiting the completeness of the dataset. Moreover, mental health disorders are heterogeneous in symptomatology and thus the use of structured fields as a research tool could be limited.

Finally, while the study provides insights into the types of interventions received, it does not extensively evaluate treatment outcomes or assess the effectiveness of specific interventions. Although it was not the aim of the paper, a more comprehensive analysis of treatment outcomes would provide a clearer picture of the quality and impact of mental health services for children and adolescents with depression.

Implications for practice

Overall, this paper examines the mental health service pathways accessed by children and adolescents with depression in two National Health Service (NHS) Trusts in England, with several implications for practice:

1. Understanding treatment effectiveness: The paper emphasises the importance of having a clear understanding of how child and adolescent depression is treated within mental health services. It highlights the need to assess whether services operate effectively and in accordance with treatment guidelines, enabling benchmarking and informing local and national commissioning decisions.
2. Monitoring mental health service data: The authors reiterate the significance of comprehensive data reporting on the referral, treatment, and discharge pathway for children and adolescents with depression. They stress the need for detailed information to evaluate the effectiveness and quality of services provided, identify variations in care, and inform improvements.
3. Standardisation of data collection and improved data quality: The study highlights the variation in data recording systems between NHS Trusts, making it challenging to directly compare service pathways, as well as the need to improve data quality and consistency in routine outcome measurement within mental health services. The authors advocate for greater standardisation in record systems used by different providers to enhance the comparability and quality of mental health service data. Efforts to standardise data collection and enhance the reliability of recorded information can provide valuable insights into the effectiveness of interventions and overall service quality (Kotecha et al., 2022).
4. Addressing long service episodes: The research finds that a significant proportion of referrals remained in contact with services for more than a year, suggesting prolonged service episodes. This finding raises concerns about the duration of treatment and indicates the need for further investigation into factors contributing to longer service durations. Understanding these factors can help identify strategies to support faster recovery for young people with depression.

Statement of interests

None to disclose.

Links

Primary paper

Wickersham, A., Westbrook, J., Colling, C., Downs J., Govind R., Kornblum D., Lewis J., Smith P. & Ford T. (2023). The patient journeys of children and adolescents with depression: a study of electronic health records. European Child & Adolescent Psychiatry.

Other references

GBD 2019 Mental Disorders Collaborators. (2022). Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet Psychiatry, 9(2):137-150. 

Feder, S.L., (2018). Data Quality in Electronic Health Records Research: Quality Domains and Assessment Methods. Western Journal of Nursing Research, 40(5):753-766. 

Kotecha, D., Asselbergs, F.W., Achenbach, S., … & Grobbee, D.E. (2022). CODE-EHR best-practice framework for the use of structured electronic health-care records in clinical research. The Lancer Digital Health, 4(10):e757-764. 

Neufeld, S. A., Dunn, V. J., Jones, P. B., Croudace, T. J., & Goodyer, I. M. (2017). Reduction in adolescent depression after contact with mental health services: a longitudinal cohort study in the UK. The Lancet Psychiatry, 4(2), 120-127.

Shorey, S., Ng, E.D., & Wong, C.H.J. (2022). Global prevalence of depression and elevated depressive symptoms among adolescents: A systematic review and meta-analysis. British Journal of Clinical Psychology, 61:287-305.

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