Introduction
Mental illness affects 20% of adolescents worldwide with half of all mental illnesses beginning by the age of 14 (World Health Organisation 2003). Research has shown that 70% of mental illnesses diagnosed before the age of 18 years persist into adulthood (Kessler et al. Reference Kessler, Angermeyer, Anthony, De Graaf, Demyttenaere and Gasquet2007). However, it is well established that the transition from adolescent to adult mental health services (AMHS) is associated with disengagement, poor continuity of care and patient dissatisfaction (Singh et al. Reference Singh, Paul, Ford, Kramer, Weaver and McLaren2010).
In Ireland, child and adolescent mental health services can be accessed both publicly through the Health Service Executive (CAMHS) and through independent services. Forty-one percent of the Irish population of 0–17-year-olds have access to private health services based on a policy financed by parents or guardians (Department of Health 2016). The mental health provisions in these policies, however, are often time-limited and may not cover outpatient services. In addition, young adults who were previously included on their parent’s policies may have difficulties obtaining private health insurance when transitioning in and out of education and first employment.
There are 66 CAMHS teams, two independent inpatient services and a small number of independent outpatient services for children and adolescents throughout the country. Available data reports 76 public inpatient beds and 26 beds in the independent sector (Mental Health Commission 2017). A Vision for Change, an Irish policy framework for development of mental health services, recommends 100 child and adolescent inpatient beds based on the 2002 census population data (Health Service Executive 2006). Because of this shortfall in capacity, the public sector may occasionally fund a small number of admissions to independent sector units.
The ITRACK study described the transition process from adolescent to adult services in the public sector in Ireland (McNicholas et al. Reference McNicholas, Adamson, McNamara, Gavin, Paul and Ford2015). This study found that despite perceived ongoing mental health difficulties, many adolescents were not being referred or were refusing referral to AMHS. The study also reported that CAMHS continued to offer ongoing care past the transition boundary. There is no data for the transition process within independent mental health services.
St Patrick’s Mental Health Service (SPMHS) is the largest independent and not-for-profit mental health service, which includes an adolescent service, offering both inpatient and outpatient multidisciplinary care. The inpatient service comprises 14 inpatient beds corresponding to 17% of national capacity (Health Service Executive 2013). The adolescent service has close links with SPMHS’s Young Adult Service (aged 18–25 years) and Eating Disorder Service (aged 18–64) and many adolescents transition to these services once they reach 18 years of age.
This study investigates the transition process of adolescents within an independent mental health service in the Republic of Ireland. The primary aims of the study are to explore the care pathways at the age of transition and to analyse if there are any socio-demographic or clinical factors associated with the choice of transfer destination. The study also examines the level of engagement following transition to independent adult services.
Method
This is a retrospective, naturalistic and descriptive study in design. Ethical approval was granted by the SPMHS Research Ethics Committee. All patients discharged from the SPMHS adolescent service aged 17 years and 6 months and older, during the 3-year period between January 2014 and December 2016 inclusive, were included in the study.
Electronic records of initial assessments, outpatient reviews and communications with General Practitioners (GP), multi-disciplinary team reports, discharge summaries and referral letters were used to collect data. All patients included in the study were grouped into three categories, based on what type of service they were discharged to: GP, public services (i.e. external transfers) or independent services (i.e. internal transfers). Data were collected regarding their socio-demographic and clinical details and the level of follow-up in patients who transferred to independent adult services. We were unable to follow-up patients who transitioned to public adult services for logistical reasons.
Statistical analysis was carried out using Statistical Package for the Social Sciences (SPSS), version 23.0. Differences between the three groups with regards to the above variables were analysed using χ 2-tests for independence and Bonferroni corrections.
Results
A total of 180 patients aged over 17 years and 6 months were discharged from the adolescent service between January 2014 and December 2016. At the age of transition, 45.6% (n=82) were discharged to their GP, 28.9% (n=52) to public mental health services and 25.6% (n=46) to independent mental health services. Of those discharged to public services, 51.9% (n=27) went to CAMHS and 48.1% (n=25) transitioned to adult services. One patient refused a referral to adult services and so went to CAMHS. Of those discharged to independent services, 97.8% (n=45) transitioned to adult services and 2.2% (n=1) went to an adolescent outpatient service. Therefore, in total, 70 adolescents (38.9%) transitioned to AMHS in either the public or independent sector. A description of the patient demographics is found in Table 1, including gender, ethnicity, parental circumstances and family history of mental illness. There were no statistically significant differences between the three discharge groups with regards to these demographic factors.
Demographic factors of adolescents undergoing transition of care
Patients were managed in the adolescent service either as inpatient (13.3%, n=24), outpatient (67.8%, n=122) or both (18.9%, n=34) (see Table 2). Moreover, 49 (27.2%) patients had attended CAMHS before attending the adolescent service, and of these, over half were discharged back to public services (55.1%, n=27) usually after discharge from the inpatient unit. There were no involuntary admissions over the 3 years. Those who attended the adolescent service as outpatients-only (n=122) were significantly more likely to be discharged to GPs (63.1%, n=77), [χ 2(4,180)=69.82, p<0.001] and those who attended the adolescent service as inpatients-only were significantly more likely to be discharged to public services (83.3%, n=20), [χ 2(4,180)=69.82, p<0.001] (see Table 2).
Clinical factors of adolescents undergoing transition of care
* p<0.001
Eighty-three (46.1%) patients had more than one psychiatric diagnosis (see Table 2). The most common diagnoses at discharge among patients in all three groups were depression (50.6%, n=91) and anxiety disorders (35%, n=63). In the patients discharged to public mental health services, there were more diagnoses of eating disorders (34.6%, n=38) and borderline personality disorder traits (19.2%, n=10) (see Fig. 1). In patients with eating disorders, approximately half were discharged to CAMHS (44.7%, n=17) and approximately half transitioned to public adult services (55.3%, n=21). In patients that remained within independent mental health services there were more cases of anxiety disorders (41.3%, n=19) and attention deficit hyperactivity disorder (ADHD) (19.6%, n=9) (see Fig. 1). χ 2 analysis suggested a significant association between diagnosis and discharge service [χ 2(28, 273)=42.55, p=0.05] but Bonferroni corrections indicated the association was non-significant.
Discharge diagnoses of adolescents undergoing transition of care. ADHD, attention deficit hyperactivity disorder; EUPD, emotionally unstable personality disorder; OCD, obsessive compulsive disorder; ASD, autism spectrum disorder.
A total of 58 (32.2%) patients had at least one inpatient admission during their time in the adolescent service (see Table 2). Of these, 62.1% (n=36) were discharged to public mental health services at the time of transition with 25.9% (n=15) going to public adult services and 36.2% (n=21) to CAMHS; 17 patients (29.3%) transitioned to the independent adult service and five (8.6%) were discharged to their GP; 11 (6.1%) patients had two or more inpatient admissions. The most common diagnoses among these patients were mood disorders (n=10), eating disorders (n=6) and borderline personality disorder traits (n=3). Nearly two-thirds of patients with two or more admissions were discharged to public mental health services (63.6%, n=7) with 36.4% (n=4) going to CAMHS and 27.3% (n=3) transitioning to adult services. The remaining patients transferred to independent AMHS (36.4%, n=4).
A total of 111 (61.7%) patients were discharged on psychotropic medication. Of these, 36.9% (n=41) were discharged to their GP, 32.4% (n=36) transitioned to independent adult services and 30.6% (n=34) discharged to public services with 20.7% (n=23) going to CAMHS and 9.9% (n=11) to adult services (see Table 2). χ 2 analysis suggested a significant association between psychotropic medication and follow-up service [χ 2(2, 111)=10.4, p=0.006, φ=0.24] but Bonferroni corrections indicated the association was non-significant. The class of psychotropic drugs most frequently prescribed in all services users were antidepressants (47.7%, n=86). Twenty patients (11.1%) were discharged on more than one psychotropic medication with the majority being discharged to independent adult services (35%, n=7) and the rest to CAMHS (30%, n=6), GP (25%, n=5) and public adult services (10%, n=2) (see Table 2).
A total of 168 (93.3%) patients had psychological/skills-based interventions before discharge/transfer and this was either in the form of individual therapy, group therapy or both. χ 2-test for independence indicated a significant association between the type of therapeutic intervention (individual/group/both) and follow-up service [χ 2(6, 180)=43.88, p<0.001, φ=0.49]. Bonferroni corrections specified the significant trends as those who underwent individual therapy being more likely to be discharged to GPs (56.2%, n=68) and those who underwent both individual and group therapy being mostly discharged to public mental health services (58.1%, n=25) (see Table 2).
A total of 52 (28.9%) patients underwent family therapy before discharge. χ 2-test for independence indicated a significant association between level of family involvement and discharge service [χ 2(8, 180)=41.7, p<0.001, φ=0.48]. Bonferroni corrections specified the significant trend as being patients who engaged in family therapy were more likely to be transferred to public mental health services (59.6%, n=31) (see Table 2).
A total of 45 patients were referred to independent adult services in SPMHS and 37 (82.2%) attended their first assessment. Of these, 34 (91.9%) transitioned to the Young Adult Service, two (5.4%) to the Eating Disorder Service and one (2.7%) to a general adult outpatient clinic; 36 (97.3%) were offered follow-up after their first assessment and 35 (97.2%) were still engaged at 3 months; 29 patients had reached 12 months post-transition at the time of data collection and of these patients 28 (96.6%) were still engaged at 12 months.
Discussion
This is the first study to examine the care pathways for adolescents at the age of transition in an independent mental health service in Ireland. The study identified important characteristics and mental health needs of adolescents within the independent sector at the time of discharge.
The most common diagnoses at discharge were mood disorders, such as depression and anxiety, similarly to the UK TRACK and ITRACK studies (Singh et al. Reference Singh, Paul, Ford, Kramer, Weaver and McLaren2010; McNicholas et al. Reference McNicholas, Adamson, McNamara, Gavin, Paul and Ford2015). Nearly half of the patients had more than one psychiatric diagnosis at discharge. High levels of comorbid mental health disorders were also reported in the ITRACK study (McNicholas et al. Reference McNicholas, Adamson, McNamara, Gavin, Paul and Ford2015) with 70% of young people experiencing multiple mental health difficulties at some point during their engagement with CAMHS. Given that psychiatric comorbidity in young people has been shown to negatively influence the course, outcomes and response to treatment (Burgic-Radmanovic & Burgic Reference Burgic-Radmanovic and Burgic2010), it is essential that they have access to appropriate services for ongoing support and specialist care. Although comorbid mental illness is well established in young people, there has been limited research into the need for different treatment modalities in children and adolescents suffering from more than one disorder (Arcelus &Vostanis Reference Arcelus and Vostanis2005), and therefore further studies are warranted.
Nearly half of patients aged >17 years and 6 months are discharged from the adolescent service back to their GP without specialist psychiatric follow-up. There was a significant association with being treated as an outpatient-only and being discharged to the GP, indicating that these patients had milder forms of mental illness as they did not warrant inpatient admission, which could be managed at a primary care level. Over 90% of patients discharged to their GP had at least one psychiatric diagnosis at discharge. It was unclear whether the patients discharged to the GP had an ongoing mental health need; however, half were discharged on psychotropic medication, therefore necessitating follow-up from a clinician. The ITRACK study reported 45% of those with an ongoing perceived mental health need were eventually transferred back to their GP (McNicholas et al. Reference McNicholas, Adamson, McNamara, Gavin, Paul and Ford2015). Given that high proportions of adolescents are discharged from psychiatric services to their GP at the age of transition, it is important to be aware of possible issues identified in studies including inadequate training of GPs, particularly in prescribing psychotropics in young people, lack of time, lack of clinical tools, lack of knowledge of referral pathways and inadequate service provisions and resources (Lucas et al. Reference Lucas, Scammell and Hagelskamp2005; Fleury et al. Reference Fleury, Imboua, Aubé, Farand and Yves Lambert2012).
Nearly 40% of adolescents were referred to AMHS at the time of discharge. This was slightly higher than figures reported in the ITRACK study (32%) (McNicholas et al. Reference McNicholas, Adamson, McNamara, Gavin, Paul and Ford2015); however, less than the 58% reported in the UK TRACK study (Singh et al. Reference Singh, Paul, Ford, Kramer, Weaver and McLaren2010). Nearly all of the adolescents remaining in the independent mental health service transitioned to independent adult services, which predominantly was the Young Adult Service. However, for adolescents being discharged to public mental health services, over half were transferred back to CAMHS and the rest to public adult services. Although we were unable to follow-up those who transferred back to CAMHS, the ITRACK study reported that adolescents with an ongoing mental health need who continued with CAMHS remained within the service for more than a year beyond the transition boundary (McNicholas et al. Reference McNicholas, Adamson, McNamara, Gavin, Paul and Ford2015), which may have resource implications.
A quarter of patients transitioned from the adolescent service to independent AMHS, with the majority transitioning to the Young Adult Service. We found high rates of continued engagement in the adult service at 3 months post-transition (97.2%) and at 12 months post-transition (96.6%). We were unable to follow-up patients who transitioned to the public adult services for logistical reasons and so could not make direct comparisons of their level of engagement with follow-up with those who transitioned to the independent adult services. In the UK TRACK study, 67.8% of those referred to public AMHS attended their first appointment and two-thirds of the referrals remained open to follow-up with AMHS following their first assessment (64.4%) (Singh et al. Reference Singh, Paul, Ford, Kramer, Weaver and McLaren2010). The higher rates of engagement in our study may be the result of having a specialised Young Adult Service and Eating Disorder Service, which are more age-appropriate and disorder-focussed than standard adult services, which may ease the transition process and improve engagement rates.
There has been a significant amount of research to elicit the common issues that adolescents experience during their transition to adult services with the aim of improving the process worldwide. Common transition issues include time-restraints, different standards of practice, not feeling adequately prepared or supported during transition and insecurity at the loss of a familiar service (Moscoso et al. Reference Moscoso, Jovanovic and Rojnic2015; Singh et al. Reference Singh and Tuomainen2015). By having specialised and age-appropriate services within the same organisation, there was likely a reduced burden of the common transition issues, and therefore, a higher level of engagement was reported.
More adolescents with ADHD were discharged to the independent adult service compared with public services. This suggests a lack of availability of adult ADHD services within the public sector and is in line with the findings in the both the UK TRACK study and ITRACK study where adolescents with neurodevelopmental disorders such as ADHD were less likely to be referred onto public adult services at the transition boundary (Singh et al. Reference Singh, Paul, Ford, Kramer, Weaver and McLaren2010; Tatlow-Golden et al. Reference Tatlow-Golden, Gavid, McNamara, Singh, Ford and Paul2018). These studies identified a perception by CAMHS clinicians that public AMHS did not accept ADHD cases or lacked appropriate service/expertise.
A lack of adequate adult ADHD services has been widely reported across Europe, which results in poor transition and distress for patients and their families (Young et al. Reference Young, Adamou, Asherson, Coghill, Colley and Gudjonsson2016). There are increasing pressures to improve adult ADHD services globally and in Ireland the ‘National Clinical Programme for ADHD in Adults’ has recently been developed as a joint initiative between the HSE and the College of Psychiatrists of Ireland. The aims are to ensure adults with ADHD have access to assessment and treatment. This includes young people with ADHD being transferred to adult psychiatry services ‘if they continue to have significant symptoms of ADHD or other comorbid mental health problems that require treatment’ with joint planning between CAMHS and adult services (Health Service Executive 2017).
More adolescents with eating disorders were discharged to public services than independent adult services and their GP. This likely reflects the gravity and chronicity of eating disorders, which have the highest mortality rates of any mental illnesses (Smink et al. Reference Smink, van Hoeken and Hoek2012), and therefore requires longer term follow-up in specialist eating disorder services. The finding that more adolescents went to public services suggests that there may be time and service limitations in the various insurance policies, which therefore require adolescents to transfer to publically funded services. For adolescents with eating disorders that were discharged to public services, approximately half went back to CAMHS and half to adult services. This finding likely reflects the different policies of local CAMHS with regard to the ages of adolescents that they will accept and illustrates the variation in the care pathways of this cohort of young people. The HSE recently launched a new model of care for the treatment of eating disorders so that all people with eating disorders have access to timely, evidence-based and high-quality care that is standardised across catchment areas. The aim is to reduce the wide variation and inequality of access, treatment and outcomes across the country so that people with eating disorders can achieve recovery and good clinical outcomes (Health Service Executive 2018).
The main limitation of the study is that, like most descriptive studies, the majority of the data is cross-sectional and therefore limits the ability to infer reliable conclusions about predictors of the discharge/transfer process. The study did provide some longitudinal data regarding the level of follow-up for adolescents who had been referred to the independent AMHS within SPMHS. Unfortunately, as we were not able to follow-up patients discharged to public adult services, we were unable to directly compare the level of follow-up in this group.
Our study describes the transition process of adolescents in an independent mental health service in Ireland. There are virtually no studies of the transition process within independent services and therefore our study provides valuable information with regards to this cohort. Our study confirms the findings of previous studies examining the transition process in public services in that many adolescents who reach the transition age are not referred to AMHS. These results are surprising given that mental illness in adolescence has been found to be a strong predictor of patient outcomes and optimal care by mental health services could prevent psychiatric morbidity later on in life, particularly in illnesses that arise in adolescence (Patton et al. Reference Patton, Coffey, Romaniuk, Mackinnon, Carlin and Degenhardt2014).
Research should be continued to explore why adolescents might not be referred to adult services by clinicians and why adolescents may refuse referrals as described in other studies (Singh et al. Reference Singh, Paul, Ford, Kramer, Weaver and McLaren2010; McNicholas et al. Reference McNicholas, Adamson, McNamara, Gavin, Paul and Ford2015). Research should also continue to look at the measures that can be implemented to improve the transition process. Our study has shown that when an adolescent transitions their care to a specialised adult service such as a Young Adult Service or Eating Disorder Service within the same organisation, then the level of engagement at follow-up is remarkably high. The implementation of more specialised and age-appropriate services for adolescents at transition may ‘bridge the gap’ between adolescent and adult services, which may meet their mental health needs better, increase the satisfaction in their care and reduce the risk of ‘falling through the gap’.
Acknowledgements
The authors would like to acknowledge the secretarial staff at St Patrick’s Mental Health Services for assistance with the project.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of interest
Dr Laura Bond, Dr Anna Feeney, Ms. Rebecca Collins, Dr Imran Khurshid, Dr Susan Healy, Dr Aileen Murtagh and Dr Paddy Power have no conflicts of interest to disclose.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that ethical approval for publication of this research has been provided by their local Ethics Committee in St Patrick’s Mental Health Services.
