A case control and follow up study of 'hard to reach' young people who also suffered from multiple complex mental disorders

Abstract

Introduction: The Innovations project 15 to 25 years (IP) was a new multidisciplinary team based within an inner city area, walk-in health centre, in the North East of England (funded from January to December 2011) developed to provide a service to identify, assess and treat HTRYP. This research project draws data from the IP and compares them to data collected from a Community Mental Health Team (CMHT) in the North East of England. Aims: Initial Phase: to describe the mental health and evaluate the outcomes (mental disorder and social function) of the HTRYP who attended the IP. Phase 1: to compare the baseline demographics (Time Point 1 (TP1)) between a matched sample of IP and a sample of YP from CMHT. Phase 2: to identify and compare the indices for severity, complexity, engagement and response to treatment in a matched sample of IP and CMHT sample at TP1 and pre-discharge (TP2). Phase 3: to assess the mental state and social function of a group of individuals from the IP and CMHT samples who were retraced and agreed to be interviewed (24 months after discharge), TP3. Methods: Phase 1 and 2: a retrospective review of the clinical case notes of the YP who attended the IP (HTRYP) and CMHT was conducted. For Phase 1 the CMHT were matched to the HTRYP on age and date of discharge. The demographic characteristics of the two samples at TP1 were compared. For Phase 2 the samples were additionally matched for; gender, highest level of educational attainment and socioeconomic status. For phase 2 the focus was on severity of mental disorder and service input and change from TP1 to TP2 and between both services. Data were analysed using SPSS version 21. Phase 3 provided a follow up evaluation of the mental state and social function of YP who attended IP and CMHT (change was assessed using the Health of the Nation Outcome Scales for Child and Adolescent Mental Health (HoNOSCA) and the Children’s Global Assessment Scale (CGAS). For this phase the samples used for retracing were further matched for primary diagnosis and severity of mental disorder at TP1. Results: Forty referrals were received by the IP service from a variety of agencies. Four referrals were not appropriate. An assessment was offered to 36, five refused. Of the 31 (86%) YP who were assessed all met the criteria for HTRYP, nine repeatedly missed appointments and seven were judged not to be suffering from complex mental disorders and were signposted to local community services. 15 (48%) were then offered individually tailored therapy. In Phase 1 significant differences at TP1 were found between the 36 HTRYP and 115 CMHT samples. The IP group experienced significantly more severe deprivation (t142= -5.6, p=<0.0001), higher rates A case control and follow up study of ‘Hard to Reach’ young people who also suffered from multiple complex mental disorders v Dr Nigel Camilleri of unemployment (χ²2 =16.696, p<0.0002) and homelessness (Wx= 1, 23.812, p<0.001) and achieved poorer educational attainment (Wx=4, 27.485, p<0.001) compared to the CMHT sample. In Phase 2, at baseline the HTRYP (median 3, CMHT median 1, χ24= 31.58, P<0.001) had more mental disorders, higher severity scores and lower levels of social function than YP attending CMHT (HTRYP HoNOSCA mean score: 19.1 and CMHT mean score: 11.2 t91= 5.53, P= <0.001, and HTRYP CGAS mean score: 51.0, CMHT mean score 58.9, t47= -2.0, P= 0.05). In terms of service input; the clinic time offered to HTRYP (1538 minutes) was significantly greater (t100= 3.79, P= <0.001) than the CMHT sample (518 minutes). Changes in outcome measures scores between TP1 and TP2 showed that the HTRYP made significantly greater improvement compared to CMHT YP; (HoNOSCA scores t54= 4.81, P= <0.001 and the CGAS scores t20= -3.61, P= <0.002). In Phase 3, only 16 (57%) of 28 HTRYP and 23 (43%) of 54 CMHT were successfully contacted. 13 HTRYP (46%) of 28 attended the follow up review compared with 9 (17%) of 54 CMHT. These YP were shown to be representative of the target populations from which they were selected. At follow up review the HTRYP, (HoNOSCA, Wx=13, p=0.031 and CGAS Wx=13, p=0.013) showed a greater clinical improvement in mental state from TP1 to TP3 compared to YP from CMHT (HoNOSCA, Wx=9, p=0.674 and CGAS, Wx=2, p=0.655). At TP3 the CMHT YP had maintained a higher overall level of social function and had lower level of deprivation than the HTRYP. However there was great variability in terms of social function between the YP within each sample (HTRYP and CMHT). Conclusion: The IP identified a high risk group of YP. They came from more deprived backgrounds and carried more burden of mental illness compared to YP attending the CMHT. Engaging the HTRYP required more clinical hours and they received a different care package to YP who attended the CMHT. The sub-set of HTRYP who received the IP therapeutic intervention, made a significant clinical improvement when compared to the YP attending the CMHT. The findings of this study suggest that HTRYP may benefit from a flexible, individualised resource intense service that includes an outreach capability to maximise engagement, assessment and intervention planning. However the sample size was small and the resource implications for this type of clinical provision are considerable. Further clinical research is needed to investigate what might be the most resource efficient and effective in terms of ways of working with this high risk group of YP to help reduce the immediate and long term burden of mental disorders.