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Young people and mental health: where are we now?

Revisiting the topic of young women and depression, Jane Briddon highlights developments in policy and research relating not only to gender but young people's mental health while also considering practice implications for primary care.

Jane Briddon
CQSW BA(Hons)
PGDipPsychSW CBTDip
Lecturer Practitioner
and Coordinator for the Education Development and Training Agency (EDTA)
School of Nursing, Midwifery and Social Work
University of Manchester
Cognitive Behaviour Therapist for the NHS within Primary Care

To understand the extent of depression in young women it is important to consider national statistics for mental health and how the rates of prevalence break down for men and women. We know that in the UK alone, between 8 and 12% of the population experience depression in any one year, and one in four women will require treatment for depression at some time, compared with one in 10 men.(1,2) The reasons for such gender differences remain unclear, but are thought to be due to both social and biological factors. Another important consideration is that depression in men may be undiagnosed with "symptoms" not necessarily being recognised.(3)

Developments in health and social care policy
Implications for women with mental health problems
In response to the prevalence of mental disorder, in particular common mental health problems such as depression and anxiety, there have been significant developments in health and social care policy. Mental health services, particularly within primary care, continue to evolve in light of policy developments and significant government spending.
In a previous article (Briddon J. Depression in young women: are you equipped to treat it? NiP 2004;17:26-58) I discussed the launch of a Department of Health Women's Mental Health Strategy - Mainstreaming: Gender and Women's Mental Health.(4) In February 2006 the Department of Health in support of the earlier strategy produced best-practice guidance Commissioning Women-Only Community Day Services.(5) The key message of this document is how best to achieve "equity of outcome for men and women in aspects of policy, workforce issues and service delivery". It offers guidelines for commissioning and defines "women-only community day services" as including "a variety of services providing community-based support to women" in order to enable access to opportunities within the "mainstream" of society including employment, education and leisure. It acknowledges the importance of responding to the "whole person" by recognising emotional, psychological, social and practical needs, and encourages not only the development of new services, but also the support of existing services often operating within the voluntary sector.
 The report also emphasises the importance of acknowledging specific "gender" differences experienced by women in day-to-day life (eg, the management of "multiple roles", the significant proportion of young women who are lone parents), and the impact of these factors on a woman's experience of mental health problems such as depression. Similarly the influence of "gender" differences on pathways into services and the consequent requirements for treatment are also highlighted so that we take into account the context of an individual's difficulties and the impact of this on both the development of problems and the process of recovery.
Other policy documents, in particular The Social Exclusion Report, further reinforce this message by highlighting the stigma of mental health problems and the double exclusion experienced by "additional inequalities", which intensify poor mental health, leading to a cycle of exclusion.(6) Similarly it emphasises the need to respond to the whole person and has been instrumental in the development and support of various social inclusion and community engagement initiatives that recognise the importance of "healthy" physical and social environments in achieving good mental health.

Implications for children and young people with mental health problems
In considering the experience of "young women and depression" it is also important to look to research and policy within the area of Children and Adolescent Mental Health Services (CAMHS). While policy changes are at various stages of implementation in the previous five years, CAMHS have benefited from the CAMHS grant and the money given to primary care trusts with targets attached to demonstrate growth in services.(7,8)
The priority placed on children's and young people's mental health is repeated in numerous policy documents and service delivery guidelines including the National Service Framework (NSF) for Children, Young People and Maternity Services and Every Child Matters, which include good mental health as an element of one of the three key outcomes.(9,10)
The NSF highlights the need for joint working and the responsibility of services such as health, education, social services, housing, local amenities and the voluntary sector in supporting children and young people with mental health problems, reiterating the importance of considering the "whole person" living in physical and social environments that can have both negative and positive influences on mental wellbeing.(9)
Sharpening the focus on child and adolescent mental health coincides with a prevalence of emotional and conduct problems, which research suggests have worsened in the UK over the past 25 years.(11) It is estimated that 3% of young people suffer from depression in any one year, and in 2003 1,075 men and 273 women aged 15-34 died as a result of suicide/poisoning of undetermined intent.(1,12)
Research has not indicated any link with deteriorating mental health and the changing face of family life (eg, increasing numbers of lone parents) or factors that relate to socioeconomic status, suggesting that worsening mental health in younger people relates to a much more complex picture of interrelating factors.(13)
In trying to unpack the possible reasons why young people may be particularly vulnerable to the development of mental health problems it is interesting to consider the findings of the report Stressed Out and Struggling by YoungMinds, which was drawn from a series of young people focus groups during 2005-2006.7 In essence the project highlighted how the stress associated with the transition from adolescence to adulthood "compounds problems already faced by young people vulnerable to mental health problems".
Key areas include:

  • Increased pressure regarding academic achievement.
  • Pressure of choice relating to sex, leaving home, drink and drugs.
  • Financial dependence on parents.
  • Media images of young people at odds with reality.
  • Decline in social cohesion and responsibility.

The report emphasises the need for a psychosocial approach to mental healthcare acknowledging that mental wellbeing is dependent on a number of factors, not least the young person's context and environment. It highlights the importance of developing services that are committed to the needs of young people and as such are accessible and engaging. It emphasises the need to help young people maintain and develop peer friendships in recognition that poor mental health can lead to loss of friends leaving young people isolated and vulnerable to greater distress. It highlights the importance of "life skills" and the need for education to provide advice on financial matters during secondary education in order to avoid future debt problems.

Developments in primary care
As primary care is often the first point of contact for people seeking help for all types of health problems, primary care practitioners need to be aware of these issues and how they might impact on presentation, and the types of help people are likely to consider. Similarly primary care practitioners need guidelines and protocols that determine how best to respond to distress within the population they serve.
The NICE Guidelines for Depression in Children and Young People are clear in explaining the responsibilities of health and social care in identifying and treating depression in children and young people, including the prescribing of antidepressant medication.(14) Alongside this practitioners should also consider the associated risk of suicide and self-harm in young people who are experiencing mental health problems. NICE guidelines on self-harm offer relevant guidance that is applicable to patients across the age range.(15)

Detection/risk profiling
The key priority for primary care practitioners is having the skill to detect depression as well as the ability to identify those children or young people who are at risk of becoming depressed.
NICE guidelines advise training to enable practitioners within primary care, schools and other related community settings (tier 1) to detect symptoms of depression and assess children and young people who may be at risk of depression.
It is expected that CAMHS (tiers 2 and 3) will work with primary care practitioners to develop appropriate "systems" for detecting, assessing, supporting and referring children and young people for further help should they require it. There are also guidelines for responding to children and young people who do not meet criteria for diagnosis, but experience ongoing problems with low mood or prolonged "sadness".
It is also advised that in assessing the young person or child, the mental health needs of the parents should also be considered (particularly if they too are experiencing depression). NICE recommends that they should be treated in parallel if the young person's mental health is to improve.
Once a young person is "in remission", NICE advises that CAMHS keep primary care practitioners aware of progress. Training is also recommended to help primary care practitioners monitor wellbeing and recognise features of depression and early warning signs during their ongoing contact with the young person. It is recommended that these skills should also be shared with the patient, family and carers in order for them to recognise when it may be necessary to seek further help. Facilitating the development of self-management techniques in young people is also recommended, again with the understanding that there may be training required to support this.
NICE also supports the provision of self-help interventions within primary care to include family and carers, with the understanding that this should only be offered as part of a supported and planned package of care. Likewise the use of "exercise" is recommended as part of a structured and supervised programme and where necessary advice on nutrition (eg, the benefits of a balanced diet), sleep hygiene and anxiety management.

The SCAN model
In my previous article I introduced the SCAN (Screening, Care, Advice, Next Step) Model as a tool for screening common mental health problems in primary care and this remains a useful and flexible tool for practitioners both with and without mental health expertise.(16) The SCAN model has now been developed to
encompass the environmental factors that influence mental distress, ensuring the "whole person" is considered. SCAN continues to be used within health and social care settings to formulate problems and aid decision-making. The model has been adapted for use with children and young people.

Conclusion
There is no question as to the extent of mental health need within the younger population as a whole; this is further compounded by the inequalities of "gender" outlined in the policy documents referred to previously. This poses challenges for primary care and demands a considered response in how best to adapt practice not only through the use of "guidelines" and the development of screening and assessment skills, but also through cross-sector and multiagency working, which ensures "a whole person" approach to care.

References

  1. NICE. 2005/022 Latest NICE guidance sets new standards for treating depression in children and young people [Press Release] 28 September 2005. Available from: http://www.nice.org.uk/page.aspx?o=273112
  2. World Health Organization. Women's mental health: an evidence based review. Geneva: WHO; 2000.
  3. The Mental Health Foundation. Statistics on mental health. Available from: http://www.mentalhealth.org.uk/information/mental-health-overview/statis...
  4. Department of Health. Mainstreaming: gender and women's mental health. London: DH; 2003.
  5. Department of Health. Supporting women into the mainstream: commissioning women only community day services. London: DH; 2006.
  6. Office of the Deputy Prime Minister. Mental health and social exclusion. Wetherby: ODPM; 2004.
  7. YoungMinds. Stressed out and struggling project. London: YoungMinds; 2006.
  8. Child and adolescent mental health. A guide for healthcare professionals. London: BMA; 2006.
  9. Department of Health. National service framework for children, young people and maternity services. London; DH: 2004.
  10. Every Child Matter. Available from: http://www.everychildmatters.gov.uk
  11. Collishaw S, Maughan B, Goodman R, Pickles A. Time trends in adolescent mental health. J Child Psychol Psychiatry 2004;45:1350-62.
  12. Office for National Statistics. Health statistics quarterly: 28. London: Office for National Statistics; 2005.
  13. Hartley-Brewer E. Perspectives on the causes of mental health problems in children and adolescents. London: YoungMinds: 2005.
  14. NICE. Depression in children and young people, identification, management in primary care community and secondary care. Clinical guideline 28. London: NICE; 2005.
  15. NICE. Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. Clinical guideline 16. London: NICE; 2004.
  16. Richards DA, Richards A, Barkham M, Williams C, Cahill J. PHASE: a "health technology" approach to psychological treatment in primary mental health care. Primary Healthcare Res Dev 2002;3:159-68.