Written by Iman Hassan

The path from teenager to young adult is hard. It’s even harder if you’re living with mental health issues, and those on the cusp of adulthood are being let down by the disconnect between child and adult mental health services.

50% of young people who were referred to child and adolescent mental health services (CAMHS) have fallen through the gap and are not referred to adult mental health services (AMHS) once they turn 18. Professor Swaran Singh and Helena Tuomainen from the University of Warwick are working with young people, carers and health professionals across Europe to change this, through a ground-breaking study called the Milestone Project.

This study is the first of its kind, highlighting the importance of the right care for those in that crucial age jump, so that their mental health does not deteriorate or continue to suffer.

It involved 1000 young people, 52 CAMHS, 8 countries (all in Europe) and 900 parents. There were 4 assessments taken over 24 months.*

Clinicians found that 75% of the participants had a need for continued treatment. However only 20% were referred to AMHS. As shown by the graph below, the groups circled were those who experienced interrupted care and they had the highest level of behavioural and emotional problems.

Image from the Festival talk showing some results from the study

Despite these findings, only 4 countries out of 28 in the EU have guidelines on transitions from CAMHS to AMHS. In terms of training, 18 countries have separate training for adult psychiatrists and child psychiatrists. This adds to the gap of service between the ages. It has also been found that there are disparities in resource allocation between health services that deal with physical health issues in comparison to mental health services.

Cathy Street, Patient and Public Involvement lead, Milestone Project, Warwick Medical School, told the audience about a young project advisor from the study and their story with the transition between CAMHS and AMHS.

The young person was referred to CAMHS aged 15 and by the time she was 18, there was a concern about moving services. Luckily, CAMHS had a flexible age range and offered her support for an extra year. At 19, she went to university but still needed help in terms of mental health. She was worried that she would not meet criteria for AMHS and ultimately didn’t get any support during this transition period. She described her 1st year of university as “punishment”, where she had been self-harming and her depression got “out of control”. In her 2nd year of university, her tutor spotted she was not well and referred her to the university counsellor, who enrolled her onto a mental health service.  She said she felt an “enormous relief”, but by that point, her mental health had unfortunately deteriorated for well over a year and she spent all those months suffering unnecessarily.

Other youth project advisors from the Milestone Project had similar stories. They felt they had to excessively fight, persuade and convince the services that they had mental health issues in order to be referred to AMHS.

Professor Swaran Singh, leader of the study, spoke about the importance of bridging the gap between child and adult mental health services: “Mental health problems are the chronic diseases of the young,” he says. The most physically robust group are the most emotionally and mentally vulnerable. The most intense neurological changes occur before puberty, which puts young people at a higher risk of mental health. It was originally thought that the brain stopped maturing at 18 years old, but it’s been found to mature much later, at 25 years old. Despite this, for many service users, transition from CAMHS to AMHS is poorly planned, executed and experienced.

There are several reasons why those who participated in the Milestone Project had not been referred to AMHS:

• There were no AMHS in their area
• The young person was considered ‘not ill enough’ and did not fit the criteria for AMHS
• It’s no longer perceived as needed by the young person or there is no desire to go to AMHS

Half of young people receiving mental health treatment are not refered to adult services when they turn 18

Rebecca Appleton, research associate at the University of Warwick, spoke about the effect “falling through the gap” has on young people and how leaving CAMHS has affected them.

It has had a serious impact on young people, and they are struggling to manage without support. As their mental health suffers, they are missing out on activities and are socially isolated, which contributes to the further deterioration of their mental health. Those who had accessed AMHS were scored much lower on behaviour and emotional problems than those who had not.

One of the young people Rebecca spoke to said, “I weaned myself of it [medication] with my mum’s supervision...I discovered my doctor could no longer prescribe medications for me as CAMHS would not see me anymore”.

There were issues with AMHS for those who were referred. The young participants felt that the appointments were short and seemed to be more focused on medication review. One parent said, “The psychologist did not want me in the room or to say anything”, and another said, “The transition between CAMHS and AMHS was a difficult time...we felt left out of the conversation”

This shows that despite recent policy guidelines, young people are not receiving the appropriate care.

What is the solution? Professor Singh states that it’s about the “commissioning lever”. The system now operates so that CAMHS ask AMHS to take cases of young adults who need help with their mental health once they reach the age of 18. However, direct services do not see transition as their responsibility. It’s not a priority amongst the emergencies and immediate problems they are facing. For AMHS to see this as a shared problem, it is vital to get commissioners to commission for good transition.

Once commissioners, clinicians, advocacy groups and service providers see this issue as a joint responsibility, we will be on our way to solving the gap between CAMHS and AMHS. Professor Singh closes the talk with this statement “Bridges, not barriers, are needed between the two services”.

*Study results: In the study, there were 763 young people who had a 2 year follow up. The average age was 17.5 and 60% of the young participants were females. There were a diverse range of mental health problems represented, with 40% of people having several mental health issues. 57% of the participants were on 1 or 2 medications and 50% were on CAMHS for more than 2 years. 25% of the participants have attempted suicide. 18% of the female participants and 3% of the male participants have had suicidal thoughts or have self-harmed. This possibly shows that the male participants were less likely to admit that they had suicidal thoughts or had self-harmed.