Eur Child Adolesc Psychiatry DOI 10.1007/s00787-015-0735-z
ORIGINAL CONTRIBUTION
Continuity of care from child and adolescent to adult mental health services: evidence from a regional survey in Northern Italy Paolo Stagi1,2 · Simona Galeotti1 · Stefano Mimmi1 · Fabrizio Starace1 · Augusto C. Castagnini1
Received: 17 November 2014 / Accepted: 14 June 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract To examine clinical and demographic factors associated with continuity of care from child–adolescent (CAMHS) to adult mental health services (AMHS), we undertook a record-linkage study to the Adult Mental Health Information System including all those 16 years old and over who were listed between 2010 and 2013 in the Child and Adolescent Neuropsychiatry Information System in Emilia-Romagna, an Italian region of nearly 4.5 million residents. From a cohort of 8239 adolescents attending CAMHS (population at risk about 144,000), 821 (19.4 %) moved to AMHS, excluding cases with specific developmental disorders, whose conditions were not managed by adult psychiatrists, and those with mental retardation who attended usually social services. Young people referred for treatment to AMHS were more likely to receive a discharge diagnosis of schizophrenia and related disorders (Odds Ratio [OR] 3.92; 95 % confidence interval [CI] 2.17–7.08), personality disorders (OR 2.69; 95 % CI 1.89–3.83), and pervasive developmental disorders (OR 2.13; 95 % CI 1.51–2.99). Further factors predicting transfer to AMHS were not living with parents, inpatient psychiatric admission, and being on medication in the previous 24 months. These findings suggest that a relatively small number of Preliminary findings of this study were presented at the international conference “Youth Mental Health: from continuity of psychopathology to continuity of care (STraMeHS)” held in Venice (Italy) on 16–18 December 2014. * Paolo Stagi [email protected] 1
Mental Health Department, AUSL Modena, Modena, Italy
2
Child and Adolescent Neuropsychiatry Service, Mental Health Department, Azienda USL, Via A. Cardarelli 43, 41124 Modena, Italy
adolescents moved to AMHS and are likely to reflect the configuration of local mental health services and alternative care available, mainly for those with less-severe mental disorders. Keywords Adolescent · Epidemiology · ICD-10 · Mental health care · Psychiatric services · Transition
Introduction Psychiatric morbidity constitutes a major health issue, and much of the disease burden from mental disorders arises in adolescence [1, 2]. Existing studies suggest that most of those referred for psychiatric treatment in the early adulthood had a diagnosis of mental disorder in adolescence and that their condition showed varying degrees of continuity over time [3–5]. Psychiatric services delivered to young people differ from adult mental health care in terms both coverage and quality of care [6], and there seems to be a growing number of adolescents with mental disorders prescribed psychotropic medication [7]. In keeping with mental health care, “transition” and “transfer” are different concepts: “transition” is a process that involves a number of issues concerning a critical period for young people who are attending mental health services, while “transfer” means the cessation of care in child–adolescent mental health services (CAMHS) and its re-establishment in adult mental health services (AMHS) [8, 9, 11, 12]. Several factors have been reported to affect the transition process such as differences in age boundaries, service thresholds, cultural context, and professional training [8–12]. Those who are most likely to make a transition to AMHS were found to experience severe and persistent mental disorders and admission to inpatient units [9, 11].
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Further reports have addressed service transition issues for patients with specific disorders such as eating disorders and neurodevelopmental disorders [13, 14]. Despite the size and importance of this problem, there is little research on service transition outcome in communitybased samples with a wide range of mental disorders [9, 11, 12, 15, 16]. The aim of this paper is to examine clinical and demographic factors associated with continuity of care from CAMHS to AMHS in Emilia-Romagna, Italy.
Method Setting Emilia-Romagna is a highly industrialized region of nearly 4.5 million persons in Northern Italy. All residents are entitled to free treatment under the Italian National Health Service. There are 11 community-based Mental Health Departments in Emilia-Romagna, comprising specialist (secondary care) AMHS, CAMHS, and addiction treatment services. CAMHS regional network consists of 110 outpatient units and 7 inpatient facilities for assessment and treatment of mental and nervous system disorders for about 700,000 people under the age of 18 years in urban and rural areas. There is a broad range of professionals and community workers, including a number of child psychiatrists among the highest in Europe, and similar to that of the best equipped areas in the USA. Further details have been described elsewhere [17].
Eur Child Adolesc Psychiatry
linking them to SISM—identified those transferred to AMHS. A further linkage was made to the regional Pharmaceutical Assistance Information System [21] and to the Hospital Discharge Records [22] to collect information about drug prescriptions and hospital psychiatric admissions in the past 24 months. Although the age for transfer of care to AMHS is usually 18 years, transfer planning between services can start since the age of 16 years. In selecting patients referred to AMHS, we relied on the following ICD-10 diagnoses on discharge from CAMHS: “organic disorders” (code F0–9), “substance-use disorders” (F10–19), “schizophrenia, schizotypal and delusional disorders” (F20–29), “affective disorders” (F30–39), “neurotic stress-related and adjustment disorders” (F40–49), “eating disorders” (F50), “personality disorders” (F60–69), “mental retardation” (F70–79), “specific and mixed developmental disorders” (F80–83), “pervasive developmental disorders” (F84), “hyperkinetic disorders” (F90), “conduct disorders” (F91–92), “emotional disorders” (F93), “attachment/social functioning disorders” (94), “tics disorders” (F95), “other and unspecified child-adolescent mental disorders” (F98–99), and “factors influencing health status and contact with services” (Z codes). Moreover, to identify factors associated with transfer to AMHS, we selected the following clinical and socio-demographic variables: (1) age at first contact with CAMHS; (2) sex; (3) nationality (Italian or foreign); (4) place of residence (100,000 100,000); (5) living with parents; (6) medical comorbidity (ICD-10 codes A00-Q99); (7) drug treatment (i.e. antipsychotics, antidepressants and anticonvulsant) and (8) inpatient psychiatric admission.
Sample This study draws its data from two databases created to generate statistics for use in mental health planning. The Emilia-Romagna Childhood and Adolescent Neuropsychiatry Information System (SINPIAER) has recorded details of all those who attended CAMHS since 2010 [18]. Patient entries include information from electronic medical records (i.e. age, gender, place of residence, date and type of contact with services, etc.) and diagnosis made by the responsible psychiatrist using the ICD-10 Classification of Mental and Behavioural Disorders of World Health Organization [19]. The Mental Health Information System (SISM) is comprehensive of all admission/contacts to AMHS aged over 18 years since 2007 [20]. Data are stored using a personal identification number that allows record linkage across the different databases with appropriate protection for anonymity. We selected all subjects 16 years old and over, whether admitted to hospital or treated as outpatients, who were listed in the SINPIAER with an ICD-10 F00-99 diagnosis between 1 January 2010 and 31 December 2013, and—by
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Statistical analysis The starting point was to examine clinical and sociodemographic features of all adolescents aged over 16 years attending CAMHS using Chi square test. Only those variables showing p values ≤0.05 were included in multivariate logistic regression to determine factors predicting transfer to AMHS. Data analysis was conducted by means of the statistical software Stata 11.0.
Results From a cohort of 10,719 adolescents 16 years old and over attending CAMHS between 2010 and 2013 (total population at risk about 144,000), there were 8239 cases with an ICD-10 F00–99 or Z diagnosis in their last contact (Fig. 1). The remaining comprised 813 cases with neurological diseases, as CAMHS provides treatment of both nervous and mental disorders, and 1667 received no diagnosis, as they
Eur Child Adolesc Psychiatry
Fig. 1 Outcome of adolescents aged over 16 years attending CAMHS in 2010–2013 (see text for details)
Table 1 Frequency of ICD10 diagnosis in adolescents aged over 16 years attending CAMHS in 2010–2013 and transfer rates to AMHS by diagnostic category
ICD-10 category
N (%)
Transfers (%)
F0 Organic disorders F1 Substance-use disorders F2 Schizophrenia/related disorders F3 Affective disorders F4-F93-94 Neurotic stress-related/emotional/attachment disorders F5 Eating and sleeping disorders F6 Personality disorders F7 Mental retardation F80–83 Specific/mixed developmental disorders F84 Pervasive developmental disorders
7 (0.1) 37 (0.4) 85 (1.0) 318 (3.9) 1244 (15.1) 263 (3.2) 297 (3.6) 2156 (26.2) 1857 (22.5) 374 (4.5)
28.6 32.4 56.5 26.4 16.6 22.8 37.4 12.5 5.4 32.4
F90 Hyperkinetic disorders F91–92 Conduct disorders F95 Tic disorders F98–99 Other/unspecified child–adolescent disorders
208 (2.5) 534 (6.5) 32 (0.4) 116 (1.4)
11.1 18.2 25.0 5.2
Z codesa
711 (8.6)
5.9
a
Factor influencing health status and contact with services
either dropped out shortly after initial contact or had yet to complete clinical assessments. As shown in Table 1, the principal diagnostic groups were mental retardation and specific developmental disorders accounting for almost 50 % of the total morbidity, followed by neurotic, stress-related and emotional disorders (15.1 %), conduct disorders (6.5 %), pervasive
developmental disorders (4.5 %), and affective disorders (3.9 %). Less common were personality disorders (3.6 %), eating and sleeping disorders (3.2 %), hyperkinetic disorders (2.5 %), schizophrenia and related disorders (1.0 %), substance-use disorders (0.4 %), tic disorders (0.4 %), organic disorders (0.1 %), and Z codes (8.6 %).
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Table 2 Clinical and sociodemographic features of potential referrals to AMHS aged over 16 years who attended CAMHS in EmiliaRomagna between 2010 and 2013
Eur Child Adolesc Psychiatry
Sex (male) Age at first contact (years)a Nationality (Italian) Place of residence (>100,000 population)c Living with parentsd Hospital psychiatric admission Medical comorbidityb Drug treatmente F0 Organic disorders F1 Substance-induced disorders F2 Schizophrenia/related disorders F3 Affective disorders F4 + F93–94 Neurotic/stress-related/emotional disorders F5 Eating and sleeping disorders F6 Personality disorders F84 Pervasive developmental disorders F90 Hyperkinetic disorders F91–92 Conduct disorders F95 Tic disorders F98–99 Other/unspecified child–adolescent disorders Z diagnosisf
χ2
Transfer
No transfer
N (%)
N (%)
460 (56.0) 10.5 (5.1) 757 (92.2) 257 (31.5) 500 (84.9) 187 (22.8) 54 (6.6) 349 (42.5) 2 (0.2) 12 (1.5) 48 (5.8) 84 (10.2) 207 (25.2) 60 (7.3) 111 (13.5) 121 (14.7) 23 (2.8) 97 (11.8) 8 (1.0) 6 (0.7)
1904 (55.9) 10.6 (4.8) 3091 (90.8) 1135 (33.5) 2104 (88.9) 150 (4.4) 238 (7.0) 472 (13.9) 5 (0.1) 25 (0.7) 37 (1.1) 234 (6.9) 1037 (30.5) 203 (6.0) 186 (5.5) 253 (7.4) 185 (5.4) 437 (12.8) 24 (0.7) 110 (3.2)
0.0 30.5* 1.7 1.2 7.2* 304.2* 0.2 346.8* 0.4 4.0* 76.0* 10.7* 8.8* 2.1 65.7* 43.8* 9.8* 0.6 0.6 15.5*
42 (5.1)
669 (19.6)
99.8*
* P ≤ 0.05 a
Continuous variables are shown as mean (standard deviation) and categorical variables as number (%)
b
ICD-10 codes A00-Q99
c
16 cases had unknown place of residence
d
1270 cases had unknown family situation
e
Antipsychotics, antidepressants, and anticonvulsants
f
Factor influencing health status and contact with services
The great majority (89.2 %) of the sample was living at home, and only 10.3 % had foreign-born parents. Furthermore, 4.7 % experienced admission to inpatient units, and 15.4 % were on treatment with antipsychotic, antidepressant, or anticonvulsant drugs in the past 24 months. Over the 4-year study period, 821 (19.4 %) young people, mean age 17.3 years, were transferred to AMHS, excluding subjects with mental retardation who attended social services (only cases requiring psychiatric treatment are referred to AMHS), and those whose condition was not managed by adult psychiatrists such as specific developmental disorders. There were also 1214 (28.7 %) potential referrals, mostly with emotional and behavioural disorders expected to remit within the teenage years, who remained with CAMHS until they finish secondary school. Of those transferred to AMHS, the mean age for males (n = 460; 56.0 %) was 18.1 years (SD 1.4) and for females (n = 361; 44.0 %) 17.6 years (SD 1.3). Transfer rates
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varied by psychiatric diagnosis, ranging from 56.5 % for cases with schizophrenia and related disorders to 5.2 % for those with unspecified and other mental disorders of childhood and adolescence (Table 1). No difference was observed between young people living in places with more than 100,000 inhabitants, or having foreign-born parents and those living in smaller places, or having Italian nationality (Table 2). Logistic regression analysis including significant socio-demographic variables showed that those who moved to AMHS were more likely to have a diagnosis of schizophrenia and related disorders (Odds Ratio [OR] 3.92; 95 % confidence interval [CI] 2.17–7.08), personality disorders (OR 2.69; 95 % CI 1.89–3.83), and pervasive developmental disorders (OR 2.13; 95 % CI 1.51–2.99). It was also found that they were less likely to live with parents, experienced inpatient psychiatric admission, and were prescribed psychotropic drugs in the 24 months before transfer to AMHS (Table 3).
Eur Child Adolesc Psychiatry Table 3 Clinical and socio-demographic features predicting transfer to AMHS (Odds ratio [OR], 95 % Confidence Interval [CI]) OR (95 % CI) Sex (male) Age at first contact Living with parents Hospital psychiatric admission Drug treatment F1 Substance-induced disorders F2 Schizophrenia/related disorders F3 Affective disorders F4/F93–94 Neurotic stress-related/emotional/ attachment disorders
1.06 (0.86–1.30) 0.99 (0.96–1.01) 0.63 (0.47–0.85)* 3.09 (2.23–4.27)* 3.15 (2.51–3.94)* 1.62 (0.53–4.95) 3.92 (2.17–7.08)* 1.21 (0.81–1.80) 0.90 (0.67–1.20)
F6 Personality disorders F84 Pervasive developmental disorders F90 Hyperkinetic disorders F98–99 Other/unspecified child–adolescent disorders
2.69 (1.89–3.83)* 2.13 (1.51–2.99)* 0.60 (0.35–1.02) 0.31 (0.12–0.84)
Z codes
0.34 (0.21–0.55)
* P ≤ 0.01
Discussion To our knowledge, this is the largest population-based study, which addresses the continuity of care from CAMHS to AMHS ever conducted. It is comprehensive of all adolescents treated for a wide range of mental disorders in secondary care settings in Emilia-Romagna between 2010 and 2013. The availability of clinical administrative data makes it possible to examine putative risk factors involved in transfer of care from child–adolescent to adult mental health services. This knowledge is essential to improve mental health services delivered to young people and to prevent psychiatric morbidity later in life as many mental disorders have their roots in adolescence [1]. The findings of the present study suggest that around one in five adolescents in contact with CAMHS moved to AMHS, pointing out that gaps in access or provision of adult psychiatric services might affect continuity of care for young people across local services. They were more likely to have severe mental conditions such as psychotic disorders, pervasive developmental disorders, and personality disorders; while more common psychiatric disorders did not predict transfer to AMHS, including neurotic disorders, mood disorders, eating disorders, and hyperkinetic disorders. It was also found that those who moved to AMHS were less likely to live with parents, tended to experience inpatient psychiatric admission, and were prescribed psychotropic drugs in the 24 months before transfer to AMHS.
There are very few surveys dealing with continuity of care for young people in community-based services with which to make meaningful comparisons. Conducted in six CAMHS in Greater London and West Midlands, the TRACK study [10] included a sample of 154 young adults and found that 90 (58 %) moved to AMHS over one year. Severe and enduring mental disorders, hospital admissions, and being on medication predicted transfer to AMHS. A similar trend can be drawn from the TRACK study in Ireland, where the number of young adults being considered suitable for transfer was higher than those transferred to AMHS [11]. The main reasons for unsuccessful transfer were refusal by service users or parents, the perceived lack of apposite services, or that AMHS did not accept referrals, as their conditions were not supported [10, 11]. In our study, little engagement with AMHS may be related not only to difficulty experienced by young people during transfer, but also to alternative care available, mainly for common mental disorders. It would appear that young people with anxiety, depression, and eating disorders prefer private specialists who are working in settings that are more acceptable than institutional ones and therefore more effective in engaging them in treatment. The overall prevalence of mental disorders in adolescents in Italy is 8.2 % [23], and half of the patients affected with severe mental disorders attended adult psychiatric services, while only a quarter to a fifth of those having moderate and mild depression and anxiety were in contact with services [24]. It is likely that access to primary care services for those with anxiety and depressive disorders is difficult [25, 26]. Efforts have been made in Emilia-Romagna to extend collaboration between community-based psychiatric services and primary care. In this perspective, general practitioners have managed anxiety disorders and mild depression in patients aged 14–64 years since 2004 [27]. In addition, there are tertiary services for young people with eating disorders, including endocrinologists, nutritionists, psychiatrists, and psychologists, and addiction services for treatment of substance-use disorders within mental health departments. However, data from primary care and specialised services were not available, and only those patients with substance-use disorders who were referred to AMHS were followed up owing to stringent standards for data protection.
Mental health service implications This study gives an estimate of the transfer rates of a number of mental disorders across local mental health services and constitutes a preliminary step towards a better understanding of psychiatric services delivered to young
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people. It contributes to building a case for improving mental health service configuration and the interface with both specialist medical services and primary care. It can be expected that extended collaboration between services will encourage a more integrated perspective on psychopathology and will enhance treatment to the benefit of patients. In Emilia-Romagna, mental health initiatives tended to focus on disorder-specific services that cross the traditional age range between CAMHS and adult services such as emotional disorders in 14–30 year olds and pervasive developmental disorders up to 40 years. This approach would be valuable for targeting interventions at specific etiological factors over time and could be further developed to include interactions with social and specialist medical services. Our findings bear implications not only for mental health service provision, but also for prevention of adult psychiatric morbidity. There has been expansion of specialised services aimed at early detection and treatment of psychotic disorders, which are often associated with unfavourable outcome and may benefit for prompt intervention [28]. It will be rewarding for future research to focus on evidence-based treatments for child and adolescent mental disorders and on service transition, and how current practices have affected this process urgently deserves investigation. It is desirable that this knowledge will lead to a more empirically based practice with implications for effective transition for those with mental disorders.
Limitations The limitations of this study are those concerning recordlinkage surveys based on information collected routinely about patients attending psychiatric community services. In addition, no socio-economic details were available, and only children and adolescents with an ICD-10 diagnosis of mental retardation, hyperkinetic disorders, and specific and pervasive developmental disorders were assessed using standardized instruments for the purpose of obtaining scholastic benefits according to Italian law. This probably accounts for the fact that mental retardation and specific developmental disorders resulted the most common conditions for which they were referred to CAMHS. Another possible issue hinges on the fact that true transfer rates to AMHS are probably higher as the data available covered a relatively short period, and we were unable to collect information about young adults with anxiety and mild depression who attended private specialists and general practitioners, as well as to report transfer rates for those with substance-use disorders and eating disorders because their conditions were managed in specialised services or outside mental health departments. Moreover, both
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nervous and mental disorders are treated in CAMHS, but the former were taken as akin to a potential risk factor of transfer to AMHS (i.e. medical comorbidity) in adolescents with mental disorders. Lastly, high standards of protection for data anonymity did not allow more sophisticated analysis of the cohort being studied.
Conclusions The findings of our study suggest that a relatively small number of adolescents moved to AMHS, mainly those affected with severe mental disorders. This situation probably reflects the configuration of local mental health services and alternative psychiatric care available for young people with milder mental disorders. Acknowledgements This study was funded by Regione EmiliaRomagna Innovation Fund, Italy, (DGR grant no. 1165–2012). Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Dr. Augusto C. Castagnini acted as external supervisor (Modena AUSL grant no. 547–2013); he devised the study and wrote and revised the paper. Ethical standards Data comply with appropriate standards of protection for anonymity, and no ethical approval for this study is required.
References 1. Patel V, Flisher AJ, Hetrick S, McGorry P (2007) Mental health of young people: a global public-health challenge. Lancet 369(9569):1302–1313 2. Kessler RC, Berglund PMBA, Demler O et al (2005) Lifetime prevalence and age-of-onset distribution of DSM-IV disorder in the National Comorbidity Study Replication. Arch Gen Psychiatry 62:593–602 3. Kim-Cohen J, Caspi A, Moffit TE, Harrington H, Milne BJ, Poulton R (2003) Pro juvenile diagnoses in adult with mental disorder. JAMA Psychiatry 60:709–719 4. Reef J, Diamantopoulou S, van Meurs I, Verhulst F, van der Ende J (2009) Child to adult continuities of psychopathology: a 24-year follow-up. Acta Psychiatr Scand 120:230–238 5. Copeland WE, Adair CE, Smetanin P et al (2013) Diagnostic transitions from childhood to adolescence to early adulthood. J Child Psychol Psychiatry 54:791–799 6. Levav I, Jacobsson L, Tsiantis J et al (2004) Psychiatric services and training for children and adolescents in Europe: results from a county survey. Eur Child Adolesc Psychiatry 13:395–401 7. Steinhausen H-C (2014) Recent international trends in psychiatric medication prescriptions for children and adolescents. Eur Child Adolesc Psychiatry (published online 8 November 2014) 8. Munoz-Solomando Townley M, Williams R (2010) Improving transition for young people who move from child and adolescent mental health services to mental health services for adults: lessons from research and young people’s experiences. Curr Opin Psychiatry 23:311–317
Eur Child Adolesc Psychiatry 9. Singh SP, Paul M, Ford T et al (2010) Process, outcome and experience of transition from child to adult mental healthcare: multiperspective study. Br J Psychiatry 197:305–312 10. Lamb C, Murphy M (2013) The divide between child and adult mental health services: points for debate. Br J Psychiatry 202(suppl. 1):s41–s44 11. Paul M, Ford T, Kramer T, Islam Z, Harley K, Singh SP (2013) Transfers and transitions between child and adult mental health services. Br J Psychiatry 202(suppl. 1):s36–s40 12. McNamara N, McNicholas F, Ford T et al (2014) Transition from child and adolescent to adult mental health services in the Republic of Ireland: an investigation of process and operational practice. Early Interv Psychiatry 8:291–297 13. Treasure J, Schmidt U, Hugo P (2005) Mind the gap: service transition and interface problems for patients with eating disorders. Br J Psychiatry 187:398–400 14. Hall CL, Newell K, Taylor J, Saval K, Hollis C (2015) Services for young people with attention deficit/hyperactivity disorder transitioning from child to adult mental health services: a national survey of mental health trusts in England. J Psychopharmacol 29:39–42 15. Pottick KJ, Bilder S, Stoep AV et al (2008) US patterns of mental health services utilization for transition-age youth and young adults. J Behav Health Serv Res 35:373–389 16. Paul M, Street C, Wheeler, Singh SP (2014) Transi tion to adult services for young people with mental health needs: a systematic review. Clin Child Psychol Psychiatry. doi:10.1177/1359104514526603 (published online 7 April 2014) 17. Pedrini L, Colasurdo G, Costa S et al (2012) The characteristics and activities of child and adolescent mental health services in Italy: a regional survey. BMC Psychiatry 12:7
18. http://www.saluter.it/siseps/sanita/salute-mentale-e-dipendenzepatologiche/sinpiaer. Accessed 5 May 2014 19. World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders, Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Geneva 20. http://www.saluter.it/siseps/sanita/salute-mentale-e-dipendenzepatologiche/sism. Accessed 13 May 2014 21. http://www.saluter.it/siseps/sanita/assistenza-farmaceutica/aft. Accessed 21 May 2014 22. http://www.saluter.it/siseps/sanita/sdo. Accessed 24 May 2014 23. Frigerio A, Rucci P, Goodman R et al (2009) Prevalence and correlates of mental disorders among adolescents in Italy: the PRISMA study. Eur Child Adolesc Psychiatry 18:217–226 24. Wang PS, Aguilar-Gaxiola S, Alonso J et al (2007) Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO World Mental Health Surveys. Lancet 370:841–850 25. De Girolamo G, Polidori G, Morosini P et al (2006) Prevalence of common mental disorders in Italy: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD). Soc Psychiatry Psychiatr Epidemiol 41:853–861 26. De Girolamo G, Bassi M, Neri G et al (2007) The current state of mental health care in Italy: problems, perspectives, and lesson to learn. Eur Arch Psychiatry Clin Neurosci 257:83–91 27. http://www.saluter.it/ssr/aree/salute-mentale-e-dipendenze-patologiche-1/programma-giuseppe-leggieri. Accessed 24 June 2014 28. McGorry P, Johanessen JO, Lewis S et al (2010) Early intervention in psychosis: keeping faith with evidence-based health care. Psychol Med 40:399–404
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ORIGINAL CONTRIBUTION
Continuity of care from child and adolescent to adult mental health services: evidence from a regional survey in Northern Italy Paolo Stagi1,2 · Simona Galeotti1 · Stefano Mimmi1 · Fabrizio Starace1 · Augusto C. Castagnini1
Received: 17 November 2014 / Accepted: 14 June 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract To examine clinical and demographic factors associated with continuity of care from child–adolescent (CAMHS) to adult mental health services (AMHS), we undertook a record-linkage study to the Adult Mental Health Information System including all those 16 years old and over who were listed between 2010 and 2013 in the Child and Adolescent Neuropsychiatry Information System in Emilia-Romagna, an Italian region of nearly 4.5 million residents. From a cohort of 8239 adolescents attending CAMHS (population at risk about 144,000), 821 (19.4 %) moved to AMHS, excluding cases with specific developmental disorders, whose conditions were not managed by adult psychiatrists, and those with mental retardation who attended usually social services. Young people referred for treatment to AMHS were more likely to receive a discharge diagnosis of schizophrenia and related disorders (Odds Ratio [OR] 3.92; 95 % confidence interval [CI] 2.17–7.08), personality disorders (OR 2.69; 95 % CI 1.89–3.83), and pervasive developmental disorders (OR 2.13; 95 % CI 1.51–2.99). Further factors predicting transfer to AMHS were not living with parents, inpatient psychiatric admission, and being on medication in the previous 24 months. These findings suggest that a relatively small number of Preliminary findings of this study were presented at the international conference “Youth Mental Health: from continuity of psychopathology to continuity of care (STraMeHS)” held in Venice (Italy) on 16–18 December 2014. * Paolo Stagi [email protected] 1
Mental Health Department, AUSL Modena, Modena, Italy
2
Child and Adolescent Neuropsychiatry Service, Mental Health Department, Azienda USL, Via A. Cardarelli 43, 41124 Modena, Italy
adolescents moved to AMHS and are likely to reflect the configuration of local mental health services and alternative care available, mainly for those with less-severe mental disorders. Keywords Adolescent · Epidemiology · ICD-10 · Mental health care · Psychiatric services · Transition
Introduction Psychiatric morbidity constitutes a major health issue, and much of the disease burden from mental disorders arises in adolescence [1, 2]. Existing studies suggest that most of those referred for psychiatric treatment in the early adulthood had a diagnosis of mental disorder in adolescence and that their condition showed varying degrees of continuity over time [3–5]. Psychiatric services delivered to young people differ from adult mental health care in terms both coverage and quality of care [6], and there seems to be a growing number of adolescents with mental disorders prescribed psychotropic medication [7]. In keeping with mental health care, “transition” and “transfer” are different concepts: “transition” is a process that involves a number of issues concerning a critical period for young people who are attending mental health services, while “transfer” means the cessation of care in child–adolescent mental health services (CAMHS) and its re-establishment in adult mental health services (AMHS) [8, 9, 11, 12]. Several factors have been reported to affect the transition process such as differences in age boundaries, service thresholds, cultural context, and professional training [8–12]. Those who are most likely to make a transition to AMHS were found to experience severe and persistent mental disorders and admission to inpatient units [9, 11].
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Further reports have addressed service transition issues for patients with specific disorders such as eating disorders and neurodevelopmental disorders [13, 14]. Despite the size and importance of this problem, there is little research on service transition outcome in communitybased samples with a wide range of mental disorders [9, 11, 12, 15, 16]. The aim of this paper is to examine clinical and demographic factors associated with continuity of care from CAMHS to AMHS in Emilia-Romagna, Italy.
Method Setting Emilia-Romagna is a highly industrialized region of nearly 4.5 million persons in Northern Italy. All residents are entitled to free treatment under the Italian National Health Service. There are 11 community-based Mental Health Departments in Emilia-Romagna, comprising specialist (secondary care) AMHS, CAMHS, and addiction treatment services. CAMHS regional network consists of 110 outpatient units and 7 inpatient facilities for assessment and treatment of mental and nervous system disorders for about 700,000 people under the age of 18 years in urban and rural areas. There is a broad range of professionals and community workers, including a number of child psychiatrists among the highest in Europe, and similar to that of the best equipped areas in the USA. Further details have been described elsewhere [17].
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linking them to SISM—identified those transferred to AMHS. A further linkage was made to the regional Pharmaceutical Assistance Information System [21] and to the Hospital Discharge Records [22] to collect information about drug prescriptions and hospital psychiatric admissions in the past 24 months. Although the age for transfer of care to AMHS is usually 18 years, transfer planning between services can start since the age of 16 years. In selecting patients referred to AMHS, we relied on the following ICD-10 diagnoses on discharge from CAMHS: “organic disorders” (code F0–9), “substance-use disorders” (F10–19), “schizophrenia, schizotypal and delusional disorders” (F20–29), “affective disorders” (F30–39), “neurotic stress-related and adjustment disorders” (F40–49), “eating disorders” (F50), “personality disorders” (F60–69), “mental retardation” (F70–79), “specific and mixed developmental disorders” (F80–83), “pervasive developmental disorders” (F84), “hyperkinetic disorders” (F90), “conduct disorders” (F91–92), “emotional disorders” (F93), “attachment/social functioning disorders” (94), “tics disorders” (F95), “other and unspecified child-adolescent mental disorders” (F98–99), and “factors influencing health status and contact with services” (Z codes). Moreover, to identify factors associated with transfer to AMHS, we selected the following clinical and socio-demographic variables: (1) age at first contact with CAMHS; (2) sex; (3) nationality (Italian or foreign); (4) place of residence (100,000 100,000); (5) living with parents; (6) medical comorbidity (ICD-10 codes A00-Q99); (7) drug treatment (i.e. antipsychotics, antidepressants and anticonvulsant) and (8) inpatient psychiatric admission.
Sample This study draws its data from two databases created to generate statistics for use in mental health planning. The Emilia-Romagna Childhood and Adolescent Neuropsychiatry Information System (SINPIAER) has recorded details of all those who attended CAMHS since 2010 [18]. Patient entries include information from electronic medical records (i.e. age, gender, place of residence, date and type of contact with services, etc.) and diagnosis made by the responsible psychiatrist using the ICD-10 Classification of Mental and Behavioural Disorders of World Health Organization [19]. The Mental Health Information System (SISM) is comprehensive of all admission/contacts to AMHS aged over 18 years since 2007 [20]. Data are stored using a personal identification number that allows record linkage across the different databases with appropriate protection for anonymity. We selected all subjects 16 years old and over, whether admitted to hospital or treated as outpatients, who were listed in the SINPIAER with an ICD-10 F00-99 diagnosis between 1 January 2010 and 31 December 2013, and—by
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Statistical analysis The starting point was to examine clinical and sociodemographic features of all adolescents aged over 16 years attending CAMHS using Chi square test. Only those variables showing p values ≤0.05 were included in multivariate logistic regression to determine factors predicting transfer to AMHS. Data analysis was conducted by means of the statistical software Stata 11.0.
Results From a cohort of 10,719 adolescents 16 years old and over attending CAMHS between 2010 and 2013 (total population at risk about 144,000), there were 8239 cases with an ICD-10 F00–99 or Z diagnosis in their last contact (Fig. 1). The remaining comprised 813 cases with neurological diseases, as CAMHS provides treatment of both nervous and mental disorders, and 1667 received no diagnosis, as they
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Fig. 1 Outcome of adolescents aged over 16 years attending CAMHS in 2010–2013 (see text for details)
Table 1 Frequency of ICD10 diagnosis in adolescents aged over 16 years attending CAMHS in 2010–2013 and transfer rates to AMHS by diagnostic category
ICD-10 category
N (%)
Transfers (%)
F0 Organic disorders F1 Substance-use disorders F2 Schizophrenia/related disorders F3 Affective disorders F4-F93-94 Neurotic stress-related/emotional/attachment disorders F5 Eating and sleeping disorders F6 Personality disorders F7 Mental retardation F80–83 Specific/mixed developmental disorders F84 Pervasive developmental disorders
7 (0.1) 37 (0.4) 85 (1.0) 318 (3.9) 1244 (15.1) 263 (3.2) 297 (3.6) 2156 (26.2) 1857 (22.5) 374 (4.5)
28.6 32.4 56.5 26.4 16.6 22.8 37.4 12.5 5.4 32.4
F90 Hyperkinetic disorders F91–92 Conduct disorders F95 Tic disorders F98–99 Other/unspecified child–adolescent disorders
208 (2.5) 534 (6.5) 32 (0.4) 116 (1.4)
11.1 18.2 25.0 5.2
Z codesa
711 (8.6)
5.9
a
Factor influencing health status and contact with services
either dropped out shortly after initial contact or had yet to complete clinical assessments. As shown in Table 1, the principal diagnostic groups were mental retardation and specific developmental disorders accounting for almost 50 % of the total morbidity, followed by neurotic, stress-related and emotional disorders (15.1 %), conduct disorders (6.5 %), pervasive
developmental disorders (4.5 %), and affective disorders (3.9 %). Less common were personality disorders (3.6 %), eating and sleeping disorders (3.2 %), hyperkinetic disorders (2.5 %), schizophrenia and related disorders (1.0 %), substance-use disorders (0.4 %), tic disorders (0.4 %), organic disorders (0.1 %), and Z codes (8.6 %).
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Table 2 Clinical and sociodemographic features of potential referrals to AMHS aged over 16 years who attended CAMHS in EmiliaRomagna between 2010 and 2013
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Sex (male) Age at first contact (years)a Nationality (Italian) Place of residence (>100,000 population)c Living with parentsd Hospital psychiatric admission Medical comorbidityb Drug treatmente F0 Organic disorders F1 Substance-induced disorders F2 Schizophrenia/related disorders F3 Affective disorders F4 + F93–94 Neurotic/stress-related/emotional disorders F5 Eating and sleeping disorders F6 Personality disorders F84 Pervasive developmental disorders F90 Hyperkinetic disorders F91–92 Conduct disorders F95 Tic disorders F98–99 Other/unspecified child–adolescent disorders Z diagnosisf
χ2
Transfer
No transfer
N (%)
N (%)
460 (56.0) 10.5 (5.1) 757 (92.2) 257 (31.5) 500 (84.9) 187 (22.8) 54 (6.6) 349 (42.5) 2 (0.2) 12 (1.5) 48 (5.8) 84 (10.2) 207 (25.2) 60 (7.3) 111 (13.5) 121 (14.7) 23 (2.8) 97 (11.8) 8 (1.0) 6 (0.7)
1904 (55.9) 10.6 (4.8) 3091 (90.8) 1135 (33.5) 2104 (88.9) 150 (4.4) 238 (7.0) 472 (13.9) 5 (0.1) 25 (0.7) 37 (1.1) 234 (6.9) 1037 (30.5) 203 (6.0) 186 (5.5) 253 (7.4) 185 (5.4) 437 (12.8) 24 (0.7) 110 (3.2)
0.0 30.5* 1.7 1.2 7.2* 304.2* 0.2 346.8* 0.4 4.0* 76.0* 10.7* 8.8* 2.1 65.7* 43.8* 9.8* 0.6 0.6 15.5*
42 (5.1)
669 (19.6)
99.8*
* P ≤ 0.05 a
Continuous variables are shown as mean (standard deviation) and categorical variables as number (%)
b
ICD-10 codes A00-Q99
c
16 cases had unknown place of residence
d
1270 cases had unknown family situation
e
Antipsychotics, antidepressants, and anticonvulsants
f
Factor influencing health status and contact with services
The great majority (89.2 %) of the sample was living at home, and only 10.3 % had foreign-born parents. Furthermore, 4.7 % experienced admission to inpatient units, and 15.4 % were on treatment with antipsychotic, antidepressant, or anticonvulsant drugs in the past 24 months. Over the 4-year study period, 821 (19.4 %) young people, mean age 17.3 years, were transferred to AMHS, excluding subjects with mental retardation who attended social services (only cases requiring psychiatric treatment are referred to AMHS), and those whose condition was not managed by adult psychiatrists such as specific developmental disorders. There were also 1214 (28.7 %) potential referrals, mostly with emotional and behavioural disorders expected to remit within the teenage years, who remained with CAMHS until they finish secondary school. Of those transferred to AMHS, the mean age for males (n = 460; 56.0 %) was 18.1 years (SD 1.4) and for females (n = 361; 44.0 %) 17.6 years (SD 1.3). Transfer rates
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varied by psychiatric diagnosis, ranging from 56.5 % for cases with schizophrenia and related disorders to 5.2 % for those with unspecified and other mental disorders of childhood and adolescence (Table 1). No difference was observed between young people living in places with more than 100,000 inhabitants, or having foreign-born parents and those living in smaller places, or having Italian nationality (Table 2). Logistic regression analysis including significant socio-demographic variables showed that those who moved to AMHS were more likely to have a diagnosis of schizophrenia and related disorders (Odds Ratio [OR] 3.92; 95 % confidence interval [CI] 2.17–7.08), personality disorders (OR 2.69; 95 % CI 1.89–3.83), and pervasive developmental disorders (OR 2.13; 95 % CI 1.51–2.99). It was also found that they were less likely to live with parents, experienced inpatient psychiatric admission, and were prescribed psychotropic drugs in the 24 months before transfer to AMHS (Table 3).
Eur Child Adolesc Psychiatry Table 3 Clinical and socio-demographic features predicting transfer to AMHS (Odds ratio [OR], 95 % Confidence Interval [CI]) OR (95 % CI) Sex (male) Age at first contact Living with parents Hospital psychiatric admission Drug treatment F1 Substance-induced disorders F2 Schizophrenia/related disorders F3 Affective disorders F4/F93–94 Neurotic stress-related/emotional/ attachment disorders
1.06 (0.86–1.30) 0.99 (0.96–1.01) 0.63 (0.47–0.85)* 3.09 (2.23–4.27)* 3.15 (2.51–3.94)* 1.62 (0.53–4.95) 3.92 (2.17–7.08)* 1.21 (0.81–1.80) 0.90 (0.67–1.20)
F6 Personality disorders F84 Pervasive developmental disorders F90 Hyperkinetic disorders F98–99 Other/unspecified child–adolescent disorders
2.69 (1.89–3.83)* 2.13 (1.51–2.99)* 0.60 (0.35–1.02) 0.31 (0.12–0.84)
Z codes
0.34 (0.21–0.55)
* P ≤ 0.01
Discussion To our knowledge, this is the largest population-based study, which addresses the continuity of care from CAMHS to AMHS ever conducted. It is comprehensive of all adolescents treated for a wide range of mental disorders in secondary care settings in Emilia-Romagna between 2010 and 2013. The availability of clinical administrative data makes it possible to examine putative risk factors involved in transfer of care from child–adolescent to adult mental health services. This knowledge is essential to improve mental health services delivered to young people and to prevent psychiatric morbidity later in life as many mental disorders have their roots in adolescence [1]. The findings of the present study suggest that around one in five adolescents in contact with CAMHS moved to AMHS, pointing out that gaps in access or provision of adult psychiatric services might affect continuity of care for young people across local services. They were more likely to have severe mental conditions such as psychotic disorders, pervasive developmental disorders, and personality disorders; while more common psychiatric disorders did not predict transfer to AMHS, including neurotic disorders, mood disorders, eating disorders, and hyperkinetic disorders. It was also found that those who moved to AMHS were less likely to live with parents, tended to experience inpatient psychiatric admission, and were prescribed psychotropic drugs in the 24 months before transfer to AMHS.
There are very few surveys dealing with continuity of care for young people in community-based services with which to make meaningful comparisons. Conducted in six CAMHS in Greater London and West Midlands, the TRACK study [10] included a sample of 154 young adults and found that 90 (58 %) moved to AMHS over one year. Severe and enduring mental disorders, hospital admissions, and being on medication predicted transfer to AMHS. A similar trend can be drawn from the TRACK study in Ireland, where the number of young adults being considered suitable for transfer was higher than those transferred to AMHS [11]. The main reasons for unsuccessful transfer were refusal by service users or parents, the perceived lack of apposite services, or that AMHS did not accept referrals, as their conditions were not supported [10, 11]. In our study, little engagement with AMHS may be related not only to difficulty experienced by young people during transfer, but also to alternative care available, mainly for common mental disorders. It would appear that young people with anxiety, depression, and eating disorders prefer private specialists who are working in settings that are more acceptable than institutional ones and therefore more effective in engaging them in treatment. The overall prevalence of mental disorders in adolescents in Italy is 8.2 % [23], and half of the patients affected with severe mental disorders attended adult psychiatric services, while only a quarter to a fifth of those having moderate and mild depression and anxiety were in contact with services [24]. It is likely that access to primary care services for those with anxiety and depressive disorders is difficult [25, 26]. Efforts have been made in Emilia-Romagna to extend collaboration between community-based psychiatric services and primary care. In this perspective, general practitioners have managed anxiety disorders and mild depression in patients aged 14–64 years since 2004 [27]. In addition, there are tertiary services for young people with eating disorders, including endocrinologists, nutritionists, psychiatrists, and psychologists, and addiction services for treatment of substance-use disorders within mental health departments. However, data from primary care and specialised services were not available, and only those patients with substance-use disorders who were referred to AMHS were followed up owing to stringent standards for data protection.
Mental health service implications This study gives an estimate of the transfer rates of a number of mental disorders across local mental health services and constitutes a preliminary step towards a better understanding of psychiatric services delivered to young
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people. It contributes to building a case for improving mental health service configuration and the interface with both specialist medical services and primary care. It can be expected that extended collaboration between services will encourage a more integrated perspective on psychopathology and will enhance treatment to the benefit of patients. In Emilia-Romagna, mental health initiatives tended to focus on disorder-specific services that cross the traditional age range between CAMHS and adult services such as emotional disorders in 14–30 year olds and pervasive developmental disorders up to 40 years. This approach would be valuable for targeting interventions at specific etiological factors over time and could be further developed to include interactions with social and specialist medical services. Our findings bear implications not only for mental health service provision, but also for prevention of adult psychiatric morbidity. There has been expansion of specialised services aimed at early detection and treatment of psychotic disorders, which are often associated with unfavourable outcome and may benefit for prompt intervention [28]. It will be rewarding for future research to focus on evidence-based treatments for child and adolescent mental disorders and on service transition, and how current practices have affected this process urgently deserves investigation. It is desirable that this knowledge will lead to a more empirically based practice with implications for effective transition for those with mental disorders.
Limitations The limitations of this study are those concerning recordlinkage surveys based on information collected routinely about patients attending psychiatric community services. In addition, no socio-economic details were available, and only children and adolescents with an ICD-10 diagnosis of mental retardation, hyperkinetic disorders, and specific and pervasive developmental disorders were assessed using standardized instruments for the purpose of obtaining scholastic benefits according to Italian law. This probably accounts for the fact that mental retardation and specific developmental disorders resulted the most common conditions for which they were referred to CAMHS. Another possible issue hinges on the fact that true transfer rates to AMHS are probably higher as the data available covered a relatively short period, and we were unable to collect information about young adults with anxiety and mild depression who attended private specialists and general practitioners, as well as to report transfer rates for those with substance-use disorders and eating disorders because their conditions were managed in specialised services or outside mental health departments. Moreover, both
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nervous and mental disorders are treated in CAMHS, but the former were taken as akin to a potential risk factor of transfer to AMHS (i.e. medical comorbidity) in adolescents with mental disorders. Lastly, high standards of protection for data anonymity did not allow more sophisticated analysis of the cohort being studied.
Conclusions The findings of our study suggest that a relatively small number of adolescents moved to AMHS, mainly those affected with severe mental disorders. This situation probably reflects the configuration of local mental health services and alternative psychiatric care available for young people with milder mental disorders. Acknowledgements This study was funded by Regione EmiliaRomagna Innovation Fund, Italy, (DGR grant no. 1165–2012). Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Dr. Augusto C. Castagnini acted as external supervisor (Modena AUSL grant no. 547–2013); he devised the study and wrote and revised the paper. Ethical standards Data comply with appropriate standards of protection for anonymity, and no ethical approval for this study is required.
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