Mental health in clinically referred children and young people before and during the Covid-19 pandemic.

The Covid-19 pandemic and mitigation approaches, including lockdowns and school closures, are thought to have negatively impacted children and young people's (CYP) mental health. However, the impact for clinically referred CYP is less clear. We investigated differences in the mental health of CYP referred to specialist Child and Adolescent Mental Health Services (CAMHS) before and since the onset of the pandemic. Using baseline data (self- and parent- completed Mood and Feelings Questionnaire and Strengths and Difficulties Questionnaire) from an ongoing RCT (STADIA; ISRCTN: 15748675) in England involving 5-17-year-olds with emotional difficulties recently referred to CAMHS (non-urgent referrals), with repeated cross-sectional comparisons of CYP (n = 1028) recruited during 5 different time  periods: (1) Before schools were closed (Group 1 (pre-pandemic); n = 308; 27.08.2019-20.03.2020). (2) Early pandemic period until schools fully re-opened, which included the first national lockdown, its easing and the summer holidays (Group 2 (in-pandemic); n = 183; 21.03.2020-31.08.2020). (3) The following school-term-schools fully re-opened and remained open, including during the second national lockdown (Group 3 (in-pandemic); n = 204; 01.09.2020-18.12.2020). (4) Schools closed as part of the third national lockdown (Group 4 (in-pandemic); n = 101; 05.01.2021-07.03.2021). (5) Schools re-opened and remained open, until the school summer holidays (Group 5 (in-pandemic); n = 232; 08.03.2021-16.07.2021). Most CYP scored above cutoff for emotional problems and depression, with three-quarters meeting criteria for a probable disorder ('caseness'). The groups did not differ on parent-rated mental health measures. However, self-rated emotional problems, depression, functional impairment and caseness appeared to be higher amongst participants recruited in the two periods following school re-openings. In particular, functional impairment and caseness were greater in Group 5 compared with Group 2. Although symptom severity or impairment did not change in the initial pandemic period, self-reported difficulties were greater during the periods after schools re-opened. This suggests possible greater stresses in the adjustment to re-starting school following recurrent lockdowns and school closures.

Editorial: Evidence in the real world - the need for context and the gender gap.

We are in a competitive, burgeoning market for journals and currently in a transition to open access publications, with the aim of making research more widely accessible. Where is the place for practice-based journals in this new and evolving world of publishing? The recent growth of CAMH in terms of Impact Factor, downloads and submissions suggests there is a need for such journals. Professionals are swamped with research findings, often contradictory, sometimes inflammatory, with little time to explore the meaning of these findings within the real world. This editorial reflects on the need for academics and practitioners to be able to debate the evidence base within the real world context (or to consider the lack of it) to inform practice and policy, and also on the importance of providing a platform for topics that are current and/or controversial. Recent contributions to CAMH are highlighted, namely the perceived gender gap in research on emotional disorders in women and girls, and the need for an ethical data sharing framework for academics to investigate the potential harms and benefits of technology. CAMH will continue to ask questions, and aim to remain relevant by focusing on both the evidence and real world context, in order to inform best practice and policy decisions.

Impact of COVID-19 on mental health research: is this the breaking point?

There are many structural problems facing the UK at present, from a weakened National Health Service to deeply ingrained inequality. These challenges extend through society to clinical practice and have an impact on current mental health research, which was in a perilous state even before the coronavirus pandemic hit. In this editorial, a group of psychiatric researchers who currently sit on the Academic Faculty of the Royal College of Psychiatrists and represent the breadth of research in mental health from across the UK discuss the challenges faced in academic mental health research. They reflect on the need for additional investment in the specialty and ask whether this is a turning point for the future of mental health research.

Cross-sectional and longitudinal associations between psychotic and depressive symptoms in depressed adolescents.

Adults with major depressive disorder (MDD) with psychotic features (delusions and/or hallucinations) have more severe symptoms and a worse prognosis. Subclinical psychotic symptoms are more common in adolescents than adults. However, the effects of psychotic symptoms on outcome of depressive symptoms have not been well studied in adolescents. Depressed adolescents aged 11-17 with and without psychotic symptoms were compared on depression severity scores at baseline and at 28- or 42-week follow-up in two large UK cohorts. Psychotic symptoms were weakly associated with more severe depression at baseline in both cohorts. At follow-up, baseline psychotic symptoms were only associated with depressive symptoms in one sample; in the other, the effect size was close to zero. This supports the DSM5 system of psychotic symptoms being a separate code to severity rather than the ICD10 system which only allows the diagnosis of psychotic depression with severe depression. There was no clear support for psychotic symptoms being a baseline marker of treatment response.

Editorial: The climate and ecological mental health emergency - evidence and action.

No previous generation of children has grown up in the context of an existential threat comparable to the climate crisis. This Special Issue examines the implications of the climate crisis for children and young people in relation to their mental health and well-being, and, as a corollary, the implications for mental health professionals. Evidence is accumulating on the prevalence of worry among children world-wide, as well as on the direct impacts of the climate crisis on mental health. Despite the huge threat that this crisis poses for the next generation's mental health and well-being, and the recognition that this is now a global mental health emergency, there has been surprisingly little research on the topic. We therefore saw the urgent need to draw together a wide range of original research and perspectives and to consider what this mean for professionals who have dedicated themselves to improving the well-being of children and young people.

Feasibility study of a new behavioural activation programme for young people with depressed mood.

BACKGROUND: Behavioural activation (BA) is effective in adults with depression but the evidence for young people (YP) is less clear. We therefore developed and tested a new coproduced BA programme. METHOD: In phase one (2014 to 2015 inclusive), we codeveloped with young people attending specialist child and adolescent mental health service (CAMHS) an 8-session BA workbook. In Phase two (2019 to 2020 inclusive), we ran an uncontrolled feasibility study in two specialist CAMHS, with BA being offered to YP by less specialised staff. RESULTS: In phase one, we tested the workbook with 15 YP with depression and other comorbidities. Satisfaction was good from both YP and staff, and 9 YP reported improvement in mood. In phase two, 51 YP were offered BA; 15 declined to take part. 36 consented with three dropping out after consent. 33 YP (mean age 14.6, 12 males, 24 females) continued treatment attending a mean of 6.6 sessions. At the end of treatment, youth-rated Mood and Feeling Questionnaire (MFQ) mean score decreased from 43.2 to 27.6, difference 14.6 (95% CI 8.7 to 20.2; n = 28), and Clinician Global Assessment Score (CGAS) mean score increased from 52.3 to 69.8, difference 18.0 (95% CI 11.9 to 24.2; n = 29). Of the 33 YP who participated in therapy, 12 (36%) recovered and were discharged. CONCLUSIONS: This programme demonstrated preliminary evidence for effectiveness and utility. Less specialised staff were able to use BA, and this may reduce secondary waits for more specialist therapy. More research is needed about the role of BA in specialist CAMHS.

Editorial: Evidence, policy and practice - gold standard, good enough or doing it differently?

Welcome to the first issue of Child and Adolescent Mental Health (CAMH) in 2021 and also to my first issue as editor-in-chief. Needless to say, 2020 has been one of the most difficult years in living memory for many children and young people around the globe, and, as we discussed in our recent issues, the potential impact of COVID-19 on children's mental health is profound. The case for increased funding for child and adolescent mental health and investing in research has never been greater. Nevertheless, as we step into 2021, there are seeds of optimism as science drives forward treatment and vaccine developments.

Editorial Perspective: Mental health needs of children and young people of Black ethnicity.1 Is it time to reconceptualise racism as a traumatic experience?

We explore racial inequality in relation to Black children and young people (CYP) and Child and Adolescent Mental Health Services (CAMHS). We argue that the experience of racism should be universally considered an Adverse Childhood Experience (ACE). We argue that racism and the vicarious trauma arising from exposure to frequent media reports of racially motivated violence against persons of Black ethnicity can all predispose Black CYP to increased risk of mental health problems. We make recommendations to improve Black CYP's early access to CAMHS, and to reduce their overrepresentation in psychiatric in-patient settings in the UK. This would require making CAMHS more welcoming to Black CYP and consideration of the impact of racism and trauma in the diagnostic and treatment formulation for Black CYP. This should include: the impact of racism in staff training, improving the cultural competence of CAMHS staff, and supporting Black CYP to articulate their experiences of racism and related traumas whilst facilitating their development of coping strategies to manage these experiences.

Child and adolescent mental health amidst emergencies and disasters.

The mental health of children and young people can be disproportionally affected and easily overlooked in the context of emergencies and disasters. Child and adolescent mental health services can contribute greatly to emergency preparedness, resilience and response and, ultimately, mitigate harmful effects on the most vulnerable members of society.

Toward precision therapeutics: general and specific factors differentiate symptom change in depressed adolescents.

BACKGROUND: The longitudinal course of multiple symptom domains in adolescents treated for major depression is not known. Revealing the temporal course of general and specific psychopathology factors, including potential differences between psychotherapies, may aid therapeutic decision-making. METHODS: Participants were adolescents with major depressive disorder (aged 11-17; 75% female; N = 465) who were part of the IMPACT trial, a randomized controlled trial comparing cognitive behavioral therapy, short-term psychoanalytic psychotherapy, and brief psychosocial intervention. Self-reported symptoms at baseline and 6, 12, 36, 52, and 86 weeks postrandomization were analyzed with bifactor modeling. RESULTS: General psychopathology factor scores decreased across treatment and one-year follow-up. Specific melancholic features and depressive cognitions factors decreased from baseline to 6 weeks. Conduct problems decreased across treatment and follow-up. Anxiety increased by 6 weeks and then reverted to baseline levels. Obsessions-compulsions did not change. Changes in general and specific factors were not significantly different between the three psychotherapies during treatment. During follow-up, however, conduct problems decreased more in brief psychosocial intervention versus cognitive behavioral therapy (1.02, 95% Bayes credible interval 0.25, 1.96), but not versus short-term psychoanalytic psychotherapy. CONCLUSIONS: The clinical response signature in this trial is best revealed by rapid reductions in depression symptoms and general psychopathology. Protracted improvements in general psychopathology and conduct problems subsequently occur. Psychosocial treatments for adolescent depression have comparable effects on general and specific psychopathology, although a psychoeducational, goal-focused approach may be indicated for youth with comorbid conduct problems.

Trajectories of depression symptom change during and following treatment in adolescents with unipolar major depression.

OBJECTIVE: To classify a cohort of depressed adolescents recruited to the UK IMPACT trial, according to trajectories of symptom change. We examined for predictors and compared the data-driven categories of patients with a priori operational definitions of treatment response. METHOD: Secondary data analysis using growth mixture modelling (GMM). Missing data were imputed. Trajectories of self-reported depressive symptoms were plotted using scores taken at six nominal time points over 86 weeks from randomisation in all 465 patients. RESULTS: A piecewise GMM categorised patients into two classes with initially similar and subsequently distinct trajectories. Both groups had a significant decline in depressive symptoms over the first 18 weeks. Eighty-four per cent (84.1%, n = 391) of patients were classed as 'continued-improvers' with symptoms reducing over the duration of the study. A further class of 15.9% (n = 74) of patients were termed 'halted-improvers' with higher baseline depression scores, faster early recovery but no further improvement after 18 weeks. Presence of baseline comorbidity somewhat increased membership to the halted-improvers class (OR = 1.40, CI: 1.00-1.96). By end of study, compared with classes, a clinical remission cut-off score (≤27) and a symptom reduction score (≥50%) indexing treatment response misclassified 15% and 31% of cases, respectively. CONCLUSIONS: A fast reduction in depressive symptoms in the first few weeks of treatment may not indicate a good prognosis. Halted improvement is only seen after 18 weeks of treatment. Longitudinal modelling may improve the precision of revealing differential responses to treatment. Improvement in depressive symptoms may be somewhat better in the year after treatment than previously considered.

Editorial: How in the world are we handling COVID-19?

These are not normal times. As an editorial team, we felt that there was an urgency to reflect on our global experiences of the COVID-19 pandemic with our international colleagues. Instead of our planned debate series, we therefore commissioned a series of reflections on the impact of the pandemic on child and adolescent mental health throughout the world. We hope that you will find these reflections informative, thought-provoking, and in some cases, inspirational.

Editorial: Screen time, social media and developing brains: a cause for good or corrupting young minds?

In 2018, the Royal College of Psychiatrists held a debate for young people about social media, a subject of their own choosing. The young people spoke eloquently but had differing views. One young person held up his smartphone and stated 'this is my heroin - it's the heroin of our generation'. In contrast, another young person argued 'I don't agree - this is my life line, I am a looked-after child, living on my own, and it's the only way I have of keeping in touch with my family and friends'.

Editorial: Pharmacotherapy and adolescent depression - an important treatment option.

Over the past decade, rates of depression and of suicide in adolescents have been increasing (Collishaw, Journal of Child Psychology and Psychiatry, 56, 2015, 370; Bor et al., The Australian and New Zealand Journal of Psychiatry, 48, 2014, 606). At the same time, there is some evidence that rates of diagnosis and, in the US at least, referral for depression in adolescents has been declining (Libby et al., Archives of General Psychiatry, 66, 2009, 633; John et al., Psychological Medicine, 46, 2016, 3315). These worrying statistics highlight the importance of disseminating accurate information about the risks and benefits of treatments for adolescent depression, in order to combat therapeutic nihilism. Extant controversy about the best ways to treat adolescent depression, and in particular with regards to the use of antidepressants, may have contributed to these trends. More specifically, we believe that some recent, high profile publications have incorrectly interpreted the benefit to risk ratio for the use of antidepressants in adolescent depression as unfavourable (e.g. Cipriani et al., The Lancet, 388, 2016, 881). In this editorial, we review clinical trial and pharmaco-epidemiological data that supports the retention of the use of antidepressants in the management of depressed adolescents.

Clinical characteristics associated with the prescribing of SSRI medication in adolescents with major unipolar depression.

Unipolar major depressions (MD) emerge markedly during adolescence. National Institute for Health and Care Excellence (NICE) UK recommends psychological therapies, with accompanying selective serotonin reuptake inhibitors (SSRIs) prescribed in severe cases only. Here, we seek to determine the extent and rationale of SSRI prescribing in adolescent MD before entering a randomised clinical trial. SSRI prescribing, together with their clinical characteristics was determined in 465 adolescent patients with MD prior to receiving a standardised psychological therapy as part of the Improving mood with psychoanalytic and cognitive therapies (IMPACT) clinical trial. Overall, 88 (19 %) had been prescribed antidepressants prior to psychological treatment. The clinical correlates varied by gender: respectively, depression severity in boys and self-harming behaviours in girls. Prescribing also differed between clinical research centres. Medical practitioners consider severity of depression in boys as an indicator for antidepressant prescribing. Self-injury in girls appears to be utilised as a prescribing aid which is inconsistent with past and current revised UK NICE guidelines.

Measurement Issues: Depression measures in children and adolescents.

BACKGROUND: Since the recognition of youth depression, numerous instruments have been developed, but there is little consensus regarding their use. In recent years, a national programme for outcome measurement has been introduced in the United Kingdom. METHOD: A pragmatic literature search was conducted to select instruments commonly used to measure depression either in research or as recommended by UK national bodies. RESULTS: 15 depression rating scales were identified. Diagnostic instruments and rating scales are described. CONCLUSIONS: Recent large depression trials have produced additional new data, and UK national organisations have made recommendations regarding the implementation of certain instruments.

Experiences and impact of psychiatric inpatient admissions far away from home: a qualitative study with young people, parents/carers and healthcare professionals.

BACKGROUND: There are significant clinical, policy and societal concerns about the impact on young people (YP), from admission to psychiatric wards far from home. However, research evidence is scarce. AIMS: To investigate the impact of at-distance admissions to general adolescent units, from the perspectives of YP, parents/carers and healthcare professionals (HCPs) including service commissioners, to inform clinical practice, service development and policy. METHOD: Semistructured interviews with purposive samples of YP aged 13-17 years (n=28) and parents/carers (n=19) across five large regions in England, and a national sample of HCPs (n=51), were analysed using a framework approach. RESULTS: There was considerable agreement between YP, parents/carers and HCPs on the challenges of at-distance admissions. YP and parents/carers had limited or no involvement in decision-making processes around admission and highlighted a lack of available information about individual units. Being far from home posed challenges with maintaining home contact and practical/financial challenges for families visiting. HCPs struggled with ensuring continuity of care, particularly around maintaining access to local clinical teams and educational support. However, some YP perceived separation from their local environment as beneficial because it removed them from unhelpful environments. At-distance admissions provided respite for some families struggling to support their child. CONCLUSIONS: At-distance admissions lead to additional distress, uncertainty, compromised continuity of care and educational, financial and other practical difficulties, some of which could be better mitigated. For a minority, there are some benefits from such admissions. CLINICAL IMPLICATIONS: Standardised online information, accessible prior to admission, is needed for all Child and Adolescent Mental Health Services units. Additional practical and financial burden placed on families needs greater recognition and consideration of potential sources of support. Policy changes should incorporate findings that at-distance or adult ward admissions may be preferable in certain circumstances.