The Longitudinal Youth in Transition Study (LYiTS) Cohort Profile: Exploration by Hospital- Versus Community-Based Mental Health Services.

OBJECTIVES: Youth face numerous challenges in receiving coordinated and continuous mental health services, particularly as they reach the age of transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). The Longitudinal Youth in Transition Study (LYiTS) follows youth prospectively as they cross this transition boundary to better understand their transition pathways and resulting symptoms and health service use outcomes. The current paper presents the baseline profile description for the LYiTS cohort and additionally examines differences in symptoms and functioning and health service utilization between youth receiving services at hospital- versus community-based CAMHS. METHODS: A cross-sectional design was used. A sample of 237 16-18-year-old youth recruited from outpatient CAMHS at two hospitals and two community sites completed self-report measures at their first of four annual assessments. A latent profile analysis was conducted to identify symptomology profiles, and youth were compared on symptoms and health service use between hospital- and community-based sites. RESULTS: Four distinct symptomology profiles were identified (subclinical, moderate internalizing, moderate externalizing, and high symptomology). Symptom profiles and functioning levels reported by youth were no different across both types of organization, although there were differences detected in health service utilization, such as type of provider seen and use of medications. CONCLUSIONS: These findings suggest that there is little difference in symptomology between youth accessing hospital versus community-based CAMHS. With growing interest in understanding the effectiveness and cost-effectiveness of different models of mental health care, these findings provide a new understanding of the clinical and service use profiles of transition-aged youth that will be explored further as this cohort is followed across the CAMHS to AMHS transition boundary.

Health System-Level Evaluation of Tele-Mental Health Services Among Children and Adolescents in Ontario, Canada.

OBJECTIVE: To describe the characteristics of children and adolescents receiving tele-mental health services in Ontario, Canada and examine access to a psychiatrist, in-person or via tele-mental health services, following a mental health and addictions (MHA)-related emergency department (ED) visit or hospitalization. METHOD: Using linked health and administrative data, we described two cohorts: (1) children and adolescents (1-18 years) who used a provincial tele-mental health programme from January 1, 2013 to March 31, 2017, comparing their MHA-related service use (outpatient, ED, hospitalization) in the 1 year prior to and the 1 year following initial consultation; (2) children and adolescents with high mental health service needs, defined as those with an incident MHA-related ED visit or hospitalization between January 1, 2013 and December 31, 2016, examining their 1-year follow-up with telemedicine and other health care utilization. RESULTS: In the first cohort, 7,216 children and adolescents (mean age 11.8 [±3.8] years) received tele-mental health services. The proportion of MHA-related ED visits [15.1% pre vs. 12.6% post (test statistic 23.57, P < 0.001)] or hospitalizations [10.2% pre vs. 8.7% post (test statistic 11.96, P < 0.001)] declined in the year following tele-mental health consultation, while local psychiatry visits increased [8.4% pre vs. 17.0% post (test statistic 298.69, P < 0.001)]. In the second cohort (n = 84,033), only 1.5% received tele-mental health services, 40.7% saw a psychiatrist in-person, and 32.5% received no MHA-related outpatient care in follow-up. CONCLUSIONS: Tele-mental health services were rarely used in Ontario, even among high-needs children and adolescents, despite their association with increased access to care and less need for acute mental health care.

Longitudinal Youth in Transition Study (LYiTS): protocol for a multicentre prospective cohort study of youth transitioning out of child and adolescent mental health services at age 18.

INTRODUCTION: Transition between health services is widely recognised as a problematic hurdle. Yet, the factors necessary for successful transition out of child and adolescent mental health services (CAMHS) as youth reach the service boundary at age 18 are poorly understood. Further, fragmentation and variability among the services provided by mental health organisations serve to exacerbate mental illness and create unnecessary challenges for youth and their families. The primary aim of the Longitudinal Youth in Transition Study (LYiTS) is to describe and model changes in psychiatric symptoms, functioning and health service utilisation at the transition out of CAMHS at age 18 and to identify key elements of the transition process that are amendable to interventions aimed at ensuring continuity of care. METHODS AND ANALYSIS: A prospective longitudinal cohort study will be conducted to examine the association between psychiatric symptoms, functioning and mental health and health service use of youth aged 16-18 as they transition out of child mental health services at age 18. We will recruit a sample of (n=350) participants from child and adolescent psychiatric programmes at two hospital and two community mental health sites and conduct assessments annually for 3 years using standardised measures of psychiatric symptoms, functioning and health service utilisation. ETHICS AND DISSEMINATION: Ethics approval has been obtained at all four recruitment sites. We will disseminate the results through conferences, open access publications and webinars.

Lessons Learned in a Physician Referral to Pediatric Telemental Health Services Program.

BACKGROUND: This study explores the physician referral and engagement process of a pediatric telemental health program based in a large urban teaching children's hospital, and identifies the processes, strengths and challenges from the perspectives of Primary Care Physicians (PCPs) and telepsychiatrist consultants. METHODS: A mixed methods approach was used. This included an online survey completed by 43 PCPs in Ontario rural communities who had referred patients to the telemental health program. Qualitative interviews were conducted with 11 child/adolescent telepsychiatrists who provide consultations via teleconferencing. RESULTS: The majority of PCPs (61%) reported somewhat to moderate satisfaction with referral experiences. Challenges identified by physicians were related to communication and administration issues including: lack of timely follow-up appointments and continuity of care; lengthy referral forms; and recommendations for mental health services not accessible in their communities. Similarly, psychiatrist consultants expressed frustration with the sparse information they received from referring physicians and most significantly, the absence of appropriate service providers/professionals during the consultation to provide collateral information and ensure uptake of recommendations. CONCLUSION: Telemental health programs provide a valuable service to PCPs and their child and youth clients that could be significantly enhanced with a different consultation model. Such models of service delivery require protocols to educate PCPs, improve communication and information sharing and establish clear expectations between PCPs and telepsychiatry consultants.

CONTEXTE: Cette étude explore l'aiguillage d'un médecin et le processus de participation à un programme de télésanté mentale pédiatrique situé dans un vaste hôpital universitaire pour enfants en milieu urbain, et mentionne les processus, les forces et les difficultés du point de vue des médecins des soins de première ligne (MPL) et des télépsychiatres consultants. MÉTHODES: Une approche de méthodes mixtes a été utilisée, ce qui comprenait un sondage en ligne auquel ont répondu 43 MPL des communautés rurales de l'Ontario qui avaient aiguillé des patients au programme de télésanté mentale. Des entrevues qualitatives ont été menées auprès de 11 télépsychiatres de l'enfant et de l'adolescent qui offrent des consultations par téléconférence. RÉSULTATS: La majorité des MPL (61 %) ont déclaré une satisfaction de passable à modérée à l'égard des expériences d'aiguillage. Les difficultés identifiées par les médecins étaient liées aux enjeux de communication et d'administration, notamment l'absence de rendez-vous de suivi ponctuels et de continuité des soins; les formulaires d'aiguillage fastidieux; et les recommandations de services de santé mentale qui ne sont pas offerts dans leur communauté. De même, les psychiatres consultants ont exprimé leur frustration quant à l'information insuffisante reçue des médecins de l'aiguillage et surtout, en raison de l'absence de prestataires/professionnels appropriés durant la consultation qui apporteraient l'information collatérale et assureraient l'adoption des recommandations. CONCLUSION: Les programmes de télésanté mentale fournissent un service valable aux MPL et à leurs clients pédiatriques, mais ils pourraient être améliorés significativement par un modèle de consultation différent. Ces modèles de prestation des services exigent des protocoles pour éduquer les MPL, améliorer l'échange de communication et d'information, et établir des attentes bien définies entre MPL et consultants en télépsychiatrie.

Resident Evaluation of a Required Telepsychiatry Clinical Experience.

OBJECTIVE: The authors explored resident experiences of telepsychiatry clinical training. This paper describes an analysis of evaluation forms completed by psychiatry residents following a required training experience in telepsychiatry. METHODS: Retrospective numeric and narrative data were collected from 2005 to 2012. Using a five-point Likert-type scale (1 = strongly disagree and 5 = strongly agree), residents ranked the session based on the following characteristics: the overall experience, interest in participating in telepsychiatry in the future, understanding service provision to underserved areas, telepsychiatry as mode of service delivery, and the unique aspects of telepsychiatry work. The authors also conducted a content analysis of narrative comments in response to open-ended questions about the positive and negative aspects of the training experience. RESULTS: In all, 88% of residents completed (n = 335) an anonymous evaluation following their participation in telepsychiatry consultation sessions. Numeric results were mostly positive and indicated that the experience was interesting and enjoyable, enhanced interest in participating in telepsychiatry in the future, and increased understanding of providing psychiatric services to underserved communities. Narrative data demonstrated that the most valuable aspects of training included the knowledge acquired in terms of establishing rapport and engaging with patients, using the technology, working collaboratively, identifying different approaches used, and awareness of the complexity of cases. Resident desire for more training of this nature was prevalent, specifically a wish for more detail, additional time for discussion and debriefing, and further explanation of the unique aspects of telepsychiatry as mode of delivery. CONCLUSIONS: More evaluation of telepsychiatry training, elective or required, is needed. The context of this training offered potential side benefits of learning about interprofessional and collaborative care for the underserved.

Using technology to deliver mental health services to children and youth: a scoping review.

OBJECTIVE: To conduct a scoping review on the use of technology to deliver mental health services to children and youth in order to identify the breadth of peer-reviewed literature, summarize findings and identify gaps. METHOD: A literature database search identified 126 original studies meeting criteria for review. Descriptive numerical summary and thematic analyses were conducted. Two reviewers independently extracted data. RESULTS: Studies were characterized by diverse technologies including videoconferencing, telephone and mobile phone applications and Internet-based applications such as email, web sites and CD-ROMs. CONCLUSION: The use of technologies plays a major role in the delivery of mental health services and supports to children and youth in providing prevention, assessment, diagnosis, counseling and treatment programs. Strategies are growing exponentially on a global basis, thus it is critical to study the impact of these technologies on child and youth mental health service delivery. An in-depth review and synthesis of the quality of findings of studies on effectiveness of the use of technologies in service delivery are also warranted. A full systematic review would provide that opportunity.

OBJECTIF: Mener une étude de portée sur l'utilisation de la technologie pour dispenser des services de santé mentale aux enfants et aux adolescents, afin de déterminer l'ampleur de la littérature révisée par des pairs, de résumer les résultats et d'identifier les lacunes. MÉTHODE: Une base de données de recherche de la littérature a recensé 126 études originales satisfaisant aux critères de l'étude. Des analyses thématiques et des résumés numériques descriptifs ont été menés. Deux analystes ont extrait les données indépendamment. RÉSULTATS: Les études étaient caractérisées par diverses technologies dont la vidéoconférence, le téléphone et les applications de téléphone cellulaire ainsi que les applications sur Internet comme le courriel, les sites Web et les CD-ROM. CONCLUSION: L'utilisation de la technologie joue un rôle majeur dans la prestation de services et de soutien de santé mentale aux enfants et aux adolescents car elle intervient dans la prévention, l'évaluation, le diagnostic, la consultation et les programmes de traitement. Les stratégies connaissent mondialement une croissance exponentielle, il est donc essentiel d'étudier l'impact de ces technologies sur la prestation de services de santé mentale aux enfants et aux adolescents. Une revue approfondie et une synthèse de la qualité des résultats des études sur l'efficacité de l'utilisation des technologies dans la prestation de services sont également justifiées. Une revue systématique complète conviendrait à cet exercice.

Choosing child and adolescent psychiatry: factors influencing medical students.

OBJECTIVE: To examine the factors influencing medical students to choose child and adolescent psychiatry as a career specialty. METHOD: Quantitative and qualitative methods were used. A web-based survey was distributed to child and adolescent psychiatrists at the University of Toronto. In-depth interviews were held with select child and adolescent psychiatrists as well as a focus group with psychiatry residents. Retrospective accounts of the factors that influenced their decision to choose psychiatry and/or child and adolescent psychiatry as a specialty were collected. RESULTS: Ninety-two percent of participants indicated that recruitment of child psychiatrists in Canada is a problem. The recent decision by the Royal College of Physicians and Surgeons to recognize child and adolescent psychiatry as a subspecialty and introduce an extra year of training was identified as a further challenge to recruitment efforts. Other deterrents included lower salary than other subspecialties, lack of exposure during training, stigma, and lack of interest in treating children. Recruitment into psychiatry was enhanced by good role modeling, early exposure in medical school, an interest in brain research, and career and lifestyle issues. CONCLUSIONS: A rebranding of the role and perception of psychiatry is needed to attract future psychiatrists. Early exposure to innovations in child and adolescent psychiatry and positive role models are critical in attracting medical students. Recruitment should begin in the first year of medical school and include an enriched paediatric curriculum.

OBJECTIF: Examiner les facteurs qui influencent le choix des étudiants en médecine d'une carrière de spécialité en psychiatrie de l'enfant et de l'adolescent. MÉTHODE: Des méthodes quantitatives et qualitatives ont été utilisées. Un sondage en ligne a été distribué aux pédopsychiatres de l'Université de Toronto. Des entrevues de fond ont été menées avec des pédopsychiatres sélectionnés ainsi qu'avec un groupe de discussion formé de résidents en psychiatrie. Des comptes rendus rétrospectifs des facteurs qui ont influencé leur décision de choisir la psychiatrie et/ou la psychiatrie de l'enfant et de l'adolescent comme spécialité ont été recueillis. RÉSULTATS: Quatre-vingt-douze pour cent des participants ont indiqué que le recrutement de pédopsychiatres au Canada est problématique. La décision récente du Collège royal des médecins et chirurgiens du Canada de reconnaître la pédopsychiatrie comme surspécialité et d'ajouter une autre année de formation a été identifiée comme étant un défi additionnel pour les initiatives de recrutement. D'autres éléments dissuasifs étaient notamment le salaire plus faible que celui des autres surspécialités, l'absence d'exposition durant la formation, les stigmates, et le manque d'intérêt à traiter des enfants. Le recrutement en psychiatrie bénéficiait de bons modèles de rôle, d'une exposition précoce à la faculté de médecine, d'un intérêt pour la recherche sur le cerveau, et d'enjeux de carrière et de mode de vie. CONCLUSIONS: Il faut redonner une nouvelle image du rôle et de la perception de la psychiatrie pour attirer de futurs psychiatres. L'exposition précoce aux innovations de la pédopsychiatrie et aux modèles de rôle positifs est essentielle pour attirer les étudiants en médecine. Le recrutement devrait débuter en première année de la faculté de médecine et comprendre un programme d'études enrichi.

Attracting Child Psychiatrists to a Televideo Consultation Service: The TeleLink Experience.

Objective. Identify aspects of psychiatry work that are rewarding, as well as those that are challenging, from the perspective of psychiatrists and residents participating in televideo consultation services. Method. A web-based survey was distributed to psychiatrists within the Division of Child Psychiatry at the University of Toronto. Also, semistructured interviews were conducted with six child psychiatrists providing services to a telepsychiatry program. Finally, a focus group interview was held with four psychiatry residents. Results. Child psychiatrists are very comfortable conducting assessments via televideo. Factors identified as being important in the decision to participate in telepsychiatry include assisting underserved communities, supportive administrative staff, enhanced rural provider capacity, financial incentives, and convenience. The study's qualitative phase identified four themes in the decision to participate in telepsychiatry: (1) organizational, (2) shared values, (3) innovation, and (4) the consultation model. Conclusion. The success of televideo consultation programs in attracting child psychiatrists to provide consultation services to underresourced communities makes an important contribution to psychiatric workforce shortages. Understanding what aspects of telepsychiatry are most appreciated by consulting psychiatrists and residents offers useful strategies to telepsychiatry administrators and medical school educators seeking to attract, train, and retain psychiatry practitioners.

Child and youth telepsychiatry in rural and remote primary care.

Young people with psychological or psychiatric problems are managed largely by primary care practitioners, many of whom feel inadequately trained, ill equipped, and uncomfortable with this responsibility. Accessing specialist pediatric and psychological services, often located in and near large urban centers, is a particular challenge for rural and remote communities. Live interactive videoconferencing technology (telepsychiatry) presents innovative opportunities to bridge these service gaps. The TeleLink Mental Health Program at The Hospital for Sick Children in Toronto offers a comprehensive, collaborative model of enhancing local community systems of care in rural and remote Ontario using videoconferencing. With a focus on clinical consultation, collaborative care, education and training, evaluation, and research, ready access to pediatric psychiatrists and other specialist mental health service providers can effectively extend the boundaries of the medical home. Medical trainees in urban teaching centers are also expanding their knowledge of and comfort level with rural mental health issues, various complementary service models, and the potentials of videoconferencing in providing psychiatric and psychological services. Committed and enthusiastic champions, a positive attitude, creativity, and flexibility are a few of the necessary attributes ensuring viability and integration of telemental health programs.

A qualitative study of young people's perspectives on receiving psychiatric services via televideo.

OBJECTIVE: It is critical to consult young people about their experiences. This study addresses the paucity of research on the perspective of young people in general, and in paediatric telepsychiatry specifically. The goal is to understand the experience of young people receiving telepsychiatry. METHOD: Interpretive interactionism (Denzin, 1989) was used to interview 30 young people; immediately following the consultation and four to six weeks later. Analysis occurred via a series of steps in keeping with the interpretive interactionist framework. RESULTS: Four themes arose repeatedly: the encounter with the psychiatrist and experience of having others in the room; the helpfulness of the session; a sense of personal choice during the consultation; and, the technology. Participants highlighted the importance of their relationship with the psychiatrist. Participant's narratives were replete with examples of ways that they actively took responsibility and exerted control within the session itself. CONCLUSION: Young people have a significant role to play in their own care. It is critical that telepsychiatry recommendations be explained and opportunities for young people to express their concerns and discuss alternatives are provided. Further efforts to include young people may include ensuring offering alternate treatments and/or negotiated when recommended treatments are unacceptable and/or resisted.

The relevance of qualitative research for clinical programs in psychiatry.

It is time to move beyond education about qualitative research theory and methods to using them to understand and improve psychiatric practice. There is a good fit between this agenda and current thinking about research use that broadens definitions of evidence beyond the results of experiments. This paper describes a qualitative program evaluation to illustrate what kind of useful knowledge is generated and how it can be created through a clinician-researcher partnership. The linkage and exchange model of effective knowledge translation described involves interaction between clinicians and researchers throughout the research process and results in mutual learning through the planning, disseminating, and application of existing or new qualitative research in decision making.