Background
Childhood and adolescence are key periods in lifetime mental health trajectories [
1]. Research from the United Kingdom estimates that around 1 in 8 children and young people have a diagnosable mental health condition, and that prevalence has increased over time [
2]. Half of all long-term mental disorders are thought to start by age 14, and three-quarters by age 24 [
1]. Despite this, many of these young people do not receive treatment [
3,
4]. The prevalence of mental health conditions is not evenly distributed across the population, with key differences between groups based on age, sex and socioeconomic conditions. Older children, girls and those from deprived areas are all more likely to present with poor mental well-being [
5‐
7]. Addressing unequal access to Child & Adolescent Mental Health Services (CAMHS) has been a longstanding Scottish Government priority [
8] and mental health and inequalities remain a key concern in the period of transition and recovery from the impacts of COVID-19 [
9]. Trends across the UK and around the world suggest increasing prevalence of mental health problems [
6] and inequalities in self-reported mental wellbeing by area deprivation [
7], although comprehensive and detailed data is lacking.
Prescribing of medications used to treat mental health conditions in children has increased in various international contexts [
10,
11] with notable rises in prescriptions of antidepressants [
12,
13] and medications to treat Attention Defecit Hyperactivity Disorder particularly among boys [
14,
15] from the 1990s up until the 2010s. Analysis of mental health prescribing in parts of the United Kingdom has previously been conducted for people of all ages, but this did not include a detailed exploration of trends in younger age groups [
16,
17]. Analysis of psychotropic prescribing rates in young people during 2020 found an initial decrease during the period of national lockdowns, followed by increases particularly for antidepressants [
18]. The number of young people being treated for mental health complaints has increased over time internationally [
19,
20] and there is emerging international evidence that this increase has accelerated since the onset of the COVID-19 pandemic [
21‐
23]. Aggregated open data on prescribing and referrals to specialist outpatient (Tier 3) services are available in Scotland and confirm a trend of increasing referral through time which has accelerated since the COVID-19 pandemic [
24]. Previous analysis of 1 year of specialist outpatient referrals in a single Scottish council region found important demographic patterns, with older children and boys more likely to be referred [
25] but did not provide population adjusted rates or a sense of temporal trends which are presented in our analysis. National-level analysis of prescribing and specialist referrals in Scotland has provided high-level summary insights [
8,
16,
26], but analysis of sub-national trends are needed to provide improved local understanding to inform service and workforce planning [
27]. Here we used individual level data for analysis of a wider range of social and demographic characteristics associated with mental health prescribing and service use.
We describe the rates of prescribing of medications commonly used to treat mental health conditions in children and explore trends in specialist outpatient referrals, rejections, and treatment both before and during the COVID-19 pandemic. We describe social and demographic characteristics for these populations, including sex, age, and home area deprivation. Finally, we quantify inequality in rates of prescription and referral by area deprivation.
Discussion
Principle findings
We found a substantial increase of mental health prescribing in children across medicines used to treat a variety of mental health conditions – with rates of anti-anxiety and sleep medication prescriptions increasing by 90% and anti-depressants by 60%. There are stark differences in who is receiving prescriptions for mental health drugs – in younger children prescriptions are predominantly for boys to treat ADHD, and in older children prescriptions are predominantly for girls to treat depression.
Overall, we found that referrals to specialist CAMHS were stable until the 2020 COVID-19 lockdown, after which there was an increase particularly among girls and those in older age groups. We found that the proportion of referrals which were being rejected increased before the COVID-19 pandemic, then accelerated following the first 2020 lockdown. The increase in rejected referrals has had the biggest impact in the youngest ages and for boys. This has resulted in a static number of accepted referrals but a change in the characteristics of the treated population who are more likely to be girls and in older age groups.
We also found a clear and persistent social gradient by area deprivation for rates of both mental health prescribing and specialist CAMHS referral. Rates for both prescribing and referrals to specialist care for children living in the most deprived areas were twice as high compared with the least.
Strengths and limitations
The data used in this study are comprehensive for the entire population of children in the NHS Grampian region. The Prescribing Information System database is the definitive data source for medicines prescribed and dispensed in the community in Scotland. The CAMHS referrals data used in this study are required to be recorded locally by the Scottish Government for quarterly reporting of national statistics on patient waiting times. This work adds value to these high-quality administrative healthcare records through individual level linkage of socioeconomic and demographic information. Investigation of the individual level records also reveals trends which are not captured in aggregate statistics available as open data. This detailed descriptive analysis will support future research aiming to identify potential mechanisms which may explain these findings, inform service planning and policies to provide treatment for equitably. This work was also informed by public involvement and engagement activities at each stage, including in research design, analysis methods and interpretation of results. A full description of these activities is included in the supplementary materials (Table S
1).
The data available to this study are of a high quality but do not represent the totality of mental health care services which are available to children and young people. Unmeasured/alternative sources of treatment for mental health (e.g. lower Tier community-based CAMHS or private and charitable organisations) are mostly aimed at people with lower severity needs. Due to the administrative nature of these data sources there is very little information relating to clinical indications. In the case of prescribing data, although medicines are grouped in the BNF based on their common usage, some medications are indicated for the treatment of a variety of conditions or can be used ‘off license’. This means that we are unable to determine conclusively why any given prescription has been given to a patient. For CAMHS referrals, additional information was not available about the clinical complaints of those receiving referrals, or for those whose referrals are rejected. It is therefore not possible to determine the reason for a rejected referral or whether those whose referrals are rejected receive subsequent treatment elsewhere for the complaint which prompted the initial CAMHS referral. An audit of rejected referrals in a number of Scottish NHS health boards found that a large majority of rejected referrals were classed as ‘unsuitable’ (i.e. they did not meet the health board criteria for referral due to severity or the nature of the complaint) or that not enough information was supplied in the referral for it to proceed [
26].
How does it compare with other work?
Sex/gender
Epidemiological studies of neurodevelopmental and mental health disorders and service use in children and young people consistently report gender differences. This study is concordant with national reporting for the whole population (including adults) which found markedly higher levels of mental health prescribing for females than males, apart from medicines used to treat ADHD [
16]. Open data for CAMHS referrals do not include a breakdown by sex so it is not possible to compare the pattern of increasing referrals for females in Grampian following the pandemic with the national picture. However, an audit of rejected referrals in seven Scottish health boards found that males accounted for a larger proportion (54%) than females, which is concordant with the findings of this work. The audit was conducted over a single year, so it is not possible to comment on trends through time.
A rapid literature review conducted in 2019 by the Scottish Government [
23] looked specifically at evidence of worsening mental wellbeing among adolescent girls in Scotland. This found evidence of generally increasing prevalence of self-reported poor mental wellbeing in a variety of indicators among adolescents generally, but particularly for adolescent girls. The review concluded that there is little robust causal evidence to explain this observation.
There are competing hypotheses about whether the observed differences in mental health service use reflect
natural differences in incidence and prevalence of mental health disorders between boys and girls, socially constructed expectations around mental health and behaviours, or the way these expectations influence professionals who make or assess referrals. Boys and girls are thought to manifest their mental health, social and behavioural patterns in different ways [
37], although it is unclear the extent to which this is a consequence of biological or social processes. There is also concern that neurodevelopmental diagnostic criteria may not adequately reflect symptom manifestations in females [
38], which may lead to delays in or lack of diagnosis and/or treatment compared with younger boys [
39].
Prevalence of poor mental health
Alongside our findings of increasing mental health prescribing and CAMHS referrals in children and young people over time, other work has observed a national increase in the prevalence of poor mental health [
40]. The Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS), which looks specifically at 13- and 15-year olds found continuous rises in the proportion with borderline or abnormal responses to the Strengths and Difficulties Questionnaire (SDQ) from 2010 to 2018 [
41]. They also found that the average Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) had decreased between 2015 to 2018, which suggests worsening mental wellbeing. Both indicators also had clear patterns by sex, with 15-year-old girls having the highest rate of borderline/abnormal SDQ and the lowest average WEMWBS scores. The Scottish Health Survey (SHeS) also looked at WEMWBS scores in children aged between 13 and 15 and found higher mental wellbeing scores in boys than girls [
7]. SALSUS reported social gradients in both SDQ and WEMWBS scores by deprivation, with the highest rates of poor mental health being found in the most deprived areas.
Potential mechanisms
The aims of this study are descriptive in nature and it is not possible to determine the mechanisms which produce the observed trends. For instance, increasing mental health prescribing and referrals to CAMHS could result from increasing prevalence of mental health disorders in the population, improved recognition of the need to seek help among young people and their carers, or improved access to treatments and referral pathways.
The same is also true of sex differences in referral and treatment for mental health conditions, although increasing CAMHS referral in girls but not boys since the start of the COVID-19 pandemic should prompt further investigation. Patterns of help-seeking behaviour may differ between boys and girls and this may also interact with age. Girls tend to appear in these records at older ages and in larger numbers, whilst boys are more likely to be in younger age groups. It may be that girls present later because their needs are not recognised at earlier ages, or that boys in need are less likely to be referred for or receive treatment once they reach adolescence.
Local changes in the demographics of the population treated by CAMHS, with higher rejections for younger boys and higher acceptances for older girls, predated the onset of the COVID-19 pandemic. Given the roughly static number of accepted referrals throughout the study period, this change in those accepted for treatment may reflect a conscious change in service prioritisation or greater levels of clinical acuity in specific population groups. Without more detailed information around reason for referral or rejection, this is not possible to determine.
Higher incidence of mental health prescribing and referral for specialist CAMHS for children in the most deprived areas has been persistent throughout the study period. The mechanisms through which area-level deprivation could influence mental health are varied [
42] and include a lack of access to material resources, support services and socioeconomic opportunities which might improve mental wellbeing.
Unanswered questions and future research
Future work should explore the incidence and prevalence of diagnosable mental health conditions to allow for comparison with patterns of increasing mental health prescription and increasing demand for specialist CAMHS. This would help to determine whether patterns from administrative and service use sources reflect underlying trends in incidence or changes in recognition of mental health conditions and help-seeking behaviour.
More comprehensive data from primary care and other mental health support services available to children and young people should be made available for future research. In particular, community-based services (e.g. CAMHS Tier 1 and 2) and GP data should be prioritised as these are likely to be the first point of contact with health professionals for people in need of support around mental health. Data from educational settings and charitable organisations providing mental health support are also likely to provide useful information. Future analysis of mental health prescribing and CAMHS referral should incorporate more detailed information related to clinical indications as well as reasons for referral and rejection. Public involvement in this work highlighted that deeper analysis of rejected referrals in the future was important and that this should explore patient pathways using routine sources of data as well as make use of qualitative methods to explore help seeking behaviours in children and their carers.
Whilst we have been able to describe patterns in prescribing and CAMHS referral by some demographic and socioeconomic characteristics, other important factors have not been possible to investigate. The limited availability and poor quality of ethnicity indicators in administrative healthcare records may underestimate inequalities [
43] and individual or household indicators of socioeconomic position were not available to us. Future research should look to link reliable sources of social data with administrative health records to better understand the complex mechanisms which influence child and adolescent mental health and service/treatment access.
Conclusions
The findings of this work indicate there is a bottleneck between rising mental healthcare need at the primary level (prescriptions) and the static size of the population of children treated by specialists in tertiary care. This study also found substantial differences in care use between the sexes at different ages, and much higher need in the most socioeconomically deprived communities. Children’s mental health care services should consider structural changes in provision which account for different patterns of need for these different populations. Frequent monitoring of care use is needed, as indicated by the rapid changes we found in specialist CAMHS referrals for older adolescent girls since the start of the COVID-19 pandemic.
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