Closing the mental healthcare gap Many young people with mental health problems will require continued healthcare as they enter adulthood, yet a significant proportion fall through the ‘care gap’ between child and adult services. We spoke to Professor Swaran Singh about the MILESTONE project’s research into this transition The challenges of
late adolescence are heightened even further for those suffering from mental health problems. Alongside dealing with developmental and situational changes, young people with mental health problems may have to make the transition between Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS), an area of great interest to the MILESTONE project, an initiative bringing together researchers from eight European countries working across nine workpackages. Based at the University of Warwick, Professor Swaran Singh is the overall coordinator of the project and is also closely involved in a study into the transition between CAMHS and AMHS. “The study has two main arms. One is to follow up a large cohort of young people who reached the transition boundary between child and adult mental health services in their own country and moved to adult care, or went elsewhere,” he outlines.
Care gap This transition typically occurs between the ages of 16 and 19, yet many young people who need continued healthcare fall through the care gap between CAMHS and AMHS, Managing the link and strengthening transition from child to adult mental healthcare (MILESTONE) Professor Swaran Singh Mental Health and Wellbeing Warwick Medical School University of Warwick T: + 44 (0) 2476 574530 E: S.P.Singh@warwick.ac.uk W: http://milestonetransitionstudy.eu/ Initially trained as a surgeon, Professor Singh became interested in mental health following involvement with human rights groups working with children traumatised in ethnic violence in New Delhi. He trained as a psychiatrist at the Post-graduate Institute of Medical Education and Research (PGI), Chandigarh, and moved to the UK in 1991. He was a Lecturer and Consultant in Nottingham and in 2001 was appointed Senior Lecturer at St George’s University, London. There he developed the ETHOS early intervention service, which gained an international reputation for its success in improving outcomes for young people with psychosis and for its cost-effective use of resources. He was appointed Professor of Social and Community Psychiatry at the University of Warwick in March 2006.
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while those who do make the transition often experience poor care. This can have serious long-term consequences, underlining the importance of the second key part of the study. “We have devised a model of care called ‘managed transition’. About 250 young people out of a cohort of 1,000 will receive an intervention,” explains Professor Singh. “Clinicians will be given detailed information about these young people, and they can make a decision on whether they need to go to AMHS. We hope those young people who need to receive adult care will do so, and those who don’t will be discharged.” The wider aim in this research is to ensure that young people approaching the transition between CAMHS and AMHS receive appropriate care. While child and adult mental health disorders were long thought to be entirely separate, Professor Singh says that thinking has since changed. “We now know that what we call adult disorders actually begin during adolescence. So 50 percent of adult mental health problems begin before the age of 16, and 75 percent begin before the age of 25,” he says. “That means our current care pathway, with the gap between child and adult psychiatry between the ages of 16 and 19, has a weakness in the system at the point where it should be most robust. That’s one of the main drivers behind this study.” The ‘managed transition’ model is designed to address these issues and ensure continuity of care. Child and adult psychiatry are two different fields however, with different conceptual frameworks, assessment methods and therapeutic interventions, so Professor Singh and his colleagues have been working to establish some common ground. “We felt that we needed to have an assessment framework, where both child and adult psychiatrists could agree on the appropriate care for each young person,” he outlines. This assessment framework is called TRAM
(Transition Readiness and Appropriateness Measure). “TRAM has two components; is the young person ready for transition? And is the young person appropriate for transition to adult care?” explains Professor Singh.
TRAM framework This framework is built on completed assessments of young people undergoing transition, as well as input from their parents and child psychiatrists, aiming to identify the information which can help inform clinical decision-making. The TRAM framework will form the basis of a specific intervention in the project, aiming to help clinicians decide which young people need to move on to adult care. “We’ve identified young people approaching the transition boundary for the relevant mental health service. We meet them, and we complete the TRAM - the young person’s version, the clinician’s version and the parents’ version,” says Professor Singh. “We put this information together, and come up with a simple, visual, summary of what the young person needs.” The TRAM report will then be sent to the clinician, helping inform their decision on whether the individual needs to make the transition to AMHS. This approach has already been used in a few cases, and the evidence so far suggests it is a helpful tool for clinicians. “Our very first few anecdotal cases suggest that clinicians have found the TRAM report very useful, and some of them have said that they changed their decision on the basis of it,” says Professor Singh. This can help ensure that young people receive appropriate care, and Professor Singh hopes that the project’s research can play a part in these terms. “We hope that young people will have a better journey to adult care and that adult services will meet their needs better,” he says. The MILESTONE team
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